Ethical Issues in the Social Worker's Role in Physician-Assisted Suicide
Manetta, Ameda A., Wells, Janice G., Health and Social Work
This article presents the results of an exploratory study of social workers' views on physician-assisted suicide (PAS), situations in which PAS would be favored, and whether there is a difference in education or training on mental health issues, ethics, or suicide between social workers who favor PAS and those who oppose PAS. A questionnaire was administered to a convenience sample of 66 social workers in South Carolina. The authors raise questions about the training in mental health issues, ethics, and suicide that social workers have received to prepare them to work with clients making this end-of-life decision. Implications for social work practice and suggestions for future research are presented.
social work education
Physician-assisted suicide (PAS) occurs when a medical doctor provides the means for death to occur and the patient self-administers it (Hendin, 1998). Even though medical doctors provide the means of death, social workers could become involved as they assist patients with end-of-life decisions (Csikai, 1999). Involvement with PAS presents an ethical dilemma, which in this article refers to a situation in which social workers think they have no definitive guidelines for professional behavior, when values governing professional behavior conflict, or when practice guidelines have not evolved to match technology (Reamer, 1998). Social workers have long been involved in ethical conflicts (Reamer). Even though disagreements are voiced within the professional body, individual social workers tend to avoid issues that might create conflict (Jansson & Dodd, 1998). Avoidance of controversy may be one of the reasons that social work researchers have conducted scant research on social workers' views of PAS (Jansson & Dod d). To address this gap, a survey was designed to examine social workers' views on PAS and to determine whether university courses or training regarding suicide, mental health issues, and ethics may have influenced their views.
PAS and Society
PAS currently is one of the most frequently debated issues in American society (Bachman et al., 1996; Foley, 1997). Abundant information indicates Americans are divided on the issue (Egendorf, 1998; Hendin, 1998; Kamisar, 1998; Scharlach & Kaye, 1997). The debate puts forth such arguments as preservation of life; autonomy and the self-determination of individuals; older people using up expensive medical services (Spong, 1998); the slippery slope that PAS will eventually lead to involuntary deaths (Gostin, 1997); and issues of ethical and moral complicity such as proxy deaths of children (Komp, 1998). Most people agree that PAS should be reserved for people who are dying from terminal illness (Egendorf, 1998). Proponents of PAS believe dying people are in intractable pain and should be allowed to end their lives and thus their pain. Opponents argue that underutilization of narcotics for pain control leaves terminally ill people in pain (H.R. 4006, 1998). Edwin S. Schneidman, founder of the American Association of Suicidology, maintains that dying is not painful; it is the illness that causes the pain. However, an individual does not have to have a terminal illness to have intractable pain, to which many people with conditions such as arthritis and fibromyalgia will attest (Kelley & Clifford, 1997).
Research on PAS
Little research has been conducted on the etiology of actual cases of PAS. The majority of available data is on suicide among individuals who acted alone. The clinical research, for example, has focused on predicting which people are likely to choose suicide as a means of ending their lives (Leenaars, 1995). Predictors of suicide include prior suicide attempt, suicide of a family member, recent loss of a loved one, pain, and psychiatric illness (Leenaars; Lester, 1992). Depression is one of the most salient features of individuals who contemplate or complete suicide (Beck, Brown, & Steer, 1989; Manetta, 1997; Osgood & Manetta, 1998). It has also been found that when individuals received mental health treatment for the depression, the desire to kill themselves diminished (Ellis & Newman, 1996; Sullivan, Ganzini, & Youngner, 1998). In addition, according to Leenaars, when people are experiencing personal difficulties or have lowered coping capacity, they are at risk of suicide. Having a terminal illness (often cited as a reason for PAS) may precipitate depression and reduced coping capacity; however, terminally ill people are rarely suicidal (Callahan, 1994). Ellis and Newman (1996) stated that "studies have shown that the main difference between terminally ill patients who become suicidal and those who don't is the presence of clinical depression in the patients who are suicidal" (p. 39). To make sound, ethical decisions, it is important for all helping professionals to be aware of the many factors involved in and treatments for depression in terminally ill individuals.
SOCIAL WORK PROFESSION AND PROFESSIONAL ETHICS
Several safeguards have been implemented in the social work profession to guide social workers in making ethical decisions regarding intervention with clients. In ethical practice, social workers adhere to federal and state legislation and their professional code of ethics. The National Association of Social Workers (NASW) Code of Ethics defines the values and principles of the profession (NASW, 1997). The NASW Code of Ethics is taught to social work students as part of their university education (Callahan, 1996). A review of text books available to social work educators reveals that some direct practice and introduction to social work texts discuss NASW's Code of Ethics (Sheafor, Horejsi, & Horejsi, 2000) and policy statements (DuBois & Krogsrud-Miley, 1999). However, Callahan suggested that social workers need more than knowledge about the NASW Code of Ethics; they need definitive practice guidelines and standards of practice if they are to engage in responsible professional practice.
NASW policy statements are intended to guide social workers in policy analysis and development, organizational legal actions, and individual social work actions (NASW, 2000). However, NASW policy statements are not practice guidelines.
SOUTH CAROLINA'S EXAMPLE
PAS Legislation in South Carolina
In 1997 the Supreme Court decided two precedent-setting cases, Washington v. Glucksberg and Vacco v. Quill (Mariner, 1998). The Supreme Court rejected the notion that PAS is a right under the 14th Amendment to the U.S. Constitution (Bresnahan, 1998; Kamisar, 1998). As part of its decision, the Court left the door open for individual states to define their own statutes and for the Court to revisit the issue and make changes if needed at a future time (Gostin, 1997). Frequent changes in federal and state legislation occur and legislation varies among states; thus, it is important for social workers to know and to be aware of the most current legislation.
At the time the survey was conducted, South Carolina was one of nine states with ambiguous laws regarding PAS. The South Carolina judicial system relied on the common law for directives concerning PAS (Assisted Suicide, 1999), using earlier cases as precedence in arriving at decisions in current cases.
Social Work Legislation in South Carolina
One way that legislation guides ethical practice is to require that social workers be licensed. The State of South Carolina Social Work Licensing Board allows social workers to be licensed at one of three levels: licensed bachelor of social work (LBSW), licensed master of social work (LMSW), and licensed independent social worker (LISW). The LBSW and the LMSW require both earning the appropriate degrees from accredited programs and passing an exam conducted by the board. Only the LISW requires a person to have a master's or doctoral degree from a social work program accredited by the Council on Social Work Education, "two years of professionally supervised experience satisfactory to the board in those services to be provided in private or independent practice" (South Carolina Department of Labor, Licensing and Regulation, Board of Social Work Examiners, 1998, p. 6), and to have passed an examination approved by members of the board.
All three levels of licensure require 20 hours of continuing education each year to maintain licensed status; 10 of those hours must be provided by trained social workers having a BSW, MSW, or DSW (South Carolina Department of Labor, Licensing and Regulation, Board of Social Work Examiners, 1998). The South Carolina Board of Social Work Examiners does not specify what content must be addressed in continuing education hours. This allows licensed social workers to choose continuing education in whatever areas interest them or in whatever areas their agencies require or sponsor. Thus, a person who works with elderly or terminally ill patients is not required to have training in end-of-life decisions. Finally, it is the responsibility of all licensed social workers to maintain their own records to verify their continuing educational experiences. These records do not have to be sent to the board for license renewal but must be submitted if requested.
No specific practice standards are available to guide practice with clients considering PAS. However, the Code of Professional Conduct adopted by the South Carolina Board of Social Work Examiners offers some guidance about who can practice with clients considering PAS. Section 1 of the code pertains to the comportment of a social worker and specifies that "a social worker shall not misrepresent professional qualifications, education, experience, affiliations, or services performed" (South Carolina Department of Labor, Licensing and Regulation, Board of Social Work Examiners, 1998, p. 6).
The South Carolina Board of Social Work Examiners provides specific guidelines regarding social workers practicing only in areas in which they have expertise (South Carolina Department of Labor, Licensing and Regulation, Board of Social Work Examiners, 1997). If a social worker is trained in childhood issues, and a client seeks assistance with gerontology issues, the social worker has a duty to refer the client to someone who has been trained in the area of gerontology. The code does not specify the number of hours that constitute "sufficient training" in suicidal behavior and suicide for offering consultation to an individual who requests PAS.
NASW AND END-OF-LIFE DECISIONS
NASW provides some guidance to social workers in the area of PAS. According to the NASW policy statement, "Client Self-Determination in End-of Life Decision," social workers may counsel terminally ill individuals regarding PAS (NASW, 2000). The policy statement does not mention that in most states, providing advice on PAS constitutes an offense as defined in state laws (Gostin, 1997). The policy statement does not provide guidance on when social workers should become involved or under what circumstances and for how long they should intervene with clients on life-support systems, with clients experiencing a painful illness, with clients with a terminal illness, or with clients requesting assistance to die. The policy statement clearly states that social workers should only be present at the assisted suicide of individuals who are competent to make decisions for themselves and who request the presence of the social worker.
Similar to the State of South Carolina guidelines, the 1997 NASW Code of Ethics states that social workers should practice only in areas for which they have specific expertise (Reamer, 1998). The development of practice guidelines or standards, as called for by Callahan (1996, 1994), would help address some of the issues about accountability in the practice process when social workers assist clients and their families who request information about PAS.
A review of the literature led us to ask the following three questions.
1. Are social workers in South Carolina in favor of PAS?
2. Under what circumstances do social workers favor PAS?
3. Is there a difference in the education or training regarding mental health issues, ethics, or suicide between social workers who favor PAS and social workers who oppose PAS?
The data were gathered by means of a questionnaire designed for this study. The survey instrument contained 26 questions, most of which required yes or no responses. These questions included demographic information on age, race, religion, and educational degree. Participants were asked to record how long they had been employed in their current positions and whether they had any university courses or training in mental health issues, suicide, or ethics. One open-ended question asked participants to identify situations in which they would likely agree to PAS.
Participant recruitment occurred at three separate workshops on suicide that were presented by the first author. As attendees entered the workshop, they were given a questionnaire and informed that their participation was entirely voluntary. They were asked to complete the questionnaire, fold it in half, and hand it back to the research assistant. Participants also were instructed that if they did not wish to complete the questionnaire they could just fold it in half and return it. A total of 98 participants, including physicians, psychologists, nurses, and social workers completed the questionnaire. The findings reported here were based on a subsample of 66 social workers who either had a South Carolina social work license or a bachelor's or master's degree in social work.
The Statistical Program for the Social Sciences (SPSS) was used to analyze the data. Descriptive statistics were calculated on demographic information. A chi-square analysis was used to determine if there were any statistical relationships between social workers who agreed and those who disagreed with PAS by whether they had university courses, additional training, and knowledge of the PAS law of South Carolina.
The participants were 56 women (84.8 percent) and nine men (13.6 percent), with a mean age of 40 years (SD = 11.36; range = 20 to 65 years). Data on gender was missing for one person (1.5 percent). Racial composition of the sample was 44 white (66.7 percent), 20 African American (30.3 percent) and one Hispanic American (1.5 percent). Data on race was missing for one person (1.5 percent). Of the 66 participants, 59 (89.4percent) were licensed social workers. The seven (10.6 percent) participants who did not have a social work license had either a bachelor's or master's degree in social work.
Responses for the first research question (Are social workers in South Carolina in favor of PAS?) were evenly divided: 50 percent (n = 33) who supported PAS and 50 percent (n = 33) who did not support PAS.
Circumstances under which PAS would be favored were listed for only 29 social workers (Table 1). Of these 29 social workers, more than half (59.6 percent) were in favor of PAS for reasons other than terminal illness. About two-fifths (41.4 percent) agreed with PAS if a person had a terminal illness, compared with 37.9 percent who were in favor of PAS when a person had a painful illness and 20.4 percent when a person had other medical or psychiatric problems.
To determine whether there was a difference in education or training in mental health issues, ethics, or suicide between people who favor PAS and people who oppose PAS, chi-square analysis was completed. More than half of the respondents had university courses in suicide and mental health (Table 2). Slightly more people who agreed with PAS (90.9 percent) than those who disagreed with PAS (72.7 percent) had training in ethics. A similar finding was evident for training in mental health (agreed with PAS, 72.7 percent; disagreed with PAS, 75.8 percent) after they completed their university degrees. A little more than half of the respondents in both groups had received training in suicide. Well over half of those who agreed with PAS (60.6 percent) and almost three-quarters of those who disagreed with PAS (72.4 percent) did not know the South Carolina PAS law at the time of the survey. Chi-square analysis was completed on all the areas of education and on knowledge of the law. Training in ethics approached signifi cance ([[chi].sup.2] = 3.667, p=.054); however, none of the differences were statistically significant at the .05 level.
Morrision (1996) talked about PAS threatening all nonfatally ill people when he described the case of Jack Kevorkian assisting in the suicide of Judith Curren, a woman who suffered from depression but no fatal illness. More than half of the respondents in this study favored PAS in situations where there was no fatal illness. Two responses involved individuals who would not be able to make decisions for themselves: someone who was brain dead or comatose and someone with cognitive deficits. Thus, the "slippery slope" of assisting in the death of nonterminally ill individuals that many people fear is evidenced by these responses.
Current legislation, the professional code of ethics, and the state code of professional conduct are the standards by which social workers are judged most frequently to determine whether they have engaged in ethical practice. At the time of this survey, only 10 (40 percent) of the respondents who agreed with PAS stated that they knew the South Carolina legislation regarding PAS. But more than half supported PAS in nonterminal situations. Painful or chronic illness or cognitive deficits do not necessarily equate to a terminal illness. As Reamer (1998) pointed out, most violations of the Code of Ethics result from mistakes such as not knowing the code's policies or the prevailing law.
Many of the social workers expressed views that were not consistent with NASW's policy statement on end-of- life decisions, which defines end-of-life decisions "as the choices made by a person with a terminal condition" (NASW, 2000, p. 41). These social workers may not be aware of the NASW policy statement.
Social Workers and Training
The majority of respondents stated that they had taken a university course or had additional training in the field of mental health, ethics, and suicide. Content of university courses and training generally include empirical research findings. Researchers in the area of suicide often point out that people with terminal illnesses may be depressed, but they generally do not want to die; that depression is the number one symptom associated with suicidal behavior; and that if the depression is treated or relieved in some other way the desire for suicide dissipates. Yet, half of the social workers studied agreed with PAS. Thus, there was a lack of congruence between the individual social workers' views and knowledge generally imparted in university courses or training on mental health and suicide.
Limitations of the Study
This study was limited by its small sample size, affecting generalizability, and use of a convenience sample of individuals attending workshops on suicide. Although convenience sampling is an acceptable means of selecting a study population, it does introduce bias into the research. The bias may stem from the fact that the individuals who chose to attend these workshops indicate a desire to learn about suicide. In addition, the respondents were asked to complete the questionnaire at the beginning of the workshop. Their responses might have been different if they had completed the questionnaire at the end of the workshop.
Another limitation was that only 29 social workers provided information on the circumstances under which they would agree to PAS. A sample of this size contributes limited information, but the results confirm the need for more extensive research in the area of social work and PAS.
CONCLUSION AND IMPLICATIONS FOR SOCIAL WORK
Few empirical studies have been conducted that address social work and PAS; thus, little research knowledge exists on which to develop practice standards (Callahan, 1996). More research is needed. First, a statewide study in South Carolina on social workers' knowledge about PAS laws would likely capture the views of workers in the many different social work practice areas. Obtaining information from social workers who work with a broad spectrum of clients would help in formulating policy since PAS and the legacy of PAS are applicable to all populations, to people with various lifestyles, to people of different racial and ethnic backgrounds, and to people with disabilities. Research on specific populations, such as people with disabilities, has shown that these populations fear that they will be the first ones affected by the slippery-slope of PAS (H.R. 4006, 1998).
Research that uses hypothetical case studies about PAS could demonstrate the reasoning processes that social workers use to make ethical decision and whether these decisions are consistent with social work values of protecting vulnerable populations, considering the intergenerational connection of individuals to families and to society, and affirming the individual's dignity and worth.
Research is also needed to identify the best means for NASW to disseminate its professional policy statements to the profession. In this study the majority of respondents who approved of PAS did so in situations contrary to the NASW policy statement.
Less than half of those who approved of PAS indicated that they had specific course content or training dealing with suicide, and an even smaller percentage indicated that they knew the South Carolina law related to PAS. This leads us to question whether social workers who have little or no training in mental health, suicide, or PAS, and who lack knowledge about state and federal legislation governing practice are sufficiently prepared to work responsibly with clients and families considering PAS. This lack of knowledge may have produced biased thinking, with social workers projecting what they would want in a situation onto their clients, the clients' families, and other professional groups. This issue points to the need for the South Carolina Board of Social Work Examiners to specify areas of expertise required for social workers engaged in end-of-life discussions. These issues are of concern to NASW as a professional group, to individual social workers, to other helping professionals, and to consumers of s ocial work services. This is an opportune time for NASW to address PAS. The profession needs to broaden its view of end-of-life decisions from the narrow biomedical (Ewalt, 1995) and single focus on self-determination to one that incorporates the core value of human relationships and protection of vulnerable populations. The debate should also look at ways to promote humane medical and mental health treatment for clients considering PAS.
ABOUT THE AUTHORS
Ameda A. Manetta, PhD, LCSW, is assistant professor, and Janice G. Wells, PhD, is assistant professor, Social Work Department, Winthrop University, Rock Hill, SC. Please address correspondence about this article to Ameda A. Manetta, 1228 Winthrop Drive, Rock Hill, SC 29732.
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Table 1. Situations in Which Social Workers Approve of Physician-Assisted Suicide (n = 29) Situation n % Terminal illness 12 41.4 Painful illness 11 37.9 Other 6 20.4 NOTE: Other includes brain dead or comatose, terminal or traumatic illness, chronic illness, on life support and wants to die, cognitive deficits, or wants to die. Table 2. Comparison of Education of Training for Respondents Who Agree and Who Disagree with PAS (N = 66) Agree (n = 33) Yes No Education or training n % n % University course Mental health 24 72.5 9 27.3 Suicide 17 51.5 16 48.5 Additional training Menthal health 24 72.7 9 27.3 Suicide 17 51.5 16 48.5 Ethics 30 90.9 3 9.1 Know the SC law 10 40.0 15 60.0 Disagre (n = 33) Yes No Education or training n % n % [[chi].sup.2] University course Mental health 27 81.8 6 18.2 .776 NS Suicide 21 63.6 12 36.4 .992 NS Additional training Menthal health 25 75.8 8 24.2 .079 NS Suicide 19 57.6 14 42.4 .244 NS Ethics 24 72.7 9 27.3 3.667 NS Know the SC law 8 27.6 21 72.4 .931 NS NOTE: [[chi].sup.2] p [greater than].05 not significant. (a)ns and percentages are based on cases for which there were valid data.…
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Publication information: Article title: Ethical Issues in the Social Worker's Role in Physician-Assisted Suicide. Contributors: Manetta, Ameda A. - Author, Wells, Janice G. - Author. Journal title: Health and Social Work. Volume: 26. Issue: 3 Publication date: August 2001. Page number: 160. © 1999 National Association of Social Workers. COPYRIGHT 2001 Gale Group.