Ethics in Clinical Practice with Older Adults: Recognizing Biases and Respecting Boundaries
Golden, Robyn L., Sonneborn, Sallie, Generations
Although much has been written in recent years about the ethics of working with the elderly, little attention has been given to the development of the clinician's knowledge of his or her own values and how these might affect work with the client. Ethics in social work, case management, nursing, and other helping professions has largely been focused on decision making rather than on the decision maker (Abramson, 1996). This article will explore the process by which practitioners must evaluate their own perceptions and actions in relation to their elderly clients within an ethical framework.
An ethical dilemma arises when the practitioner has to choose between two or more conflicting values. The dilemma is further complicated when practitioners are unaware of how their own personal values and biases may influence their decision-making processes. Although a substantial body of literature addresses ethical issues in working with the elderly, most of it focuses on the ethics of a clients particular situation. This article focuses on how the clinician's personal biases may affect and motivate decisions, and how, as a result, the acceptable boundaries between the interests of the client and the interests of the clinician, as set forth in the professionals' respective codes of ethics and standards of practice, may become blurred.
Recognizing bias and respecting boundaries are closely intertwined. In this article, boundaries refers to the line between therapeutic and nontherapeutic behavior. A boundary violation occurs when the practitioner's actions are not checked by the rules of professional conduct. In their research, Levkoff and Wetle (1993) showed that healthcare providers who assess the needs of the elderly often make decisions based on their own preferences, attitudes, and beliefs and other factors of which they may be unaware. Practitioners who are well versed in identifying and working through ethical dilemmas and who comfortably and consistently explore their own personal prejudices and biases will practice more effectively.
It is important to note up front that all human beings have biases and that biases should not be looked at as "bad" or "wrong" It is important that practitioners become aware of their own biases and understand their origins so they can make conscious decisions regarding their actions. Issues of biases and boundaries are often complicated when the client is an older adult, because aging is particularly likely to create personal issues for the practitioner-aging is something everyone must face.
A professional's personal biases can result in countertransference, which refers to the conscious or unconscious phenomenon that occurs when the clinician reacts to a client based on the clinician's own past experiences, preferences, preconceptions, fantasies, and fears. Very simply put, countertransference is the powerful linkage between the helper's personal feelings and his or her interventions and behaviors (Genevay and Katz, I99o). While Freud defined countertransference as "an unconscious process involving the arousal of the analysts unresolved conflicts and problems that had to be eliminated in order to function effectively,' the countertransference process is now regarded as an appropriate, natural conscious or unconscious emotional response. If it is understood, countertransference can be an important therapeutic tool, serving as a basis for empathy and deeper understanding. Left unchecked, however, countertransference may result in a tendency for the clinician to "overhelp" or "underhelp" based on his or her own feelings, rather than on the clients situation and needs.
Webster's Dictionary defines ethics as "a set of moral principles and values; the discipline dealing with what is good and bad and with moral duty and obligation" Since all aspects of the helping professions have ethical implications, it is important for all clinicians to develop a personal code of ethics. …