Ethical issues do not exist within a vacuum; rather, they emerge, evolve, and adapt within the sociocultural context of a particular society. In past decades, the field of professional ethics has received increased attention. Much of the discussion began in the 1960s in the medical field, where the blending of ethics, legalities, and medicine has become known as bioethics. Its emergence occurred because there was a need to talk about how research and healthcare decisions and regulations could be made, who could make them, and what their long-term implications would be. In the late 1960s, philosophers, theologians, physicians, lawyers, policy makers, and legislators began to write about these questions, hold conferences, establish institutes, and publish journals for the study of bioethics. Around the same time, many existing professional organizations and agencies, such as those for counseling, social work, and law enforcement, began implementing their own ethical codes. When an institution is young, the creation of a formal code of ethics is standard practice to inform prospective members; unify, advise, and protect existing members; help resolve ethics issues; protect those that the profession serves; and help establish and distinguish an organization, agency, and its members.

Two events in the 20th century served as catalysts to facilitate the codifying principles and behaviors that protected the rights of research participants. This set the context for establishing codes of ethics in human service arenas, including social work. One event was the atrocities exposed during the Nuremberg trials in Germany in 1945 and 1946. Another significant event occurred in the United States when, in 1932, the Public Health Service initiated a syphilis study on 399 African American men from Tuskegee, Alabama. The goal of the study was to observe the men over a period of time to examine how the disease progressed in African Americans. When the study began, there was no cure; however, 15 years into the study, penicillin was discovered to be a cure for syphilis. The research participants were never informed, and treatment was withheld in spite of the fact that by the end of the experiment in 1972, 128 men had died either from the disease or related complications [1].

Two events in the 20th century served as catalysts to facilitate the codifying principles and behaviors that protected the rights of research participants. This set the context for establishing codes of ethics in human service arenas, including social work. One event was the atrocities exposed during the Nuremberg trials in Germany in 1945 and 1946. Another significant event occurred in the United States when, in 1932, the Public Health Service initiated a syphilis study on 399 African American men from Tuskegee, Alabama. The goal of the study was to observe the men over a period of time to examine how the disease progressed in African Americans. When the study began, there was no cure; however, 15 years into the study, penicillin was discovered to be a cure for syphilis. The research participants were never informed, and treatment was withheld in spite of the fact that by the end of the experiment in 1972, 128 men had died either from the disease or related complications [1].

Postmodernism is a reaction to the belief that there is "rational scientific control over the natural and social worlds" [3]. Postmodernism is characterized by diversity, pluralism, and questioning the belief that there are objective laws or principles guiding behavior [3,95]. This perspective recognizes that knowledge is not error free and the world is characterized by fluidity [45]. Postmodernists argue that ethical principles should take into account historical and social contexts to understand individuals' behaviors [4]. According to this view, the concepts of "right" and "good" are seen as social constructs influenced by historical and current social forces [45]. This philosophical climate emphasizes situational ethics in which there are no black and white rules about principles of good and bad. Ultimately, a set of universal ethical principles cannot be easily applied [3].

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].

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.

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]:

The NASW Code of Ethics is the ethical code most widely used by social workers in the United States. It is divided into four sections [8]:

I. Preamble – Summarizes the mission of social work and the six core values of the profession. The mission of social work is "to enhance human well-being and help meet the basic needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty" [8]. The six core values are:

II. Purpose of the NASW Code of Ethics – Provides an overview of the purpose and functions of the Code. This section identifies the Code's six major aims [8]:

III. Ethical Principles – Presents six broad principles that can be drawn from the six core values stated in the preamble [8]:

II. Purpose of the NASW Code of Ethics – Provides an overview of the purpose and functions of the Code. This section identifies the Code's six major aims [8]:

IV. Ethical Standards – This section includes specific principles clustered around six major categories, which include the following [8]:

In its most general and rudimentary categorization, ethics can be classified into three different headings: deontologic (i.e., mandatory) ethics, teleologic (i.e., aspirational or consequential) ethics, or virtue ethics [16]. When a social worker wears a mandatory ethics lens, he/she views the world in terms of polar opposites, in which one must make a choice between two behaviors. On the other hand, those who adopt aspirational ethics assume that there are a host of variables that play a role in benefiting the client's welfare [16]. Those who adhere to virtue ethics assume that the moral character of the social worker or even the social service agency will drive ethical behavior and decisions [48]. For all ethical decision-making models, there is an underlying ethical theory that drives the model. Therefore, it is important to understand the various ethical theories.

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.

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 modern teleologic ethical theory is existentialism. In its pure form, no one is bound by external standards, codes of ethics, laws, or traditions. Individual free will, personal responsibility, and human experience are paramount. This perspective assumes that a person is highly aware and sensitive and has the capacity to reflect on his or her personal responsibility, freedom, pressures experienced by others, and practical constraints of a situation [50]. Existentialism lends itself to social work because one of the tenets is that every person should be allowed to experience all the world has to offer. A critique of the existential ethical theory is that because it is so intensely personal, it can be difficult for others to follow the reasoning of a social worker, making proof of the ethical decision-making process a concern.

Another modern teleologic ethical theory is pragmatism. To the pragmatist, whatever is practical and useful is considered best for both the people who are problem solving and those who are being assisted. This ethical model is mainly concerned with outcomes, and what is considered practical for one situation may not be for another. Pragmatists reject the idea that there can be a universal ethical theory; therefore, their decision-making process may seem inconsistent to those who follow traditional ethical models.

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

Osmo and Landau note that there are two types of argumentation: explicit and implicit [25]. Implicit argumentation involves an internal dialogue, whereby the practitioner talks and listens to him/herself. This internal dialogue involves interpreting events, monitoring one's behavior, and making predictions and generalizations. It is more intuitive and automatic, and this type of dialoguing to oneself has tremendous value because it can increase the practitioner's level of self-awareness. However, Osmo and Landau also argue for the importance of social workers' use of explicit argumentation [25]. Research indicates that just because a professional code of ethics exists, it does not automatically guarantee ethical practice. Explicit argumentation involves a clear and explicit argumentation process that leads to the ethical decision. In other words, the social worker must provide specific and explicit justification of factors for a particular course of conduct regarding an ethical dilemma [25]. Explicit argumentation is like an internal and external documentation of one's course of action. One can explain very clearly to oneself and others why one made the choices.

In general, decision analyses typically include the following: acknowledging the decision, listing the advantages or disadvantages (pros or cons), creating the pathways of the decision, estimating the probabilities and values, and calculating the expected value [23].

Naming the dilemma involves identifying the values in conflict. If they are not ethical values or principles, it is not truly an ethical dilemma. It may be a communication problem or an administrative or legal uncertainty. The values, rights, duties, or ethical principles in conflict should be evident, and the dilemma should be named (e.g., this is a case of conflict between client autonomy and doing good for the client). This might happen when a client refuses an intervention or treatment that the social worker thinks would benefit the client. When principles conflict, such as those in the example statement above, a choice must be made about which principle should be honored.

Loewenberg and Dolgoff's Ethical Principles Screen is an ethical decision-making framework that differs slightly from the Kenyon and Congress models [28]. This method focuses on a hierarchy of ethical principles to evaluate the potential course of action for ethical dilemmas. The hierarchy rank prioritizes ethical principles; in other words, it identifies which principle should be adhered to first. The first ethical principle is more important than the second to the seventh [11]. Social work professionals should strive for the first ethical principle before any of the following ethical principles. In a situation where an ethical dilemma involves life or death, then this ethical principle should be adhered to first before principle 6, which is adhering to confidentiality. When reading Loewenberg and Dolgoff's hierarchy, the social worker can see that only conditions to maintain the client's right to survival (ethical principle 1) or his/her right to fair treatment (ethical principle 2) take precedence to ethical principle 3, which is free choice and freedom or self-determination.

Mattison challenges social work professionals to not only use decision-making models to infuse logic and rationality to the decision-making process, but to also incorporate a more reflexive phase [24]. Practitioners frequently overestimate their own levels of competence, which places them at risk in making errors. Self-reflection is vital to combat this tendency. This involves objective and direct observation and evaluation of one's own thought processes [86]. In many ways, Mattison's assertion is similar to Betan's call for integrating a hermeneutic perspective to ethical decision making. This is referred to as ethical self-reflection. The process is to learn more about oneself as a decision maker or to better understand the lens one wears to make decisions [24]. It is impossible to remove one's character, conscience, personal philosophy, attitudes, and biases from the decision-making process [31]. Just as social work emphasizes the person-in-situation perspective in working and advocating for clients, so too should the person-in-situation perspective be employed in increasing self-awareness as a decision maker in ethical situations [24]. The person-in-environment perspective argues that to understand human behavior, one must understand the context of the environment that colors, shapes, and influences behavior. Therefore, the social worker must engage in an active process by considering how their individual level (e.g., prior socialization, cultural values and orientations, personal philosophy, worldview), the client's domain (e.g., values, world views, beliefs), organizational context (i.e., organizational or agency culture, policies), professional context (i.e., values of the social work profession), and societal context (i.e., societal norms) all play a role in influencing moral decision making [24].

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:

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.

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].

The ethical concerns in managed care revolve around the issue of whether a social worker or practitioner should continue to provide services outside the parameter of the managed care contract [16]. Is early termination of services deemed on a probability that payment will not be obtained? In a cost-benefit analysis, what is the role of the client? How does the ethical principle of beneficence come into play? Certain diagnoses will be deemed reimbursable by the managed care organization. Is it beneficial for the client if a different diagnosis is given in order for services to continue [114]?

Confidentiality, which is founded on respect and dignity, is of paramount importance to the therapeutic relationship. However, managed care systems also present challenges to the ethical issue of client confidentiality, as they often request that clients' records be submitted for review and approval of services [38,114]. Accessible electronic health records further complicate this issue [88]. Consequently, social workers and other practitioners should explain up front and provide disclosure statements that establish the limits to confidentiality, what types of information must be shared, how this information is communicated, treatment options, billing arrangements, and other information [38,39]. Knowing that other staff members may obtain sensitive information can influence the extent to which sensitive information is included in notes [88].

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].