Transcript Document

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AIDS 2014 skills-building session
Understanding and using:
Difficult Decisions: A Tool for Care Workers
Managing Ethical Dilemmas When Caring for Children and Families of
Key Populations
People 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
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Imagine…
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IMAGINE:
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For a number of months, you have been working with a single
mother who is known to use drugs. She is receiving HIVrelated 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.
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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.
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What should you do?
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Learning objectives
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At the end we hope you will:
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Understand the meaning of an ethical dilemma, and how it is
different from an ordinary dilemma and a common service
delivery problem;
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Understand the impact on care workers of not properly managing
ethical dilemmas in terms of moral distress & moral residue;
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Be oriented to “Difficult Decisions” guidance, and to using the
Four-Step Tool when faced with a serious ethical dilemma;
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Know how, as an organization, you might incorporate the use of
the Four-Step Tool into your work.
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Guidance, and a simple tool you
can use
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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
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The PDF document:
“The guidance”
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The PDF document contains:
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Guidance to understanding ethics and
ethical dilemmas
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The Four-Step Tool to solving ethical
dilemmas
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Instructions on how to use the tool
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Three ethical dilemmas solved using
the tool
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A “Pocket Guide” for use when
handling time-sensitive ethical
dilemmas in the field
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Other explanatory information and
references
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The MS Word document:
“The Four Step Tool”
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The editable “MS Word” document
containing the Four-Step Tool can be
either
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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
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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.
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The PowerPoint document:
Orientation Slides
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A PowerPoint slide deck that you or your manager can use to
take your colleagues through a 3-hour orientation to:
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understand and learn how to use the Four-Step Tool; and to
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implement the guidance in your organization.
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many of the slides in the Orientation Slide Deck are similar to the
slides being used in this workshop.
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Why is an ethical decision-making
tool needed?
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Without it, care workers can make decisions that
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Don’t apply the same standards as their co-workers
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Leave them feeling upset or frustrated
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Result in stigmatization and discrimination against those they care
for—even if it wasn’t their intent
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Leave those they care for feeling betrayed
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The tool is important to care workers
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This tool is important to key populations
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How this guidance can help
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By reading and discussing the guidance, and then using the
Four-Step Tool, care workers can:
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Make better, more consistent decisions; and
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Ease their burden: reducing distress, uneasiness, and the lasting
burden and burnout that can come from making choices when
faced with an ethical dilemma
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When to use it & when not to use it
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The Four-Step Tool is meant to be used when:
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We are facing an ethical dilemma – not an ordinary dilemma, and
not a common service delivery problem (this is explained in the
next slides)
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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:
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a decision must be made very quickly in the field;
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the dilemma is not ethical in nature; or
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the situation is a common service delivery problem.
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What is ethics
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Ethics is about how we understand what is ‘right’ and what is
‘wrong’, and what is ‘just’ and what is ‘unjust’
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Ethics is about asking, “What should we do?” when we face
difficult choices.
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This is not the same as asking,
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“What does the law tell me to do?”,
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“What does my organization tell me to do?” or
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“What does my religion, culture, or society tell me to do?”
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The difference between a problem,
an ordinary dilemma, and an
ethical dilemma
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This guidance is written to help solve a type of problem
called an ethical dilemma
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There are other types of problems: common service delivery
problems that do not involve dilemmas, and ordinary
dilemmas that are not ethical in nature.
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Learning to distinguish between these three types of
problems is important.
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A service delivery problem is not
necessarily a dilemma
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A problem in the delivery of care, treatment or support, is:
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Any situation, including an ordinary dilemma or an ethical
dilemma, which requires a solution.
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All dilemmas are problems, but not all problems are
dilemmas.
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What separates a dilemma from a common service delivery
problem is that with a dilemma there are two or more
undesirable options.
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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.
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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.
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Common service delivery
problem
Dilemma
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.
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.
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A dilemma is not necessarily an
ethical dilemma
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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
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where we are from,
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where we live,
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our religion, gender identity, sexual orientation, culture, policies,
or the law.
It is important to understand that not all dilemmas are ethical
dilemmas.
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Ordinary dilemmas & ethical
dilemma
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An ordinary dilemma is one that does not involve a conflict
between ethical values and principles.
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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.
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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.
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Ethical dilemma
Ordinary 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.
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.
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How do we make ethical
decisions?
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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
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what we should do;
why we should do it; and
how we should do it.
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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?”
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Often, it is about making the best possible choice when two
or more options are available.
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have an ethical decision-making framework?
Ethicists tell us that:
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People retreat to their own sense of morality (which could
differ or be influenced by bias);
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Inconsistency in processes from one worker to the next;
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Lack of support for care worker to manage moral distress and
moral residue;
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We look to policies but they are insufficient, and
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The danger that not all options will be fully explored, or
rather that they will not be fully explored based on an ethical
framework
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The Four-Step Tool – an overview
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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.
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The Code of Ethics – an anchor for
your decision-making
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To anchor our decision-making in a common set of ethical
values and principles, the document “Difficult Decisions”
contains a Code of Ethics.
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The Code of Ethics:
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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.
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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
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Using the Four-Step Tool:
Briefly describing the situation
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Before we go through the four steps, we are asked to
describe the situation.
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Sometimes, a situation comes up, and it is difficult to express
it in terms of an ethical dilemma before we go through the
steps.
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However, describing the situation briefly will get us started.
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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?
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Using the Four-Step Tool:
Step 1 – The 4-Box Method
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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.
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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.
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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.
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Using the Four-Step Tool:
Step 1 – The 4-Box Method
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It is not important that we put this information in the right
box, since the boxes are related to each other.
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Also, it is not necessary to answer every question.
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What matters is:
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we separate fact from assumption;
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we identify the important information that we need to help us
make a decision;
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we challenge our biases about key populations
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we check information and facts with our client(s) as much as is
possible.
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For instance, in Step 1…
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… we first might write, in the Health, Care & Support Needs
box, “Fact: The child is unsafe or in danger.”
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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.
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We might then change our mind after talking to the mother.
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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.
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Using the Four-Step Tool:
Step 2 – Determine the Ethical
Values & Principles in Conflict
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This step will help further clarify and identify the ethical
dilemma.
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Here, we determine which values, responsibilities or
concerns are pulling us in different directions.
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To help complete this step, we use the Code of Ethics.
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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.
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Using the Four-Step Tool:
Step 2 – Determine the Ethical
Values & Principles in Conflict
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For instance, we might circle “Managing Conflicting
Obligations” and “Health and Wellbeing” and write:
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Using the Four-Step Tool:
Step 3 – Explore options and
consider their strengths and
weaknesses
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Here, we explore all the options and consider the potential
outcomes.
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There might be variations on one option; list the variations
too (i.e. Option 1a, 1b, 1c, etcetera).
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In the 2nd and 3rd column, we list the strengths and
weaknesses of each option.
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Using the Four-Step Tool:
Step 3 – Explore options and
consider their strengths and
weaknesses
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When thinking about strengths, think about things like:
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what ethical principles each option prioritizes or upholds, and
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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:
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what ethical principles each option violates and
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how hard it would be to implement them in real life.
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Using the Four-Step Tool:
Step 3 – Explore options and
consider their strengths and
weaknesses
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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.
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Example of a completed Step 3
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Using the Four-Step Tool:
Step 4a – Choose an Option and
Take Action
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The last step is to make a decision and act on it.
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We must choose which option(s) have the highest degree of
advantages compared to disadvantages.
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We should involve the client(s) in choosing from the options,
unless it would cause more harm or undue burden to do so
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Using the Four-Step Tool:
Step 4a – Choose an Option and
Take Action
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Develop an action plan and document what we are going to
do.
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Decide how to communicate this plan to the client(s) and
other relevant stakeholders to maximize their understanding
and acceptance of the plan.
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Using the Four-Step Tool:
Step 4a – Choose an Option and
Take Action
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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.”
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Using the Four-Step Tool:
Step 4b – Evaluate the plan
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Next, evaluate what happened:
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Did we obtain the results you intended?
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Is more follow-up or action needed?
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Could it be helpful to include other services or service providers
that are sensitive to this population?
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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.
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Example of what you might write
after you evaluate the plan
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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. “
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Using the Four-Step Tool:
Step 4c – Debriefing as a group
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At this stage, we are urged to come together as a team of staff
or peers and to debrief the decision we made.
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When we do so, we should reflect on whether organizational
change is needed to address these situations in the future.
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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.
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It helps us learn how to analyze and break down a situation
into smaller components, and to then build a shared
approach.
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Exercise working in pairs
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Work in pairs for 15 minutes;
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Try to complete Steps 3 & 4 to the best of your abilities;
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Refer to the principles from the code of ethics – they are
listed on Step 2;
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We have limited time: You do not have to come up with every
option
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We will take 10 minutes to debrief in a large group
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Pocket guide to handling ethical
dilemmas in the field
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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.
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It doesn’t work well when the situation requires a quick
response.
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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.
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Pocket guide to handling ethical
dilemmas in the field
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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.
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Discussion: Implementing the
Four-Step Tool in our organization
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You will want to discuss how, as an organization, could you incorporate
the use of the Four-Step Tool into your work? For instance…
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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…
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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?
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
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ongoing trends,
the need for new policy, or
the need for additional ethics training as a result of using the Four-Step Tool?
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What’s happening next with this
project
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Dissemination! – Help us get the word out! We have a
dissemination package if anyone wants to actively help.
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Evaluation: An independent evaluator is conducting a
process and outcome evaluation in three sites – Melbourne,
Beirut, and Nairobi – to be completed by next summer.
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To download the guidance, tool
and slides:
www.careworkerethics.org
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Contact information
John Miller
[email protected]
Kate Iorpenda
[email protected]
Harriet Chiomba
[email protected]