Resolving ethical conflicts in a managed health care environment.

The managed health care environment is replete with situations that create ethical conflicts for the professional social worker. This article examines two such conflicts--competing fiduciary relationships and justice versus injustice--as they relate to social work practice and the 1996 revised NASW Code of Ethics. Mechanisms to reduce these ethical conflicts are presented. The obligation for social workers to participate in social action as a method of reducing injustices found in managed care environments is examined through the principle of distributive justice, egalitarianism, and the NASW Code of Ethics.     

An ethical framework for community health workers and related institutions

The aim of this article is to provide practical ethical guidance and to foster further critical reflection on ethical issues in the work, education, and training of community health workers. The analysis includes implications for associated institutions. We first summarize the roles of community health workers and some evaluations of their work. After next highlighting ethical elements from the literature, we then give a justification for the ethical framework that follows. The article then provides a detailed discussion of a set of basic ethical principles for the field of community health work. Among the principles, we argue that the following 3 should have a foundational role: equal and substantial respect, justice, and care. Among these, respect is most fundamental.     

Nursing and justice as a basic human need

This paper explores the idea that justice is a basic human need akin to those famously depicted in Maslow's hierarchy of human needs and, as such, warrants recognition as a core element in representative ideas about nursing. Early nurse theorists positioned the principles and practice of nursing as having their origins in ‘universal human needs’. The principle of deriving nursing care from human needs was thought to provide a guide not only for promoting health, but for preventing disease and illness. The nursing profession has had a longstanding commitment to social justice as a core professional value and ideal, obligating nurses to address the social conditions that undermine people's health. The idea of justice as a universal human need per se and its possible relationship to people's health outcomes has, however, not been considered. One reason for this is that justice in nursing discourse has more commonly been associated with law and ethics, and the legal and ethical responsibilities of nurses in relation to individualized patient care and, more recently, changing systems of care to improve health and health outcomes. Although this association is not incorrect, it is incomplete. A key aim of this paper is to redress this oversight and to encourage a broader conceptualization of justice as necessary for human survival, health and development, not merely as a professional value, or legal or ethical principle for guiding human conduct.     

Die normativen Grundlagen Sozialer Arbeit – (auch) ein Beitrag zur Public-Health-Ethik

Social work and public health are different but mutually connected. Both are professions with their own ethical foundations. Despite all differences, they have the same goal: to protect and to enhance the well-being of people. This is, in part, why the fundamental ethical principles of social work are salient for developing public health ethics. As a human rights profession, social work respects the personal autonomy of clients, supports solidarity-based relationships in families, groups or communities, and attempts to uphold social justice in society. Social workers need to adopt special professional attitudes: sensibility for the vulnerabilities of clients, care and attentiveness for their resources and strengths, assistance instead of paternalistic care and advocacy in decision making for clients’ well-being when clients are not able to decide for themselves. These fundamental ethical principles are the basis for discussion of special topics of social work ethics as public health ethics, for example, in justifying intervention in individual lifestyles by public services without the participation or consent of the affected persons.     

Promoting a Social Justice Approach to Prevention: Future Directions for Training,Practice, and Research

The final paper of this special issue devoted to prevention and social justice calls for prevention practitioners and researchers to redirect their energy and resources to creating genuine social change. To begin, the contribution of the American Psychological Association ethical code to social justice-oriented prevention work is explored, and significant ethical issues that need to be further addressed by the current code are briefly outlined. Second, we discuss the implications of a social justice approach to prevention for training, practice and research. Finally, we invite readers to take the lead in putting a social justice prevention approach into practice.     

Implementation of Health and Mental Health Evidence-Based Practices in Safety Net Settings

Implementation of evidence-based practices (EBP) in health and mental health settings has not been as successful as anticipated. Patients in safety net settings have even less opportunity to receive evidence-based care. Translation research has been dominated by efficacy trials, which often do not translate to the complexity of safety net settings. Implementation research to date seems to focus mostly on provider and organizational contextual factors more than macro and patient factors crucial to outcomes in safety net settings. Focus on translation and adaptation of interventions to safety net settings, and use of qualitative methods to flesh out complex processes and involve more stakeholders will help give safety net patients access to state of the art care. This issue is important for social workers to understand due to their ethical obligation to advocate for social justice and access to care for vulnerable and oppressed populations.     

Goodness of fit: social work education and practice in health care

This study addresses the fit between social work education and practice in health care. A random sample of NASW members identifying with health care (N = 179) responded to a mail survey about the utility of core knowledge and roles that we had identified by reviewing seven commonly used health care social work texts. Quantitative data revealed knowledge and roles most frequently used in health care settings as well as differences in roles used dependent upon department name; and different professionals supervising social workers. Qualitative data from four open-ended questions provided suggestions for what knowledge and skills should be taught in social work programs, the best forums/methods for teaching this content, and topics for continuing education. Findings are discussed in relation to six key areas of the peer-reviewed literature: vulnerable populations/diversity, ethical dilemmas, interdisciplinary collaboration, mental health, managed care/accountability, and advocacy. Implications for social work practice, education, and research are discussed.     

The legal clinic: helping social workers master the legal environment in health care.

The social environment for all is becoming increasingly legalized. This fact is evidenced in the extensive entitlement regulations and ethical decision-making processes surrounding health care consumers and professional providers. The authors of this paper describe a program designed to educate social workers in an acute care hospital to the legal issues and considerations that influence decision-making and interventions in social work practice. The purpose of the paper is two-fold: to highlight the program planning process in establishing and institutionalizing a Legal Clinic for social work, and secondly to stress the significance of legal content in the knowledge base of social workers in health care settings.     

Patient stories, narratives of resistance and the ethics of humane care: a la recherche du temps perdu

Over the past 20 years, the study of patient-physician relationships and the discourse of clinical encounters has become a major area of inquiry. Interest in these topics is closely linked to an ethic of humane care, reflecting widespread criticism of a technocratic approach to clinical practice. A narrow framing of this approach led to the neglect of a category of patients' socially grounded accounts of their illness and treatment experiences referred to as 'narratives of resistance'. The problem addressed in this article is the lack of connection, in research and practice, between an approach grounded in a humane care ethic and an ethic of social justice that addresses the impact of social and economic inequalities on rates of illness and access to health care. The aim is to open up a critical discussion among researchers, health care educators, practitioners and patients about relationships between ethical standpoints, clinical practice and research.     

试论制度安排与健康公平的实现

健康公平是人类共同追求的目标,但由于经济、社会和文化等因素又造成了健康的极大不公平。遗憾的是,我国卫生改革从一开始就缺乏伦理基准,医疗服务过度市场化倾向、政府责任不到位和伦理缺席已将卫生改革引向功利主义的死胡同,使得卫生改革背离了公正目标。如何通过有效的公共政策和制度安排促进健康公平,这是全社会关心的问题。在今后的深化改革中,必须加大政府的投入,围绕公平目标,建立覆盖全民的医疗保障体制。     

Health promotion and the common good: Towards a politics of practice

One of the ethical dilemmas facing health promotion and disease prevention (HP/DP) practitioners is ensuring that programmes undertaken in the name of health as a ‘common good’ do not unnecessarily restrict individual liberties. This dilemma is compounded by theories of the common good being essentially normative and broadly categorized as libertarian (individual rights) or social justice (collective responsibilities). Both of these common good theories are described and critiqued. While the libertarian theory offers an important caution against the tendency of state institutions to undermine individual autonomy, a social justice theory is more consistent with research on health determinants and the historical practice of public health. The problem of individual liberties becomes most acute when HP/DP is restricted to efforts to curb or proscribe individual health behaviours. A social justice approach to HP, however, must be complemented by a ‘deliberative democratic’ practice. Such a practice recognizes the contingency involved in most HP/DP decision making, and the need for inequalities in opportunity for poor or socially disadvantaged (oppressed) groups in order to achieve greater equality in health outcomes. The argument presented draws primarily from debates within the public health, health promotion and disease prevention literature, and is illustrated by reference to two recent attempts in Canada to formulate ethical principles for health promotion practice.     

Health benefits of primary care social work for adults with complex health and social needs: a systematic review

The prevalence of complex health and social needs in primary care patients is growing. Furthermore, recent research suggests that the impact of psychosocial distress on the significantly poorer health outcomes in this population may have been underestimated. The potential of social work in primary care settings has been extensively discussed in both health and social work literature and there is evidence that social work interventions in other settings are particularly effective in addressing psychosocial needs. However, the evidence base for specific improved health outcomes related to primary care social work is minimal. This review aimed to identify and synthesise the available evidence on the health benefits of social work interventions in primary care settings. Nine electronic databases were searched from 1990 to 2015 and seven primary research studies were retrieved. Due to the heterogeneity of studies, a narrative synthesis was conducted. Although there is no definitive evidence for effectiveness, results suggest a promising role for primary care social work interventions in improving health outcomes. These include subjective health measures and self‐management of long‐term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance. Although few rigorous study designs were found, the contextual detail and clinical settings of studies provide evidence of the practice applicability of social work intervention. Emerging policy on the integration of health and social care may provide an opportunity to develop this model of care.     

Ethical dilemmas in home health care: a social work perspective

The survey in this article examined several factors related to the frequency and difficulty of resolving four ethical conflicts in a national sample of 364 home health care social workers. Ethical conflicts regarding the assessment of mental competence, self-determination, and access to services were moderately frequent and difficult to resolve, whereas conflicts over implementing advance directives were infrequent and not difficult to resolve. Each ethical conflict involved multiple stakeholders. Multiple regression analyses revealed significant predictors of the frequency and difficulty of resolving the ethical conflicts. Implications for practice and administration in home health care and social work education are discussed.     

Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class,multiethnic populations

BACKGROUND: This article proposes a conceptual framework for addressing social contextual factors in cancer prevention interventions, and describes work that operationalizes this model in interventions for working class, multiethnic populations. METHODS: The Harvard Cancer Prevention Program Project Includes Three Studies: (1) an intervention study in 25 small businesses; (2) an intervention study in 10 health centers; and (3) a computer simulation modeling project that translates risk factor modifications into gains in life expectancy and number of cancers averted. The conceptual framework guiding this work articulates pathways by which social context may influence health behaviors, and is used to frame the interventions and guide evaluation design. RESULTS: Social contextual factors cut across multiple levels of influence, and include individual factors (e.g., material circumstances, psychosocial factors), interpersonal factors (e.g., social ties, roles/responsibilities, social norms), organizational factors (e.g., work organization, access to health care), and neighborhood/community factors (e.g., safety, access to grocery stores). Social context is shaped by sociodemographic characteristics (e.g., social class, race/ethnicity, gender, age, language) that impact day-to-day realities. CONCLUSIONS: By illuminating the pathways by which social contextual factors influence health behaviors, it will be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.     

Ethics and health planning: implications for education

Over the past decade in this country, there has been a rekindling of interest in the ethical questions of public policy. Moreover, the concern for ethical issues is nowhere more evident than in the field of health care. However, the ethical problems of health planning, particularly as practiced at the regional level, have scarcely received attention. This article explores the ethical dimensions of health planning and argues that health planners have not been adequately prepared, neither through their education nor through socialization in the profession, to deal with the complex ethical issues facing them. However, health planning theory can be enriched and practice improved if the ethical issues are confronted. Health planning is viewed as one means of achieving social justice because the benefits and burdens associated with health care are distributed to the members of society by the decisions made in the health planning process. However, planning decisions are not meekly accepted by the persons affected. More often than not, health planning decisions produce substantial political controversy, which is due, in part, to the planning methods commonly used. The synoptic or comprehensive planning approach avoids ethical questions by ignoring them. The incremental planning approach deals with them but only in terms of political process. Neither of these approaches is particularly useful for resolving health planning's ethical questions. The implications of these findings for education in health planning are discussed. The merits of the case study as a means of ethical education are presented.     

Complex Hospital Discharges: Justice Considered

How do we respond to the patient who no longer needs inpatient care but refuses to leave the hospital? Complex hospital discharges commonly involve consideration of legal, financial, clinical, and practical issues. Yet, the ethical and contextual issues embedded in complex inpatient discharges are of concern and have not received adequate attention by medical ethicists. The aim of this work is to encourage clinicians and administrators to incorporate a justice rubric when approaching inpatient discharge dilemmas. This paper presents justice as the ethical principle most neglected in situations involving complex discharges and suggests that a justice focused lens allows clinicians and administrators to move beyond notions of patient autonomy in crafting morally responsible hospital discharge decisions that reflect efficient stewardship of an appropriate share of medically indicated services. This issue deserves additional attention from medical ethicists in the future.     

Harm reduction: a social work practice model and social justice agenda

Efforts in the United States to eradicate drug use through supply reduction (that is, the War on Drugs) have increasingly violated the principles of social justice and human rights, both locally and globally. This has created ethical conflicts for social workers in policy making, practice, and research. Harm reduction has been conceptualized as a peace movement and is aligned with the humanistic values around which social work is organized. The authors examine how social workers may reduce the ethical conflicts associated with efforts to address substance abuse by adopting a harm reduction approach to policy, practice, and research. They examine current drug policies, the consequences of the policies, and, in particular, how the policies affect social workers as practitioners, agents of social control, and guardians of social justice.     

Ethical analysis of the decision-making process in occupational health practice

BACKGROUND: Changes in workplaces and work organizations represent a challenge for governments, social partners and occupational health professionals whose aim is to appropriately satisfy emerging requirements and needs. An increasing number of occupational health problems requires a high-quality standard practice supported by ethically consistent decisions. The ethical aspect of the practice is strictly linked to that of appropriateness, involving requirements of effectiveness, efficiency and respect of ethical principles of the individual, community and society. OBJECTIVES AND METHODS: The paper aims at focusing the ethical components of the quality of an occupational health program by taking a systematic approach to the ethical problems. The approach consists of a 2-step process. The first step consists of appraising the basic ethical principles of the dilemma ("to do good": to prevent or to remove evil and to do or to promote good; "not to do evil", implying not to inflict evil; to do no harm; autonomy implying respect of other's freedom and self-determination; justice implying equity, solidarity and non discrimination). The second step consists of detecting the stakeholders involved or interested in the decision. The alternatives are discussed according to the assessment of ethical costs (violating the consistentprinciple) and ethical benefits (fulfilment of the consistent principle) for the stakeholders. RESULTS: Systematic analysis of the ethical components of the dilemma according to ethical principles and their discussion within a framework involving different stakeholders makes it possible to recognise ethical costs and ethical benefits of the alternative decisions. The decisions may have different costs and benefits, which should be considered and weighed to take a proper decision. Although there is no certainty about the suitability of the decision, the assessment of the ethical components may be a valuable tool in decision-making based on the awareness that any ethical aspect has been considered. CONCLUSION: Occupational health professionals are requested to act with respect for general ethical principles and preferences of the individual, groups and setting. A high-quality practice will take into account the ethical content and the ethical conduct and any intervention will include analysis of ethical principles to compare alternative decisions and their consequences for the different stakeholders. This approach guarantees a practice based on, in addition to scientific evidence, the assessment of ethical costs and ethical benefits to favour decisions preventing conflicts.     

Professional ethics in occupational health--Western European perspectives

In this paper, the foundations of professional ethics in occupational health care is described and discussed. After an introduction reminding of the global developments of world economy, communications and trade and reference to cultural and social developments, reference is given the four basic ethical criteria of biomedical ethics of beneficence ("doing good"), non-malfeasance (avoidance of harm), autonomy (integrity) and Justice/Equity-The "Appletown consensus" of 1989. These criteria provide the basis for current thinking and practice in health professions of Western Europe. The principles of ethical analysis, as currently practiced is described using a practical case scenario drawn from experience of challenging tasks for Occupational Health Services in Western Europe. Specific challenges to professional ethics are discussed-the growth of knowledge in subjects and academic disciplines relevant to occupational health and the multiple loyalties of occupational health professionals. The principles of ethical codes and their implementation are touched on. In conclusion, the universality of professional ethical principles of bioethics-including occupational health-is discussed in observing global inter-cultural commonalities and convergence on ethical criteria of central importance. Emphatic recommendation is given to continue inter-cultural exchanges with a view to improve understanding of impact of contextual and cultural factors on ethics in professional occupational health practice.     

Translating psychosocial insight into ethical discussions supportive of families in end-of-life decision-making

A large number of Americans would rather rely on family and friends more than their physicians about end-of-life care and decisions. Moving beyond traditional clinical ethics and its dyadic focus on the physician-patient relationship, this article presents an approach to ethical decision-making at the end of life that is more inclusive of the patient's family and has the potential to advance social work practice in end-of-life care. Initial attention is given to how psychosocial and bioethical perspectives and practices interact to shape understanding of moral issues in end-of-life decisions. Morally relevant principles are then adapted from contextual therapy as being useful for including more of a family focus and viewing ethical decision-making at the end of life as a family process. Specifically, focus is on exploring the ethical dynamics of family systems that impact the decision-making process and translating psychosocial insight into ethical discussions that are supportive of families. The case of a patient with sudden and unexpected brain death and without advance directives demonstrates one family's unresolved grief and illustrates how its members were helped to reason morally about end-of-life choices. Contributions of a social worker and bioethicist are illustrated.