SoCial Work CaSE StuDiES –, Exams of Social Work

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Ethical

Dimensions in

the Singapore

Context

Written by BK Seng

SoCial Work

CaSE StuDiES –

Inner Cover Pg

Acknowledgements

CFAR of SIM University for the research grant. Viven Quek my research assistant for researching and collating the numerous case records. Practicum students for the cases they have written up as part of their requirements. MSF for publishing the book.

Foreword

Social work faces controversial circumstances that pose the question “is there a right way of doing things.” Some call it ethical dilemma or options, and in essence they deal with value questions that someone in training or young in the profession will be confronted with. This compilation of case studies is of direct relevance in Singapore although the issues and themes about human responses, moral philosophy and ethical codes of practice makes it relevant to many contexts in which social work is practised.

The cases are best read and discussed with a prior understanding of basic social work ethics, values and practice. The depth of discussion and challenges to practice can then be lively and thought provoking with a foundation in what is distinctive about social work.

Case studies help to raise ethical awareness as we draw on professional training in linking theory and practice which is an essential aspect of the quality of the services offered to clients.

Anyone who is engaged in educating students or training social service staff regarding ethics and value will find this a useful resource. Opening up discussions and safe space to explore personal values and assumptions in developing the professional self will go some way in raising social work practice.

Ang Bee Lian

Director of Social Welfare, Ministry of Social and Family Development

Foreword

Two Children Families

_- Case Study 5a: The Tan Family

• Case Study 5b: Kumar and Nanki Devi
• Case Study 5c: Roslia and Ali
• Discussion_

The Unprofessional Colleague

- Case Study 6: Mr. Cho

Problem of Addiction in Children

_- Case Study 7a: Aziz

• Case Study 7b: Michael
• Discussion_

Abused Wives

_- Case Study 8a: Mdm Tang and Mr. Chan

• Case Study 8b: Nisha and Fadil_

The Plight of a Foreign Spouse

- Case Study 9: Dewi

Obligation to Client Advocacy and Obligation to Employing Organization

When Your Client Cannot Decide

- Case Study 10: Faridah

To Tell or Not

To Tell

Case Study 1: Kelvin - The Untold Truth

At 30 years old, Kelvin is at the prime of his life, holding a good position as a financial advisor in a foreign bank. He is also preparing to marry his fiancée of 10 years after much prudent planning for his marriage and waiting for their HDB Built-To-Order flat to be ready by the end of 2011.

Little does he expect to suffer a relapse of colon cancer and be admitted to the hospital so soon. His illness was first diagnosed 6 years ago and in 2009, he went through a major surgery; a surgery that gave him only a 50% chance of recovery. Being a Christian and actively involved in his church since 1996, Kelvin then had a positive outlook on life and the surgery turned out to be a great success, allowing him to recover well. Unfortunately, this relapse in April 2011 unveils cancer cells that have spread to his bladder, and the prognosis is poor, averaging between 3–6 months to live according to his doctor.

Kelvin is the youngest in a family of four siblings. He is staying with his second sister and her family, while his parents and two other married siblings live in the same block but on different levels. The family is a close-knit household, with the children coming home regularly for meals. His mother, Mrs. Tan, is devastated by her son’s current relapse and is distressed by his condition. She expresses her grief at having her youngest son, who is obedient and filial, doing well in his career, and about to get married in May 2011, suffer “this terrible curse”.

The oncologist-in-charge, Dr Malcolm, is reluctant to release the news of the prognosis to Kelvin and his family. The main reason for Dr Malcolm’s unwillingness to do so stems from Kelvin’s overly positive attitude that he will recover from his illness. Believing that miracles and healing can happen again, the bridegroom has begun his wedding preparations, trying on his wedding suit and pestering the hospital to discharge him soon. His fiancée, another devout Christian, also believes that Kelvin will heal with “God’s help and grace”. Colleagues and church friends are, nevertheless, also supportive and visit him often in the hospital. The couple has plans for their future, based on

To Tell or Not To Tell

the premise that Kelvin will recover; there is never a doubt in their minds about Kelvin’s recovery.

Jane, their assigned medical social worker, is informed by Dr Malcolm that Kelvin has not been told that he is terminally ill; neither has his family. In a hospital-based setting, it is usually the doctor who releases the diagnosis to the patient and his/her family but Dr Malcolm has taken an unusual stance of choosing not to reveal the severity of the relapse to Kelvin—and this puts Jane in a dilemma.

In Jane’s area of work, she is expected to provide psychosocial support and counseling to patients and their families. This includes managing expectations of the illness of both the patient and the family, looking at possible financial issues when it comes to medical expenses, loss of employment and income issues, advanced care planning and discussing with those concerned about their perceptions toward end-of-life care. As for Kelvin, Jane is assured that he is financially prepared for his hospitalization and treatment expenses, given his training as a financial advisor; and he has been frugal all this while as he has been saving for his marriage and new flat. However, Jane is skeptical that Kelvin is emotionally prepared for a terminal illness after having a brush with death in 2009. His mother is already an emotional wreck, displaying difficulties accepting Kelvin’s current relapse and fearing that she will not be able to cope with his illness upon discharge. She needs a great deal of emotional support from the social worker. Meanwhile, Kelvin’s fiancée has been kept busy with their marriage preparations, genuinely believing that a miracle will happen: that Kelvin will recover.

Questions

What would you do if you were Jane? Would this be an ethical dilemma for you as it is for Jane? Would you persuade Dr Malcolm to reveal the prognosis to Kelvin or perhaps to his family? Or would you override Dr Malcolm’s decision of not wanting to reveal the prognosis and reveal it to Mrs. Tan, Kelvin or his fiancée? What if Mrs. Tan stops you in the ward dormitory during one of your

To Tell or Not To Tell

would undeniably proceed with his marriage preparations after knowing his prognosis. Basically, it would be difficult for the hospital staff to anticipate exactly how he would react to the news of his diagnosis despite his past reactions and coping skills.

Although social workers have been slated to play a supportive role within the multidisciplinary team, we should not forget that our professional values and skills are a perfect match for providing core services in hospice and palliative care. We are in an excellent position to advise our colleagues in other disciplines on providing culturally appropriate care for those in need, and assisting them in using a holistic perspective aimed at enhancing the quality of life of those afflicted by a terminal illness amidst these challenging times. Even when a cure is not viable, social work practitioners in palliative care settings are specifically trained to assist the family to enable them to cope and manage the illness better. The philosophy of care practiced in most palliative care is to enhance the quality of life no matter how short or long the prognosis. Recent literature has pointed us to a rehabilitative approach in palliative care (Bray and Cooper, 2004; Doyle et al, 2004; Tookman et al, 2004). This may appear to be a contradiction initially but upon reflection, the concept of rehabilitation does fit in with the principles of palliative care with its emphasis on quality of life. The palliative rehabilitation approach differs in concept from traditional mainstream rehabilitation, which may require readjustment and a shift in perception for some team members. Sensitivity to the patient’s choices and wishes remain paramount and should dictate realistic goals and collaborative teamwork. This approach accommodates the changing and fluctuating needs arising from diagnosis to terminal care of palliative care patients.

In any form of service delivery, effective service depends on cooperation among professional disciplines such as doctors, nurses and physiotherapists with due regard to one another’s respective areas of competence. Hence, although Dr Malcolm’s decision not to reveal Kelvin’s diagnosis has resulted in an ethical dilemma for Jane in her area of work, it should not hinder Jane from working with Kelvin or his family. It is unlikely for Mrs. Tan not to pursue Dr Malcolm for some answers regarding treatment options or for her not to

To Tell or Not To Tell

seek his opinion on Kelvin’s condition and how she should go about caring for him. The onus is on Jane to be honest in her dealings with the Tan family, an obligation that a social work professional owes to her clients.

By being honest, however, does not mean one has to be brutally so. In life and in death, it is not possible to make accurate predictions, even in medical diagnoses, and sometimes, patients do live longer than their prognosis, even if one does not believe in miracles. It is always good in the worst of circumstance to leave a little ray of light rather than to dash all hopes.

Discussion

1. In situations where the professionals working on a case disagree on a course of action, what are the solutions?
2. Who should determine the final decision?
3. Is a compromise possible?

References:

Tookman, A. J., Hopkins, K., & Scharpen-von-Huessen, K. (2004). Rehabilitation in palliative medicine. In D. Doyle, G. Hanks, N. Cherny, & K. Calman (Eds.) Oxford textbook of palliative medicine (3rd ed.). Oxford: Oxford University Press. Quek, K. C. (2012, December 11). Tell dying patients the truth. The Straits Times.

To Tell or Not To Tell

Discharge Problem

Ageing is a normal progression of life, mostly an irreversible process contrary to what advertising and marketing in skin care and nutritional supplement companies would try to convince their potential customers otherwise. The problems associated with ageing are not just limited to our tiny island of more than 6 million inhabitants; it is universal, especially among developed countries.

According to the Singapore Population Census 2011 survey, “the number of residents aged 65 years or older will multiply threefold from the current 300,000 to 900,000 in 2030” (Department of Statistics Singapore, 2012). In other words, 1 out of 5 residents will be a senior. In addition, the National Health Survey 2004 showed that a whopping 85% of Singapore Residents aged between 65 and 74 years suffered from one or more of the following conditions: diabetes mellitus, hypertension and high total blood cholesterol. While the prevailing chronic medical conditions existing in the elderly population in Singapore represent a glaring marker, mental health issues are also a concern for the government as the elderly is more prone to mental health issues such as depression and dementia. Current resources for the elderly in Singapore have been stretched to a maximum, and hospital occupancies have reached a record high, so much so that even private nursing homes have been roped in to provide additional beds to house the sick and mostly elderly patients who face issues surrounding their discharge in hospitals.

Medical social workers in hospital-based settings frequently face the dilemma of being pressured to free up limited beds and medical resources while discharging patients when the patients are not ready and also unwilling to return home, but the reality is that there is simply a shortage of beds within the hospitals in Singapore. Essentially, the conflict faced by the worker is, on one hand, the ethical responsibility to protect the interest of the client, and on the other, the worker’s responsibility to conform to the organization’s policies, rules and recommendations. This is an example of conflicts in the duty of fidelity: “divided loyalties” or loyalties owed to multiple parties, as described by Proctor, Morrow-Howell, and Lott (1993) according to Reamer (1990, p. 87) and Beauchamp and Childress (1994).

Discharge Problem

Let us look at the illustrated case study below.

Case Study 2: Mdm Chua

Mdm Chua Ah Lian, aged 76 years, is admitted to the Institute of Mental Health on November 11, 2010, after acting strangely for several weeks. She exhibited symptoms of paranoia against the family maid and hit the maid occasionally when instructions were not followed according to her wishes. Whenever Mdm Lim, her sister-in-law, tried to intervene, Mdm Chua threatened to hit Mdm Lim’s elderly and sick husband instead. Mdm Lim was upset over this incident and after discussing with her family and seeking advice from SAFE@TRANS Centre (a center specializing in elderly abuse), she decided to admit Mdm Chua into the Institute of Mental Health for a psychiatric assessment and treatment.

During her stay at the hospital, Mdm Chua’s mental state and executive functioning skills are assessed by the doctors. Apart from her poorly controlled diabetic condition and some minor cognitive deficits due to a stroke many years ago, the doctors find that her memory skills and daily functioning level are adequate for her to live within a community setting. The only problems foreseen by the team are her personality traits: quick temperedness, becoming agitated easily and her domineering nature. She is also secretive and not forthcoming with information about her past.

Meanwhile, Mdm Lim makes it known to the social worker, Sanni, that she will not be accommodating her sister-in-law in the house because she is fearful for her family’s safety; the family too is unsupportive of the idea of continuing to care for Mdm Chua.

The patient subsequently becomes fixated on getting a HDB rental flat so that she would have a roof over her head instead of depending on others for accommodation. However, the occupational therapist and physiotherapist have both assessed her functional state and have recommended that it will not be safe for her to live alone. Her gait is unsteady and weak; her diabetes is poorly controlled. Coupled with the fact she has a history of defaulting

Discharge Problem

After several years into their marriage, her husband took in a second wife but Ah Lian declined to reveal much about this, except that he passed away almost twenty years ago and she remained a widow for many years after that. At the time of her husband’s death, her children had started to become financially independent and had moved out of the house to live on their own. After her husband’s death, Ah Lian moved to live with her children, rotating her stay among her three sons, but gradually she moved to stay with her daughters after several complaints from her sons. Apparently, she would become very domineering and controlling after staying for a period of time with each of her sons. Her daughters-in-law were unhappy and resented her presence. Eventually, her rotational stays with her sons came to a halt.

About a year ago, in November 2009, her eldest daughter decided to cut off all ties with Mdm Chua by changing her telephone number and later moving to a new abode. The other three sons followed suit and stopped Mdm Chua from visiting them too. Her youngest daughter, Jenny, a sales executive working at the local cable TV station, took her for six months but decided to chase her mother out of her house following a quarrel.

As Mdm Chua had no place to go, her late husband’s sister, Mdm Lim, took pity on her and allowed her to stay with them in the family property, the bungalow house in which Mdm Chua had spent many years of her life. Unfortunately, it took only four months before Mdm Chua turned bossy and demanding again, wanting to be in control of household matters. Family relations finally reached a boiling point with the current incident when she became paranoid about the family maid, exhibiting violent behaviors toward the maid and threatening to physically hurt Mdm Lim’s 71-year-old husband. In light of Mdm Chua’s personal history and background, Sanni now has a better understanding of the family dynamics resulting in the family’s rejection of Mdm Chua. Sanni also finds out that Jenny is still contributing $400 in cash through interbank GIRO to her mother’s account. Unfortunately, Jenny is unwilling to come forward for a discussion regarding her mother’s care plans and demands her other siblings to take more responsibility for their mother. Sanni meets with similar resistance from the other children whom she is able to locate and contact, with the exception of her eldest daughter.

Discharge Problem

With the help of proper medication and a period of stay in a stable environment, Mdm Chua’s mental and emotional health begins to improve. In a lengthy session with Sanni, Mdm Chua agrees that she is not able to live independently at the moment and has no objections to Sanni applying for a sheltered home on her behalf. However, she expresses her difficulty in financing her stay at the sheltered home with her limited savings, and voices her desire for her children to support her stay financially at the sheltered home with the help of the Tribunal Court under the Parents’ Maintenance Act. As there is now a firm discharge plan in place, Sanni is able to extend Mdm Chua’s stay at the hospital for a little longer with the support of the psychiatric team.

Two months later, sometime in February 2011, after filing a report at the Tribunal Court, four of her children agreed to contribute financially toward Mdm Chua’s stay at a sheltered home. Meanwhile, Mdm Chua remains at the hospital, pending a vacancy at the sheltered home.

As social workers, we often speak of allowing our clients to practice self- determination. Self-determination is one of the important tenets of social work principles but in reality, this may be just our delusion. Hartman proposed that for genuine self-determination to exist, it would require clients to have “access to resources, access to opportunity, and access to power,” but this is something which many clients lack (Hartman, 1997, p. 216). Our clients approach us primarily because they lack resources to deal with their problems and thus need our assistance.

What does self-determination really mean? According to the British Association of Social Workers, “Social Workers should respect, promote and support people’s dignity and right to make their own choices and decisions provided that this does not threaten the rights, safety and legitimate interests of others” (BASW, 2012). On a similar note, the National Association of Social Workers (NASW) in the USA states the following: “Social Workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self determination” (NASW, 2008). Looking at both statements, one can see that self-determination is hedged with caveats: it should be

Discharge Problem