#77233: Ethics for Social Work

It is important to understand historical philosophical underpinnings in order to understand the evolution of the definition of ethics and how ethical principles emerged [3]. Historically, ethics is viewed as developing within two major eras in society: modernism and postmodernism.

Reamer provides an excellent synopsis of the historical climate in social work that set the stage for the evolution of ethical norms, principles, and standards [6]. He identifies four stages in the profession's history: the morality period, the values period, the ethical theory and decision-making period, and the ethical standards and risk management period. He argues that from the early conception of the field, social work focused primarily on the client's values and eventually matured and shifted to wrestling with complex ethical dilemmas. The culmination of this maturation is reflected in the field's third code of ethics, ratified by the National Association for Social Work (NASW) in 1996. The following is a brief overview of each historical period in social work [6].

As noted, the first informal code of ethics targeted to caseworkers was developed by Mary Richmond in 1920 [7]. In 1955, the American Association of Group Workers, American Association of Psychiatric Social Workers, American Association of Social Workers, Association of the Study of Community Organization, National Association of School Social Workers, and the Social Work Research Group consolidated to form the NASW. In 1960, the NASW formulated and approved their first Code of Ethics [75].

It consisted of 14 general and idealistic statements that described social workers' responsibilities and obligations to the field [7]. In 1979, this Code of Ethics was revised, and the second iteration consisted of a ten-page document that described social workers' conduct and their responsibility to their clients, colleagues, professional field, and society. It was the first time that it was explicitly stated that social workers needed to abide by any disciplinary rulings based on the code. In 1990, another revision was made. This third iteration eliminated the prohibition against soliciting colleagues' clients and added a statement that prevented social work professionals from exploiting relationships with clients for personal advantage or accepting anything for making a referral. In 1993, the fourth iteration included two additional amendments—social workers' responsibility to impaired clients and the prohibition against dual relationships [7].

There were many criticisms of these different iterations. Some argued that the previous codes applied to direct service professionals and less so to supervisors, administrators, or educators. Others argued that the previous codes focused on work with individual clients and did not deal with groups and/or families. Finally, issues that were becoming increasingly relevant such as confidentiality, technology, sexual harassment, managed care, cultural sensitivity and competence were not at all addressed in the previous code [7]. Consequently, the NASW set out to again revise the Code of Ethics, and in 1994, formed a committee of social work leaders, educators, professionals, and experts in ethics to develop a new code. It was finally approved by the Delegate Assembly in 1996 and went into effect on January 1, 1997 [7]. In 2008, the code was amended to include additional contemporary issues, specifically gender identity or expression and immigration status. In 2017, the code was revised substantially, with a focus on issues related to the use of technology [8,76]. An additional revision was completed in 2021 (as discussed). The current Code of Ethics is considered to be one of the most comprehensive ethical standards in NASW history. It will be examined in greater detail in various sections throughout the course.

Frequently, the terms values and ethics are employed interchangeably; however, the terms are not synonymous. Values are beliefs, attitudes, or preferred conceptions about what is good or desirable that provide direction for daily living. They stem from our personal, societal, and agency values. Rokeach has argued that values may be organized into two categories: terminal values and instrumental values [9]. Terminal values describe the desired end-goal for a person's life; they are identified as: happiness, inner harmony, wisdom, salvation, equality, freedom, pleasure, true friendship, mature love, self-respect, social recognition, family security, national security, a sense of accomplishment, a world of beauty, a world at peace, a comfortable life, and an exciting life. Instrumental values are those that help a person to achieve their desired terminal values, such as love, cheerfulness, politeness, responsibility, honesty, self-control, independence, intellect, broad-mindedness, obedience, capability, courage, imagination, logic, ambition, cleanliness, helpfulness, and forgiveness. Ultimately, all of these types of values influence how a person will behave. Not all individuals will identify with all of these values; most will have a few terminal values that are important to them. When there is conflict or tension between values, such as politeness and honesty, individuals will begin to prioritize [9,69].

It is important for social workers to have a high level of self-awareness, understand the nature and origins of value conflicts, and understand the impact of values on their decisions. Values include our life experiences, worldview, cultural outlook, professional values (e.g., training), societal values (e.g., in the United States: achievement, equality, freedom, justice, self-actualization), and religious beliefs. Values are also based on knowledge, aesthetics, and morals [10].

Ethics are the beliefs an individual or group maintains about what constitutes correct or proper behavior [13]. To put it simply, ethics are the standards of conduct an individual uses to make decisions. The term morality is often confused with ethics; however, morality involves the judgment or evaluation of an ethical system, decision, or action based on social, cultural, or religious norms [13,14]. The term morals is derived from the Latin word mores, which translates into customs or values.

An ethical dilemma presents itself when a social worker must make a choice between two mutually exclusive courses of action. The action may involve the choice of two positives or the choice of avoiding two harms. If one side of the dilemma is more valuable or positive than the other side, then there is no dilemma because the choice will lean toward the side that is more desirable [15]. The process of making the choice is the ethical decision-making process.

Ethical decision making is influenced by the ethical principles to which individuals adhere. Ethical principles are expressions that reflect humans' obligations or duties [10]. These principles of correct conduct in a given situation originated from debates and discussions in ancient times and became the theoretical framework upon which we base our actions as individuals and societies. Most prominently, it was the Bible and Greek philosophers, such as Plato and Aristotle, who created most of the familiar ethics and morals in use today.

The following are general ethical principles that social work professionals recognize [10]:

Based on these ethical principles, professions develop ethical codes that embody the values of the profession and guide behaviors of members. Of course, codes of ethics do not guarantee ethical practice [99]. They do not always provide clear direction, and in some cases, the tenets of the codes are in direct conflict with each other.

It is also important to note that codes of ethics should be dynamic, reflecting the changing social and cultural climate. If the codes are not revised periodically, they can become obsolete [99].

Client A, a Chinese immigrant man 85 years of age, is brought to the hospital's emergency department by ambulance after his wife found him lying on the floor after a fall. Because Client A and his wife speak limited English, Chinese-speaking hospital staff is located to help with interpreting.

After testing is complete, the emergency room physician diagnoses Client A with aortic dissection. The client must make a decision of whether to proceed with surgery, which has significant risks. He is informed that he has only a slight chance of recovery given his age. He is also informed he must make a decision immediately. Client A and his wife say they cannot make a decision without consulting with their children, who are in transit to the hospital but still a few hours away. The treating physicians are pressuring the client to make a decision, as the window for success is short. A white social worker visits the couple. She knows that Asian culture is very family oriented and highly collectivistic. She indicates to the physicians that, in this case, decision-making will not necessarily revolve around self-autonomy.

In this case, the social worker is operating under the value of promoting the dignity and worth of the person, which is at the heart of social work. This value is reflected in NASW Ethical Standard: 1.02: Self-Determination. Another important ethical consideration stems from the Standard: 1.05: Cultural Awareness and Social Diversity. Western values emphasizing autonomy are not necessarily paramount for all clients. In Client A's case, given his collectivistic cultural orientation, family decision-making is vital. Before making any decisions or recommendations, the social worker also addresses her own level of competence, which reflects Standard 1.04: Competence.

Deontologic theories concentrate on considering absolutes, definitives, and imperatives [7,79]. Deontologic theories may also be referred to as fundamentalism or ethical rationalism [17]. According to this perspective, ethical behavior is based on objective rules an individual follows in order to fulfill his/her obligation to society, the profession, the community, clients, and/or employers [48,80,101]. Persons adhering to this perspective ask: What rules apply? What are the duties or obligations that provide the framework for ethical behavior [102,103,104]? The deontologic theorist would argue that values such as self-determination and confidentiality are absolute and definitive, and they must prevail whatever the circumstances (i.e., universally applicable) [17]. Other underlying principles include beneficence, non-maleficence, and justice [103]. An action is deemed right or wrong according to whether it follows pre-established criteria known as imperatives. An imperative in our language is viewed as a "must do," a rule, an absolute, or a black-and-white issue. This is an ethic based upon duty, linked to absolute truths set down by specific philosophical schools of thought. As long as the principles dictated by these imperatives are met with dutiful compliance, one is said to be acting ethically.

The precepts in the deontologic system of ethical decision making stand on moral rules and unwavering principles. No matter what situation presents itself, the purest deontologic decision maker would stand fast by a hierarchy of maxims. These are as follows [18,103]:

Social work professionals making ethical decisions under the deontologic ethical system see all situations within a similar context regardless of time, location, or people. It does not take into account the context of specific cultures and societies [17,78]. The terminology used in this system of beliefs is similar to that found in the legal justice system.

One of the most significant features of deontologic ethics is found in John Rawls' Theory of Justice, which states that every person of equal ability has a right to equal use and application of liberty. However, certain liberties may be at competition with one another. There are also some principles within the same ethical theoretical system that can conflict with one another. An example of this conflict might involve a decision over allocation of scarce resources. Under the principle of justice, all people should receive equal resources (benefits), but allocation can easily become an ethical dilemma when those resources are scarce.

A framework of legislated supportive precepts, such as the NASW Code of Ethics, serves social work professionals by protecting them in their ethical practice. However, even these systems of thought will not clearly define the right answer in every situation. Most professionals will not apply the concept of the means justifies the end if the end outcome is harmful to the patient, client, or others in their social group. When duties and obligations conflict, few will follow a pure deontologic pathway because most people do consider the consequences of their actions in the decision-making process.

Telos is a Greek word meaning end, and the teleologic ethical theories (or consequential ethics) are outcome-based theories [105]. It is not the motive or intention that causes one to act ethically, but the underlying goal and consequences of the act [7,79]. If the action causes a positive effect, it is said to be ethical. So here, the end justifies the means. From this perspective, the question is: What are the possible good and bad outcomes? What would be the most or least harmful [101,102,104,105]? Teleological theories focus more on societal effects of actions, while deontological theories emphasize effects on the individual [103]. Therefore, deontological theories may be more patient-centered.

The founder of modern utilitarian ethics, Jeremy Bentham, introduced in An Introduction to the Principles of Morals and Legislation the principle of utility for the evaluation of appropriate actions [12,13]. The rightness or wrongness of a selected action is decided according to whether the action would maximize a positive outcome, that is, whether the action would bring less pain and more pleasure to the most people. Bentham quantifies the amount of pain and pleasure created from actions in a moral utilitarian calculus that examines the rightness or wrongness of the selected actions in terms of seven factors: intensity, duration, certainty, propinquity or remoteness, fecundity, purity, and extent [12,13,14].

Virtue ethics is based on the belief that moral character is the foundation for ethical decision making. Virtues, such as integrity, wisdom, compassion, courage, truthfulness, and modesty, will guide ethical behavior [48,51,67,79,101]. According to Aristotle, there are two categories of virtues: intellectual and moral. Intellectual virtues include wisdom, understanding, and prudence; moral virtues encompass liberality and temperance [107].

This perspective does not emphasize rules or the motivations or outcomes of an action. Instead, it focuses on the individual's personality traits or character. Professionals with this perspective ask themselves what a good practitioner would do in light of an ethical dilemma [104]? Virtues relevant to the practice of social work include openness, care, compassion, honesty, empathy, patience, gratitude, humility, hopefulness, courage, fair mindedness, and diligence [52]. Virtue ethics theorists argue that primary and continuing social work education should focus on character formation in addition to social work competencies and skills in order for practitioners to develop crucial virtues to become a good person [51,53]. In reality, social workers simultaneously employ multiple ethical theories. In doing so, they mitigate the limitations inherent in using only one primary ethical theory. Ethical dilemmas may be analyzed using all three major ethical theories [54]. The deontologic framework assists social workers to consider their absolute principles and obligations, for example, through the use of the NASW Code of Ethics. The utilitarian framework offers a cost and benefit analysis of certain actions taken, and virtue ethics provides an opportunity for the social worker to reflect on his/her character, motives, and the type of social worker he/she wants to be [54].

A relational model of ethics focuses on the network of relationships and social connections rather than universal absolutes, as humans are embedded in a social web [81; 82; 108]. Cooperation and care are key in relational ethics. Gilligan's ethics of care is an example of relational ethics. At the heart of relational or care ethics is consideration of the care responsibilities of a practitioner [104].

In summary, ethical dilemmas may be analyzed using all three major ethical theories [54]. The deontologic framework assists social workers to consider their absolute principles and obligations, for example, through the use of the NASW Code of Ethics. The utilitarian framework offers a cost and benefit analysis of certain actions taken, and virtue ethics provides an opportunity for the social worker to reflect on his/her character, motives, and the type of social worker he/she wants to be [54]. Traditionally, social work has focused mainly on deontological and utilitarianism as the dominant ethical paradigms [109].

The 1990 NASW Code of Ethics was classified as deontologic because it contained three ethics statements that were more rule-based [21]. The most recent NASW Code of Ethics also has a deontologic style because it also includes the responsibility of the social work professional to understand the ethical statements instead of merely inscribing the ethical statements as a prescriptive rule [21]. It has been noted that the values set forth in the NASW Code of Ethics are deontologic in nature, but frequently, social workers will use teleologic reasoning to make their decisions when confronted with ethical dilemmas [7].

As discussed, professional ethical codes define a particular organization's values and create boundaries that members must abide. In practice, most social work professionals adopt a combination of ethics that agree with personal and client values and prioritize these values based on the situation or application, while at the same time adhering to professional codes of ethics. This often occurs naturally, without giving much thought to the theories that the various values are derived from. One study found that social work professionals tend to adhere to deontologic ethical principles; however, in their day-to-day practice, they utilize a utilitarian approach [55].

Ethics inform all aspects of practice, not just the resolution of dilemmas. It is important to remember that ethical obligations and repercussions differ somewhat between applications. Ethics used in research are abstract and do not necessarily take into account a unique client situation; however, when performing an assessment to guide a real-world intervention, values must be evaluated and prioritized to help clients achieve specific goals [43]. Most practitioners would agree that personal value systems must be flexible in order to accommodate the needs of the individual client-system (e.g., clients from differing cultures, elderly clients, clients with substance abuse disorders, groups). Of course, certain values, such as respect, should always be a high priority. It has been shown that respect is a fundamental value in social work and that demonstrating respect toward clients (in a variety of ways) can lead to better outcomes [44].

It is also important to understand that each objective's or each intervention's outcomes can be evaluated using different theoretical lenses or outlooks. A social worker can compare the outcomes of similar cases against the intervention being evaluated, but practitioners may judge the outcome differently based on their personal values and ethics. Bloom argues that deontologic (i.e., absolutist) ethics are "fairytale-like and unsuited to the real world" because they promote an all or nothing attitude during evaluation and an unrealistic expectation of perfection [43]. On the other hand, teleologic (i.e., consequential) ethics allow for acceptance of varying degrees of success and for outcomes to be gauged by a variety of measures. If the goals of an agreed upon intervention plan are not 100% achieved, the absolutist social worker will deem the intervention a failure, but the practitioner using consequential ethics will view the achieved positives and eliminated problems of an intervention, individually, as successes.

Although the all or nothing approach may have some merit and may work for a given objective (i.e., target) or intervention, there are instances where even a fraction of improvement is very desirable. Bloom gives the example of an elderly man that is extremely angry and resentful at being moved into a nursing home due to lack of social contacts/support [43]. Ensuring anger reduction is important, but because it may be unlikely that his anger will ever dissipate completely, clinicians should identify another acceptable outcome. By comparing his case to other similar cases or research studies, a social worker can identify an average and the range of decrease in anger and resentment among many individuals and use that to set an intervention goal, which can either be a percentage of improvement or a reduction on a 10-point scale [43]. The goal may be a 30% reduction in anger or going from a 9 to a 6 on a 10-point scale.

If there is only a 10% reduction in anger during the intervention period, and the goal was not reached, the evaluation can reach several conclusions. Practitioners with an absolutist ideology might contend that the intervention failed because the goal was not realized. This presents a separate ethical issue: whether to continue the intervention despite a lack of documented improvement with an extremely difficult client (and at the potential expense of helping another client). However, during the course of the intervention, a social worker with a consequentialist ideology may decide that 10% is all that is realistically achievable for the client; additionally, they can note other specific positives and eliminated negatives achieved as individual successes, even if the overall goal was not reached. This social worker may decide it best to terminate the intervention, having the belief that the client has stabilized to an appropriate level for the given situation (i.e., the client's anger level is within the normal range, or the improvement is outside the range but further anger reduction is unlikely). This allows the social worker to produce the greatest good for a greater number (e.g., to help another recent nursing home resident with anger and resentment issues).

Ethics also play a large role in the ongoing and dynamic client assessment process. Bloom outlines six particular ethical considerations for social work [43]:

These same ethical considerations, with minor alterations, can and should be applied to research settings [43]. They can also be used to solve ethical dilemmas.

One of the criticisms of ethical decision-making frameworks is that they portray decision making in a linear progression, and in real life, such prescriptive models do not capture what professionals do [30]. In essence, these frameworks stem from a positivist approach. Positivism values objectivity and rationality. In subjectivity, one's values, feelings, and emotions are detached from scientific inquiry. Research has indicated that practitioners having these linear ethical decision frameworks in their knowledge base do not necessarily translate them into ethical practice. Consequently, Betan argues for a hermeneutic approach to ethical decision making. The person making the decision is not a detached observer; rather, the individual is inextricably part of the process. Betan maintains that this is vital because "ethics is rooted in regards to human life, and when confronting an ethical circumstance, one calls into service a personal sense of what it is to be human. Thus, one cannot intervene in human affairs without being an active participant in defining dimensions of human conduct and human worth" [30]. In one qualitative study, counselors were asked to walk through their ethical decision-making processes [85]. The researchers found that the counselors did not necessarily follow the steps outlined in various decision-making models. Instead, they tended to make a quick and automatic decision based on their experiences, their personal values and worldviews, and their professional responsibilities. This does not necessarily mean that professionals should discard the linear approaches to ethical decision making. Rather, professionals should work toward understanding how the principles fit within the therapeutic context as well as the larger cultural context. Furthermore, some maintain that even if practitioners follow a decision-making model, they are often prone to rationalizing their decisions despite ethical violations [110]. Another criticism is that ethical decision-making models are difficult to implement. When an ethical issue arises, decisions are often made rapidly, and as such, going through numerous steps may seem burdensome and inefficient [56]. Many ethical decision-making models also fail to take into account diversity and culture [112].

As discussed, ethical decision making does not operate within a vacuum. As Mattison acknowledges, there is an array of factors that influence the ethical decision-making process [24]. Consequently, it is impossible to talk about ethical decision making without looking at the psychology of moral development. Psychologists have looked at many of the same questions that philosophers have pondered but from their own professional perspective. Their theories of moral development permit us to learn something else about how moral disagreements develop and even how we may untangle them. Lawrence Kohlberg, a former professor at Harvard University, was a preeminent moral-development theorist. His thinking grew out of Jean Piaget's writings on children's intellectual development. Kohlberg's theories are based on descriptive norms (i.e., typical patterns of behavior) rather than on proven facts. Others in this field have taken issue with his categories, saying they are based too exclusively on rights-oriented ethical approaches, particularly those based on responsibility for others.

Kohlberg presumes that there are six stages of moral development that people go through in much the same way that infants learn first to roll over, to sit up, to crawl, to stand, and finally to walk [32]. The following section is from Lawrence Kohlberg's theory on moral development. There are two important correlates of Kohlberg's system:

These correlates, especially the latter one, are important when it comes to assessing the nature of disagreements about ethical judgments. Kohlberg has characterized these stages in a number of ways, but perhaps the easiest way to remember them is by the differing kinds of justification employed in each stage. Regarding any decision, the following replies demonstrate the rationale for any decision made within each stage level.

Stage 1: When a person making a stage 1 decision is asked why the decision made is the right one, he or she would reply, "Because if I do not make that decision, I will be punished."

Stage 2: When a person making a stage 2 decision is asked why the decision made is the right one, he or she would reply, "Because if I make that decision, I will be rewarded and other people will help me."

Stage 3: A stage 3 decision maker would reply, "Others whom I care about will be pleased if I do this because they have taught me that this is what a good person does."

Stage 4: At this stage, the decision maker offers explanations that demonstrate his or her role in society and how decisions further the social order (for example, obeying the law makes life more orderly).

Stage 5: Here, the decision maker justifies decisions by explaining that acts will contribute to social well-being and that each member of society has an obligation to every other member.

Stage 6: At this final stage, decisions are justified by appeals to personal conscience and universal ethical principles.

It is important to understand that Kohlberg's stages do not help to find the right answers, as do ethical theories. Instead, recognizing these stages helps social work professionals to know how people get to their answers. As a result, if you asked the same question of someone at each of the six levels, the answer might be the same in all cases, but the rationale for the decision may be different. For example, let us suppose that a social worker is becoming more involved in the life of his female client. He drives her home after Alcoholics Anonymous meetings and is talking with her on the weekends. Here are examples of the rationale for the social work professional's decision and reply, in each stage, to the question of whether this relationship is appropriate.

Stage 1: "No, because I could lose my license if anyone found out that I overstepped the appropriate boundaries."

Stage 2: "No, because if I became known as a social worker who did that kind of thing, my colleagues might not refer clients to me."

Stage 3: "No, because that is against the law and professionals should obey the law," or, "No, because my colleagues would no longer respect me if they knew I had done that."

Stage 4: "No, because if everyone did that, social workers would no longer be trusted and respected."

Stage 5: "No, the client might benefit from our relationship, but it is wrong. I need to merely validate her as a human being."

Stage 6: "No, because I personally believe that this is not right and will compromise standards of good practice, so I cannot be a party to such an action."

These stages can give the social work professional another viewpoint as to how ethical decisions can get bogged down. A person who is capable of stage four reasoning may be reasoning at any level below that, but he/she will be stymied by someone who is trying to use a stage six argument. Ideally then, if discussion is to be effective or result in consensus or agreement, the participants in that discussion should be talking on the same level of ethical discourse.

Whenever individuals gather to address a particular client's case, the members of the team must be sure that they are clear about what values they hold, both individually and as a group, and where the conflict lies. Is it between the values, principles, or rules that lie within a single ethical system? Is it between values, principles, or rules that belong to different ethical systems? When consensus has been reached, the members should be aware of the stage level of the decision.

Since Kohlberg formulated his theory, several theorists have revised or reinvented it. James Rest used Kohlberg's theory as a basis for his Schema Theory [58]. Schema Theory consists of three domains: personal interest schema, maintaining norms schema, and postconventional schema [59]. The personal interest schema focuses on the individual experiencing the moral dilemma and how he/she should evaluate the personal gain or loss. During this period, there is almost no thought about the ultimate ethical decision or how it will impact society [59]. The maintaining norms schema is based on law and order. In this phase, a person will make an ethical decision based on laws and recognizing that disruption and disorder will occur if laws are not adhered to [59]. The post conventional schema is the most advanced type of moral reasoning in Schema Theory. It stresses shared ideals that are open to the evaluation by the community. Consensus building, due process, and safeguarding rights of all members in society are emphasized [59].

Kohlberg's theory of moral development and followers of Kohlberg's theory have been criticized for being androcentric. In other words, his moral dilemmas capture male moral development and not necessarily female moral development. Gilligan, backed by her research, argues that men and women have different ways of conceptualizing morality, and therefore, the decisions made will be different [33]. This does not necessarily mean that one conceptualization is better than the other. Brown and Gilligan maintain that men have a morality of justice while women have a morality of care [34]. This is particularly relevant in social work because the field has a predominance of female social workers. This longing for relatedness and connectedness results in a "feminine" ethic of care, and it is this that guides female professionals' ethical decision making [35]. In other words, the decision-making process includes both a rational-cognitive component as well as a personal-emotive one. The social worker's "feminine" ethic of care involves a dynamic process of balancing objectivity, systematization, and rationality to reflect upon the moral dilemma, without forsaking the affective component [35]. Since Gilligan's work, scholars have discussed care ethics and mature care, which encompasses a relational care but also reflective examination of the self. In other words, ethics of care involves the care of others as well as self [60]. From this perspective, an ethical professional is one who cares for the needs of others, but also recognizes his/her own needs. Furthermore, ethics of care is not restricted to women; rather, some argue care is essential to morality [61]. Ultimately, the goal is not to elevate one form of moral development as the scientific standard; rather, it is crucial to view female ethics of care as complementing the standard theories of moral development.

Much of the traditional ethical systems and philosophies that have influenced the United States stems from Christian-based and scientific empiricism [42]. Positivism assumes there is one universal that can be counted or measured. In addition, it postulates that reality is objective and value-free [42]. This positivistic approach to ethics was challenged by Joseph Fletcher in 1966 when he published Situation Ethics. He challenged the assumption made by many scholars in the 20th century that one resolved ethical dilemmas by turning to universally accepted principles. His work caused a paradigm shift from a universal approach to ethics to deconstructing it and developing a constructivist, contextual approach [42]. In situation ethics, one takes the context (including culture and diversity) into account.

Others argue that a postmodernist perspective is beneficial when working with clients from diverse cultures [65]. This approach argues for cultural relativism, maintaining that there is no reference point to which to compare cultural norms [65].

In our multicultural society, definitions of "good" or "bad" will inevitably vary from group to group. One of the struggles when dealing with multiculturalism and diversity issues while developing ethical guidelines is the question of how to develop one ethical guideline that can fully apply to the many diverse groups in our society. Strictly speaking, multiculturalism promotes the idea that all cultural groups be treated with respect and equality [19,68]. The complexity of defining multiculturalism and diversity is influenced by the tremendous differences within a group in addition to the differences between groups. Certainly religion, nationality, socioeconomic status, education, acculturation, and different political affiliations all contribute to this within-group diversity. To make matters even more complex, multiculturalism and diversity within a society are dynamic rather than static, as are the words used to describe problems [44]. For example, the term "vulnerable populations" has long been used in social work research and practice. However, in the past few years experts have begun to argue that the term undermines the social work value "respecting the dignity and worth of the person," as it may convey a lack of ability to make decisions [90].

Consequently, the questions that arise in this debate are: Should ethical guidelines be based on the uniqueness of groups, taking into account distinct values, norms, and belief systems? Or should ethical guidelines be developed based on the assumption that all human beings are alike [44]? Some experts have argued that the underlying values of many of the professional codes of ethics in the United States mirror "Americanness," essentially overemphasizing autonomy and individualism [66]. If clients ultimately want to be treated with dignity and respect, then honoring dignity may be more important than honoring autonomy [66].

Several ethical decision-making models have been reviewed in this course. The major criticism of these models is that they do not take into account issues of diversity. Garcia, Cartwright, Winston, and Borzuchowska developed the Transcultural Integrative Model for Decision Making, which includes a self-reflective activity [27]. This allows practitioners to recognize how cultural, societal, and institutional factors impact their values, skills, and biases. Furthermore, the model stresses the role of collaboration and tolerance, encouraging all parties to be involved in the evaluation of ethical issues and promoting acceptance of diverse worldviews [27].

The authors of this model maintain that its strength lies in the fact that it is based on several underlying frameworks: rational, collaborative, and social constructivist. It employs a rational model in providing a sequential series of procedures. The collaboration model is used because it acknowledges the importance of working with all stakeholders involved, employing a variety of techniques to achieve consensus. Finally, the Transcultural Integrative Model employs social constructivist principles by acknowledging that meanings of situations are socially constructed [27]. No single theoretical framework can provide solutions to complex and multifaceted ethical solutions; therefore, an array of strengths from various frameworks is harnessed. The Transcultural Integrative Model consists of four major steps, with sub-tasks within each step [27].

Self-care is at the heart of social work practice [115]. If social workers do not prioritize their own wellness, compassion fatigue, burnout, and secondary traumatization can result, which leads to higher attrition rates and can harm clients.

Before the 2021 revisions to the NASW Code of Ethics, there was only implicit reference to self-care [116]. In an effort to clarify the importance of this issue, new language about self-care was added to the Purpose and Ethical Principle sections of the Code of Ethics [116]. The Purpose section now includes the following language [8]:

In the 2017 NASW Code of Ethics, references to cultural competence were changed to cultural awareness [8,91]. However, the 2021 update reverts back to the language of cultural competence, as it connotes the inclusion of culturally informed practice and cultural awareness. The concept of cultural humility has also been added to the standard [116].

Standard 1.05, which is titled "Cultural Competence" reads [8]:

(a) Social workers should demonstrate understanding of culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.

(b) Social workers should demonstrate knowledge that guides practice with clients of various cultures and be able to demonstrate skills in the provision of culturally informed services that empower marginalized individuals and groups. Social workers must take action against oppression, racism, discrimination, and inequities, and acknowledge personal privilege.

(c) Social workers should demonstrate awareness and cultural humility by engaging in critical self-reflection (understanding their own bias and engaging in self-correction), recognizing clients as experts of their own culture, committing to lifelong learning, and holding institutions accountable for advancing cultural humility.

(d) Social workers should obtain education about and demonstrate understanding of the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability.

(e) Social workers who provide electronic social work services should be aware of cultural and socioeconomic differences among clients' use of and access to electronic technology and seek to prevent such potential barriers. Social workers should assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.

The 2021 Code of Ethics, with its emphasis on cultural competence, calls for understanding and demonstration through knowledge.

Today, social workers use a variety of technologies in their daily practice with clients, families, stakeholders, and colleagues. These technologies include e-mail, social networks, videoconferencing, smartphones, blogs, and electronic records [92,93]. The 2017 revision of the NASW Code of Ethics included many changes and new standards that reflect the role of technology in social work; these remain in place with the 2021 revision. However, it is important to note that all of the ethical standards outlined in the NASW Code of Ethics apply to social workers who use technology with clients. Social work professionals should consider how the ethical principles and standards apply to technologic tools and interactions. For example, the NASW Code of Ethics includes five ethical standards regarding technology and informed consent [8]:

Interprofessional collaboration is defined as a partnership or network of providers who work in a concerted and coordinated effort on a common goal for clients and their families to improve health, mental health, and social and/or family outcomes [118]. It involves the interaction of two or more disciplines or professions who work collaboratively with the client on an identified issue [119]. Providers come together to discuss and address the same client problem from different lenses, which can ultimately produce more inventive and effective solutions [120]. The client/patient is not excluded from the process; rather, shared decision making by all team members advances the goal of improving client/patient outcome(s) [118].

Interprofessional collaborations have been touted for multiple reasons. Positive outcomes have been demonstrated on individual and organizational levels. For example, on the client level, reduced mortality, increased safety and satisfaction, and improved health outcomes and quality of life have been demonstrated [121,122,123]. Practitioners also experience benefits, including increased job satisfaction, staff retention, improved working relationships, and more innovative solutions to problems [121,123,124].

There is a difference between the traditional model of professional ethics and interprofessional ethics [125]. The traditional model revolves around a single profession's unique code of ethics, which addresses the specific profession's roles, expertise, core values, and ethical behaviors. Each professional's code of ethics demands the practitioner's loyalty and commitment to the values, specialty, and expertise [125]. On the other hand, interprofessional ethics emphasizes the relationship and interactions of practitioners from different professions and the unique ethical issues that emerge from working with a diverse team (e.g., interpersonal conflict, misuse of power, respect) [125]. Practitioners in an interprofessional setting should engage in collective interprofessional ethics work, which is defined as "the effort cooperating professionals put into collectively developing themselves as good practitioners, collectively seeing ethical aspects of situations, collectively working out the right course of action, and collectively justifying who they are and what they do" [126].

Standard 2.03 in the NASW Code of Ethics states [8]:

(a) Social workers who are members of an interdisciplinary team should participate in and contribute to decisions that affect the well-being of clients by drawing on the perspectives, values, and experiences of the social work profession. Professional and ethical obligations of the interdisciplinary team as a whole and of its individual members should be clearly established.

(b) Social workers for whom a team decision raises ethical concerns should attempt to resolve the disagreement through appropriate channels. If the disagreement cannot be resolved, social workers should pursue other avenues to address their concerns consistent with client well-being.

Because interprofessional team members come from different disciplines, there may be divergent views on how to handle ethical dilemmas. This is a challenge and can result in friction among the team. Practitioners should communicate openly about each members' roles, expertise, and responsibilities in client care and decision-making processes [99]. It is also important to delineate who will be involved in the informed consent process, documentation, and record keeping. Most importantly, practitioners should not act outside the scope of their practice and licensing and regulatory requirements.