Introduction
Self-determination represents an ethical concept outlining that clients are qualified to make own decisions concerning their treatment and lives. Indeed, the self-determination concept is essential to social workers who often make reference to it when faced with ethical dilemmas. The self-determination ethical standard is adequately described in the National Association of Social Workers (NASW) Code of ethics as one of the significant ethical responsibilities of social workers. Although it is one of NASW’s most important ethical standards, critics argue that a person can never fully be self-determined. In this way, social workers confront an impossible ethical dilemma of whether to promote self-determination or uphold societal convention, which, in most cases, contradict one another. Conversely, proponents argue that self-determination empowers and acknowledges clients as the best resource for their desired needs and treatment interventions. The self-determination ethical standard requires social workers to respect and promote the essential right of a client to make own decisions; however, the standard is limited in the situations that clients pose imminent risks to themselves and others.
Client’s Right to Self-determination
NASW recognizes the responsibility of social workers to respect and promote the right of clients to self-determination, as well as helps them recognize and elucidate their goals. However, Woodcock (2018) suggests that social workers should limit the client’s ability to make personal decisions regarding their lives when the client can harm themselves or others. Accordingly, the social worker need to adequately utilize own informed expert opinion to ascertain whether a client poses significant threats to self and others. Woodcock (2018) defines imminent risk as the likelihood that if a social worker does not intervene immediately, a person will engage in an act that harms themselves or others. Woodcock (2018) further mentions suicide and self-harm as notable examples of imminent risks. The NASW argues that social workers should uphold the client’s right to make personal decisions, as well as fulfill ethical obligations in the social work practice. Reamer (2006) avers that social workers should inform a client about available resources that can be utilized to fulfill a client’s needs. The clients need to be helped with regard to comprehending alternative social care interventions, as well as appraising impacts of each application care options.
Involuntary Clients and the Right to Self-determination
Social workers provide services indiscriminately. Often, they deal with involuntary clients. The involuntary service users may range from clients who will not respond to any care-giver to those who cooperate with social workers because they feel that they have no other choice. Gambrill (2010) perceives involuntary clients as those individuals required by the law or coerced to work with social workers. The mandate is a requirement anchored on law and encompasses working with families in child protection related cases. In addition, the mandate covers protection of mental health patients from self harm. The mandate also includes persons living with disabilities as well as those with ongoing criminal cases. The nature of involuntary clients makes such engagement challenging because they may not be ready to cooperate and may reject proposed social help services. However, despite being coerced into accepting social services, the involuntary clients have the right to self-determination. The NASW standard emphasizes that, in a situation whereby a client is receiving involuntary services, the social workers are expected to provide adequate information to the client (Woodcock, 2018). The information acquired is utilized to determine the type of services the client should be receiving, as well as explain the criteria to be followed by the client to refuse social help services.
The NASW standards recognize that involuntary clients claim certain rights. Foremost, nurses are required to fulfill their ethical obligation of the services offered. Hence, the coerced client may be able to comprehend the purpose and goals of the recommended services and the mode of intervention. In addition, Banks and Gallagher (2009) posit that social workers can also evaluate evidence supporting the intervention and how the patient is likely to benefit from participating in the social service. Moreover, the ethical social work practice does not support the tendency of social workers to force client into services. The NASW standard explains that social workers should instead inform the clients that they retain the right to refuse social services (Woodcock, 2018). Particularly, social workers are advised to explain in detail what the client is required to do, and the services that they may refuse. Kwon, Kolomer, and Alper (2014) reveal that social workers are primarily required to help patients and their families understand the nature of particular illnesses. They are equally tasked with the responsibility of guiding patients through the diagnosis process, as well as counsel patients about decisions that need to be made. Therefore, the consequences of refusing services should also be explained if the client decides not to fulfill their mandate. The client, for example, may be incarcerated or denied access to a child by the child support agency if he or she refuses certain mandated services. On the occasion that a client requests for legal advice, a social worker is obligated to provide such services.
The involuntary clients equally have self-determination rights because social workers are required to honor it. Kwon, Kolomer, and Alper (2014) acknowledge that social workers are ethically obligated to enhance the self-determination of involuntary clients. Hence, the social workers may attempt to convince involuntary clients to participate in social services. According to Kwon, Kolomer, and Alper (2014), social workers can engage the clients by empathizing with them while acknowledging their predicament and building trust to make them more willing to participate in services. Furthermore, social workers can recommend alternative choices such as family counseling if the client refuses to participate in personal counseling. Even though honoring self-determination for clients that harmed others or pose risks may be challenging, social workers should accept and address the challenges with confidence and pride.
Suicidal and Homicidal Client’s Autonomy and Self-determination
Social workers are often required to provide competent care to suicidal or homicidal clients. First, social workers should detect the risk posed by these clients. Second, social workers should interview clients or family members to comprehend suicidal or homicidal plans and intentions. Third, social workers determine the degree of imminent risk based on data collected from the client or family. Consequently, the social workers use their professional knowledge based on the information collected to grant autonomy and self-determination rights.
The social workers particularly rely on the exception of self-determination outlined in the NASW code of Ethics to acknowledge a client’s autonomy and self-determination. Banks and Gallagher (2009) contend that exception typically occurs when the patient poses a significant, predictable and looming risk to self and others. Here, the nurse relies on their professional judgment to execute decisions that may or may not honor the client’s autonomy and right to participate in decision-making. Reamer (2006) reports that the exception applies to situations in which the client is suicidal or homicidal. In this case, if the client is about to commit suicide or homicide, the social workers are ethically allowed to initiate the necessary steps that contradict the client’s right to self-determination in order to protect the clients, as well as other people.
The NASW code attaches significance to the right to life at the expense of respecting a client’s self-determination. Kwon, Kolomer, and Alper (2014) maintain that social workers can determine the right to self-determination and autonomy with regard to the extent of harm or threat posed by the client. Therefore, if a social worker encounters suicidal or homicidal patients, he or she can decide not to honor the self-determination right. Instead, they can initiate procedures of admitting the client to a psychiatric facility. However, the decision to admit the client to a psychiatric facility should be the last resort upon determining the degree of threat posed by the client.
Suicidal and homicidal clients have the right to autonomy and self-determination. Even though the social workers may determine the clients who claim the right to self-determination founded on specific situations, the NASW ethical standard does not encourage social workers to ignore self-determination. Reamer (2006) contends that the standard only limits self-determination thus signifying the need to execute the least-intrusive decisions and social work procedures. Therefore, as outlined in the NASW code, social workers should try as much as possible to honor self-determination. Notably, suicidal and homicidal clients have the right to self-determination and autonomy thus the code urges nurses to honor it by first implementing less-intrusive approaches (Yeung et al., 2010). The approaches first implemented by the social workers should attempt to respect and expand self-determination without subjecting the clients or other people to risk.
The attempt to expand self-determination for homicidal and suicidal clients encompasses the use of crisis intervention methods to convince the client to re-evaluate their suicidal or homicidal thoughts and plans. Consequently, the social worker is able to explain in detail the consequences of such thoughts and how it is likely to affect the people involved. Significantly, a social worker can engage the client by developing safety procedures that protects the client and other people. Yeung et al. (2010) acknowledge that the safety procedures or plans may encompass constant monitoring of the client by close family members or other information support systems instead of rushing to admit the client in a psychiatric facility. Moreover, a social worker can honor self-determination by requesting the client to authorize the decisions to inform the intended target of crime. The potential target can then choose to stay away from danger and allow the homicidal client to re-evaluate the homicide thoughts and plans. Finally, a social worker can fulfill ethical obligation by offering and explaining alternative intervention strategies such as referral to a mental health professional or physician. The physician can then prescribe appropriate medication for the suicidal or homicidal client.
The New York State Law provisions for Involuntary Commitment
The New York State Law for involuntary commitment is designed to assist clients with mental health problems to receive the necessary care and treatment for their condition. According to King (2020), if an individual refuses treatment, the law allows family members, friends, and social workers that fulfill the specified criteria to apply for involuntary commitment for an alleged mentally-ill patient. The law specifically outlines that a client may be involuntarily committed or institutionalized if two physicians agree and present adequate supporting evidence that the patient is mentally-ill and requires inpatient care and treatment (King, 2020). Moreover, a person may be committed or institutionalized if the said individual demonstrates an impaired judgment to an extent that they cannot comprehend the need for social care and treatment. Finally, the law outlines that a person can be committed or institutionalized in a mental health facility if he or she poses substantial threat or harm to self or others. The substantial threat may comprise the inability to provide essential needs such as food, shelter and clothing (King, 2020). In addition, a person may pose an imminent threat if he or she acts dangerously against self and others. Hence, the imminent threat posed should go against standard mental health guidelines to warrant commitment in a mental health institution.
Reflection on the New York State Law
Patients exhibiting mental health illnesses deserve an equivalent degree of personal autonomy and self-determination. As such, I do not agree with the New York state law relating to involuntary commitment. Hedman et al. (2016) contend that many people living with mental health conditions are perceived as individuals not better placed to make own decisions relating to mental health care services. However, I feel that that mental health patients can make own decisions. In addition, I believe that a care-intervention strategy effectively works if the patient is actively involved in the process. I feel that involuntary commitment and institutionalization is a serious breach of personal liberty. The NASW code only limits self-determination as it expects social workers and other caregivers to exhaust all less-intrusive treatment approaches (McGinty et al., 2018). It is, therefore, important for caregivers to respect the fundamental rights and decisions made by people living with mental health problems. I urge the New York state to adopt laws that reflect the value of upholding a patient’s dignity, autonomy, and self-determination. Involuntary commitment and institutionalization should be initiated after healthcare workers have exhausted all less-invasive care approaches like counseling. The involuntary commitment should also be sanctioned if a client poses serious physical threat to self and others.
Conclusion
Self-determination, as outlined in NASW’s Code of Ethics, empowers clients to make own decisions unless they pose serious, foreseeable, and imminent danger to themselves and others. In view of this, social workers should consider self-determination as a standard that they use to assist clients to accomplish their goals, as well as help patients exhibiting mental health problems to develop practical coping skills. Essentially, the NASW requires social workers to honor self-determination though it may be limited in instances whereby the patient is a potential threat to self and others. Consequently, the homicidal and suicidal clients have autonomy and self-determination rights. However, when dealing with these kinds of clients, social workers are obligated to initiate strategies that aid them to comprehend why the services are necessary. Similarly, this applies to involuntary commitment or the institutionalization of patients, whereby caregivers should engage patients in decision-making processes.
References
Banks, S., & Gallagher, A. (2009). Ethics in professional life. Basingstoke, Hampshire, England: Palgave Macmillan.
Gambrill, E. (2010). Evidence-based practice and the ethics of discretion. Journal of Social Work, 11(1), 26-48.
Hedman, L., Petrila, J., Fisher, W., Swanson, J., Dingman, D., & Burris, S. (2016). State laws on emergency holds for mental health stabilization. Psychiatric Services 67, 529-535.
King, S. (2020). New York State mental health involuntary commitment laws. Legal Beagle. Retrieved from https://legalbeagle.com/6759290-new-health-involuntary-commitment-laws.html.
Kwon, S., Kolomer, S., & Alper, J. (2014). The attitudes of social work students toward end-of-life care planning. Journal of Social Work in End-of-Life & Palliative Care, 10(3), 240-256.
McGinty, E., Goldman, H., Pescosolido, B., & Barry, C. (2018). Communicating about mental illness and violence: balancing stigma and increased support for services. Journal of Health Politics, Policy and Law 43, 185-228.
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Yeung, K., Ho, A., Lo, M., & Chan, E. (2010). Social work ethical decision making in an inter-disciplinary context. British Journal of Social Work, 40(5), 1573-1590.