Running head: CLIENT’S RIGHT CONFLICTS WITH ETHICAL OBLIGATION
When Clients’ Right to Self-determination and Autonomy Conflicts with the Ethical
Obligation to Ensure Truthfulness and Full Disclosure in the Name of Clients’ Quality of
Life and of Least Harm: Considerations of Client Refusal of Hospice Care
Leanna E. DeBauche
University of Wisconsin, Oshkosh
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CLIENT’S RIGHT CONFLICTS WITH ETHICAL OBLIGATION
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Social workers are commonly faced with making difficult ethical decisions. It is
incumbent upon the social worker to define the values that are held by relevant parties involved
in the ethical decision in addition to the affiliated ethical principles that are correlated to those
values. It is when defining values and related principles that the social worker is often faced with
surfacing ethical dilemmas. It is up to the social worker to first consult with ethical laws, agency
policy and procedure, and the NASW code of ethics to seek applicable directives. Then, it is up
the Social Worker to place hierarchical rating of applicable ethical principles to determine
possible options for resolving the dilemma in an ethically compliant way. For example, given the
following case scenario, a social worker is tasked with carrying out the aforementioned method
to ensuring that the most ethically appropriate decision is made when proceeding:
A social worker in an oncology service at a major university hospital, was assigned a
terminal cancer patient—a mother of three young children, with a devoted and supportive
husband and family. The physician determined that further efforts would be futile, thus making
the patient’s continued hospital stay an improper utilization of resources. She ordered the social
worker to refer the patient for hospice care. A major difference between hospice care and
palliative care involves treatment. While hospice care generally precludes aggressive treatment
and is often viewed as “end-of-life care,” palliative care enables patients, families, and
physicians to determine appropriate care, and its time frame tends to be open-ended. Hospice
care is covered by Medicare and other health plans, while palliative care is often not a covered
service. However, the physician ordered hospice care in this case, and palliative care was not an
option in every area of the country. The worker attempted to present the hospice concept to the
patient and family, and it was adamantly refused. Both patient and family associated hospice care
with death. They did note accept the patient’s poor prognosis and requested continued care and
CLIENT’S RIGHT CONFLICTS WITH ETHICAL OBLIGATION
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treatment in the hospital. Due to financial considerations, palliative care was not an alternative
for this family at that time.”
Looking at this case scenario from a critical, general decision-making lens, the social
worker is suddenly faced difficult ethical dilemmas. Most apparent is the dilemma of the client’s
and her family’s right to self determination and autonomy, and that rights confliction with the
social worker upholding the ethical principles of least harm, quality of life, and truthfulness and
full disclosure. It becomes evident that in order to uphold these ethical principles, the social
worker may inevitably devalue the client’s self-determination and autonomy, but only with solid
ethical reasoning to support that decision.
Although the client and her family stated a desire for the client to stay at the hospital and
continue to receive treatment, this is violation with the Hospital’s Policy and Procedures, which
support the discharge of the patient to follow up care when having the patient remain in that level
of care is no longer indicated by the medical provider. Thus, the social worker is ethically
obligated to inform the family of this fact and is also obligated to remain truthful with
subsequent documentation. That said, it becomes apparent that the social worker cannot consider
the client remaining in her current level of care at the hospital as a feasible option. Thus, the
social worker must consider viable, ethically appropriate, alternatives.
The social worker must still attempt to uphold the client and her family’s values, even if
some options are off the table. The social worker must consider, through a genuine lens of
empathy that this is a difficult time for the client and her family and that the client and her
family’s experience of denial is a succinct possibility. When considering the ethical principles of
least harm and quality of life, it becomes clear that the social worker must provide assessment,
education, and supportive counseling. The social worker should create space for the client and
CLIENT’S RIGHT CONFLICTS WITH ETHICAL OBLIGATION
her family to discuss The social worker must consider that the client and/or her family could
have a miscomprehension surrounding the nature of hospice services and that they may have a
limited understanding regarding how hospice care can be helpful in reducing pain and improving
quality of life. The social must educate the client and her family regarding hospice’s ability to
potentially support the client at home, as the client may not consider the time she may miss by
attempting to stay in the hospital, when her medical provider has unequivocally stated that the
effectiveness of further treatment is no longer indicated.
The social worker should reference and utilize methods to discuss life limiting diagnoses
and “help people meet their final goals- even in the presence of denial” (Jackson, 2013, p. 22).
“The aim is not to tear down the edifice of denial necessary to emotional well-being, but rather,
to attend to issues that, if unaddressed, could make the dying and bereavement process all the
more difficult” (Jackson, 2013, p. 22). It is these service implications that correlate with the
social worker’s ethical obligations of truthfulness and full disclosure, quality of life, and
ensuring least harm.
Onyeka (2010) indicated specific directives for social workers in the position of having
clients and/or their families who are in denial regarding a terminal diagnosis and correlating
ethical implications this presents for the social worker:
“Denying a cancer diagnosis may result in a refusal or delay in intervention
(maladaptive), while a denial of impact (e.g. “I can carry out all activities as before the
diagnosis”) may help maintain patient’s morale, cause him to comply with treatment
instructions and go on with his life (adaptive). Intervention should be sought when the
denial adversely affects the patient’s well-being. In the face of denial, clinicians should
show empathy and maintain the relationship by seeing the patient often. The latter feel
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CLIENT’S RIGHT CONFLICTS WITH ETHICAL OBLIGATION
abandonment easily and therefore need to know that they are not in it alone. However,
clinicians should avoid being too personally involved so as not to lose perspective on the
seriousness of the illness or treatment options as a result of the development of emotional
self-protection or “clinician denial”. Family support interventions involving the social
worker may be necessary while pharmacological treatment using anxiolytics and
antidepressants can provide symptomatic relief. Where there is a possibility of self-harm,
harm to others or worsening of symptoms despite the treatments given, a psychiatric
consult is crucial.” (p.123)
The social worker should reference and utilize methods to discuss life limiting diagnoses
and “help people meet their final goals- even in the presence of denial” (Jackson, 2013, p. 22).
“The aim is not to tear down the edifice of denial necessary to emotional well-being, but rather,
to attend to issues that, if unaddressed, could make the dying and bereavement process all the
more difficult” (Jackson, 2013, p. 22). It is these service implications that correlate with the
social worker’s ethical obligations of truthfulness and full disclosure, quality of life, and
ensuring least harm.
That said, the social worker, though ethically obliged to make a valiant attempt to
properly educate and guide the client and her family, also must acknowledge that the client and
her family may still refuse the hospice referral, or to even think or talk about dying. The client
and her family are supported in their right to self-determination of health care decisions, as
defined by the Patient Self Determination Act ("Law for Older Americans", 2013). This act
ensures patients’ rights to “consent to or refuse any medical treatment or diagnostic procedure
relating to physical or mental health, including artificial nutrition and hydration, to hire or
discharge medical providers and authorize admission to medical and long-term care facilities, to
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CLIENT’S RIGHT CONFLICTS WITH ETHICAL OBLIGATION
consent to measures for comfort care and pain relief, to have access to all medical records, take
whatever measures are necessary to carry out wishes, including granting releases or waivers to
medical facilities and seeking judicial remedies if problems arise” ("Law for Older Americans",
2013). Thus, the social worker must, even in the face of continued refusal of hospice services,
are still to provide resources for future service needs. In a final attempt to uphold ethical
principles that prioritize the client and her family’s quality of life and to ensure harm reduction
moving forward, the service focus must end with ensuring a relationship has been formed. The
social worker must assist the client and her family in determining what future factors may
present that indicate when they are ready for treatment so that when the client and her family do
go looking for support, they will know what to do if or when further services are needed.
This case study is difficult to manage through an empathetic lens. Facing a terminal
illness is a trying time for any client and/or families. Given that social workers are required to
provide meaningful and impactful services, to the best of their ability, it can be difficult to
embrace and support a client who is in distress regarding the future loss of their lives in the face
of upholding certain ethical principles. Practicing with ethical integrity can be difficult and
seemingly unsettling but utilizing appropriate ethical reasoning tools and dedicating service
provision and delivery to reflect as such becomes all the more necessary.
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CLIENT’S RIGHT CONFLICTS WITH ETHICAL OBLIGATION
References
Jackson, K. (2013). Transitions to Hospice Care — Social Workers Foster Meaningful
Conversations About Dying. Social Work Today, 13(4), 22. Retrieved from
https://www.socialworktoday.com/archive/070813p22.shtml
Law for Older Americans. (2013, March 18). Retrieved October 13, 2019, from
https://www.americanbar.org/groups/public_education/resources/law_issues_for_consum
ers/healthcare_agent/
Onyeka, T. (2010). Psychosocial issues in palliative care: A review of five cases. Indian Journal
of Palliative Care, 16(3), 123–128. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3012234/
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