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Case introduction

Mrs. Chan
is a case of the agency’s End of Life Community Support and Care Project. She
is 69 years old and has been suffering from Parkinson’s Disease for 10 years
and was having sever uncontrolled, involuntary movement like rigorous arms and
legs swing and every time when this happen, she is in very bad temper and keeps
on blaming, picking on and scolding her husband. Mrs. Chan used to be a wife
with strong and controlling personality. Since the onset of the disease, she has
been taken care of by her husband. Mr. Chan, aged 75, is suffering from Diabetes
Mellitus and hypertension himself currently needs to take care of Mrs. Chan
around the clock. The couple lives alone in a public housing estate unit. They
have a son who has his own family and seldom comes home for visit because he
has to make his ends meet. The couple was referred by the clinic to the social
worker. Both of then are the major clients of the worker who plans to see if
they need any support during this late stage of disease. Today, when the social
worker visited the family, Mrs. Chan, when alone with the worker, expressed
that her husband had once tried to press the pillow on her face for a few
second then withdrew. She was not sure if he intended to suffocate her or just
did it in accident. She was afraid that her husband will again lose control and
do it again on her. She, although seemed to be scared, objected reporting this
to the police and she expressed that Mr. Chan was a good husband and he was
just too pressed for taking care of her all along the years. She requested the
worker not to talk to her husband on the issue and keep this confidential. The
worker called their son, Ah Fai and he expressed that he was not able to
neither take care nor support his parents but believed that his father has been
doing all good and all he could to take care of his mother. He was quite remote
from what was happening to his parents. Mr. Chan expressed no special issue he
concerned in the period but he remained most of the time silence during the
home visit.

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Ethical Issues:

Worker’s intuitive
moral (Kitchener, 1984) sense didn’t provide a decision lead to the protection
of both the wife and husband. Worker came up with the following considerations:

a.     
Keep
this confidential as requested by Mrs. Chan. This would keep the work relationship
with the couple. But this may take the risk if Mr. Chan really did it and would
do it again and it might lead to the worst scenario, homicide.

b.     
Persuade
Ms. Chan, to have her consent to disclose this to Mr. Chan, explore if this was
true, his intension because this might due to the unbearable stress level caused
by taking caring of his wife. If he did it in purpose, need to consider if this
needed to be reported to the police. But this would totally break the trust and
work relations with both the wife and the husband. And worker seems not supporting
the caregiver, instead, she might take him to jail and at the same time, the
caregiver stress would be overlooked.

 

In option
a, worker could keep the request of Mr. Chan, confidentiality issue is not
violated. By being faithful to Mrs. Chan, keeping secret for her can uphold the
principle of Fidelity. The relationship with both the wife and husband will not
be damaged. This might help in future support to their needs since one of the
service objectives is to provide support to the caregivers.

If worker
choose option b, it might break the relationship with Mrs. Chan since worker didn’t
have her consent to talk to Mr. Chan on the issue. The relationship between the
couple might be spoiled because this may expose Mr. Chan’s intention of his
very special action. He might no longer be regarded as a good husband, a good
caregiver nor a good father. This would harm the worker client relationship
which would not be beneficial to any subsequent care plan.

 

According
to the following principles or values of
ethical decisions, worker finally made decision:

Autonomy:

Since Mrs.
Chan always blamed and scolded her husband when she couldn’t control her motor
skills, she was infringing the right of her husband. And if her husband really
put the pillow on her face, he was, in return encroach upon the right of his
wife. Was Mrs. Chan allowing the freedom of being taken care by her husband in
such a way? Was Mr. Chan willing to take care of his wife? were there other
choices for them since long term home care was such a burden and torture to the
aged couple. To make this clear and to provide options should be an imperative
role or intervention to worker. Furthermore, Mrs. Chan should be informed of
choices she can have if disclosing or not disclosing her husband’s action by
worker. She should be well supported by worker and informed by ways to protect
herself and her husband since she totally agreed that Mr. Chan is so tortured
by taking care of her as an end stage patient.

 

Nonmaleficence:

If Mr.
Chan did the action intentionally, he might have some thought in his mind. Either
he had already been super overstressed and he might do it again in some time
when he loses his emotion control. Probably homicide her beloved wife was not
his wish. Worker should help in his emotion release and coach him to protect
himself from being convicted and protect his wife once his stress level blast
off. This would eliminate the harm to both of them. Do no harm was the most key
concern of worker.

 

Justice:

Since
worker was not sure if Mr. Chan did the action intentionally. It was important
to give him a chance to voice out his stress and thought, especially at that very
special action moment. He needed to have the chance to listen or understand his
wife’s thought and at the same time, Mrs. Chan needed to voice out her fear and
concerns to her husband. Worker needed to create a fair base for them to
communicate on the issue. The couple needed to be treated equally.

 

Veracity:

Since
worker was not sure if Mrs. Chan told the truth. Or she was having
hallucinations and delusions in her late stage of Parkinsonism. Talking to Mr.
Chan could help to verify that to that or verify his intention and let him
learn that his stress was understood and should be looked into.

 

Beneficence:

  Option
b intended to do good to both stake holders if Mr. Chan’s stress and intention
would be looked into and eliminated with the subsequent intervention of the
worker. With the disclosure of the issue, it helped to prevent Mr. Chan from exposure
to homicidal risk. Furthermore, it might help to prevent Mr. Chan from the risk
of committing crime.

 

Fidelity:

Since the
underlying issue was the care burden, efforts in taking care of a late stage
wife should be honored and commitment in resolving or eliminating the caring
stress should be promoted among the family. Ah Fai should also be invited to
join interviews and his effort for support can sure mitigate the tense
relationship between the couple.

 

Referring
to the Universalizability Theory (Kitchener,
1984, p.53), worker answered the 3 important questions as follows:

1.     
If
I were in a similar situation, I would want my therapist to reveal my husband’s
action such that he learned to protect himself, even though I might have been
killed.

2.     
If
my family were in a similar situation, I would want the therapist to verify the
husband’s intension and let him know the best way to protect his wife and
himself when his stress resilience level is due.

3.     
 If other people were in a similar situation, I
want the therapist to disclose the situation, too. This would prevent tragedy
like “homicide the beloved, with one killed and one put in jail consequently”.

 

Each of
the options up held different ethical values. By and large, I would apply the Balancing Principle (Kitchener, 1986)
to conclude the planned action. By having Mrs. Chan’s “accountability with
discretion” (Zymond & Boorthem, 1989), Worker and Mrs. Chan need to plan
for the timing and the circumstance to talk to Mr. Chan. The stress, fear and
concern for each other would be looked into. This would help to produce the
least possible harm to the family.

 

As worker
would continuous to work with the family, monitor the decision and its outcomes
were necessary. If necessary, reevaluate the decision. Further work on mutual
understanding between the couple, stress release of each of them, encourage
support and monitoring from Ah Fai, or even, an alternative care plan for Mrs.
Chan was needed. No matter the case would finally be reported to the Police or
not, worker would carefully document all the decisions made, all consultations
workers made, the responses of all family members related to all the actions
taken. This is to protect all the stake holders and the worker (Hecker, 2010)
from any disputes aroused and keep track for all the analysis needed.

 

 

References

Kitchener,
K.S. (1984). Intuition , critical evaluation and ethical principles: The
foundation for ethical decisions in counseling psychology. Counseling
Psychology, 12, 43-55.

Kitchener,
K.S. (1986). Teaching applied ethics in counselor education: An integration of
philosophical processes and philosophical analysis. Journal of Counseling
Development, 64, 306-310.

Hecker,
L. (2010).  Ethics and professional
issues in couple and family therapy. New York: Routledge.

The
American Association For Marriage and Family Therapy (2015). Code of ethics.
USA: AAMFT. Retrieved from

http://www.aamft.org/imis15/AAMFT/Content/Legal_Ethics/Code_of_Ethics.aspx
on 27.01.2018

Zygmond,
M.J. & Boorhem, H.  (1989). Ethical
decision making in family therapy. Family Process, 28, 269-280

 

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