Social Work and Hospice Ethics: Words Matter

“Ethical responsibilities flow from all human relationships.”

Code of Ethics,
National Association of Social Workers

An apparent convergence exists between social work values and hospice values. This coming together is interesting and worth some further exploration and discussion. Values exist at the core of professional ethical behavior. Values and ethics have a direct effect on professional practice. They are represented by key words and phrases. The key words coincide in these two aspects of health care, in the social work profession and the hospice care movement. They also diverge.

Both sets of values emphasize the central importance of human relationships. Both are explicit about the worth and dignity of the individual. Both agree that respect for the individual is a critical idea. Both hold self-determination as a fundamental concept. Both sets of values are aimed directly at meeting the needs of vulnerable populations. Cultural competence and knowledge of social diversity are viewed as vital to high quality service provision. Both clusters place emphasis on advocacy for the population served and the style of service provided. Political action is included in advocacy. Research, education, and outreach are embedded in core values. Accountability to patient, family, community, and profession is required. Integrity is explicit and expected: behavior in a trustworthy, honest, and responsible manner.

These are some of the most basic values and principles aimed directly at the population served, whether that population is individuals, families, groups, communities, or society. Ideally, within this scenario, the patient will receive excellent care. For convenience, the key words and phrases are re-stated here:

Central importance of human relationships;
Worth and dignity of the individual;
Respect for the individual;
Importance of self-determination;
Addressing the needs of vulnerable populations;
Cultural competence and social diversity;
Advocacy, including political action;
Research, education, and outreach;
Accountability;
Integrity.

Interestingly, several key words revered and emphasized in hospice care are absent from the social work ethical code. They are: compassion, and its natural outgrowth, empathy. Hospice care has gone far in this direction, stating eloquently that “compassion has no borders.” This refers also to the major hospice initiative directly in sub-Saharan Africa (Foundation for Hospices in Sub-Saharan Africa). This is additionally a clear example of “cultural competence and social diversity.” The hospice movement is committed to it. It is also an example of hospice dedication to advocacy, outreach, and the principle of the central importance of human relationships. Hospice care is a strong international pursuit with offshoots in many countries. The hospice movement urgently requests world governments to declare hospice and palliative care as a human right (e.g.: World Hospice and Palliative Care Day; The Prague Charter). Compassion and empathy are visible deeds; compassion is a clearly articulated word.

In its international aspect, something similar might be said of social work. The profession has a wide and powerful international footprint – a strong international professional presence. Compassion and empathy are the heart of social work service provision everywhere in the world. These are global concepts for the profession as it is actually practiced. Compassion is the awareness of another person’s suffering and the wish to relieve it. Empathy is the power of understanding and imaginatively entering into another person’s feelings. Both are foundational in social work. Both are the historical bedrock of the profession.Yet, the words “compassion” and “empathy” are not mentioned once in the National Association of Social Workers (NASW) Code of Ethics. The reasons are unclear. These are key words and core concepts in clinical social work. They should be added to the social work ethical code. All members of the profession must begin with this shared and documented understanding of past history and present expectations. True intra-professional collaboration is easier and better that way.

Conversely, a defining concept closely held by the social work profession is absent from hospice mission, values, and ethics statements. That concept is “individual well-being in a social context.” In the same paragraph, the NASW Code of Ethics further states, “Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living.” The interaction of the person and his social environment are clearly acknowledged and carefully considered. The social environment is profoundly influential also in the individual’s personality development, character structure, and problem configuration. From infancy onward, the person is formed by this indispensable, crucial interaction. This early influence is unavoidable.

Nowhere in formal hospice values, mission, and ethics statements does this concept appear in its entirety. Much text space is appropriately devoted to issues concerning the patient’s physical environment. The same is not true for statements about the social environment in its fuller meaning. In order to holistically understand and care for the hospice patient and family, the deep force and power of the social environment demands recognition. It is essential that this concept be codified and available for all hospice workers. A code of ethics statement will highlight its importance. The statement would then act as one of several starting and follow-through points in hospice care. The code of ethics forms a basic framework of care provision for all interdisciplinary team members. It is important that the team members start with the same understanding. That is part of what makes a team. It is apparent from actual hospice care practices that much attention is indeed usually paid to the influence of the patient’s social environment on his past and present wellbeing. A further recommendation can then be offered. Hospice values and Code of Ethics statements should explicitly include the concept of individual wellbeing in a social context.

Everyone has human relationships. It follows that everyone also has ethical responsibilities that flow from those relationships. A well-defined and comprehensive code of ethics helps professionals to practice with focus and confidence. It directs the practitioner’s attention to ethical responsibilities for others. It requires the practitioner’s concentration and assent. It helps professionals to clarify and understand in actual practice how to fulfill their responsibilities to patients. It helps the recipients of services to understand and trust service providers. It encourages the wider society to recognize and differentiate appropriate and inappropriate service and service providers. This is also professional accountability.

A code of ethics should not be a rigid, inflexible document. It should be amenable to change as warranted by changing times, increasing experience and experiment and research, and intelligent thought and discussion. The changes may be frequent. The trustees and executors must allow for this. Words are important expressions of thinking and action. Words do matter. A code of ethics must encompass key words and phrases that capture and reflect the heart and soul of professional conduct. The core of conduct is values, ethical principles, and ethical standards.

Social work and hospice services fit together well because of shared values and ethics. Both sides benefit, the social work professionals and the hospice programs that employ them. Each side has much to offer and to teach the other side. Because of ethical similarities, hospices are especially well prepared to be host facilities for clinical social workers. Because of their keen focus on the person in a social context, social workers are well prepared to: (1) work with the patient-family constellation, and (2) act as liaison between the family and the hospice interdisciplinary team. Social workers also make unusually productive team leaders because of their ability to facilitate communication and build consensus among group members. Hospice volunteer coordination and instruction is another place of high achievement for social workers.

An admirable relationship exists between social work and hospice. The shared values and ethics cause successful, satisfying partnerships. Patients tend to thrive when care providers partner together and feel fulfilled, when they feel successful and satisfied. And when patients do thrive, it furthers the care providers’ sense of satisfaction. Success is energizing. It breeds more success. More commitment. Formal values/ethics statements can be the starting catalyst for this upward spiral of optimism.

Update revisions are needed in the NASW Code of Ethics and also in the hospice movement statements of mission, values, and ethics. Revisions in our codes of ethics can ultimately lead to improved patient care, patient satisfaction, and patient outcomes. A code of ethics guides professional conduct. It is highly significant in that sense. Several suggestions for revision are mentioned here. We have the opportunity now to improve on what was earlier thought to be near-perfection. We have the capability. Only the strength and energy to act are held in question. Together, we are stronger. Strength is found through joint effort and collaboration. Together, we will grow.

Rea L. Ginsberg, LCSW-C, ACSW, BCD
Guest Writer

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References:
Code of Ethics, National Association of Social Workers, 2008.
See also: www.socialworkers.org .

Code of Ethics, Board of Social Work Examiners, Department of Health and Mental Hygiene, State of Maryland, 13 June, 2011, http://dhmh.maryland.gov/bswe .

National Hospice and Palliative Care Organization, www.nhpco.org .
See also: NHPCO Standards of Practice for Hospice Programs, 2010, downloadable PDF file on NHPCO website.

Hospice and Palliative Care CODE OF ETHICS, National Hospice and Palliative Care Organization, www.nhpco.org .

Annual Report 2012, National Hospice & Palliative Care Organization [NHPCO] See also: www.nhpco.org .

Foundation for Hospices in Sub-Saharan Africa, www.fhssa.org .

Mission Statement, National Association for Home Care and Hospice, www.nahc.org .

The Prague Charter: Relieving Suffering,
petition urging world governments to recognize palliative care as a human right, https://secure.avaaz.org/en/petition/The_Prague_Charter_Relieving_suffering .

The Joint Commission, www.jointcommission.org .

Theodore H. Koff, Hospice: A Caring Community, Cambridge, MA: Winthrop Publishers, 1980.

I am a retired Director of Social Work Services and Hospice Coordinator. I dedicated most of my professional life to work with – and on behalf of – emotionally disturbed and physically handicapped children. Later work involved elderly patients who were hospitalized or resided in long term care facilities. I have worked in private non-profit social agencies, a school for blind and multiply handicapped children, and a large multi-function sectarian facility for the oldest elderly. I have always loved working in the field of health care and never plan to retire from this work. My special focus is bereavement and grief work. My commitment endures.

In terms of credentials, I currently hold licenses to practice social work at the highest level in the State of Maryland (LCSW-C) and in the District of Columbia (LICSW). I also hold a license to practice in the State of Illinois (LSW), where I was born and grew up. I am certified by the Academy of Certified Social Workers (ACSW), an arm of the National Association of Social Workers, where I have been a member for approximately 41 years. I also hold Board Certified Diplomate (BCD) certification by the American Board of Examiners in Clinical Social Work. I am a “Board Certified Supervisor” for social workers in the State of Maryland.

Social media: I am a very active member of LinkedIn. My LinkedIn Profile is current and available on that website directly or by finding it with a Google search of “Rea Ginsberg.” I’m also on Twitter @rginsberg2.