Dolgoff loewenberg & harrington ethical decision making model

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GUIDELINES FOR ETHICAL

DECISION MAKING: THE

DECISION- MAKING PROCESS AND TOOLS

CHAPTER 4

In the previous chapter, we examined philosophical components, contemporary approaches, and values as background for ethical decision making. In this chapter, we turn to the practical components of decision making itself. Sometimes a social worker can realize instantly that an ethical decision must be made. More typically, decision making is a process or series of thoughts and activities that occur over time and that result in a person or group acting (or not acting) in a particular manner. The process may not be conscious, but it always precedes making the ethical decision itself. Decisions will be better, more effective, and more ethical to the extent that the process becomes conscious.

Ideally, decisions are approached step by step so that one moves through a series of stages until, at the end of the process, one makes the decision. It is erroneous to assume that only one person, the decision maker, participates in this process. There may be many participants in the decision-making process, but there is only one responsible decision maker. Many different persons present information, react to assessments, introduce additional options, or make changes in the environment; these, in turn, change the nature of the data on which the decision is based or the nature of the decision that is made.

Observing decision making is like watching ocean waves approach the shore. Choices are always influenced by previous decisions that lead to new directions. Ethical decision making is far too complex to permit the development of a "how-to" problem-solving model, but a model may help social workers understand what is involved in ethical decision making. Like all models in science, such a model will simplify reality by focusing on only one decision. A model is a permissible didactic device as long as it is understood that in real life every decision is preceded and followed by other decisions, many of which have a direct bearing on the matter under consideration. In Figure 4.1, we present a general model for decision making that is

59

60 CHAPTER 4

FIGURE 4·I I A GENERAL DECISION-MAKING MODEL

1. Identify the problem and the persons, institutions, clients, professionals, support systems, victims, and others that I---- are involved in this problem.

j 2. Determine who should be involved in the decision making.

j 3. Identify the relevant values held by those identified in

step 1, including the client and worker.

j 4. Identify the goals and objectives whose attainment you

believe may resolve (or reduce) the problem.

j 5. Identify alternate intervention strategies and targets, and

assess the effectiveness and efficacy of each alternative in terms of the identified goals.

j 6. Select and implement the most appropriate strategy.

j 7. Monitor the implementation, paying particular attention to

unanticipated consequences; evaluate the results and e-- identify additional problems, opportunities, and options.

applicable to many different siruarions and is nor limired to ethical decisions. This model is based on the assumption that social workers can plan rationally what is needed for intervention in human situations and that they want to minimize the irrational, the impulsive, and the unplanned consequences of actions.

GUIDELINES FOR ETHICAL DECISION MAKING: THE DECISION-MAKING PROCESS AND TOOLS 61

1. Identify the relevant professional values and ethics, your own relevant values, and any societal values relevant to the ethical decision to be made in relation to this ethical dilemma.

2. What can you do to minimize conflicts between personal, societal, and professional values?

3. Identify alternative ethical options that you may take. 4. Which of the alternative ethical options will minimize conflicts between your

client's, others', and society's rights and protect to the greatest extent your client's and others' rights and welfare, and society's rights and interests?

5. Which alternative action will be most efficient, effective, and ethical, as well as result in your doing the "least harm" possible?

6. Have you considered and weighed both short- and-long term ethical consequences?

7. Final check: Is the planned action impartial, generalizable, and justifiable?

FIGURE 4.2 I ETHICAL ASSESSMENT SCREEN

ETHICAL ASSESSMENT SCREEN The social worker who is alert to the ethical aspects of practice will examine and assess the available options and alternatives somewhat differently than her colleague who is not as concerned with those aspects. This becomes clear when we consider various assessment criteria. In Figure 4.2, we present an ethical assessment screen designed to help social workers furrher clarify and integrate the ethical aspects of decision making in social work practice.

PROTECTION OF CLIENTS' RIGHTS AND WELFARE

The definition of rights and privileges changes over time, and these changes may create ethical problems. What is thought ro be a right at one time may not be so defined in another era-for example, social workers were once expected to protect confidenti- ality, no matter what the obstacles. Today, social workers remain concerned about confidentiality but may not be able to completely protect it for various reasons: changes in laws; court decisions; the introduction of new technologies; managed care and administrative record keeping required by funding and accrediting organizations; participation and consultation with team members, including those from other disciplines; and responsibility to supervisors and courts. In chapter 5, new privacy regulations required by the Health Insurance Portability and Accountability Act (HIPAA, 1996) that became effective in 2003 will be discussed.

Changing definitions of rights may also create ethical problems for social workers. Consider the ethical problems faced by social workers in the adoption field as the right of adopted persons to information about their biological parents is becoming recognized in more and more jurisdictions. At one time, the biological and adoptive parents were assured that such information would remain confidential and would never be shared with

62 CHAPTER 4

the adoptee. Now, when court decisions or legislative enactments in some states support the right of adopted persons to this information, social workers in these jurisdictions have little choice but to reveal it. Is it ethical for other social workers to continue to tell biological and adoptive parents that this information will always remain confidential when they have no way of ensuring this promise? This problem is not limited to courts and adoptees. No social worker can ever assure complete confidentiality because the social worker often cannot control what others (interdisciplinary team members, insurance companies, etc.) will do with the information she appropriately shares.

PROTECTION OF SOCIETY'S INTERESTS

Sometimes it is difficult to balance society's interests with a client's interests. If a client tells his social worker that he has committed a property crime, the social worker must weigh her obligations to the client against her obligations to society. Social control is one of the functions of every social worker, but so is the maintenance of a helping relationship. To which function should the practitioner give priority if she cannot pursue both at the same time? Does it matter whether the law violation harms another person? Can lawbreaking be overlooked when a client makes progress toward attaining identified and constructive intervention goals? Keep these questions in mind as you assess the ethical dilemmas posed in Exemplar 4.1.

_ I SECURlTY OR PROTECTION? John Newton was a likable young man-22 years old, not steadily employed, but always willing to help. Even before Ray Dunkirk, the community worker, had arrived on the scene, John had organized a number of young adults into a club. This club was well known in the neighborhood for the many helpful services it provided. The community's elderly population was especially appreciative of the security services that the group gave them. Thefts and holdups of older people had ceased ever since this club began to operate in the community. However, Ray became aware that John had intimidated local store owners and obtained regular payoffs from them in return for promising them "protection." What was Ray Dunkirk to do? He considered various options, including the following:

• Overlooking John's protection racket in view of the many positive things he was doing that were benefiting the community

• Reporting John's protection racket to the police, because illegal activities should never be condoned

• Strengthening his relations with John with the view of helping to guide him away from the illegal activity; in the meantime, he would not report the law violation to the police

What are the ethical aspects in choosing the best option? One ethical dilemma is how to balance the best interests of the various persons and groups involved: older persons, storekeepers, the community, t.he larger ~ociety, an? others. Anothe~ ques- ion concerns the ethics of doing something that might result 10 the return of VIOlence :gainst the older people of this community. The following discussion is inten,ded to help social workers cope with these conflicts and find answers to these questions.

GUIDELINES FOR ETHICAL DECISION MAKING: THE DECISION-MAKING PROCESS AND TOOLS 63

THE "LEAST HARM" PRINCIPLE

Sometimes social workers are confronted by problems for which there are no positive choices. Regardless ofthe option chosen by the client and/orthe worker, some harm will cometo one person or another, perhaps even to the client or to the social worker. What is the ethical choice in such situations? The "least harm" rule suggests choosing the option that will result in the least harm, the least permanent harm, or the most easily reversible harm. These are not always simple decisions, and in some cases, there are complex considerations. A social worker has to consider "the least harm to whom?" A given choice may result in the least harm to one person but major harm to another person.

Consider the options facing EBen Ashton, the social worker who has to consider the options in the Madurai family situation (Exemplar 1.1). Does the least harm principle offer guidance in choosing the most ethical alternative? How?

Some have suggested that the routine application of the least harm principle may diminish the possibility of choosing the most effective intervention technique. There may be times when it is justified to use an option that has great risks but enhances the likelihood of a successful outcome. However, such a choice should be made only with the full consent and agreement of the client.

EFFICIENCY AND EFFECTIVENESS

Many people think that efficiency and effectiveness are synonyms, but there are important differences between the two terms, especially when it comes to ethical decision making. The efficiency criterion is concerned with the relative cost (including budget, staff time, agency, and community resources) of achieving a stated objective. Whenever two options will lead to the same result, the one that requires fewer resources is the more efficient one. The effectiveness criterion, on the other hand, relates to the degree to which the desired outcome is achieved. When the implementa- tion of one option results in halving the number of poor people in a county, while the second option reduces the poverty population by 80%, the latter option is the more effective one-but its cost may be so high that it is considered inefficient.

Difficult choices arise when the more efficient option is the less effective one or vice versa. In addition, making decisions only on the basis of efficiency and effectiveness criteria may result in unethical decisions. At times, the most efficient or the most effective option must be rejected because of its ethical implications. As early as 1975, Cuba tracked down Cubans who had lived in Africa and tested them for diseases. Cuban officials also committed people to sanitariums when they tested HIV positive, where they were forced to remain, despite human rights complaints by Cubans and other persons. Later, some HIV-positive men and women were allowed to leave if their condom use and hygiene were approved (Aguilera, 2003). In the United States, these actions may be seen as highly effective at controlling the transmission of HIV but questionable from an ethical point of view. For example, sending poor people or people with chronic mental illness to another city or deporting them to another country may be the most effective and most efficient way of eliminating poverty or the expense of long-term or repeated hospitalizations, but such decisions must be dis- missed out of hand by anyone who is concerned with the ethical implications of these proposed plans.

64 CHAPTER 4

More often, the ethical assessment of an option is not as clear as in these examples, so a social worker may find it difficult to make a decision. For example, what are the ethical implications of forcing poor people to work, a more efficient option? Work is highly valued in our society, but force means limiting a person's freedom, another important value in our society. The ethical assessment, in this case, demands that we assess work and independence against the loss of freedom. In the past, social work ideology rejected the various "workfare" programs that forced poor people to work. With the implementation of Temporary Assistance fat Needy Families (TANF), a change in societal and social work ideology and values is apparently taking place. Although a professional consensus on the issue may be lacking, there appears to be less agreement on whether "workfare" is ethical than was true in the past (Dolgoff, 2002).

Another kind of ethical quandary arises out of the continuing efforts to dein- stitutionalize patients of mental hospitals. When this policy was first proposed some years ago, certain professionals supported and implemented the program because they thought it would tight a wrong. In some instances, the option of releasing mentally ill patients from hospitals was adopted even though it was known that most communities lacked adequate resources for caring for these people. Many state governments were unable to help communities with the problem because they themselves were facing major budget cuts. How ethical was it to institute a strategy that might result in some long-range improvements, but in the short run might harm many fragile people, as well as others? Was it ethical to do so without first ensuring the availability of adequate community resources? Consider this question by using the ethical assessment screen (Figure 4.2). The ethical assessment screen provides a sequence of questions to be answered systematically that takes a person through the important variables to consider in order to arrive at a thoughtful and careful ethical decision.

RANK ORDERING ETHICAL PRINCIPLES In the preceding sections we discussed a number of ethical criteria that some social workers have found helpful when assessing decision alternatives. These criteria have not been arranged in any order of priority. More specific guides are needed whenever two or more of these criteria point toward different alternat.ives. Even though some social workers disagree, we believe that the preferred way of resolving such conflicts among ethical principles is a lexical ordering ofthese principles-that is, tank ordering them from the most important to the least important. Such ordering is necessary even though "ordering principles is not an easy task" (Christensen, 1986, p. 82).

A lexical ordering of ethical principles can provide social workers with a guide, but such a guide is not meant to be a magic formula that can be applied blindly. As Baier (1958) suggested, the principle of priority should be used when two or more moral rules (standards) conflict. Based on the earlier work of a number of authors including Baier (1958), Kitchner (1984), Joseph (1985), Lewis (1984), Reamer (1983), Siporin (1983), and Zygmond and Boorhem (1989), we have prepared guides for ethical decision making. Social workers rarely make direct use of theoretical knowledge or philosophical principles when making practice decisions. Instead, they have integrated knowledge and values into a set of practice principles, and these are what social workers use at the critical points in the decision-making process. We have

GUIDELINES FOR ETHICAL DECISION MAKING: THE DECISION-MAKING PROCESS AND TOOLS 65

Examine the Code of Ethics to determine if any of the Code rules are

applicable. These rules take precedence over the worker's

personal value system.

One or more of the Code rules apply:

The Code does not address the specific problem or several Code rules provide conflicting guidance:

Follow the Code rules.

FIGURE4.3 I ETHICALRULESSCREEN(ERS)

used the work of the authors mentioned, as well as additional sources and our own practice experience, to prepare the following two guides or screens that we believe will be helpful in making ethical decisions. We call these guides the ethical rules screen (ERS) and the ethical principles screen (EPS) (see Figures 4.3 and 4.4). These guides are meant to be tools; they should not be applied blindly.

The ERS should always be used first. Only when this screen does not provide any satisfactory guidance should the social worker use the EPS. To be useful, a guide for rank ordering ethical principles must clearly indicate the order of priority of such principles. Once such a priority list has been established, the operating rule is that the satisfaction of a higher-order principle takes precedence over the satisfaction of a lower-order principle. Even though there is not yet any general agreement on the rank order of professional ethical principles, we have developed the EPSon the basis of our perception of what might be the consensus among social workers. All ethical principles are important. When more than one ethical principle is relevant in the analysis of a set of practice options and each of these principles leads to a different outcome, the rank order suggested in the EPS should be used to make a decision. In other words, an assessment based on Ethical Principle 1 is more compelling than one using Ethical Principles 2 or 3. For example, if both confidentiality (Principle 6) and fulldisclosure (Principle 7)apply, the ethical principle ofconfidentiality should receive priority. Because the EPS is the key ethical assessment tool for resolving ethical practice dilemmas, we will comment in detail on each of these principles.

66 CHAPTER 4

Protection of Life

Equality andlnequaJity

Autonomy and Freedom

Least Harm

Quality of Life

Privacy and Confidentiality

Truthfulness and Full Disclosure

FIGURE 4.4 I ETHICAL PRINCIPLES SCREEN (EPS)

ETHICAL PRINCIPLEI The protection of human life applies to all persons, both to the life of a client and to the lives of all others. This principle takes precedence over every other obligation. "The right to life is the most basic of all rights, for if one's right to life is violated one cannot enjoy any other rights" (Kuhse & Singer, 1985, p. 509).

Most physicians follow this principle of saving and prolonging human life, regardless of the resulting quality of life or the economic costs involved. This life- sustaining principle received wide publicity through the cases of Karen Ann QuinJan and Terri Schiavo, whose physicians refused to withdraw life-support systems, even though these patients had been unconscious for many years and there was no further hope for any positive change. Today, physicians keep many Americans "alive" through the use of high-tech life-sustaining instruments. Social workers, on the other hand, tend to place more emphasis on improving the quality of life for individuals, groups, and communities. Most of the time, social workers are not aware of any conflict between the biophysical principle of sustaining life and the psychosocial principle of improving life. At times, however, there is conflict. One example is the case of a middle-aged man with marked hypertension. The medication that brought down his life-threatening blood pressure also caused sexual impotence (Roberts, 1989). Is it ethical for a social worker to support this client's decision to stop taking the medication so that he can once again enjoy sexual relations? Such a decision may lead to an improvement in the quality of his life (Ethical Principle 5), but it may also contribute to shortening his life span (Ethical Principle 1).

GUIDELINES FOR ETHICAL DECISION MAKING: THE DECISION-MAKING PROCESS AND TOOLS 67

ETHICAL PRINCIPLE 2 The principle of equality and inequality suggests that all persons in the same circumstances should be treated in the same way-that is, persons in equivalent situations have the right to be treated equally. At the same time, persons in different situations have the rightto be treated differently if the inequality is relevant to the issue in question. Unequal treatment can be justified when other considerations such as beneficence (the duty to do good, not harm others) outweigh the equality principle or on the grounds that such unequal treatment will promote greater equality (Frankena, 1973, p. 52). This principle was formulated by Kitchner (1984) and is based on the seminal work of Rawls (1971). Kirchner specifically applied this principle to ethics; she taught that a principle can suggest an obligation, but if there are special circumstances or conflicting obligations, one should always act on the basis of the obligations derived from the higher principle.

This principle applies in situations that involve child abuse or elder abuse because the abused child (or elder) and the abuser are not in an equal position. In these circumstances, the principles of confidentiality and autonomy with respect to the abusing adult are of a lower rank order than the obligation to protecr the child or older person, even when it is not a question of life and death. Another situation in which this principle applies occurs when several families apply for limited resources. For example, after a natural disaster, many families may need emergency housing, but higher priority may be given to finding housing for families with small children or frail elderly and lower priority may be given to families with only healthy adults. Should family composition or prior lifestyles be taken into consideration? In situations where one family is demonstrably nearer nutritional or other disaster, the ethical principle permits or even requires the unequal allocation of scarce resources.

ETHICAL PRINCIPLE 3 A social worker should make practice decisions that foster a person's self-determination, autonomy, independence, and freedom. Freedom, rho ugh highly important, does not override the right to life or survival of the person him- or herself or of others. A person does not have the right to decide to harm someone else on the grounds that the right to make such a decision is his or her autonomous right. When a person is about to make such a decision, the social worker is obligated to intervene because Ethical Principle 1 takes precedence.

The risklbenefitratio may also help determine when the auronomy principle applies and when it is ethical to ignore aclient's "decision." Ifthe condition facing aclient is life threatening and if the risk of intervention is minimal (while the potential benefit of the intervention isgreat), the social worker may consider proceeding even without aclient's consent. In this situation, the client's refusal mayor may not be considered an indication of his lack of competency.' On the other hand, if the risk is great and the potential benefit minimal, the client's refusal is logical and should be accepted.

ETHICAL PRINCIPLE4 The least harm principle holds that when faced with dilemmas that have the potential for causing harm, a social worker should attempt to avoid or prevent such harm. When harm is unavoidable, a social worker should always choose the option that will cause the least harm, the least permanent harm, and/or the most

"Competency is a legal construct and may vary by state; social workers should know the process and requirements for having someone declared incompetent in the starefs) in which they practice.

68 CHAI>TER 4

easily reversible harm. If harm has been done, rhe social worker should attempt where possible to repair the harm done.

ETHICAL PRINCIPLE 5 A social worker should choose the option that promotes a better quality of life for all people, for rhe individual as well as for the community. Consistent with the Code of Ethics, "social workers should promote the general welfare of society, from local to global levels, and the development of people, their communities, and their environments" (NA5W Code, 1999, 6.01).

ETHICAL PRINCIPLE 6 A social worker should make practice decisions that strengthen every person's right to privacy and confidentiality. Keeping confidential information inviolate is a direct derivative of this obligation. Professionals have a duty to protect the privacy of clients and groups to the greatest extent possible consistent with laws and the will and agreement of the clients. Confidentiality, however, is not sacrosanct when the social worker can prevent violence or harm of a serious nature to others.

ETHICAL PRINCIPLE 7 A social worker should make practice decisions that permit her to speak the truth and ro fully disclose all relevant information to her client and to others. Social and professional relationships require trust in order to function well, and trust, in turn, is based on honest dealing that minimizes surprises so that mutual expect- ations are generally fulfilled.

ApPLICATION OF ETHICAL DECISION-MAKING SCREENS

Let ustry to apply these two ethical decision-making screens to analyze Exemplars 4.2, 4.3, and 4.4.

_ I WHAT WILL HAPPEN TO JIMMY PREGO?

Jimmy Prego is a passive, deeply disturbed early adolescent who lives in a therapeutic home where he has sometimes had to be protected from other residents. He is now ready to be moved to a less restrictive environment but clearly needs a therapeutic foster home, something your supervisor originally suggested. You have contacted such a home and begun plans to move Jimmy in about two weeks. When you inform your supervisor that you have initiated the move and that everything is proceeding as usual, he tells you that space has become available in an even less restricted group home run by your agency and that it would be appropriate to move Jimmy to the group home instead of the therapeutic foster home.

You tell your supervisor that you will check it out, but he seems a little uncomfortable. When you check out the group home, you discover the residents are older, bigger, and more aggressive than Jimmy. You do not agree that the group home is appropriate for Jimmy, who has had difficulty defending himself where he currently resides. Also, you learn that the agency has placed pressure on the supervisors to boost the group home's census, an action related to agency financial considerations. Jimmy's mother is unable to assist in making the decision because of overwhelming personal and mental health problems. Jimmy's problems and his youth make him incapable of making the decision. Mrs. Prego insists that she trusts you and trusts that you will do what is best for Jimmy.

GUIDELINES FOR ETHICAL DECiSION MAKING: THE DECISION-MAKING PROCESS AND TOOLS 69

Several issues are involved in rhis exemplar. Erhical Principles 4 (least harm) and 5 (quality of life) are particularly relevant here. Will the least harm be done by confronting your supervisor and succeeding in obtaining the placement in the therapeutic home, even if it means reducing the agency income when that is what the agency needs? When you examine the Code of Ethics for applicable standards, you find that your "primary responsibility is to promote the well-being of clients" (NASW Code, 1999, 1.01). Who is your client and to whom do you owe loyalty- Jimmy, his mother, your supervisor, your agency, or yourself-as you make your decision about the correct thing to do? Whose best interest takes priority, that of the client, agency, or worker? In addition, some social workers might argue that Ethical Principle 5 isrelevant because the worker wants to promote a better quality of life for Jimmy Prego and the right treatment situation will support that outcome.

Next, who is competent to make decisions? When clients lack "the capacity to provide informed consent, social workers should protect clients' interests by seeking permission from an appropriate third party" (NASW Code, 1999, 1.03c). Jimmy is not capable of making an informed choice. Mrs. Prego trusts you and wants you to make the best decision for her son. Is your supervisor an appropriate third party? He is placing the agency needs before those of Jimmy. In addition, "social workers should not allow an employing organization's policies, procedures, regulations, or administrative orders to interfere with their ethical practice of social work" (NASW Code, 1999, 3.09d). You, the social worker, may be the only one in this situation who is competent to make decisions for the best interest and protection of Jimmy and to advocate for the right treatment plan. Jimmy's needs take priority over the supervisor's, the agency's, and your own needs. Exemplar 4.3 provides another example.

_ I STARTING IN PRNATE PRACTICE Cliff Baxter is an experienced social worker who recently resigned his agency job in order to devote all of his time to private practice. Before Cliff left the agency, Dennis Norton, a colleague in the agency, told him that he would be willing to refer clients to him for a "finder's fee." As in many private practice beginnings, Cliff is having a difficult time making ends meet. His income last month was not even sufficient to pay the rent for the office. Should he give Dennis a call?

We will use the ERS and examine the NASW Code of Ethics to determine if there are any rules relevant to this situation. The NASW Code (2.06c) states: "Social workers are prohibited from giving or receiving payment for a referral when no professional service is provided by the referring social worker." This rule provides such clear and unambiguous guidance that no further screening seems necessary. Cliff should not call Dennis to take advantage of his offer. Are there ethical issues if Cliff calls Dennis and lets him know he would be happy to accept referrals, but he cannot pay a finder's fee? Should Cliff report Dennis's unethical practice?

70 CHAPTER 4

In Exemplar 4.4, we will apply the EPS.

• I THE WRONG MAN SITS IN PRISON Raul Lovaas has been enrolled in a drug rehabilitation program to break his cocaine addiction. The program's treatment routine includes pharmacological treatment, group therapy, and individual therapy. You are his social worker. You have succeeded in establishing a good relationship with Raul in the daily treatment sessions. One morning Raul tells you that, some years ago, he accidentally injured a bank guard during a holdup. He was never caught by the police, but another man was convicted for this crime and now sits in prison on a lengthy sentence. For several days you have been trying to convince Raul that he should talk to the police in order to free an innocent man from prison. Raul not only refused to listen to your suggestion but said that he expects you to keep in complete confidence what he has told you. What should you do?

These are some of the thoughts that you have:

1. Raul has neither a legal nor a moral right to have another man serve a lengthy sentence for a crime that Raul committed.

2. The "wrong" that you may cause by breaking confidentiality is hardly of the same importance as the wrong inflicted on an innocent person who is now imprisoned.

3. The effectiveness of the entire program may be compromised if it becomes known that social workers do not always keep confidential the information they receive from clients.

4. On the other hand, your whistle-blowing can cause the release of the wrongly convicted person.

We will focus our analysis on the latter two considerations because the first point, though obvious, does not relate directly to what you, the social worker, should do, but rather to what the client is ethically required to do. At least two ethical principles are involved in the second consideration: Ethical Principle 3, the principle of autonomy and freedom, specifically the freedom of an innocent man who is now imprisoned; and Ethical Principle 6, the principle of confidentiality, specifically respecting the confidence of the information that your client, Raul, gave you. Some may also base their decision on Ethical Principle 2, the principle of equality and inequality, because an innocent man in prison is obviously not in an equal situation and requires additional resources in order to regain access to equal opportunities. Because Ethical Principle 6 (confidentiality) is of a lower order than Ethical Principles 2 and 3, the second consideration leads to the decision that you are ethically justified in breaking confidence and reporting to the police what you have learned from Raul.

From a practice point of view, the third consideration may be especially important because in most situations we would hesitate to do anything that might impede the effectiveness of an intervention. It might be argued that a program that can improve the quality of life (Ethical Principle 5) of many addicts should receive

GUIDELINES FOR ETHICAL DECISION MAKING: THE DECISION-MAKING PROCESS AND TOOLS 71

preference over rhe quality of life of one individual, even if that person is falsely imprisoned. It is likely, however, that such reasoning involves a number of fallacies, including the following:

• We have no information on the effectiveness of this rehabilitation program. How effective is it in improving the quality of life of all/most/some participants?

• We do not know what impact, if any, breaking confidentiality will have on the effectiveness of the program. It may well be that other participants will be happy that the worker was instrumental in freeing an innocent person from prison.

• Statistical probabilities are never a permissible substitute for ethical screen mg.

In other words, the quality of life principle (Ethical Principle 5) is not relevant in this situation, but even if it were, it would be of a lower order than Ethical Principles 2 and 3. Consideration 3 is therefore not relevant and should be ignored in making an ethical decision. We would conclude that you are obligated to inform the police if you are unable to convince Raul to do so himself.

THE IMPORTANCE OF IDENTIFYING ONE'S OWN HIERARCHY OF VALUES

Although the NASW Code of Ethics (1999) recognizes "the possibility of conflicts among the Code's values, principles, and standards," it does not specify which values, principles, and standards are most important and ought to outweigh others in instances when they conflict. Nevertheless, social workers are frequently faced with conflicting standards and loyalties and a hierarchy may help when choosing among principles. Earlier we introduced our lexical arrangement of ethical principles based on our own work and that of others. Ultimately, each social worker when faced with conflicts in ethical standards or loyalties must utilize such a priority ladder. The reason we emphasized the need for each social worker to carefully clarify her own values is that each social worker, when faced with dilemmas, must depend on her own hierarchy of principles.

Originally, Loewen berg and Dolgoff (1988) based the hierarchy on their percep- tion of what the common consensus might be, and the hierarchical list of principles was changed in the following edition (Loewenberg & Dolgoff, 1992). Beyerstein (1993) suggested that because a professional code of ethics is created through a democratic process, members of the profession can only agree on the obvious and they "fudge" difficult or contentious principles through compromise, leaving the choice of a hierarchy of principles to the individual decision maker.

Over time, the makeup of the profession itself has become more diverse as a result of immigration and other societal and professional factors, including generational and other differences, which may result in more disagreement about the relative importance of ethical principles. We have found that there is little agreement on the rank ordering of the ethical principles, suggesting that percep- tions may change over time.