__________ Frederic G. Reamer, Ph.D., Professor, School of Social Work, Rhode Island College, Providence, RI. Copyright © 2022 Authors, Vol. 22 No. 1 (Spring 2022), 14-32, DOI: 10.18060/25719 This work is licensed under a Creative Commons Attribution 4.0 International License. Managing Ethics Challenges in Social Work Organizations: A Comprehensive Strategy Frederic G. Reamer Abstract: Social workers are keenly aware of ethical challenges in professional practice. Formal ethics education strives to acquaint social workers with common ethical dilemmas in practice and decision-making protocols and frameworks. However, the social work literature includes relatively little information about practical resources promoted in allied professions that can be useful to social workers who encounter ethics challenges. This article discusses the role of four principal resources: informal ethics conversations among social workers and other colleagues (“curbside consults”), formal ethics consultations, agency-based ethics committees, and ethics rounds. The author includes illustrative examples demonstrating social workers’ use of these resources to manage ethics challenges skillfully. Keywords: Ethical, ethics, ethics committees, ethics consultation, ethics rounds In many key respects, ethics has come of age in social work. Unlike earlier generations of social workers, today’s social work educators are expected to include comprehensive ethics education in undergraduate and graduate programs, and in continuing education throughout their careers (Congress et al., 2009). According to the Council on Social Work Education’s (CSWE; 2015) Educational Policy and Accreditation Standards, social work education programs must ensure that students have the ability to make ethical decisions; use reflection and self-regulation to manage personal values and maintain professionalism in practice situations; demonstrate professional demeanor; use technology ethically and appropriately to facilitate practice outcomes; and use supervision and consultation to guide professional judgment and behavior. Ideally, core content includes understanding the nature of social work values, ethical dilemmas, ethical decision-making frameworks, and ethics risk management (managing ethics challenges in a way that protects clients and prevents ethics-related litigation and complaints). Ethics education in allied professions—including psychology, psychiatry, mental health counseling, marriage and family therapy, medicine, and psychiatric nursing—has matured similarly (Martin et al., 2017). One key difference, as evidenced by a comprehensive search of the social work literature, is that the social work profession has lagged behind other professions—especially health care professions—in its efforts to establish routine, systematic mechanisms in agency settings to identify, assess, address, and monitor challenging ethical issues. This discussion highlights and reviews the ways in which social work agencies can address ethical issues systematically and on an ongoing basis through four strategies: ethics conversations, ethics consultation, ethics committees, and ethics rounds. about:blank Reamer/MANAGING ETHICS 15 The Evolution of Social Work Ethics Ethics knowledge and education in social work have evolved since the profession’s formal inauguration in the late nineteenth century, though not always in a linear fashion (Banks, 2012; Barsky, 2019; Dolgoff et al., 2012; Reamer, 2014). There have been several key stages, including the morality period, values period, ethical dilemmas and decision- making period, risk management period, and digital period. Morality Period Social work’s historical literature suggests that, during its earliest years, beginning in the late 1800s, the profession was focused much more on the morality of clients rather than of practitioners. In many discussions, one finds references to concern about the moral fiber, or the alleged lack thereof, of clients who struggled with issues such as poverty, unemployment, alcohol use, or poor health (Reamer, 2018). The phrase “professional ethics” did not exist. Some of the discussions of clients’ morality during this period had a rather paternalistic tone. Values Period As social work matured in the early and mid-twentieth century, a handful of scholars and practitioners began exploring and writing rich commentaries about the profession’s core values, such as client dignity, respect, self-worth, self-determination, and confidentiality (Banks, 2012; Gordon, 1965). These important discussions and analyses sought to explore the implications of social work’s central values, especially when there were conflicts among the profession’s values, the broader society’s values, and social workers’ personal values. During the turbulent 1960s and early 1970s, several social work authors wrote about the complex connections between social work values and contemporary controversies surrounding civil rights, women’s rights, welfare rights, discrimination, and abortion (Vigilante, 1974). Ethical Dilemmas and Decision-Making Period The scholarly winds began to shift significantly during the late 1970s and early 1980s, largely because of the dramatic emergence of the broader field of applied and professional ethics, especially bioethics (Barsky, 2019; Dolgoff et al., 2012; Reamer, 2018). During this period, increasing numbers of scholars and practitioners in a wide range of professions (for example, medicine, nursing, psychology, social work, journalism, business, law enforcement, engineering) focused explicitly for the first time in their respective histories on the nature of challenging ethical dilemmas facing practitioners. During this period, scholarship burgeoned on the subjects of ethical dilemmas in practice and ethical decision-making protocols (Barsky, 2019). The richest discussions identified links between ethical theory, drawn from the discipline of moral philosophy, and real-life challenges faced by professionals, particularly those involving conflicts between professional duties and obligations (Bryan et al., 2022; Reamer, 2018). Textbooks in diverse professions included, for the first time, in-depth overviews of ethical dilemmas and conceptual frameworks practitioners could use to address them ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 16 (Beauchamp & Childress, 2019; Bryan et al., 2022; Martin et al., 2017). In social work common topics concerned the nature of professional paternalism, the limits of clients’ confidentiality rights, managing informed consent challenges, complicated boundary issues, dual relationships, conflicts of interest, allocation of limited resources, and compliance with allegedly unjust laws, among others. Over time, social work education programs developed curricula to teach students about ethical dilemmas and decision-making (Congress et al., 2009; Reamer, 2001). It was during this period when the concepts and practice of formal ethics consultation, ethics committees, and ethics rounds—the focus of this discussion—first emerged, primarily in health care professions and, more modestly, in social work. These were deliberate efforts to help practitioners make sound ethical judgments when dilemmas arose. Over time, social work scholarship has explored the importance of high-quality ethical decision-making (Mertens & Ginsberg, 2008), including the use of heuristics and subjective assessments to make difficult judgments (Devlieghere & Roose, 2020; Taylor, 2017). Ethical Risk Management Period In the early 1990s, the winds shifted yet again. Although many social workers sustained their interest in ethical dilemmas and decision-making, new concerns emerged regarding ethics-related risk management (Reamer, 2018). Data began to circulate concerning increases in lawsuits and licensing board complaints that raised ethical issues (Phelan, 2007; Strom-Gottfried, 2000). Increased publicity circulated by the National Association of Social Workers, Association of Social Work Boards, and state licensing boards alerted social workers to relatively new information about the ways in which social workers’ ethical judgments could lead to litigation and complaints filed with licensing boards and professional social work associations. Social workers discovered how disgruntled clients and others could file formal complaints alleging, for example, mismanagement of clients’ confidential and privileged information, boundary and dual relationship violations, conflicts of interest, negligent service delivery, and inappropriate termination of services (Gricus, 2019). For the first time in social work’s history, literature emerged about the links between social workers’ ethical judgment and potential malpractice, negligence, and professional discipline (Barsky, 2019; Reamer, 2015). Licensing boards developed publicly available websites listing social workers who were sanctioned because, for example, they committed fraud, had sex with clients, and disclosed sensitive confidential information without proper authorization (Gricus, 2019). Professional ethics no longer were limited to questions such as “What’s the right thing to do in this complicated situation?” For many social workers, ethics now included questions such as “Can I be sued or have a licensing board complaint filed against me if I . . .?” This became especially relevant as social work licensure and regulation expanded throughout the United States, beginning with the formal registration of social workers in California in 1945. The formal regulation of social work created boards’ authority to sanction social workers who violated ethical standards (Dyeson, 2004). In addition, beginning in the 1990s social workers became increasingly concerned about the risk of being named in a lawsuit (Reamer, 2015). Thus, ethics-related risk management became a Reamer/MANAGING ETHICS 17 relatively new component of social work education and training. During this period, the focus of ethics consultation, ethics committees, and ethics rounds narrowed to explore the connection between ethical decision-making and prevention of litigation and formal ethics complaints. Digital Period Social workers are now in the midst of what can best be described as the digital period. Today’s social workers can provide services online or via video counseling or text messages to clients they never meet in person (Lamendola, 2010; Menon & Miller-Cribbs, 2002). They may receive Facebook friend requests from clients or former clients that lead to boundary challenges. In this digital era, social workers can use e-mail as a therapeutic tool and provide clients with specialized smartphones that enable them to record and transmit summaries of their moods to their clinicians and caseworkers, receive therapeutic messages and alerts, and communicate with other people in their digital network who face similar life challenges (a virtual support group). Social workers’ sudden pivot to remote delivery of services due to the onset of COVID-19 in 2020 greatly expanded practitioners’ encounter with technology-related ethical issues, particularly concerning issues of informed consent, privacy, confidentiality, and professional boundaries (Banks et al., 2020; Reamer, 2021). Strengthening social workers’ ability to identify and manage ethical issues can no longer be delegated to undergraduate and graduate student classrooms and sporadic post- graduate continuing education workshops, seminars, and webinars. It is time for social workers to learn from longstanding initiatives in allied professions to enhance practitioners’ ability to regularly identify, assess, address, and monitor challenging ethical issues in work with individual clients, families, couples, groups, organizations, and communities. These efforts can include a range of protocols, including (1) informal ethics conversations among colleagues, (2) conferring with an ethics consultant, (3) consulting with an ethics committee, and (4) presenting at ethics rounds. Ethics Conversations In some instances, social workers who encounter ethical dilemmas can choose to confer with colleagues informally, or what is known as a “curbside consult.” These conversations typically occur “off the record” during conversations in a colleague’s or social worker’s office, on the telephone, or on a videoconferencing call. Ordinarily, these informal ethics conversations are not documented in the client’s record or chart (Jiwani, 2017; Jonsen et al., 2015; Kuczewski et al., 2018). In some instances, social workers, especially those in private (independent) practice, may consult informally with members of their peer consultation groups (Golia & McGovern, 2015). Ethics Consultation Ethics consultation—first provided primarily in hospitals—began in the late 1960s and early 1970s (Fletcher et al., 1989; La Puma & Schiedermayer, 1991). In the late 1970s, Pelligrino (1978, 1979) and Siegler (1978, 1979) published several influential papers that ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 18 proposed a role for “clinical ethics” as a discrete and unique field of expertise, and in 1985 the University of California, San Francisco, and the National Institutes of Health co- sponsored a conference on ethics consultation (Bermel, 1985). By 1990, ethics consultation in health care had developed so substantially that a professional journal, the Journal of Clinical Ethics, began publication. Recent systematic reviews of pertinent research provide evidence that ethics consultation in health care settings can have a significant impact on key outcomes, such as decreasing length of stay in an intensive care unit and increasing family and healthcare provider satisfaction (Au et al., 2018; Crico et al., 2021). Over the years, ethics consultation has assumed a variety of forms and tasks that can be usefully incorporated into social work settings (Aulisio et al., 2003). Ethics consultation is typically available to practitioners who encounter a challenging, sometimes deeply troubling, case-specific ethical dilemma. In health care settings, for example, ethics consultation is often sought when a staffer feels caught between family members’ wishes concerning treatment of a gravely ill relative and accepted medical practice which suggests an alternative course of action (Beauchamp & Childress, 2019). Typically, ethics consultants obtain formal training in ethics theory, core ethics concepts, and what has become known as applied, professional, or practical ethics, to supplement their substantive expertise in their respective professions (Jiwani, 2017; Jonsen et al., 2015; Kuczewski et al., 2018). These are individuals who are trained to identify, analyze, and help resolve ethical challenges. Occasionally, an organization will retain a moral philosopher who specializes in professional ethics. In large human service agencies, such as hospitals, ethics consultation may be provided by formally trained staff members. Although these individuals tend to have expertise with respect to bioethical issues (with regard, for instance, to ethical decisions about end-of-life care, organ transplantation and allocation, genetic engineering, and reproductive rights), in principle, staff social workers could be trained to provide ethics consultation. Using in- house social workers may be appropriate in other settings as well, such as school systems, mental health centers, child welfare agencies, and the military. This may require social workers to enroll in ambitious ethics-related continuing education to ensure appropriate knowledge and skills germane to ethics consultation. Realistically, many social workers are likely to be employed in settings that do not have ethics experts on staff. Social workers in modest-sized family service agencies, clinical group practices, substance use disorder treatment programs, group homes, and correctional facilities, for example, are not likely to have resident ethics experts. They may need to reach out to social workers who specialize in professional ethics for consultation services. These may be available at departments and schools of social work and through a professional social work organization, such as the National Association of Social Workers or the Clinical Social Work Association. Ethics consultants can serve several different roles, depending on the employment setting, responsibilities, and particular training and expertise. These roles include those of professional colleague, educator, mediator, advocate, and case manager (Goldman et al., 1983; La Puma & Schiedermayer, 1991). As a professional colleague, the ethics consultant’s mission is to provide a coworker with a thoughtful assessment and reaction to Reamer/MANAGING ETHICS 19 ethics challenges, similar to traditional clinical consultation. In this respect, the social work ethics consultant would help tease out important ethical issues and, while drawing deliberately on relevant ethics concepts and standards, think through options. This consultation, which is typically documented in the client’s record or an administrative file, may include a focused discussion of a complex ethical issue, perhaps related to a coworker’s dilemma related to disclosure of a client’s confidential information to protect a third party from harm or whether it is appropriate to search online for information about the client without the client’s knowledge or consent. An ethics consultant can also be an effective educator (Aulisio et al., 2003; Jiwani, 2017). It is common, for example, for an ethics consultant to provide in-service training on ethical challenges that agency staffers are likely to encounter. Through lectures, case illustrations, simulations, and group discussions, the social work ethics consultant can enhance colleagues’ ability to recognize and address ethical issues in that particular work setting. The ethics consultant may acquaint staffers with common ethical challenges relevant to the agency’s mission and client population, key concepts and resources, and decision-making models and options. As a mediator, the social work ethics consultant can help staffers and clients resolve differences of opinion, drawing especially on social workers’ mediation skills (Goldman et al., 1983; La Puma & Schiedermayer, 1991). For example, in this role the social work ethics consultant might facilitate discussions between a client who believes the agency violated her confidentiality rights and an administrator who is responsible for responding to clients’ complaints. As an advocate, a social work ethics consultant can assist a client or colleague who believes their rights have been violated in some manner (Jonsen et al., 2015; Kuczewski et al., 2018). This might be appropriate if an ethics consultant is contacted by a colleague who believes she has been unfairly disciplined by the employer because she inadvertently disclosed protected health information in an email message to the parent of an adolescent client or to an attorney representing one parent in a child custody dispute. Finally, an ethics consultant can also function as a case manager. In these instances, for example, a social worker may assist a colleague who has been sanctioned by a licensing board for an ethics violation. Under the terms of the licensing board’s consent agreement or consent order, the disciplined practitioner may be required to arrange a series of sessions with an ethics expert to discuss and assess the ethical issues that gave rise to the board’s concerns; ultimately, the ethics consultant would be expected to file a report with the licensing board summarizing the consultation, assessing the practitioner’s fitness to practice, and offering any relevant recommendations. In this sense, the ethics consultant is helping the disciplined colleague manage the licensing board case. In the United States, members of the National Association of Social Workers can also obtain ethics consultation from the National Office of Ethics and Professional Review and from some state NASW chapters that offer ethics consultation. According to the national office’s policy, ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 20 The Office of Ethics and Professional Review provides individual ethics consultations as a benefit of NASW membership. Ethics consultations are a free resource for members who encounter ethical dilemmas and/or have ethics related questions. Consultation services are intended to guide members through the applicable standards in the Code along with other pertinent considerations and resources that address their concerns and allows them to make reasoned ethical decisions. While we can discuss ethical issues, we cannot provide definitive answers for a particular situation or make decisions for members. (NASW, 2022, paras. 1-2) In Canada, for example, the Newfoundland and Labrador College of Social Workers, the provincial regulatory body and professional association, also offers ethics consultation to practitioners. According to the organization’s website, ethics consultations draw directly on the Canadian Association of Social Workers (CASW, 2005a) Code of Ethics, CASW’s (2005b) Guidelines for Ethical Practice, Newfoundland and Labrador College of Social Workers Standards for Practice (2020), and the Social Workers Act (2010). Ethics Committees The concept of ethics committees (also known as institutional ethics committees) first emerged in 1976, when the New Jersey Supreme Court ruled that Karen Ann Quinlan’s family and physicians should consult an ethics committee to help them decide whether to remove Quinlan from life-support technology (Post & Blustein, 2015). In 1975, after being out with friends, Quinlan unexpectedly lapsed into a coma. Upon arrival at a hospital, doctors could find no specific reason for the coma, and started life support, which included a respirator. Quinlan’s health steadily deteriorated and very soon her coma was diagnosed to be irreversible. In a landmark lawsuit, Quinlan’s parents asked that the respirator be disconnected and that their daughter be allowed to die ''with grace and dignity,'' (McFadden, 1985, para. 10) because there was no hope she would recover. A Superior Court judge denied the parents’ request, but the decision was reversed in an appeal to the New Jersey Supreme Court. The court determined that Quinlan, who was in a persistent vegetative state, had a constitutional and common-law right to refuse treatment, even if the refusal would result in her death. Nonetheless, her physicians were unwilling to remove her from a ventilator unless they were reassured that they could not be sued for this action. The court ruled that if a hospital ethics committee agreed with their prognosis—that there was no reasonable possibility of Quinlan returning to a cognitive, sapient state—the physicians would be immune from any legal liability for removing her ventilator at her parents’ request (In re Quinlan, 1976). Ethics committees, which have been most prominent in healthcare settings (hospitals, nursing homes, rehabilitation facilities, hospice, and home healthcare programs), and typically include representatives from various disciplines and positions, such as nursing, medicine, social work, the clergy, and agency administration (Hester & Schonfeld, 2012). Some ethics committees include a formally educated ethicist—either an agency employee (for instance, in large teaching hospitals) or an outside consultant—who has formal training https://journalofethics.ama-assn.org/2006/09/hlaw1-0609.html Reamer/MANAGING ETHICS 21 in applied and professional ethics, moral philosophy, and ethics consultation. Some ethicists are trained philosophers or theologians with a special interest in professional ethics, and some are members of a human services profession (such as social work, nursing, or medicine) who have supplemental education related to ethics. Many ethics committees provide agency staff with case-related consultation services and nonbinding advice, particularly when staff members or clients want assistance thinking through difficult ethical decisions. For example, in hospital settings ethics committees may offer consultation and nonbinding advice on issues related to termination of life-support technology, the use of aggressive care with terminally ill patients, patients’ right to refuse treatment, and patients’ eligibility for organ transplantation. Although ethics committees are not always able to provide definitive advice or guidance about complex ethical issues, they can offer colleagues and clients a forum for organized, focused, explicit, and principled exploration of ethical dilemmas. This can provide participants with a greater understanding of the issues and options they face and enhance the quality of their decision-making. Many ethics committees also serve other functions. Some are responsible for reviewing existing ethics-related policies and suggesting revisions, sometimes in response to controversial case-related issues that arise in the agency. For example, an ethics committee in a family service agency may review agency policies and guidelines related to complicated confidentiality issues (such as disclosure of confidential information to the parents of clients who are minors, disclosure of information about deceased clients to their relatives, and disclosure of information in response to subpoenas or informal requests from law enforcement officials). An ethics committee in a community mental health center may review and suggest revisions of the agency’s policies concerning the termination of services to clients who do not comply with treatment recommendations. Ethics committees also draft new ethics-related policies and procedures for more formal review and approval by agency administrators and boards of directors. For example, in a program that serves clients who have serious drug and alcohol challenges, the ethics committee may draft new guidelines concerning the hiring of former clients as staff members. An ethics committee in a nursing home may draft new guidelines concerning consensual sexual relationships among residents, and an ethics committee in a residential treatment program for children with serious disabilities may draft new guidelines concerning the handling of gifts given to staff by the children’s parents or guardians, or how staffers should manage online communications with clients and former clients in order to maintain clear professional boundaries. Ethics committees also sponsor ethics-related training and education for agency staff. This may include continuing education seminars for licensed practitioners and various types of in-service training on a range of ethics-related topics. Ethics committees may help develop the training and education curriculum, develop teaching material, and recruit presenters. Agency ethics committees provide social workers and their colleagues with a valuable resource when they encounter complex ethical issues. Social workers should not assume, ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 22 however, that ethics committees function as final arbiters or judges of what is ethically right or wrong. Although ethics committees are sometimes approached about relatively simple ethical matters, more typically they are asked to consult on remarkably difficult and controversial issues that resisted easy resolution by line staff and their supervisors before reaching the ethics committees. In such instances, as one may expect, ethics committee members themselves may disagree about what is ethically appropriate. Ethics Rounds Health care professionals are familiar with the age-old tradition of grand rounds. Typical grand rounds consist of presenting the medical problems and treatment of a particular patient to an audience of doctors, physician assistants, nurses, pharmacists, residents, and medical students. Grand rounds are designed to keep participants up-to-date regarding important developments and provide a forum for comment and consultation on complex cases. Grand rounds have been a staple in medical education for more than a century. In the late nineteenth century, the Johns Hopkins Medical School, led by Sir William Osler, introduced bedside teaching as a new approach to clinical education. Residents learned as faculty moved from patient to patient, explaining their methods of diagnosis and treatment. Over time, these rounds moved from the bedside to an auditorium, leading to the inauguration of grand rounds. During the earliest years of the grands round tradition, patients were present. This practice waned by the 1980s due to concerns about patient privacy and to encourage candid discussion among practitioners and other participants (Sandal et al., 2013). Ethics rounds in health care settings (hospitals, rehabilitation and long-term care facilities, and nursing homes) emerged soon after the emergence of the bioethics field in the 1970s. Modeled after grand rounds, ethics rounds typically include presentations and discussions of complex cases or more didactic presentations on key topics (Airth-Kindree & Kirkhorn, 2016; Silen et al., 2016; Teti, 2020). Case Examples Social workers’ use of informal ethics conversations, formal ethics consultation, ethics committees, and ethics rounds should not be limited to health care settings and can be implemented fruitfully in a wide range of social work organizations and programs. The professional literature suggests that these strategies and resources are not used routinely in many social work settings (Banks, 2012; Barsky, 2019; Reamer, 2018). Here are several real-life examples that can model the use of these strategies and resources in social work, based on the author’s experience: Community Mental Health Agency A social worker served as a clinician in a community mental health center serving people who struggle with severe and persistent mental illness. Most of her clients have been diagnosed with schizophrenia, bipolar disorder, depression, and anxiety. https://en.wikipedia.org/wiki/Residency_(medicine) Reamer/MANAGING ETHICS 23 One of the social worker’s clients struggled with co-occurring issues, including bipolar disorder and heroin use. During one clinical session, the client, who was in long-term recovery, told the social worker that “I have something I need to get off my chest. It’s been eating away at me.” The client explained that he has been experiencing “overwhelming” guilt because of a murder he committed seven years earlier when he was actively using and selling heroin. The client told the social worker that one night, when he was selling heroin, one of his customers grabbed bags of heroin and fled without paying. The client reported that he chased after his customer, fired warning shots in the air using the gun he routinely carried, and, when the customer continued to run, fired his gun at him to scare him. The client told the social worker that his poorly aimed shot killed the man instantly. The client said he ran from the scene and was never caught. The police consider this to be a “cold case.” The social worker was unsure about how to handle the client’s confidential disclosure, particularly considering that, at the time of the disclosure, the client was stable and did not pose a serious, imminent, or foreseeable threat. One decision concerned whether to include explicit details about the client’s disclosure in the case record. A second decision concerned whether the social worker had a duty to disclose this information to law enforcement officials or protect the client’s confidentiality. As a first step, the social worker sought out a trusted social work colleague at the mental health agency. They discussed the situation informally (a “curbside consult”) but were not able to reach consensus about the appropriate course of action. During their conversation they struggled to reconcile the social worker’s duty to protect the client and the social worker’s gut instinct that she may have an obligation to disclose information about the unsolved murder based on her understanding of “duty to protect” guidelines she had learned in graduate school. Nonetheless, the social worker found the discussion helpful because it reinforced her hunch that this was an unusually complex ethical dilemma. As a second step, the social worker contacted her former social work professor who specializes in professional ethics. They reviewed all of the relevant details. The professor, who served as an ethics consultant to this social worker, systematically applied relevant standards in the NASW (2021) Code of Ethics concerning exceptions to clients’ confidentiality rights, federal law governing confidentiality disclosures in mental health settings (Health Insurance Portability and Accountability Act [HIPAA]), a state statute governing protection of confidential health care information and disclosures to law enforcement officials, and the state’s social work licensing regulations, which include a section on social workers’ duty to protect clients’ confidentiality and related exceptions. The professor offered his advice and, out of an abundance of caution, encouraged the social worker to present the case to the mental health center’s ethics committee, which had been established about two years earlier. The professor told the social worker that consultation with the agency’s ethics committee would serve two purposes. First, the social worker would have the benefit of review by a cross-section of colleagues who had received in- service training in ethics consultation and decision-making. Second, in the event that a third party raises questions about the social worker’s judgment, she would be able to cite her consultation with the agency’s ethics committee as evidence of her good faith effort to manage this ethical dilemma responsibly. ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 24 Based on these consultations with the social worker’s colleague, the social work professor who served as an ethics consultant, and the agency’s ethics committee—along with careful review of the NASW (2021) Code of Ethics (especially standard 1.07[c] concerning confidentiality exceptions) and relevant federal and state laws—the social worker concluded that her case notes should be vague (referring only to the client’s disclosure of a “past traumatic event”) and that she was not permitted to disclose the information without her client’s consent, particularly since, at the time of the disclosure, there was no evidence that disclosure of this confidential information would likely prevent serious, imminent, and foreseeable harm. The mental health center’s clinical director recognized that this case offered a valuable teaching opportunity for agency staffers concerning management of a complex ethical dilemma. About one month after the acute dilemma, the social worker and her supervisor assembled the agency’s entire clinical staff and presented the case during an ethics round. Following the case presentation, staffers discussed the scenario’s unique features and the social worker’s decision-making process. Substance Use Disorder Treatment Program A social worker was employed at a large family services agency. His principal responsibilities included counseling adolescents who struggle with mood disorders. One of the social worker’s clients, a 16-year-old boy, had been referred by the boy’s school-based counselor. The client told the agency’s social worker that he was feeling depressed primarily because of his parents’ impending divorce. After seven counseling sessions, the social worker concluded that the boy was using alcohol and marijuana excessively and in dangerous quantities. The boy agreed that he had developed a substance use problem and asked for help. The family services agency recently received a federal grant to provide state-of-the-art counseling services to adolescents who have been diagnosed with co-occurring issues (mental health and substance use disorder issues). The boy’s social worker told him about the substance use disorders program at the agency and offered to make a referral. The boy jumped at the chance, in light of his eagerness to get his substance use under control. However, the boy refused to give the social worker permission to inform his mother—his primary caretaker—about his substance use challenges and enrollment in the agency’s substance use disorders program. The social worker used his clinical skills in an effort to get the client to consent to disclosure to his mother. Unfortunately, these efforts did not succeed, yet the boy reiterated his eagerness to enroll in the agency’s substance use disorders treatment program. The social worker was unsure about his duty to protect the boy’s confidentiality and whether the agency could enroll him in the substance use disorders program without parental consent. The social worker conferred informally with his colleague in the agency’s substance use disorders treatment program (a “curbside consult”). After considerable discussion, the two agreed that they were uncertain about the minor’s right to consent to treatment without disclosure to his parents. Shortly thereafter, the two contacted a local social worker who frequently conducted ethics trainings at local human services agencies. The ethics consultant helped the two staffers identify key guidelines that are relevant to Reamer/MANAGING ETHICS 25 this decision. These included the NASW Code of Ethics standard 1.03(c) that advises social workers to consider whether clients have the capacity—legal or otherwise—to consent to services: “In instances when clients lack the capacity to provide informed consent, social workers should protect clients' interests by seeking permission from an appropriate third party, informing clients consistent with the clients' level of understanding” (p. 8). Additional guidelines recommended by the ethics consultant included provisions in HIPAA regarding minors’ privacy rights; the federal regulation entitled Confidentiality of Substance Use Disorder Patient Records (Title 42 C.F.R. Part 2, 2017), which state that “If a minor patient acting alone has the legal capacity under the applicable state law to apply for and obtain substance use disorder treatment, any written consent for disclosure . . . may be given only by the minor patient” (section 2.14); and applicable laws in the social worker’s state governing minors’ right to consent to substance use disorder treatment without notification and consent of parents/guardians. During this discussion, the social workers and ethics consultant discovered that these various guidelines may clash with each other. For example, HIPAA generally permits parents and guardians to access otherwise confidential information concerning their minor children. However, the law in the social workers’ state permits treatment of a minor for substance use disorders without parental or guardian knowledge or consent if there is evidence that disclosure to the parent or guardian would be deleterious or harmful to the minor. In an effort to further analyze this ethical dilemma, the social workers requested consultation with the ethics committee that the family services agency recently formed to provide staffers with consultation. The ethics committee also consulted with a local health care law attorney with whom this agency’s administrators typically consult when complex ethical issues arise. In the end, the ethics committee and attorney agreed that state law—to which federal regulation Title 42 C.F.R. Part 2 directed them—permits the agency to provide services to the adolescent without parental notification under some narrowly defined circumstances. They advised the social worker to carefully document in the case record his consultation and the rationale for his decision. Recognizing that the social worker’s employer might not protect the social worker if, for example, the parents challenged the employer’s judgment, out of an abundance of caution the social worker sought external consultation from a local social work ethics expert and another attorney who specializes in health care law and risk management. The chair of the agency’s ethics committee asked the social worker for his permission to share the case at an upcoming all-staff training on ethics—the equivalent of ethics rounds—as an exemplary illustration of sound ethical decision-making. School A social worker served adolescent students enrolled at a school sponsored by a pediatric psychiatric hospital. All of the students had difficulty succeeding in their local school due to their severe psychiatric diagnoses and behavioral health challenges. One of the students—who had been diagnosed with reactive attachment disorder—also received mental health counseling from another clinical social worker in the same hospital’s outpatient clinic. https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=aa173e270b5d7c2093bfe50f1a2d0c00&term_occur=999&term_src=Title:42:Chapter:I:Subchapter:A:Part:2:Subpart:B:2.14 https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=a78e098f12f0351f4a265a6f68823e4e&term_occur=999&term_src=Title:42:Chapter:I:Subchapter:A:Part:2:Subpart:B:2.14 https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=61a953a9609c7df53daccf0883c43204&term_occur=999&term_src=Title:42:Chapter:I:Subchapter:A:Part:2:Subpart:B:2.14 https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=c7acafb2978c42d2e3be10d443769d74&term_occur=999&term_src=Title:42:Chapter:I:Subchapter:A:Part:2:Subpart:B:2.14 https://www.law.cornell.edu/definitions/index.php?width=840&height=800&iframe=true&def_id=aa173e270b5d7c2093bfe50f1a2d0c00&term_occur=999&term_src=Title:42:Chapter:I:Subchapter:A:Part:2:Subpart:B:2.14 ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 26 One afternoon, a local police detective contacted the hospital following a shooting at a nearby shopping mall. The two social workers’ client, the student, was the principal suspect based on several eyewitness reports. The detective learned from one of the eyewitnesses that the student attended the school sponsored by the psychiatric hospital. At the time, the student was a fugitive. The detective asked the social workers for information about the student, including the date of their last contact, the student’s last known whereabouts, and their clinical impressions. The social workers told the detective they needed to confer with each other about disclosing confidential (protected health) information to her. The social workers spoke privately, away from the detective, about whether these circumstances warrant disclosure (a “curbside consult”). The social workers were unsure about the “rules” germane to management of this ethical dilemma. The social workers told the detective they needed to consult with hospital administrators and arranged to contact the detective later that afternoon. The social workers then contacted their immediate supervisor, who then contacted the hospital’s ethics consultant and the chair of the hospital’s ethics committee. The five of them conferred for an hour; the chair of the ethics committee called a local social work ethics expert for consultation. The ethics consultant systematically reviewed the potential implications of (1) standards in the NASW Code of Ethics governing disclosure of confidential information without client consent, (2) HIPAA (which would apply only to the social worker who provides outpatient counseling to the student, not the school-based social worker), (3) the federal Family Educational Rights and Privacy Act (FERPA), which would apply only to the social worker assigned to the hospital’s school, (4) state laws governing confidential health care information, (5) social work licensing regulations governing client confidentiality, and (6) hospital policy governing management of protected health information. After considerable discussion, which ultimately included the hospital’s attorney and risk management officer, the group agreed that all key relevant guidelines included language permitting disclosure of confidential information without client consent to the detective to address an imminent health or safety emergency. The hospital sponsors an annual ethics conference for all health and behavioral health employees. The chair of that year’s conference invited the two social workers, the chair of the hospital’s ethics committee, the community-based ethics consultant, and the hospital’s attorney to serve on a panel that presented this case scenario in the format of an ethics round. Private (Independent) Clinical Practice A clinical social worker in private (independent) practice provided services to a 20- year-old college student who attended a nearby university. The student sought counseling to help her cope with a longstanding eating disorder. Nearly seven months after in-person counseling began, the student’s university suddenly closed all dormitories due to the onset of the COVID-19 pandemic and required students to return home or some other destination. The student moved back home with her parents in another state, approximately 225 miles away. Reamer/MANAGING ETHICS 27 The student contacted the social worker soon after she returned home and informed her about the move. The student, who reported feeling “very fragile and vulnerable,” told the social worker that she was eager to continue the counseling remotely and was not interested in finding a new therapist in her home community. The social worker was unsure whether she could provide services to her client remotely, particularly given the client’s reportedly fragile condition and the fact that the social worker was not licensed in the student’s home state. The social worker conferred with members of her peer consultation group, who recommended that she contact a former professor of hers who teaches social work ethics for informal consultation. The ethics consultant identified several key guidelines for the social worker to consider. These included (1) 2017 additions to the NASW Code of Ethics concerning remote delivery of services across jurisdictional lines, (2) provisions in technology-related practice standards adopted jointly by the NASW, Association of Social Work Boards, CSWE, and Clinical Social Work Association (2017) concerning provision of remote services across jurisdictional lines, (3) provisions in the licensing regulations in the social worker’s state and in the client’s home state concerning provision of remote services across jurisdictional lines, and (4) an executive order issued by the governor of the student’s home state shortly after the onset of the COVID-19 pandemic permitting clinical social workers licensed in other states to deliver services remotely to residents of the student’s home state, in an effort to enhance citizens’ access to services. The ethics consultant also advised the social worker to contact her malpractice insurer to ensure proper coverage for interstate provision of remote services and to contact the social work licensing board in the student’s home state to confirm that the governor’s executive order was still in effect and that the social worker was permitted to provide clinical services to the student remotely, across state lines. Out of an abundance of caution, the ethics consultant also advised the social worker to call the NASW Office of Ethics and Professional Review, which offers ethics consultation to NASW members. Following the consultation, the ethics consultant invited the social worker to present her ethical dilemma and decision-making during a national ethics education webinar for social workers facilitated by the ethics consultant, a form of ethics rounds. Implications for Practice During the course of their careers, social workers are bound to encounter ethics challenges. Common ethical dilemmas concern management of confidential information, informed consent, conflicts of interest, boundary issues and dual relationships, documentation, termination of services, use of technology, professional paternalism, whistle blowing, and allocation of limited resources, among others. To supplement the foundation-level ethics knowledge social workers should acquire during their formal education, many social workers expand their knowledge as a result of post-graduation continuing education. It is critically important for social workers to build on this foundational knowledge and broaden their systematic use of protocols designed to assist practitioners who encounter complex ethical dilemmas. A number of allied professions have cultivated practical mechanisms to enhance practitioners’ ethical decision-making, ADVANCES IN SOCIAL WORK, Spring 2022, 22(1) 28 including informal ethics conversations, formal ethics consultation, ethics committees, and ethics rounds. It is time for social workers to embrace this same fruitful approach. They can do so by taking several practical steps. Social workers employed in agency settings can identify colleagues who are keenly interested in professional ethics and meet to discuss the development of agency-based protocols. This can include identifying staffers who have in- depth ethics knowledge and expertise who would be willing to serve as both informal (“curbside”) and more formal consultants when ethical challenges arise. If necessary, social workers can explore ways for staffers to gain comprehensive ethics knowledge and skills by attending widely available institutes, conferences, and webinars designed for this purpose (for example, sponsored by the Association for Practical and Professional Ethics, NASW, and various professional ethics centers). Further, social workers employed in organizations can take the initiative to form an ethics committee in settings where one does not exist. These committees can provide staffers with case-based consultation, review existing ethics-related policies, and develop new policies when the need arises. In addition, social workers can organize ethics rounds that feature complex and timely ethical issues for discussion among agency staffers. These ethics rounds can include case presentations and panel discussions, highlighting the relevance of social work values and ethical standards. Social workers in independent practice can take deliberate steps to raise and address complex ethical issues during peer consultation meetings. They can also ensure that they and their colleagues—including those who are members of social work clinical societies— are familiar with consultation resources such as local and national ethics experts, and NASW (both the national Office of Ethics and Professional Review and state chapters that offer ethics consultation to members). Social workers’ use of these strategies and resources—ethics conversations, ethics consultation, ethics committees, and ethics rounds—does not necessarily occur linearly. These options can be used selectively—mixed and matched—as needed, depending on the nature of the ethical issues that must be addressed, the practice setting, and available resources. In some instances, informal ethics conversations may suffice. In others, social workers will find it necessary to seek more formal consultation from ethics experts and ethics committees. In particularly complex cases, social workers will want to gather colleagues and present challenges during an ethics round in an effort to learn and think through responsible handling of difficult circumstances. What is vitally important is that social workers who encounter challenging ethical issues are fully aware of the deliberate steps they can take to act responsibly in an effort to protect clients, third parties, and themselves. 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