Ethical Issue: Under what Circumstances Should Social Workers Break Client Confidentiality - Research Paper Example

Ethical Issue: Under what circumstances, if any, should social workers break client confidentiality? Introduction Confidentiality in social worker and client relationships is one of the most important ethical and professional responsibilities in the field of social work. In most any profession, the requirement of confidentiality pervades and often defines client-employer or patient-health worker relationship. Compliance with this responsibility is crucial because it often helps establish a relationship of trust between the client and the social worker. And without this trusting relationship, the social worker would not have the expected impact on the client’s life. Moreover, the client would not feel open and comfortable with his or her social worker. The Code of Ethics for social workers set forth that social workers: are obligated to respect their clients’ right to privacy and not to extract information from their clients unless it is essential in delivering services; when information is later shared, such is considered confidential; and they are allowed to disclose confidential information only with the client’s consent or of a person duly authorized by the client to issue consent on the his behalf (National Association of Social Workers “Code of Ethics in English”). This principle of confidentiality is however not absolute. The Code of Ethics has made provisions for exceptional circumstances in the provisions of confidentiality. In instances when there is a need to disclose confidential information about the client in order to prevent an impending, foreseeable, and imminent harm to the client or another identifiable person, then this confidentiality requirement may be violated. This disclosure however should be kept to the least information possible or such information as needed by authorities to ensure the client’s or another person’s safety (National Association of Social Workers “Code of Ethics in English”). So, considering the above circumstances alone, there are instances when the confidentiality requirement may not always apply to the client and to his social worker. This social worker and client confidentiality agreement is severely tested in instances when it clashes with a person’s duty to warn – when other people or the client himself is put in danger and authorities need to be informed in order to prevent harm on the client or to other people (Aidslaw, p. 1). The confidentiality agreement between the client and the social worker also demands that the social worker should inform the client of the risk, rights, opportunities, and obligations which the social service would also bring to him; it also demands that the social worker should inform his clients about the limits of the confidentiality agreement, the purpose of such agreement, and how such confidentiality agreement may be used (Code of Ethics, as cited by Schachter “Ethics”). In many cases where the confidentiality agreement is put into issue, instances of ethical violations usually involve times when the social worker is compelled to reveal information about his client. In cases where it is imperative that information about the client has to be revealed, the social workers may be violating ethical principles: that of “informing the clients when the relationship is first established of possible risks associated with accepting service as well as the limits on privileged communication” (Schachter “Ethics”). Social workers sometimes do not completely and clearly explain to their clients that confidentiality has its limits, that for compelling reasons, information gathered from clients may be revealed to law enforcement officers (Schachter ‘Ethics”). Some social workers may not reveal such limits of confidentiality to their client because the latter may end up not disclosing any information at all. Moreover, revealing to the client the limits of confidentiality is confusing and contradictory during the social worker’s initial discussion with his client which involves having to tell his client that whatever he would reveal would be completely safe and be kept in confidence (Schachter “Ethics”). In assessing this ethical issue, it is also import to note the Tarasoff case and its implications in the current social work and medical practice. In the Tarasoff v. Regents of the University of California case (1976, as cited by North Central Regional Educational Laboratory “Home”) Prosenjit Poddar, a University student, was a client of the psychiatrist at the university’s student health center. He was undergoing therapy because he was having an unhealthy attachment to Tatiana Tarasoff, a fellow student who spurned his affections. The psychiatrist assessed that Poddar was dangerous because he was pathologically attached to Tarasoff and that he was even planning to buy a gun to kill her (North Central Regional Educational Laboratory “Home”). The psychiatrist informed the police about Poddar’s plans; however, on questioning, the police officers evaluated Poddar and concluded that he was rational. The police also told Poddar to stay away from Tarasoff (North Central Regional Educational Laboratory “Home”). About two months after, Poddar succeeded in killing Tarasoff. Tarasoff’s parents filed a suit against the university, the health center staff, and the police officers however the case was dismissed (North Central Regional Educational Laboratory “Home”). On appeal, Tarasoff’s relatives expressed that the defendants had the duty to inform Tarasoff or her family members of the possible danger to her life. The court ruled that the therapist had the duty to warn Tarasoff of the danger to her life (North Central Regional Educational Laboratory “Home”). On an amici curiae petition however, the court absolved the police of any responsibility. This case has now become a landmark case in deciding on violations or exceptions to the confidentiality agreement between client and health worker and even social worker. With an impending danger on the client’s or another person’s life, confidence may be violated in favor of a person’s safety and wellbeing. Discussion Social workers may reveal to other people privileged information about their clients with the latter’s consent. Absent this consent from the client, the social worker can be held legally responsible for violating social worker client privilege. In the case of AIDS patients, an analysis of this dilemma was undertaken by the AIDSLAW organization (p. 1) and they pointed out that mental health professionals and social workers are often faced with the problem of dealing with HIV/AIDS patients. On one side of the argument, there is a basic right on the client’s part and an obligation on the social worker’s part to keep information about the client confidential. And in AIDS patients or clients, this right or duty is an even more imperative requirement because of the social stigma that often accompanies the disease. However, there is also a duty to warn other people if the client himself poses an impending danger (AIDSLAW, p. 1). In instances when a client does not wish to inform his spouse or his partner about his infection; or when the client is a teenager who does not want to inform his/her parents to know; when the client is an IV drug user who is sharing needles with other people; or when the client is an active sexual worker (AIDSLAW, p. 1), the social worker has a duty to warn. Analysts point out that as expected, the social workers and even the mental health providers do not have clear answers on when to maintain confidentiality and when or to whom they may disclose information about their client. Their concern is on the guidelines which need to be followed in order to avoid liability. However, the law is not always forthcoming in settling these questions (AIDSLAW, p. 1). This is mostly due to the fact that the duty of confidentiality is a relatively new mandate which has not yet been defined well by the courts. And, due to diverse opinions regarding control measures in relation to the spread of HIV, many of the statutes which are meant to govern the issue appear to impose contradictory provisions. Consequently, there is no clear way of deciding the issues until the courts address their merits (AIDSLAW, p. 1). It is imperative to keep in mind the exceptions to the confidentiality rule. In the case of David v. Lhim (as cited by Corbin “Features”), the court ruled that the staff psychiatrist who knew of the client’s plan to kill his mother was to be held liable. They emphasized the ruling in the Tarasoff case and awarded in favor of the estate of the deceased. The offender in this case who had schizophrenia informed his psychiatrist that he wanted to kill his mother (David v. Lhim, as cited by Corbin, “Features”). However, with this knowledge, the psychiatrist still did not warn the intended victim. Upon the client’s release from the psychiatric institution, he succeeded in killing his mother (Reamer, as cited by Corbin “Features”). We see another application of the Tarasoff principles in the case of Chrite v. United States (as cited by Corbin “Features”) where a Veterans Administration patient Henry Smith wrote a threatening note on the day of his release from the hospital. Such note was recorded in his case notes, however, no warning of his intent ever reached his mother-in-law who was his intended victim (Corbin “Features”). Smith later succeeded in his threat to kill his mother-in-law. When this case was brought to the court by the victim’s husband who was seeking legal claims against the hospital staff for their failure to warn the intended victim of the client’s plans, the court ruled in favor of the plaintiff. The courts once again emphasized that the hospital staff, armed with information crucial to the life of another person had the duty to inform the intended victim of the client’s plans (Chrite v. United States). In yet another case, we see the application of the exceptions to the confidentiality mandate. In Jablonski v. United States (as cited by Corbin “Features”), defendant Jablonski had a history of violence; and he also threatened to rape and kill his mother-in-law. Again, like the previous cases, Jablonski succeeded in killing his mother-in-law (Kimball). The victim’s daughter – Jablonski’s estranged wife filed a case with the VA hospital where Jablonski was being treated prior to his murderous act. The court again ruled in favor of the plaintiff, emphasizing that the VA hospital “should have concluded, based on the information and prior records available, that Kimball was a foreseeable victim” (p. 31). In the cases above, we see instances where the client-social worker privilege may not apply, where the duty to warn or to inform the proper authorities is important in order to keep the client and other people safe. It is important to note however that there is a need to assess the individual situation in any situation before a finding of liability on the social worker’s part may be assessed. There is first a need to assess what imminent harm is; who the intended victim is; and what actions actually constitute a warning (Corbin “Features”). The courts had occasion to rule on several cases where they clearly defined what imminent threats were. In the case of Mavroudis v. Superior Court and Thompson v. County of Almeda, the court ruled that the threat to the person must be specific or identifiable. If the threat appears to be general, the threat is more difficult to anticipate or predict; hence it cannot actually be classified as imminent. The most important and the best remedy for therapists or social workers treating clients who pose an immediate danger to themselves and to other people is to have these clients hospitalized (Corbin “Features”). In the case of Currie v. United States, the court ruled that it is legal for therapists to hospitalize clients who pose a danger to other people. Through these rulings we realize that the confidentiality rule is not absolute when the welfare of the client and that of other people is at stake. The social worker must be vigilant in making an accurate assessment of the client’s thought processes and learn to evaluate warning signs among clients which may imply impending dangers. Clients who do not necessarily have mental disorders or affectations may even express to their social workers the fact that they want to commit a crime. In these instances, confidentiality may be breached. Since, it may not be possible to stop the potential criminal from committing his crime or the act of stopping the criminal may endanger the social worker’s life, the remedy of warning the potential victim may be the more prudent move. The Tarasoff decision already sets a clear precedent on the management of the above cases by imposing on psychiatrists, and by association – social workers – an obligation to inform the intended victim of the threats of the patient on his life (Roth & Meisel, p. 508). Among suicidal clients, the social worker may also break the confidentiality agreement. Mishna, et.al., (p. 573) emphasizes that social workers in private and government agencies may often find themselves working with clients who are depressed and who are grappling with their suicidal thoughts. More than any other problem involving depressed clients, suicide often poses the most complex ethical and legal challenges (Mishna, et.al., p. 573). Studies which sought to evaluate the ethical and legal considerations arising from clients who are contemplating suicide have been conducted, and some of them have managed to reveal that advancing one answer in the question or issue being posed should not be the main consideration. Authors however emphasize that “in training and the workplace, social workers must fully consider the complexities and ambiguities of a client’s experiences as well as their own clinical, ethical, and legal obligations” (Mishna, et.al., p. 573). And most studies involving suicidal clients still emphasize the limit to confidentiality – that it may be violated in instances when the client seeks to harm himself (University of Michigan, School of Social Work, p. 7). Although a client has the right to self-determination, it is accepted that a person’s right to determine his or her situation is compromised during depression and suicidal ideation. Therefore, in this instance, the patient’s rights may be overridden and a more prudent decision may be made for him. Moreover, it is justified for the social worker to set aside the client’s right to confidentiality and “to ensure that they exercise their capacities to the fullest feasible extent” (Hepworth, p. 64). With proper care and guidance, it is possible to dissuade the client’s suicidal thoughts and consequently prevent further attempts at suicide. As was previously mentioned, it may also be necessary to break confidentiality in clients who have HIV/AIDS, especially those who are sexually active, who are not using protection, and who are not informing their partners of their affliction. HIV/AIDS is highly transmissible in instances when no precautions to prevent transmission are undertaken by the AIDS patient. In some instances, it is difficult for a person with a non-medical background (e.g. social worker) to evaluate the issue and the client’s medical condition. Social workers are not fully qualified to make the proper assessment of an AIDS patient and the imminent danger such patient can pose on his sexual partners. Some analysts claim that in instances when the AIDS patient is occasionally engaging in unprotected sex, an imminent danger to victims cannot fully be determined (Aronstein & Thompson, p. 252). If however, all the conditions for unprotected and anonymous sex with unidentifiable sexual partners are met, then the social worker can rightly break the confidentiality agreement. However, the social worker must first try and exhaust all possible remedies as far as the client is concerned. The social worker can try to talk his client into informing his sexual partners about his condition (Aronstein & Thompson, p. 253). It is still important to preserve the social worker and client trusting relationship because upon knowing of the breach in confidentiality, the client may sever the relationship and all contact with the social worker. This would “preclude any gains that might have been made, including stopping the dangerous behavior” (Aronstein & Thompson, p. 253). The client may even be incited to anger by the social worker’s actions and may take his anger out on his partner. Some clients may take on a more depressing change of attitude and end up committing suicide (Aronstein & Thompson, p. 253). It is also important to note that in cases of child abuse, confidentiality may also be breached. Admittedly, confidentiality is a crucial requirement in ensuring and maintaining a trusting relationship with one’s client (Reid “Children, Families, and Schools”). Social workers assigned to schools are however often faced with students who are going through some kind of abuse from their parents, guardians, teachers, and other people. It is important therefore for social workers to put across the message to students that they cannot offer them absolute confidentiality because there may be instances when this confidentiality agreement has to be breached (Reid “Children, Families, and Schools”). In fact, social workers who are assigned to schools are often ordered specifically to note signs of abuse perpetrated on students. And when children report abuse, the automatic obligation of these social workers is to disclose it to the proper authorities. However, in the current state of the disclosure process, the legal provisions which govern the disclosure policies have not been firmly set in some states; it is also sometimes clouded by legal and ethical principles being implemented in different states (Reid “Children, Families, and Schools”). In these instances, it is important for social workers to be fully acquainted with the legal mandates protecting minors with regard to confidentiality. The rights of the child will definitely affect the amount of information which would be revealed to other people. And “to the extent that it is possible and feasible, school social workers should involve the student and the student’s family in decisions to breach confidentiality (Reid “Children, Families, and Schools”). Uppermost in the mind of the social worker when dealing with abused children is the need to immediately stop the abusive practices. The social worker can hardly take matters in her own hands and stop the abuse herself. Authorities therefore have to be informed of the child’s situation. However, care in consulting with the parents or the child’s guardian must be taken before breach of confidentiality (Reid “Children, Families, and Schools”). Conclusion In order to gain a trusting and therapeutic relationship between a social worker and his client, the confidentiality agreement must be upheld. However, such confidentiality agreement may be legally and ethically violated in several exceptional circumstances. These circumstances may involve: plans of suicide by the client; HIV/AIDS patients who are having unprotected sexual encounters with anonymous sexual partners; clients who are planning to commit crimes; and in cases of child abuse. The social worker must however try his very best to first convince the client to discontinue with his suicide plans; or to inform his sexual partners of AIDS affliction; to inform authorities of the abuse he is experiencing; or to give himself up to the authorities. These remedies by the client himself would shift the responsibility to the client and the social worker would not be the one to breach confidentiality. It may also be possible for the social worker to first inform his client of the fact that he is going to inform authorities of his plans. In the end, the client is properly informed of the social workers plans to breach confidentiality. Although the breach of confidentiality may destroy the trusting relationship between client and social worker, it can however, ensure that the client’s and other people’s lives are kept safe. Works Cited Aronstein, D. & Thompson, B. “HIV and social work: a practitioners guide”. pp. 252-253. 1998. New York: Haworth Press Chechak, D. “Confidentiality and informed consent in social work”. p. 1. (n.d) School of Social Work University of Western Ontario. Scribd database. 02 February 2010 from http://www.scribd.com/doc/7894505/Confidentiality-and-Informed-Consent “Confidentiality Vs the Duty to Warn”. p. 1. (n.d) AIDSLAW.org. 02 February 2010 from http://www.aidslaw.org/confident.pdf “Duty to Warn”. Home. (n.d) North Central Regional Educational Laboratory. 02 February 2010 from http://www.ncrel.org/sdrs/areas/issues/envrnmnt/css/cs3lk1.htm Hepworth, D., Rooney, R., Rooney, G., & Strom-Gottfried, K. “Direct Social Work Practice: Theory and Skills”. 2010. Canada: Cengage Learning Mishna, F., Antle, B., & Regehr, C. “Social Work with Clients Contemplating Suicide: Complexity and Ambiguity in the Clinical, Ethical, and Legal Considerations”. Clinical Social Work Journal, volume 30, number 3, pp. 1573-3343 NASW Delegate Assembly “Code of Ethics of the National Association of Social Workers”. 2008. National Association of Social Workers. Reid, L. “Practice Update from the National Association of Social Workers”. Children, Families, & Schools, volume 2, number 2. National Association of Social Workers “Right to Die Issues”. p. 7. (n.d) University of Michigan. 02 February 2010 from http://www.ssw.umich.edu/simulation/rube-rightToDie.pdf http://www.socialworker.com/home/Feature_Articles/Ethics/Confidentiality_&_the_Duty_to_Warn:_Ethical_and_Legal_Implications_for_the_Therapeutic_Relationship/ Roth, L. & Meisel, A. “Dangerousness, confidentiality, and the duty to warn”. 1977. American Journal of Psychiatry, volume 134, pp. 508-511 Schachter, R. “From the Executive Director: The limits of confidentiality put social workers in a bind”. Ethics. 2001. National Association of Social Workers New York City Chapter. 02 February 2010 from http://www.naswnyc.org/e6.html Read More