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AIDS 2014 skills-building session
Understanding and using:
Difficult Decisions: A Tool for Care WorkersManaging Ethical Dilemmas When Caring for Children and Families of Key PopulationsPeople Living With HIV, People who use Drugs, Sex Workers, Transgender People, Gay Men, and other Men who have Sex with Men Melbourne, Australia, Monday July 21st 2014
+Imagine… IMAGINE:
For a number of months, you have been working with a single mother who is known to use drugs. She is receiving HIV-related services from your outreach organization. She has a three-year-old daughter who lives with her. On a home visit you find needles on the floor of the apartment.
You are worried about the mother’s safety, and worried about the child’s safety as well. However, you do not want to report the situation, because you fear losing the client's trust—she is your client, after all. You also know that even if the child is removed from her parent, it will be difficult to find the child another home because the child is also HIV-positive.
What should you do?
+Learning objectives
At the end we hope you will: Understand the meaning of an ethical dilemma, and how it
is different from an ordinary dilemma and a common service delivery problem;
Understand the impact on care workers of not properly managing ethical dilemmas in terms of moral distress & moral residue;
Be oriented to “Difficult Decisions” guidance, and to using the Four-Step Tool when faced with a serious ethical dilemma;
Know how, as an organization, you might incorporate the use of the Four-Step Tool into your work.
+Guidance, and a simple tool you can use
This workshop refers to three related documents:1. THE GUIDANCE;
2. THE TOOL; and
3. THE ORIENTATION SLIDES
These can be found and downloaded on www.careworkerethics.org
+The PDF document:“The guidance”
The PDF document contains:
Guidance to understanding ethics and ethical dilemmas
The Four-Step Tool to solving ethical dilemmas
Instructions on how to use the tool Three ethical dilemmas solved using
the tool A “Pocket Guide” for use when
handling time-sensitive ethical dilemmas in the field
Other explanatory information and references
+The MS Word document: “The Four Step Tool”
The editable “MS Word” document containing the Four-Step Tool can be either copied and saved as a template on a care
worker’s computer, to be later completed on a computer when trying to solve an ethical dilemma (each ethical dilemma would be saved with a file name identifying the dilemma);
OR
Copied and saved as a template on a computer, and printed out to be filled in by pen or pencil by care workers who do not work with computers.
+The PowerPoint document:Orientation Slides
A PowerPoint slide deck that you or your manager can use to take your colleagues through a 3-hour orientation to: understand and learn how to use the Four-Step Tool; and to implement the guidance in your organization. many of the slides in the Orientation Slide Deck are similar
to the slides being used in this workshop.
+Why is an ethical decision-making tool needed?
Without it, care workers can make decisions that Don’t apply the same standards as their co-workers Leave them feeling upset or frustrated Result in stigmatization and discrimination against those
they care for—even if it wasn’t their intent Leave those they care for feeling betrayed
The tool is important to care workers
This tool is important to key populations
+How this guidance can help
By reading and discussing the guidance, and then using the Four-Step Tool, care workers can:
Make better, more consistent decisions; and
Ease their burden: reducing distress, uneasiness, and the lasting burden and burnout that can come from making choices when faced with an ethical dilemma
+When to use it & when not to use it
The Four-Step Tool is meant to be used when: We are facing an ethical dilemma – not an ordinary
dilemma, and not a common service delivery problem (this is explained in the next slides)
When the ethical dilemma is troubling us, and we have the time to carefully consider the options.
The Four-Step Tool is not meant to be used when: a decision must be made very quickly in the field; the dilemma is not ethical in nature; or the situation is a common service delivery problem.
+What is ethics
Ethics is about how we understand what is ‘right’ and what is ‘wrong’, and what is ‘just’ and what is ‘unjust’
Ethics is about asking, “What should we do?” when we face difficult choices.
This is not the same as asking, “What does the law tell me to do?”, “What does my organization tell me to do?” or “What does my religion, culture, or society tell me to do?”
+The difference between a problem, an ordinary dilemma, and an ethical dilemma
This guidance is written to help solve a type of problem called an ethical dilemma
There are other types of problems: common service delivery problems that do not involve dilemmas, and ordinary dilemmas that are not ethical in nature.
Learning to distinguish between these three types of problems is important.
+A service delivery problem is not necessarily a dilemma
A problem in the delivery of care, treatment or support, is: Any situation, including an ordinary dilemma or an ethical
dilemma, which requires a solution.
All dilemmas are problems, but not all problems are dilemmas.
What separates a dilemma from a common service delivery problem is that with a dilemma there are two or more undesirable options.
The options might be undesirable on their own, or they might be undesirable because trying one, and failing, eliminates the possibility of trying the other option.
+Which of the two situations below is a common service delivery problem, and which is a dilemma?A mother’s young daughter is not listening to her and they are arguing a lot. She asks for your help in improving the situation with her daughter. In this situation, there is no situation of physical or emotional danger to the child, but the mother is tired and frustrated.
A mother has two children who are each asking for a new shirt. In this situation, both children already have several shirts, but the shirts are getting old. The mother only has money to pay for one new shirt.
+
Common service delivery problem
A mother’s young daughter is not listening to her and they are arguing a lot. There is no situation of physical or emotional danger to the child, but the mother is tired and frustrated.
Dilemma
A mother has two children who are each asking for a new shirt. Both children already have several shirts, but the shirts are getting old. The mother only has money to pay for one new shirt.
Why? there are strategies that we can try that will not make
things worse in any way.
Why? There are two undesirable options. If the mother buys a shirt for one
child, the other will be unhappy.
+A dilemma is not necessarily an ethical dilemma
Remember that ethics is about how we understand what is ‘right’ and what is ‘wrong’, and what is ‘just’ and what is ‘unjust’—regardless of where we are from, where we live, our religion, gender identity, sexual orientation, culture,
policies, or the law.
It is important to understand that not all dilemmas are ethical dilemmas.
+Ordinary dilemmas & ethical dilemma
An ordinary dilemma is one that does not involve a conflict between ethical values and principles.
An ethical dilemma is a situation where conflicting values, beliefs, responsibilities, or concerns pull us in different directions, and we are trying to make a decision that does the most good or the least harm—in other words, a decision that is ethical.
+Which of the two situations below is an ordinary dilemma, and which is an ethical dilemma?My wife is HIV+, and so is one of our two children. My HIV+ child is running out of medication. Also, my wife and I are running out of money and we can’t afford to buy both medications and food for the next two weeks. If we spend our remaining money on my son’s medications, all five of us will go hungry and both my wife’s health and my son’s health will be jeopardized. If I buy food, my son could get sick or develop resistance to his HIV medications. What should I do?
I have to decide between a) riding a bicycle to work on a rainy day and getting there on time but arriving with my clothes soaking wet, and b) taking public transportation to work and arriving dry, but arriving slightly late. In this scenario, there is no risk of being fired or docked pay for arriving late or arriving with wet clothes. I will, however, be seen as slightly unprofessional.
+ Ethical dilemma
My wife is HIV+, and so is one of our two children. My HIV+ child is running out of medication. Also, my wife and I are running out of money and we can’t afford to buy both medications and food for the next two weeks. If we spend our remaining money on my son’s medications, all five of us will go hungry and both my wife’s health and my son’s health will be jeopardized. If I buy food, my son could get sick or develop resistance to his HIV medications. What should I do?
Ordinary dilemma
I have to decide between a) riding a bicycle to work on a rainy day and getting there on time but arriving with my clothes soaking wet, and b) taking public transportation to work and arriving dry, but arriving slightly late. In this scenario, there is no risk of being fired or docked pay for arriving late or arriving with wet clothes. I will, however, be seen as slightly unprofessional.
Why? Both obvious options have an undesirable component, which makes it a dilemma.
In addition, there are conflicting ethical values
These values and responsibilities are pulling me in different directions.
Why? Both obvious options have an undesirable component, making it a dilemma.
However, there is no conflict between ethical values or principles or responsibilities.
+How do we make ethical decisions?
Ethical decision-making is a process that helps us to look carefully at the ethical dilemmas that we face so that we can decide and explain what we should do; why we should do it; and how we should do it.
Ethical decision-making starts when we recognize that we are facing competing choices that involve ethical values or principles and helps us answer the question: “What should I do?”
Often, it is about making the best possible choice when two or more options are available.
+What happens when an organization doesn’t have an ethical decision-making framework?
Ethicists tell us that:
People retreat to their own sense of morality (which could differ or be influenced by bias);
Inconsistency in processes from one worker to the next;
Lack of support for care worker to manage moral distress and moral residue;
We look to policies but they are insufficient, and
The danger that not all options will be fully explored, or rather that they will not be fully explored based on an ethical framework
+The Four-Step Tool – an overview
The so-called four steps in the Four-Step Tool are:
1. Identifying the facts surrounding the decision;
2. Determining why this is an ethical dilemma, which means determining what values, beliefs, responsibilities, or concerns are pulling us in different directions, using the Code of Ethics;
3. Exploring the different options, and what is good or bad about each option; and
4. Making a decision—in other words, taking action, based on which option does the most good, or the least harm.
+The Code of Ethics – an anchor for your decision-making
To anchor our decision-making in a common set of ethical values and principles, the document “Difficult Decisions” contains a Code of Ethics.
The Code of Ethics: gives us a method for working through the competing
values and interests in an ethical dilemma; and is a code for how we believe we should behave as care
workers when acting on those values.
16 ethical values and principles are defined. In Step 2 of the Four-Step Tool, we are asked to circle the values and principles that are pulling us in different directions, and to explain why.
+The Ethical Values & Principles in the Code of Ethics
Dignity Diversity
Advocacy Security
Quality Accountability
Privacy Confidentiality
Managing Conflicting Obligations
Fair and Equitable Access
Health and Wellbeing Informed Choice
Empowerment Cooperation
Family Prioritizing children while supporting parents or caregivers in key populations
+Using the Four-Step Tool: Briefly describing the situation
Before we go through the four steps, we are asked to describe the situation.
Sometimes, a situation comes up, and it is difficult to express it in terms of an ethical dilemma before we go through the steps.
However, describing the situation briefly will get us started.
This is where we should really ask ourselves: Is this really a dilemma or is it a common service delivery problem? If it is a dilemma, is it an ethical dilemma? Or is it an ordinary dilemma?
+Using the Four-Step Tool: Step 1 – The 4-Box Method
In this step, we are asked to fill in 4 boxes, identifying what we know, what we don’t know, what is an assumption, what is a judgement, what is based on bias, and what is an emotional reaction.
We are asked to consider our own emotions, feelings and values, and also to consider the thoughts, emotions, and cultural traditions of the person to whom you are providing care and other relevant stakeholders—family, children, or other caregivers, etc.—as this can help you further understand the issues.
This should involve talking to the client(s) about the situation and asking what they want, unless it would cause more harm to the client(s) to do so.
+Using the Four-Step Tool: Step 1 – The 4-Box Method
It is not important that we put this information in the right box, since the boxes are related to each other.
Also, it is not necessary to answer every question.
What matters is: we separate fact from assumption; we identify the important information that we need to help
us make a decision; we challenge our biases about key populations we check information and facts with our client(s) as much
as is possible.
+For instance, in Step 1…
… we first might write, in the Health, Care & Support Needs box, “Fact: The child is unsafe or in danger.”
Later, as we question ourselves, we might decide that we have not got enough evidence to make such a statement. Perhaps we have bias about the child’s mother and her ability to be a good parent.
We might then change our mind after talking to the mother.
We would then change what we have written to: “Assumption: The child is unsafe or in danger.” -- and find out more information about the child’s safety.
+Using the Four-Step Tool:Step 2 – Determine the Ethical Values & Principles in Conflict
This step will help further clarify and identify the ethical dilemma.
Here, we determine which values, responsibilities or concerns are pulling us in different directions.
To help complete this step, we use the Code of Ethics.
We circle the values from the Code of Ethics that are relevant to our situation, and in the right-hand column, we explain the issue.
+Using the Four-Step Tool:Step 2 – Determine the Ethical Values & Principles in Conflict
For instance, we might circle “Managing Conflicting Obligations” and “Health and Wellbeing” and write:
+Using the Four-Step Tool:Step 3 – Explore options and consider their strengths and weaknesses
Here, we explore all the options and consider the potential outcomes.
There might be variations on one option; list the variations too (i.e. Option 1a, 1b, 1c, etcetera).
In the 2nd and 3rd column, we list the strengths and weaknesses of each option.
+Using the Four-Step Tool:Step 3 – Explore options and consider their strengths and weaknesses
When thinking about strengths, think about things like: what ethical principles each option prioritizes or upholds, and how easy each option is to implement using the ethical
principles from step 2 and the facts you identified in step 1.
When thinking about weaknesses, think about things like: what ethical principles each option violates and how hard it would be to implement them in real life.
+Using the Four-Step Tool:Step 3 – Explore options and consider their strengths and weaknesses
For example, we might write:
Option Strengths Weaknesses
I report her to the organisation and let law and policy take their course.
I protect myself from any disciplinary action and someone else more qualified can assess the risk and the action to be taken.
Most likely outcome the woman will be angry and never allow me to visit her again. She would never trust me or the organisation.
+Example of a completed Step 3
+Using the Four-Step Tool:Step 4a – Choose an Option and Take Action
The last step is to make a decision and act on it.
We must choose which option(s) have the highest degree of advantages compared to disadvantages.
We should involve the client(s) in choosing from the options, unless it would cause more harm or undue burden to do so
+Using the Four-Step Tool:Step 4a – Choose an Option and Take Action
Develop an action plan and document what we are going to do.
Decide how to communicate this plan to the client(s) and other relevant stakeholders to maximize their understanding and acceptance of the plan.
+Using the Four-Step Tool:Step 4a – Choose an Option and Take Action
An example of what we might write here is:
“The plan is: I will try option one. At least it gives my client the opportunity to discuss things with me. It may actually build trust if she knows that I am listening first. I will have to be clear about my responsibilities and agree with her how we can assess things going forward and at what point I would have to involve the organization.”
+Using the Four-Step Tool:Step 4b – Evaluate the plan
Next, evaluate what happened: Did we obtain the results you intended? Is more follow-up or action needed? Could it be helpful to include other services or service
providers that are sensitive to this population? Self-evaluate to reflect on the decision-making process and
outcomes achieved, and your own feelings about the situation. Here it can be useful to share the write up to discuss the situation with others.
+Example of what you might write after you evaluate the plan
For instance, here, we might write:
“I feel like I took a chance. It could have gone wrong, but luckily it didn’t. I feel it was the right decision, especially after I had taken time to better assess the situation, but it was still not an easy decision.
I must admit that I did think ‘what would happen if I got it wrong and something happened to her daughter?’ but at the same time I knew I had to give the family a chance together. “
+Using the Four-Step Tool:Step 4c – Debriefing as a group
At this stage, we are urged to come together as a team of staff or peers and to debrief the decision we made.
When we do so, we should reflect on whether organizational change is needed to address these situations in the future.
When we debrief, we give each other support. These decisions can be troubling. Supporting one other helps reduce stress, uneasiness, a lasting burden, and burnout.
It helps us learn how to analyze and break down a situation into smaller components, and to then build a shared approach.
+Exercise working in pairs
Work in pairs for 15 minutes;
Try to complete Steps 3 & 4 to the best of your abilities;
Refer to the principles from the code of ethics – they are listed on Step 2;
We have limited time: You do not have to come up with every option
We will take 10 minutes to debrief in a large group
+Pocket guide to handling ethical dilemmas in the field
Remember: The Four-Step Tool is meant for when there is a serious ethical dilemma and we have the time to carefully consider the options.
It doesn’t work well when the situation requires a quick response.
For quick decisions in the field, there is a pocket guide. It summarizes the four steps and asks us some of the most important questions.
+Pocket guide to handling ethical dilemmas in the field
The Pocket Guide looks like this. We can print it off, cut it out and keep it with us when we go into the field. Or, we can tack it up on the wall of our office.
+Discussion: Implementing the Four-Step Tool in our organization You will want to discuss how, as an organization, could you incorporate
the use of the Four-Step Tool into your work? For instance… How will you know when to use it and when not to use it? Will you print out the Four-Step Tool and fill it in by hand, or will you complete
it on the computer? Where will you store and keep your case files?
You will want to discuss how, as an organization, are you going to come together to debrief and support one another when you make decisions using the Four-Step Tool? For instance… When will you debrief--during regular staff meetings, or other times? Who will convene the debriefing meetings? Who will lead the discussions?
How, as an organization, are you going to identify ongoing trends, the need for new policy, or the need for additional ethics training as a result of using the Four-Step Tool?
+What’s happening next with this project
Dissemination! – Help us get the word out! We have a dissemination package if anyone wants to actively help.
Evaluation: An independent evaluator is conducting a process and outcome evaluation in three sites – Melbourne, Beirut, and Nairobi – to be completed by next summer.
+To download the guidance, tool and slides:
www.careworkerethics.org
