Social Work Ethics: An Exploration of Values, Ethical Dilemmas, and Critical Practice, Lecture notes of Social Work

Download Social Work Ethics: An Exploration of Values, Ethical Dilemmas, and Critical Practice and more Lecture notes Social Work in PDF only on Docsity! THE MEANING OF ETHICS AND ETHICAL DILEMMAS IN SOCIAL WORK PRACTICE: A QUALITATIVE STUDY OF GREEK SOCIAL WORKERS A thesis submitted for the degree of Master of Philosophy By Dimitra Giannou School of Health Sciences and Social Care Brunel University July 2009 2 Abstract Social work struggles between the dichotomy of “individual” and “society” as it is characterized as enhancing both individual well-being and social justice. As these are not always easily balanced and social work has limited autonomy, social workers must develop their capacity for making moral judgments and defend these within their various roles and responsibilities. Studies which explore the role of ethics in social work practice enhance the potential for maintaining a common identity. This exploration permits a deeper understanding of social work ethics and reinforces a common framework inclusive of purpose and standards for the profession. These studies also capture the contextual factors impacting on the moral agency of social workers, and thus substantiate the role for social work in a world with structured oppression. The purpose of this study was to obtain an in-depth understanding of social work ethics in the practice context of public hospitals in Greece. Using a case study design, data was gathered to explore and understand the role of social work ethics in daily practice and the formation of what is perceived as “good” practice. The analysis followed Yin‟s (1993) descriptive strategy. Data collection included fifteen in-depth interviews with hospital social workers, a group interview with social work academics, and a thematic analysis of the social work journal of the Hellenic Association of Social Workers (HASW). The meaning of ethical dilemmas and problems appeared to be constructed by personally held values, a lack of attention in social work education and the HASW on social work ethics, a professional emphasis on individualism rather than collectivism, and insufficient social protection in Greece. Importantly, these factors led to a fairly consistent response to ethical problems. “Having a clear conscience”, character traits such as bravery and imaginativeness, as well as the use of psychotherapy emerged as characteristics of “good” social work practice. These findings are of value to those who try to restore the values and ethics as central in social work. Values and ethics as key elements of social work expertise can lead social workers to a more competent and effective practice in terms of their ethical engagements. 5 2.3.4 The National Health System in Greece 63 2.3.4.1 Social work in Greek public hospitals. 67 2.3.5 Summary 68 Conclusion 69 Chapter 3 Theoretical foundations: social work ethics and critical social work practice Introduction 72 3.1 Politics and ethics 73 3.1.1 Social policy and social work 76 3.1.2 Politics and social work ethics 79 3.2 Critical practice and social work 81 3.2.1 Critical practice and its values 82 Conclusion 85 Chapter 4 Study Design Introduction 87 4.1 Qualitative research methods and the case study approach 88 4.1.1 Data collection methods and a case study approach 93 4.2 Ethical considerations 94 4.3 The sample 95 4.3.1 Research sites 96 4.3.1.1 Athens 96 4.3.1.2 Patra 97 4.3.2 The participants 97 4.4 Data Collection 103 4.4.1 Securing the sample 103 4.4.2 Pilot work 105 4.4.3 The interviews and reflections on them 105 4.5 Data analysis and management 107 4.5.1 Empirical description and thematic analysis 108 4.5.2 Analyzing interview data 110 6 4.5.3 Analyzing the social work journal Conclusion 111 112 Chapter 5 Social Work Practice in Greek Public Hospitals: The meaning of ethics and ethical dilemmas Introduction 114 5.1 Values and the social work identity 115 5.1.1 Caring and protecting 116 5.1.2 Respect 119 5.1.3 Self determination 124 5.1.4 Summary 125 5.2 The social work role in Greek public hospitals 126 5.2.1. Psychotherapeutic practice 127 5.2.2 Psychosocial support and discharge planning 129 5.2.3 Advocacy 132 5.2.4 Social control 135 5.2.5 Financial assistance 138 5.2.6 Summary 139 5.3 The meaning of ethical principles in practice 139 5.4 Understanding ethical problems and their impact on practice 146 5.4.1 The absence of welfare support 147 5.4.2 Structured social exclusion 152 5.4.3 Bureaucracy and public hospitals 154 5.4.4 The under-funding of public health 156 5.4.5 Health professionals and unethical practice 158 5.4.6 Social workers and the violation of law and organizational rules 164 5.4.7 Summary 167 5.5 Understanding ethical dilemmas 167 5.5.1 Truth telling 5.5.2 Autonomy versus safety 167 172 5.5.3 Patient best interests versus hospital rules 175 5.5.4 Protecting oneself 178 7 5.5.5 Obstacles in the resolution of ethically difficult situations 179 5.5.6 Summary 182 5.6 Evaluating hospital social work practice 183 5.6.1 Characteristics of the “good” social worker 186 5.6.2 Personal values as the moral base for “good” social work 186 5.6.3 Psychotherapy and the “good” social worker 188 5.6.4 Summary 190 Conclusion Chapter 6 Ethics and Ethical Dilemmas and the Broader Social Work Context: Social work education and the Hellenic Association of Social Workers 191 Introduction 194 6.1 Ethics and ethical dilemmas in social work education 195 6.1.1 Social theory versus social work practice 196 6.1.2 Social work students and practice learning 197 6.1.3 Whistle blowing 202 6.1.4 Accountability and social work academics 205 6.1.5 Summary 206 6.2 Hellenic Association of Social Workers and the promotion of social work ethics 207 6.2.1 Roles and responsibilities for ethical social work 209 6.2.2 New knowledge and knowledge transfer for ethical social work practice 210 6.2.3 Summary 213 Conclusion Chapter 7 Discussion and Conclusion 214 Introduction 217 7.1 The meaning of ethics and ethical dilemmas in hospital social work practice in Greece 218 7.1.1 Social work in Greek public hospitals 219 7.1.2 The meaning of ethics in hospital social work practice 220 7.1.3 Ethical dilemmas and ethical decision-making 225 10 Chapter 1 Introduction 1.0 An introduction to social work ethics Historically, social work is identified with the “helping” or “caring” professions as it is dedicated to help people meet their needs and advance their potential in a continuously changing society. Social work indeed began as a philanthropic helping activity, but it was developed as a special scientific field. Therefore, the identity of social work needed to be more specific and formed with specific characteristics which would enable a unique description of its practice among the other “helping” professions and the social sciences. By defining or characterizing it as both a science and a profession, we acknowledge elements in social work such as the existence of specific theories, ideologies, methods, techniques, and values and ethics. Furthermore, we recognise social work as having a social function which is provided by the state vis à vis the department of social welfare. We also acknowledge that this role is in a constant state of development, like everything else in society, by what we briefly call social dynamics. Current ethical codes define social work as a profession which has its main purpose defined in relation to social change. Specifically, the International Federation of Social Workers (2005) and the U.S. National Association of Social Workers (1999) see social work as a profession that not only helps individuals to meet their needs, but also promotes social justice and social change. Importantly, the notion of social change can only describe an explicit change to the structure of a given society, a transformation of important aspects of human societies, changes in beliefs, values, culture, attitude, social relationships, civilization, stratification and anything else that affects human lives (Goode, 1988). What remains for social workers then, is to depict the changes that need to be done in order to ensure the personal and social well-being of all individuals. Therefore, social workers should be engaged not only for the purpose of social change, but for a common vision of what can replace an old status. Social workers should, therefore, define specific aims for social change in order to ensure their professional accountability and scientific identity. Social work by its engagement with specific values and ethics determines the kind of social change that the profession wants to bring. Thus, by the use and interpretation of the profession‟s 11 values, the purpose of the profession is not abstract and could be identified in exploring practice. Through our common values and ethics we gain a common vision and a common identity that no one can take from us or criticize us for being unspecific. Through the profession‟s common values and ethics a vision for change and its identity emerges. Thus criticisms aimed at suggesting social work lacks specificity or remains undefined are unfounded. Although social work is not the only profession that is dedicated to the promotion of important values, its relationship with social policy, its holistic approach to human needs and its engagement with mutually opposed values create complicated ethical dilemmas. There is an apparent agreement in the literature that social work tries to practise among conflicting interests, and therefore complicated ethical dilemmas are common in every day social work practice (IFSW, 2005; Rossiter, 2001; Briskman, 2001; Clark, 2000). For example, by approaching an individual‟s needs holistically, social workers have to deal with various needs and rights that should be addressed simultaneously. However, this is practically impossible. In light of these conflicts, social workers can only proceed by making value judgements (Clark, 2000). As stated above, the concern of social work is not only to help individuals, but also to affect change in society to enable it to adequately correspond in its response to individual needs. Tragically, as Rossiter (2001) argues, this is something that social workers forget or ignore: …I realized how exhausted and beleaguered I am by a lifetime of being positioned as a “professional helper” by a state that organizes the people‟s problems as individual pathologies that are best administered by professionals who are trained not to notice the state (pp.2). If social workers are only familiar with seeing injustice as having only to do with individual relationships, then structural or social policy issues are removed from decision-making, including the value judgements they make. In this instance, they are unable to identify all of the stakeholders that are implicated within a problem(s); the identification of which is a very important part of the ethical decision-making process (Boland-Prom and Anderson, 2005). Consequently, an important condition for what is perceived as a “good” social work practitioner is introduced. In particular, and as Speicher (1998) indicates, ethical awareness is a prerequisite of ethically informed decision-making, and ethical decision-making is a significant aspect of social work practice as social workers continually mediate among conflicting interests or competing values (Clark, 2000). 12 Furthermore, social work‟s ethics and values are not a matter for finding “goodness” or, as Briskman (2001) says, a place of “innocence” in social work practice. Rather, by focusing on ethical social work issues we acknowledge and identify a special characteristic of our professional identity, and we confirm the criteria by which effective or “good” social work practice is judged. In addition, we acknowledge the process of decision–making as a critical element of professional practice, which thereby necessitates that social workers have the knowledge and skills necessary to interpret the ethical underpinnings of practice. However, it is managerialism which eventually defines the criteria by which social workers evaluate their effectiveness (Kirkpatrick, 2006; Meagher and Parton, 2004; Rubin and Babbie, 2001). Social work interventions are more strictly controlled and oriented to achieve specified targets that are cost-effective. In addition, the new meaning of accountability, underpinned by the managerial ethos, requires social workers to take a more instrumental and impersonal approach to their work to be accountable to their clients and to the organization through various detailed administrative procedures (Banks, 2007; Meagher and Parton, 2004; Gibbs, 2001; Clark, 2000). Similarly, there is a newer emphasis on outcomes providing “hard evidence”. Social work researchers are expected to conduct studies without focusing on value commitments, but rather to produce evidence-based knowledge which is often separated from the recognition of social conditions as ongoing obstacles to social well-being (Gibbs, 2001; Banks, 1998). Nevertheless, managerialism also led to the professionalization of social work (Banks, 2008). Accordingly, the professionalization of social work and the advancement of social work education have led to a growing interest in social work ethics (Banks, 2008). Although there is already an extensive theoretical literature on social work ethics, only scant research has been conducted on ethical issues since 1980 (Jansson and Dodd, 1998). Nevertheless, it is argued that in a time that the moral agency of the social work profession is challenged by the prevailing managerial ethos, bureaucracy and the fragmentation of the profession, research on social work ethics can enhance the potential of social workers for maintaining a common identity. Moreover, as social workers are professionally engaged to enhance both individual well-being and social justice, social work research must be committed to enhance the mission of social work and the scientific accountability of the profession. Jansson and Dodd (1998) argue that social work researchers should develop studies so as to reinforce the moral agency of the social work profession and support practitioners to develop their capacity for making moral judgments and defend these within their various roles and responsibilities. Social work studies and mainly those with a 15 following questions were developed to form a study exploring social work ethics in Greek public hospitals: 1. How do Greek social workers conceptualise ethics and their relationship with professional practice (e.g. social work code of ethics)? 2. What is the relationship between values and ethical principles and how do they inform the practice behaviour of Greek social workers? 3. What is the Greek social worker‟s experience of ethical dilemmas and the ethical decision-making process? 4. How do Greek social workers perceive ethics as contributing to good social work and/or the evaluation of practice? The research questions evolved during the process of a theoretical review of social work ethics. Theoretically it is argued that social work education is one of the main formational factors of social work identity and is responsible for training social workers to be ethically aware (Clifford and Burke, 2005; McAuliffe, 2005). Accordingly, the establishment of a code of ethics is normally one of the major responsibilities of the professional associations that are the official bodies responsible for the regulation of a profession (Clark, 2000; Banks, 1998). As the Hellenic Association of Social Workers is currently a member of the International Federation of Social Workers (IFSW) it is perceived that HASW is the official body responsible for the promotion of social work ethics. Therefore, possible scenarios were explored between the ways that ethics were perceived and practiced by the social workers and the ways that these were dealt by the social work education and HASW. According to the above theoretical considerations data from HASW and social work academics were also obtained so as to further our understanding on the above research questions. Findings from this study indicated that the prominent ethical problems of Greek hospital social workers involved the insufficient and ineffective welfare state and the unethical practice of other health and social care professionals. Despite the structural roots of their ethical problems, all hospital social work practice appeared to be focused on micro-level intervention. Collective values were absent from their ethical decision-making while individualistic values such as self- determination and autonomy were dominant within the narratives. A version of the ethic of care also appeared to underpin the ethical decision-making of these hospital social workers. More specifically, their ethic of care resembled one that was embraced in absence of their consideration of the broader political environment. As a result, and consistent with some critics of 16 the ethic of care, this narrow view appeared to reinforce paternalism and parochialism rather than a more cognitive appreciation of rights and justice as necessary aspects of a caring behavior (Meagher and Parton, 2004). Interestingly, all the participants appeared to determine that it was their personal values that provided important guidance for ethical decisions. Any consideration of professional knowledge and training or the professional association‟s code of ethics was not apparent. It is anticipated that the dissemination of this study to Greek social workers is an initial effort to enable social workers to develop their ability to be ethically aware and learn to reflect on the ethical dilemmas of their practice. Moreover, this study encourages the efforts of those who try to establish a common framework inclusive of purpose and standards for the social work profession. In addition, the qualitative orientation of this study highlights the contextual factors that determine the ethical obstacles of social workers who daily try to respond to their clients‟ needs. Therefore, this study empowers social workers as they were able to identify and describe with their own words the realities of their practice. 17 Chapter 2 Literature Review Introduction Ethical dilemmas are considered as an inherent characteristic of the social work identity and reflect the involvement of social workers in multiple obligations often framed by conflicting values (IFSW, 2005; Banks, 2001; Rossiter, 2001; Clark, 2000). In fact, ethical awareness has currently emerged as a primary social work skill enabling social workers to respond effectively to their professional responsibilities and make ethically informed interventions (Banks, 2001; Rossiter, 2001; Clark, 2000). Theoretical and empirical investigations into the meaning of ethics and ethical dilemmas in social work practice respond to theories that perceive social work as a value-laden profession and used to accomplish the balance between societal and personal well-being. In addition, as social work is defined in relation to social change, it is important for social work research to determine the contextual factors that constrain the ability of the social workers to promote their professional values and ethics. The purpose of this chapter is to present the literature review of this thesis. It is grouped into three main sections. The chapter begins with a review of the philosophical and theoretical approaches to ethics as these are the origins of the substantial concepts used within the ethical code. The focus here is to understand the influences of these approaches in the formation of social work identity and practice. In the second section the social work identity is discussed through the elaboration of its values and ethics. Following is the presentation of fundamental ethical dilemmas as consequences of the inherent ambiguities of social work identity. The emerging skill of ethical awareness as a prerequisite of ethically informed decisions and value-based evaluation are also illustrated through the existing theoretical social work literature. In addition, through a review of the existing empirical studies, the place of social work ethics and ethical dilemmas in daily practice is identified. 20 could be resolved by placing virtues in what we perceive as the social worker‟s identity. Moreover, they believe that doing a task well is not merely a matter of following rules, rather it involves the skills and virtues of a person. Corresponding to this idea, the question of “what is good social work practice” is replaced by the question of “what is a good social worker”. Virtue ethics give a moral meaning to the social work profession because social workers‟ actions are not driven by abstract obligations based on deontological rule books. Contrarily, social workers‟ actions take on a real moral worth as they reflect the importance of the values that the social work profession is supposed to promote. Nevertheless, there is one problematic area based on how social work virtues are established and defined in the first place (Houston, 2003). This idea becomes more complicated when we consider Aristotle‟s doctrine on means, whereby a good life is the means between vice and virtue and that too much virtue could be a bad thing (Benn, 1998). In response to this challenge, McBeath and Webb (2002) propose that virtues must be developed from a conscious analytical process rooted in dialogical exchanges between committed inquirers. They also explicitly suggest several virtues for social workers based on the Aristotle‟s ethical theory: justice, reflection, perception, judgement, courage, prudence, liberality and temperance. Nevertheless, by accepting traits of character uncritically as virtues is opposite to the core theory of virtues and perhaps oversimplifies Aristotle‟s theory about virtues. Even if Aristotle himself explicitly defined some core character virtues, his theory implied a more complicated formation of virtues. Still, his theory gave some guidance on what could be defined as virtue. First of all, his doctrine of means, as previously mentioned, proposed that virtue must depend on the circumstances and must be discerned by careful judgement. To reach an absolute trait of character cannot be seen as an end in itself. In addition, a state of character is seen as virtue only if it operates as virtue. For example, courage is not a virtue in the case of a courageous murderer, because murder is not seen as enhancing “good life” or human happiness. In this case, therefore, courage is not a virtue because it does not serve its main purpose (Benn, 1998). The discourse on virtue ethics does not solve all moral problems or dilemmas. However, it enables a revelation of moral and ethical concerns that enhance the action-based account of Kantian and utilitarian approaches on ethics. In particular, it emphasizes our priority on the individual, the social worker as a moral agent who plays a role in the production and reproduction of the public sphere and has powers to affect the structure of social relations contained therein 21 (McBeath and Webb, 2002). By finding the reasons for their actions, social workers are becoming more than technical agents of the welfare state when policy intentions are uncertain and they judge whether they produce ethical actions or not. Furthermore, virtue ethics place social workers in a position to consider their profession not merely as an abstract duty. Through reflection and self awareness social workers can strengthen their conscience about what they ought to do and to resist imposed organizational constraints. Virtue ethics and particularly Greek philosophy was always a part of the education in Greece and integrated not only in philosophy courses but also in history, mathematics, science, and literature. More importantly, there are a series of quotes originated by the Greek philosophers that are part of the folk language and verbal expression of the Greeks. Therefore, it is anticipated that Greek philosophy has deeply characterized the Greek culture as it is reflected in every day language. In this sense, Greek social workers are culturally informed about virtue ethics even if virtues are not considered as a special social work skill or approach. 2.1.2 Christianity and ethics Christianity affected deeply the spiritual and social life of all European countries including Greece. In particular, the Greek Orthodox Church as the official religious institution of Greece for most of the history of the Greek state affected deeply the political and cultural identity of Greek society (Papanoutsos, 1995). For example, the Greek governments were church-oriented since 1967 (Herzfeld, 1993). Later, there were political parties which undermined the pervasive social power of the Orthodox Church. Nevertheless, even in our days, ideologically to be Greek means to be a member of the Greek Orthodox Church. There are two main influences of Christian philosophy which are important in ethics. First, Christianity gives greater importance to human will at the cost of human logic namely a human being‟s ability for rational thoughts. Human rationality, despite its critical power, is powerless without God‟s grace and without the person‟s good will to be driven to the salvation of his/her soul. The second critical influence of Christianity is the acceptance that the human mind is incapable of solving on its own, the great problems of human ethical life. Therefore, God‟s authority is needed in order to guide humans to find solutions to difficult or unresolved ethical problems in their lives. Christians believe that humans have the ability to do good deeds and to make choices of goodness. More importantly, humans are free to choose. Therefore, they must 22 have the will to produce good deeds. This is why human action has a genuine ethical substance because the source is free will and activity. Thus, humans are responsible for their own actions. An action is determined as good not by its outcome, even if it produces something good in the long term. An action is good only if the motive and the intention of the actor is in accordance with the good deed. If the actor‟s motive is evil then the action is evil too (Papanoutsos, 1995). It is widely acknowledged that the Greek Orthodox Church has an enormous impact on the political and social arena in Greece. For example, the Orthodox religion and tradition are part of the primary and secondary curriculum in schools while there is a poignant absence of education in other religions. In reference to social work in Greece, the Orthodox Church was always involved in social work education. More importantly, as it is one of the major cornerstones of the welfare state in Greece, the Orthodox Church is the primary founder and manager of many social agencies where social workers practice. 2.1.3 The philosophical approach of Immanuel Kant Ethical action for Kant was any action derived from what humans perceive as their duty. He also formulated a dual principle, the “categorical imperative”, which functioned as an indicator of ethical human activity: 1. Always act so as to treat humanity, whether in your own person or in that of others, as an end and not as a means; and 2. Act only on that maxim that you can make a universal law (Rhodes, 1986). Autonomy and freedom were two absolute values for Kant. He believed that since people were rational beings, they had the ability to create universal laws and follow them. Furthermore, people were self-regulated by their own rules/laws because they were free to determine for themselves without laws imposed by others. Thus, the two notions of autonomy and freedom were identical in Kantian theory and interdependently connected (Rhodes, 1986). In contrast with other theories on ethics, such as hedonism and utilitarianism, Kant believed that the purpose of ethics was not to teach people to reach for their personal happiness. On the contrary, ethical living for Kant was achieved at the cost of our urges and instincts. However, he also suggested that people should be aware of their personal needs and wills. This was because 25 and Strang, 2004; Maeckelberghe, 2004; Meagher and Parton, 2004; Koehn, 1998; Abramson, 1996). In reference to social work, the ethic of care is at the core of social work values, theory and practice since social work‟s inception (Meagher and Parton, 2004). In fact, the psychodynamic practice theory in social work highlights the importance of the relationship between the social worker and the client (Perlman, 1971). However, it is argued that neo-liberal policy trends and particularly management dominates the nature of what it is perceived as a “good” social work practitioner. In particular, managerial control requires social workers to take a more instrumental and impersonal approach to their work and be accountable not only to their clients, but also to the detailed administrative and task procedures of the employing organization (Banks, 2007; Meagher and Parton, 2004). Similarly, bureaucracy and professionalism for feminist ethics are both oriented to control and to establishing order. Decision-making is an impersonal and abstract process bounded on ethical principles and detached from the contextual dimension of social work practice and the service users (Banks, 2007; Meagher and Parton, 2004; Koehn, 1998). Feminist theorists argue that social workers must respond to these challenges by restoring care to the centre of social work. However, critical theorists argue that emphasizing the caring aspects of social work ignores “the complicity of social workers in the reproduction of the oppressive conditions within the practice context and beyond it” (Healy, 2000, pp.3). In particular, Meagher and Parton (2004) call attention to the “dark sides” of the ethic of care. In particular, they argue that some earlier theorists of the ethic of care were anti-political placing a personal relationship, particularly the mother child relationship, as the founding metaphor. Therefore, the identification of the ethic of care with a dyad of a person who cares and the “present other in need” does not respond adequately to the macro-level concerns for equal distribution of power and resources (Meagher and Parton, 2004). Similarly, the micro-level care leads to paternalism which sees “care-givers” as more capable of assessing the needs of “care-receivers”, and parochialism which sees the caring relationships in which people are engaged as most important (Meagher and Parton, 2004). In other words, Koehn (1998) argues that there is some sort of “political naiveté” in the version of the ethic of care which focuses solely on inter-personal relationships and she comments: 26 In deciding how best to care, we must look to an end of our interaction with other members of the community, an end that includes communal justice understood roughly as rendering each member his or her due (pp.37). However, critical theorists also see some opportunities when social work is engaged to the ethic of care, however, only when used in conjunction with political theory and knowledge on social relationships in macro-social structures. In particular, Meagher and Parton (2004) argue that “justice without care becomes a harsh and impersonal justice, while care without justice is inconceivable in politicized ethics of care” (Meagher and Parton, 2004, pp.24). The contribution of the ethic of care is that it challenges the image of the autonomous person that pursues or masters an independent life. Contrarily, it recognizes the context as able to diminish ones ability for self-determination and autonomy. Therefore, social workers can switch their focus from the assessment of ones abilities to exercise certain competencies to the ways that the context can enable the person to be more autonomous (Maeckelberghe, 2004). Moreover, the ethic of care provides a framework for arguing for decreasing managerial control in favor of an ethical decision-making process that acknowledges the emotional commitment of the relationship between social workers and their clients (Meagher and Parton, 2004). 2.1.6 Postmodernism, ethics and social work The period between 17th and 18th century, known as modern period, was characterized by the prevalence of science. This period is also known as the “age of reason” because at that time science represented something absolute, certain and genuine. Science, with its research of concrete things and strict organized methods of enquiry, managed to gain people‟s trust and put forth objectivity and rationalism as absolute values. Postmodernism appeared as a rebellion movement against the “authority” of scientific reasoning. This movement saw connections between the period of European colonization throughout the world, and the objectivist approach to knowledge, truth and value that characterized modern European thought at the time. Colonialism was intellectually justified by a belief in the objective superiority of modern European values and institutions to indigenous ones. Therefore, postmodernists argued that Eurocentric notions of objective truth, reason and value, were inherently linked to colonial oppression (Benn, 1998; Papanoutsos, 1995). 27 Postmodernism highlights the uncertain nature of social life and promoted openness to the meaning of how people understand society. For postmodernists there is no objective method to understand the world and any notion of truth is subsequent to the differences of meanings that every person gives. In reference to ethics, postmodernists reject any notion of universal ethical principles. Ethical principles have become a dogma by the continuous efforts of western culture, and have led society to coercion instead of a pure moral discourse. Ethical notions should survive only through negotiation and consensus, although negotiation is not guaranteed to produce consensus. Therefore, the ambiguity and the uncertainty of ethical norms and principles should be acknowledged (Hugman, 2003). The consequences of postmodern thinking in social work are seen as multiple. In particular, if no knowledge is acknowledged as “truth”, then the ideal of professional expertise becomes implausible. But, postmodernists argue that the knowledge and skills of the professional must be subject to validation by the service users (Hugman, 2003). Radicals also agree with the annulment of the expert‟s power, however, they still base this idea on their indubitable critical theory of social structures. Nevertheless, criticisms about postmodern social work have emerged. Critics argue that social work needs a common understanding for social phenomena (e.g domestic violence). In particular, Hugman (2003) argues that uncertainty is not helpful and disorientates the focus of the social workers. It also seems that uncertainty regarding major social problems is an opportunistic way of thinking and obscures the efforts for the elimination of the social problems. Unavoidably in their daily practice, social workers must give solutions, make decisions and they have a social/ organizational and ethical obligation to justify these. Therefore, these decisions must be based on terms of knowledge and skills, but also in relation to concrete values (Hugman, 2003; Clifford, 2002; Walker, 2001; Payne, 1999). 2.1.7 Summary This section briefly discussed the influences of philosophical ethics in social work. It was argued that although difficult to articulate the relevance of philosophical ethics and social work practice (Banks, 2008), professional values and ethics are best understood by identifying their philosophical origins. 30 However, multiple ethical barriers or obligations create dilemmas in social workers‟ efforts to pursue their professional purposes. Ethical dilemmas reflect the complexity of the social work profession in terms of several factors such as its purposes and the multiple loyalties of social workers. This section presents fundamental ethical dilemmas of social work practice in relation to ambiguities and ethical obligations of the profession. In addition, ethical decision-making is also presented as an inherent part of social work practice, especially when social workers act upon their dilemmas in the form of moral judgments or decisions. 2.2.1 Values and ethics and the social work identity Values have been defined in numerous ways. The Central Council for the Education and Training of Social Workers (CCETSW) (1976) defines values as: “a value determines what a person thinks he ought to do, which may or may not be the same as what he wants to do, or what it is in his interest to do, or what in fact he actually does” (pp.14). Feather (2002) defines values as general beliefs about desirable actions and goals. They are assumed to transcend situations and are not equally important for each individual. Values influence and justify particular types of positive or negative attitudes that an individual holds in regard to possible events and outcomes. A similar definition is given by Dominelli (2002), although she argued that a common characteristic of all values is that all are socially constructed and historically specific. In addition, values should not be treated interchangeably with ethical principles. Values should determine the desired ultimate ends, and ethical principles or ethics the recommended approaches to achieve them. This is why ethics are often named as instrumental values (Clark, 2000). Professional values are those embraced by the consensus of a body of practitioners given their relevance to the profession. This formulation of values is commonly expressed by a stipulated ethical code. They are used to characterize the practitioners‟ behavior in practice and outline the responsibilities in particular interventions. They also give a common sense of professional identity since practitioners, through values, can talk about similar entities (Dominelli, 2002). In reference to social work, Payne (1996) proposes that values are important to understanding the profession because they reflect the ways that social workers currently think and practice with difficult cases or problems. Social work values and ethical principles are integrated into codes of ethics. “Codes of ethics are documents that aim to identify the broad values, principles and standards of ethical conduct on 31 which a particular profession is based” (Bowles et al., 2006, pp.75-76). Moreover, as Banks (1995) argues, a code of ethics binds social workers under a common professional identity and publicizes its ideals and intentions. She also identifies four general functions of codes of ethics. In particular, she argues that codes of ethics are a guide for: (a) conduct and ethical decision- making; (b) protection for users from malpractice or abuse; (c) the “professional status” of social work; and (d) establishing and maintaining professional identity. Furthermore, ethical codes aspire professionals as they contain universal statements about the nature of the good society and the virtues of “good” professionalism. In this sense, codes of ethics are the means through which the social work profession maintains a common vision despite the historical and political changes and the consequent fragmentation within profession (Banks, 2003). And finally, codes have an educational role as they promote the development of ethical awareness and encourage reflection in practitioners (Ibid). Nevertheless, protecting users from day-to-day social work practice and avoiding the misinterpretation of ethics is not a tangible achievement through the sole usage of a code of ethics. Ethical standards and principles should be seen in reference to a specific context, otherwise serious harm can result (Bowles et al., 2006). Additionally, Sonnenberg (2004) argues that very general codes like those of IFSW and BASW encourage reflection and debate, but give little guidance. On the other hand, very detailed codes tend to be prescriptive and limit the professional freedom of judgement. Therefore, codes of ethics can never ensure ethical behaviour because integrity and morality are qualities that cannot be coerced. Bowles et al. (2006) suggest that in order to attain an adequate response to the social work code of ethics, social workers should be able to see ethical principles as interrelated. Following an ethical principle at the cost of another is seen as misinterpretation of the code and can lead to the fragmentation of the social work profession. In fact, social work is often characterized as a fragmented profession with a variety of purposes leaving it vulnerable to arbitrary definitions of its identity. There are several difficulties in conceptualizing the social work identity including the range and types of problems social workers address, settings in which they practice, levels of practice, interventions and methods used, and populations served (Gibelman, 1999; Banks,1995). Policy and the nature of welfare are also factors related to the social work identity. Policy changes and underpinning ideologies and values pertaining to the welfare state are reflected in the nature of social work. For example, Banks 32 (1998) notes that social work is enormously affected by globalization, neo-liberalism and the ideology of new management. Specifically, she argues that greater bureaucratic accountability and greater specialization and fragmentation of professional roles are the results of the current political state. Some believe that social work holds on to a common identity despite its fragmented nature through its values and ethics (Clark, 2000; Banks, 1995). However, as noted previously, social work is also a part and an expression of the welfare state. As the welfare state functions under the capitalistic economic and political systems, it also serves to ensure survival of this system and its values. The welfare system is underpinned by the value of competitive individualism as it functions within capitalism. Therefore, the welfare state supports the existing economic and social order by enabling private capital to remain profitable (Banks, 1995). On the other hand, the welfare state and the social work profession are developed in order to express the social concern for values such as justice and equality. Consequently, social work has an intrinsic role of social controller, and its primary aim to work in the best interest of users falls on the contradictory principles of the welfare state (Clark, 2000; Banks, 1995). Many of the critics that social work faces reflect the controversies of the welfare state‟s values. And in many cases, the blame remains in social work and not in the welfare system. Moreover, the debate on values is never transferred to the economic/political system. It is believed that understanding the social work role within the function of the welfare state, and awareness of its underpinning values permit social workers to make a more informed use of their professional role and skills. In addition, this awareness protects social workers from feelings of guilt as a result of the social policy‟s insufficiencies (Clark, 2000; Banks, 1995). Despite the difficulties in defining social work and its changing nature, the definition provided by IFSW (2005) could be a starting point in understanding the nature of the social work identity: The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work. 35 responsibility. In fact, ethical awareness is stressed as a specific skill in the current social work literature (Clark, 2000; Speicher, 1998; Banks, 1995). 2.2.2 Social work education and ethics Since ethical awareness is considered as a social work skill, then social work schools have the main responsibility to provide students with the appropriate educational opportunities (Clifford and Burke, 2005; McAuliffe, 2005). However, literature on social work ethics provides little information about the place of ethics within the curriculum and what educational processes are necessary for the training of ethical awareness skills. Overall, social work in Greece is underdeveloped and this is partly because it lacks postgraduate education and research. Moreover, social workers in Greece have limited opportunity to follow international developments within the profession (Dedoussi et al., 2004; Georgoussi, 2003; Stathopoulos, 1999; Kalinikaki, 1998). Within this context, social work ethics is an underdeveloped aspect of practice. Not surprisingly, from a review of the social work schools‟ curricula, only two out of the four have a course for the social work ethics, which is held for one semester, one hour a week. In reference to social work education in the US, Dodd and Jansson (2004) described the American traditional three step model of teaching ethics to students. In step one, academics often begin by discussing the nature of values, the development of values within the profession of social work, and different schools of ethical reasoning. In step two, students learn to recognize ethical issues in their professional environment and develop an understanding of why it is so important to address ethical issues in practice. In the third step, the code of ethics of the National Association of Social Workers is usually discussed. In reference to Australian undergraduate social work education and ethics, McAuliffe and Ferman (2002) made four suggestions based on a qualitative study of social workers. First, they proposed that students should learn ethical language to be able to appropriately articulate their positions on issues and dilemmas. Furthermore, a language of ethics would enable a shared meaning in relation to complex value issues and promote a deeper analysis of ethical dilemmas. Second, they suggested that students should be familiar with the available models on ethical decision- making to be able to clearly identify conflicting ethical principles and an explicit justification of 36 their actions. Third, they argued that the elaboration of the ethical code should not be missing from the curriculum, and students should have the chance to critique the code and examine its weaknesses through a range of scenarios. Lastly, they highlighted the importance of ethical dialogue. Ethical issues and dilemmas should not be dealt in isolation, but rather by an unconstrained dialogue characterized by openness, trust and mutuality between students and academics. Focusing on social work education in English universities, Clifford and Burke (2005) suggest that curriculum should bring together the teaching of social work ethics with the teaching of anti- oppressive values. In this sense, teaching social work ethics must highlight and acknowledge the role of power in shaping and determining social relationships, and the unequal power relations between individuals and organizations. The authors argue that social work education on ethics should stop relying only on utilitarian and Kantian approaches, which are individualistic in scope, and should take into account more collective approaches. For instance, social workers cannot engage in an ethical dialogue without taking into account the differences in power among participants, and how this power determines their points of view on ethics. Moreover, student social workers should understand the importance of the multidisciplinary work on ethics and the involvement of service users in ethical discourse. Another critical point in the Clifford and Burke (2005) argument is that academics should strive to minimize the existing divide between the academic arena and practice realities. In order to achieve that, teachers should take responsibility for raising ethical issues about racism, sexism, harassment and other matters so students can learn about the struggle to live by the recommended values. Dodd and Jansson (2004) suggest that ethical reasoning is not sufficient for social work practice and students should be educated in ethical advocacy. Ethical advocacy involves ensuring that clients‟ needs and perspectives are adequately represented in ethical deliberations, both through social work involvement in individual cases and their efforts to become more involved in ethical deliberations. Schools should prepare students to confront the difficulty to engage in ethical discourse and ethical decision-making in social work organizations. The authors indicate that social work schools seem to ignore the fact that social workers are often excluded from ethical deliberations in their workplace, therefore, students must be taught how to get involved. Consequently, teaching of ethics should include teaching of strategies for social workers in order to achieve an equal involvement in ethical decisions. 37 2.2.3 Value-based evaluation of social work practice As a value-ladened profession, ethics should be perceived as an inherent part of what is seen as social work effectiveness. Social workers should include the examination of their professional values and ethics as an inherent part of their evaluative practices. In addition, since ethical awareness is one of the social work skills, practitioners should be competent to examine the ethical dimensions of their practice. Evaluation is a form of practice that aims to assess the effectiveness of interventions in terms of their aims and objectives (Adams et al. 2002). Evaluation is also defined as making a judgment about the value of something. It involves the use of criteria and standards. In this sense, professionals can evaluate the ethical and moral assumptions behind their practice (Goldenberg, 2005; Seedhouse, 2005). All evaluation activities have the potential to help social workers become better helpers and more flexible in their work with clients. Practice decisions also have the potential to harm clients. Therefore, evaluation is necessary if practice is to be considered as ethical (Staudt, 1997). The meaning and importance of values, rather than numerical worth, as the center of the evaluation process is currently supported by many authors (Taylor, 2006; Goldenberg, 2005; Seedhouse, 2005; Dominelli, 2002; Everitt and Hardiker, 1996; Schon, 1987). Goldenberg (2005) and Seedhouse (2005) disagree with the argument that evaluation and judgments could be made using value-free methods. They argue that evidence and values are forever entwined, and that all decisions or judgments are a balance of evidence and values. In particular, what we perceive as evidence in evaluation is a product of a broad spectrum of knowledge, including scientific evidence, personal experience, personal values, economic and political considerations, and philosophical principles. Nevertheless, people seem to ignore values or seemingly regard their decisions and judgments as value-free. Furthermore, evaluation is recognized as a significant managerial strategy for ensuring the efficiency, economy, effectiveness and accountability of organizations and projects operating in the market place. Moreover, policy or politicians can utilize evaluation in order to demonstrate success at a time of acute social and economic failure. This fact perhaps obligates social workers to strive to identify the ways that policy makers utilize such evaluations. A new emphasis on hard evidence for the outcomes of social work interventions is widely documented, and it is seen as influenced by the ideology of New Management which relies more on evidence-based knowledge 40 each person. This principle also recognizes that each person is different and has different needs. This leads to the second principle which is the principle of need. This principle states that social workers should consider and measure the relative importance of various needs and support and distribute resources accordingly. The third criterion is the principle of compensation. Social workers should also consider cases where individuals or groups, having been deprived of services in the past, are suffering the effects of this deprivation in present generations. As a result, social workers should consider how to compensate these generations to stop the ongoing reproduction of inequality. Notions such as positive discrimination derive from the principle of compensation. The last criterion is the principle of contribution. A simple interpretation of this principle is that services and resources should be distributed to individuals in proportion to the contribution they have made. Ethical dilemmas often involve issues related to the boundaries of the client-social worker relationship. Professional boundaries are seen to exist in order to protect the client from the social worker and to establish the professional nature of the relationship. Clients are vulnerable to social workers‟ influence as they are more powerful given their role is legitimated by an organization. Therefore, social workers are responsible for resisting the abuse of this power and to practice in an ethical manner (Johner, 2006). Dual relationships, for example, have recently been a central focus of discussions in the social work literature and are regarded as one of the ethical issues of practice. Dual relationships occur when social workers relate to clients in more than one relationship, whether professional, social, or business. They are considered as situations with a potential for exploitation. However, some consider positive benefits from dual relationships. For example, some argue that dual relationships offer protection against the damage done within the traditional model of therapy because they do not reinforce the therapist‟s power advantage (Mayer, 2005). Examples of actions that indicate dual relationships include when a social worker is involved in the personal and social life of a client, promoting client dependence, reversing roles with clients, when a social worker is almost always available, gift giving, providing nonprofessional services, mutual acquaintances such as friends, and joint affiliations and memberships. Managing dual relationships in social work present many challenges especially in small communities were dual relationships are more commonly found. Maintaining client confidentiality and privacy is seen as a specific challenge (Galambos et al., 2006). Confidentiality as an ethical principle expresses the human right of privacy. Privacy refers to the degree of control that a 41 person has over what happens to information about them. In reference to social work, confidentiality is one of the primary ethical obligations of the practitioner and is related to boundary issues. Abrogation of confidentiality should happen only when harm to other people or to the client is likely to happen. However, decisions on information disclosures become even harder especially when agencies or pressure from laws for the disclosure of information taken in confidence. In such cases, consequent role conflicts for social workers occur and complicate practice. Reamer (1982) distinguishes two categories of dilemmas in reference to social workers‟ relationships with colleagues and employers. The first category includes what is referred to as whistle blowing, namely exposing questionable practices among colleagues. The second category includes instances when a practitioner must decide whether to violate an agency regulation or administrative policy in order to safeguard the welfare of a client, a colleague, or oneself. Compelling, but competing values are almost always inherent to such situations. Whistle blowing refers to an action when it meets three criteria: (a) the act of notifying powerful others of wrongful practices in an organization (b) the action is motivated by the desire to prevent unnecessary harm to others; and (c) the action is of an employee or former employee who has privileged access to information (Greene and Latting, 2004). Whistle blowing is often seen as a form of advocacy and adheres to basic ethical principles of the profession which explicitly encourage social workers to expose any unethical conduct of colleagues or organizational practices that violate human rights (IFSW, 2005; NASW, 1999). Ethical dilemmas also emerge when professional integrity or autonomy conflicts with social policy. Professional integrity refers to the social worker‟s obligation to act in a manner befitting his/her knowledge and status in society. Professionals should take responsibility for their actions and ensure that their actions are in line with the social work ethical code. These include being committed to ongoing knowledge and skill development, avoiding the use of special knowledge and skills for inhuman purposes, not abusing the relative powerlessness of the users, not bringing into disrepute the good name of the profession through malpractice, and monitoring and challenging agency policies and practices which may be contrary to the ethical code (Banks, 2001). 42 Professional autonomy refers to the power of professionals to make their own considered decisions and judgments based on their expertise and ethical values. However, it is widely acknowledged that professional autonomy is restricted for social workers in contrast with other professionals such as lawyers and doctors. This is because social work is often practiced in bureaucratic organizations that have specific rules and procedures governed by a hierarchical structure (Banks, 1995; Reamer 1982). As a moral activity, social work is obligated to find the ethicality of its actions beyond the stipulated policy or organizational regulations. In fact, Banks (1995) suggests that laws indicate what social workers can or cannot do through legitimate actions. However, laws are insufficient to indicate what social workers are obligated to do from an ethical perspective. Therefore, ethical dilemmas emerge when social policy or agency regulations are viewed by social workers as violating the welfare of their clients. In such cases the usage of professional autonomy is seen as welcome despite the fact that it is also seen as a negative value given it triggers issues of power in the relationship between the social worker and client. In fact, social workers are ethically engaged to protect their clients from their own power as malpractice. Additionally, social workers are professionally and ethically engaged to see the welfare system not as it is now, but as it should be to sufficiently cover human needs. In this sense, the engagement of social workers to simultaneously address social change and limited welfare resources create complicated ethical questions such as is it ethical for social workers to work within the current welfare system, and questions about the ethical distribution of limited resources. Notions of equality and social justice are inherent in these ethical deliberations. Although there is a growing body of literature that deliberates the types of ethical dilemmas that social workers are currently faced with, there can be no predetermined solutions. This is so because it is recognized that there are a variety of factors involved that frames each situation differently. Therefore, an ethical dilemma can be likened to a mosaic made up of factors that construct the picture of the decision situation for the social worker (O‟Sullivan, 1999). Nevertheless, ethical decision-making models have been developed to build a framework for the various interacting elements of the ethical dilemmas that need fitting together to permit social workers to thoughtfully deliberate. 45 those who relied on technical considerations discontinued advocating. Similarly, Banks and Williams (2005) found that only one small proportion of social work students articulated an ethical dilemma as a conflict of values that involved alternative choices. In addition, students‟ accounts had no elements of decision-making. In fact, the researchers noted that students referred to broad issues, such as drugs and alcohol or physical conduct, for the description of ethical dilemmas. Moreover, McAuliffe (2005), using an action research model, implemented the concept of Reamer‟s ethical audit1 in 11 organisations in Australia and recorded the outcomes. The researcher found that participants admitted that their involvement in the study marked the first time they had to think about and discuss ethical issues in practice. Specifically, practitioners claimed this was the first time they used ethical language, and the first time they began to see various and differing perspectives on controversial situations. The ethical audit procedure also demonstrated that it was an effective tool for the review and modification of the policy relevant to daily practice, and therefore deemed to enhance the quality of services. In terms of the impact of ethical dilemmas on social workers, two studies have indicated various short and long term effects in their personal and professional lives. McAuliffe (2005) interviewed thirty Australian social workers and found several difficult emotional conditions associated with the experience of an ethical dilemma. These emotional conditions included stress, depression, agitation and irritation, isolation, overwhelming feelings, paranoia, anger, frustration and decreased tolerance for both clients and colleagues. An important emotional condition was also associated with feelings of “unfinished business”. Some physical symptoms were also expressed by participants. The most common physiological response reported was physical exhaustion. Other physical symptoms described by participants were insomnia, high blood pressure and immune system problems. The same emotional conditions as a result of ethical dilemmas were also noted by Banks and Williams (2005). As far as the long term impact of ethical dilemmas is concerned, McAuliffe (2005) found that the participants identified impacts on their attitudes and awareness, practice, and personal relationships. In concrete terms, some acknowledged the value of the social work profession; however, some discredited the humanitarian role of social services organizations. For others, the realization of the political and power dynamics had a positive impact to strengthen their personal commitment to social work. There was also an increased awareness of the importance of the clarified roles and responsibilities in the workplace and a greater awareness of the importance of boundaries issues in relation to clients, colleagues 1 Reamer‟s ethical audit is a method that examines the familiarity with known ethics- related risks in practice as well as the organisation‟s procedures and protocols for handling ethical issues, dilemmas and decisions. 46 and managers. It was important to note that four social workers made the decision to leave direct client work as a result of the long term impacts of ethical dilemmas, while another four left their respective places of work with feelings of „unfinished business‟. The social workers who resigned from their job or from the profession had little support either from colleagues or supervisors at the time of experiencing the ethical dilemma. Findings from the study of McAuliffe (2005) also indicated that participants used a variety of mechanisms in order to be able to cope with stressful ethical dilemmas. Some tried to make light of the incident with humour and others were attentive to physical fitness and self care. Another strategy employed by other social workers was to focus on tasks that needed to be achieved on a daily basis so that the bigger picture would not become overwhelming. Yet others denied the reality of the situation by ignoring the case and moving to another case or by using more extreme forms of denial. Social support was proved to be a very important factor involved in the ethical dilemmas, as many of the participants who felt considerably isolated in their places of work and who experienced high levels of stress were simultaneously unable to access good social supports. Conversely, negative effects were fewer for those who had good social supports and they were able to work through the ethical dilemma quickly. One study, although not particularly concerned with the exploration of social work ethical dilemmas, importantly indicated the value preferences of the social workers. As ethical decision- making involves moral judgements these findings indirectly suggest possible factors related to ethical decisions. In particular, Furman et al. (2007) who qualitatively explored potential ethical dilemmas as a result of an immigration law found that only few MSW and BSW responded to macro level concerns, while social justice and community organisation intervention were notably missing from the data. The value preferences of social workers are considerably important especially when related with the findings of a qualitative study that illustrated the ways that individual ideologies and beliefs impact social work practice. In particular, Sullivan (2008) explored social work practice with older people in UK community care. Findings of this study indicate that social workers‟ ideologies and perceptions dictated their practice while different meanings introduced by their clients were ignored. More importantly, social workers‟ perception of their duties appeared to be originated and controlled by organizational rules and policy. At the same time, social work ethics appeared 47 to be loosely applied and clients were excluded from the ethical decision-making of the social workers. The attitudes and beliefs of US social workers about sexual involvement with clients were quantitatively explored by two studies. Jayaratne et al. (1997) found that 43.7% of the social workers believed that feeling sexually attracted to a client was appropriate, and 52.4% acknowledged feeling sexually attracted with their clients. However, only 1.1% of the social workers declared having sex with a former client. In contrast, Mittendorf and Schroeder (2005) using an exploratory survey found that all of their respondents believed that erotic contact between social worker and client was usually harmful to the client and always inappropriate. However, many of the social workers (54%) affirmed that they had clients who reported having had sexual contact with a previous therapist. These respondents acknowledged having had a total of 245 clients who reported having sex with their previous therapists. Importantly, of those social workers who believed that one or more peers had initiated sexual contact with clients, only 15% reported these violations of ethics to an ethics committee or licensing board. This finding is considerably important as whistle blowing is currently considered as one of the ethical responsibilities of social workers which is related to their ethical obligation to protect their clients from malpractice. However, there was no empirical study examining the issue of whistle blowing and whether social workers ethically embrace whistle blowing practice. Importantly, the above studies detected several factors related to the development of social work ethical dilemmas, however, in various contexts. Policy issues, cost-effectiveness and organisational values appeared to be strongly involved. Nonetheless, further research is needed in order to understand the factors effecting the ethical decision-making process of the social workers. In addition, some studies indicated that, overall, the ability of social workers to ethically analyse their cases possibly leads to a stronger engagement with advocacy and recognition of important factors (i.e social policy, organisation rules) that affect practice. However, there are no studies exploring why social workers do not acknowledge conflicts in values in the first place or their prior education on social work ethics. In addition, further research is needed to explore the role of social workers‟ ideologies and/or value preferences that impact on ethical decision- making. Although two empirical studies indicated the emotional impact of ethical dilemmas on social workers, there are no studies indicating the ways that emotions affect the ethical decision-making 50 managed care restricted services that might benefit clients and was more focused on profits than clients. Yet, the majority of students (62.1%) also believed that social work values were not difficult to apply in US agencies of any kind. Two other studies were particularly concerned with the factors that influence the ethical decision- making of social workers when they decide whether to support the autonomy of older people. Healy (1998) using a mixed method approach examined cognitive status, safety and caregiver burden and the degree that these factors influenced social workers‟ support for autonomy. The three most frequently mentioned factors influencing participants‟ decisions were the evaluation of cognitive capacities (92%), followed by safety/risk factors (73%), and then caregiver/family issues (50%). Overall, respondents showed a relatively low level of support for autonomy. In a later study, Healy (2003) using a qualitative approach explored the existence of ethical tensions embedded in the decision-making processes of home health care social workers as they evaluated decisional capacity of the elderly experiencing cognitive impairment. Findings of this study suggested that there was a particularly strong ethical tension when social workers experienced pressure from other professionals as well as when they were uncertain about the decisional capacity of their clients. Clinical uncertainty was influenced by 4 major factors: (a) when the person had a partial cognitive impairment; (b) when the person had a mental health problem; (c) when there was interplay of health and mental health problems; and (d) when the aetiology of the poor decisional capacity of a person was unclear. When the social workers were certain that an elderly person‟s lack of decisional capacity was contributing to an unsafe situation, their action was very strong in support of beneficence, toward securing safety and in resisting pressure of other professionals. However, when social workers were uncertain about their judgments, they sometimes re-evaluated their own decision-making. Thus, balancing autonomy and beneficence was perceived as a very difficult course of action. The involvement of social workers on ethical committees has also been empirically documented. Csikai and Sales (1998) surveyed 85 social workers who where members of hospitals‟ ethics committees and 85 chairs of the same ethics committees of which the participant social workers were members. Generally, social workers and chairs held highly congruent expectations regarding the relative importance of various social worker contributions to the ethics committee. However, social workers desired significantly more involvement in almost all areas of committee activity than chairs felt they should have. Both social workers and their chairs felt that social workers should be most heavily involved in case consultation activities, slightly less involved in 51 policy development and review, and much less in educational activities. Similarly, Csikai (2004) explored social workers‟ participation in the resolution of ethical dilemmas in hospice settings. The findings from the 110 hospice social workers suggested that social workers‟ participation in ethical committees was moderate by providing only information related to the clients‟ circumstances, and therefore staying outside the real ethical discourse of the cases brought to the committees‟ meetings. Nevertheless, social workers, even if they have minor roles on ethical committees, must independently make decisions on cases with ethical implications. This is particularly relevant given ethics committees typically meet on an infrequent basis. In contrast with the studies discussed in the previous section (2.2.5, pp.43), the majority of the studies in health care contexts were quantitatively approached. Specifically, only one qualitative study was found to explore the ethical decision-making process of social workers, but focused on a particular ethical issue. Although, there are some large-scale studies indicating what social workers identify as ethically problematic in their practice, little is known about social workers‟ attitudes and ethical decisions on about the contextual factors involved in ethical decision- making. 2.2.7 Summary In this section social work‟s ambiguities were discussed through the elaboration of its values and ethics. Social work is a profession difficult to characterize as there are a variety of factors that frame the professional entity. These include the range of organizations where the social work profession is practiced, the variety of social problems that social workers address, and the policy and the nature of the welfare state. However, social work values and ethics provide the way for social workers to identify themselves as a separate professional entity. Social workers are able to define and articulate the specific content of their professional purposes, such as social change and human well-being, through the language of ethics. Furthermore, the imposition of values into social workers‟ evaluative process is seen as an effort to control what the current political system demands to count as “good social work practice”. This effort will hopefully enable humanitarian values and ideals to take a proper scientific stance and a practical place in the dominant ideology of the neo-liberal “what works”. Ethical dilemmas reflect the ambiguities and the complexities of the social work profession in terms of its multiple obligations, its commitment to mutually opposed ethics, and the dual 52 professional purpose to ensure both individual and the societal well-being. In addition, limited welfare resources require social workers to ensure equal distribution of these as they are ethically engaged to promote social justice. This commitment requires them to make moral decisions on who deserves to be benefited or not. Similarly, as social workers are ethically obligated to protect and enhance the well-being of their clients, issues of power and the possibility of dual relationships are ethically problematic. In addition, workers are obligated to ensure that their clients are both protected from any harm and their potential for self determination and autonomy enhanced. However, social workers are simultaneously obligated to protect their employer and follow any regulatory rules. When these rules or the practise of colleagues are thought to violate or obscure the benefit of their clients, then ethical dilemmas emerge and social workers must try to balance their multiple obligations and the consequent conflicting ethical principles. Balancing conflict among such responsibilities is an effort that necessitates moral judgments and ethical decision-making. Therefore, ethical skills are considered as prerequisite for social workers to be able to maintain a critical attitude towards their dilemmas. In particular, ethical awareness and critical reflection have been proposed as skills which enable social workers to determine, control and enact the values that the profession ideally promotes (Bowles et al., 2006; Speicher, 1998; Banks, 1995; Reamer, 1982). Social work ethics is an important, but infrequently researched aspect of practice. In fact, Jansson and Dodd (1998) argued that the empirical studies of social workers on ethics in health care are minimal. However, a focus on social work ethics in health care settings seemed to have emerged particularly in recent years. This is probably because researchers believe that health care is the most ethically problematic context for social work practice. Nevertheless, the majority of these studies are relevant to US social work settings while the empirical studies relevant to European countries are considerably few in number. Not surprisingly, none of the empirical studies were specifically relevant to Greece. Studies conducted in a variety of social work settings indicate that overall, social workers appeared to adhere to individualistic values such as self-determination than to collective ones such as social justice (Woodcock and Dixon 2005; Banks, 2005; Kugelman, 1992). In addition, even when social workers acknowledged policy as opposed to social work values they did not respond to macro level concerns in terms of action (Furman et al., 2007). Targeted studies on social work ethics in health care showed that the majority of workers acknowledged ethical dilemmas in cases which involved medical issues such as end-of-life care, and decision-making 55 2.3.1 The history of social work in Greece Social work has a deeply contextual nature as practitioners work among people and their environments. In addition, social work is engaged in promoting social justice and social change, and therefore, the focus of workers becomes one of changing the environment or aspects of it. In this sense, to understand the profession and the role of applied ethics we must have a clear idea of the context in which social workers practice (Bowles et al., 2006). Although social work has changed since it was first established in Greece, it is important to briefly describe its historical evolution. This is followed by a brief review of its work status in Greece. When the Second World War started in 1940, Greece was enslaved and the population experienced deprivation. At the end of the war, a civil war began and people continued to suffer from the consequences. During this period, however, the reconstitution of the country started. The welfare program of Marshal, founded by the American government, undertook the development of public works and community development programs (Stathopoulos,1999). American consultants and volunteer organisations who had come to Greece to help with the reconstruction of the country argued that the effectiveness of these programs was not good enough. The need for trained staff to deliver the social programs was subsequently identified and the first social work school established by the American College “Pierce” in 1945. Three years later in 1948, the Christian Association of Youth in Greece with the support of the International Christian Association and the support of the “Royal Welfare of Greece”, founded the second social work school. The third school was founded by the “Royal National Institution” and the fourth was founded by the Greek Orthodox Church. In 1950 the Hellenic Association of Social Workers was founded, and in 1959 the first law was passed describing the role of the social work profession. Three years later in 1961, a second law described the settings where social work could be practised. At this time, leftists were provoking social workers and arguing that since social work schools were funded by Liberals and Royals the ideals of the profession were not democratic and social workers were not close to the working class. In addition, with the church‟s involvement in two schools, social work in Greece was viewed more as an apostolate activity rather than a distinct profession (Stathopoulos, 1999). 56 There are two committees in Greece for the development of the social work profession. The first was established in 1956 by the Orthodox Church in collaboration with the Unitarian University Service Committee of the US. In the first years of its establishment the committee actively engaged in social work education in Greece. In particular, it financially supported the translation of some of the basic social work texts from the US, organized the first educational seminars for social workers, and developed the curriculum in consultation with social work academics from US universities. Similarly, the second committee was founded by the Orthodox Church in 1979 and supported the development of the profession. Both committees continue their function to date, but with limited activity (Kalinikaki, 1998). Currently, there are four schools of social work in Greece which can provide a license for practice. All of them are established as Higher Schools of Social Work (HSSW) and they provide a three and a half year training course followed by a six month placement for practical experience. Due to the National Educational System in universities, students enter social work schools at the age of 18 or 20. Older students in social work schools already have a degree from another school. The social work schools are not multicultural as the majority of students are Greeks. Only a small portion of social work students are from Cyprus, and an even smaller portion of students are children of expatriate Greek families who return to Greece for their studies. This is promoted by the Greek government by allowing children of Greek emigrants to enter any university they like so as to support their families on return to their homeland (Pediaditaki, 2003). There is no official data for the number of the employed social workers. However, Dedoussi et al. (2004) estimate that over 1000 social workers are employed in the health sector nationwide. In addition, the status of the social workers in health sector is low, as medical services in Greece remain doctor-orientated and the multidisciplinary approach is rare (Dedoussi et al. 2004). In fact, Dedoussi et al. (2004) indicate several factors that determine the low status of the profession. They state that there are a limited number of vacancies for qualified social workers and, in the private sector, it is rare for employers to offer more than one or two posts for social work. And finally, continued education is not a requirement and is rarely provided by employers. 57 Dedoussi et al. (2004) describe the profile of the typical social worker in Greece: A typical social worker in Greece is a middle-aged married or single woman working for the last 10 years in health or social services, who rarely finds the time or the money to attend scientific meetings despite the fact that s/he may have at least one other degree qualification before training in social work. S/he is employed at staff grade and has little or no prospects of promotion. Central policy on social workers is lacking, and the profession is lacking, and the profession is in the early stages of self- organizations (pp. 274). In addition, results from Georgoussi (2003) survey which explored the nature of the daily work of social workers, indicated that activities were characterized as “first aid” and no work related to planning, research, supervision, or consistent record-keeping. Moreover, Pediadikaki (2003) argues that social work‟s character is very confusing to the majority of the Greek citizens. To summarize, social work in Greece was deeply influenced by the liberal ideology that prevailed in Greece, by the United States and the Christian Orthodox Church in Greece. In particular, the first social work academics were educated in US and the establishment of the welfare state was funded and formatted by the directions of the US government. Simultaneously, the Christian Orthodox Church with its power to influence and intervene in the political affairs of Greece managed to form the social work identity as a philanthropic activity. Therefore, social workers remained, for many years, uneducated in critical or radical social work practice. And although social work was considered as a moral activity, its purposes remained disconnected with the aims of social change. As social work is mainly practised within the limited welfare organisations founded by the state, it remains a professional with low status. Educational opportunities for social workers are considerably limited, and only those who are able to fund themselves have the opportunity for advanced education in European or American universities (Dedoussi et al., 2004; Georgoussi, 2003; Stathopoulos, 1999; Kalinikaki, 1998). It is vitally important that social work ethics is understood in relation to the Greek context in which social work is practiced. Although the HASW is currently a member of the International Federation of Social Workers (IFSW), the ability and competence of social workers to practice social work ethics are considerably dependent on the diversity of contexts. 60 Social protection in Greece ranks very low in comparison to European standards. Specifically, Greece is among the countries of the Southern European block (Italy, Greece, and Portugal) that spend considerably less than the average of the Member States of EU countries on social protection (Sotiropoulos, 2003). In addition, Greece is the only EU country which has not developed a minimum income scheme to protect citizens from poverty and social deprivation, while 21% of the population is at risk of poverty. The poverty rate is above 33% for the elderly and very old in Greece, in contrast to the equivalent figure for the EU which is 20%. This is partly because the minimum pension benefit is below the poverty limit. In addition, new groups of people that are perceived as vulnerable have started to form. For example, the “generation of 700 euros” is an expression that is currently used in Greece and characterizes 25-35 years old citizens who are overworked, underpaid, debt ridden and insecure. Poverty is more apparent in rural areas and unemployment, and access to the labour market and social services appear to be the major contributing factors. However, informal social networks and the family as the nucleus of the Greek society still play an important role in preventing poverty and social exclusion (Yfantopoulos, 2004). Another important characteristic of the Greek culture is that blood is the basis of the Greek race. As Herzfeld (1993) indicates, in Europe blood had, by the early nineteenth century become a symbol of kinship that was able to convert social relationships into a national culture. In addition, Greece is a country where ideologically to be Greek means to be a member of the Orthodox Church. Taking this into account in the logic of competition over resources, being Christian can become a highly relative and contestable quality (Herzfeld, 1993). Therefore, blood and the Christian religion are symbols of a collective identity that serve to discriminate those who belong to the Greek nation from those who belong in other nations. To briefly summarize, the Greek welfare state undertakes the most important actions for the social work profession. Social work activities are characterized by “first aid” and the individualization of problematic situations, in contrast to a collective treatment. In addition, social work in Greece lacks, to a great extent, the critical approach which is necessary for the qualitative enhancement of the profession (Pantazis, 2007; Georgoussi, 2003). Therefore, it is doubtful how social work can contribute of the reformation of the welfare system in Greece. 61 2.3.3 The social work profession within a globalized environment Globalization is one of the most common terms used to characterize the new social reality and modern life. Although the term is not well defined, it is widely used to connote a global integration in which diverse people, economies, cultures, and political processes are increasingly subjected to international influence. Globalization is particularly correlated with the economical activities of western countries and the technological advancements in transport and communication. Due to its nature, globalization affects every aspect of human life (social and political structures, welfare state, culture, demography, education, employment, family, world ecology, personal lives of individuals) because it creates multiple and extensive world networks and procedures that overpass national borders (Midgley, 1997). Current literature suggests that globalization has developed social problems including unemployment, poverty and economic instability, increased immigration, racism and ethical conflicts, economic and social exclusion, human trafficking, arms and drugs trade. In addition, some argue that the motivation behind globalization was for the domination of the west and has subsequently eliminated the local cultural differences mainly in the countries of the Third World (IFSW, 2005; Ferguson, 2004; Midgley, 1997). Within a globalized environment, social work has also changed enormously. In terms of its methods, the focus of some social workers has turned from case work to community development activities. More importantly though, social work has been affected by the economical values and principles that underpin the current welfare state internationally. Agencies that function with the terms and purposes of businesses are currently those which provide social services. In effect, social workers are currently pressured to function under the managerial control and managed care policy. In fact, the impact of globalization, privatization, new managerialism and technocratization on social work have been extensively documented. For example, Gibbs (2001) says that in New Zealand it is normal for social workers to talk of “core business”, “maintenance of mission” and “budgetary control”. Globalization in Greece brought a considerable capital accumulation in certain sectors of the economy (e.g. banking, mass media). In addition, privatisation processes have been put forward in various sectors that were traditionally under public ownership control (e.g. banking, 62 transportation, telecommunication and energy). This process started in the early 1990‟s under the New Right government and has continued by the PASOK (Zambeta, 2000). Furthermore, through the vitiation of national borders and the transfer of populations, Greece was rapidly transformed from a country of a high national and religion homogeneity to an increasingly multicultural society. Currently, partly due to its geographical position, Greece is the country of arrival for many immigrants and refugees. Most of them see Greece as a geographical bridge to economically developed European countries. However, many of them remain or they are sent back to Greece due to the refugee European Law of Amsterdam. Despite the fact that immigration has become a matter of concern for the authorities for almost a decade, it is still impossible to trace the exact numbers, places of origin and social characteristics of immigrants living in Greece. The fact that not all of them are documented prevents the collection of accurate data; official estimates differ largely from information deriving from non-governmental organisations (Greek Council of Refugees, CARITAS, etc.) or the numbers immigrants give (Petronoti and Triandafyllidou, 2003; Zambeta, 2000). Generally, the effect of globalisation on Greek culture has not been extensively documented. However, Voulgaris (2006) suggests that the Greek identity is currently characterized by “cultural conservatism” as a by-product of the historical process of its formation during the “long XIX century”. Cultural conservatism in Greece is currently provided by the dialectic between globalisation and the national identity, as well as the disjunction between state and nation that this dialectic produces. In addition, Zambeta (2000) notes that globalisation and Europeanisation is considered by Greek citizens as threatening for the traditional national culture. In this context Greek language and the Orthodox Christian religion are considered as the crucial distinctive elements of being Greek. Therefore, nationalism and xenophobia are some of the unavoidable implications of this discourse. Globalization also promotes the international exchange of knowledge and professional experience. Industrialized countries are recognizing the need to provide their students with a global consciousness and with experience in other countries in order to compete in the global economy. The EU has instituted policies that have increased the number of students studying outside their home countries, but within the Union. With the expansion of the EU and the implementation of the Bologna initatives, academic structures are harmonized within the European countries. Nevertheless, international higher education has been turned into a big 65 other diagnostic/ laboratory services such as gynaecological tests, X-rays, or nuclear medicine. In fact, Greece is the country with the highest private expenditure among the EU member states (Yfantopoulos, 2004). The substandard quality of mental health services in public hospitals also led people to use private mental health services. In addition, most primary care consultations are provided by contracted office based doctors and dentists. Moreover, it is likely that many NHS and insurance funded doctors receive informal payments from private centres to channel patients for diagnostic or laboratory tests (Mossialos et al., 2005; Ballas and Tsoukas, 2004; Liaropoulos, 1998). 4. Lack of management control and accounting systems- Public hospitals lack clear decision- making guidelines about where money should be spent. This is true both in the case of investments in new facilities and, even more so, in the case of consumables. There is no formal procedure, or even a budgeting system, for buying equipment on the basis of need. Rather, it all depends on idiosyncratic decisions by the hospital chairman. Authors also indicate that managers who were appointed to run hospitals, or chairpersons appointed to run the Regional Health System (PESY) tended to be political appointees – mostly members or sympathizers of the ruling party. Most heads of public organizations were, and with a few exceptions continue to be, similarly appointed in a clientelistic fashion. Top management positions in public organizations in Greece have traditionally been reserved for government supporters or sympathizers. In reference to the National Health System, Liaropoulos (1998) says: “Manpower planning, technology assessment and quality assurance are non-existent activities, and the whole system is run on political criteria. Hospitals are still run by untrained career civil servants, and members of the boards of directors, each headed by a doctor, are political appointees with no interest in efficient operation” (pp.166). The NHS in Greece is also characterized by non-effective systems of organising and coordinating medical records, tracking how health resources are used, and measuring and monitoring the outcome of care. This problem is exacerbated by the fact that most doctors do not keep medical records in private practice even if they are contracted by health insurance funds, and if they do, these records are inaccessible. In addition, there is no actual assessment of needs for supplies and equipment, and procurement is usually based on doctors‟ opinion (Rovithis, 2006; Mossialos et al., 2005; Yfantopoulos, 2004; Ballas and Tsoukas, 2004; Liaropoulos, 1998). In comparison to other European countries, Greece also maintains the lowest number of employees in the health sector (Polyzos and Yfantopoulos, 2000). 66 A noteworthy development was the establishment of Regional Directorates (PESYs) in 2001. The legal status of each individual hospital was abolished with PESYs acting as intermediaries between the minister of Health and hospitals. Regional directors were given the power to influence personnel allocation by allowing, for example, personnel to move across departments on across hospitals. Today, the National Health System consists of 128 city hospitals and a number of associated rural area health centres organized into 17 PESYPs. In 2002 the government gave permission to doctors to provide health services and diagnostic tests beyond the regular hours. The purpose was to advance hospital productivity and competitiveness by allowing doctors access to medical equipment, and giving citizens access to the doctor of their choice. However, citizens are obligated to pay for health services. Therefore, it is doubtful whether this measurement reduced unethical practices except to privatize the health services in another manner (Alexiadis, 2003). As described above, the NHS in Greece is characterized by multifaceted deficiencies. Nevertheless the health status in Greece, in comparison to other European countries, is ranked high with increasing life expectancy and decreasing infant mortality. Some of the factors that have contributed to the improved health status include: improvements in living standards, the Mediterranean diet and better access to health care and pharmaceutical therapies (Yfantopoulos, 2004). Every public hospital is administrated by its Administration Manager and Board. The Administration Manager is the main person responsible for the organization, coordination and control of all services in the hospital. S/he also participates on the Administration Board with the chair of president. S/he has the authority to form a scientific board for the hospital, and his/her main responsibility is for the efficient use of hospital income and property. The purpose of the Administration Board is to deal with the hospital‟s problems. It is responsible for proposals in reference to the budget and development planning. It is composed of five members: the general administration manager, three managers of the three departments of the hospital, (administration, medical and nurse departments), and the president of the scientific board. The scientific board is composed of 6 doctors with various positions in the hierarchy of the hospital‟s medical department, a scientist who is not a doctor but is a member of the hospital‟s medical department, and a nurse. The main responsibility of the scientific board is to consult with administration board about any scientific issue in the hospital. It also organizes and controls every educational 67 program for health care professionals in the hospital and it deals with the ethical issues of the hospital (Alexiadis, 2003). 2.3.4.1 Social work in Greek public hospitals Social work is practised in Social Services Departments (SSD) of public hospitals which were first established by the Minister of Health and Social Care in 1956. In 1978, the responsibilities of social workers in hospital settings were specifically defined by a law: “the social worker in the health sector contributes to the provision and therapy of emotional or socio-economical problems which are results of physical or psychological damage to people, difficult environmental conditions or problems in their personality which make diagnostic or therapeutic action difficult” Pandazakas and Mendis, 2002, pp. 98). At the 2nd Congress of social workers in 1981, the role of the hospital social worker was redefined as supportive to the scientific team of a hospital. Specifically, the role of the social worker was to inform the other health professionals about the social history of patients and their special problems. One other aspect of their role was to ensure the patients‟ social environment was supportive and responsive to their health needs. Lastly, social workers were to activate resources from the state for further support as appropriate. The responsibilities of the SSD in hospitals were redefined again in 1986 with a relevant law which is still active today. The current role of the social workers in hospitals is defined as: “the responsibility and care of the patients who are hospitalized for every social problem that affects them, the search and exploration of the reasons which cause these problems in each case but also the care for the elimination of these problems in the wider scope of the state‟s policy” (P.D 87/86; Pandazakas and Mendis, 2002, pp. 97-98). Until 1986, SSDs were parts of the administration department of each hospital. With the newer law of 2001, SSDs belong to the medical department of the hospital (Pandazakas and Mendis, 2002). Some hospitals that have not yet revised their rules and continue to place the SSDs in the administration division. However, it is anticipated that in the near future these SSDs will be part of medical departments. 70 how these ensure human and social well-being. Since there is no universally acceptable truth of what is human and/or social well-being, then social workers must also be able to explicitly articulate their philosophical and theoretical assumptions that construct their perceptions of well- being. The review of social work theories indicated that social workers are expected to deal with complex ethical dilemmas in practice due to their engagement with equally welcomed and often conflicting values and multiple obligations often framed by conflicting interests. Indeed, findings from empirical studies on social work ethics outlined the nature of ethical dilemmas in some practice environments, including hospital contexts, in the US, UK and Australia. However, social workers appeared not to be overly concerned with collective values, such as social justice, they could only broadly define their ethical problems, and they were not competent with ethical analysis and language. This knowledge is valuable to those who are concerned with the advancement of social work into a profession competent to make structural changes, and a collective of ethically aware practitioners who are able to identify the underlying values in their practice environments and interventions. The evolving interest in research, although often underpinned by the managerial ethos (Webb, 2001), challenges social workers to put forward their own criteria of what is important for further evaluation as exploration. Therefore, empirical studies on social work ethics highlights the moral dimension of practice by reviewing how professional values are applied in real practice environments. In particular, existing studies on social work ethical dilemmas enable practitioners to recognize the contextual factors as well as their personal/professional ideologies and values that structure their interventions (e.g ethical decisions) (Bowles et al., 2006). Despite the fact that there is a growing body of empirical studies on social work ethics, no study was identified as being relevant to the Greek context. However, this is probably just one of the elements that captures the underdevelopment of social work in Greece. In particular, the literature on social work and social policy in Greece indicates that social work is currently bound to a welfare state that is not sufficiently capable of providing adequate social protection to Greek citizens. Not surprisingly, within this context social work still has a low status, and lacks postgraduate education and research that could enhance the scientific competence of social workers. 71 Nevertheless, social workers must respond on a daily basis to their clients needs within a context where its fundamental welfare structures are characterized by fragmentation, clientelism, insufficient and inadequate funding. How Greek citizens experience these structures in their every day lives and how social workers practice their ethical engagements within these structures is less understood and virtually undocumented. However, the main purpose of this study is to focus on the social workers‟ experiences of these structures as these are related with their ethical commitments to enhance both social justice and individual well-being. In the following chapter social work ethics will be discussed in relation to critical social work practice which theoretically underpins this thesis. It is anticipated that the critical approach on social work ethics expands our understanding from the broad conceptualization of philosophical ethics to a more relevant conceptualization of ethics in social work. This understanding highlights the role of social work in promoting social justice, and also acknowledges that social workers practice within a context of national laws, international and national policies and particular cultural characteristics (Banks, 2008). 72 Chapter 3 Theoretical foundations: social work ethics and critical social work practice Introduction Current codes of ethics are comprised of a series of opposed values and ethics, which social workers are expected to promote equally (IFSW, 2004; NASW, 1999) ensuring that both individual and social needs are met. In fact, social work ethics is an emerging subject area that enables practitioners to re-establish social justice at the center of their professional aims. Social work values and ethics help practitioners deal with social change, allowing them to see beyond the situation at that moment in time and perceive a more effective route to achieving their aims. However, it is believed that ethical theories are not sufficient to guide social workers in the structural context of their work. In particular, Banks (2008) argues that ethical practice is often decontextualized in the existing social work literature. In particular she says: There is a tendency in some of the ethics literature to focus on the individual practitioner making difficult ethical decisions in cases that are sometimes constructed in ways that are decontextualized, both from the character and motives of the individual people involved and from the organization, policy, political and social context. This influences how practitioners conceive of and demarcate the domain of „the ethical‟ and their perceptions of their ability to act (pp.1244- 1245). Policy issues are not only disconnected from ethical social work practice, but is seems that social work has been ignoring its structural role. In particular, it is well documented that social work was always more dedicated to the micro-level practice at the expense of its professional obligation to social change (Dudziak, 2002; Gibelman, 1999; Payne, 1999; Figueira- McDonouhg, 1993; Beck, 1959). Therefore, social workers remained uneducated about the political and economic framework in which they function. This resulted in the disregard of the more contextual and policy-related issues in either their ethical decision-making or value judgments (Banks, 2008). The purpose of this chapter is to outline the ways that social work ethics are intimately related to policy analysis and practice. Furthermore, it is argued that the critical approach to social work practice provides an adequate framework allowing practitioners to respond to the moral aspect of the social work identity and its consequent ethical tensions. The chapter is grouped into two main 75 Similarly, Marx developed the theory of “materialism interpretation of history” and he argued that human beings cannot be understood in isolation from the social arrangements in which they live and the place which they occupy within these arrangements (Kamenka, 1969). The main contribution of Marx was that he bridged politics, state, and authority with economy. In fact, the whole idea of Marxist theory could be a single proposition, that the general character of the social, political and spiritual processes of life are determined by the mode of production in material life (Kamenka, 1969). Therefore, Marx believed that economy is superior to politics. For Marx each society has a mainly economic base. Therefore, the class structure of a society is determined by the struggle of the classes to control the means of production. Interestingly, in Marx‟s theory all kinds of ideological beliefs (e.g. political, moral, religious) are determined by the class structure – as this structure changes, ideology and morality change. Socialism emerged from Marxist theory and promoted a different political and moral outlook. Socialism investigates the social obstacles to human happiness and how they can be removed. Therefore, a series of values emerged and challenged the dominant social values that were reinforced by the logic of capitalism. Socialism promoted ideas of community, pleasure, and success through collective action and challenged the capitalistic value of a “successful” person who attains economic or political power (Galper, 1980). Furthermore, socialist doctrine was that “the majority of people should take control of their own society in their own best interest as they see that interest” (Galper, 1980, pp.30). Therefore, socialism promoted democracy as a value and political system, equality in the distribution of social resources, anti-oppressive values and social solidarity (Galper, 1980). In relation to the current political and economical system and the role of social policy, Iatridis (2002) argues that in a state which operates within the structures of a free market, two elements are in continuous tension: (a) the citizen as a person with rights, responsibilities and needs and; (b) the economic dynamics which are related to the stakeholders of the free market. Social policy mediates in the relationships between the two, ensuring that those who dominate the market will also cover citizens‟ needs and rights. However, with the dominance of liberalism and its relevant individualistic values, an inviolate line between the public and private realms was imposed, minimising the opportunities for social policy interventions (Morone, 1997). Similarly, Iatridis (2002) believes that what defines the content and the activities of social policy is mainly the dominant ideology. Therefore, there are different definitions of social policy. For 76 example, one view sees social policy as only dealing with the activities of the welfare state, that is, issues such as poverty, physical or psychological problems and social security. At the other end of the scale, a comprehensive definition involves all the issues that affect society such as those relating to economics, politics, administration, ideology, and social and psychological conditions. It is believed that both social policy and the welfare state that function within a free market are oriented to cover the needs of the economic policy. Therefore, the nature of social policy is powerfully defined by the economic policy. Iatridis (1985) exemplified this point by indicating that if economy needs an increase in unemployment to stabilize the markets, then the economic logic will dominate the values of social policy that are opposed to unemployment. Both social work and the welfare state will then just support the unemployed and also accept the social reality. However, social values appear to reinforce liberal politics and individualism in current societies. In particular, Rothstein (1998) indicates that the individualistic outlook of large social groups is continuously increasing at the expense of duties and commitments that had prevailed earlier, both in the family and in social life generally. Social work is an institution that can never escape the impact of society, being bound by statutory duties to promote specific policies. However, it is argued that as a social force it has a role to play in changing world social structures. This role requires a critical understanding of the ways that the political, economic and social arrangements, ideologies and values construct society (Adams, 2002). 3.1.1 Social policy and social work Social work is a profession currently defined as working for the promotion of social change so as to ensure a just society and the wellbeing for all individuals (IFSW, 2004; NASW, 1999). In other words, the social work profession is called on to deal with the impact of social structures on groups, individuals and communities, whilst simultaneously working to change those very same structures (Adams, 2002). Although there is no explicit denial of this dual responsibility, it seems that social work still struggles to find a proper balance between them. This is because social work has shown a lack of interest in broad social policy. In particular, Payne (1999) argues that social workers do not respond adequately to the macro-level objectives of the profession. He also 77 comments that social work seems to consider economic values as alien or inappropriate to welfare work, although they are necessary for the promotion of economic justice. In fact, in much of the social work literature it is argued that the profession should see economic security as forming the cornerstone of social change. Accordingly, Gibelman (1999) argues that social workers seem more devoted to the “psychotherapeutic enterprise” rather than to structural purpose and social change. Social work has never been able to attain its role in social policy development. Beck (1959) argued that the first effort at special training for social change methods was developed around the second decade of the twentieth century. However, social work education remained dominated by the psychoanalytical theory which did not lend itself to social change. Therefore, there was a persistent failure in social work to demonstrate its ability for social reform. Interestingly, Beck (1959) argued that community social work at that time was a process of “hidden manipulation”. An adherence to a basic set of humanistic and democratic values in social workers made them ever responsive to human needs (Beck, 1959). However, the advancement of radical and critical approaches reinforced the growing awareness of underlying causes of social problems (Adams, 2002). Inevitably, this also led to the recognition of the ambiguous role for social work as a political mechanism that contributed to securing the structures of unjust society (Banks, 1995). In fact, policy changes and underpinning ideologies the welfare state are reflected in the nature of social work (Adams, 2002). For example, Banks (1998) notes that social work is enormously affected by globalization, neo-liberalism and the ideology of new management. Specifically, she argues that greater bureaucratic accountability and greater technocratization, and the fragmentation of professional roles are the results of the current political state. However, criticism about the controversial role and identity of social work served to strengthen its image as an aspect of public policy. Politics started to be acknowledged as the context of social work practice, and the dialectic between politics and practice started. Nevertheless, it is argued that social workers still prefer to remain “apolitical” by not engaging in political action. In fact, Dudziak (2002) ascribed this stance as an effort to divide the “social” from the “political” dimension of things by only acknowledging the “social”. She illustrates this point very clearly: If our mandate is social justice, then the polis or the “political” in all its myriad meanings is already present. Yet as a profession not only do we not embrace the 80 a mechanism to evaluate practice, and defend social work‟s humanitarian character (Bowles et al., 2006; Feather, 2002; Clark, 2000; Fritzche, 1995). Authors who are concerned with social work ethics indicate that they should be perceived as intimately connected with politics especially in relation to the structural objectives of the profession (Banks, 2008; Bowles et al., 2006; Maeckelberghe, 2004; Meagher and Parton, 2004; Clark, 2000; Healy, 2000). However, notions such as the “ethical aware practitioner” often tend to focus on the individual practitioner rather to their ability to act on given structures. In this way, social work ethics are decontextualized, and then, instead of being activated as the base of social work‟s activity they remain as “mental abstractions” (Banks, 2008; Clark, 2000). However, it is also suggested that without emphasizing the role of social workers as moral agents, they become technical agents of the welfare state and they are prone to adhere to unethical structures and policies (McBeath and Webb, 2002). In short, it seems that values and ethics provide the moral worth of social work practice, including political action. This means that unless social workers operate from an ethical base, they are liable to seek social change by following a demagogue advocating ideas unrelated to the social work‟s fundamental values of social justice and human rights (Beck, 1959). Banks (2008) argues that in social work literature there are no apparent linkages between social work and politics. This argument is also reinforced by the fact that the majority of studies on social work ethics that were reviewed appeared to be concerned only with micro-level social work interventions. Similarly, Payne (1999) argues that social work avoids embracing political, economic, or aesthetic values, probably to attain scientific status. Nevertheless, since social work is a profession constructed through legislative decisions it cannot exclude itself from political discourse by staying artificially politically neutral. In this sense, ethical social work practice should not be seen solely as a disposition to act ethically, but crucially it must involve opposing dominant policies that are inimical to good ethical outcomes (Bowles et al., 2006). Stipulated policies or organizational regulations cannot provide social work, a moral activity, with the ethical justifications for its actions. Social workers are, however, called to respond to social justice even though there is no general agreement on these fundamental concepts (Briskman, 2001). Thus, to respond adequately social workers should be able to articulate a clear vision of what is perceived as “social good”, and embrace its responsibility to have a clear ideological 81 stance. The approach which places social justice as the leading value and aim of social work practice is critical practice. 3.2 Critical practice and social work Critical practice originates from radical and structural traditions that provide the perspective that social, political and economical structures influences human behavior. Therefore, human suffering could only be understood within specific contexts. In addition, critical practice is underpinned with social theories that emphasize that society does not exist in an unchanging or slowly changing social order, but that it evolves or may be subject to revolutions (Payne et al., 2002). This is why the main characteristic of critical practice offers the prospect of transformation by not being bound by the status quo (Payne et al., 2002). According to critical theories, human beings may act to change general social forms by the use of power. Power for critical theorists is used both for the maintaining the status quo in the face of a threat of change but also is a means of change. In fact, Webb (2001) argues that change is about producing conditions, effects and situations different to the status quo. Thinking critically is a way of thinking that enables practitioners to uncover the hidden assumptions and the ideological underpinnings of human activity, as well as the collective representations of the world. The essential elements of critical thinking include: reflectivity, openness, understanding and exploring language, considering the content of our judgments and questioning ideology. Through this process practitioners are able to make structural connections between individual behaviour and the wider contexts where humans act (Payne et al., 2002). In particular, reflectivity is the ability of a person to analyse and understand others‟ experiences and influences (Miehls and Moffatt, 2000). This means that all people can change through the experience of others‟ meanings and ideas. Moreover, through reflectivity a person has a better understanding of himself or herself in relation to the prevailing social situation. Consequently, practitioners are better able analyse people‟s problems by viewing them in the appropriate context. Crucially this process entails the recognition of the taken-for-granted beliefs that are transmitted from generation to generation and internalized through early socialization within a particular cultural context. Due to their nature, sociocultural beliefs tend to be persistent and resistant to change. Therefore, they must be understood if social change is within social work‟s scope of action (O‟Sullivan, 1999). 82 Overall, critical social work practice means a continuous and thoughtful consideration of the ways that our everyday actions are part of continuing streams of either social change or stability (Payne et al., 2002). This questioning approach leads to critical action which is about making change efforts from within organisations. Initially, when social workers transform understandings by making them critical, they become relocated in their wider context. Subsequently, understandings are revisited continually. This process advances the potential for social workers to discover oppressive features, and then develop an emancipatory and empowering potential for their actions. This is integral to continuing critical action (Payne et al., 2002). It has emerged that critical practice is concerned with human emancipation, which means liberating people from whatever causes them to suffer unnecessarily (O‟Neill, 2005). According to critical theories, unnecessary suffering is caused by the social, political and economic structures that create and reproduce inequalities between groups. These structures are oppressive as some people enjoy greater liberties than others in their effort to realize their full human potential. Emancipatory practice guides people to recognise their oppression and its causes so empowering them to liberate themselves (O‟Neill, 2005; Payne et al., 2002). Thus, the aim of critical practice could be defined as the pursuit of just social arrangements as represented by the value of social justice (Clark, 2000). The following section is a discussion about the relevant values of critical social work practice. It focuses specifically on social justice, which could be seen as both the aim and the core value of critical practice. As a large and complex aim and value, social justice is discussed in relation to its consequent values, such as equality and human rights, which are often seen as emphasizing individuality (Clark, 2000). 3.2.1 Critical practice and its values Critical practice does not necessarily encompass a different set of values and ethics than those prescribed in the ethical documents of social work. However, it highlights the importance of particular sets of values and leads social work to critically think about its ethical engagements (Dominelli, 2002). One of its most important characteristics is that critical practice places values and ethics in context to enable their meaningful implementation in everyday practice. Critical practice challenges individualization given it usually neglects that individuals are part of wider groups. In this sense, ethics such as self-determination can be perceived as an inappropriate 85 Critical practice has also encompassed critical reflection as a transformative learning process that aims to prepare practitioners to challenge and change dominant power relations and structures (Morley, 2007). Reflective practice enables practitioners to improve their practice by understanding and learning to articulate the theories, the unquestioned values and norms that inform their practice. The combination of critical theories and reflection raises practitioners‟ awareness about the political dimensions and processes implied in the construction of knowledge. Moreover, the purpose of critical reflection is to analyze, resist and change constructed power relations, structures and ways of thinking (Osmond and Darlington, 2005). Critical reflection is attuned with the commitment of critical social work practice to social change, social justice, and anti-oppressive practice as it enables practitioners to appreciate the political and social context of their clients‟ experiences. Moreover, it enables practitioners to gain insight into how their own values and beliefs may contribute to dominant power relations and therefore to the oppression of vulnerable people. This is highly important for social workers in terms of their ambiguous role (see also sections: 2.2, pp.29; 3.1.1, pp.76). In this respect, Morley (2007) argues that critical reflection minimizes the potentially unintentional contradictions between social workers‟ practice and their emancipatory intentions. Conclusion Political practice was always the neglected side of social work intervention (Gibelman, 1999; Payne, 1999; Figueira- McDonough, 1993). It appears that this was reinforced by stereotypes in relation to what constitutes a scientific status and the image of a caring profession. Payne (1999) argues that science is believed to be a value-free activity. As such, social workers excluded themselves from the political discourse, staying artificially political neutral; to attain scientific status. Furthermore, Dudziak (2002) argues that humans are educated to believe that conflict is a negative value and should be avoided as it may detract from the image of a “caring” and “positive” social worker. As Figueira-McDonough (1993) argues, even in countries where welfare policy is most advanced and social workers have gained considerable recognition as service deliverers, their presence at the level of policy development and program leadership is hardly recognized. Nevertheless, social justice has always been a leading value for the social work profession. In response to this objective, social workers should be equipped to build a clear conception of 86 justice against which to compare the prevailing situation. However, ethical analysis alone is not adequate for progression towards social justice, its implementation requires a commitment to policy practice that includes policy analysis and social action. Critical practice emerges as an important approach to social work as it also identifies the profession as promoting greater social equality and interventions beyond the personal level (Payne et.al., 2002). Furthermore, the critical analysis of social work ethics uncovers the ambiguities in social work due to a framework of structured inequalities and social injustice in which the profession operates (Rossiter, 2001). To this end, the contribution of critical reflection appears to be paramount. Values associated with a critical social work practice can shape progressive action which is committed to understanding power, inequality, and the subjective experience of well-being. Macro political values associated with socio-economic understandings of social policy, such as redistribution of resources, is critical theory‟s contribution to the construction of the morally active practitioner. In this sense, ethical social work practice is about social workers becoming ethical activists. This means social workers actively challenging the structures that do not support human well-being (Bowles et.al., 2006). 87 Chapter 4 Study Design Introduction The central aim of this study was to explore the role of social work ethics in Greece by looking at the case of social work practice in the Social Services Departments (SSD) of public hospitals. In particular, the focus of this study was to depict the role of ethics in the formation of what social workers perceived as ethically difficult situations and the consequent decisions they made. In addition, the role of ethics in the formation of the social work identity and the ideal or “good” social worker was also of interest to further understand how ethics are involved in the evaluative process of practice. As noted in previous chapters, social work ethics in Greece is an under researched area. To reiterate, the following questions were developed to focus on social work ethics in public Greek hospitals: 1. How do Greek social workers conceptualise ethics and their relationship with professional practice (e.g. social work code of ethics)? 2. What is the relationship between values and ethical principles and how do they inform the practice behaviour of Greek social workers? 3. What is the Greek social worker‟s experience of ethical dilemmas and the ethical decision-making process? 4. How do Greek social workers perceive ethics as contributing to good social work and/or the evaluation of practice? In order to adapt these questions to the Greek context of social work practice, the word “ethics” was replaced with “deontology”. According to Banks (2003) the usage of the word “deontology” instead of “ethics” is typical for some southern European countries. Furthermore, the exact Greek translation of “ethics” is too abstract and has no reference to ethical rules of professional practice. Instead, “deontology” is a word that is used in social work education and is commonly known among professionals, and essentially refers to what is understood as social work practice ethics. For example, Greece uses the term “deontological code” instead of “ethical code” of practice. 90 involves more than observing the social world; it requires interaction with the social world. In fact, they propose that the researcher must be part of the process, and needs to understand the symbolic nature of social action in the search for meaning. Therefore, in qualitative studies there is a strong emphasis on the detailed description of social settings, events, and individuals as qualitative researchers reinforce that social behaviour can only be understood in relationship to the context. Another characteristic of qualitative studies is that they use multiple methods such as interviewing, observing, and gathering documents. In qualitative studies social phenomena are seen holistically and the research questions are formed progressively according to the interactive process between the researcher and participants (Rossman and Rallis, 2002). In this study I wanted to describe the simultaneous interaction of many factors that shape ethics and social work practice in Greek public hospitals. Therefore, studying the interdependence between social workers and their environment was seen as a necessary condition for meeting the goals of this study. In this sense, the exploration of the political, cultural and organizational context of social work practice in Greece, described in section 2.3 (pp.54) was extremely important in order to understand the meaning of social work ethical dilemmas as an aspect of the social work reality in Greece. Importantly, empirical data was also obtained from social work academics and the HASW which are significant parts of the social work context in Greece. Furthermore, if social work ethics have something important to say about resolving difficult practice situations then ethics should answer what practitioners ought to do, but in reference to the concrete and real situations that social work is practised. Therefore, the role of the researcher is to highlight the specific context and the relevant factors that create difficult ethical considerations for social workers. In other words, a study on social work ethics should appreciate the nature of the settings in which ethical dilemmas and issues arise. The contribution of case study research is that it permits social work ethics to be understood contextually, to reveal practice realities and to obtain a more realistic perspective of professional practice. Qualitative methodology at this point recognizes and breaks the artificial borders that separate the moral, from the social, cultural, political and the personal. Processes such as ethical decision- making should not be considered as a straightforward application of a prescribed formula, but rather as a process that is sensitive to particular situations and processes where human creativity is involved in handling moral problems (Hoffmaster, 1992). Qualitative data can reveal what theoretically this thesis supported - that values and ethics are inherent in social work practice 91 even when ethical language is not used (Taylor, 2006; Seedhouse, 2005; Goldenberg, 2005; Adams et al. 2002; Everitt and Hardiker, 1996; Schon, 1987). It was also anticipated that participants‟ depth descriptions in semi-structured interviews would give them space to articulate ideas and concepts that, under a different set of rules, might never be shared. When the study population is perceived as vulnerable, this also takes on an ethical dimension which constitutes an ethical responsibility for the researcher to create a path by which vulnerable people will be heard in the public domain. Although social workers are rarely characterized as a vulnerable population, this study provided them with an opportunity to speak about their reality in their own words. In addition, the analysis of the Greek social work journal showed that practical issues related to practice were rarely published. Additionally, the studies reviewed from English journals were not relevant to Greek context. Therefore, it was very important that through this study Greek social workers had the opportunity to articulate their thinking about their own experiences. As Shaw and Gould (2001) state: … qualitative research can support values of decreasing inequalities and increasing life chances of all citizens by documenting inequalities in lives and analyzing precisely how social structures and social policies enhance and restrict opportunities for individuals and group (p.15). Brody (1993) also supports the importance of empirical studies in bioethics and medicine. He indicates that by discovering the ethical issues that actually arise in practice, a moral evaluation of ethical policies may be enabled. In reference to social work ethics in health care, Jansson and Dodd (1998) argue that in contrast with the extensive theoretical social work literature on ethics, scant empirical research has been conducted on ethical issues since 1980. In addition, they stress the importance of contextual factors that affect the ethical deliberations of social workers. They argue that researchers should analyze the extent that ethical decision-making process is influenced by organizational factors, and that the examination of specific factors that encourage or discourage ethical deliberations is crucially important. Although, these authors do not support the absolute use of qualitative research methods in social work ethics, their identification of the importance of contextual factors make qualitative methods relevant for this study. Qualitative studies have long been criticized because of their focus to intense empiricism and overly interpretative analysis of data which cannot easily be accounted as “evidence”. However, as applied social work ethics in Greek public hospitals had not been previously explored, a 92 qualitative study would enable the identification of relevant variables or questions that need exploring. In contrast, positivistic methods which test and explore predetermined variables or hypothesis would already have an inherent bias towards personal thinking or interpretations of the researcher (Conley and O‟Barr, 1990). This study adopted a single case design in which the case was the practice of social workers in public hospitals in Greece. Similar to other qualitative studies, case studies are more likely to be appropriate for “how” and “why” questions. However, there are no research questions typical to case studies as they do not favor any particular form of data (quantitative versus qualitative). A case study is a research approach that explores a contemporary phenomenon within its real-life context usually using multiple sources of evidence. The exploration of the complex interactions between the phenomenon under study and its context often necessitates the usage of multiple sources of data and the exploration of multiple units of analysis (Yin, 1993). In addition, a case study emphasizes detailed contextual analysis of a limited number of events or conditions and their relationships (Soy, 1996). Fieldwork is carried out in targeted fashion by focusing on the evidence deemed relevant and within a time-limited fashion (Yin, 1993). There is one basic set of research designs for case studies: single case studies and multiple-case studies (Yin, 1993). In single case studies there is one unit of analysis. However, within the single case may still be incorporated subunits of analysis, so that a more complex or embedded design is developed (Yin, 1993). The subunits can often enhance the insights into the single case. Three rationales can justify the usage of a single case design. First is when the research question is to confirm or extent a clear set of theoretical propositions. In this way, a single case is chosen which meets all of the conditions for testing the theory. A second rationale for a single case is where the case represents an extreme or unique case. The third rationale for a single case is where the case serves a revelatory purpose. This means that the purpose of the study is to provide insights into a phenomenon or a situation previously inaccessible to scientific observation. The case study is therefore worth conducting because the descriptive information alone will be revelatory (Yin, 1993). To summarize, the purpose of this study was to obtain a deep understanding of the meaning of ethics and ethical dilemmas in social work practiced in public hospitals in Greece. It was also argued that both social work practice and ethics are socially constructed and situated in the historical, political, social and cultural context. Therefore, this study adopted a case study design 95 expressed personal opinions, but thoughtfully and with care as this could possibly exert psychological pressure to participants. None of the participants declared being psychologically pressured or deceived. 4.3 The sample Qualitative studies such as this, which stress in-depth investigation in a particular context, typically use purposive sampling. In this sampling strategy the credibility and accountability of the study is not based on the sample‟s size as the goal is depth as opposed to breadth. Therefore, the sample is sufficient enough when the researcher judges that s/he has reached the required depth or situation. Furthermore, in purposive sampling the sample is composed of participants who can provide the rich information necessary for the purpose of the study and meet identified criteria of interest (Bailey, 2007). My initial target was to complete at least twenty interviews with hospital social workers. However, I had great difficulty obtaining letters of approval from hospitals, and I finally stopped at fourteen because at this stage no further new themes appeared to be emerging. I also determined that an exploration of social work academic‟s accounts of ethics and as those of the HASW would allow a deeper understanding of ethics in social work practice as hospital participants continuously made reference to their education and professional association. Therefore, I decided to supplement my data with a group interview with university-based social work academics, and one interview with a member of the Hellenic Association of Social Workers (HASW). The focus of the data obtained by the interview with the representative of HASW was on issues that had already emerged from the interviews with the hospital social workers, but also to explore HASW‟s contribution to the promotion of social work ethics in professional practice. It is worth noting that the representative of HASW was very active in the association, and had several years experience in hospital practice. In addition, I reviewed the journal of the HASW in order to examine how the HASW and social work practitioners encounter ethical issues through the Greek social work literature. My purpose of the group interview with the social work academics was to examine the ethical dilemmas that they or their students faced in their practice. For example, I was interested in 96 knowing how the academics managed ethical issues that students experienced in practice learning. Purposive sampling was used in order to ensure that all hospital social workers had obtained a BA in social work, and had a minimum of one year postgraduate work experience. For the social work academics, each participant had obtained a higher education qualification and had to be supervising students in practice settings. To ensure that this group interview would not be biased by hierarchical power and lessen the possible consequences of disclosing of personal experiences, participants had similar job classifications. 4.3.1 Research sites The hospital social workers who participated in this study were employed by six public hospitals which are all subjected to the structure and services prescribed by the National Health System of Greece. The social work academics were employed in the social work department of a Technological Institute (TEI), located in one city in Greece. The university was founded in 1983 and the social work department was formed in 1984. Every year approximately 130 students start their studies in the department. The education of the social workers lasts for four years, divided in eight semesters. The last semester is a full time practice in a social work placement. The department offers students only a BA degree and there are no MA programs. The Hellenic Association of Social Workers (HASW) is located in Athens, although it has regional committees in twenty four cities in Greece. 4.3.1.1 Athens Athens is the capital of Greece having a population of more than 3,700,000 and is the largest city in the country. This constitutes 34.3% of the overall population of Greece (Iosifides et al., 2007). Athens dominates Greece mainly because of its population size, the concentration of industry and the centralized administrative system. Iosifides et al. (2007) argue that Greece, and in particular Athens, was a mass immigration destination in the early 1990s. More than 800,000 immigrants live in Greece, although it is estimated that this number does not reflect the real figure as many immigrants avoid registering in the census. 97 Four of the six hospitals in this study were in Athens. Three of these hospitals were general hospitals with approximately 60-100 beds. They each employed one social worker. The fourth hospital in Athens was a 1000-bed child mental health hospital that provides both medical and psychiatric services to the public. This hospital employed ten social workers who primarily work in the psychiatric departments. Overall, five of the participants in this study were working in a hospital in Athens. The representative of the HASW had also worked in a hospital in Athens, and she was a member of the central committee of Athens2. 4.3.1.2 Patra Patra is the capital of the Prefecture of Achaia. It is one of the most important cities in Greece and it is the biggest city of Peloponnesus. It is the fourth biggest city in Greece after Athens, Piraeus, and Thessaloniki, with almost 160,000 people. Patra has the biggest harbor in West Greece and connects Greece with Italy and Peloponnesus with Ionian islands of Greece. Patra has two general public hospitals, one child hospital and one special hospital for pneumonic diseases. Patra is also a city that has many immigrants due to its harbour. Two of the hospitals in this study are located in Patra. One is a university hospital with more than 1500 beds and twelve social workers. The final hospital is a 400 bed general hospital employing 8 social workers. Nine of the participants were employed in a hospital in Patra. 4.3.2 The participants The current study focused mainly on social workers working in public Greek hospitals. As the qualitative design of this study permitted multiple sources of data, interviews with three social work academics and one interview with a representative of the HASW were also obtained in order to shed light on issues that emerged from the interviews with hospital social workers. Table 1 outlines the number of interviews held and the participating organizations3: 2 Further description has been omitted to protect the identity of all participants. 3 Identified information of the sites was not shared in order to protect confidentiality and anonymity. All names of the organizations as well as of the interviewees appear as pseudonymous.