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| Practical Application of Ethical Principles |
| Columns - Professional Development | ||||||||
| Friday, 30 November 2001 | ||||||||
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In this column, we will look at the practical application of ethical principles in the daily work of addiction professionals. As our patients present with more complex clinical pictures, we are faced with more complex ethical decisions. Issues such as appropriate placement for treatment, professional scope of practice, and criteria for discharge are a regular part of addiction counseling. While the scope of the challenge is considerable, we do have some tools at hand to help us get the job done.Placement for treatment Regarding appropriate placement for treatment, we can use the wisdom of the ASAM Patient Placement Criteria, 2nd Edition (ASAM PPC-2). This well-tested document provides guidelines for determining the best clinical match between a given patient and a given level of care. An attractive part of the design of this document is that it does not disregard the clinical judgment of a counselor, but rather helps a counselor review six specific dimensions for each individual patient. The combination of an ASAM guideline and clinical judgment would likely lead to a recommendation for placement in an appropriate level of care for each and every patient. If only it were that easy! After all that clinical work we then must consider other issues, such as financial ability, legal implications, and geography. Sometimes the best clinical match is not financially possible for a patient, overridden by legal mandates, or perhaps unreasonable in light of geographic reality. We also have the NAADAC Code of Ethics to help guide us in placement decisions. Specifically, Principle 7.c requires us to "hold the welfare of the client paramount when making any decisions or recommendations concerning referral. Professional scope of practice Working with increasingly complex clinical issues, today's addiction professional is beset by countless demands for diversified treatment services. A few decades ago, most of our services were directed toward alcoholism. Then we added drug treatment to our menu of services. Now we are seeing an expansion of the word addiction to incorporate non-chemical problems such as gambling, the Internet, sex, and eating disorders. We are left with the questions: Who is trained to treat which disorder(s)? Based on what qualifying criteria? As we begin the discussions on establishing qualifying criteria for expanded addiction services, what is currently available to serve as interim guidelines for today's provider? What already exists at this dawning of the robust debates that are to come in the current decade? Fortunately, we need not look far. The NAADAC Code of Ethics is at hand. In Principle 3 of NAADAC's Code we are reminded "that the profession is founded on national standards of competency ... [and we] ... recognize the need for ongoing education as a component of professional competency." In Principle 2.c we are reminded to "... recognize boundaries and limitations of the member's competencies and not offer services or use techniques outside of these professional competencies. It is not only the reputation of an individual clinician that is at question. It is the credibility of our entire treatment system that hinges on practicing within our competencies. Applying NAADAC's Code of Ethics, with diligent forethought, today's addiction professional can serve patients while staying responsibly in a defined scope of practice. Criteria for discharge When is the appropriate time to discharge a patient? Based on what criteria? Once again, we can refer to the ASAM criteria, and to NAADAC's Code of Ethics for help in answering these two questions. Using these two guidelines, we can make a clinical decision on the appropriate time to discharge, while respecting the individual needs of a given patient. Perhaps the most brief, and accurate, description of appropriate discharge time is when the patient is well enough. As with other healthcare disciplines, we do not work with patients until they are well, but only until well enough. That is, well enough to move to a less intensive level of care. No one leaves an operating room well. No one even leaves a hospital well. Each level of medical service discharges a patient when that person is well enough. So too with addiction services: The guideline for discharge is when the patient is well enough. More specifically, ASAM criteria present the components to be assessed for when a patient is well enough. Add to that matrix, NAADAC's Code of Ethics, Principles 7.b and 7.c. In 7.b we are reminded to "... terminate a counseling ... relationship when it is reasonably clear ... that the client is not benefiting from the relationship." In 7.c we are reminded to "... hold the welfare of the client paramount when making any decisions ... concerning ... termination of treatment. For anyone caught in concrete thinking, the above guidelines will be discounted as smoke and mirrors. Such persons may want mathematical precision in any placement and discharge guidelines. They are respectfully encouraged to consult with colleagues who have established competency in using ASAM criteria, in applying professional ethics, and in exercising ethical decision-making procedures. Ethical decision-making For addiction professionals, the ASAM criteria and the NAADAC Code of Ethics may suffice for making informed clinical recommendations on behalf of each individual patient. In some other cases, a third tool may be needed from the clinical tool kit. Procedures for ethical decision making are receiving more attention in addiction settings. This is due, in no small part, to the increased complexity of providing addiction services to meet the needs of today's clients. In the scope of this column, we can briefly introduce three models for ethical decision-making. It seems obvious to begin with a model presented by a reader-friendly author who is well known in our profession - William White. He has contributed a great deal in advancing our thinking, and thereby advancing our competencies. In Critical Incidents: Ethical Issues in Substance Abuse Prevention and Treatment, White presents a three question model for ethical decision-making: 1) Whose interests are involved, and who can be harmed? 2) How could the application of various universal values shed light on the appropriate action to be taken in this situation? 3) What standards of law or professional propriety apply to this situation? Loewenberg, Dolgoff, and Harrington's Ethical Decisions for Social Work Practice, offers an eleven-step model for decision-making. At great risk of oversimplifying, their questions cover the same ground as White's, but with more specificity in each area that is examined. That is, in each of the above models we are invited to consider who is at risk, what are the guidelines, and what good will be achieved. In her book, Social Work Values and Ethics, Elaine Congress introduces a five-step model under the acronym ETHIC. E is for "examine" (the values of all parties). T is for "think" (about any ethical standards, laws, or regulations that apply). H is for "hypothesize" (about possible consequences of our decision). I is for "identify" (those who will be harmed by, and those who will benefit from, our decision). C is for "consult" (with others, to bring fresh perspectives and subjectivity). Which of these three models (and there are others) is best? That decision must be left to each individual clinician, or each treatment team, or each facility, to decide. You are encouraged to look at all three, and then see which you prefer. I have found it interesting to apply all three to a given case study, and then compare outcome decisions. Perhaps that exercise can help you find the best fit for yourself. It is not any one particular model that is encouraged, but rather that you have, and regularly use, some formal process for ethical decision-making. Combining the tools Increased clinical complexity can lead to increased burnout and eventually to compassion fatigue. With the routine application of several tools, we can extend the professional life of individual clinicians, thereby making them available to help even more individuals with addictive disorders. It is not only their professional life that is extended, but their professional effectiveness, and their professional reputation. Ethics are an essential ingredient in professional practice. Applied ethics are an essential ingredient in enhancing professional effectiveness. Dust off your ethics and put them to work for you. References: American Society of Addiction Medicine, Patient Placement Criteria for the Treatment of Substance-Related Disorders, Second Edition (ASAM PPC-2). ASAM, Inc., (1996). Located at web site: www.asam.org Congress, Elaine. (1999). Social Work Values and Ethics. Chicago: Nelson-Hall. Loewenberg, F., Dolgoff, R., and Harrington, D. Itasca. (2000). Ethical Decisions for Social Work Practice, 6th Edition. Illinois: F.E. Peacock Publishers. NAADAC, The Association for Addiction Professionals; Code of Ethics. Located at web site: www.naadac.org White, William. (1993). Critical Incidents: Ethical Issues in Substance Abuse Prevention and Treatment. Bloomington, Illinois: Lighthouse Training Institute.
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