MH-15

Lesson 15: Ethical Considerations

Readings:

Social Work Code of Ethics http://www.socialworkers.org/pubs/code/code.asp Psychologist Code of Ethics http://www.apa.org/ethics/code/index.aspx

Public Health Code of Ethics, “Principles of the Ethical Practice of Public Health”

http://www.apha.org/~/media/files/pdf/about/ethics_brochure.ashx

Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html Family Education Rights and Privacy Act (FERPA) General Guidance http://ed.gov/policy/gen/guid/fpco/ferpa/students.html

Commentary

The subject of ethics in mental health is interesting and can be examined in many ways. We can examine it from the requirements of a particular discipline (public health, social work, etc.), from a legal perspective, from the treatment aspect, from an economics point of view and so on.

As a first step to studying the ethical treatment of persons with mental illness, we suggest that you review Lesson 4 on Mental Health Policy and the Law. In that lesson, we saw how the treatment of persons with mental illness has become more humane, stemming from the Civil Rights movement and several important legal cases, including Schloendorff v. Society of New York Hospital (1914), Brown v. Board of Education (1954), Pate v. Robinson (1966), Ford v. Wainwright (1986) Addington v. Texas (1979), and Olmstead v. L.C. (1999). From these important legal cases stemmed protections such as the right to treatment, right to a competency trail, awareness of the risks and harms of treatment, required informed consent to receive treatment, the right to a humane treatment plan and the right to participate in individual treatment planning. These legal cases have served as the foundation of the ethical treatment of individuals with mental illness.

In this lesson we will explore ethical codes. In addition to the above mentioned legal cases, ethical codes have been developed in the psychology, social work and public health fields to preserve the rights of all persons who receive treatment, including those with physical and/or mental illness. We will examine various aspects of professional ethics, some discipline codes and the Health Insurance Portability and Accountability Act (HIPAA), one of the federal acts that further protect individual and privacy rights. The Family Education Rights and Privacy Act (FERPA) is another act that protects the privacy of students’ educational records and has some implication here.

Social Work Code of Ethics

The Social Work Code of Ethics is a comprehensive articulation of the behaviors required of all social workers to assure the ethical treatment of clients. If you visit http://www.socialworkers.org/pubs/code/code.asp , you’ll see that the code focuses on the core values of service, dignity and worth of the person, the importance of human relationships, integrity, and competence. The specific ethical considerations of the social worker’s relationship with clients include (1) commitment to clients; (2) self-determination; (3) informed consent; (4) competence; (5) cultural competence and social diversity; (6) conflict of interest; (7) privacy and confidentiality; (8) access to records; (9) sexual relationship; (10) physical contact; (11) sexual harassment; (12) derogatory language, (13) payment for services; (14) interruption of services and (15) termination of services. This code of ethics is used by most licensing boards to assure a commitment of all clinical social workers to these core values.

Psychology Code of Ethics

Similar to the Code of Ethics for Social Workers, a code of ethics has also been developed for clinical psychologists by the American Psychological Association. Go to http://www.apa.org/ethics/code/index.aspx . Here, five core values are articulated, including (1) beneficence and non-malfeasance; (2) fidelity and responsibility; (3) integrity; (4) justice; and (5) respect for people’s rights and dignity. Psychologists’ standards are similar to those of social workers, and include competence, confidentiality and privacy and human relations.

Public Health Code of Ethics

While social workers and psychologists are more concerned with the individual, public health has to consider the well-being of the community. The Public Health Code of Ethics, or “Principles of the Ethical Practice of Public Health,” while still acknowledging the importance of the protection of human subjects, is focused on collaborative decisions making, democracy to encourage consensus building, the health of the community, assurance of community input (particularly for marginalized populations), public information, and a “mandate to seek information to inform public actions” (APHA, 2002).

Risks and benefits focus upon the community rather that of the individual.

Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA)

In addition to the various codes of ethics outlined above, mental health professionals providing treatment are also subject to the Code of Ethics regulations under federal law. The Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996. HIPAA is geared to protect the privacy of individually identifiable health information. One of the main benefits of HIPAA is that it gives individuals and their families some protections that permit them to keep their insurance benefits when they change or lose their jobs, divorce, or have other changes in their situation. It also gives added protection to individuals when their personal health information is electronically transmitted.

Educational records are exempted from HIPAA (Overcamp-Martini, 2006) because they are addressed under the Family Educational Rights and Privacy Act (FERPA). FERPA is a federal law that protects the privacy of students’ educational records. Until a student reaches the age of 18, parents maintain certain rights pertaining to their child’s educational records. After the age of 18, these rights transfer to the student.

HIPAA and FERPA are just two of the many laws that may need to be addressed when dealing with confidentiality. In their book, Professional Ethics for School Psychologists, Williams, Armistead, & Jacob (2008) make the distinction between the law and professional ethics. They state, “professional ethics is a combination of broad ethical principles and rules that guide a practitioner’s conduct in his or her professional interactions with others. In contrast, the law is a body of rules of conduct prescribed by the state that has binding legal force” (p. 10). As might be expected, tension between ethics and these laws exists.

Finding our way through the many different professional ethical codes and federal and state laws in multiple disciplines can be a daunting task (Prodente, Sander, Grabill, Rubin, & Schwab, 2003).

Human Subjects Research

In addition to privacy laws, the federal government requires social science researchers to have all research on human subjects reviewed by an Institutional Review Board (IRB), usually within a university, though there are independent review boards as well. IRBs are required to review all research designs, instrumentation, consent forms, protocols and data collection methods to assure that the research poses no threat to those being studied. They also assure that subjects have given their consent to participate, are aware of any risks of the research, and are assured that information from the study will be kept confidential (see 45 CFR part 46 ).

The emergence of IRB oversight has required researchers to balance the need to protect individuals with mental illness from any harm that might result from research, and the need for research to improve their quality of care. Michels (1999) describes some of the important historical events that led to tighter restrictions on mental health research and reflects that “the inability of [persons with mental illness] to provide full informed consent may leave them vulnerable to exploitation. The greater problem is that too little research is conducted on their behalf” (p. 1450; see also Zywicki, 2007). Changes to IRB regulations to streamline, clarify, and simplify the process are currently under review by the DHHS Office of Human Research Protections (OHRP) (see http://www.hhs.gov/ohrp/humansubjects/anprmchangetable.html .)

Economics and Mental Health Care Ethics

Another area of concern with relationship to ethics of mental health care is what part economics plays in the equation. Much of this discussion surrounded the debate leading up to the passage of the Affordable Care Act (see for example, Matthews, 2009).

There is considerable tension between mental health care economics (including mental health care costs and efficiencies) and the delivery of quality mental health care. While professionals are obligated to follow their perspective codes of ethics advocating that persons with mental illness deserve high quality treatment, practical concerns regarding mental health care costs also need to be considered to assure that mental health care is affordable. In their examination of the relationships between economics and mental health care ethics, Chisholm and Stewart (1998) explore the core principles of both fields to see if there are areas in which there is common ground. In economics, these include resource scarcity, opportunity cost, efficiency and welfare maximization. In mental health care ethics, core principals are autonomy, beneficence, non-maleficence and justice. This article is important because it examines how both economics and ethics affect mental health care decision making.

Ethics and the Community

The relationship between culture and ethics is also an important part of this discussion. This is particularly true because of public health’s focus on the community. We can find an example of this in small rural communities. Roberts, Battaglia & Epstein (1999) describe their experiences in two rural/frontier states, Alaska and New Mexico. They note that about 15 million of 62 million rural United States residents struggle with mental illness and substance abuse. Furthermore, they frequently have higher rates of chronic illnesses which increase their risk for medical/psychiatric comorbidities (p. 498). Services, however, are limited due to shortages of mental health professionals, limited access to inpatient care and emergency services, insufficient amount case management and community-based supports and systems of care that are both poorly integrated and poorly funded. Because of these issues, rural mental health personnel face difficult ethical dilemmas. The authors describe six attributes of these isolated environments that may be encountered. They include 1) relationships, role and boundary problems because of the size of the community; 2) confidentiality because of the “fishbowl” nature of small towns in which persons can be observed going into clinical and other treatment settings; 3) cultural issues; 4) “generalist” care and multidisciplinary team issues in which there are not enough specialty professional available so that decisions are often made by individuals without specialty training, but who act in expanded capacity; 5) limited consultation for ethics issues; and 6) heightened stresses on caregivers because of their own isolation.

Conclusion

This lesson has provided only a brief discussion of the codes by which professionals should practice, the law governing our interaction with mental health consumers, the tension between economics and ethics, and some of the ethical dilemmas faced in small, rural and frontier communities. We have also examined some of the laws surrounding human subjects’ research. While this is neither an exhaustive list of ethical issues, nor an in-depth look at how important the issue is in our daily endeavors, it, nonetheless, gives an overview of some of the areas in which each of us must function in an ethical way.

Discussion: Answer the following discussion questions and post your answers on the discussion board.

Compare the APHA, NASW and APA Codes of Ethics. How are they similar to each other? Do they conflict with each other and how? What have you learned from this lesson that you were not aware of before?

References

American Public Health Association (2002). Principles of the ethical Practice of public health. Public Health Leadership Society. Retrieved on 12/7/14 from http://www.apha.org/~/media/files/pdf/about/ethics_brochure.ashx

Chisholm, D. & Stewart, A. (1999). Economics and Ethics in Mental Health Care: Traditions and Trade-offs. Journal of Mental Health Policy and Economics 1, 55-62. http://www.icmpe.org/test1/journal/issues/v1i2/v1i2text01.pdf .

Matthews, M. (2009). The ethics of health care reform. Issue Brief: Institute of Policy Innovation. Retrieved on 12/7/14 from: http://www.ipi.org/ipi_issues/detail/the-ethics-of-health-care-reform

Michels, R. (1999). Are Research Ethics Bad for Our Mental Health? New England Journal of Medicine, 340, 1427-1430.

Overcamp-Martini, M.A. (2006). The law, ethical guidelines, records, assessments, and reports for school-based practice. In Franklin, C., Harris, M.B., & Allen-Meares, P., Eds., The School Services Sourcebook: A Guide for School-Based Professionals. NY: Oxford University Press, 905-912.

Prodente, C., Sander, M., Grabill, C., Rubin, M., & Schwab, N. (2003). Addressing unique ethical and legal challenges in expanded school mental health. In Weist, M., Evans, S., & Lever, N., Eds., Handbook of School Mental Health: Advancing Practice and Research. NY: Kluwer Academic/Plenum Publishers, 363-374.

Roberts, L.W., Battaglia, J., & Epstein, R.S. (1999). Frontier ethics: Mental health care needs and ethical dilemmas in rural communities. Psychiatric Services, 50(4), 497-503.

Williams, B.B., Armistead, L, & Jacob, S., (2008). Professional ethics for school psychologists: A problem-solving casebook. NASP.

Zywicki, T.J. (2007). Institutional review boards as academic bureaucracies: an economic and experiential analysis. Northwestern University Law Review, 101 (1), 861-896.

( http://www.law.northwestern.edu/lawreview/v101/n2/861/LR101n2Zywicki.pdf ).