Moral and Ethical Framework Appraisal

high-risk area of paediatrics with paediatricians increas- ingly reluctant to be involved,7 especially as expert wit- nesses or in controversial areas (e.g. suspected fabricated or induced illness). There are fears that this will have harmful consequences for the protection of future children.

Emotional responses are understandable given the nature of child protection, and such responses and intu- itions may be morally important. Moreover, the ability to have feelings towards others and to respond to them is an essential part of any interpersonal relationships – and pro- fessional relationships are no exception. But such responses highlight rather than preclude the need for rational analysis. This paper analyses some of the issues raised by child protection and suggests responses to them.

The general duty of care and standard of care

Clinicians should have the best interests of their patients as their first concern. This involves two sometimes con- flicting obligations, namely:8

● to provide treatment that confers more benefits than harms;

● to respect patients’ rights to exercise as much self- determination (autonomy) as they are able.

P A P E R S

Ethical issues in child protection

Vic Larcher

Great Ormond Street Hospital, London, UK

Email: [email protected]

Abstract

The management of child protection concerns arouses strong emotions and controversies and creates

ethical tensions for all concerned. This paper provides a rational analysis of some of the issues involved

and suggests responses to them.

The ethical and legal duties of health-care professionals are to act in the best interests of the child

by safeguarding children and reporting concerns. But this may involve conflicts with parents and

produce reluctance of professionals to become involved, especially in controversial types of abuse.

Mandatory reporting of concerns might overcome such reluctance, but may be ineffective in the face

of diagnostic uncertainties. Assembly of a stronger diagnostic evidence base would seem ethically

justified, but organization of the necessary case controlled studies might be problematic. Even with a

comprehensive evidence base, individual diagnoses of abuse will always involve value judgements that

should be underpinned by effective training and assessment of core competencies of professionals.

These manoeuvres are unlikely to prevent both justified and vexatious complaints, often in relation to

breaches in professional duties or concerning professional misconduct. The tendency to blame experts

may have contributed to a reluctance of other professionals to become involved, despite proposals for

reforms in the expert witness and court systems.

Current approaches to child protection may neither promote greater understanding nor be in the

best interests of children. A revised social contract for the effective protection of children could include:

a duty of care that adequately addresses the primacy of the child’s welfare; the acquisition of a sound

evidence base; professional transparency and accountability (but with protection from malicious and

vexatious complaints); and a shift emphasis towards a more inquisitorial system that embraced the

principles of truth and reconciliation.

Clinical Ethics 2007; 2: 208–212

Introduction and background

The investigation and management of actual or suspected child abuse, maltreatment or neglect continue to generate intense emotions and controversy.1 Although it is clear that some children are abused or neglected, the evidence upon which suspicions or diagnoses are based is increas- ingly questioned.2,3 There have been recommendations that the investigation and management of child protection (CP) concerns be addressed with greater professional transparency, responsibility and accountability.4 Pro- fessionals attract censure for both perceived failures and over-zealousness in protecting children.5 They increasingly face complaints6 and accusations of professional miscon- duct and negligence, especially in their role as expert wit- nesses. In consequence, child protection has become a

Vic Larcher did his basic medical training at Cambridge University and St Bartholomew’s Hospital. He then trained as a paediatrician with specialist interest in children’s liver disease with the late Alex Mowat at KCH London. He was appointed consultant paediatrician at Queen Elizabeth Hospital for Children (subsequently Royal London) and as consultant in Paediatrics and Clinical Ethics at Great Ormond Street (2005). He did his MA in Medical Ethics and Law at King’s College London. He is chair of Great Ormond Street and ICH REC and co-chair of GOSH Clinical Ethics Committee, RCPCH Ethics Advisory Committee.

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Ethical issues in child protection 209

The standards required to fulfil these duties are set out in codes of good medical practice,9,10 defined in law11 and emphasized in a code of professionalism.12 They apply just as much to CP as they do to any other area of medical practice.

Young children lack the necessary criteria of under- standing, rationality, self-awareness and reflective capacity that would enable their autonomy to be respected. However, age alone is not the sole determinant of a child’s capacity to make informed choices about whether to undergo treatment or investigation. For a child who lacks capacity, those with parental responsibility have the ethi- cal duty and legal power to make decisions provided that they act in his or her best interests.

Actual or suspected abuse or neglect and best interests

The child health professional’s primary ethical and legal duties are to the child.13 In normal circumstances profes- sionals and parents work together in the best interests of the child, in a relationship based on trust and mutual respect.

In actual or suspected abuse professionals may have good reason to believe that the actions or behaviour of parents/carers are not in the best interests of the child. They may find parental accounts of the child’s injury or illness implausible or inconsistent. Unlike lawyers, who must accept that their clients are telling the truth, doctors have no such obligation if there are good reasons to sus- pect otherwise, thus undermining the basis of the thera- peutic relationship. Difficulties may also arise if a parent believes that the doctor is not taking his/her account of the child’s illness seriously. This is especially problematic when the doctor suspects that the child’s symptoms are being exaggerated, fabricated or induced.1,14,15

All medical interventions, including those which form part of CP investigations, require valid, adequately informed consent.11,16 Parents have the power and respon- sibility to give consent on behalf of young children who cannot do so for themselves. However, they may be reluc- tant to consent to interventions that are intended to cor- roborate abuse (e.g. detailed skeletal survey X rays, forensic examinations in sexual abuse cases) and may, as a consequence, lead to the removal of their child. For many ‘incompetent’ children in whom abuse is suspected such interventions are in the child’s best interests because they are intended or necessary to protect the child from harm. Yet professional discomforts in performing sometimes inva- sive investigations without wholehearted parental agree- ment remain.

Matters are more complex for legally competent older children who refuse to undergo examination in cases of suspected or actual child sexual abuse. There are strong ethical justifications for respecting their refusal, irrespec- tive of its consequences; it could be regarded as unethical to force examination on any child who was capable of informed refusal, even if it were regarded in her best inter- ests to proceed.

The duty of care in child abuse

The duty of all professionals confronted with actual or sus- pected abuse or neglect is clear. They should act in the

best interests of children by protecting them from avoid- able harms that may lead to serious physical or emotional injury. All involved in the care of children should respond to CP concerns in an appropriate fashion and with as much care and intellectual rigour as they might show in dealing with a serious physical condition.4 Mandatory reporting of abuse has been suggested as a means of ensur- ing that professionals fulfil this duty. However, diagnostic uncertainties, lack of evidence base for all types of abuse, lack of core competencies to deal with particular types of abuse, and fear of censure or complaint may all lead to reluctance to be involved and lead to recruitment difficul- ties to posts that carry specific CP duties.17

Mandatory reporting of concerns

Some countries have introduced mandatory reporting of CP concerns.18,19 However, definitional and diagnostic problems produce ambiguities and difficulties in setting reporting thresholds that are neither too specific nor too generous.20 Mandatory reporting may lead some profes- sionals to become over-zealous in reporting so as to avoid risk of censure, while others might prefer risking sanctions from non-reporting to the social and professional conse- quences of accusations of wrongful reporting. More worry- ingly, others may respond by not identifying features of abuse – by limiting clinical assessment to the bare mini- mum – or by avoiding child protection duties altogether.21

There is little evidence that mandatory reporting improves reporting rates or increases the numbers involved in child protection work. Moreover, it might have other unfore- seen adverse consequences for the welfare of children and families, e.g. by compromising therapeutic relationships.22

In the UK it could be argued that the 2004 Children Act23

and designation of the child protection register as a database create a legislative basis for mandatory reporting, but this has not lessened reluctance of professionals to be involved in CP cases. Mandatory reporting is also unlikely to be effective when there is diagnostic uncertainty or when there is insufficient evidence to confirm or refute suspicions.

Responding to diagnostic uncertainty

Responding to diagnostic uncertainty creates dilemmas for professionals. One response is to perform further investiga- tions intended to: (a) exclude natural conditions that might help to explain the child’s symptoms; or (b) provide protection from possible accusations of negligence or mis- conduct.

Some investigations may benefit the child by enabling positive diagnoses of abuse to be made (e.g. identification of perpetrator DNA in sexual assault) or enabling relevant treatments to be given (e.g. treatment of sexually trans- mitted diseases). Others have less tangible benefits but may prevent injustice to individuals on whom suspicion is misplaced.

However, a balance needs to be struck between per- forming investigations that safeguard the interests of carers and the need to protect children. For example, the attempt at exclusion of brittle bone disease in a child with multiple fractures, by searching for specific defects in col- lagen synthesis, or the genes that might lead to them, may be fair to parents or others suspected of abuse of the child.

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taking them might be via the PIAG system.28 Collection of anonymised normal data from existing health-care records might not require specific consent, but would require ethical review. Any approach requiring contact with children or families would require scientific and ethi- cal review and consent. Public consultation and involve- ment in the design of research projects should provide greater transparency and understanding and possibly aid recruitment in these sensitive areas

However, it is important to recognize the limitations of this approach. Even sophisticated evidence bases are unlikely to define the precise force necessary to produce a particular injury in a particular individual. This will always involve balancing probabilities using professional judge- ment in accordance with professional values and stan- dards, for which training is necessary.

Maintaining standards to fulfil duty of care

Professionals should approach the investigation of CP con- cerns with the same standards that apply to other aspects of medical practice. This requires adequate training designed to maintain defined levels of competency and reduce apprehension and in turn provide some protection against complaints.29,30 Although an evidence-based, com- petency defined, accredited training programme in child protection for entry-level junior doctors has been estab- lished, a similar programme for higher trainees and consul- tants is also needed, with the means to test its effectiveness.

Until uniform training and accreditation systems are established, requirements for regular updating in child pro- tection skills for could be built into the appraisal system in a similar fashion to the need to update life support skills.30

To avoid censure and complaint, paediatricians will also need to show that their actions were reasonable, balanced, based on the best available evidence, respectful of the rights of those concerned, the result of open minded delib- eration and respectful of the law.

Confidentiality and complaints

The reporting of actual or suspected child abuse or neglect is justifiable if its intention is to protect the child, or even others in the family, from harm. It requires disclosure of personal information to those who have a statutory duty to investigate concerns. While professionals have a general duty of confidentiality that precludes disclosure of personal information without consent, this duty is not absolute.28,31

It may be neither necessary to obtain consent to share information nor to disclose that it has occurred when there are reasonable grounds to believe that the child will be at risk of serious harm as a result. Decisions to disclose information or maintain confidentiality are matters of pro- fessional and value judgements that must be reasonable and accountable and as such open to challenge, whatever their outcome.

Paediatricians have been the objects of complaints and allegations of professional misconduct for both per- ceived over-zealous reporting and for failure to protect children. Controversial types of abuse (e.g. suffocation or fabricated or induced illness) are more likely to produce complaints, with some individuals being especially tar- geted.32 Although relatively few complaints have been

Yet such tests do not reliably identify all genetic or metabolic causes of brittle bones and take time to accom- plish, during which time crucial delays may occur in implementing a child protection plan. Nor do positive tests in themselves (e.g. the presence of minor clotting dis- orders in a child with multiple bruises) necessarily exclude abuse. Moreover, some investigations may lack diagnostic and forensic specificity and sensitivity, while others may have true or potential physical harms (e.g. radiation bur- den in skeletal surveys – detailed X-rays of the child’s bones) or psychological harms (e.g. needle phobia from repeated blood tests). Appliance of technology may there- fore be unable to provide diagnostic certainty. Repeated testing in these circumstances can be perceived as an abuse to the child perpetrated by professionals, especially where there are suspicions that illness or symptoms may be induced or fabricated.14,15

Assembling an evidence base

Although there is much unequivocal evidence that abuse and neglect occur,24 the extent to which an evidence base exists for the diagnosis of all types of abuse is less certain. It has been argued that some diagnoses lack a scientific evidence base (e.g. factitious or induced illness [FII]). If this is so, there is a duty to accumulate evidence that improves diagnostic accuracy and helps to prevent harms to all those involved. Meta-analyses25 have been useful in this respect, but have also identified conditions in which definitive evidence is lacking, for example metaphyseal fractures, and have not yet covered others (e.g. visceral injuries in children). They have highlighted the need for case controlled studies, since randomized controlled stud- ies may neither be practicable or ethical in child protec- tion and evidence gleaned from animal or adult studies may not be applicable. However, such studies, including the evaluation of the relevance, sensitivity and specificity of diagnostic investigations, entail the collection of nor- mative data about non-abused children.

Collection of personally identifiable data currently requires consent of the parties and approval by a research ethics committee. The latter may be reluctant to sanction this research because of its lack of direct benefit to those involved and perceived intrusion on personal liberties. However the collection of anonymised data, subject to stringent safeguards to prevent wrongful use, and its use in case-controlled studies may be ethically justified because of the beneficial consequences in protecting children and preventing wrongful convictions on incomplete evidence. Harris has argued that participation in such research, pro- vided there is minimal harm and invasion of privacy, also respects the obligations of individuals in society to be just and to ‘do their share’.26 If participation contributes to public good by discharging moral obligations, then parents are justified to consent to their children’s involvement on the assumption that the child, if competent to choose, would want to do what was right.

An approach that collects personally identifiable data, but with the facility to opt out has been used in the Avon Longitudinal Study of Parents and Children (ALSPAC) and has yielded epidemiological data about factors con- tributing to abuse.27 There may well be a public policy or public interest justification for studies using personally identifiable data and an appropriate mechanism for under-

210 Larcher

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Ethical issues in child protection 211

Clinical Ethics 2007 Volume 2 Number 4

substantiated, individuals may have great difficulty in dealing with the adverse publicity that may accompany them, even when they have acted in good faith.29 High rates of stress, burn-out and psychological morbidity have been reported in hospital-based child protection profes- sionals.33 In consequence, difficulties in recruitment to child protection posts may pose future risks to children.17

Conversely, those parents/carers who believe themselves the victims of false accusations or unsafe convictions of child abuse face similar vilification, censure, social ostracism, with unpleasant consequences to themselves and their families.34

Although professionals must be accountable for the reliability of their interpretation of clinical facts and research findings,1 challenges should be made in a rational and appropriate manner, despite the adversarial nature of child protection hearings and the strong emotions that may be aroused. Dealing with vexatious or malicious com- plaints is more difficult, since any public response risks breaching confidentiality and refusal to comment may be misinterpreted as a desire to keep secrets or hide the truth. There may be little public realization that some com- plaints are vexatious or malicious.35 While some agencies, e.g. the Law, have mechanisms for dealing with vexatious complaints, professional regulatory bodies seem to lack them. Employing trusts do have a duty to investigate com- plaints, and should have no qualms in publicly rejecting those shown to be without foundation.

Hall has suggested that regulatory bodies should only investigate concerns about a professional’s competence or behaviour if they are raised by judges, magistrates or direc- tors of social services, or have been investigated and upheld by appropriate local multi-agency procedures.29

The Chief Medical Officer’s (CMO) recent proposals for reform of professional regulation also introduced a local mechanism for investigating professional misconduct, albeit without multi-agency input.36 Following the Appeal Court’s decision on the initial Meadow v GMC judgement, it is clear that expert witnesses are not immune from disci- plinary proceedings concerning their evidence even when it is given in good faith.38 The result of this judgment is unlikely to overcome professional reluctance to become involved in CP cases, especially as the CMO’s proposals on regulation seem to lower the burden of proof for estab- lishing professional misconduct.36 Neither will it satisfy those who feel that the only way forward is a wide-ranging public inquiry into child protection processes and proce- dures, and an opening up of the procedures of Family Courts to public scrutiny.

The court system and expert witnesses

Some cases heard by Courts, particularly those involving suffocation, poisoning, multiple fractures and brain haem- orrhage, have attracted attention and controversy espe- cially with regard to performance of experts. But many doctors have little practical understanding of the legal sys- tem and even expert witnesses can be unfamiliar with the day-to-day workings of the Court, as would most lawyers with the day-to-day practice of medicine.

Doctors encounter difficulties with the adversarial nature of the Law, its complex rules of evidence, differing burdens of proof in criminal and civil cases, and the fact

that law tends to be binary (e.g. guilty/not guilty) rather than dealing in the balancing of probabilities, variables and uncertainties that form part of clinical practice. For example, a paediatrician, by applying accumulated clinical judgement, might be so sure that abuse had occurred in a particular child such that, if there were a specific medical treatment available for abused children, s/he would use it without hesitation. To the paediatrician, therefore, the diagnosis of abuse might be ‘beyond clinical doubt’. This is rather less stringent than believing that it is beyond rea- sonable doubt that the terms of a criminal indictment are fulfilled. However, it is more stringent than the civil law’s requirement of demonstrating, on balance of probabilities, that abuse is more likely to have occurred than not.

In Court, paediatricians may find that their role as witness to fact has changed to that of expert witness (EW), a role for which they may be unprepared. Defining the duties, responsibilities and competencies of expert wit- nesses is helpful but, without better training and some form of protection for those who give evidence in good faith, is unlikely to increase numbers of witnesses or over- come reluctance to be involved. Some of these issues have been addressed by proposals to reform the EW system by transferring the function of EW in CP cases to NHS teams who will be commissioned trained and accredited for this purpose,38 but procedural matters, e.g. defining and assess- ing core competencies and training, will need resolution.

It will still be possible for either side to commission experts in the hope that they will provide support for their respective cases. While this may be in the best interests of the accused (in the sense that it upholds justice) it may not reflect what paediatricians consider the best interests of the child. Equally, separating the role of EW from those who have clinical care of the child may be desirable but logistically impossible.

There is a view that the initial conviction in the Clark case resulted from faulty judicial process rather than professional misconduct by the paediatric expert wit- ness.5,39 There may be some grounds for doubting whether an adversarial system is an appropriate one to deal with such intense personal tragedies as the death or serious injury to a child. A more inquisitorial approach to com- plex child deaths or CP cases may be justifiable, especially if it focuses on the needs of children rather than the rights of adults. The reforms suggested by the Kennedy Report on sudden unexpected deaths in infancy40 are a useful starting point, since they provide a framework for evaluat- ing complex situations where a mixture of medical, social and other factors operate. They could be applied, subject to audit and evaluation, in areas where abuse/maltreat- ment enters the differential diagnosis, but they do require a re-establishment of confidence in the system, which cur- rently may be difficult to attain. In the meantime profes- sionals need to know the rules of courts, understand the code of conduct for expert witnesses and prepare them- selves thoroughly.

An alternative approach to deeply divisive, ethically troubling issues is the concept of truth and reconciliation, involving restorative rather than adversarial or redistribu- tive justice.41 By uncovering pertinent facts, distinguishing between truth and lies and allowing for forgiveness and healing, it seeks to heal relations between opposing sides. If confronting and reckoning with the past are necessary

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in a changing world. Report of a working party. London: RCP, 2005 13 Judgments – JD (FC) (Appellant) v East Berkshire Community

Health NHS Trust and others (respondents) and two other actions (FC). 21 April 2005 UKHL 23

14 Royal College of Paediatrics and Child Health. Fabricated and Induced Illness by Carers. Report of a working party of the Royal College of Paediatrics and Child Health. London: RCPCH, 2002

15 Department of Health. Safeguarding children in whom illness is fabri- cated or induced. London: Department of Health, 2002. See http.//www.doh.gov.uk/acpc

16 Department of Health. Reference guide to consent for examination and treatment. London: The Stationery Office, 2001

17 Bannon M. Community child health in crisis. Arch Dis Child 2004;89:695–6

18 Stretch R. The duty to report child abuse in France: lessons for England? Child Fam Law Q 2003;15:139–49

19 Bell L, Tooman P. Mandatory reporting laws: a critical overview. Int J Law Fam 1994;8:337–56

20 Levi BH, Loeben G. Index of suspicion: feeling not believing. Theor Med Bioeth 2004;25:277–310

21 Diaz A, Neal WP, Nucci AT, Ludmer P, Bitterman J, Edwards S. Legal and ethical issues facing adolescent health care professionals. Mt Sinai J Med 2004;71:181–5

22 Budai P. Mandatory reporting of child abuse: is it in the best interest of the child? Aust N Z J Psychiatry 1996;30:794–804

23 The Children Act, 2004. See ss11 (1)(f), (2)(a) and ss12 (6)(b), (7)(a)

24 Chadwick DL. The evidence base in child protection litigation. BMJ 2006;333:160–1

25 www.core-info.cf.ac.uk 26 Harris J. Scientific research is a moral duty. J Med Ethics

2005;31:242–8 27 Avon Longitudinal Study of Parents and Children (ALSPAC). See

http://www.alspac.bristol.ac.uk/pub/index.shtml 28 Royal College of Paediatrics and Child Health. Responsibilities of doc-

tors in Child protection cases with regard to Confidentiality. London: RCPCH, 2004

29 Hall DM. Is protecting children bad for your health? Arch Dis Child 2005;90:1105–6

30 Bannon MJ, Carter YH. Paediatricians and child protection: the need for effective education and training. Arch Dis Child 2003;88:560–2

31 General Medical Council. Confidentiality: Protecting and providing information. London: GMC, 2002. See www.gmc-uk.org.

32 Marcovitch H. Diagnose and be damned. BMJ 1999;319:1376–7 33 Bennet S, Plint A, Clifford TJ. Burnout, psychological morbidity, job

satisfaction, and stress: a survey of Canadian hospital based child protection professionals. Arch Dis Child 2005;90:1112–16

34 MAMA (Mothers Against Munchausen syndrome by proxy Allegations). See www.msbp.com

35 Marcovitch H. GMC must recognise and deal with vexatious com- plaints fast. BMJ 2002;324:167

36 Good Doctors Safer Patients. The Chief Medical Officer’s review of medical regulation following Dame Janet Smith’s inquiry into the circumstances of the murders committed by Dr Harold Shipman. See http.//www.dh.gov.uk/publications/policy and guidance articles

37 General Medical Council v Meadow [2006] EWCA Civ 1390 (26 October 2006)

38 Bearing Good Witness: Proposals for reforming the delivery of medical expert evidence in family law cases – a consultation. See http:// www.dh.gov.uk/Consultations/LiveConsultations/fs/en

39 Hey EN. Suspected child abuse: the potential for justice to miscarry. BMJ 2003;327:299–300

40 The report of a working group convened by the Royal College of Pathologists and the Royal College of Paediatrics and Child Health. Sudden unexpected death in infancy: a multi-agency protocol for care and investigation. London: The Royal College of Pathologists and the Royal College of Paediatrics and Child Health, 2004

41 Avruch K, Vejarano B. Truth and reconciliation commissions: a review essay and annotated bibliography. Soc Justice Anthropol Peace Hum Right 2001;2:47–108

for transition from conflict, resentment and tension, there may be ethical justifications for trying such an approach in child protection, or in modifying our current adversarial approach.

Conclusion

The investigation and management of child protection concerns will always be controversial and difficult. However, the obligation to protect the weak and vulnera- ble from abuse, neglect and exploitation is fundamental to civilized societies. Given that diagnoses are based on bal- ancing probabilities and uncertainties there is always a potential for injustice to all concerned. The tendency to blame experts for what may be system failures has arguably resulted in CP becoming a high-risk area of paediatrics with a reluctance of professionals to become involved.

The current adversarial approach, with its heroes, vil- lains and victims, hypotheses and counter-hypotheses, does not promote greater understanding and may not be in the best interests of children. Potential elements of a revised social contract for the effective protection of chil- dren might include the following: a duty of care that ade- quately addresses the primacy of the child’s welfare; the acquisition of a sound evidence base; professional trans- parency and accountability (but with protection from malicious and vexatious complaints); and a shift emphasis towards a more inquisitorial system that embraced the principles of truth and reconciliation.

It is time for a frank and informed discussion of the issues that arise in child protection, which might lead to redefining the moral contract between professionals and society for the benefit of children. This is surely what chil- dren want and deserve.

References

1 Craft AW, Hall DM. Munchausen syndrome by proxy and sudden infant death. BMJ 2004;328:1309–12

2 Paterson CR, Burns J, McAllion SJ. Osteogenesis imperfecta: the dis- tinction from child abuse and the recognition of a variant form. Am J Med Genet 1993;45:187–92

3 Geddes JF, Vowles GH, Hackshaw AK, Nickols CD, Scott IS, Whitwell HL. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain 2001;124:1299–306

4 The Victoria Climbie Inquiry. Report of an inquiry by Lord Lamming. Cm 5730. London: The Stationery Office, 2003. See http://www. victoria-climbie-inquiry.org.uk/index.htm

5 Horton R. A dismal and dangerous verdict against Roy Meadow. Lancet 2005;366:277–8

6 Kmietowicz Z. Complaints against doctors in child protection work have increased fivefold. BMJ 2002;324:167

7 Dyer O. Doctors reluctant to work on child protection committees. BMJ 2004;328:307

8 Chantler C, Doyal L. Medical ethics: the duties of care in principle and practice. In: Powers M, Harris N, Lockhart-Miriams A, eds. Clinical Negligence. London: Butterworths, 1995

9 General Medical Council. The duties of a doctor registered with the General Medical Council. London: GMC, 2002

10 Royal College of Paediatrics and Child Health. Good medical practice in Paediatrics and Child Health: duties and responsibilities of paediatri- cians. London: RCPCH, 2002

11 Montgomery J. Health Care Law. Oxford: Oxford University Press, 2004

12 Royal College of Physicians. Doctors in society: Medical professionalism

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The Role of Ethical Theories in Decision Making by Social Workers Rujla Osmo & Ruth Landau

This study analyses the arguments provided by a convenience sample of 62 Israeli social

workers for their preferred ethical principles in terms of ethical theories. Content analysis

of arguments given in four different contexts shows that the large majority of social

workers in the study based their arguments on either deontological or utilitarian ethical

concepts, less frequently using concepts from virtue theory, rights theory and care theory

of ethics. However, the analysis reveals a discrepancy: when social workers were requested

to justify their rank ordering of ethical principles without reference to a specific practice

situation, they most frequently preferred concepts reflecting deontological theory of ethics,

such as right intention, universalism, and duty. In contrast, when confronted with a

specific practice situation, the social workers’ most frequently chosen concepts were

relating to results, consequences, and utility, concepts identified with the utilitarian

theory of ethics. In view of the findings, the need for more thorough knowledge of a

variety of ethical theories and their potential role in ethical decision making in social

work practice and education are discussed.

Keywords: Ethical Theories; Ethical Dilemmas; Ethical Argumentation; Ethical

Decision-making; Ethical Principles

Introduction

Social work deals with individual and social problems and situations that are, by

definition, difficult and complex. Many situations in which social workers intervene

become ethically complicated, as they involve aspects of social control and change

vis-à-vis less powerful clients. These complications increase when we consider the

general societal context and that of the agency, as well as social workers’ professional

and personal values.

Even though social workers’ professional values may be partly compatible with

societal values, there may be important differences in emphasis, priorities or

Correspondence to: Rujla Osmo, Senior Teacher, Paul Baerwald School of Social Work, The Hebrew University of

Jerusalem, Mount Scopus, Jerusalem 91905, Israel. Email: [email protected]

Social Work Education Vol. 25, No. 8, December 2006, pp. 863–876

ISSN 0261-5479 print/1470-1227 online # 2006 The Board of Social Work Education DOI: 10.1080/02615470600915910

interpretation (Loewenberg et al., 2000). Moreover, a social worker’s professional

values are not always consistent with one another, and even a consistent set of values

may not always be uniformly implemented under the everyday rules by which we live.

In a pluralistic society, we must make a conscious effort to continuously evaluate our

professional values and rebuild them into the structures of our concrete daily

existence (Cooper, 1993). That is, in each situation, social workers must decide anew

which professional ethical principle has priority and with respect to whom (Hugman

& Smith, 1995).

The perspective with which social workers view the world reflects their personal

philosophy and value systems that derive from both their personal and their cultural

history (see Abramson, 1996). Indeed, recent research evidence indicates that there is

no difference between social workers’ professional and personal ethical hierarchies,

even though they do not hold a universally accepted hierarchy of ethical principles

and they tend to apply different ethical hierarchies in different situations (Landau &

Osmo, 2003). Landau and Osmo’s results indicate that, while social workers appear

to attach great importance to the professional ethical principles, their personal values

may play a great role in their ethical decision-making processes. The preponderance

of social workers’ personal values on their decision-making processes needs further

analysis.

It has been suggested that social workers need to ‘identify their own personal

values’ (Loewenberg et al., 2000, p. 133), to know themselves ethically (Abramson,

1996), to engage in explicit argumentation that can make a significant contribution

to the quality of decision making (Osmo & Landau, 2001), and to take a more critical

stance towards their professional work (Gambrill, 1997; Mattison, 2000). Explicit

scrutiny of the issues and explicit justification of the decision-making process in

cases of ethical dilemma are important facets of social work practice and lead to

crucial professional debate and critique. Personal accountability (Goldstein, 1998)

demands that social workers offer articulated arguments for their preferred ethical

principles when dealing with different ethical dilemmas. This articulation is

particularly important since social workers are increasingly subject to scrutiny for

purposes of quality assurance and payment authorization and they are increasingly

asked to provide evidence as the basis for further treatment decisions (Proctor,

2002).

Articulating their arguments in decision making exposes social workers to critical

thinking and public scrutiny, as well as allowing examination of the implicit

deliberations guiding practitioners. Argumentation is an act of forming a rationale,

drawing conclusions and applying them in discussions and decisions (Toulmin et al.,

1984; Imbrognio, 1997). An argument must involve at least two statements—one

putting forward a particular view and at least one specifying reasons for that view.

When we argue, we do not merely say what we think, we also say why we think it.

This allows others to make critical judgments as to whether they should agree or not.

Argumentation is an important element in ethical decision making. Yet, despite the

importance of social workers’ ethical decision-making processes, there has been little

empirical research by social workers in the field of ethics (see Jansson & Dodd, 1998),

864 R. Osmo & R. Landau

particularly on argumentation in ethical decision making (see Osmo & Landau,

2001).

Although there are a number of models of ethical decision making in social work

(Reamer, 1990; Rhodes, 1986; Loewenberg et al., 2000; Congress, 1999; Mattison,

2000), we still know very little about the actual process of social workers’

argumentation when they are confronted by ethical dilemmas in practice. How do

social workers justify their decisions and choices? How do they formulate their

arguments? What are the terms they use? Are these terms drawn from one or more

theoretical frameworks of ethics and are these frameworks similar or different?

Rhodes (1998) argues that social workers must ask what sort of perspectives or

guidelines help them to evaluate and justify decisions concerning ethical dilemmas

and what constitutes an adequate ethical framework. Cooper (1993) observes that

justification refers to the belief system or theory that is being used to give meaning to

our way of life. Examining arguments for ethical decision making in terms of major

ethical theories may shed more light on social workers’ preferences in ethical

approach within a given cultural and situational scene.

Ethical theories in the social work literature can be divided into two major groups

in order to help social workers recognize and understand the principles on which

their ethical decisions are based (e.g. Mattison, 2000; Reamer, 2001). (1)

Deontological theories claiming that certain kinds of action are inherently right or

good, as a matter of principle. This group of theories focuses on fulfilling one’s

duties; respecting the rights and autonomy of others and treating others with equal

justice. (2) Teleological theories arguing that certain actions are to be performed

because they are good by virtue of their consequences. One teleological orientation

that has influenced social work is the utilitarian one (Reamer, 2001).

Banks (2001) broadly identifies two kinds of ethical theories: (1) those that focus

on principles of action, such as deontological (e.g. respect for the individual person

and recognition of users’ rights to freedom in making their own decisions and

choices) and utilitarian orientations (e.g. utility and justice); (2) those that focus on

the character of the moral agents and their relationships with each other, such as

virtue ethics and the ethics of care. Further, Hinman (1994) introduces the rights

theory of ethics as one of the contemporary theories of ethics.

In this study we adopt Banks’ broader perspective based on a more contemporary

classification of ethical theories in the philosophical ethical literature (Beauchamp &

Childress, 1994; Hinman, 1994; Brannigan & Boss, 2001). This includes a number of

ethical theories relevant for social work, in addition to those more cited ethical

theories in social work literature: virtue, care and rights ethical theories.

Each of these theories, at least in their strong version, claims to be exclusively

correct. According to Hinman, the utilitarian theory claims that ‘morality is solely a

matter of consequences’; the deontological theory alleges that ‘morality is a matter of

having the correct intention, one that can be willed universally for all human beings’;

the rights theory sees the ‘only moral issues as being issues of rights and correlative

duties to respect the rights of others’, and the virtue theory maintains that ‘morality is

primarily about character’ (Hinman, 1994, p. 54), that is, having the moral virtues of

Social Work Education 865

someone who acts from proper motives such as acting with respect, beneficently and

with fairness (Beauchamp & Childress, 1994). The ethics of care theory, related to

virtue ethics in some respects, focuses on a set of character traits that are valued in

close personal relationships: compassion, sympathy, fidelity, and the like

(Beauchamp & Childress, 1994).

This study examines social workers’ arguments for their preferences of ethical

principles in general and specifically in the context of different situations containing

ethical dilemmas (professional and personal). The social workers’ arguments are

examined in terms of the five ethical theories presented above. We aim to answer the

following questions.

1. Do social workers’ arguments reflect one or more ethical theories in their choice of

ethical principles?

2. Do social workers’ arguments reflect different ethical theories in different practice

situations?

3. Is the content of the social workers’ arguments congruent with the content of the

ethical principles in terms of ethical theories?

Methodology

Procedure

The present study is part of a larger study of ethical decision making by social

workers (Landau & Osmo, 2003; Osmo & Landau, 2003).

As a first stage we compiled a list of 12 ethical principles in social work, based on

ethical principles as reflected in relevant social work literature (Bloom, 1990;

Loewenberg et al., 2000; Reamer, 2001) and in the codes of ethics of social workers

(IASW Code of Ethics, 1994; NASW Code of Ethics, 1996). Respondents were

requested to rank these 12 ethical principles in order of importance and then to

present arguments for their rankings of the first three and the last ethical principles.

Our aim was to examine social workers’ arguments concerning ethical principles with

respect to practice situations both as professionals and as individuals. Consequently,

in the pre-test, participants were requested to rank the ethical principles and their

arguments for two practice situations twice: once as professionals and once as

individuals. However, due to the time required to complete the tasks involved in the

study and respondents’ comments, following pre-test, the respondents were

randomly divided into two groups. One group was requested to rank the same 12

ethical principles in order of importance with respect to two specific practice

situations containing an ethical dilemma (vignettes). The second group was asked to

rank the 12 ethical principles in order of importance with respect to one specific

practice situation but to do it twice: first from a professional point of view and then

from a personal point of view (i.e. they were asked to assume that the described

situation occurred in their own personal life). Next they were requested to offer

arguments for their rankings of the first two ethical principles concerning each

vignette.

866 R. Osmo & R. Landau

Instrument

The instrument used in this study was a structured questionnaire, specifically

constructed for the larger study. Here we present the parts of the instrument relevant

for this analysis.

(1) The list of 12 ethical principles: (a) equality and inequality (equal persons have

the right to be treated equally and non-equal persons have the right to be treated

differently if the inequality is relevant to the issue); (b) basic justice (in the allocation

of resources, before the courts, etc.); (c) privacy and confidentiality; (d) protection of

life; (e) the good or the interest of the individual; (f) truthfulness and full disclosure;

(g) autonomy and personal freedom; (h) quality of life; (i) provision of basic human

needs; (j) the good or interest of the public; (k) least harm; and (l) the obligation to

obey the law and regulations.

(2) Participants were requested to rank the list of 12 ethical principles generally

and in two specific situations. In this study we used a ‘critical incident’ approach, a

common strategy for studying decision-making and discretionary processes (e.g.

Drury-Hudson, 1999). The first vignette described a practice situation where a

pregnant 14-year-old adolescent does not want her parents to know about her

condition [a modified version of a case described in Loewenberg & Dolgoff (1992,

p. 40)]. The second vignette described a three generational family, in which the 70-

year-old mother lives with her child’s family. She becomes the center of conflict

between the couple. The only old age home in the town that the social worker finds

suitable is far less desirable to her than the family’s home (Loewenberg & Dolgoff,

1992, p. 192). The vignette with the pregnant teenager was used for both groups of

respondents. These vignettes were selected because the dilemmas intrinsic in their

content seemed adequate to be discussed from different ethical perspectives.

(3) Open-ended qualitative information on arguments for the three most important

and the last (twelfth) choice was recorded for the general ranking of the ethical

principles—‘Please give your arguments why the three ethical principles you placed in

the three first places are the most important and in the last place the least important in

your opinion’. Respondents were similarly requested to give their arguments for the

two most important choices of the ethical principles for each of the vignettes.

The initial draft of the questionnaire, which included the rankings of all four

situations (the general ranking of the 12 ethical principles, the ranking of the two

specific vignettes and ranking of the pregnant teenage vignette from a personal point

of view), was pre-tested by 12 senior social workers. This showed that it was necessary

to divide the questionnaire and create the two groups because of the questionnaire’s

length and difficulty. The administration of the final form of the questionnaire and

the qualitative information required about 30–40 minutes.

Sample

The social workers in this convenience sample were recruited from community and

hospital social services in Jerusalem and the metropolitan area of Tel Aviv in Israel.

Social Work Education 867

The social workers were all professionally trained and certified with at least a BSW

(comparable in training to the MSW in the United States). Questionnaires were

distributed to social work practitioners by the directors of social services. Response

rate reached about 50%. This response rate is due to the lower response by

participants requested to return the questionnaires to the researchers by mail. Of the

66 questionnaires returned to the researchers, 62 were useable (gave arguments

justifying their preferred principles).

The sample distribution was: 92% were females, 73% were married, 33% had a

BSW degree, 18% had a MSW, 3% had PhDs, and 46% were students in a MSW

program. The mean age of the respondents was 36 years (SD59.29; range 23–58);

they had been at their current workplace for a mean of 9.38 years (SD58.2; range 1–

29); 63% of the sample worked in the areas of health and mental health, 10% in child

and youth care, and 37% in other areas of social work care; 87% of the sample were

Jewish, 5% Muslim, 2% Christian and 6% did not give a religion; 50% of the sample

claimed to be secular, 18% traditional, 23% religious, 3% very religious and 6% did

not answer the question.

Content Analysis of Arguments

The following coding instructions were specially constructed to analyze the

arguments.

1. Indicate whether the respondent included reasons for the ranking of a given ethical

principle in her argument.

2. Indicate whether the content of the arguments for the ranking of a given ethical

principle relates to one or more of five identified ethical theories: (a) utilitarian; (b)

deontological; (c) rights; (d) virtue; (e) care.

Each statement in the response was coded separately, allowing each respondent to

apply more than one argument and, consequently, to rely upon more than one

ethical theory.

The operational coding instructions were as follows.

1. The argument was coded as utilitarian if it or part of it included ideas or words

dealing with utility and consequentialism, such as maximizing the good and

minimizing harm, or words such as gain, loss, and results.

2. The argument was coded as deontological if it or part of it included ideas or words

dealing with duty, intention, or categorical imperative.

3. The argument was coded as rights based if it or a part of it included ideas or words

dealing with rights, eligibilities, and the respective obligations.

4. The argument was coded as virtue based if it or part of it focused on the social

worker or included ideas or words dealing with his or her traits.

5. The argument was coded as ‘ethics of care’ if it or part of it focused on the client or

included ideas or words dealing with the professional relationship and the process of

care.

868 R. Osmo & R. Landau

The reliability of the coding instructions was determined by reaching agreement of

85% among three judges: the authors and a third coder (a doctoral student in social

work). The data characteristics allow only basic statistical analyses, such as

percentages.

Results

The majority of respondents provided arguments only for their first two rankings of

ethical principles, so only these are analyzed.

Seventy percent of the sample of social workers (N562) gave arguments justifying

their two first preferred principles in the general rank ordering of ethical principles

and in the context of the first vignette (pregnant adolescent). Sixty-two percent of the

participants gave arguments justifying their rank ordering of the two preferred ethical

principles for the second vignette (three-generational family) and for the first vignette

from a personal point of view. A total of 329 arguments were offered; many of the 62

respondents offered more than one argument for each of their rankings.

The arguments of the two most important ethical principles in each of the four

contexts were analyzed for content. They were analyzed without differentiating

between the first and second preferred principle, since the respondents were asked

only to give arguments for the importance of the principles they ranked in the first

two (three) places without specifically differentiating between them.

Research question 1—Do social workers’ arguments reflect one or more ethical theories in their choice of ethical principles?

Table 1 shows the frequency of the arguments, in terms of ethical theories, in the

four contexts: A—general ranking; B—pregnant adolescent (professional dilemma);

C—three-generational family (professional dilemma); D—pregnant adolescent

(personal dilemma).

The most salient ethical theory emerging from the total number of arguments is

the utilitarian ethical theory (35%), followed by the deontological theory (27%). The

Table 1 Frequency of the Arguments in Terms of Ethical Theories in Four Different

Contexts (%)

Contexts Ethical theories A B C D Total

Utilitarian 28 36 48 37 35 (115) Deontological 33 23 22 24 27 (88) Rights 11 15 12 10 12 (41) Virtues 21 11 10 10 15 (48) Care 7 15 8 19 11 (37) Total 100% (123) 100% (114) 100% (50) 100% (42) 100% (329)

Notes: A5general ranking; B5pregnant adolescent (professional dilemma); C5three-generational family (professional dilemma); D5pregnant adolescent (personal dilemma). Number of participants562.

Social Work Education 869

remaining 38% of the arguments were divided among three ethical theories: virtues

(15%); rights (12%); and care (11%).

Research question 2—Do social workers’ arguments reflect different ethical theories in different practice situations?

Table 1 shows that deontological ethical theory is the dominant theory used to

justify the preferred ethical principles in the context of general ranking of ethical

principles (A533%), but it appears less frequently in the arguments justifying

preferred ethical principles related to specific situations (B523%, C522%, D524%,

respectively). However, the utilitarian theory was used more frequently to justify

preferred ethical principles in specific situations—36% of the arguments in the case

of the pregnant adolescent (B), in 48% of the arguments concerning the three-

generational family situation (C) and in 37% of the arguments concerning the

situation of the pregnant adolescent from a personal point of view (D). In contrast,

only 28% of the arguments related to the preferred ethical principles in the general

context were utilitarian (A). The arguments referring to virtue theory, like those

relating to deontological theory, are used more frequently in the context of general

ranking of ethical principles than in the context of specific situations (A521% vs.

B511%, C510% and D510%). Care theory is minimally reflected in the arguments

in the general ranking of ethical principles (A57%). Yet, this theory is more frequent

in the pregnant adolescent situation in both professional and personal contexts (B

and D). No differences were found for arguments reflecting rights theory among the

different contexts.

No notable differences in the classification of ethical theories were found by

comparing the arguments between the professional and personal evaluation of the

pregnant adolescent vignette (B and D). We found that utilitarian theory was more

frequently used in the content of the three-generational family vignette (C) than in

the pregnant adolescent vignette (B and D). We also found that care theory was used

twice as frequently in the pregnant adolescent vignette (B and D) than in the three-

generational family vignette (C).

In summary, the results show that the content of social workers’ arguments, in

terms of ethical theories, changes with the context of practice situations. There is a

marked difference in the content of arguments used in the general rank ordering of

ethical principles and in different specific practice situations. No such difference was

found in the content of the arguments from a professional and a personal point of

view.

Research question 3—Is the content of the social workers’ arguments congruent with the content of the ethical principles in terms of ethical theories?

Examination of the relationships between the content of the arguments of ethical

theories and the ethical principles for each of the four contexts revealed the following.

1. Of the 123 arguments given in the general ranking of ethical principles, the ethical

principle of sanctity of life was found to be the salient principle justified (25%); 52%

of these justifications were in terms of deontological ethical theory. The following

870 R. Osmo & R. Landau

arguments in the sample exemplify the relationships between the ethical principle

and ethical theory: ‘The principle of sanctity of life is an ultimate value. When

sanctity of life is jeopardized, we lose our human image’ or ‘Life for me is sacred,

and everything possible has to be done in order to secure it’.

2. Some 114 arguments were given in the context of the pregnant adolescent vignette

from a professional view. The good of the individual was found to be the most

important ethical principle justified (19%). Forty-five percent of the arguments for

this choice were identified as utilitarian (e.g. ‘My intention is [to secure] the welfare

of the adolescent and of the child. That is, can the adolescent fulfil the parental role?

Will the child born to this mother have adequate life conditions?’) and 36% as care

theory (e.g. ‘As a professional, I must present [the adolescent with] all the possible

alternatives, such as to abort, not to abort, without parents’ knowledge, or with their

cooperation, etc. If she still struggles [to make a decision], I will refer her to receive

mental and physical help, support and guidance during the pregnancy’). Another

important ethical principle in this context was confidentiality and privacy, justified

by 19% of the arguments. Twenty-seven percent of their content was identified as

deontological (e.g. ‘The principle of confidentiality and privacy is important because

it guards/defends human dignity, autonomy and personal freedom’) and 23% as

care theory (e.g. ‘The adolescent who trusts me must receive maximum help and

support from me, which cannot be provided without my keeping the confidentiality

that she trusts me to’).

3. Fifty arguments related to the three-generational family vignette. Twenty-four

percent of the sample chose to justify the ethical principle of public good. All of the

arguments for this principle were identified with the ethical theory of utilitarianism

(e.g. ‘In this instance I have chosen to ‘‘sacrifice’’ the personal welfare of the

grandmother for the welfare of other members of the family; because of the number

of people involved whose condition can improve, and considering their future’).

4. Forty-two arguments related to the context of the pregnant adolescent vignette from a

personal point of view. The social workers’ arguments in this context are similar to the

arguments from a professional point of view in their preferences for utilitarian and

deontological theories (see Table 1). As in the context of the professional point of

view, the principle of individual’s good was the most important ethical principle

justified (29%) (e.g. ‘Personal freedom is important because it’s a basic human need’,

reflecting deontological theory or ‘As a young adolescent, can she understand her own

good?’ reflecting utilitarian and care theories of ethics. Unlike in the professional

context, the results regarding the other ethical principles were insignificant.

The results indicate that, in general, the content of the social workers’ arguments is

congruent with the content of the ethical principles in terms of ethical theories. The

content of arguments in relation to ethical theories was distributed among all of

them, except for the ethical theory of rights. This result contributes to the inner

reliability of the study.

Discussion and Implications for Practice and Education

This study focuses on the arguments provided by social workers for their preferred

ethical principles in terms of ethical theories when confronted with ethical dilemmas.

Social Work Education 871

Our results illuminate a rather unknown area in the process of social workers’ ethical

decision making in practice.

Content analysis of arguments, given by the participants in different contexts,

shows that the large majority of social workers in the study based their arguments on

either deontological or utilitarian ethical concepts. The most salient ethical theory

emerging from the aggregate arguments for the four different contexts examined was

utilitarian, followed by deontological theory. Utilitarian principles have traditionally

been the most popular guides to social workers’ ethical decisions, at least in part

because they appear to foster generalized benevolence; a principle that requires one to

perform acts resulting in the greatest good appeals to professionals whose primary

mission is to provide aid to those in need (Reamer, 1990).

When social workers are requested to justify their rank ordering of ethical

principles without reference to a specific practice situation, they most frequently use

deontological theory of ethics, justifying their choices with concepts such as right

intention, universalism and duty. This result confirms previous findings in our

overall study (Landau & Osmo, 2003; Osmo & Landau, 2003) where most of the

social workers considered the 12 ethical principles to be important or very important,

emphasizing a deontological approach. The general reliance on deontological

concepts implies that social workers deeply value universal ethical principles based on

duty and good will. It is important to mention that we adopted a design that presents

to the respondents a standardized base of ethical principles for rank ordering them

and justify their ranking based on ethical principles as reflected in relevant social

work literature (Bloom, 1990; Loewenberg et al., 2000; Reamer, 2001) and in the

codes of ethics of social workers (IASW Code of Ethics, 1994; NASW Code of Ethics,

1996). Although this design allows better comparisons among the social workers than

asking for individualized lists of ethical principles, presenting the social workers with

a list of the 12 ethical principles to rank could have oriented them towards ethical

theories that lend themselves towards presentation in terms of universal principles

and therefore favor deontological theories.

However, the picture becomes more complex when practice situations are

examined. When social workers were confronted with a specific practice situation,

the content of their argument changed. While justification based on concepts from

deontological and utilitarian theories of ethics is still more frequent than those based

on concepts from the remaining three ethical theories, concepts arising from

utilitarian ethical theory became a more frequent choice than those from

deontological theory of ethics.

Utilitarian theory concepts were used to a differing extent in the two practice

situations (36% and 37% of the arguments concerning the pregnant adolescent from

a professional and personal point of view, respectively, and 48% of the arguments

concerning the three-generational family). In these specific contexts, the social

workers most frequently chose concepts relating to results, consequences, utility, etc.

and there was less use of concepts of intention, duty and universalism.

Our results provide additional support to Loewenberg et al.’s (2000) contention

that social workers are deontological in principle but adopt a utilitarian approach in

872 R. Osmo & R. Landau

practice. Carr (1999) argues that it is natural to ask where and when it is appropriate

to reason from a utilitarian or deontological point of view. The only general answer

to this question is that this must be contextually determined. Banks (2001) also

contends that neither deontological nor utilitarian theories of ethics ‘can furnish us

with one ultimate principle for determining the rightness or wrongness of actions’

(p. 34) while Beauchamp & Childress (1994) write that there is a ‘common morality

theory’ which is pluralistic and combines various ethical theories. Indeed, the current

trend in professional ethics is to broaden the perspective of ethical theories from a

dichotomous stand (deontological and teleological) to a more pluralistic and

differential approach, namely theories that emphasize different aspects of ethical

dilemmas (Brannigan & Boss, 2001). Yet, in our results, rights theory, virtue theory

and care theory were used less frequently than expected. The highest percentage

associated with concepts from rights theory appeared in the context of the pregnant

adolescent as a professional dilemma (15%), dealing with the adolescent’s right to

manage her life as a basic right that the practitioner must respect. The concepts of

virtue theory formed 21% in the general ranking of ethical principles and those of

care theory 19% in the ranking of ethical principles concerning the pregnant

adolescent from a personal point of view. These results suggest that the social

worker’s image of her/himself matters in general (virtue theory), but is less central in

specific practice situations. Particularly when a situation is examined from a personal

point of view, the respondent’s argument focuses on the person to be helped

revealing the relative importance of concepts from care theory. These results thus

raise the question of the social workers’ internalization of the importance of values

identified with theories of virtues, care and rights.

Although participants in this study were not asked to justify their preferences for

their ethical principles in terms of ethical theories, our content analysis of their

arguments shows that concepts of ethical theories were identifiable and congruent

with the ethical principles preferred.

While no one ethical theory offers the complete truth to a moral dilemma, a

diversity of ethical theories can give us a more comprehensive tool for effectively

analyzing ethical dilemmas. Boss (1998) suggests adopting a multidimensional

approach that draws from the strengths of each theory: ‘All theories have the same

ultimate goal to provide a rational basis for making better moral decisions’ (p. 40).

Because ethical theories can aid ethical decision making, we support recommenda-

tions in the social work literature that ethical theories be taught in social work

education (e.g., Rhodes, 1998; Mattison, 2000). Furthermore, as we found far less

justification for ethical decision making in terms of concepts from the ethical theories

of virtue, care and rights, we suggest that these theories specifically be included in

social work education emphasizing the following issues: social work students should

ask themselves what kind of individuals or social workers they want to be. In virtue

ethics, it is having certain feelings, as well as acting in certain ways, that makes an

action ethically right. Virtuous practitioners care because they sympathize with the

client’s suffering and pain (Brannigan & Boss, 2001, p. 38). Social work students

should reflect what care they want to provide to their clients. Care ethics, primarily

Social Work Education 873

connected with the feminist approach and developed from Gilligan’s study of moral

reasoning, claims that we are at our moral best when we are caring and being cared

for (Brannigan & Boss, 2001, p. 38). Care, not rational calculations nor an abstract

sense of duty, creates moral obligation. In terms of this theory, to take care of a client

is to be attentive to his or her needs. Thus, an ethics of care requires that we improve

our communication skills and moral sensitivity (Brannigan & Boss, 2001, p. 38).

Social work students should consider whether the various rights of those involved in

the situation are fulfilled. Since rights occupy a rather central place in our lives, it

seems appropriate that, when confronted with ethical dilemmas, social workers ask

questions such as: What are the client’s rights to non-interference? What are the

client’s positive rights and consequently society’s obligations? However, rights are

only one element to be examined when facing an ethical dilemma. As Hinman (1994,

p. 250) argues, close relationships, such as social worker–client relationships, cannot

be based solely on rights. These theories emphasize concepts central for practice such

as respect for and fulfillment of clients’ rights, care for clients, compassion, sympathy

and solidarity, and make the social worker aware of what kind of practitioner he/she

wants to be.

We also suggest that critical thinking be taught together with ethical theories. This

would not only enable students to apply ethical theories while considering possible

interventions but also teach them the limitations of each theory in explaining and

resolving ethical dilemmas. For example, as the arguments of most of the

respondents’ related to utilitarian ethical theories, students should be made aware

that it is not easy to decide the worth of an action when it is not clear how much

utility is enough and how utility is to be measured in terms of consequences, given

the limits of prediction (Hinman, 1994, pp. 163–178). Nor does utility necessarily

consider the dignity and rights of each individual (Brannigan & Boss, 2001, p. 27).

Indeed, classic utilitarianism, when taken to the extreme, can justify trampling on the

rights of a vulnerable minority in order to benefit the majority (Reamer, 2001, p. 28).

Applying such ethical theories to real-life professional decisions may provide valuable

guidance, and thus enhance a more reflective practice.

Students, and particularly practitioners, must be able to critically discuss the

reasoning behind their discretionary choices and be able to stand the scrutiny and

examination of professional colleagues and legal instances, justifying their

discretionary choices in terms of professional standards and values. That is, their

ethical justifications must be tied to normative professional justifications and be in

congruence with what can be called the ‘reasonable’ social worker. This requires

special attention in view of the research evidence indicating that personal values may

play a great role in their ethical decision-making processes (Landau & Osmo, 2003).

The prospect that social workers may be influenced in some situations by competing

codes of rules, such as the degree of religiosity of social workers, which may be in

conflict with the professional code of ethics, emphasizes the need of social workers’

awareness of their own belief system (Osmo & Landau, 2003).

The need to develop self-awareness and the ability to articulate explicitly their

thoughts may prove important in eliminating instances of arbitrary and

874 R. Osmo & R. Landau

discriminatory decisions which may disregard clients’ values and preferences. The

analyses of case studies may be useful in this respect. Specifically, they may help

students to recognize the possible contribution of each ethical theory when reflecting

on particular cases. The application of ethical theories, usually connoted with

philosophical content, in case studies may assist students in the translation of

theoretical concepts to specific practice situations.

Seventy percent of the social workers in the study provided arguments for their

preferred ethical principles, allowing us to assume that they are competent in

justifying their ethical decisions. However, disturbingly, 30% of the participants did

not justify their choices at all and their rankings appeared indistinct and unreflected.

Moreover, we found that when the respondents were asked to give a total of more

than six arguments, there was a decline in the number of arguments they gave. This

may be due to the difficulty that participants reported in giving arguments for their

preferred ethical principles. This difficulty may arise because social workers are not

used to engaging in an explicit process of justifying their actions and decisions in real

situations.

The results should be seen in the light of the limitations of the study, namely that it

was carried out with a relatively small convenience sample size. Yet, our findings

suggest that ethical theories may provide a meaningful tool in comprehending and

assessing ethical dilemmas. The findings justify further research, with larger samples

of social workers in various practice areas of social work also considering cultural,

social, ideological and gender differences on the application of ethical principles in

ethical decision making in social work.

Authors’ Note

The responsibilities and contributions in this paper were distributed equally between the authors.

References

Abramson, M. (1996) ‘Reflections on knowing oneself ethically: toward a working framework for social work practice’, Families in Society: The Journal of Contemporary Human Services, vol. 77, pp. 195–201.

Banks, S. (2001) Ethics and Values in Social Work, 2nd edn, Palgrave, Houndmills, UK. Beauchamp, T. & Childress, J. (1994) Principles of Biomedical Ethics, 4th edn, Oxford University

Press, Oxford. Bloom, M. (1990) Introduction to the Drama of Social Work, F. E. Peacock Publishers, Itasca, IL. Boss, J. A. (1998) Analyzing Moral Issues, Mayfield Publishing Company, Mountain View, CA. Brannigan, M. C. & Boss, J. A. (2001) Healthcare Ethics in a Diverse Society, Mayfield Publishing

Company, Mountain View, CA. Carr, D. (1999) ‘Professional education and professional ethics’, Journal of Applied Philosophy,

vol. 16, pp. 33–46. Congress, E. P. (1999) Social Work Values and Ethics, Nelson Hall Publishers, Chicago. Cooper, D. E. (1993) Value, Pluralism and Ethical Choice, St. Martin’s Press, New York. Drury-Hudson, J. (1999) ‘Decision making in child protection: the use of theoretical, empirical and

procedural knowledge by novices and experts and implications for fieldwork placement’, British Journal of Social Work, vol. 29, pp. 147–169.

Social Work Education 875

Gambrill, E. (1997) Social Work Practice: A Critical Thinker’s Guide, Oxford University Press, Oxford.

Goldstein, H. (1998) ‘Education for ethical dilemmas in social work practice’, Families in Society: The Journal of Contemporary Human Services, vol. 79, pp. 241–253.

Hinman, L. M. (1994) A Pluralistic Approach to Moral Theory, Harcourt Brace College Publishers, Fort Worth, TX.

Hugman, R. & Smith, D. (1995) ‘Ethical issues in social work: an overview’, in Ethical Issues in Social Work, eds R. Hugman & D. Smith, Routledge, London, pp. 1–15.

Imbrognio, S. (1997) ‘Strategies for argument and tactics for intervention: the case of unresolved issues in privatization’, Journal of Applied Social Sciences, vol. 22, pp. 73–81.

Israeli Association of Social Workers (IASW) (1994) Code of Ethics of the Social Workers in Israel, IASW, Tel Aviv.

Jansson, B. S. & Dodd, S. J. (1998) ‘Developing a social work research agenda on ethics in health care’, Health and Social Work, vol. 23, pp. 17–25.

Landau, R. & Osmo, R. (2003) ‘Professional and personal hierarchies of ethical principles’, International Journal of Social Welfare, vol. 12, no. 1, pp. 42–49.

Loewenberg, F. M. & Dolgoff, R. (1992) Ethical Decisions for Social Work Practice, F. E. Peacock Publishers, Itasca, IL.

Loewenberg, F. M., Dolgoff, R. & Harrington, D. (2000) Ethical Decisions for Social Work Practice, 6th edn, F. E. Peacock Publishers, Itasca, IL.

Mattison, M. (2000) ‘Ethical decision making: the person in the process’, Social Work, vol. 45, pp. 201–212.

National Association of Social Workers (NASW) (1996) Code of Ethics, NASW, Washington, DC. Osmo, R. & Landau, R. (2001) ‘The need for explicit argumentation in ethical decision making in

social work’, Social Work Education, vol. 4, pp. 483–492. Osmo, R. & Landau, R. (2003) ‘Religious and secular belief systems in social work: a survey of

Israeli social worker professionals’, Families in Society, vol. 84, no. 3, pp. 359–366. Proctor, E. (2002) ‘Decision-making in social work practice’, Editorial, Social Work Research, vol. 26,

no. 1, pp. 3–5. Reamer, F. G. (1990) Ethical Dilemmas in Social Service, 2nd edn, Columbia University Press, New

York. Reamer, F. G. (2001) Tangled Relationships: Managing Boundary Issues in the Human Services,

Columbia University Press, New York. Rhodes, M. (1986) Ethical Dilemmas in Social Work Practice, Routledge and Kegan, Boston. Rhodes, M. (1998) ‘Ethical challenges in social work’, Families in Society, Journal of Contemporary

Human Services, vol. 79, pp. 231–232. Toulmin, S. E., Riecke, R. & Janik, A. (1984) An Introduction to Reasoning, Macmillan, New York.

Accepted January 2005

876 R. Osmo & R. Landau

Vol. 36 No 3, September-December 2018 • ISSNe: 2216-0280

O ri

g in

a l a

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Protection of children and adolescents

victims of violence: the views of the

professionals of a specialized service

Priscila Arruda da Silva1

Valéria Lerch Lunardi2

Rodrigo Dalke Meucci3

Simone Algeri4

1 Nurse, Ph.D. Scholarship PNPD, Federal University of Rio Grande –FURG-, Brazil.

email: [email protected]

2 Nurse, Ph.D. Retired Professor, FURG, Brazil.

email: [email protected]

3 Physiotherapist, Ph.D. Professor FURG, Brazil.

email: [email protected]

4 Nurse, Ph.D. Professor Federal University of Rio Grande do Sul, Brazil.

email: [email protected]

Conflict of interest: none.

Receipt: March 27th, 2018.

Approved: September 19th, 2018.

How to cite this article: Silva PA, Lunardi VL, Meuc- ci RD, Algeri S. Protection of children and adolescents victims of violence: the views of the professionals of a specialized service. Invest. Educ. Enferm. 2018; 36(3):e02.

DOI: 10.17533/udea.iee.v36n3e02

Protection of children and adolescents victims of violence: the views of the professionals of a specialized service

Objective. To know the obstacles faced by the professionals to work in network and challenges of the work of the professionals in the Reference Center Specialized in Social Assistance (CREAS) of a municipality in the extreme south of Brazil. Methods. It is a qualitative study, developed with twelve professionals of a CREAS. Data collection was performed through a semi-structured interview, from April to May 2016. The interviews were submitted to content analysis. Results. The fragmentation among the various services that make up the victim assistance network is an obstacle for professionals as they are unable to continue the recovery and health promotion actions of these families. The professionals point out the bureaucratic procedures, the accumulation of functions and the lack of human and financial resources as a routine problem and that seriously hinders the progress of the service. Conclusion. For the professionals, the protection network

Protection of children and adolescents victims of violence: the views of the professionals of a specialized service

Invest Educ Enferm. 2018; 36(3): e02

presents weaknesses that compromise the guarantee of the rights of children and adolescents.

Descriptors: adolescent; child; exposure to violence; child advocacy qualitative research.

Protección a niños y adolescentes víctimas de violencia: miradas de los profesionales de un servicio especializado

Objetivo. Conocer la problemática de la violencia intrafamiliar contra niños y adolescentes a partir de la percepción de los profesionales de un Centro de Referencia Especializado en Asistencia Social (CREAS) de un municipio del extremo sur de Brasil. Métodos. Se trata de un estudio cualitativo desarrollado con doce profesionales de un CREAS. La recolección de datos se realizó mediante una entrevista semiestructurada, en el período de mayo a junio de 2016. Los testimonios se sometieron al análisis de contenido. Resultados. Entre los diversos servicios que componen la red de atención a las víctimas, la fragmentación es el principal obstáculo para los profesionales en medida que no logran dar continuidad a las acciones de recuperación y promoción de la salud de familias afectadas. Los trámites burocráticos, la acumulación de funciones y la falta de recursos humanos y financieros son destacados por los profesionales como un problema rutinario que dificulta seriamente la prestación del servicio. Conclusión. Para los profesionales, la red de protección presenta fragilidades que comprometen la garantía de los derechos de niños y adolescentes.

Priscila Arruda da Silva • Valéria Lerch Lunardi • Rodrigo Dalke Meucci • Simone Algeri

Invest Educ Enferm. 2018; 36(3): e02

Descriptores: adolescente; niño; exposición a la violencia; defensa del niño; investigación cualitativa.

Proteção a crianças e adolescentes vítimas de violência: olhares dos professionais de um serviço especializado

Objetivo. Conhecer os obstáculos enfrentados pelos profissionais para atuação em rede e desafios da atuação dos profissionais no Centro de Referência Especializado em Assistência Social (CREAS) de um município do extremo sul do Brasil. Métodos. Trata-se de um estudo qualitativo, desenvolvido com doze profissionais de um CREAS. A coleta de dados foi realizada por meio de entrevista semiestruturada, no período de abril a maio de 2016. Os depoimentos foram submetidos à análise de conteúdo. Resultados. A fragmentação, entre os diversos serviços que compõem a rede de atendimento às vítimas, se constitui em obstáculo para os profissionais à medida que eles não conseguem dar continuidade às ações de recuperação e promoção da saúde dessas famílias. Os trâmites burocráticos, o acúmulo de funções e a falta de recursos humanos e financeiros são apontados pelos profissionais como um problema rotineiro e que seriamente dificulta o andamento do serviço. Conclusão. Para os profissionais, a rede de proteção apresenta fragilidades que comprometem a garantia de direitos de crianças e adolescentes.

Descritores: adolescente; criança; exposição à violencia; defesa da criança e do adolescente; pesquisa qualitativa.

Protection of children and adolescents victims of violence: the views of the professionals of a specialized service

Invest Educ Enferm. 2018; 36(3): e02

Introduction

I ntrafamily violence has become an increasingly common social and global problem in our society. Because it is a phenomenon with deep roots, implying immediate and future damage to the physical and mental health of its victims,(1-3) as well as the possibility of its reproduction to future

generations,(3) its approach has been characterized as a public health issue. Since the implementation of the Brazilian Federal Law n. 8069 of July 13, 1990 (Statute of the Child and Adolescent-ECA),(4) which provides for the integral protection of children and adolescents, it was established that children and adolescents are a priority, and the state, society, community, family and public power should to secure their rights, as well as to put them to safety from all forms of violence.

Thus, it demands the articulation of a network that meets the needs of approaching the problem in its complexity, through interdisciplinary and intersectoral actions.(5) The network of protection for victims and their families, represented as “the set of significant people systems that make up the relationship links received and perceived by the individual“(5: 247) is made up of various sections, such as the Council of Law, the Guardianship Council (CT), the public prosecutor’s office and the juvenile court, as well as the other institutions that provide care, such as schools, health units, shelters, among other social support networks. Among the various services that deal with situations of violence, the Specialized Reference Center on Social Assistance (CREAS), chosen as the locus of this research, constitutes an important reference point in the care of children and adolescents who are victims of violence. It is a state public unit, created by the federal government in partnership with the municipalities to meet the Federal Constitution, the Statute of the Child and Adolescent (ECA) and the Organic Law of Social Assistance – Ordinance No. 878 of 12/3/2001.(6)

This service has as its role to be in reference, in the territories, of offer of social work specialized in the Unique System of Social Assistance (SUAS) to families and individuals in situations of personal or social risk, for violation of rights. Its role in SUAS also defines its role in the service network.(7) In order to carry out its activities, the services offered in CREAS should be developed in an articulated way between institutions and agents that operate in a given territory sharing objectives and purposes in a continuous process of information flow and permanent dialogue.(7)

Considering the importance of the work of CREAS in the attempt to minimize the damages caused by the violence suffered and to break the cycle of violence, this study seeks the answer to the following question: What obstacles and challenges that you face in your daily work? The answer to this question can support actions that advocate the organization of the network, effectiveness and networking interactions, as well as providing solutions and

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Invest Educ Enferm. 2018; 36(3): e02

decision making, for example, the creation of public policies directed to the problems identified. In this perspective, the objective of this study is to know the obstacles faced by professionals to work together others instances and challenges the work of professionals in CREAS of a municipality in the extreme south of Brazil.

Methods The municipality where the present study was carried out is characterized as particularly vulnerable in the situation of violence and sexual exploitation against children and adolescents. It is a port city with approximately 207,000 inhabitants, located in the southern half of Rio Grande do Sul, with the second largest port in Brazil.(8) Rio Grande is currently one of the most vulnerable point of sexual exploitation in the Federal Highways highlighted by Childhood Brazil and the International Labour Organization.(9) CREAS, installed in the municipality in 2002, was one of the pioneers in the implementation of this service. They attend daily denunciations of the most varied forms of violence against children and adolescents between zero and eighteen, elderly and women. It is a service that develops, among other actions, the social protection of young people in compliance with socio-educative measure of assisted freedom and community service provision.

Five social workers, five psychologists, a secretary and a social educator participated in the study. All twelve participants linked to the service accepted to participate in the study, by signing the informed consent term. The recommendations of Resolution 466/2012 of the National Health Council were followed, and the Ethics Committee of the Federal University of Rio Grande, under the CAAE, approved the project: 49775415.8.0000.5324. After the authorization of the coordinator of the service, the professionals working at CREAS were invited to participate in the research. Then, they were clarified as to the confidentiality of the interviewees’ identity, the confidentiality of the

data and the possibility of withdrawing at any time from the research. It was also clarified the way they would be identified in the work: through the letter “E” and the sequence number of the interviews (E1, E2 … E12), thus preserving their anonymity.

The data collection took place between April and May 2016, which were previously scheduled at the professionals’ workplace. The statements were recorded and later transcribed. In the data analysis, the Bardin-inspired content analysis technique was used.(10) The data were initially organized, then analyzed and categorized in order to respond to the study objective.

Results In the process of data analysis emerged two categories, developed below, namely: Obstacles faced by professionals for networking and Challenges of the work of professionals in CREAS.

Obstacles faced by professionals for networking Difficulty of articulation. CREAS workers reported difficulties in the different services that make up the protection network, such as lack of articulation and communication between services, as evidenced by the following statements. There is a great difficulty of partnership, there is no connection of this network, something we could talk about, discuss the problems that come to the service (E8). In many situations, the CREAS professional sees himself alone, we do not have the support we need from the services, especially essential services that should guarantee the protection of the victims with us, but unfortunately in some cases the child is exposed, unprotected (E12). For professionals interviewed there is a lack of articulation and commitment of the network for that service can be effective in the service. Fragmentation, among the various

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Invest Educ Enferm. 2018; 36(3): e02

services that make up the network (Guardianship Council, Juvenile and Youth Court, Police Station for Child and Adolescent Protection, Social and Health Services, Education, NGOs), constitute an obstacle for professionals as they are unable to continue the recovery and promotion of family health. The lack of effective communication between the different services that integrate the network of care for children and adolescents victims of violence, makes the work of CREAS not very effective, according to the following reports: when a child arrives at the service and, after evaluating, we refer this child to different devices network service, but unfortunately we do not have the return (E7). Besides the difficulty in referrals, there is no reference and counter reference of the cases (E5). When we need to refer a child, we need to get in the queue, so we cannot solve the problem immediately (E1).

Effective action to guarantee the rights of children and adolescents. According to the professionals’ report, when families seek help in specialized care services, the first difficulty is in providing care quickly and resolutely, which corroborates the violation of the rights of children and adolescents. Many victims remain in waiting queues for care here at CREAS creating obstacles and even loss of contact of this family (E1). The number of processes accumulated, the bureaucratic procedures, are pointed out by professionals as a routine problem of the specialized service network and that seriously hinders the progress of CREAS. According to the coordinator of the service, delinquency of justice contributes to the violation of the rights of children and adolescents because the response does not come when it is needed, meanwhile the child becomes helpless, often there is evasion of the family and consequently of the victim, which may lead beyond impunity, a possible revictimization of the child and/or adolescent (E11). The problem is even greater when it requires specific measures to protect the victim, such as the removal of the family, due to insufficient institutional shelter programs for children and adolescents in situations of violence

(E4). According to E8, the service to the abuser is not yet a reality in the city due to numerous problems, including the lack of a qualified professional to attend this type of clientele and investments in this type of professional such as training and working conditions (E8).

Challenges of the work of professionals in CREAS Lack of investment in training professionals. The interviewed professionals report that although they are able to identify families in situations of vulnerability and risk of intrafamily violence, there is no support from municipal management in refresher courses and periodic training to attend to this clientele (E4). For professionals, working with violence is a topic that in fact requires a lot of technical preparation, which requires updated knowledge about the subject and the exchange of knowledge between different devices (E1). Characterized as an environment with high emotional overload, it is notorious in the speech of professionals, the lack of care and appreciation of these workers by managers. The professional E2, says that the team feels unmotivated by lack of professional appreciation and, often, no profile for the type of work. E3, perceives an authoritarian and collecting management, distant from the team and deficient in the needs of the servers. E8 already feels the need to work out the frustrations, since the work depends on other institutions and these, present resistance.

Insufficiency of material and human resources. The accumulation of functions and the lack of human resources has compromised the good progress of the service, according to the professionals’ reports. The narratives reveal how this process has been configured: The imposition of the juridical in the questions of producing evidence, is a difficulty that we face, we need to make psychological evaluation reports (E2). The realization of psychological evaluation is not predicted as an activity in CREAS policy, but in

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the accomplishment of psychosocial monitoring, and the fact that we carry out the evaluations, we are very exposed (E5). We need to serve the entire territory and we do not have enough human resources to meet the demand (E9). Difficulties with regard to financial transfers from municipal resources also affect the service. According to the professionals, there are no computers for all employees, which makes it unfeasible, especially in terms of agility and quality of service (E4). Often the difficulty in working on CREAS is the lack of expedient material such as educational games, psychological tests, bibliographies (E1). We miss the printer because we have to move to another device to use the printer (E10). It is noteworthy that fifteen years have passed since the implementation of the service in the municipality and there is still no computerized system for the registration of CREAS information, thus corroborating so that the delays in service are even greater.

Discussion The reality found allows us to bring up a problem that occurs in the daily lives of many families, which can corroborate so that silence overcomes the revelation of violence. The results of this study show that the victims are treated in the service; however, they cannot always guarantee the effectiveness of the referrals. The fragmentation of the services that make up the network of care for children and adolescents has compromised the progress of CREAS and, furthermore, exposing the victim to a possible risk of death and injuries that may affect their development. Networking is a strategy that strengthens advocacy, accountability and support for victims of violence. In the meantime, the literature reveals that actors in the networks of attention to situations of violence in the country also recognize that the interinstitutional action, rather than a principle, is an absolute necessity in the face of the complexity of the problem.(11)

The testimonies of the subjects are in line with the findings of several studies that affirm that effective and decisive care in the face of a case of violence against children and adolescents goes beyond individual, institutional and social aspects, especially in the establishment of referral and contraceptive systems.(12-14) However, this service network, although highly valued, is considered insufficient, especially in actions directed at children and adolescents who are victims of violence. It is understood that official documents related to violence are put to society, but without a wide and sufficient discussion and mobilization of the protagonists, favoring the maintenance of possible barriers as pointed out in the study. There is a movement to approve laws, ordinances and decrees related to violence, however, it is not enough to approve it only if the network for dealing with violence is disjointed, lacking in inputs and strategies, fragility of knowledge and incipient management in this sphere of violence.(12,13)

The discrediting of legal instruments, judicial organs and police authorities, as well as the disqualification of professionals in the specialized care of children and adolescents victims of violence are realities also pointed out in other studies.(15,16) They possibly contribute to that many families choose not to seek care prioritizing to protect themselves “in a wall of silence,” meanwhile, children and adolescents remain unprotected. Effective action by law enforcement agencies and the judiciary is key. However, criminal accountability does not mean ensuring peace in family or social relationships. In certain situations, the legal punishment of the aggressor should be added to other measures that contribute to the promotion of a culture of citizenship, accountability and protection of children and adolescents.(17) Integral care for the victim, including the aggressor, may be an important step in the attempt to break the violence, so it is recommended that qualified care be used to re-socialize the agents that cause violence, thus avoiding the recurrence of violence.(18) Although

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it is recommended that the intervention be directed not to only the victim, but also the family as the focus of attention, the results show that professionals have faced structural and economic limitations, which restricts the professional performance in the scope of intervention. It is known that this is not an exclusive difficulty of the municipality, it is also identified in other studies the inter-sectoral difficulties regarding the articulation with the care network, reference processes and against reference and interlocution of the professionals involved.(14,19)

The valorization of professional training in attending to situations of violence was one of the actions judged by the interviewees as important, since the decision making in relation to the diagnosis, care, notification and referral of the situation of violence seems to be strongly related to the knowledge of the protection of the victim, represented by legislation, but also as an ethical issue of the professional for the protection of the child under his or her care.(20) The Child and Adolescent Statute (ECA) previse a creation and investment in the qualification and training of professionals to receive and be able to attend the demand of care.(4) Although professionals have built and developed specific knowledge throughout their professional trajectory, many are inserted into the service without any preparation, what they consider as something negative for the service, because their absence increase the chances of failure in care. However, what has been observed is the search by own initiative to take courses and specialization in the area, discuss cases and professional demands as a team.

Support for professionals is essential for the operation of a service. This support encompasses all the investment needed for a policy to take place, and involves the professionals who are relating to it. Thus, it is understood that the strengthening of the care network goes not only through the expansion of specialized services, but also through the permanent training of professionals in order to ensure a qualified care for victims of violence. (21,22) Violence is not limited only to care directed at injuries, but also to a knowledge that allows to

handle this problem in a more secure and qualified way, which is in line with what professionals have reported, i.e. the need for training of the teams that work with this clientele. This reinforces the need to “give voice” to these professionals in order to point not only to their desires in relation to their work, but also to health care so that they can be strengthened when the violence face them in their daily work. Thus, strengthened may have a more successful intervention with better care.

Conclusion. The effective protection and guarantee of the rights of children and adolescents is a reality that needs to be addressed, as well as overcoming situations that violate their rights, require knowledge and reflection on how municipalities are articulating in the cases of violence against children and adolescents. It was evidenced in this study that the services that make up the protection network still present weaknesses in the municipality investigated. Unpreparedness about how to work in a network, through lack of communication among workers, lack of return of the services to which the user was referenced, and the lack of accountability of the professionals involved in the care can signal, besides the lack of commitment in the guarantee of right of children and adolescents, limitations of the management and organization of the set of services that make up this network.

Thus, the disarticulation of the network, in fact, is a fragility that requires special attention from municipal management, given the need for protection organs and institutions to be articulated and strengthened, so that their actions are effective. Thus, to qualify the network, qualified and training professionals are needed, as well as the valorization of those involved.

The present study had as limitation its accomplishment in a single scenario, so these analyzes could be limited, since they represent perceptions of a particular group, and it is not possible to generalize the results. Also, it is important to note that, although health professionals are not part of these services, they must always act in an articulated way, in a multiprofessional work, either in the care and in

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the formulation of a care plan focused on the real needs of families. Although the study presents limitations, the data point to the need for new investigations, considering the perception of workers from other sectors of the municipality studied, which would broaden the discussion about the obstacles and the challenges faced and would allow the planning of actions.

This study advances the production of knowledge in that guaranteeing rights to children and

adolescents is an urgent necessity that needs to be addressed. It suggests, in addition to the planning of actions with a view to networking, the need for permanent education in order to qualify the protection services of the municipality under investigation.

Acknowledgments: To the National Council for Scientific and Technological Development -CNPq, for the research assistance (Process nº 401609 / 2015-4.

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References 1. Hillis S, Mercy J, Amobi A, Kress H. Global Prevalence of Past-year Violence Against Children: A Systematic Review

and Minimum Estimates. Pediatrics. 2016; 137(3):1-13. 2. Walsh J, Spangaro J, Soldatic, K. Global understandings of domestic violence. Nurs. Health Sci. 2015; 17(1):1-4. 3. World Health Organization. Global status report on violence prevention [Internet]. 2014 [cited 20 Dec 2016].

Available from: http://www.who.int/violence_injury_prevention/violence/status_report/2014/en/. 4. Brasil. Estatuto da Criança e do adolescente: lei n. 8.069, de 13 de julho de 1990, e legislação correlata. 9. ed. –

Brasília: Câmara dos Deputados, Edições Câmara; 2010. Available from: http://www.crianca.mppr.mp.br/arquivos/ File/publi/camara/estatuto_crianca_adolescente_9ed.pdf.

5. Rosa EM, Lira MOSC. Intrafamiliar violence against children and adolescents: support and overcoming network. J Hum. Growth Dev. 2012; 22(2):246-52.

6. Brasil. Ministério da Previdência e Assistência Social. Portaria nº 878/2001, de 03 de dezembro de 2001, Estabelece diretrizes e normas do Programa Sentinela, e dá outras providências. Republicada, no Diário Oficial da União, Brasília.

7. Ministério do Desenvolvimento Social (MDS) 2013. CREAS Institucional. [cited 12 Nov 2014]. Available from: http://www.crianca.mppr.mp.br/arquivos/File/suas/creas/creas_institucional.pdf

8. Instituto Brasileiro de Geografia e Estatística. População estimada para o Município do Rio Grande. 2014 [cited 2017 Oct 12]. Available from: http://www.cidades.ibge.gov.br/xtras/perfil.php?lang=&codmun=431560&search =riogrande-do-sul|rio-grande

9. Childhood Brasil. 6º Mapeamento de Pontos Vulneráveis à Exploração Sexual de Crianças e Adolescentes nas Rodovias Federais Brasileiras.2014 [cited 2017 Nov 20]. Available from: http://www.namaocerta.org.br/pdf/ Mapeamento2013_2014.pdf

10. Bardin L. Análise de Conteúdo. São Paulo: Edições 70; 2011. 11. Pelisoli C, Pires JPM, Almeida ME. Violência sexual contra crianças e adolescentes: dados de um serviço de

referência. Temas Psicol. 2010; 18(1):85-97. 12. Cardoso AVM, Teixeira SM. Políticas de atenção à criança e ao adolescente em situação de risco social. Emancipação.

2017; 17(1):45-57. 13. Ribeiro JP, Silva MRS, Cezar Vaz MR, Silva PA, Silva BT. The protection of children and adolescents: an analysis of

public policies and their relationship with the health sector. Invest. Educ. Enferm. 2013; 31(1):133-41. 14. Lopes CS, Brisola EMA. Trabalhadores do centro de referência especializado em assistência social: dificuldades

vividas no cotidiano profissional. Rev. Ciênc. Humanas. 2017; 10(20):134-47. 15. Hohendorff JV, Patias ND. Violência sexual contra crianças e adolescentes: identificação, consequências e

indicações de manejo. Barbarói. 2017; 49(1):239-57. 16. Souza AMF, Sousa FJP. Avaliação do enfrentamento às violências contra crianças e adolescentes: a experiência da

Comissão de Prevenção aos Maus-Tratos em uma Unidade de Saúde da Família da SER V. Rev. Avaliação Polit. Publicas. 2014; 2(14):128-47.

17. Deslandes S, Mendes CHF. Quem avalia, atua melhor! Guia para análise avaliativa dos municípios no enfrentamento da violência intrafamiliar e exploração sexual de crianças e adolescentes. Rio de Janeiro: Fiocruz; 2011.

18. Vieira MS, Grossi PK, Costa RG. O enfrentamento à violência sexual contra crianças e adolescentes: os caminhos para a municipalização das ações em Porto Alegre. Anais 2º Encontro Internacional de Política Social 9º Encontro Nacional de Política Social; 2014. Available from: http://repositorio.pucrs.br/dspace/bitstream/10923/9469/2/o_ enfrentamento_a_violencia_sexual_contra_criancas_e_adolescentes_os_caminhos_para_a_municipalizacao_das_ acoes_em_porto.pdf

19. Gonçalves CFG, Silva LMP, Pitangui ACR, Silva CC, Santana MV. Atuação em rede no atendimento ao adolescente vítima de violência: desafios e possibilidades. Texto Contexto Enferm. 2015; 24(4):976-83.

20. Silva PA, Lunardi VL, Ribeiro JP, Oliveira AMN, Vasquez TCS. A notificação da violência intrafamiliar contra crianças e adolescentes por profissionais de saúde no Brasil. Av. Enferm. 2015; 33(1):142-50.

21. Deslandes SF, Mendes CHF, Pinto LW. Proposição de um índice do enfrentamento governamental à violência intrafamiliar contra crianças e adolescentes. Cad. Saúde Pública. 2015; 31(8):1709-20.

22. Deslandes SF, Mendes CHF, Luz ES. Análise de desempenho de sistemas de indicadores para o enfrentamento da violência intrafamiliar e sexual contra crianças e adolescentes. Cien. Saude Colet. 2014; 19(3):865-74.

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How to make good choices? Ethical perspectives guiding social workers moral reasoning

Annalisa Pasini

Department of Sociology, Università Cattolica Sacro Cuore, Milan, Italy

Ethical perspectives in social work: a classification

Social work is intrinsically ethical because social workers have the responsibility to act intentionally in difficult situations to pursue a ‘good’ aim. Therefore, they need to reflect on ethical dimension as well as on professional methods and skills. The ethical dimension in social work can be considered from many theoretical perspectives, each of which observe different aspects, have different underlying values and request different answers. In order to understand the challenges that social workers face in practical situations, it is useful to know the different approaches and then integrate them in a composite scenario. This is very important in a professional context where the ethical dimension seems obscured by other issues, like organizational rules and procedures, resources cutting, and so on. Instead, ethics is deeply linked to cultural, organizational, political, and professional dimensions of daily practice.

This paper proposes a classification of the ethical perspectives in social work that pre- sents principal-based approaches and ‘situated approaches’ (Banks, 2010; Banks & Nøhr, 2012). Highlighting their differences can stimulate more ethical consciousness. The first category includes the main ‘classical’ orientations of traditional philosophy – the teleolog- ical and deontological – alongside the rights-based approach. They are presented together here because they have a general and abstract character and develop a wide ethical theory,

ABSTRACT Framing and distinguishing mainstream social work ethical perspectives could be useful for social work students and practitioners facing moral choices in daily practice. The article presents a summary and classification of a range of ethical theories and provides some insights into the relationship between ethical thinking and practice issues. It distinguishes between classical approaches and ‘situated’ positions. The former – which includes teleological, deontological, and rights-based approaches – refer to universal and general principles. ‘Situated’ ethics are linked to specific and unique situations of professional practice. Finally, the article suggests some useful questions derived from each approach in order to help students to reflect on complex ethical choices occurring in daily practice.

KEYWORDS Ethical perspectives; moral choices; teaching ethics; social work practice

ARTICLE HISTORY Received 12 December 2014 Accepted 5 August 2015

CONTACT Annalisa Pasini [email protected]

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capable of guiding professional choices as impartially and objectively as possible. In order to answer to the question: ‘on what criteria is an action considered good?’ the teleological perspective refers to the goals that the action pursues, the deontological refers to the prin- ciples that inspired it and the rights-based approach refers to the respect and promotion of a person’s rights.

On the other hand, ‘situated’ approaches refer to the peculiarity of each situation social workers face. The people and the specific relationships of daily practice are at the center of this analysis. Within these approaches, virtue ethics and relational ethics can be distin- guished. Virtue ethics refers to the character of the agent, while relational ethics is a set of positions where the social worker–service user relationship is the primary ethical focus.

Within this second group, the ethics of care, narrative ethics, and face-to-face ethics will be specifically analyzed: Each of these can suggest interesting reflections to social work practice. To answer to the question ‘on what criteria is an action considered good?’, virtue ethics focuses on the choice of the agent. The relational perspectives emphasize the moral character of caring process (ethics of care), the sharing of an ethical story with the inter- ested subjects (narrative approach), and the understanding and respect for the idea that it is impossible to fully understand ‘the Other’ totally (face-to-face ethics).

Table 1 highlights the different approaches presented in the article, identifying their principal focus, key authors, and theoretical frameworks. These different perspectives will be analyzed referencing concrete situations that social workers face in daily practice.

Principle-based perspectives

The first principle-based approach is teleological perspective. It supports the centrality of the goal, as Aristotle suggested (Banks & Nøhr, 2003). In social work, this refers to paying attention to the aims of an intervention and to its consequences, like the utilitarian stream

Table 1. Ethical perspectives in social work: a classification.

Note: Adapted from Hinman (1994), in Osmo and Landau (2006).

Ethical perspectives Focus Key authors or streams of reference

Principle-based ethical perspectives

Teleological perspective Goals and consequences of actions Aristotle Mill, Bentham (utilitarian perspective)

Deontological perspective Correct intentions; principles valid for all human beings

Kant

The main concept: self-determi- nation

Rights-based perspective Rights and respect of others’ rights Universal Declarations (including the UN, 1948) Social Work Code of Ethics (2004)

‘Situated’ perspectives

Ethics centered on the agents

Virtue ethics Moral character of the agent Aristotle Virtue as dialogical element Habermas (proportionist approach)

Relational ethics

Ethics of care Care relationship Feminist theory Narrative ethics Shared stories Narrative approaches Face-to-face ethics Sociality, impossibility of totally

knowing the Other Lévinas

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suggests. Social work embeds two goals: the promotion of individual well-being on one side, and the achievement of social justice on the other (Banks & Nøhr, 2003). For example, a social worker seeks to help a service user with severe economic needs by evaluating how to improve his/her standard of life. The choice of finding a job or helping the person to access benefits depends both on the specific situation (what is good for this person?) and on the rules and available resources with respect to social fairness (what is feasible and fair?).

Actualizing social work principles are not easy. Thinking about the promotion of indi- vidual well-being, different people can have divergent opinions on what is ‘good’ and how to pursue it. For instance, can an alcoholic recognize that to quit drinking is a ‘good’ act? How do we resolve the difference between a disabled older person’s wish to stay at home while his daughter would rather place him into residential care? Even social justice is neither easy to define nor to pursue. Should a disabled person have the same opportunities as an able-bodied person? Is it right that a specific law helps him/her find a job?

Reflecting on these aspects, a social worker can adopt the other classical principle-based perspective, the deontological one. According to this, true moral duty consists of doing what is right only because it is right, by virtue of human rationality. Social workers must first let people make their own choices. Kant’s idea that every person should be treated with respect, as self-determining, and with their own goals (Banks & Nøhr, 2003), has translated into a key social work principle. It was already in the list of Biestek’s casework values (1961) and it reflects Rogers’ unconditional positive regard (1961). But self-determination is not a straightforward principle: What about a person who desires something that goes against their well-being or that of others around them, such as the alcoholic who is not willing to quit drinking and is violent towards other family members?

The deontological perspective is present in many countries as a code of ethics for social work to guide professional behavior. In Italy, Social Workers’ Deontologic Code (Ordine Nazionale degli Assistenti Sociali, 2009) indicates the professional principles and respon- sibilities towards service users, colleagues and other professionals. The code prescribes rules and behavior, but is not substitutive of moral consciousness: each case is unique and it requires well well-thought-out choices, because people are different and contexts are different at social, cultural, and organizational level. What can be good for one service user may be discriminatory for another.

The last principle-based theory is the rights-based approach. It refers to universal and general principles that should govern human acts. It has its roots in universal declarations adopted by international organizations, including the Universal Declaration on Human Rights (the UN, 1948). In social work, the international Ethics in Social Work; Statement of Principles (IFSW & IASSW, 2004) ‘recognizes rights that are accepted by the global commu- nity.’ These rights are not taken for granted and require constant attention. For example, we can consider disabled people’s or women’s condition in certain cultures. If a social worker is not careful, he/she runs the risk of contributing to structural oppression (Dominelli, 2004). For instance he/she could propose a paternalistic intervention that contributes to stigmatiza- tion and labeling rather than promoting rights. The more critical and radical approaches to social work can be useful because they consider and highlight the requests of service users’ movements and their fight for social justice and active citizenship for all (Barnes, 1997).

The language of rights is not without critics either: it refers to a western and individualistic conception (Banks & Nøhr, 2012) that is very different from collectivist cultures in southern and eastern parts of the world. Here solidarity, harmony, and interconnectedness in one

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community prevail (Ife, 2001). Furthermore, rights are abstract and generic concepts. It is common in social work practice to face conflicting rights and it can be difficult to promote competing rights and avoid oppression for one while asserting the rights of the other. For example, the right of a child to be looked after at home, or the right of a woman belonging to specific ethnic group to plan her own life.

Following Nussbaum (2002), we could substitute the concept of rights with that of capa- bilities (Sen, 2001): ‘what people in specific circumstances are effectively able to do and to be, using the intuitive idea of a good life and dignity that most humans expect’ (Nussbaum, 2002, p. 57). Nevertheless, a capabilities approach requires cultural and social development as well as political commitment for an equal distribution of resources. In this way everyone could be empowered to apply his/her skills and choose his/her life plan.

‘Situated’ perspectives

Next to principle-based perspective, ‘situated’ ethical perspectives can offer a complemen- tary ethical point of view. In fact, they help social workers to understand and manage specific ethical issues emerging in daily practice.

In order to comprehend them, we need to consider three levels: macro, meso, and micro. The macro context consists of the country where social work practice occurs: its cultural, legal, and political aspects are relevant like as social work education system and its the- oretical framework. The ‘meso’ context consists of agencies, professional mandates, local services, teamwork, service users, and so on. Finally, the micro context includes family and community relationships and traditions. All of this asks for cultural sensitivity, but also attention towards emotions, relationships, and motivations of all actors, including social workers (Banks, 2008).

‘Situated’ perspectives inevitably lose some generalizations about ethical discourse but, in turn, they enhance the value of real moral experiences. These experiences are limited, but they allow more personal and creative reflection (Baldwin & Estey-Burtt, 2012). This often emerge within teamwork or professional peer relationships: the paper concentrates only on individual dimension in order to clarify the different perspectives.

Among situated perspectives, we can distinguish virtue ethics from relational approaches.

Virtue ethics Virtue ethics focuses on the character of moral agents. For Aristotle, virtue (‘what kind of person should I be?’) implies not only the rational ability to decide, but also the willingness to act for ‘good.’ In social work, it require social workers to employ their morality while acting in care relationships, considering policies, organizations, values, and culture in which they are based.

According to Clark (2006), it is neither possible nor desirable that social workers are neutral if they want to help people. In order for them to help, they should envision what could be ‘good’ for every different person in different contexts. We should not consider helping as a mere application of professional competences nor simply respecting rights or following guidelines. It is an ethical duty to take responsibility to work towards the ‘good’ for people going through difficult situations. When a social worker tries to help a disabled older person at home, or checks if a family is eligible for a provision, he/she is foremost someone who is trying to help people in need.

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Within mainstream virtue ethics, we can place another approach, the so-called ‘propor- tionist’ approach (Lovat & Gray, 2008), founded on the ideas of Habermas. Here, virtue is not an individual concept, but a dialogical element emerging from intersubjective commu- nication. Social workers formulate judgments drawing on their own experience and vision of the world, together with that of service users, in the specific situation. This interaction generates unpredictable consequences; so ethics should focus ‘on the reflective-interpre- tational process that enables the social worker to choose how to act’ (McBeath & Webb, 2002, p. 1016).

Social workers’ actions are not ‘good’ in absolute, but refer to a unique situation. For example, a social worker is not facing just a 15-year-old pregnant girl. He/she is interacting with a specific girl named Katy, with her requests and her thoughts, her doubts and worries, her family, friends, and social context. The social worker will learn what is good for Katy and for the baby by meeting her, learning her story, and reflecting with her.

The proportionist perspective is interesting because it focuses on social workers’ point of view and their interaction with service users, alerting on some issues that can affect inter- subjective communication, like lack of time or power imbalance or cultural assumptions. It guides us towards the ‘situated’ relational ethical perspectives.

Relational perspectives Within situated approaches, relational perspectives underline the contextual and specific dimension of ethics, and its social and political frame (Ricoeur, 1997). Moral actions are closely related to relationships. In this case, social workers are interested in what service users ask them, what they believe, and what they are experiencing, even before respecting professional standards or considering their own morality.

Social workers should seek a ‘relational good’ (Donati & Solci, 2011), originating from being involved in the relationship. Several experiences in different countries are based on this relational logic (Folgheraiter, 2011), such as self-help mutual-aid groups (Folgheraiter and Pasini, 2009), family group conferences (Morris, 2011), or dialogical methodologies (Seikkula & Arnkil, 2006). They show that ‘it is sociality and humanity, modulated in the correct ethical and scientific terms, which legitimate whatever helping practices are adopted’ (Folgheraiter, 2012, p. 17).

Among the most significant relational perspectives, are the ethics of care, narratives ethics and face-to-face ethics.

Ethics of care The ethics of care (Barnes, 2006) focuses on the responsibilities linked to care relationships and suggests that such relations develop and build everyone’s morality. Not only frail people experience or need care: it is a founding component of life that includes both receiving and giving care, as shown, for example, in a parent–son relationship.

Rooted in feminist reflections (Gilligan, 1982), the ethics of care suggests that professional care derives from private and family’s caring actions in which mainly women are involved. There are four relevant ethical dimensions: attentiveness, responsibility, competence, and responsiveness (Tronto, 1993). These elements become more concrete if we think about a relationship between a social worker and a disabled older person whose caregiver is his daughter.

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Attentiveness implies the capacity to listen to what the older person thinks and says, including the care he/she receives, and then to answer in the appropriate way. The social worker should extend attention to the daughter and other professional or informal caregiv- ers, if he/she does not want to face the risk that the capacity to care is ‘running out.’

Responsibility is the capacity of intervening: it means the motivation to take concrete action, which should follow the understanding of the other’s need. In the case of the older person, it is not the ‘formal’ responsibility of the social worker or the family and/or cultural bond of the daughter. It is rather the ‘apprehension’ arising from the other’s vulnerability, as the philosopher Hans Jonas suggests (1979).

The third ethical component of care is competence. For a social worker, a strong motiva- tion is not enough: he/she needs knowledge, skills, and judgment to drive the appropriate actions and resources. The results of helpful action should indicate that the older person and his/her family are better off and perceive such improvement.

The fourth and last component of care consists in the responsiveness, the availability of both helping and being helped. We need to assess this from the point of view of the people cared for. The older person, but the daughter as well, find themselves in a vulnerable situa- tion and the social worker should not exercise illegitimate power, although well meaning, to think that he/she knows what is good without asking them.

The ethics of care underlines the commitment to ‘take to heart’ (as Don Milani wished for, 1967) and to be involved even emotionally in situations of vulnerability. Social workers should recognize the resources of each individual and commit to an ethical exchange of actions to reach ‘good’ life improvement. All the practices of care ‘taking place both inside and outside the family represent a “strategic” moral resource’ for society (Williams, 2005, p. 20). The ethics of care invites social workers to use them consciously and intentionally to promote collective well-being and social justice (Koggel & Orme, 2010; Tronto, 2010).

Narrative ethics We can also include narrative approaches in their various forms within ‘situated’ perspec- tives. A ‘weak’ narrative stream focuses on methodology: the story is the central instrument that allows a collection of data and materials in order to develop ethical thinking. As Banks and Nøhr demonstrate in their volume ‘Practising Social Work Ethics around the World’ (2012), the analysis of concrete ‘ethical cases’ allows differing values and principles to be reconciled in daily practice.

A more radical narrative position considers social work as a narrative practice (Baldwin & Estey-Burtt, 2012). This field of theory and practice is made up and shaped by narrative practices between users and social workers: ‘generative talks that are capable of simultaneously challenging traditional understandings and offering new possibilities of actions and change’ (Parton, 2003, p. 9, cited in Wilks, 2005).

According to Wilks (2005), this approach allows the inclusion of service users within ethical reflection. The social worker has the moral responsibility not only to listen to and comprehend the story of the people involved, but to recognize these people as ‘moral Others’ (Baldwin & Estey-Burtt, 2012). He/she should know that his/her position could diverge from theirs; but everyone in the relationship can contribute to create a new, shared story. In this way, the situation can evolve towards the ‘good.’ Such a story is intrinsically ethical, based on mutuality and solidarity, attention for the uniqueness of the ‘Other,’ care and trust. According to Baldwin & Estey-Burtt (2012), this is the way to respect social workers’ values.

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In this perspective, a dilemma such as the decision about removing a child because of abuse or neglect is not a matter of principles; it is not about the safeguarding of the child and the obligations of his/her mother, or the contrast between their rights. Instead, it is an intersection of different stories and the social worker must not only consider the rational dimensions, but the emotional implications as well. Thus, he/she should listen to the mother and the child to understand their perspectives. Perhaps the former knows her difficulties, but she is alone, she has to work hard and does not have any social support.

Hearing and considering everyone’s voice does not mean avoiding professional reflection in order to weigh up what should be done; it implies being able to take an ethical decision through interaction with and interpretation of that specific moral story (Wilks, 2005). Today this can be very difficult: narrative practice needs time for dialog, resources, and cultural sensitivity, which are often in conflict with managerial objectives and requests for evidence.

Lévinas’ face-to-face ethics Lévinas’ face-to-face ethics (1972) is also based on responsibilities derived from interactions between the social worker and user. It is a radical challenge to social work ethics because ethics transcends understanding and it is placed in the ‘face’ of the ‘Other.’

According to Lévinas, ethics goes with sociality and asks to meet ‘the singularity and irre- ducible uniqueness’ of the ‘Other,’ who is ‘Infinity.’ We cannot know him/her as a ‘Totality,’ which is made of concepts, representations, and thought processes that enable each of us to comprehend the world around us.

As a result, it is not an ethical practice to immediately apply professional skills and scientific knowledge to contextualize a person and gives reasons for his/her behavior. It is also not fully ethical to try to understand the situation by sharing it with others involved, according to critical social work. The capacity to mediate both the theoretical knowledge and the specific relationship experience through professional reflection (Schön, 1999) develops a more ethical social work, but it does not respect the ‘Infinity.’ Social workers need to ‘stand’ in front of service users as ‘Infinity’ and try to respect the impossibility of fully knowing them.

We need an ‘unsettled’ social work in Rossiter’s (2011) terms: totality – represented by using knowledge and skills, being part of an organization and formulating judgments to act in the best way for social justice – does not have to ‘kill’ the impossibility of knowing the ‘Other.’ When a person meets a social worker, the latter should refrain from his/her own convictions and temptations to identify immediately provisions that he/she could offer. He/ she should find the time to ‘stand’ in front of the ‘Other’ and truly listen. He/she will not be able to totally understand the person in front of him/her and the situation in which the person lives, but he/she will trust that a good solution will emerge from the relationship.

This uncertainty is not easy to bear or to pursue in a professional context that requires standards to achieve, and the application of guidelines and risk management, but it is a challenging way to work ethically.

Conclusions

This analysis of different ethical perspectives confirms the research findings of Osmo and Landau (2001), that no theory alone captures the development of a complete moral reason- ing. It is rather the combination of several approaches that can help social workers to solve the numerous and diverse situations they face. Each point of view focuses on certain ethical

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dimensions, and raises specific ethical questions. Put together, these questions can help the social worker to make better moral choices, even in the context of difficult dilemmas.

Firstly, the practitioner could refer to social work universal and general principles. He/ she could ask himself/herself:

• Am I aiming at well-being and social justice? What are the consequences of my actions? (teleological perspective)

• Upon which principles are my intervention based? What are my moral duties? (deon- tological perspective)

• Which and whose rights are involved in the situation? (rights-based approach)

Nevertheless, it is also important to consider the specificity and uniqueness of each pro- fessional situation. The social worker exercises his/her capacity to judge and make choices aligned with his/her moral conscience. Thus the question could be:

• What kind of social worker should I be? (virtue ethics)

The previous questions address only the individual dimension of ethics. The relational dimension, so important for social work, invites us to question the relational attitude and the helping dynamic, avoiding power imbalances, and fostering empowerment. The questions that summarize, even in a partial way, relational approaches could be as follows:

• Am I caring with attentiveness, responsibility, competence, and responsiveness? (ethics of care)

• Am I allowing the other to tell his/her story? Am I giving the right value and can I build a shared narrative? (narrative approach)

• Am I capable of not inserting the ‘Other’ in my concepts? Am I respectful of what he/ she is bringing to the relationship? (face-to-face ethics)

As Banks (2010) suggests, social workers need mainly reflections – rather than ethical models for decision-making – to explore in depth the ethical dimension intrinsically linked to their work.1 This reflection means consciousness and awareness: there are different rela- tionships and different values and perspectives, within the institutional and cultural context, which impact on ethical actions and sometimes constrain them.

Social work students are required to learn a critical approach. In order to respect and appraise the relational dimension of ethics, they need to learn ethical dialog where personal positions about values, professional, and organizational principles are explicit. Teamwork and peer relationships are privileged opportunities to exercise it during education and training. In this way, they can learn to find shared positions or they can understand and accept disagreement and conflicting positions.

Finally, they can recognize the political dimension of ethics that is strongly connected to the social mandate, the commitment to justice and equity, and the context of culture and institutions.

Only an effort to develop an ethical reasoning at different levels allows a social worker to manage typical dilemmas of practice (Banks, 1995). Thus, a more complete definition of professional competence can be reached where, along with knowledge and professional skills, social workers’ ethical reflection is considered. A social worker’s familiarity with

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reflection on the sense and the way of working not only increases his/her moral stature but also professional effectiveness and the legitimacy of interventions.

Note

[1] See Hugman (2005) too.

References

Baldwin, C., & Estey-Burtt, B. (2012). Narrative and the reconfiguration of social work ethics. Narrative Works, 2, 1–19.

Banks, S. (1995). Ethics and values in social work. London: Macmillan. Banks, S. (2008). Critical commentary: Social work ethics. British Journal of Social Work, 38,

1238–1249. Banks, S. (2010). Interprofessional ethics: A developing field? Notes from the ethics & social welfare

conference, Sheffield, UK, May 2010. Ethics and Social Welfare, 4, 280–294. Banks, S., & Nøhr, K. (Eds.). (2003). Teaching practical ethics. Copenhagen: FESET. Retrieved from

www.feset.dk Banks, S., & Nøhr, K. (Eds.). (2012). Practising social work ethics around the world: Cases and

commentaries. London: Routledge. Barnes, M. (1997). Care, communities and citizenship. Harlow: Addison Wesley Longman. Barnes, M. (2006). Caring and social justice. London: Palgrave. Biestek, F. P. (1961). The casework relationship. London: Allen and Unwin. Clark, C. (2006). Moral character in social work. British Journal of Social Work, 36, 75–89. Dominelli, L. (2004). Social work: Theory and practice for a changing profession. Cambridge: Polity

Press. Donati, P., & Solci, R. (2011). I beni relazionali: che cosa sono e cosa producono [Relational Goods.

What they are and what they produce]. Torino: Bollati Boringhieri. Folgheraiter, F. (2011). Fondamenti di metodologia relazionale. La logica sociale dell’aiuto [Foundation

of relational methodology]. Trento: Erickson. Folgheraiter, F. (2012). The mystery of social work. Trento: Erickson. Folgheraiter, F., & Pasini, A. (2009). Self-help groups and social capital: New directions in welfare

policies? Social Work Education, 28, 253–267. Gilligan, C. (1982). In a different voice. Harvard: Harvard University Press. Hugman, R. (2005). New approaches in ethics for the caring professions. Basingstoke: Palgrave

Macmillan. Ife, J. (2001). Human rights and social work. Oxford: Oxford University Press. International Federation of Social Work (IFSW), & International Association of Schools of Social

Work (IASSW). (2004). Ethics in social work. Statement of principles. Jonas, H. (1979). Das Prinzip Verantwortung [The prinicple responsibility]. Frankfurt am Mein:

Surkamp. Koggel, C., & Orme, J. (2010). Care ethics: New theories and applications. Ethics and Social Welfare,

4, 109–114. Lévinas, E. (1972). Humanisme de l’autre home [Humanism of the other man]. Montpellier: Fata

Morgana. Lovat, T., & Gray, M. (2008). Towards a proportionist social work ethics: A habermasian perspective.

British Journal of Social Work, 38, 1100–1114. McBeath, G., & Webb, S. A. (2002). Virtue ethics and social work: Being lucky, realistic, and not

doing ones duty. British Journal of Social Work, 32, 1015–1036. Milani, D.L., & di Barbiana S. (1967). Lettera a una professoressa [Letter to a teacher]. Firenze:

Libreria Editrice Fiorentina. Morris, K. (2011). Thinking family? The complexities for family engagement in care and protection.

British Journal of Social Work, 42, 906–920. doi:10.1093/bjsk/bcr116

386 A. PASINI

Nussbaum, M. (2002). Giustizia sociale e dignità umana. Da individui a persone [Social justice and human dignity. From individual to persons]. Bologna: Il Mulino.

Ordine Nazionale degli Assistenti Sociali. (2009). Codice Deontologico dell’Assistente Sociale [Social work deontologic code].

Osmo, R., & Landau, R. (2001). The need for explicit argumentation in ethical decision-making in social work. Social Work Education, 20, 483–492.

Osmo, R., & Landau, R. (2006). The role of ethical theories in decision making by social workers. Social Work Education, 25, 863–876.

Ricoeur, P. (1997). La persona [The human being]. Brescia: Morcelliana. Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. London: Consable. Rossiter, A. (2011). Unsettled social work: The challenge of Levinas’s ethics. British Journal of Social

Work, 41, 980–995. Schön, D. A. (1999). The reflextive practioner: How professionals think in action. New York, NY:

Basic Books. Seikkula, J., & Arnkil, T. E. (2006). Dialogical meetings in social networks. London: Karnac Books. Sen, A. (2001). Development as freedom. Oxford: Oxford University Press. Tronto, J. C. (1993). Moral boundaries: A political argument for an ethics of care. New York, NY:

Routledge. Tronto, J. C. (2010). Creating caring institutions: Politics, plurality and purpose. Ethics and Social

Welfare, 4, 158–171. UN. (1948). The universal declaration on human rights. Wilks, T. (2005). Social work and narrative ethics. British Journal of Social Work, 35, 1249–1264. Williams, F. (2005). Linking care practices to a political ethics of care. Birmingham, AL: University

of Birmingham.

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