Case Scenario:

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The Acme Community Supports Organization is a publicly funded organization with the mandate to provide community living services to clients released from active-care psychiatric hospital.  The mission of the organization is to provide services and links to services to assist clients who suffer from mental illness.  Social workers in this organization are expected to integrate and maintain these persons in the community.  One of the goals of this organization is to reduce expensive active-care hospital use by decreasing the relapse rates of psychiatric patients and providing active supports for independent living.

Roxanne is a thirty-six year old client who suffers from schizophrenia, paranoid type.  She is a single mother with two children: a girl age 12 years old and a boy ages 8 years old.  Roxanne functions well when on her medications and maintains a three-bed-room townhouse in low-income cooperative housing.  Roxanne has been taking her medications for one and a half years and attends parent support groups and appropriate counselling.  She has been hospitalized 8 times in the last 10 years.  Her children have been apprehended by social services once when Roxanne had an active episode and left them alone for 2 days, but for the most part she has been a loving and devoted mother.

Recently Roxanne told her social worker that she does not need to continue her medications.  She complains of weight gain, blunted affect, agitation and body shakes as some of the more intolerable side effects of her medications.  She also says she is unhappy: she has no extended family support, which she feels is due to her past erratic behaviour during her active psychiatric episode.  Her ex-husband lives in another town and sees the children infrequently, partly because the children are settled in their home and school and partly due to animosity between him and Roxanne.

Roxanne is lonely and feels her excess weight caused by the medications makes her unattractive and unable to find a romantic partner.  She is also “fed up” with her neighbours in her housing unit and believes they get overly involved in her affairs and talk about her behind her back

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Questions:

What is your initial reaction to Roxanne’s desire not to continue with medications? What is the basis of your reaction and what values underlie your reaction? What are the primary ethical issues in this situation? And why have you chosen these? Using the 8 steps to ethical decision-making model, comment on the process of completing those steps and the outcome you uncovered (include your answers to the 8 step model questions at the end of your paper). What sections of your professional code of ethics apply to the issues you have identified?What, if anything, have you done to critically monitor your thinking during your responses to these questions and the questions within the 8 step model?

 

Analysis:

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Roxanne appears as if she is managing and functioning well with her children. However, upon hearing her statements and concerns, Roxanne seems as if she is falling under the similar mental patterns of paranoid schizophrenia. Prescription medication has a variety of benefits, but due to how chemical receptors react to the body, they can potentially lose their efficacy in terms of how users are managing their thoughts. It is the thoughts of this writer, that to gain total wellness, one must comply with medication dosages, as well as, seek the appropriate talk therapy. It is common for individuals suffering from mental health conditions, to be compliant with medication but still experience symptoms of mental health illness. This writer believes Roxanne needs to address her concerns with her primary care provider. The concern is that Roxanne is feeling adverse side effects from the medication. At which point, the prescribing doctor could change the medication brand, as well as adjust medication dosages. The social service worker could also speak with Roxanne’s prescribing doctor as they could disclose the statements that are indicating the medication is not working effectively. The worker would need to obtain informed consent to release Roxanne’s statement to the doctor. Roxanne is the expert of her body, she is aware of what is right, what is working for her, and the way she chooses to express her feelings is her choice. If she believes that the medication is affecting her negatively, then she has the right to access the correct medication, even if it may take a few adjustments to reach a steady state. This thought is in alignment with the second ethical code of respecting the intrinsic worth of their service users, as outlined by the Ontario Social Worker and Social Services Worker. 

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            Individuals have diverse backgrounds that can include education and life experiences. Some individuals have educational qualifications that allow them to diagnose, prescribe, and delve into the workings of the mind. Licensed individuals must adhere to their standards of practice and code of ethics while working within their scope of practice. The idea is that within the code of ethics, social service workers must remain competent within their professional capacity. It is unethical for a qualified individual to provide service in an area that they are not allowed qualified. The social service worker must work within their scope of practice, as they guide service users to the correct services and access links. This writer believes that individuals should work within their competence, capacity, seek consultation, debrief, and refer out when necessary. The social worker working with Roxanne may need to remember that Roxanne’s best interest is the primary obligation. 

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            The primary ethical issues of the social service worker revolve around the first code of ethics, choosing the best course of action for Roxanne. The worker must work and advocate in Roxanne’s best interest while respecting her intrinsic worth.If Roxanne is stating that the medication is no longer working for, then the social worker must respect her statement, while guiding her to make an informed decision. If it is the case that the medication is not working, then the social worker can employ ethic number two and eleven by carrying out her professional duties with objectivity while advocating for Roxanne’s best interest. Advocating for Roxanne’s will greatly impact her use of the agency services and help to keep the peace with her neighbours as new medication could provide mental stability.  This writer believes that these are the primary ethical issues as Roxanne’s overall health and well-being is extremely important. If Roxanne is not taking her medication, she could begin to experience schizophrenic episodes, endanger her children, and possibly relapse into the active-care psychiatric hospital. If Roxanne is feeling empowered, fulfilled, happy, and that she is living within her personal best interest, then there is the possibility that she could continue to stay integrated into her community.

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            Ethical decision making requires one to be authentic when deliberating options by understanding that strictly applying arbitrary rules to service users is not ethical decision making. One must examine situations by examining their principles, values, and interests while weighing out of the negative and positive elements. When one can gain awareness of themselves, while making decisions, they will be able to provide sound rationales of their choices and judgements.  The Eight-Step Ethical Decision-Making Model encourages one to stimulate self-reflection through discussion. (Miller, 2007, p. 35) It was essential to have the relevant background information of the servicing agency, which includes their missions and expected roles of the social service workers. It was useful to have Roxanne’s history in terms of her diagnosis and her family situation. Information that would have been useful in the decision-making process includes the date Roxanne became a client of the agency, the dates of the eight hospitalizations, and the date of the last active episode. Having that information would help with deciding the severity of the presenting problem in step one of the model. If Roxanne’s active episode was recent, then she may require immediate help, further assessment, and consultation with her family doctor. There may not be enough time to implement step eight, as Roxanne could potentially need hospitalization sooner than later. The model allows for critical analysis of many factors through the questions raised throughout each step.

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The different people involved in the situation automatically assume a different level of involvement, risk, and, ultimately, the consequences of the decision. The question arises in Roxanne’s case; she is the primary person faced with the presenting problem, but how does the weight of the other individuals involved affect Roxanne? Each party (the organization, the social worker, the support groups, the counselor, and the prescribing doctor) all play an integral role in Roxanne’s care. Each party’s standards of practice, code of ethics, values, ethics, and morals, have an impact on the weight of the outcome. If the agency were to decide that Roxanne cannot relapse due to funding, then they could have a vested interest in advocating the doctor to change her medication. Even if that is not the best choice of action, if the doctor agrees with Roxanne, and takes her off the medication, then Roxanne could relapse. The relapse could lead to the social service worker having to advocate for Roxanne’s housing as well as the children’s well-being. The writer chose the outcome based on simple information; when the majority of individuals have a complicated case history. There will be times that not all the information will be available, and sometimes information could come to light when it is too late to take into consideration. In the case of Roxanne, a potential role of the social service worker is to advocate for Roxanne when Roxanne cannot do it herself. The worker must provide Roxanne the services and links to make the appropriate decisions or to help evaluate her thoughts and goals.

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Other information that would be useful in answering steps three and four is the geographical location of the agency and Roxanne. Governing licensing standards of practice and code of ethics can vary between states, provinces, and countries. As well, laws and regulations can vary between municipalities and cities. Individuals need to be knowledgeable of the applicable laws and how those laws could affect a client’s circumstance. For example, in a case of children who are older than Roxanne’s children, knowing the age of majority, or the age that a child is no longer considered a child is essential information when deciding potential outcomes and their consequences. The Government of Canada lists the definition of a minor child and the definition of a minor for child protection purposes on their website. In the province of British Columbia, the definition of a minor child is the same definition of minor for child protection purposes; the age is nineteen. In Ontario, the definition of a minor child is eighteen, whereas the definition of a minor child for protection purposes is under the age of sixteen. (Canada, 2013) Roxanne’s children play an essential role in the potential issues within step two, as the outcomes and consequences equally affect them.

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      Social service workers have a professional obligation and duty to clients to be of service utilizing the standards of practice, code of ethics, and values at the forefront of their critical thinking. Miller (2007) mentions key ethical codes extrapolated from the Canadian and National Association of Social Workers. The two associations describe ethical codes that imply that social service workers should think critically in a non-judgemental, objective, and practical manner. There is a perceived level of inexperience that comes with being a novice in any situation. It is not to say that those with experience are any more skilled than those who are not. Formal education, such as college courses, or specific seminars, textbooks, or experiential consultation, can be of great benefit to the novice social service worker. The writer, in this situation, is a novice, with little to no experience in a case similar to Roxanne’s. It is the belief that formal education provides a foundation to course requirements, and allows one to develop their skills and knowledge. However, the writer has personally experienced that practical experience lends to a certain level of competency. It is the hope that through ongoing education, consultation, listening, and patience that one can gain the tools to monitor their thoughts critically. Through self-reflective practices, such as this paper, it allows one to become familiarized with the questions that follow under each step. There will be times that a social service worker can reach a reasonably straightforward decision quickly, and there will be times that critical thinking will be an essential tool. Social service workers, when critically thinking, must monitor their values, beliefs, and consider relevant case information to create alternative courses of action while applying the applicable professional codes.  A novice can learn a great deal from those who provide consultation and feedback. (Thank you!)

 

8-Step Ethical Decision-Making Model

 

Step 1: Identify the problem:

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Who is involved, what is their involvement and how are they related:

• Roxanne – a 36-year-old mother, hospitalized and diagnosed with schizophrenia (paranoid type), stabilized with medication

• Children – Roxanne’s two children, aged 12 and 8

• The Acme Community Supports Organization – publicly funded organization, community living which provides services and links to services to assist clients who suffer from mental illness

• Social worker – the one assigned to Roxanne, the role of the social worker is to integrate and maintain clients of The Acme Community Supports Organization into the community

• Support groups/ appropriate counseling – Roxanne uses these services

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Describe the presenting problem:

• Roxanne no longer wants to comply with her medication dosage as she believes she is suffering adverse side effects

• Roxanne has also mentioned key events that could lead one to believe that she is not taking her medication (believes she has no family support due to her past behaviour, believes her husband will not visit the children due to the issues between her and him, she believes the medication is causing her weight gain, she believes the weight gain is preventing her from finding a partner, believes her neighbours are involved in her business while talking about her behind her back)

• Roxanne is not happy with her relationships with her ex-husband, immediate family members, and neighbours, and she is also feeling lonely

 

Who has the right/and or responsibility to make the decision:

• Roxanne has the right to make her own decisions in terms of taking her medications

• The social worker can only provide her service within the agency of integrating and maintaining Roxanne in the community

• The Acme Community supports Organization can only provide their services of providing community living, and regulating the social service workers

• The medical/prescribing doctor, who Roxanne is in care of has the right and responsibility to adjust her medications and dosages

• The support groups and appropriate counseling has a responsibility of ensuring they are hearing and addressing Roxanne’s concerns

 

Who bears the highest risk from the decision, what is involved, what is at risk:

• Roxanne and her children bear the highest risk from Roxanne’s decisions. If Roxanne decides not to take her medication, she could potentially have a psychotic episode, which leads to hospitalization, which could lead to losing her housing status and her children. Her children could possibly end up in foster care or separated or perhaps move to the other town, where her biological father lives

• The organization and the social worker can only guide their clients by advocating for their best interests, but ultimately, the decision and responsibility falls on the client

• There is also the chance that the prescribing doctor did not do their diligence in making sure the medication and dosage are enough. There is a possibility the medication is not working, or that there is another brand that may not produce as many adverse effects. Roxanne could potentially be taking a medication that is not reacting and may need a new brand and dosage.

• The support groups and appropriate counseling bears the lowest risk as they can only guide and support Roxanne within a limited capacity relevant to their standards of practice and code of ethics

 

What are the relevant situational features (agency, family, job, community): 

• Roxanne is functioning well, as she is under the care of the social worker and the agency. The agency has a mission of providing services and links to assist clients who have a mental illness. It seems as if Roxanne and her children are doing well since they are under the care of the agency. It appears as if her support groups and counseling are doing the best that they can, given if Roxanne has addressed her concerns to them. It is mentioned that her children are doing well. I am unsure if she has a job, but she is feeling isolated from her family, her children’s father, and her neighbours. It seems as if she is not satisfied with her community. Roxanne is also unhappy with her body image, agitation, and body shakes. These unhappy thoughts and descriptions are relevant as it allows her team to mentalize Roxanne’s world.

 

Step 2: Identify the potential issues involved

 

What type of issue is it (ethical, legal, personal, clinical, or a combination of these)?

• Ethical

  • There is an ethical responsibility for all modalities of service to work within their competent and professional capacities

  • The medical doctor has an ethical responsibility to ensure Roxanne’s medication, and the dosage is efficient

  • The agency has an ethical responsibility to provide its service carefully

  • The social service worker has an ethical responsibility to the agency to assist, integrate and maintain their service users within the community, and they also have a responsibility to work within their codes

• Legal

  • There is a legal responsibility that revolves around the care of Roxanne’s children

  • Social services or a children’s aid society, must due their diligence to ensure the quality of safety Roxanne’s children are using

  • It is believed that the medical doctor’s bear the responsibility of proper prescribing practices

• Personal

  • Roxanne bear the responsibility to take care of her children

  • The ex-husband/father – although he has not been mentioned yet and we do not know his side of the story, could potentially have the responsibility to care for his children, unless he a court order stating otherwise

• Clinical

  • The Acme Community Supports Organization has the responsibility of their mandate, and they have chosen to provide community living services for clients who are released from active-care psychiatric hospitals, provide services and links to services to those suffering from mental illness and employ qualified social service workers

  • The social service workers employed by the clinic/agency, are expected to integrate and maintain these persons in the community, this means the social worker is responsible for providing the appropriate service and service links for Roxanne and her children  

 

What personal values, basic moral principles or guidelines should be considered?

• Personal values

  • Roxanne: authenticity, achievement, honesty, happiness, integrity, meaningful life, peace, pleasure, respect, stability, love, success, equality, good health

  • Social Worker: compassion, contribution, justice, honesty, integrity, competence, service, responsibility, openness, patience, equality, kindness

  • Support groups, counselor, doctor: compassion, success, trustworthiness, equality, support, care, tolerance, quality of work

• Basic moral principles

  • Roxanne: complying with medication use, being responsible for her thoughts, feelings, and actions, taking care of her children, attending support groups

  • Social worker: must work within their codes to provide the best interest for Roxanne while helping her find the appropriate care and services, and acting in Roxanne’s best interest

  • Doctor: must make the decision to be qualified and competent in which medication brands are there, and which type and dosage would be appropriate for Roxanne

• Guidelines

  • Anything governing body codes of ethics and standards of practice

  • Acme Supports Organization: the mandate of the organization to provide community living services and links to services to assist clients who suffer from mental illness

What relevant societal or community values should be considered?

• Societal and community values

  • The Acme Supports Organization has obligations to the public as they fund the organization, making the right decisions to integrate and maintain the client into the community

  • Roxanne has obligations to be courteous, polite, and respectful to her neighbours in her housing unit

  • Doctors, counselor, and support groups have obligations to maintain their competency while working within society

 

 

Step 3: Review the relevant ethical codes

 

Identify relevant professional standards that could be applied to the identified issues

• Social service worker within the agency will have to abide by the following standards and codes, and the doctors will have their professional standards of practice which would include prescribing rights

• OCSWSSW code of ethics

  • 1 maintain the best interest of the client

  • 2 respect the intrinsic worth of professional relationships

  • 3 carry out professional duties and obligations with integrity and objectivity

  • 6 protect confidentiality

  • 8 no provision of work which discredits profession or public trust

  • 10 shall promote excellence

  • 11 advocate change in the best interest and benefit to the client, society, the environment, and the global community

• OCSWSSW standards of practice

  • 1 relationship with clients – setting goals, adapt and evaluate goals; observe, clarify and inquire about information presented by the client; respect and facilitate self-determination; demonstrate uniqueness; aware of their values, attitudes and needs and how those impact the client

  • 2 competence – aware of the professional scope of practice; provide competent service; seek supervision, consultation, and education; work within the scope of practice; refer where necessary; remaining current with education, policies, legislation, programs and issues related to the community

  • 2 integrity – maintain clear and appropriate professional boundaries; present the correct professional qualifications, education, experience, and affiliation; promoting social change on behalf of their clients; knowledge and sensitivity to cultural and ethnic diversity assist clients in accessing the necessary information, services, and resources

  • 3 responsibility – deliver clients services, respond to client queries, concerns, and complaints in a timely manner, no discrimination for any reason

• CASW – all values are applicable

  • 1 – respect for the inherent dignity and worth of a person

  • 2 – pursuit of social justice

  • 3 – service to humanity

  • 4 – integrity in professional practice

  • 5 – confidentiality in professional practice

  • 6 – competence in professional practice

 

Step 4: Know the applicable laws and regulations

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Identify relevant laws, regulations, agency policies and procedures.

• Laws

  • Those that reflect the proper care, non-neglect, and no abuse towards children

• Regulations

  • Any regulations related to patients who were once hospitalized for mental health issues

  • Any regulations which relate to Roxanne’s community housing or low-income cooperative housing

• Agency policy and procedures

  • Social workers are expected to integrate and maintain clients in the community

  • Agency provides active supports and links to services for independent living while providing services and links to service

Step 5: Obtain consultation

Identify the conflicts you are experiencing internally

• Conflicts of honouring the client to be the expert of their mind and body

• Understanding her kids are of utmost priority

• Medication side effects, dosages, and compliance

• The work the agency provides for the community

• Trying to minimize relapse due to the agency being publicly funded

• Roxanne’s feeling of loneliness, isolation, uncomfortable with her own body

• The amount of work it would take to find new housing and to move Roxanne and her kids

Identify the conflicts you are experiencing that are external

• Agency can work only within their capacity and their public funding

• A social worker can only work within the capacity of code of ethics and standards even if it doesn’t completely align with what they feel inside; for example, the social worker wants her off of the medication, but cannot make that decision or tell Roxanne to stop

Identify who (colleagues, faculty, supervisors, professional organizations/committees, professional literature, etc.) you would seek assistance from around these internal/external conflicts.

• Roxanne’s team could coordinate a group meeting to discuss:

  • Doctor: medication brand, dosage, compliance

  • Social service worker: helping to reduce expenses of care, stating what Roxanne has told her, make sure her children are okay, find new housing

  • Support group/counselor/therapist: their perspective of Roxanne’s presenting condition (has she stopped taking the medication as it may be evident in her statements

 

Step 6: Consider possible and probable courses of actions

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Generate all possible courses of action.

• Roxanne stops taking her medication

• Roxanna relapses and has another psychotic episode

• Roxanne loses her children

• Roxanne’s ex-husband takes responsibilities for the children

• Roxanne takes an updated medication prescribed by her doctor

• Roxanne stops being a service user of the agency

Step 7: Enumerate the consequences of the various courses of actions

• 1 Roxanne relapses and has another psychotic episode – even though Roxanne is on her current medication, and she could run the risk of having another episode, this episode could lead to hospitalization, unnecessarily use the agency resources, children’s aid could reprimand her children

• 2 Roxanne loses her children – her children could be placed in the foster system and separated, they could experience emotional stress and trauma

• 3 Roxanne stops taking her medication – her symptoms of paranoid schizophrenia could intensify; she could have erratic behaviours; could endanger herself, the children, her neighbours, her care team

• 4 Roxanne stops being a service user of the agency – she could be left to figure out her life herself without the resources and service links; they could lose their housing; end up homeless, sick, or hospitalized

• 5 Roxanne takes an updated medication – new medication will take time for an adjustment; however it could end up working efficiently; Roxanne could experience less adverse side effects, and could change some of her thoughts

• 5 Roxanne’s ex-husband takes the responsibility of their children – some pressure and burden can be lifted from Roxanne, and she could spend some time focusing on taking care of herself

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Step 8: Decide on the best course of action

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Select the best course of action.

• Roxanne’s social worker and primary care team, meet to listen to Roxanne’s concerns and develop the appropriate course of action

• The team includes the social worker, the prescribing doctor, the counselor, and the agency representative who works with finding housing

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Develop an action plan to implement the action.

• The team will meet to discuss Roxanne’s medication efficacy, and they will help go through her thoughts and mental processes

• There is a possibility they will ask Roxanne if she is okay to way for a specific time to see how the medication is reacting, this allows the proper follow-up to check where she is mentally

• The housing representative can work with Roxanne to see if there any concerns they can address immediately, while in the meantime searching for new housing for Roxanne and her kids

• The social worker will provide the necessary resources, and document all the interactions and meetings, and they will work in Roxanne’s best interest while facilitating her to make the best decisions

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Identify how you will evaluate the action taken and the outcome.

• Case notes will allow check-in to see if Roxanne is satisfied with housing, continued attendance for support groups will ensure her children are being taken care of, the counselor can assess her progress, the doctor can check if the medication is producing less adverse side effects, Roxanne’s thoughts, feelings, and behaviours can be monitored over a defined time which will see if she is experiencing the same feelings or if adjustments to her medication are helping

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Examine the implications of your action.

• There is a possibility Roxanne could feel overwhelmed by her medical team all meeting with her at once, and this could lead to a higher increase of paranoid thoughts

• she could ignore them all and run away and leave her kids abandoned

• she could decide she is going to stop taking all medication at once and have another psychotic episode

• Roxanne could remove from the agency care and try to live a successful life which can turn out to be unsuccessful

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What have you learned from the process? 

• A person who is involved in social services can potentially have a large team taking care of them, and all team members equally play a role in helping by providing service

• That each member has a unique input when it comes to what their qualifications are, and each member must practice within their scope

• That collaboration for decision making is a necessary process, which involves cooperation, being patient, listening and respecting each other, while applying these concepts to the service user

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What implications are there for future ethical decision making?

• One person is not responsible in totality for the service user, and the service user also must be responsible for their wellbeing

• Social workers must understand their professional responsibilities while working within their codes and professional scope of practice

• Trying to take on an entire case could lead to poor service

• Using available tools and the appropriate modalities can be beneficial to all, this means being resourceful, cooperative, patient, friendly, courteous, polite and knowing ones professional and ethical limits

 

 

References

Canada, G. o. (2013, 02 25). Provincial definitions of a child - Canada.ca. Retrieved from Government of Canada: https://www.canada.ca/en/immigration-refugees-citizenship/corporate/publications-manuals/operational-bulletins-manuals/refugee-protection/canada/processing-provincial-definitions-minor.html

Miller, P. (2007). Ethical Decision Making In Social Work and Counselling. Toronto: Nelson Education Limited.

OCSWSSW. (2018). Code of Ethics and Standards of Practice - OCSWSSW. Retrieved from Ontario College of Social Worker and Social Service Workers: https://www.ocswssw.org/professional-practice/code-of-ethics/