Ruth Lipschutz, LCSW, ACSW, and Mary Garrison, LCSW, ACSW
Many social workers across the nation are wrestling with questions on how to ethically practice in a COVID-19 world. Some of the many questions currently circling provide challenges and offer necessary focus on ethical practice; they may include the following:
What if I am not vaccinated and want to do in-person sessions?
What about settings that are providing in-person services or planning to restart/increase in-person services?
Is it ethical to see clients in-person if I am not vaccinated?
Do I need to disclose my vaccine status to my clients?
COVID-19 has confronted social workers and practice settings with ethical dilemmas on a myriad of levels related to decisions focusing on client service engagement in-person or via telehealth services, return to work criteria, the use of personal protective equipment (PPE), and vaccines. Social workers emerge as frontline health professionals to those impacted with mental health and addiction issues. This role leaves social workers with difficult decisions related to health and safety due to COVID-19. Furthermore, social workers not only need to address concerns of those they serve, but those of their colleagues, broader society, and their own health and safety.
Social workers often grapple with decisions based on personal values and beliefs. Social workers have the right to their personal needs and beliefs. Professionally, they have obligations to be aware of and make decisions based on the NASW Code of Ethics, federal, state, and local directives/orders, and recommendations from local and national public health agencies (i.e., Centers for Disease Control and Prevention, local health departments).
The NASW Code of Ethics recognizes that, “there are many other sources of information about ethical thinking that may be useful,” but that, “social workers should consider the NASW Code of Ethics as their primary source.” It goes on to state: “[S]ocial workers also should be aware of the impact on ethical decision making of their clients' and their own personal values and cultural and religious beliefs and practices. They should be aware of any conflicts between personal and professional values and deal with them responsibly.”
Social work is a values-based profession. The core values of the profession and several standards of the NASW Code of Ethics offer clear guidance in addressing this article’s posed questions (see questions at top). Areas within the NASW Code of Ethics that can assist social workers with these questions include the following principles and standards:
Value: Service
Ethical Principle: Social workers' primary goal is to help people in need and to address social problems. Social workers elevate service to others above self-interest.
Value: Social Justice
Ethical Principle: Social workers challenge social injustice.
Value: Dignity and Worth of the Person
Ethical Principle: Social workers respect the inherent dignity and worth of the person.
Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients' socially responsible self-determination. Social workers seek to enhance clients' capacity and opportunity to change and to address their own needs. Social workers are cognizant of their dual responsibility to clients and to the broader society.
Value: Importance of Human Relationships
Ethical Principle: Social workers recognize the central importance of human relationship
Value: Integrity
Ethical Principle: Social workers behave in a trustworthy manner.
Social workers are continually aware of the profession's mission, values, ethical principles, and ethical standards and practice in a manner consistent with them. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated.
Value: Competence
Ethical Principle: Social workers practice within their areas of competence and develop and enhance their professional expertise.
1.01 Commitment to Clients
Social workers' primary responsibility is to promote the well-being of clients. In general, clients' interests are primary.
1.02 Self-Determination
Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients' right to self-determination when, in the social workers' professional judgment, clients' actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.
1.03 Informed Consent
(a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions.
1.06 Conflicts of Interest
(a) Social workers should be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment. Social workers should inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible. In some cases, protecting clients' interests may require termination of the professional relationship with proper referral of the client.
3.09 Commitments to Employers
(b) Social workers should work to improve employing agencies' policies and procedures and the efficiency and effectiveness of their services.
(c) Social workers should take reasonable steps to ensure that employers are aware of social workers' ethical obligations as set forth in the NASW Code of Ethics and of the implications of those obligations for social work practice.
(d) Social workers should not allow an employing organization's policies, procedures, regulations, or administrative orders to interfere with their ethical practice of social work. Social workers should take reasonable steps to ensure that their employing organizations' practices are consistent with the NASW Code of Ethics.
4.03 Private Conduct
Social workers should not permit their private conduct to interfere with their ability to fulfill their professional responsibilities.
4.04 Dishonesty, Fraud, and Deception
Social workers should not participate in, condone, or be associated with dishonesty, fraud, or deception.
4.06 Misrepresentation
c) Social workers should ensure that their representations to clients, agencies, and the public of professional qualifications, credentials, education, competence, affiliations, services provided, or results to be achieved are accurate.
5.01 Integrity of the Profession
(a) Social workers should work toward the maintenance and promotion of high standards of practice.
(b) Social workers should uphold and advance the values, ethics, knowledge, and mission of the profession. Social workers should protect, enhance, and improve the integrity of the profession through appropriate study and research, active discussion, and responsible criticism of the profession.
6.01 Social Welfare
Social workers should promote the general welfare of society, from local to global levels, and the development of people, their communities, and their environments.
Social workers' primary responsibility is to promote the well-being of clients. In general, clients' interests are primary. Social workers are free to make choices regarding vaccinations and to assess their personal risk tolerance level to meet their personal needs. As health professionals, social workers have an obligation to be aware of current research, recommendations and guidelines related to protecting clients, employees, staff, colleagues, and the community including the health risks associated with in-person services and possibilities for virus transmission. Vaccine status and use of appropriate PPE (e.g., masks) are crucial factors in assessing the transmission risk level with COVID-19.
Self-determination is a central value of social work. “It is ethically insufficient to simply approach informed consent as an administrative procedure. Informed consent needs to be conceptualized as a moral obligation rather than a procedure to meet legal or policy requirements. Informed consent is, at its core, about morality—about reducing or alleviating suffering or harm of people. It should be understood as a duty, an expression of social work values, and an act of advocacy for human rights.”
Clients have a right to be fully informed of all benefits and risks associated with the services provided. Many social workers are asking for or requiring disclosure of vaccine status from clients in determining the appropriateness and safety of in-person service. Social workers have an ethical obligation to fully disclose their vaccine status as well as all other risk factors and precautions in their settings in order to promote clients' self-determination. Providing accurate education and information empowers clients to participate fully in decision-making.
Vaccination status alone does not negate the responsibility to take other precautions (e.g., masks, proper air filtration, distancing, sanitizing common surfaces). Clients can only make informed decisions based on full disclosure of all relevant factors related to their health and safety.
Social workers also need to consider the health of the client and whether their occupation, health status, or behaviors put them at heightened risk of contracting the virus and then spreading it through an in-person visit. Additionally, some individuals may be at greater risk of severe illness should they contract COVID-19.
The NASW Code of Ethics speaks to social workers’ commitments to clients, colleagues, employers, the profession, and society. Social workers are called on to avoid conflicts of interest, to model honesty, and to live unto the highest standards of the profession to promote the welfare of society. In a pandemic situation, social workers have the right to remain unvaccinated and determine their personal risk tolerance. As professionals, the NASW Code of Ethics requires social workers to also assess the impact of those personal decisions on clients, colleagues, work settings, and society. With COVID-19, decisions on a personal or micro level can have impacts on the mezzo and macro levels of the profession.
Social workers also have an obligation, during this time of pandemic, to take all steps possible to protect clients, colleagues, and the greater society. If employer decisions are inconsistent with the NASW Code of Ethics, Standard 3.09 encourages social workers to “take reasonable steps” to advocate for policies and procedures that are consistent with the Code and to “not allow” an employer’s policies and procedures to “interfere with their ethical practice of social work.”
The standard of care directs us to assess choices based on “the way an ordinary, reasonable, and prudent professional would act under the same or similar circumstances.” Reasonable indicates an obligation to a critical thinking process in making professional decisions. Some questions that will be valuable in the ethical decision-making process include: Why am I making a particular choice? Why at this time? What will the potential impact be on clients, colleagues, my work setting, and society? How has the NASW Code of Ethics informed my decision-making process? In addressing an ethical dilemma, what procedural standard of care did I use to come to my decision? Do I have all the information I need to guide my decision-making? Am I able to provide appropriate and adequate informed consent?
In offering COVID-19 liability risk guidance to social workers to avoid complaints of contributory negligence, NASW Assurance Services states that “providing in-person services during this crisis adds new risk to clients, providers, and the community. If teletherapy is an option for your client, please continue.” They add that “additional caution” should be used when considering in-person care and that, “it is risky to resume in-person services without setting forth safety-focused changes and procedures to protect clients.” In addition to having written COVID policies and being in compliance with all federal, state, and local health guidelines, they recommend the following risk management steps:
Conduct a regulatory and safety review, understanding the status of any local and/or state emergency and shelter-in-place orders.
Perform risk analysis and plan an in-person safety process, considering each client’s and immediate family members’ health risk categories. In addition, consider your health risk, any surrounding staff, and family members when all return home.
Document the safety plan and course of action.
With the plan developed, set expectations with clients. This can be by an informed consent that adopts your regional and service area considerations with the health department, CDC, and regulatory guidance.
Document all the steps and decisions in each in-person client file, keeping in mind the decision by the social worker that the client’s need for services cannot be adequately met through another method besides in-person care. If harm occurs, professional documentation needs to show a clear justification for the decision.
Each social worker’s vaccine status is an essential factor in a thorough risk analysis in the provision of services. Therefore, it is essential for all social workers to disclose their vaccine status to facilitate an ethically informed consent process. Social workers do not need to specify why they have chosen to be or not be vaccinated, but withholding this crucial fact amounts to a form of paternalism, interferes with client self-determination, and violates a core element of informed consent to empower clients.
As scientific information develops, especially around ways to stop the spread of COVID-19, it is essential that social workers understand they will be held to the highest standard of care and should expect to consider what a reasonable professional in a similar situation should have known and should have implemented in the situation. Vaccine status is a time- and condition-sensitive issue. A foundational source for assessing the standard of care is the NASW Code of Ethics. As an additional resource, practitioners should also consult with their professional liability insurer for further risk management guidance.
Social workers are faced with ethical dilemmas on a daily basis. Practicing during a pandemic significantly increases the occurrence of those dilemmas and the accompanying stressors. The NASW Code of Ethics recently added self-care as an aspirational principle. It states:
Professional self-care is paramount for competent and ethical social work practice.
Professional demands, challenging workplace climates, and exposure to trauma warrant that social workers maintain personal and professional health, safety, and integrity.
Social work organizations, agencies, and educational institutions are encouraged to promote organizational policies, practices, and materials to support social workers’ self-care.
In addition, the NASW Code of Ethics added self-care to the value of integrity:
Value: Integrity Ethical Principle: Social workers behave in a trustworthy manner. Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in a manner consistent with them. Social workers should take measures to care for themselves professionally and personally. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated.
When personal values conflict with professional social work values or when confronted with ethical dilemmas, social workers should seek appropriate ethical consultation and support. NASW offers many COVID-19 resources on its website and ethics consultation through the Office of Ethics and Professional Review. Social workers are dealing with the increased personal and professional stress of living through a pandemic and intensified social justice challenges. In addition to the effects on ourselves and our families, many of the populations social workers serve are the most impacted by these events. Leaning into best practices and the highest standards of practice calls on all of us to start with awareness of the care and support we need for ourselves.
REFERENCES
NASW RRG Statement on In-person Social Work/Mental Health Services During the COVID-19 Crisis: https://naswassurance.org/statement-on-in-person-services/
COVID-19: Legal Considerations for Social Workers Resuming In-Person Services: https://www.socialworkers.org/About/Legal/Legal-Issue-of-the-Month/Legal-Considerations-for-Social-Workers-Resuming-In-Person-Services
Reamer, F. (1993). The Philosophical Foundations of Social Work. Colombia University Press