SOCIAL WORK IN HEALTHCARE

Social workers have played a vital role in healthcare settings since the early twentieth century. Social work was introduced to medical settings in the United States by Dr. Richard C. Cabot in 1905. Cabot, a professor of both clinical medicine and social ethics at Harvard University, was instrumental in adding social workers to his clinic staff at Massachusetts General Hospital. Under the direction of their first department head, Ida Cannon, these social workers helped patients and their families cope with illness, disease, disability, and hospitalization by focusing particularly on their psychosocial needs, including their emotional reaction and adaptation (Rossen).

Over time, social work's function and influence in healthcare settings have expanded significantly (Miller and Rehr). In addition to assisting hospitalized patients and their families, social workers provide genetic counseling, hospice services, psychotherapy and counseling in mental-health agencies, and treatment of people with eating disorders and substance abuse problems. These opportunities exist in hospitals, neighborhood health and family planning clinics, psychiatric institutions, community mental-health centers, nursing homes, rehabilitation centers, and other long-term care facilities. Social workers' specialized role is to help patients and their families cope with illness and disability.

Many social workers in healthcare settings provide patients and their families with counseling, and information about and referral to needed resources (e.g., home healthcare, financial assistance, nursing home placement). Social workers are also skilled in organizing and facilitating support groups for various populations, such as cancer patients, rape victims, and parents of seriously impaired infants. They work to enhance the availability of community-based resources (e.g., healthcare clinics in low-income neighborhoods or residential programs for children with AIDS), advocate on behalf of individual patients who are in need of services, and advocate to ensure that important public policy issues related to healthcare are addressed (e.g., funding for lead screening or guidelines concerning involuntary commitment of mentally ill individuals to psychiatric hospitals).

Social workers typically function as part of an interdisciplinary team, which may include physicians, nurses, nutritionists, rehabilitation staff, clergy, and healthcare administrators. On occasion, they facilitate the process through which healthcare professionals negotiate differences of opinion or conflict among themselves concerning specific ethical issues. Social workers' skilled use of mediation techniques can help to resolve disagreements that sometimes arise in healthcare settings. Their sensitivity to ethnic and cultural diversity can be particularly helpful when there is a clash between patients' and families' ethnically or culturally based values and prevailing ethical norms, policies, and healthcare practices (e.g., concerning the use of mood-altering medication, autopsy, or blood transfusion).

Bioethical issues in healthcare settings present social workers with complex challenges (Reamer, 1985, 1987). Some of these ethical issues pertain to specific medical conditions. Examples include ethical dilemmas related to a family's decision about withdrawal of a patient's life support, abortion following a rape, organ transplantation, the use of restraints with a noncompliant psychiatric patient, or a patient's decision to refuse neuroleptic medication. When such issues arise, social workers often serve as important intermediaries in relationships among patients, their families, and healthcare professionals. In these instances, social workers help patients and their families make difficult personal decisions, facilitate communication among members of the healthcare team, advocate on a patient's or family's behalf, or raise policy issues that need to be addressed by a hospital, nursing home, or rehabilitation center.

Other bioethical issues concern the nature of relationships and transactions between social workers and patients or their families. For example, social workers in healthcare settings must be familiar with privacy and confidentiality norms that govern relationships with patients and families. They must also be sensitive to complex ethical issues involving patients' right to self-determination, informed consent procedures, truth telling, professional paternalism, and whistleblowing (Loewenberg and Dolgoff; Reamer, 1990).

In particular, social workers can clarify differences among the ethical obligations that guide various professions. For example, social workers in a healthcare setting can help clarify the ethical responsibilities of various professionals when staff suspect child abuse or that a patient with AIDS poses a threat to a third party.

Healthcare social workers are also involved in discussion and formulation of the ethical aspects of healthcare policy and administration. This may take several forms. Social workers may participate as members of institutional ethics committees (IECs) that discuss ethically complex cases and policies. They may have a particularly valuable perspective because of their extensive contact with patients and their families and can, therefore, contribute to discussions about, for example, resuscitation guidelines, patients' right to refuse treatment, advance directives, organ transplantation, treatment of severely impaired infants, and the privacy rights of AIDS patients. Similarly, social workers are active participants on institutional review boards (IRBs) that examine a variety of ethical issues in research on human subjects.

In addition, social workers may be involved in discussions about the ethical aspects of healthcare financing mechanisms and cost-containment measures. They may also propose ways to advocate on patients' behalf or to advocate for policy reform that may provide a more just allocation of scarce healthcare resources at the local, national, or international level. An example is social workers' participation on a hospital committee to assess the pressure to limit care provided to, and hasten discharge of, psychiatric patients covered under managed care programs operated by private insurers. In these instances, social workers may help identify the psychosocial consequences of various strategies to allocate limited healthcare resources.

As a profession, social work has its formal origins in nineteenth-century concern about the poor, and is an out-growth of the pioneering work of charity organization societies and settlement houses, primarily in England and the United States (Brieland; Leiby). Thus, social workers are inclined to be attentive to the needs of low-income, culturally diverse, and oppressed patients and families.

Although contemporary social workers provide services to individuals and families at all points on the socioeconomic spectrum, the profession continues to have an abiding concern for the disadvantaged. As a result, social workers in healthcare settings are alert to ethical issues that involve such populations as low-income patients, abused children and elders, women, refugees and immigrants, substance abusers, ethnic minorities, and gay or lesbian individuals. Concern about such vulnerable groups—for example, with respect to their access to healthcare, their privacy rights, or discrimination against them by healthcare providers—is one of social work's principal hallmarks. Social workers may advocate for individual patients and families whose rights are threatened or who are victims of institutional abuse or discrimination. They also may advocate for public policy that will enhance protection of the rights of these populations.

Like all healthcare professionals, in order to participate fully in discussions of bioethical issues and dilemmas, social workers need specialized knowledge and training. First, they need to be familiar with the history, language, concepts, and theories of bioethics, particularly as they have evolved since the early 1970s. Second, social workers should be knowledgeable about formal mechanisms that can help healthcare professionals monitor and address bioethical issues. These include phenomena such as IECs, IRBs, utilization review and quality assurance committees, informed consent procedures, and advance directives. It is also useful for social workers to be acquainted with relevant codes of ethics and legal considerations (statutes and case law) related to patients' rights and healthcare professionals' obligations.

Finally, social workers should be familiar with the various schools of thought that pertain to ethical decision making and ethical theory. This can be particularly useful when social workers are involved in discussion of cases with professional ethicists, for example, when a decision must be made about when and how to tell a fragile, terminally ill patient the truth about his or her diagnosis, or to disclose confidential information, against a patient's wishes, in order to protect a third party. This training may be offered as part of agency-based in-service education, professional conferences, or undergraduate and graduate social work education.

Especially since the early 1970s, social workers have been aware of the diverse and complex bioethical issues involved in healthcare, whether it involves acute or chronic, inpatient or outpatient, or medical, rehabilitative, nursing, or psychiatric care. Social workers' growing awareness of, and enhanced expertise in addressing, bioethical issues helps to ensure the protection of patients' and families' rights and the soundness of ethical decisions made in healthcare settings.

frederic g. reamer (1995)

bibliography revised

SEE ALSO: Bioethics Education: Other Health Professions; Clinical Ethics: Institutional Ethics Committees; Confidentiality; Family and Family Medicine; Informed Consent: Meaning and Elements of Informed Consent Palliative Care and Hospice;Paternalism; Privacy in Healthcare; Teams, Healthcare; Whistleblowing

BIBLIOGRAPHY

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