Applying ethical theoretical frameworks to the practice scenario of Gifty
Ethics have been widely considered to have a central role in social work, from both a personal and a professional perspective (Beckett and Maynard, 2013; Rutter and Brown, 2015). Ethics can be defined as the implicit agreement that individuals in society make with each other, which lays out expectations on how members of that society interact with each other on a daily basis (Kymlicka, 2003). However, the way that individuals understand and interpret this implicit ethical agreement tends to differ based on cultural, religious, social circumstances and experiences (Spano and Koenig, 2007). Therefore, ethical dilemmas come up often in social work, based in particular on the fact that social workers are often working with difference and diversity (Rossiter, 2011). In this way, ethical dilemmas in social work can be defined as trying to do the right thing, in the right way, at the right time, with the right people, and with the right spirit, something that is rarely simple or straightforward (Hugman and Carter, 2016).
This essay will explore the ethical dilemma in Gifty case (Appendix1); while the case study will not be repeated, the specific ethical dilemmas will be outlined. The essay will start by exploring different theoretical approaches to this case, a deontological approach (Candee and Puka, 1984) and a utilitarian approach (Osmo and Landau, 2006). Following on from this, Beauchamp and Childress’ (2001) four principles of ethics will be applied to the case, with a focus on beneficence and respect for autonomy. The SIAC model of ethics will then be applied to this case. (Icheku, 2012).
Although, Josephson’s (2002) six pillars model was considered as it focused exclusively on character traits for ethical decision making. The SIAC model four steps to principle reasoning (Appendix 6) was considered appropriate in the case of Gifty. This will be elaborated upon in more detail later in the essay. Finally, the impact of personal value(Bank, 2006) and professional values (HCPC, 2012) on ethical decision making will be considered, and it will be shown that while the ethical decision to be made in this case is complex, the application of SIAC model and theories is helpful for social workers trying to make sense of these types of complex dilemma.
This case scenario involves ethical dilemmas based on Health, socialisation and finance. In relation to health, Gifty has signed a Do Not Resuscitate (DNR) in the presence of her General Practitioner (GP), something that the family believes they should have been more involved in. In relation to socialisation, Gifty wants to attend college. Her family has expressed concerns that being exposed to new people in new circumstances will lead her to be more at risk of abuse or being taken advantage of. The final ethical decision relates to finances, Gifty has expressed that she would like to have more control over managing her finances on a day to day basis, something her family believe she does not have the capacity to do.
The first theoretical model to be considered is deontology. This model has its root in the writings of Emmanuel Kant, and the approach is based on a belief that there is a moral righteousness related to actions themselves, rather than on the consequences of that action (Gray, 2010). Essentially, this means that actions are to be considered ethical if they are based on rational and universally true principles (Icheku, 2011). This is important to social work, because social work is based on the inherent belief in specific values, and to some extent this is what defines the profession on a whole (HCPC 2017; BASW, 2018). Some of the strengths to this model include that it tends to provide clear guidance, related to the adherence to strict ethical obligations and duties (Banks, 2014). Applying this model to the case study as a social worker, core principles that could be considered as important for all situations include autonomy and independence (Icheku, 2011). In this way, Gifty would be allowed to make her own decisions on all these issues, and a social worker working from a person-centred perspective would support her to make this possible.
However, deontology is a model that can be considered callous and uncaring in the unflinching way it applies overarching principles of ethics (Reamer, 2006). In relation to this case, it is difficult to apply, because the familial dynamics are so complex, meaning that ethical principles can be in conflict. For example, while the principle of autonomy is important to social work (Banks, 2014), this could come into conflict with the protection of vulnerable individuals, another important principle for social work (Ferguson, 2007). For example, Gifty taking on more responsibility for her day to day life will undoubtedly create more risks of abuse or being taken advantage of, and under an approach that sees there is a duty to protect vulnerable individuals as a fundamental principle; this would be something to avoid (Gray, 2010).
The other theory to be discussed is that of utilitarianism, or consequence based theory, which focuses on the need to generate the greatest amount of happiness for the greatest number of people, moving the discussion away from the strict morality related to specific actions (Kelly, 1990). Social worker using Utilitarian approach to resolve Gifty case will consider that, it is ethically justifiable for the greatest good of the family to outweigh Gifty decision (Icheku (2012). The family is concern that Gifty could be at risk of physical and financial abuse, if she is allowed to attend college, manager her finance. Also the DNR order may lead to Gifty’s death which would have devastating effect on the family. Cordona (2009), stated that there is an established relationship between vulnerability and risk. Based on this, it is important to consider the family perspectives and not dismiss them, because their happiness is important under utilitarianism (Reamer 2006). Applying the Utilitarian approach means that the happiness of the family member will override Gifty decisions. This means that utilitarianism justify an approach that is not person centered and focuses more on assessment of overall happiness for those involved. This is a key limitation as it is cold calculating ethical model in its purest form (Kelly, 2009). Furthermore the decision that one comes to could be legally wrong, creating significant ethical issue for the social worker (Icheku 2012). Another identified weakness by Evans and Whittaker (2010), is that not everyone will be happy with the utilitarian approach as the family interest will override Gifty decision. This will mean Gifty is been treated as means to an end and not as individual (Bank, 2012). The strength of the consequential based theory is that it guides social worker to allocate limited resources effectively according to service user’s need (Parrot, 2014).
This section will explore ethical principles that can guide practice in this case. An ethical principle can be considered to be a guiding factor that leads decision making for an individual, professional, community or society (Gillon, 1994). The four ethical principles to be considered here are autonomy, beneficence, justice and non-maleficence (Beauchamp and Childress, 2001). Within this model, justice relates to the need to ensure that actions taken are right, or righteous, and this is significantly linked to the legal frameworks that apply to this case, factors that will be discussed in more detail in the next section (Freeman, 2011). Non-maleficence relates to the need to not negatively impact on an individual due to your actions, and is a principle that is highly regarded in the medical profession (Gillon, 1994). While these two principles are significant to this case, this section will instead focus on autonomy and beneficence as they relate to Gifty, and as was shown in the previous section, these two factors are particularly pertinent to this case.
Autonomy in this case is of fundamental importance from a legal and ethical perspective. Gifty requires an assessment under section 9 of the Care Act 2014, and a key principle of this act is autonomy, and the rights of individuals to make decisions related to the care and support they received (DoH, 2016). It is extremely important in cases like this that concerns related to risk, like those expressed by the family, do not outweigh an individual’s right to make their own decisions (Mantell and Clark, 2010). This links with another key piece of legislation in this area. Under section 1 of the Mental Capacity Act 2005, one of the core principles is stated to be the right to make unwise decisions, and, therefore, if Gifty wants to manage her finances, even if this is considered unwise by those around her, this is her right (Johns, 2014). It has been shown that taking back even a small amount of control in this way, for example, around finances, health or socialisation, can be enormously empowering (Ferguson, 2007). Therefore, the principle of autonomy would guide an ethical decision maker in this case towards allowing Gifty the greater control over these areas.
The other ethical principle to be considered here, that of beneficence, relates to the moral obligation to take actions that are beneficial to others (Beauchamp and Childress, 2001). In this case, the family may feel that not allowing Gifty to manage her finances is in her best interest. In considering what activity would be of most benefit to Gifty, this could include not allowing her to manage her finances for risk of financial abuse. Abuse and neglect of vulnerable adults causes substantial trauma, and should be avoided if possible (Johnson, 2007). The principle of beneficence, therefore, would dictate that strong consideration be given to reducing the ability of others to take advantage of Gifty going forward. However, the legal framework around capacity is likely to be the determining factor in this case.
As discussed in the introduction, this case study evaluation will be based on the SIAC (Icheku, 2011) model. The first step to consider in the SIAC model is to summarise the facts of the case (Icheku, 2011). While the full details will not be repeated here, there are some important dynamics to consider in engaging with the ethical dilemmas of this case. This case involves a service user with a learning disability, and social work with learning disabilities is one of the most complex areas of practice, and this has been shown consistently in research (Williams, 2006). Alongside this, the hearing and sight loss will present substantial difficulties in relation to effective communication (NHS England, 2017). Beyond these points, the fact that Gifty is a black female means that she is likely to have experienced significant marginalisation in her life (Hooks, 1992). Furthermore, she has experienced two significant recent bereavements, as her mother and father have both died in the past nine months. This type of significant bereavement can exacerbate any isolation and marginalisation felt by someone like Gifty (Kubler-Ross, 2014).
These points are all pertinent to the next step of the SIAC model, which is to identify the ethical issues and different perspectives involved (Icheku, 2011). In this case, there are three fundamental areas from an ethical perspective, related to finances, socialisation and health. However, they all ultimately come down to the perspective of Gifty, who wants to take on more power for herself, and more control over her life, and the concerns of the family, who worry that in doing this she would be placed at substantially more risk. This leads on to the third stage of the SIAC model, which relates to applying relevant value and legal principles (Icheku, 2011). The legal principles have been discussed above, and it was shown that ultimately what will be the key determining factor in this case will be whether Gifty has capacity or not to make these decisions, in line with the Mental Capacity Act 2005. However, even if she does have capacity, there are important values, like beneficence that was outlined above, that are still important to the case, and this will need to be weighed up alongside these legal imperatives (Beauchamp and Childress, 2001). The final section of this model is to consider the most effective option. In this case, that would mean undertaking an assessment of capacity with Gifty, and if she has capacity, supporting her to make these decisions in the safest and most empowering way possible.
Social work values are a foundation block for the profession, and some have stated that the unique worth of the profession relates to these values and the related ethical principles (Banks, 2014). However, it is also important to recognise that at times personal values could impact on decision making in practice, in particular when there are complex ethical decisions being made like in this case (Payne, 2015). For example, there is the potential that a social worker will have strong religious perspectives on certain issues, and this could lead them to impose these values on a service user (Spano and Koenig, 2007). Social workers have a responsibility to engage with and reflect on their own values in a way that avoids this type of oppressive practice, in line with the professional Standards of Proficiency (HCPC, 2017), the Professional Capabilities Framework (BASW, 2018) and the Knowledge and Skills Statement for the profession (DoH, 2015). Furthermore, these documents shape professional values, and these are the values that all professionals must share in their practice, regardless of their professed personal values (Banks, 2014).
In this case, there are cultural, experiential and religious personal values that could impact on the case. For example, if the social worker comes from a culture that values autonomy or independence, they may be more inclined to find that the decision making rights of Gifty to be the most important factors in this case. This could even impact on how they undertake a mental capacity assessment, and research has shown that there is a subjective element to these types of assessments (Mantell and Clarke, 2010). While there is no clear answer to a complex case like this, the most important factor will be to keep Gifty at the centre of all decision, and this is in line with social work values (BASW, 2018), legal requirements (DoH, 2016) and the majority of ethical models and theories that have been explored here (Rossiter, 2011).
In conclusion, this essay has explored the ethical dilemmas in Gifty case in detail. Initially the case study was explored in relation to deontology and utilitarianism. Following on from this, several ethical principles were applied to this case. The SIAC model of principle reasoning was then applied to the case, before finally moving on to look at the impact of professional and personal values. It has been shown clearly that supporting Gifty to make her own decisions is the preferred approach to take, and should provide for the most balanced consideration of the values of autonomy and beneficence. However, this needs to be considered alongside the perspectives of the family members, who should not be marginalised, as well as the legal frameworks. It is important, however, that the presumption of capacity, a key principle under the Mental Capacity Act 2005 section 1, is upheld at all times.
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Gifty case scenario
Gifty’s siblings have contacted the Community Learning Disability team for support and an assessment of need under the Care Act 2015 (S’s 9-13), as they were concerned about Gifty’s change in behaviour since the death of their parents. Their concerns are that, whilst Gifty is happy that Rachel has moved into the family home, she has advised the family she now wishes to make more of her own decisions. These incorporate three areas, health, socialisation and finances.
Gifty has told her siblings that she recently visited the GP accompanied by a support worker at the day centre and completed an Advance Medical Directive indicating she does not want to be resuscitated (DNR) if she is involved in an accident. This followed an incident in which her best friend at the day centre was involved in a Road Traffic Accident and became paralysed, in a wheelchair and without speech; by using a communication board, Gifty’s friend has told Gifty, she would rather not be alive than paralysed and without speech. The family are upset that this occurred without their knowledge.
Gifty also wants to attend the local college, Although Gifty is open to suggestions regarding what course to take, she is adamant she want to meet more people and make more friends.
Additionally, Gifty wants to manage her own benefits and finances just like some of her other friends at the day centre.
Gifty’s family do not agree with Gifty’s decisions. They feel that Gifty lacks capacity (Mental Capacity Act 2005), is too vulnerable to make her own choices and would be put at risk by mixing with other people who could take advantage of her.
KNOWLEDGE AND SKILL STATEMENT (ADULT)
- Statement overview
- Role of the social worker with adults
- Person centred practice
- Mental capacity
- Effective assessments and outcome based support planning
- Direct work with individuals and families
- Supervision, critical reflection and analysis
- Organisational context
- Professional ethics and leadership
- Level of capability: social worker working in an adult setting at the end of their first year in employment.
- The National Framework for the Assessment of Social Workers at the end of their Assessed and Supported Year in Employment
Health & Care Professions Council
- Practise safely and effectively within your scope of practise
- Practise within the legal and ethical boundaries of your profession
- Maintain fitness to practise
- Practise as an autonomous professional exercising their own professional judgement
- Be aware of the impact of culture, equality and diversity on practice
- Practise in a non-discriminatory manner
- Maintain confidentiality
- Communicate effectively
- Work appropriately with others
- Maintain records appropriately
- Reflect and review practice
- To assure the quality of their practice
- Understand the key concepts of the knowledge base relevant to the social work profession
- Be able to draw on appropriate knowledge and skills to inform practice
- To establish and maintain a safe practice environment
Deontology-Duty Based Ethics
Deontology is duty based ethic, developed by a German philosopher Immanuel Kant in 1724(Icheku, 2012). According to Candee and Puka (1984), deontology is grounded on fulfilling ones duty in a situation , respecting the right and autonomy of other and treating others equally. Deontology is a moral philosophy based on human reasoning and founded on the ultimate principle of respect for individual (Bank, 2012). Kant emphasised that people should be treated as being who have ends , that is choice and aspiration not just as object or means to an end (Bank ,2012). Kant believe that the only good action is one that is done from sense of duty and not inclination (Bank, 2012).
Utilitarianism – Consequence Based Theory
• The ethical theory of utilitarianism was developed by Jeremy Bentham and Stuart Mill (Bank, 2012); both men argued that a decision is ethically right if it generate the greatest amount of happiness for the greatest number of people (Icheku, 2012).
The ethical theory is based on, the ability to predict the consequences of action and John Stuart Mill’s (1806-1873) concept of doing the greatest good for the greatest number (Evans & Whittaker 2010:58).
SIAC Model (Icheku 2011)
• S = Summarize facts in the scenario
• I = Identify and examine ethical issues and look at different perspectives
• A = apply relevant values or legal ethical principles
• C = Consider the option which is more effective and has the least consequence
• Icheku, V. (2011) Understanding ethics and ethical decision making: case studies and discussions. Indiana: Xlibris Corporation.
Professional Capabilities Framework – BASW 2018
Banks, S. (2012) Ethics and values in social work. 4th ed. London: Palgrave Macmillan.
Department of Health (2015) Knowledge and skills statement for social workers. London: TSO.
Icheku, V. (2011) Understanding ethics and ethical decision making: case studies and discussions. Indiana: Xlibris Corporation.