5 Discussions - w2

Self-Determination and Confidentiality: The Ambiguous Nature of Decision-Making

in Social Work Practice

Catherine Saxon George A. Jacinto

Sophia F. Dziegielewski

ABSTRACT. This article seeks to further clarify the ambiguous nature of two of social work’s most important values: self-determination and confidentiality. Previous research indicates that many ethical decisions in social work practice are difficult to make; and, many times decisions are made based on the worker’s values and experiences rather than on written ethics, laws, and agency policy. To explore this concept further, an open-ended survey instrument was distributed to 82 social work stu- dents after completing the required practice classes. The participants were asked whether they would break confidentiality based on a specific vignette and describe what decision was made and why. Results indi- cated that degree level (MSW versus BSW) proved to be a significant factor related to whether and/or why the respondent would break confi- dentiality. In addition, students with more paid work experience were more likely to question the issue of confidentiality and were more likely to break it. Two issues reflected in the decision-making process involved ensuring client safety and self-determination. In conclusion, this article

Catherine Saxon, MSW, is affiliated with and George A. Jacinto, LCSW, is Instruc- tor, School of Social Work, University of Central Florida, Orlando, FL. Sophia F. Dziegielewski, PhD, LCSW, is Professor and Director, School of Social Work, Univer- sity of Cincinnati, Cincinnati, OH.

Address correspondence to: Dr. Sophia F. Dziegielewski, PhD, LCSW, Professor and Director, School of Social Work, 4130 One Edwards Center, P.O. Box 210108. University of Cincinnati, Cincinnati, OH 45221-0108 (E-mail: Sophia.Dziegielewski@ uc.edu).

Journal of Human Behavior in the Social Environment, Vol. 13(4) 2006 Available online at http://www.haworthpress.com/web/JHBSE

© 2006 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J137v13n04_04 55

explores possible reasons for breaching confidentiality and pitfalls that can occur for all professionals in making these types of decisions. Fur- thermore, it explores the ambiguous nature of problem solving in this area, and suggests ways that social workers can improve their decision- making skills. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@ haworthpress.com> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Confidentiality and social work, self-determination, ethics and social work practice, ethics and confidentiality

Many American’s highly value a person’s right to self-determination and privacy. In fact, “every person has a right to determine for himself [or herself] when, how, and to what extent he [or she] wants to share (or have shared) information about himself [or herself] with others” (Loewenberg & Dolgoff, 1996, p. 76). To maintain a client’s privacy or confidentiality requires that information learned regarding the client should not be openly disclosed (Loewenberg & Dolgoff, 1996; Loe- wenberg, Dolgoff, & Harrington, 2000). Overall, confidentiality can be a complicated process, since, there are certain circumstances in which breaching it is sanctioned by both state laws and professional standards. For example, confidentiality may be breached with or without the cli- ent’s consent in order to report instances of neglect and abuse. Other cir- cumstances include times when a client may be a danger to self or others, or when other compelling reasons exist, such as imminent harm to a client or if the law requires disclosure. Most professionals agree that there are situations in which breach of confidentiality is certainly justifi- able and expected (Dunlap & Strom-Gottfried, 1998; Gothard, 1995). Yet, the principles that surround maintaining confidentiality are impor- tant for gaining client trust and support from the client (Edwards, 1999). Therefore, the purpose of this article is to preview this complex issue and to examine the variability that can surround making such ethical de- cisions.

Throughout the years, maintaining ethical practice (including confi- dentiality) has been at the forefront in the field of social work. So impor- tant, in fact, that in 1996 the National Association of Social Workers (NASW) modified the existing version of the Code of Ethics. This was the first substantial revision in almost 20 years and only the third time

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the Social Work Code of Ethics had received major revisions through- out the history of NASW. These changes “significantly expanded ethi- cal guidelines and standards for social work practice” (Reamer, 1998, p. 492). The importance and complexity of privacy and confidentiality is evident since no less than 18 separate paragraphs of the Code of Eth- ics are devoted to these issues (Dickson, 1998).

The 1996 NASW Code of Ethics provides lengthy standards with re- gard to privacy and confidentiality, clearly stating that social workers should “respect clients’ right to privacy . . . and . . . should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons” (NASW Code of Ethics, 1996, Standard 1-1.07, p. 10). A social worker should make ev- ery attempt possible to adhere to the rules of confidentiality promoting self-determination, but should also be aware that there are some situa- tions that should not be kept confidential (Kirst-Ashman & Hull, 1993). In most cases where maintaining confidentiality is an issue, consider- ation is needed in order to determine what is “sufficiently compelling to warrant a breach of confidentiality” (Kopels & Kogle, 1994, p. 2).

As with other decisions made in social work practice, ethical deci- sions are not usually simple, right or wrong choices made without a great deal of thought. Instead, they generally involve choosing between two undesirable actions and neither choice may appear to be the correct one, yet some considerations will outweigh others. For example, deci- sions must be made if maintaining the client’s right to self-determina- tion may actually cause him or her harm (Strom-Gottfried & Dunlap, 1999). In social work practice, ethical decisions often must be made quickly but with sufficient thought and attention to assure the right de- cision is made (Levy, 1993; Loewenberg, Dolgoff, & Harrington, 2000). Furthermore, although helpful as a guideline, the NASW Code of Ethics does not provide specific direction when professional values clash (Reamer, 1995).

The declared purposes for the Code of Ethics are to espouse ethical conduct and to control ethical violations by establishing guidelines of professional behavior (Berliner, 1989; Reamer, 1995). “[The] . . . code of ethics cannot resolve all ethical issues or disputes or capture the rich- ness and complexity involved in striving to make responsible choices within a moral community” (NASW Code of Ethics, 1996, p. 4). In- stead, a code of ethics describes values, principles, and standards to which social workers “aspire and by which their actions can be judged” (NASW Code of Ethics, 1996, p. 4). Although there have been numer- ous books written regarding the importance of ensuring ethics and val-

Saxon, Jacinto, and Dziegielewski 57

ues, and specifically addressing the issue of self-determination and client confidentiality, few evidence-based studies specifically address this issue. The purpose of this study is to explore whether or not social work students would break confidentiality based on a specific vignette and their reasons why.

PREVIOUS LITERATURE

After an exhaustive search, it was discovered that two studies in the area of confidentiality were found that addressed issues concerning eth- ical dilemmas that arise in the field of social work with both individuals and groups. A study by Holland and Kilpatrick (1991), conducted in At- lanta and the surrounding area in 1989, attempted to identify “dimen- sions of ethical judgment” used by 27 social workers (p. 138). All of the social workers held Masters degrees in social work and each had a vary- ing amount of experience in the field. Most of the social workers were female and all were directly involved with clients. Holland and Kilpat- rick (1991) contend that in order to appropriately consider ethical di- lemmas social workers should be aware of, and not discount, their own as well as their client’s current circumstances. When ethical situations arise these issues are never simple and interpretation often requires a “thoughtful content analysis of the participants’ values and commit- ments” (Holland & Kilpatrick, 1991, p. 138).

The study focused on analyzing various ethical issues that social workers are exposed to regularly in their duties. In addition to defining, addressing, and resolving the issues, the participants’ background and associations were analyzed, as well as any professional happenings that might have impacted the respondent. An interview format was used to explore how practicing social workers comprehend and handle ethical issues and their responses were examined in an attempt to recognize “common themes and differences regarding these issues” (Holland & Kilpatrick, 1991, p. 139).

The results of this study identified three dimensions that seemed to be fundamental to the ways that social workers managed ethical dilemmas. First, decisions were often based on a continuum ranging from “an em- phasis on means to an emphasis on ends” (Holland & Kilpatrick, 1991, p. 139). Reasons given for decisions made ranged from acknowledging laws and procedures to focusing on gaining positive outcomes for cli- ents. In the second dimension, social workers made decisions based on interpersonal orientations that ranged from emphasizing client auton-

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omy and freedom to stressing the importance of mutuality. For exam- ple, many respondents emphasized client self-determination over client safety, while others justified denial of client self-determination in order to protect the client from hurting him or herself. In the third dimension, authority for ethical decisions was explored. In this area, responses var- ied from “reliance on internal or individual judgment to compliance with external rules, norms, or laws” (p. 140). Many respondents based their decisions on personal self-direction rather than agency policy, and other respondents were more likely to follow the policies and laws.

Holland and Kilpatrick (1991) concluded that decisions made re- garding ethical issues are most likely affected by prior experience, de- gree of professional, developmental and situational factors that include the immediate organizational or professional context, the characteris- tics of their work roles, and the overall organizational culture. In clos- ing, the authors observed that of the 27 respondents participating in their study, not one participant referenced the NASW Code of Ethics as a resource in helping make an ethical decision (Holland & Kilpatrick, 1991).

In a second study, Dolgoff and Skolnik (1996) investigated how 147 social workers make ethical decisions in the group setting. A survey in- strument was used which consisted of background information and seven vignettes that all involved competing ethical issues. Each vignette was followed by an open-ended question, allowing for an explanation of the action needed to resolve the dilemma. The seven vignettes con- sisted of ethical dilemmas involving group self-determination, primary responsibility to client, confidentiality, self-determination, informed consent, and authenticity. Also included was a list of sources that the participant would use to assist with the decision-making. The choices included practice wisdom, Code of Ethics, another professional code, particular philosopher or religious teaching, book or journal article, or other sources.

These authors concluded that the primary method used by social workers in the group setting for making ethical decisions was practice wisdom, which was highly influenced by contextual elements and per- sonal values. In addition, the majority of the respondents sought com- promise solutions rather than a specific yes or no type of answer. Similar to Holland and Kilpatrick (1991), Dolgoff and Skolnik (1996) showed limited use of the NASW Code of Ethics to assist with making ethical decisions and additional instruction on the Code was suggested to better prepare students for ethical decision-making.

Saxon, Jacinto, and Dziegielewski 59

Although the two studies mentioned above do not specifically ad- dress confidentiality and self-determination, these previous studies do address ethical dilemmas in social work practice and how decisions are made. In the present study, social work students were asked whether or not they would break confidentiality and how they viewed client self- determination when presented with a situation where it was believed that a client was unable to meet his or her own needs and care for him or herself.

METHODOLOGY

Sample

Eighty social work students at a large Southeastern university were presented with a case scenario. The students had varying levels of edu- cation ranging from at the BSW and MSW level, with all participants reporting that they had taken at least one or more social work practice class. Five (6%) of the students were first-year BSW students; 21 (26%) were second year BSW students; 12 (15%) were first-year MSW stu- dents, and the majority were (n = 44 or 54%) second-year MSW stu- dents. In terms of gender, the majority (n = 64 or 78%) of the sample were female, and the remainder of the respondents (n = 18 or 22%) were male. Participant ages ranged from 20 to 59 years, with the majority 57 or 70 percent between 20 and 29 years of age; 12 or 15% of the respon- dents were between the ages of 30 and 39; eight or 10 percent were be- tween 40 and 49 years of age, and five or six percent were 50 to 59 years old. Only 77 of the 80 respondents answered the question regarding race with the majority of the sample (n = 61 or 81%) being Caucasian, eight (10%) were Hispanic, four (5%) being African-American, three (4%) as Asian, one (1%) as Hispanic/Asian. Additionally, the number of years of paid social work experience differed among the participants with 79 (of the 80 respondents) answering the question and the majority (n = 47 or 59%) having no paid social work experience. Three (4%) of the re- spondents reported less than one year of experience, and 29 (37%) had more than one year.

Case Vignette

The survey instrument consisted of two parts: demographic informa- tion and the case presentation. Demographic information included the

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participant’s gender, age, race, education level (years of social work ed- ucation), and paid social work experience. The case vignette (see Table 1 for copy of vignette) was presented and each participant was asked to read it. Based on the information contained in the vignette, the respon- dent was asked to answer with a “yes” or “no” as to whether or not he or she would break confidentiality. It was made clear in the vignette that the social worker was concerned that the client would be unable to meet his own activities of daily living and refused the social worker’s at- tempts to arrange to get him help. An open-ended response section al- lowed the respondent to explain why he or she chose yes or no in response to the vignette. To ensure face validity, the initial case vignette was pilot tested with four social workers that were asked to complete and offer suggestions for improvement. Minor changes were made based on these suggestions. Suggested changes included: gathering in- formation regarding the academic level of the social work student, the number of years of paid social work experience, and more space for re- spondents to explain why they chose yes or no to the vignette.

Procedure

One hundred copies of the vignette were made and distributed in the Spring 2001 semester to 100 social work students who were required to attend a school-sponsored job fair. Of the 100 surveys distributed, 80

Saxon, Jacinto, and Dziegielewski 61

TABLE 1. Vignette

Mr. P is a 78-year-old man who has just been discharged from the hospital. He lives in an apartment by himself. His brother lives in his own apartment in the same building. You are a hospice social worker. It is Friday at 3:30 p.m. and you are visiting with Mr. P to complete an initial psychosocial assessment. During your assessment you conclude that it is not safe for Mr. P to be by himself because he is unable to meet his own self-care needs. Since he ap- pears very weak, it is difficult for him to get out of bed on his own and he has no caregiver. You discuss your concerns with Mr. P. Mr. P appears alert and oriented to person, place, and time, and strongly declines any assistance. He states that he is not agreeable to move to an assisted living facility or nursing home. Even if Mr. P agreed to some type of outside assis- tance, it would be impossible to have services in place in the next two days. You suggest to Mr. P that maybe his brother could check in with him over the weekend, but Mr. P insists that he will be fine by himself, and requests that you not inform his brother. His sister, who lives out of state, will not be available to help for several days. Would you break confidentiality and ask his brother to check in on Mr. P over the weekend?

Yes______ No______

Please explain your answer.

were completed and returned, equating to a response rate of 80 percent. Once the completed surveys were collected, the data were analyzed. For the open-ended responses (qualitative responses), it was necessary to convert the narrative responses to categorical data that could be ana- lyzed further. Once coded, each narrative response was examined and then categorized accordingly.

RESULTS

The vignette required that 80 entry-level social workers complete the survey and answer with either a “yes” or “no” response. Of the 80 stu- dent social workers (55 MSWs and 25 BSWs), 37 students (or 46.3%) stated that they would break confidentiality. The remaining 43 (53.7%) re- spondents stated that they would not break confidentiality (see Table 2). This response was broken down further by education level, where the results showed that 36 percent (n = 20) of the MSW students would not break confidentiality while the remaining 64 percent (n = 35), however, would do so. For the BSW students, the results showed that 32 percent (n = 8) would not break confidentiality while 68 percent (n = 17) would.

The narrative section of the survey allowed the participants to state why they would or would not break confidentiality. The responses were

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TABLE 2. Results of the Vignette

Overall results of Vignette N = 80

Variable Yes No

Frequency 37 43

Percentage 46.3% 53.7%

Results of Vignette Based on BSW Students N = 25

Variable Yes No

Frequency 17 8

Percentage 68% 32%

Results of Vignette Based on MSW Students N = 55

Variable Yes No

Frequency 20 35

Percentage 36% 64%

categorized as follows: safety, confidentiality was not broken, social work ethics, start where the client is and others (see Table 3). The re- sults showed that of the 80 students responding to the vignette, only 77 chose to explain their answer. As stated above, 37 students chose to break confidentiality, and, of those, 35 explained their answers. Forty- three students chose to not break confidentiality, and, of those, 42 ex- plained their answers (see Table 3).

Of the 77 participants that explained their answers, there was a statisti- cally significant relationship between students choosing whether or not to break confidentiality and their explanations (chi-square = 76, df = 6, p = .001). The majority of respondents (n = 33 or 43%) stated that their rea- son for breaking confidentiality would be for client safety. One person (1%) stated that confidentiality would not be broken and 14 (18%) chose “other.” In addition, 26 students (34%) stated social work ethics and en- suring client self-determination, and three of the respondents (4%) stated that they would “start where the client was,” and, since it was not clear

Saxon, Jacinto, and Dziegielewski 63

TABLE 3. Analysis of Responses

Reasons for Answer Based on Answering “Yes” *(N = 35)

Variable Client Safety Confidentiality Was Not Broken Other

Frequency 33 1 1

Percentage 94% 3% 3%

*Two individuals said yes but did not explain their answers.

Reasons for Answers Based on Answering “No” *(N = 42)

Variable Social Work Ethics/Self-determination Start Where Client Is Other

Frequency 26 3

13

Percentage 61.9% 7.1% 31%

*One individual said no but did not explain the reason.

Overall Sample Reasons Given *(N = 77)

Variable Client Safety Confidentiality Was Not Broken Social Work Ethics/Self-determination Start Where Client Is Other

Frequency 33 1

26 3

14

Percentage 42.9% 1.2%

33.8% 3.9%

18.2%

*Of the 80 individuals in the sample, 3 participants did not give detailed reason for their decisions. Therefore, subsequent analysis of the reasons was calculated on an N = 77.

whether this meant enhancing self-determination, it was left as a separate category.

When explanations as to why one would (or would not) break confi- dentiality based on the vignette were analyzed separately using a “yes” or “no” response, the results varied. The overwhelming majority of stu- dents (n = 33 or 94%) who responded “yes” to the vignette and ex- plained their answer, stated that their reason for breaking confidentiality was due to client safety. One student stated that telling the client’s brother about the situation would not be breaking confidentiality, and the remaining student’s (n = 1 or 3%) answer was coded as “other.”

There were 43 respondents who answered “no” to the vignette and, of those, 42 explained why. Twelve respondents (29%) stated that based on social work ethics such as self-determination was the reason they said “no” and 14 students (33%) indicated specifically that self-deter- mination was the only reason. Three (7%) of the respondents gave the reason for not violating confidentiality as “they needed to start where the client was” and 13 participants (31%) stated other individual or non-specific reasons.

After analyzing the data for correlations between the respondent’s gender and age and whether the answer to the vignette was “yes” or “no,” no significant difference was found. However, a significant dif- ference was noted between the level of social work education and whether or not they would break confidentiality (Chi-square = 10.29, df = 3, p = . 01). In this regard, the students in the second year of either the BSW or MSW program were more likely to question the issue of confidentiality and break confidentiality in regard to this case. A signifi- cant difference was also noted with regard to the number of years of paid experience a student had and whether or not they would break con- fidentiality (Chi-Square = 17.68, df = 8, p = .02). Students with more experience were more likely to question the issue of confidentiality and were more likely to break it.

DISCUSSION

This presentation of a potential problem often confronted by social workers exemplifies the variation in response patterns that can occur among beginning professionals. Regardless of the level of education, graduating social workers read the case and used their individual ethi- cal decision-making methods to develop their answers. Although the majority of social work students agreed that they would not break con-

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fidentiality (n = 43 or 53%), a significant number stated that they would (n = 37 or 47%), especially if it meant ensuring the safety of the client. Given that these respondents were almost evenly divided about how best to respond to this situation, it appears that for these begin- ning social work professionals, confidentiality was not a “yes or no” issue. When confronted with certain situations in the field of social work, deciding what constitutes client self-determination, ensuring client safety and what should remain confidential can be difficult and can present an ongoing struggle for even the seasoned social work stu- dent.

The findings regarding the reasons why social work students chose to either break or not break confidentiality were varied. Of the 35 students who chose to break confidentiality and explained why, 95 percent (n = 33)–an overwhelming majority–stated that ensuring “client safety” was the reason. Based on the vignette, they decided that the client was in danger and a breach of confidentiality that could involve a report to the appropriate agency to ensure client safety and protection would be ap- propriate.

On the other hand, those who would not break confidentiality offered various reasons, and the responses heavily related to ethical principles such as ensuring client self-determination. Twenty participants be- lieved that client self-determination was more important than breaking client confidentiality. Three participants stated that it was important to start “where the client is,” and therefore respect client self-determina- tion. The remainder of the participants in this area–20 social work stu- dents–would not break confidentiality, as they felt this was critical to the helping relationship and other ways of helping the client were sug- gested.

According to these respondents, social work values and ethics can be perceived as ambiguous within certain situations, especially those in- volving conflicts between client self-determination versus client safety. While self-determination and safety were concerns shared by some re- spondents as a reason for maintaining confidentiality, there were no fol- low-up questions that analyzed these concerns in depth. Therefore, further research that addresses the reasoning of practitioners in explor- ing the multifaceted issues associated with client safety and self-deter- mination would contribute important insights to this discussion. The ambiguous nature of this type of work is further complicated by deci- sions in regard to confidentiality and ethical practice. Therefore, the de- cisions social workers can confront on a daily basis in practice are not necessarily simple and straightforward (Loewenberg, Dolgoff, & Har-

Saxon, Jacinto, and Dziegielewski 65

rington, 2000). This study is similar to findings by Holland and Kilpat- rick (1991) and Dolgoff and Skolnik (1996), concluding that many decisions social workers make are primarily based on their own per- sonal values and life experiences. Similar to previous studies, social workers in this study did not appear to be truly “objective” and “non-judgmental” and in reviewing the open-ended comments, it was common for the explanations of the decisions made to be directed, at least in part, by personal experiences and values. This makes being aware of one’s values and experiences and how it may influence ethical decision-making crucial.

Education in the field of social work at the BSW and MSW level ap- peared to be related to decision-making. Furthermore, it appeared that the level of education (either BSW or MSW) impacted whether or not a social worker would be more inclined to question the issue of confiden- tiality. Significant differences between education level and breaking confidentiality differentiated first-year and second-year BSW and MSW students. In looking at the qualitative responses, the second-year BSW students and the second-year MSW students were more likely to question the issue of confidentiality and break confidentiality when compared to the first-year students of both the Bachelors and Masters levels. Although the exact reason for this difference cannot be deter- mined, one possible reason is the increased exposure to ethical dilem- mas in the classroom and field placement experiences. Many times instructors, especially in the second year of the BSW or MSW program, present vignettes related to ethical dilemmas that may also be found in the field setting. These dilemmas are generally discussed at length and this allows for the students to hear varying opinions while problem solving within the group setting. This can allow additional opportunity for students to experience social work practice as it really is, and not simply review how it has been portrayed in textbooks.

It is important to note that there was little difference between the MSW and BSW students’ responses to the survey. In this study, 36 per- cent of the MSW students and 32 percent of the BSW students upheld confidentiality. While 64 percent of MSW students and 68 percent of BSW students stated they would breach confidentiality. Both BSW and MSW students reported they would uphold confidentiality approxi- mately one third of the time. It is important to note that by a significant majority BSW and MSW students reported they would breach confi- dentiality.

A final item worthy to note, based on subject feedback, was that dur- ing the administration of the survey many Masters-level social work

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students voiced difficulty in trying to answer the vignette. Masters-level students voiced the need to analyze the vignette and would try to ask the researcher questions, requesting clarification on various aspects of the case. It appeared difficult for them to simply read the vignette, answer the question and give an explanation. One of the explanations for this could be the level of critical thinking taught at the Masters level. In con- trast, almost all of the Bachelors-level social work students seemed to have no difficulty accepting the survey at face value and completing it.

If this study were to be reproduced there are several considerations that would be suggested. First, the sample was limited to only one school of social work and it would be interesting to see how this school compared with others across the United States. Second, this survey did not ask respondents to say what sources they utilized to approach the ethical situation. In analyzing the data, it would have been more com- plete had that information been available to compare to the previous studies. This data would possibly have offered reasons as to why educa- tion level seemed to be significant in choosing “yes” or “no” to the spe- cific vignette. It would also be interesting to compare these student responses with other students in the helping professions. Similar to pre- vious studies, the social workers in this study did not mention the Code of Ethics in the decision-making process, but did mention ethical princi- ples. It would be interesting to see if these ethical principles were de- rived directly from the NASW Code of Ethics.

When looking specifically at issues in client confidentiality and self- determination, managed behavioral health care has clearly impacted the practitioner-client relationship (Dziegielewski, 2004, 2002; Loewen- berg, Dolgoff, & Harrington, 2000). At times, these contractors require that information be provided that may compromise professional stan- dards of confidentiality. These student social workers may be placed in a dilemma regarding the NASW Code of Ethics and the contradiction encountered with information disclosure procedures of managed care organizations (Loewenberg, Dolgoff, & Harrington, 2000; Strom- Gottfried, Kimberly, & Corcoran, 2000). In addition, technological ad- vances utilized in current practice stress the reliance of the industry on utilization reviews through increased use of electronic data collection and storage which has put the confidentiality of client information at risk (Strom-Gottfried, Kimberly, & Corcoran, 2000). Regardless of the exact impact of the managed care practice principles and the technolog- ical advances often employed, the professional decisions made by pro- fessional social workers are never easy and straightforward. This can create a new dimension that needs to be factored into an already ambig-

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uous decision-making process where social workers cannot help but be influenced by either organizational or managerial expectations. These requirements add a number of complex elements to decisions about re- leasing confidential information regarding clients.

In this study, many social workers decided to break client confidenti- ality and report the situation to the appropriate office of adult protective services. While other participants did not see the situation described in the vignette as life-threatening therefore it did not need to be reported. What complicated this analysis further was how social workers inter- preted the legal system, and the laws that govern practice. This lack of continuity in itself can make social workers ambivalent about the appro- priate response in extreme cases. Not only is there ambivalence and confusion among practitioners, courts across the country have also had difficulty in regard to decisions about the duty to warn. For example, the Tarasoff case (1976) has lead to differing interpretations of the relation- ship of a therapist and client. This confusion becomes obvious when the Florida court, in the case of Boynton v. Burglass (1991), differed from the California court in the Tarasoff (1976) decision. In this case, a psy- chiatrist named Dr. Burglass had been treating Lawrence Blaylock as an outpatient. Blaylock shot and killed Wayne Boynton, Jr. and Boynton’s parents sued Dr. Burglass because he had failed to warn the victim that Blaylock had threatened to seriously harm him. The Court’s analysis was the first of its kind in Florida and stated that mental health profes- sionals in Florida do not have a duty to warn the potential victim of threat posed by a voluntary client. The district court based its decision on three reasons: (a) the mental health professional does not have the ability or right to control a client, and cannot be held liable for what a client does; (b) because the inner workings of the human mind is essen- tially mysterious, mental health professionals are under no legal duty to foretell when a client will injure another person; and (c) the court requir- ing duty to warn would negatively affect the treatment relationship (Behnke, Winick, & Perez, 2000).

Furthermore, from an organizational perspective, in Green v. Ross (1997) the Florida court interpreted the language of the law to allow practitioners to warn, but does not require disclosure of confidential in- formation to third party or the police of a serious threat by a client. As social workers struggle whether to honor “duty to warn” by preventing danger to self or others thereby ensuring safety, confusion remains as court interpretations around the country differ. It is not surprising that social workers in this study and otherwise would vary their approaches to maintaining confidentiality since the legal system remains unclear re-

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garding disclosure of confidential information (Behnke, Winick, & Perez, 2000).

Managerial, technological and legal pressures, accompanied with the ambiguous nature that surrounds when to support self-determination and not reveal confidential information, may contribute to these begin- ning professionals’ difficulty in making the most appropriate decision. Beginning social work professionals may start to believe that regardless of what they do, information that is disclosed is no longer confidential and protected. The level of seriousness with regard to the breach of con- fidentiality in this case might be considered low in comparison to a case where a social worker is laboring under the decision to warn a potential victim of a client’s intent to inflict harm; although, it requires use of the principles involved with more complex cases. Furthermore, social workers need to clearly discuss with clients the bounds of confidential- ity and when the social worker is obligated to break it.

To date, there are no simple answers or clear guidelines for the deci- sion to violate client self-determination or confidentiality. This made the decision a difficult one for social workers that analyzed this case vi- gnette and decided to break client confidentiality by asking the brother to check on him. Maintaining client self-determination and autonomy is an issue that must be considered and compared with the danger clients present to themselves by being unable to meet their own care needs without assistance (Corey, Corey, & Callanan, 1998). As can be seen in the splitting of this sample, decisions like this, although encountered by social workers on a daily basis, are never easy. Nor should they be. Each individual and situation is unique and deserves careful ethical deci- sion-making.

In closing, the vignette used in this study could be adapted as a teach- ing tool in which students would reflect on the following questions:

1. What are the ethical issues presented in this case? 2. How does the principle of self-determination apply in this case? 3. List the aspects of confidentiality involved in this case. 4. Mr. P appears to be at-risk for unintended self-harm. Should he be

assessed for involuntary placement since it appears he cannot care for himself?

5. Explain the ethical problems of confidentiality and self-determi- nation inherent in contacting Mr. P’s brother against his wishes.

In addition to theses questions, the following assignment can be used which provides fertile ground for discussion by social work educators

Saxon, Jacinto, and Dziegielewski 69

of the reasoning patterns used by the student to problem solve ethical decision-making. For each of the following courses of action list a ratio- nale for selecting and rejecting the action in Mr. P’s case.

1. The social worker decides to respect the principles of confidenti- ality and self-determination and do nothing.

2. The social worker assesses for involuntary placement due to Mr. P’s impaired judgment about his current life circumstances.

3. The social worker decides that the least restrictive route is to con- tact Mr. P’s brother who will check in on him during the weekend.

4. The social worker explains to Mr. P. that you are not convinced he can attend to his needs and present him with the options based on your assessment.

5. Based on the above options or others, what course of action would you favor? (Be sure to give your own rationale for the decision.)

CONCLUSION

As stated earlier, social workers regularly make difficult decisions that, in many cases, have no “right” or “wrong” answers. This study supports the contention that important social work values such as client self-determination, ensuring client safety and maintaining confidential- ity can constitute an ambiguous process, creating a disjunction between values and process where there may not be a “correct” answer. This study reminds educators of the importance of including analysis of per- sonal values and life experiences as well as social work ethics, laws or agency policies (Loewenberg, Dolgoff, & Harrington, 2000). If schools of social work spend little time on ethical content and decision-making, social work students may be lead to believe that learning about social work ethics is their responsibility. Lack of information and training in this area can create a disservice to students that will have ramifications in terms of decisions and resulting consequences.

The responses to the survey suggest a need for guidelines that social work educators can use in courses across the social work curriculum. The development of ethical decision-making skills related to practice examples is critical for successful practice. The social work educator may want to use a simple framework to process ethical issues using the following or similar steps. First, when working with case examples, stu- dents must first decide what ethical dilemma or dilemmas are present. Second, check the NASW Code of Ethics to determine what procedure

70 JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT

is recommended. Third, review research literature to determine the best practices related to the issue. Fourth, list the possible ethical responses to the ethical dilemma. Fifth, order the responses based on their ethical soundness based on the NASW Code of Ethics, best practices informa- tion and precedents set in your current work environment. Sixth, project the likely outcome based on each of the responses that appear appropri- ate. Seventh, when unsure about the choices, consult with another social worker about direction. When possible, consult with a supervisor about the case. Finally, present the option(s) you have chosen to the client.

Barker (2003, p. 387) states “self-determination is an ethical princi- ple in social work that recognizes the rights and needs of the clients to be free to make their own choices and decisions.” Self-determination raises concerns about the client’s participation in case decisions. What is the capacity of the client to make informed decisions? When present- ing options to clients it is important to understand the client’s level of functioning as well as developmental level. The social worker provides the client with choices discusses resources and explores consequences of various choices (Barker, 1999).

There needs to be more discussion regarding the NASW Code of Eth- ics, focusing on how the code can serve as universal resource for poten- tial ethical dilemmas faced by practitioners. The dearth of empirical literature regarding the issue of confidentiality suggests more research is needed. Since practice decisions are rarely based on dichotomous principles (yes or no answers), future research needs to expand this con- cept and involve a number of choices over a continuum spanning from least to most desirable. The continuum fits well with the principle of self-determination because most individuals prefer selection from two or more choices when solving complex problems. In this turbulent envi- ronment, client issues are often complex and multidimensional, and the greater knowledge and skill a practitioner is able to acquire in ethical decision-making the better.

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