Ethical Dilemmas - 4 case studies
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Indiana Wesleyan University, Marion *
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170
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Philosophy
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Apr 3, 2024
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Case Study: When “Best Interests of Client” Harm a Third Party
Abstracted from an unpublished paper by Karen Altenberg Libman, MSW, MBA
This ethical dilemma takes place in a special education treatment center for emotionally disturbed children, ages 6 through 12 years. Part of the treatment involves individual psychotherapy, and Suzanne, aged 7, diagnosed with attachment disorder, has been seeing the caseworker twice weekly since entering the agency program, eight months previously. She lives in a group home with her 3-year-old sister, Cindy, and three other children. The sisters have been
in a group home for two years, and parental rights are in the process of being terminated. Alternatives for long-term placement are being explored. Each child has her own worker, and the
dilemma presented here is discussed from the perspective of Suzanne’s worker. Both Suzanne’s and Cindy’s workers have been asked to make an independent recommendation regarding priorities. Should the sisters be placed together, or should each sibling be planned for separately? Both workers are aware that a recommendation to maintain the
sibling relationship is likely to greatly reduce the adoption chances of the younger sibling: Cindy
is a more desirable candidate if she is alone.
The worker faces a primary responsibility to Suzanne, as well as a responsibility to avoid harm to a relevant third party, Cindy. Suzanne’s best interest is clearly to have the support of her sibling in the face of multiple family losses, plus an improved chance of adoption because her connection with a younger; and therefore more desirable (in terms of adoption), sibling. This “best interest” could, however, harm Cindy, who could find an adoptive home more easily independent of Suzanne.
Case Study: When Living Feels like Dying: Ethical Decision Making with a Depressed Dialysis Patient
Abstracted from an unpublished paper by Mary A. Kardauskas, SHCJ, MSW
The Department of Social Work Services and Utilization Case Management at a major medical center employs two full-time renal dialysis social workers to address the biopsychosocial needs of patients in the inpatient and outpatient dialysis units. Renal social workers proved emotional and concrete support services to patients and families on a long-term basis, addressing patients’ adjustment to illness, right, financial/resource concerns, and social support needs. Renal workers also discuss the issue of advance directives with patients and are occasionally called on to interpret patients’ wishes when surrogates cannot be reached during a medical crisis. Mrs. B., a divorced 38-year-old, was diagnosed with end-stage renal disease (ESRD) and juvenile-onset diabetes. She had been a hemodialysis patient since 1996. Forced to leave her job in 2001 due to rapidly declining health, Mrs. B. was soon after faced with desertion by her husband. Her mother, sensing her need and vulnerability, moved in to provide stability and support to her daughter and 8-year-old grandson. Her mother and her son have turned to religion for support. Over the past year, Mrs. B. has been repeatedly hospitalized, and her intermittent depression has been noted by family and staff. One day during her treatment, she announced to her physician and social worker, “I’m tired of fighting. Living on this machine is worse than dying.” She stated she wanted to terminate treatment. Her mother long ago agreed to act as her son’s guardian, and she knew he would be well cared for. Mrs. B. had an advance directive that named her mother as her decision maker should she be unable to make decisions herself. Mrs. B.’s mother was appalled by her daughter’s request. She stated that her daughter is “too young to die,” and considered her daughter’s request suicidal. She stated that Mrs. B.’s giving up like this would set a bad example of coping for her son. Their church holds that all life is sacred, that taking life is a sin, and the “God never gives you more than you can bear.” She insisted that the hospital deny Mrs.B.’s request because her depression rendered her incompetent to make medical decisions. She invoked her power as the decision maker named in her daughter’s advance directive. Case Study: In the Client’s Interest: Self Determination and Mental Disability
Abstracted from an unpublished paper by Jose Carlos Vera, MSW
An urban, community-based organization provides services specifically targeted toward an immigrant minority population. These services include case management, team parenting, alcohol and drug treatment, advocacy, and housing. Another client of the agency refers Luisa for services, and she is assigned to this caseworker. She is 18 years old, homeless, and mentally disabled. Although her family resides in
a nearby county, she refuses contact with them, preferring to live independently on the city streets. Luisa is placed in a home, but she runs away, presumably returning to the unsafe neighborhood where she had been living. The worker loses contact with her.
A week later, through the client who originally referred her, the worker learns that Luisa has been sexually and physically abused. The worker is concerned about her safety, fearing further rape, murder, and violence if this young woman continues to live on the streets. He feels that Luisa does not have the mental capacity to look out for herself and take even elementary precautions to prevent harm.
When he contacts her on the street, Luisa is adamant. She desires to remain in the neighborhood, which she has come to know. She does not desire agency involvement, housing, or other services. All that she asks is that she be left alone to live as she wishes. She is not harming or disturbing anyone and wishes to live as she chooses. The worker respects Luisa’s right of self-determination--her right to determine what is best for her. Her mental status in terms of her disability has not been legally determined, so the presumption must be that she is competent. However, her mental limitations are immediately apparent, and Luisa is at risk of harm if she continues to live on the street. It would seem to be in her best interest to offer her protection from harm. Case Study: Determining an Acceptable Risk for a Vulnerable Client: Where Protection Impacts Self-Determination
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Abstracted from an unpublished paper by Mira Underwood, MSW
A large urban county hospital provides ambulatory care and hospital services to the surrounding area through it emergency department, and three intensive care units provide extensive Level 1 Trauma services to its critical care patients.
Marco Madrera, a 20-year-old male who is in a wheelchair due to paraplegia from a gunshot accident at 16, underwent a hip disarticulation-a surgical removal of the entire lower limb at the hip level-due to large necrotizing fasciitis on his buttocks and severe sepsis. He remained in the ICU for 3 weeks, and was then transferred to a step-down ward where he received daily wound care to ensure that the infection in his body finally subsided. During the second month of his hospital stay, Marco has started refusing lab work and treatments, saying that he “just wants to get out.” After many life-saving medical procedures, medications, and two months of acute care, he is ready for discharge, with temporary wound care services provided by an out-of-hospital health provider. The patient’s medical team, including the social worker, are recommending a temporary stay at a skilled nursing facility (SNF) for wound care, physical rehabilitation, and assistance in adjusting to his amputation before returning to the community. The SNF would then connect Marco to an intensive case management service, available only to SNF residents, for community follow-up after discharge, to assist him in locating accessible and adaptable housing to maximize
independence, and to provide on-site support services. Marco is adamant in refusing to go to another “medical facility,” and demands to be discharged home, although he has expressed some interest in finding new housing. Currently, Marco lives in a large public housing complex, sharing an apartment with three other young men, and does not have a room for himself. He has “only partial use” of the bathroom, as it is not wheelchair accessible. Additionally, the apartment is on the top of a steep hill: He must climb stairs to reach it, and he relies on people walking by to carry him up. He shops at a local corner store for food and drink, and smokes marijuana “whenever I feel like it.” As Marco is also malnourished, the social worker makes a report to APS due to self-neglect with physical dependency.
Marco’s six siblings, his grandmother, and his mother currently live in the area. When Marco was 16, while his mother was in prison, he and his father were shot while driving in a car.
Upon discharge from this first hospitalization as a paraplegic, Marco lived first with his grandmother and later with a sister. Currently, the quality of family relationships is uncertain, and there is no possibility of Marco’s living with family members upon discharge. There is no contact with his father. Marco’s healthcare team, which includes the social worker, believe that if he returns to his pre-admission living conditions, he will continue to make poor decisions, and that his physical condition, given his current additional difficulties, will deteriorate. This would create additional health issues, as well as increase the possibilities of death resulting from neglect. While the social worker wants to respect Marco’s right to self-determination, which he expresses by saying that he “knows what is best” for him, she believes that discharge to a
temporary SNF could connect him to the intensive management and appropriate and safe housing. His self-determined plan to return to his pre-hospitalization circumstances have made Marco’s team question his competence to make a plan for himself, leaving the social worker to question her responsibility to protect him from harm. No competency examination has been administered, and it is highly unlikely that Marco would accede to one.