2016 ETHICS & CLINICAL SOCIAL WORK

Laura Guidry-Grimes, PhD(c)

Center for Ethics @ MWHC
Clinical Ethicist
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D ISCLAIMER AND C ONFLICT- OF-INTEREST
S TATEMENT

Disclaimer: Although this presentation is

representative of what we do here, my opinions
are my own and should not be taken as policy
for Medstar Washington Hospital Center or
Medstar Corporate.

Conflict-of-Interest (COI): I do not have any COI

relevant to this training program.

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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O UTLINE

 Introduction to Ethics and Bioethics

Services

 Historical Overview of Ethics and

Social Work

 The “Difficult” Patient

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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WHAT IS ETHICS?
 Ethics is the formal, systematic study of what
counts as the good, who we ought to be, what
types of responsibilities we have, and how we
should judge right from wrong action.

 Ethicists provide reasons for choosing one

course of action over others
 More than merely feeling something to be
desirable or preferable

 Can be independent of religious, cultural, and

legal considerations

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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STEPS TO ETHICAL E VALUATION
 What are the relevant facts?
 Med state, psych state, social situation,
feasible options, etc.

 Who or what could be affected by the way the

decision is resolved?
 Who has a stake in the outcome?

 What are the relevant ethical considerations?

 Patient autonomy, professional integrity, fairness,
patient welfare, respect, pluralism/diversity,
religious freedom, etc.

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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STEPS TO ETHICAL E VALUATION

 What is the primary ethics question? Others?

 Separate from what should be done medically,
legally, culturally

 Who is morally responsible for what?

 Consider roles, institutional constraints

 Which options are ethically permissible?

Which course of action is morally preferable?

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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B IOETHICS S ERVICES :
C ENTER FOR E THICS @ MWHC AS E XAMPLE
 Ethics Consult Service
 24 / 7, 365 days per year
 Recommendations in chart and curbside coaching
 Rounding

 Ethics Committee
 Organizational Ethics Subcommittee
 Policy Subcommittee

 Educational initiatives
 Continuing training on EOL care, code status,
informed consent
 Moral distress programming
 Ad hoc talks

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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B IOETHICS SERVICES: W HERE WE A SSIST
 Preventive ethics and crisis assistance
 End of life and goals of care
 Are there good moral reasons to withdraw LSTs?

 Code status
 Would resuscitation and intubation be more harmful than
beneficial? Should this decision be left to the family?

 Surrogacy and capacity

 Who is the ethically appropriate decision maker?

 Professionalism
 Is there a strict moral obligation to treat abusive patients?

 Many, many others

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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EARLY THINKING U NDERLYING SW
 Industrialization and urbanization at the end of
the 19th century  economic and social
imbalances  concerns about instability in
communities, consequences for government
 “The Curse of Pauperism”
 The poor treated as moral defectives, as sources
of unrest, as personally irresponsible if they did
not work
 Poor communities treated paternalistically as
shiftless, in need of empirical study

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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PROGRESSION IN PROFESSIONAL SW

 Shift in attitude after personal exposure to

poor individuals and their particular
circumstances
 Addressing structural and environmental
causes (esp. public health barriers,
problems of industrialization)
 Morally investigate social systems, rather
than poor individuals
 Community advocacy against governmental
regulations that cause social imbalances and
economic oppression

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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EVOLVING ETHICS AT THE C ORE OF SW
 Addressing barriers to personal fulfillment and
well-being
 Institutionalized and embedded inequities
 Identifying needs, improving access to resources
 Problem-solving re: the systematic nature of
disadvantage and poverty
 Inadequate housing, healthcare, alcoholism, and
violence demanded that a social worker take an
ethically investigative role with a focus on social
justice and social reform.
 Seeing those in need of SW as distinct, complex
individuals

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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“VALUES AND ETHICS ARE THE L IFE-B LOOD
OF THE P ROFESSION ”

 Beginning in the 1980s, increased attention

to applied ethics and ethical theory in SW
 Development of a professional code of ethics
 Progress of ethical attitudes to those in need
of SW helped to define the profession
 Initial focus on socially-caused economic
imbalances has “evolved into an ambitious
attempt to grasp and resolve complex ethical
issues” (Reamer, 1998)
Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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THE C OMMON PICTURE OF THE “D IFFICULT ”
PATIENT
 15-60% of patients considered “difficult” by
treating physician

 Some effects:
 Stressed relationships, increased conflict
 Negative feelings from all parties
 Cracked professionalism
 Unsuccessful treatments or poor compliance

 Assumed causes:
 Pt has a mental illness (perhaps undiagnosed)
 Social or moral failures on the part of the pt

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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A NOTHER LOOK

“reframing the ‘difficult’ patient as someone

who perceives himself as wronged in the
medical encounter—perceives being
treated unfairly, disrespectfully, dismissively,
condescendingly, or offensively—generates
an ethical duty to address, validate,
repair, or assist in making amends”
(Fiester)

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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 Q UESTIONS TO C ONSIDER
 Whose perspective is being trusted and solicited?
 Are there barriers to respectful communication?
 What are the circumstances of this pt?
 How might this pt’s health status be due to factors
outside of his/her control?
 Is the label of “difficult” being applied mainly to pts
who are time-consuming, repeatedly/ increasingly ill, or
asking lots of questions of the physicians?
 Is the medical team demonstrating empathy, moral
courage, and virtue?
 Other questions to consider? Examples?
Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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 WHAT IS MORAL D ISTRESS ?
 When you are in a morally charged situation,
believe you know what ought to be done, but
you are constrained from doing it
 Perceived or actual powerlessness

 Problem of moral residue, feeling compromised

 Threat to moral integrity – “the sense of wholeness

and self-worth that comes from having clearly
defined values that are congruent with one’s actions
and perceptions” (Epstein & Delgado)

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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C ONSTRAINTS ON THE MORAL A GENT
 Role obligations & competence
(e.g., nurse, not physician)
 Laws, policies, codes
 Power hierarchy
 Realities of time
 Limited resources, staff
 LOS pressures
 Others?

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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 SOURCES & C ONTRIBUTING FACTORS

 Individual, case-specific  Institutional, systemic

 disagreeable family  hostile climate
 abusive patient  inadequate
mechanisms for safe
 staff conflict reporting
 demands for futile  unclear or problematic
treatment policies or guidelines
 poor communication  insufficient training
 misunderstanding of EOL  distrust among staff
options

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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C RESCENDO E FFECT

 After repeated MD, level of moral residue

builds
 Insufficient preventive ethics and resolutions
 Increasing sense of powerlessness, isolation

 Negative effects on job satisfaction, well-

being, relationships, sense of agency

 CE moral insensitivity, conscientious

objections, burnout
Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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C OPING WITH AND PREVENTING MD
 AACN Guide:
 Ask: become aware MD is present
 Affirm: make a commitment to address MD
 Assess: identify sources of MD and make action plan
 Act: implement strategies to preserve integrity

 Moral distress programming

 Discussions, workshops, educational sessions

 Ethics involvement
 Consultation, follow up, education
 Organizational ethics and review of policies/practices

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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 R EFERENCES & R ESOURCES
• American Association of Critical-Care Nurses. The 4A’s to Rise above Moral Distress. web:
<http://www.aacn.org/WD/Practice/Docs/4As_to_Rise_Above_Moral_Distress.pdf>

• Epstein, E. and S. Delgado. “Understanding and Addressing Moral Distress.” The Online
Journal of Issues in Nursing 15.3 (2010): web.

• Epstein, E. and A. Hamric. “Moral Distress, Moral Residue, and the Crescendo Effect.”
Journal of Clinical Ethics 20.4 (2009): 330-342.

• Fiester A. The ‘difficult’ patient reconceived: an expanded moral mandate for clinical ethics.
Am J Bioeth 2012;12(5):2-7.

• NASW Code of Ethics: http://www.socialworkers.org/pubs/code/default.asp

• NASW. “Social Work History.” http://www.naswdc.org/pressroom/features/general/history.asp

• Reamer, Frederic G. “The Evolution of Social Work Ethics.” Social Work 42.6 (1998): 488-
500.

• University of Kentucky Program for Bioethics. The Moral Distress Project. web:
<http://moraldistressproject.med.uky.edu>.

Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics

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Laura Guidry-Grimes, PhD(c) | MWHC Center for Ethics
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