By: Lee J. Zook
Winter 2001, Vol. 8, No. 1
Ethics: To Tell or Not to Tell-A Case Study
by Lee J. Zook, Ph.D.
Some years ago, prior to teaching in undergraduate social work, I was working with families and children in an outpatient psychiatric setting, Children' Agency. In the previous year, I had completed my MSW, having practiced social work several years with an undergraduate degree. The Director of Social Services at the Children' Agency was my supervisor. We used a team model in our work, with any particular team consisting of at least a social worker, a psychologist, and a psychiatrist. Sometimes other professionals, such as educational specialists, early childhood development specialists, and social group workers were also on the teams. I had first-rate colleagues in whom I could confide about clinical and ethical issues. Continuous learning was valued, especially as it related to clinical practice.
While I was at Children' Agency, Mary Jones (a fictitious name) applied for a job as a social worker. Four years earlier, I had seen Mary as a client while working for an emergency service at Adult Hospital, a psychiatric facility for adults.
My contact with Mary had been rather brief at Adult Hospital. She came to be admitted to the hospital as her psychiatric condition was deteriorating. Mary told me she was a social worker with an MSW and had been in and out of psychiatric hospitals for many years. I located her chart, noted that she was previously diagnosed with schizophrenia, undifferentiated type, did the basic paperwork that social workers did on admission, consulted with the admitting psychiatrist, and took her to the hospital ward. It was a rather simple, routine admission; there were no police or court documents, and she was a voluntary client. However, the situation was a bit unsettling. My feelings had to do with the fact that I was leaving my position in the near future to pursue an MSW, and here I was, a young, rather inexperienced, “untrained” social worker, admitting an older, more experienced social worker with an MSW to a psychiatric hospital. However, I went on with my business and put the event in perspective. After all, academic degrees do not preclude a person from having a mental illness.
So now, three years later, I had my MSW, and Mary came for a job interview at Children' Agency where I was employed. I had no responsibility for employment decisions. My supervisor, who was the Director of Social Services, and the psychiatrist, who was also the Executive Director, made these decisions. But I was faced with an uncomfortable dilemma-an ethical dilemma for which I did not see any clear answer.
On one hand, I was concerned about whether Mary would function as a competent professional colleague. Was her illness in remission? If so, would it remain in remission? If not, what would the impact be on clients? Would she be able to function adequately to work with clients who came to the agency? If she would not, would harm come to clients?
On the other hand, my knowledge of her illness was unquestionably confidential. Further, what right or responsibility did I have to suggest that a person who had a mental illness should not be hired? What right or responsibility did I have to divulge information about her (past) condition to anyone?
There was also the possibility that I could speak to Mary and verbalize my concerns to her. Would this be appropriate? Would Mary remember who I was? After three years, did the brief encounter we had give me the prerogative to confront her about her past or ask about her present condition?
The following discussion focuses on the NASW Code of Ethics and how it may be useful in this situation. At the time, I was not this thorough and did not think much about the Code of Ethics. I struggled in my own mind about what to do. If this were occurring now, I would first of all confer with the Code of Ethics. The first sentence of the preamble of the Code states:
The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty.
In this situation, one could contend that clients coming to Children' Agency were the vulnerable people referred to in the Preamble. On the other hand, one could also make a case that Mary, a person who is living with a persistent and long-term mental illness, is a vulnerable person.
As a social worker, I am particularly concerned about creating opportunity for persons with disability. And in this instance, vulnerability of a specific person could be viewed as more important than vulnerability of a general client population.
In further examination of the Code, Section 1.07 Privacy and Confidentiality, paragraph (c) is instructive.
Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that social workers will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person.
This paragraph seems to suggest intervention in the situation with Mary is not appropriate. Do not break confidentiality. However, it also says that there are situations in which confidentiality is not the primary concern. Disclosure of confidential information may be made when it is crucial to “prevent serious, foreseeable, and imminent harm to a client or other identifiable person.” But could I argue that there was such serious, foreseeable and imminent harm to anyone? Would it be appropriate, with the knowledge that I had, to suggest such harm would occur? If the answer to the last question is affirmative, what does that infer about persons with a mental illness?
Other paragraphs in Section 2.09, Impairment of Colleagues, are also on point.
(a) Social workers who have direct knowledge of a social work colleague' impairment that is due to personal problems, psychosocial distress, substance abuse, or mental health difficulties and that interferes with practice effectiveness should consult with that colleague when feasible and assist the colleague in taking remedial action.
(b) Social workers who believe that a social work colleague' impairment interferes with practice effectiveness and that the colleague has not taken adequate steps to address the impairment should take action through appropriate channels established by employers, agencies, NASW, licensing and regulatory bodies, and other professional organizations.
I did have knowledge of Mary' impairment. However, to infer that her impairment would interfere with her work as a professional social worker could be seen as prejudiced toward persons with a mental illness. Did I have enough information about Mary to “consult” with Mary as paragraph (a) suggests?
Further, Section 4.02, Discrimination, states that: “Social workers should not practice, condone, facilitate, or collaborate with any form of discrimination on the basis of race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability.” (Italics added.) This suggests that revealing anything about Mary' condition or even confronting Mary with the situation would be discriminatory.
Finally, since Mary was a professional, didn’t she have the responsibility to make sure her “mental health difficulties” did not interfere with her professional judgment and performance as is stated in Section 4.05, Impairment, paragraph a?
(a) Social workers should not allow their own personal problems, psychosocial distress, legal problems, substance abuse, or mental health difficulties to interfere with their professional judgment and performance or to jeopardize the best interests of people for whom they have a professional responsibility.
Paragraph b. of Section 4.05, Impairment goes on to say, in part, that social workers whose “mental health difficulties interfere with their professional judgment and performance” need to seek help, make adjustments in their work situation, or quit practicing.
Doesn’t this mean that since Mary is a professional, she needs to deal with these issues? If that is the case, what is my role?
Obviously, the Code is not a clear set of rules. Rather, it gives guidance to social workers. While it is instructive, the Code does not specify what course of action is best in all instances. As stated in the Preamble, “Core values, and the principles that flow from them, must be balanced within the context and complexity of the human experience.” Professional judgment also comes into play in making ethical decisions.
In summary, there seemed to be no ideal course of action in this situation. I did not know how to predict what would happen if I talked with Mary. It is conceivable that I would have a colleague who was less than happy with my reminding her of her illness. If I did intervene by reporting to persons responsible for hiring, confidential information would be divulged. I could be identified as practicing discrimination toward persons with a mental illness. If I did not intervene, and she was hired, harm could come to clients.
There seemed to be no ideal answer and no way to avoid the situation. There may have been other options, but none seemed apparent to me at the time.
When I relate this case in class, I ask students to work in groups, make a decision, and explain to the rest of the class how they came to their conclusion. Obviously, the Code of Ethics should be a guide in such decisions. But other questions about how to make these types of decisions are also important. Is it appropriate to discuss such issues with my other colleagues? If yes, under what circumstances should such issues be discussed, formally or informally? Should a professional social worker consult with the National Association of Social Workers about such a decision? In general, should a supervisor be consulted about such decisions? In this instance, this would not have seemed appropriate, as the supervisor was also the person in charge of hiring.
In conclusion, there are times in social work practice when professionals are placed in situations, through no wrongdoing on anybody' part, in which dilemmas occur because of a conflict in values or ethical principles within the situation itself. In those situations, it is not a matter of choosing good versus evil, or choosing right versus wrong. It is a matter of choosing between the better of two goods or, possibly more often, the lesser of two evils. Making those decisions is often not pleasant. In fact, it can be quite anxiety provoking. But it is also impossible to side step the issue when doing nothing will predictably yield a certain outcome.
I would welcome a discussion about this case. What would you do? How would you decide what you would do? What besides the Code of Ethics should aid one in making this decision? These are some of the questions that we could discuss together.
National Association of Social Workers. (1999). NASW Code of Ethics. Available online at http://www.socialworkers.org/Code/ethics.htm.
Lee J. Zook, Ph.D., is Associate Professor of Social Work at Luther College in Decorah, Iowa.