CORE 581: Professional Practice Issues and Professional Ethics in Community Rehabilitation Professional Practice Issues and Professional Ethics in Community Rehabilitation Ethical Decision Making Example Application SCENARIO Juan and Jack (both physically disabled) have been friends for many years and have now decided to pool their financial resources and live together in a two bedroom adapted apartment. Juan and Jack have contracted with Jane at the Care at Home Agency to hire a Personal Care Attendant to assist them with personal care needs and also assist in maintaining their home. Recently, Lisa (their new aid) has developed a romantic relationship with Jack. While, it started innocently enough with Lisa providing extra support around the house she is now spending more and more time at the home but not within the guidelines that were previously negotiated. This now leaves Juan feeling awkward around them and uncomfortable in asking for assistance. Juan, although requiring less assistance with personal care than Jack, no longer asks for his daily personal care from Lisa. Juan s health is gradually deteriorating and he is becoming despondent. He does not want to intrude in his long time friend s relationship but on the other hand believes that Lisa is financially obligated to provide support to Juan. Juan confided in Jane that he is torn between supporting his friend and his new relationship and his own health. What should Jane do? Apply the Canadian Code of Ethics for Rehabilitation Professionals - Ethical Decision Making Steps 1. Identify the individuals and groups potentially affected by the decision 2. Identify the ethically troubling issues, including the interests of persons who will be affected by the decision, and the circumstances in which the dilemma arose [includes pointing out the areas of the CARP code that are applicable as well as a rationale 3. Consider how your personal biases, stresses, or self-interest may influence the development of choices of action [this refers to your personal biases not that of the characters in your case study 4. Develop alternative courses of action. 5. Analyze the likely risks and benefits of each course of action on the persons likely to be affected. 6. Choose a course of action, after conscientious application of existing principles, values and standards. 7. How will you ensure the plan is acted upon? 8. Establish a plan to evaluate the results of the action, including responsibility for correction of negative consequences. 9. Evaluation the organizational systems in which the situation arose and discuss how one could remedy the circumstances which may facilitate and reward unethical practice.
Step 1: Identify affected parties: The individuals or groups that are affected in this vignette are Jack, Juan, Jane, Lisa, the home care agency and related profession, Juan and Jack s families, assuming that they are involved in their lives. Step 2: Identify ethical issues using CARP CARP PRINCIPLE UNETHICAL ACTIONS Principle 1: Respect for the Dignity and Autonomy of Persons General Respect: 1.1 Demonstrate appropriate respect for the knowledge, insight, experience, and areas of expertise of others with whom they are professionally involved. Non-Discrimination: 1.5 Act to prevent or correct practices that are unjustly discriminatory, and avoid or refuse to participate in practices that are disrespectful of the legal, civil, or moral rights of others. Not practice, condone, facilitate, or collaborate with any form of unjust discrimination. Vulnerability: 1.6 Take extra measures to protect the rights of persons with diminished autonomy or ability to protect their own rights because of their physical, mental or economic status lack of language, age, gender or other condition that contributes to vulnerability for discrimination, neglect or abuse. 1. Lisa is disrespecting Jane and the agency by engaging in a dual and intimate relationship with a client and not disclosing it. 2. Lisa is disrespecting Juan and his family by neglecting Juan s care, which can affect Juan s well-being, financial situation, and trust 3. Lisa is disrespecting Jack and Juan s friendship 1. Lisa is contracted to provide care for Juan, but her relationship with Jack results in Juan being robbed of this care. 2. Lisa is creating a situation where Juan is forced to choose between reporting Lisa s malpractice and supporting Jack. 1. Lisa is exploiting Jack and Juan s resources by residing at their home for personal reasons. Neglect in care may cause Juan s health to decline and prohibit him from full societal participation. Juan may have to find a new home away from Jack. Juan s autonomy, welfare and liberty rights are diminished. Community: 1.7 Respect families of clients, social and workplace or school networks and enlist their support in achieving rehabilitation goals when the client agrees to such collaboration. Informed Consent: 1.8 Honour the right of clients, students, research participants, and direct recipients of services to give informed and specific consent to their participation and to withdraw that consent when desired. Inform recipients of legitimate third party restrictions. 1. Lisa is disrespecting Jack and Juan s families by not providing equal care for both individuals and fails to account for how her actions will affect their families, financially and emotionally. 2. Juan s goals may be hindered due to diminished health and well-being. Other professionals may find it difficult to help Juan because of unstable conditions. Lisa is reducing Juan s supports. 1. Juan was not fully informed of the changes or relationship between Lisa and Jack and was not given any choices in terms of allowing Lisa to stay for personal reasons.
Informed Choices: 1.10 Offer clients options to make informed choices regarding rehabilitation plans and fully explain confidentiality issues prior to obtaining formal consent. Informed consent involves choices, not single proposals. 1.11 Ensure that the person giving voluntary consent understands the information that a prudent person would wish to know; includes what interventions and supports are proposed, and the risks and financial implications. 1.15 Inform parties of ethical responsibilities and roles when employed by third parties for purposes other than direct client services; ensure that individuals with disabilities and/or disadvantages are aware of the limitations on their freedom of consent and protection of confidentiality. Privacy: 1.18 Respect the privacy of individuals by soliciting only that personal information that is relevant to providing quality professional services. Professionals should also inform individuals of the potential risks associated with disclosing personal information. Extended Responsibilities: 1.25 Assume overall responsibility for the scientific and professional activities of their assistants, employees, supervisees, and students with regard to the Principle of Respect for Dignity and Autonomy of Persons Principle 2: Responsible Caring for the Best Interests of Persons 2. Lisa did not inform Jane or Jack and Juan s families about her relationship with Jack, such that proper resolutions and steps could be followed. 3. Juan was not informed by Lisa of how her relationship with Jack would affect the services and aid that he was receiving or the financial issues that he would face if he and Jack had to break their mutual funding agreement. 4. Lisa did not discuss with clients her ethical responsibilities and the consequences of her dual relationship. While Lisa did not restrict Juan from reporting her, Jack s friendship restricted Juan from doing so. 1. Lisa is at Juan and Jack s residence for extended periods of personal time, which creates a potential for both Juan and Jack s privacy to be violated. 1. Insufficient information to judge whether Jane handled this situation properly. Given that Lisa s has damaged Juan s life, Jane should have allocated more effort to overseeing Lisa s actions General Caring: 2.1 Protect/promote the welfare of persons with a disability and/or disadvantaged, families, students, research participants, colleagues, and others; avoid doing harm; make reasonable efforts to correct harm. 1. Juan experiences a lack of basic care, which may cause stresses in other life areas; there has been no effort to correct this harm done. Juan, Jack and their families welfare are at risk Competence: 2.2 Practice only within the boundaries of established competency, based on such criteria as education, training, supervised experience, professional credentials and appropriate professional experience. CRDS professionals seek to gain and maintain interdisciplinary competence, including in interdisciplinary ethics. Professionals notify appropriate persons when they are ill qualified to perform responsibilities. 2.4 Continually monitor rehabilitation plans to ensure continued viability and effectiveness, remembering that people have the right to make choices. Not place, or participate in placing, persons in positions that will harm them or others. 2.5 Delegate activities only to persons who are competent to execute them, continue practices only when they benefit others, only when physical/psychological conditions do not impair their ability to benefit others, and refer to appropriate alternative services as needed. Self-Awareness and Self-Care: 2.6 Evaluate own experiences, attitudes, culture, beliefs, values, social context, individual differences, and stresses that may influence their interactions with others, and integrate this awareness into all efforts to benefit and not harm others. 2.8 Take measures to recognize professional/personal limitations, balance one s professional/personal life, to prevent 1. There is potential that Jane and the agency are not properly employing people for the job of a care aid, both practically and ethically. 2. Lisa may not be sufficiently trained in dealing with ethical dilemmas and the procedures or rules regarding personal relationships with clients. 3. Lisa may not be competent enough to maintain professional boundaries and fulfill her responsibilities. 4. Lisa did not carry out practices that only benefit Jack and Juan, but also herself, impairing Juan s ability to receive benefit from services. 5. Both Lisa and Jane failed to monitor the rehabilitation plans of Juan, leading to health and psychological stress. 1. Lisa did not reflect on the consequences of her dual relationship 2. Lisa did not evaluate how an imbalance between her personal and professional life could lead to negative consequences for all parties involved (e.g. failure to provide Jack with care if they are in a dispute).
excessive stress and impairment; cease provision if impaired. 2.9 Recognize their own needs, and not undertake activities in which personal problems lead to inadequate performance 3. Lisa did not evaluate how her relationship with Jack would lead to inadequate performance and negatively affect everyone involved (e.g. inability to handle care for both individuals) Prevent Harm: 2.12 Alert employers to working conditions that potentially disrupt or damage their abilities to effectively perform or result in harm for persons with disabilities. 1. Lisa did not inform Jane or the agency of her dual relationship and how this was affected Juan s health and his ability to participate in activities Client and Community Collaboration: 2.14 Cooperate with clients, team members, other professionals, and community services in serving the interests of clients. Implementing collaborative decisions unless such decisions clearly violate the ethical principles and are likely to result in harm to others. Support your position with reasoned argument and in a respectful manner. 2.15 Respect the rights and reputation of associated institutions, organizations, or firms when making statements. When organizational demands conflict with the ethical principles, specify to responsible officials the nature of conflicts, commitment to their code of ethics, and desire to effect change by constructive organizational action. Principle 3: Integrity in Professional Relationships Accuracy and Honesty 3.1 Act honestly in professional relationships and not participate in or condone, dishonesty, fraud, or misrepresentation. 3.2 Consult on a benefit/harm analysis of the scientific and human values before making exceptions to honest communication. If information is withheld in the best interest of the client, provide immediate disclosure to respect others and maintain profession public trust. 3.3 Accurately represent their own and their associates qualifications, education, experience, competence, and affiliations. Objectivity/Lack of Bias: 3.11 Evaluate how personal experiences, attitudes, values, social context, individual differences, and stress levels influence activities and integrate this awareness into all attempts to be objective and unbiased in their professional activities. 3.13 Honour commitments in any agreement, unless there are unexpected circumstances. If such circumstances occur, make a full and honest explanation to other parties involved. Avoid Conflict of Interest: 3.15 Not exploit professional relationships to further personal, political, or business interests at the expense of the best interests of clients. Avoid dual relationships that impair professional judgment or increase the risk of harm to others. 3.16 Take precautions when dual relationships cannot be avoided and may compromise professional objectivity. 3.17 Not engage in sexual intimacy with current or past clients. 3.21 Discontinue service if conflict of interest compromises service delivery. 1. Lisa did not cooperative with Juan, Jane, the agency or other professionals in Juan s life for the best interest of Juan. Juan s health is at risk, which hinders societal participation. 2. Lisa is jeopardizing Juan and Jack s choice of living independently. 3. Lisa did not respect the rights and reputation of her agency, Jane or her field of work. She is creating stigma around related fields, jeopardizing the trust of clients and their families towards various agencies that can provide them with support. 1. Lisa did not disclose her relationship with Jack to parties involved and withheld information for her own benefit, risking public trust in the profession. 2. Lisa misrepresented the agency and the profession by engaging in behaviours that are not in line with agency/professional expectations. 1. Lisa does not evaluate how her dual relationship affects Juan s health and goals, Juan and Jack s friendship, the agency, and her personally. 2. Lisa did not fully explain her relationship and possible consequences to any parties involved and failed to fulfill her job commitments and ethical responsibilities. 1. Lisa entered into a dual relationship with Jack, which increased all sorts of risks for Juan, Jack, their families, and the agency 2. Lisa exploited her clients resources and placed her own interests above her clients. 3. Lisa did not avoid dual relationship, intimacy with client or discontinue service after compromised ability to provide care for Juan.
Reliance on the Profession: 3.25 Understand and abide by profession ethical and practice standards. Do not advocate, sanction, participate in, or condone acts prohibited by the Code unless it is detrimental to the rights and well-being of others. Consult with professionals when a difficult ethical dilemma arises. Co-operate with committees authorized by a professional association to investigate or act upon ethical violations. Principle 4: Responsibility to Society Development of Society: 4.12 Uphold the profession s responsibility to society by promoting the highest standards of the profession, complying with educational standards, and by supporting measures to maintain accountability. 1. Lisa did not abide by professional and ethical guidelines set out by her agency and profession and did not consult with others when faced with an ethical dilemma 2. Lisa s actions were detrimental to the rights and well-being of all parties involved, especially Juan. 1. Lisa did not uphold professional responsibilities, establish proper professional boundaries and take responsibility for the consequences of her actions.. Care of a client was neglected. Step 3. Our own biases that are included in this dilemma: Overconfidence Bias. With our educational background in community rehabilitation and disability studies, we often make assumptions that other people have been through relevant training and have the knowledge and competency to handle ethical issues. We believe that our judgements are more sound than Lisa s; therefore we may judge her actions more harshly. Our subjective confidences in the reliability of our judgement may be greater than the objective accuracy of those judgements. Cultural and Value Biases. The intrinsic cultures and values that we have developed from working with devalued and marginalized individuals, reflect the utmost respect we have for these individuals. Lisa may be come from a culture where this is not recognized, resulting in different attitudes and behaviour towards disabled persons. Lisa may value personal relationships over professional ones and act according to those priorities. Experiential Bias. With our experiences in working in human services, we understand the standards of morality and positive inclusive actions that can be made to better serve our clients. We assume that Lisa s experiences are the same as ours and act from the same worldviews as we do. Confirmation bias. Since the purpose of this assignment was to evaluate Lisa s actions, we mainly searched for evidence that demonstrated that Lisa was unethical; therefore, we may ignore possible evidence that counters our conclusions. Group think bias. As we are a group of friends and classmates working together, we tend to work in harmony and agree with one another s views. This narrows our thinking, decreasing the number of possible alternative conclusions. Step 4 and 5. Develop alternative courses of action and identify the risks and benefits: Courses of Action Benefits Risks Plan A: Jane fires Lisa with no prior warning, based on the premise that Lisa was neglectful in the care of her clients Opens position for more qualified aid Family might feel safer with Lisa out of the shared home Funds allocated to appropriate care of both clients Jack is emotionally impacted by Lisa s absence; Jack and Juan s friendship and mutual housing is jeopardized Lisa s position is not immediately filled
Plan B: Jane conducts peer consultations with each party to set the record straight and to understand everyone s perspectives and resolution intentions. Jane then conducts a carefully regulated meeting between all parties to come to a resolution where all parties are taken into account and are satisfied. Agency reputation and standards will be upheld and the agency is taking action and being accountable Involved parties are aware of the situation and can openly and honestly engage in conversation. No rash decisions made that escalates situation. Minimize the risk of possible legal disputes; more collaborative solutions Ensure that the safety and rights of all vulnerable persons are protected. Legal dispute between Lisa and Jane on the grounds of wrongful dismissal on Jane s part; reduces agency reputation if it proceeds to court Creates more power dynamics and conflicts at the meeting if not well regulated; potential to cause tension, and break in relationships If no mutual resolution made, Juan and Jack might fear advocating for their rights in the future Issue delay; time dilutes the urgency of the situation and Jack and Juan receives no care and distrusts agencies Plan C: Juan and Jack given the options of both moving out or one moves out. Plan D: Provide Lisa the choice of choosing exclusively one of two options: either you are still the client s provider of support, or you are romantically involved with Jack, but not both Plan E: Replace Lisa, and put Lisa in another placement. Lisa completes educational program about workplace ethics before return. The agency reviews and adheres to CARP codes more closely. An interdisciplinary monitoring body is to be developed through specialized training to conduct quarterly reviews, gather data, develop ways to ensure that ethical codes are well implemented and refines how to deal with violations. Alleviates relationship tensions Juan and Jack s friendship remains Allows Juan to find more suitable care and build new supports Lisa will be more aware of her duties and professional and personal boundaries If Lisa chooses the relationship, the needs of Juan and Jack can be met by a more qualified aid Lisa stays in a relationship with Jack with no repercussions; less emotional complications Lisa and Jack can continue relationship Juan has his needs met by new aid No turnover time for training a new aid, as they would just be trading placements. Consistent implementation of ethical guidelines; ensures all staff are better equipped to handle ethical dilemmas; provides systematic method to assess ethical practices and deal with violations Financial issues for clients and their families if new accommodations, aids or agencies are required Both clients become left without companionship Clients may not find immediate care if relocates quickly If Lisa chooses the job, she might face psychological confusion from being in a dual relationship to a single role; creates animosity between Juan and Jack over Lisa s choices and awkward environment that impedes care; Juan may feel guilty. If Lisa chooses the relationship: Juan and Jack s friendship broken; immediate aid not available Juan and Jack might not adapt to the new aid Juan might fall into the same position as before New aid over-scrutinized because of previous situation The agency may be viewed as too lenient on Lisa No new guidelines to ensure that Lisa is taking full responsibility for her actions; it takes time to develop a monitoring body and new ethical practices Step 6, 7 and 8: Choose a course of action, a way to ensure that the plan is acted upon and a method of evaluation:
Step 1: Consultations Step 2: Collaborative Meeting Jane should consult other agency experts and her superiors on how to approach this ethical issue. This would allow Jane to gain insight into the different facets of the issue and possible pathways to resolution. Jane should then meet separately with all parties involved to gain an understanding of how each individual perceives the situation and the impact that it has on them. Individuals will be given a chance to express their thoughts and opinions on the matter without outside influence. Jane should organize a meeting involving all parties for open and honest discussion and inform all parties of the purpose and structure of the meeting and ensure that all perspectives are heard in a respectful and non-confrontational manner. The meeting must be regulated well to prevent new conflicts and arguments from arising. For example, Jane can present a summary of the perspectives that she gathered from individual consultations and present courses of actions and then proceed to allow parties to speak. Together, parties can brainstorm and explore the risks and benefits of various courses of action for each individual. Caution to focus the collaborative meeting to minimize redundancy and increase productivity towards a solution in a timely manner. Step 3: Arrive at a Solution It should be noted that until we conduct steps 1 and 2, we cannot forsee what the details and content of the meetings will be. As an example, after weighing all the risks and benefits for all parties, the most appropriate and realistic solution that we have come up with would be a combination of Plans B and E. This solution would allow all parties' voices to be heard, empower vulnerable individuals to advocate for their rights, careful consideration of the issue, prevention from rash decisions that may further escalate the issue, ensure that the safety and the rights of all vulnerable persons are protected, consistency in the organization and involvmenet of all levels of the organization. Step 4: Plan Implementation and Evaluation The agency should review the CARP code of ethics and its adherence to the code. The agency should establish an ethics monitoring body of trained individuals to assess how the CARP code is implemented in the work field. A quarterly report should be made to the executives of the agency where reviews and adjustments are made accordingly. The monitoring body should work collaboratively with support workers to gather information from clients and their families (e.g. through monthly progress reports, surveys, individual interviews) and evaluate whether implemented plans follow ethical codes and protect clients. Establish guidelines and protocols to deal with violations of the CARP code. Document cases and clear consequences of violations. An entry training course in ethics should be mandatory for all agency employees to minimize the number of ethical issues that arise. In this situation, for example, Lisa should be given a warning for her violation, required to complete a training program on ethics, return to work at a different placement on a probationary basis and provide monthly reports to her supervisor. A performance review by her supervisors and clients will determine whether she can return to work independently. Step 9: Evaluation of Organizational Systems. When discussing the potential solutions that could be taken to resolve this issue, our group began to speak on the lack of regulation of care, and policy in relation to the organizational system from the agency that was likely to allow these actions from caretakers to occur. We then, analyzed what effective regulation would look like to prevent such happenings. All group members recognized that there wasn t any assessment produced by Jane. We recognize that if Jane produced these assessments for Lisa, Juan and Jack; earlier acknowledgement of the issue and intervention could have been taken earlier before Juan s health became a heightened concern due to neglect from Lisa. With earlier intervention, the ethical solution that we have created (Step 4: Plan and Implementation and Evaluation), could then have provided a quick and appropriate remedy of the issue to all parties involved.