- The dilemma involves fidelity to a client who is unable to communicate. Mr. and Mrs. Smith have been married for sixty years. Now in his mid-eighties, Mr. Smith has suffered several strokes that have rendered him semicomatose. Mrs. Smith is legally blind, walking with the aid of a cane. She remains perceptive, however, and makes all of the financial decisions for the couple. She also oversees all of Mr. Smith’s medical decisions. Mr. Smith was recently admitted to the hospital with pneumonia and bedsores, but Mrs. Smith has elected, even in her current state, to take him home.
The physician has requested social work intervention, believing Mr. Smith’s needs are too great to be met by the feeble Mrs. Smith. He fears Mr. Smith’s care may be compromised and also fears Mrs. Smith may injure herself or become ill while caring for her husband. The physician wants Mr. Smith returned to a long-term care facility in order to ensure the safety of both parties. Though Mr. Smith is unable to speak, Mrs. Smith has told the physicians that her husband would not want to be in a place like this. She also feels that her husband deserves better care than that offered at the facility. To ease the physician’s worries, she relays that two neighbors will help her care for her husband. The conflict involves ethical, as well as legal issues.
- Though she is legally blind and walks with a cane, Mrs. Smith is still competent. Her brain is fully-functioning, and she is perceptive. She shows no signs of devolved decision making; therefore, the social worker understands that any decision making on Mr. Smith’s behalf does indeed fall to his wife, as stated in an article published in The New England Journal of Medicine . If an individual is without cognitive or verbal ability, their patient’s rights will devolve to their spouse, parent, or guardian, assuming that a person is cognitively aware and able to communicate (2010). While this is the law, ethically the social worker is bound to helping the client, Mr. Smith. As stated in Charles S. Levy and Simon Slavin’s book, “Social Work Ethics on the Line”, a social worker’s first and only priority are the best interests of the client (2013). Though guidelines set by the law must be followed at all times, there are instances where the law may be superseded to suit the best interests of the client. Though Mrs. Smith is perceptive and able to make decisions for her husband, as well as communicate the decisions she makes, leaving the long-term care facility may not be what is best for Mr. Smith. Mrs. Smith is in her 80’s, blind, and unable to walk without a cane. The age, health, and professional nature of the two neighbors willing to help also raises questions, and possible ethical dilemmas (2013). Support is important but releasing a sick, elderly individual into the hands of the inexperienced is unethical and irresponsible. Assessing Mr. Smith’s needed separately from Mrs. Smith’s legal rights to make decisions for him may create a legal dilemma, depending on the outcome.
- In order to make a decision, I would attempt to follow ethical guidelines as outlined in “Ethical Decisions for Social Work Practice” . After assessing Mr. Smith’s condition, I would assess Mrs. Smith’s mental awareness. The facility in which Mr. Smith was placed would also need to be evaluated. Mrs. Smith expressed displeasure in the care her husband had been receiving; allegations such as this need to be taken seriously, from an ethical standpoint (2011). If the facility were found to mistreat patients, it would need to be shut down. If it was found to be perfectly adequate, a reasonable decision might be reached with Mrs. Smith. Mrs. Smith’s physical health would also need to be assessed. Would she be capable of fulfilling all of Mr. Smith’s many needs? The competence, age, health, and professionalism of the neighbors in question would also all need to be answered (2011). After all of these questions were answered, assuming the facility provided adequate care, and Mrs. Smith and her neighbors could also provide adequate care, it would still be ethically irresponsible to leave an 80 year old invalid in the charge of a nearly blind 80 year old woman. Although she might have help and the law states that patient’s rights would fall to her, the social worker would be ethically bound to suggest that Mr. Smith remains in the facility or that Mrs. Smith finds a facility that she is happier for him to stay.
- After consulting with several social workers on this matter, they concurred that my initial instincts were correct. It is the law; patient’s right would fall to a spouse, parent, guardian, or whoever held Mr. Smith’s power of attorney. My only defense would be to argue the unethical nature of the decision as well as the potential health hazard that Mrs. Smith caring for Mr. Smith might pose. Research showed that perhaps my only hope in completely preventing Mrs. Smith from taking Mr. Smith home with her would be to prove her incompetence, which would also be unethical .
- Laws in Wisconsin helpful to my case is scarce. I was able to find one that was particularly helpful. Though she would have no malicious intent, according to laws published in Wisconsin Medical Journal, if Mrs. Smith were to take Mr. Smith home and be unable to care for him it would be considered elderly abuse. The same would be said if she left him with unfit neighbors. Because she lives alone, has a poor social network, would still be dependent on the victim, is elderly herself, and has access to respite care that she has refused I would be able to argue that Mrs. Smith would be subjecting Mr. Smith to abuse. Because Mrs. Smith is also almost blind and unable to walk without a cane, it is also arguable that she has a functional impairment, which is also a specification for elderly abuse when carrying for the elderly (2010). This law would make me consider fighting to keep Mr. Smith in a long-term facility.
- There are many courses of action and many outcomes. One outcome is to let Mrs. Smith take Mr. Smith and leave, allowing her and her neighbors to care for him. Mr. Smith may live out the rest of his days happy, and Mrs. Smith may miraculously avoid physical ailment but this is unlikely. The likely outcome of this is that the neighbors do not continue to lend support until Mr. Smith’s death, Mrs. Smith takes on the full burden of Mr. Smith’s needs, and both fall into very poor health. Mr. Smith may get bed sores or fall very ill while Mrs. Smith contracts all of Mr. Smith’s illnesses and grows frailer with all of the work required to care for him. Another possibility is that Mrs. Smith amicably agrees to leave Mr. Smith in the long-term care facility, visiting him as often as her health will allow. This will allow them both to remain as cared for as possible. If Mrs. Smith’s health ever deteriorates badly enough, she may join him in the home. Or, if she is unsatisfied with this facility, she may find another, and the same outcome can proceed. A third possibility is that I, the presumed social worker, fight Mrs. Smith in a legal battle. Though she holds no ill intentions toward her husband, I would use Wisconsin law against her, assuming that the situation would only set Mr. Smith up for abuse. The stress of the legal battle would leave me feeling ethically confused. It might leave Mrs. Smith feeling unhealthier than before, as well.
- Though I would not want to fight Mrs. Smith on this matter, Mr. Smith is a client and therefore, my priority. I would try to reason with her and convince her as kindly as possible that Mr. Smith needed to remain in the facility. If it is not this one she would need to find another one; she would at least be in charge of that. However, if it came to it, I would engage in a legal battle with her because, in the end, I would be protecting the health of both Mrs. Smith and her husband, even if Mrs. Smith would not realize this.
References
Dolgoff, R., Harrington, D., & Loewenberg, F. (2011). Ethical Decisions for Social Work Practice. Stamford: Cengage Learning.
Levy, C. S., & Slavin, S. (2013). Social Work Ethics on the Line. London: Routledge.
Silveira, M. J., Kim, S. Y., & Langa, K. M. (2010). Advance Directives and Outcomes of Surrogate Decision Making before Death. The New England Journal of Medicine, 1211-1218.
Thomson, M. J., Lietzau, L. K., Doty, M. M., Cieslik, L., Williams, R., & Meurer, L. N. (2010). An Analysis of Elder Abuse Rates in Milwaukee County. Wisconsin Medical Journal, 271-276.
