Today social workers face the challenges of the most complex ethical dilemmas in the history of the profession. Contemporary changes in postmodern society have brought forth ethical dilemmas in all areas of practice. However, social workers have the opportunity to shape these transformations through their work. This article discusses a framework for thinking about and taking action about the ethical dilemmas in social work practice through moral citizenship.
Radical transformations in health care and social welfare institutions are occurring through developing technology. Technology can offer opportunities for treatment, choice, and the potential for longer life, but also can bring profound ethical dilemmas about access to and refusal of services and informed consent. For example, groundbreaking research in genetics offers new ways to identify people at risk of developing fatal and debilitating diseases. Yet more is known about prediction than prevention or treatment. Access to technology and control of the results, stigma, discrimination, and psychological burden create ethical ambiguity in counseling people who may be affected by the technology (Thompson, 1994).
Increased knowledge and access to information in postmodern society bring the risk of reduced privacy and choice. Electronic databases receive detailed health care information about consumers from health care providers. These databases, which serve the health insurance industry, have the potential to restrict consumers' access to future insurance coverage and bypass the consent process (Fraser, 1994; Reamer, 1993). Social workers are challenged to provide adequate informed consent to clients about the risks and benefits of release of information.
Client as Consumer
Health care has become a product, marketed to the highest bidder, in a marketplace of strangers. The recipient of health care services is now considered a "consumer" rather than a "client" or "patient." Health care as a "service" has changed to health care as a "product" based on a premise of profit (Arboleda-Florez, 1987). The fundamental relationship between care provider and receiver is being redefined, creating ethical issues related to quality, advocacy, and trust.
The move to managed care has resulted in a system of rationing care, with cost-effectiveness the major mechanism for determining eligibility for services. Social workers are expected to act as gatekeepers, deciding who will have access to or be denied services according to the values and philosophy of a profit-making entity (American Medical Association, Council on Ethical and Judicial Affairs, 1995).
The gap between the rich and the poor is widening. The United States has become the most economically stratified of all the industrialized nations (Wolff, 1995). The richest I percent of the population now own nearly 40 percent of the nation's wealth. The minimum wage lags far behind the nation's average hourly wage (U.S. Department of Labor, 1996). Thus, increasing numbers of people live in poverty, without basic needs being met and within a context of decreasing resources for human services.
The knowledge available about integrating ethical action into practice is mixed. Research about ethical models and theoretical approaches is relatively recent (Cossom, 1992; Holland & Kilpatrick, 1991; Manning, 1990). There is an expanding literature from social work ethicists that explores the philosophical foundations of social work ethics and provides analysis of particular ethical dilemmas in practice (Abramson, 1983; Allen, 1993; Imre, 1982; Joseph, 1983; Levy, 1976, 1982; Loewenberg & Dolgoff, 1982; Reamer, 1982; Rhodes, 1986; Siporin, 1982). Missing is a clear, practical framework for the daily work of social workers in all practice areas.
Moral citizenship is the responsibility to determine right and good behavior as part of the rights and privileges social workers have as members of a community that includes clients, colleagues, agencies, and society. …