Download a PDF of this article

The professional socialization of social workers involves the process of acquiring knowledge and skills, values, attitudes, and professional identity (Miller, 2010). As a field liaison for graduate social work students, one of my responsibilities was to link field placement experiences with classroom work. I accomplished this with seminars, site visits, and review of written agreements, reflections, and evaluations. Barretti (2004) notes that virtually everything faculty and field instructors do and say profoundly influences their students. Professional competencies that lead to professional socialization involve a process where students begin to utilize professional language in their construction of events, and to implement actions to address ethical issues and dilemmas (Dolgoff, Lowenberg, & Harrington, 2009; Holosko & Skinner, 2009; Horner & Kelly, 2007; Manning, 1997). In this paper, I describe an ethical dilemma with respect to research at a field placement. I then analyze the dilemma, and finally discuss how an intern can work toward promoting client self-determination and social justice with respect to a complex dilemma.


Social workers are responsible for promoting social justice, integrity, and the dignity and worth of the person. Social justice, as defined by the NASW Code of Ethics (1999), is the pursuit of social change on behalf of vulnerable populations, striving to ensure that individuals have access to needed information, services, and resources, and that they can meaningfully participate in decision-making processes. Social workers promote the “dignity and worth of the person” and ensure client self-determination. “Integrity” implies that social workers act honestly and responsibly, and promote ethical practices on the part of the organization with which they are affiliated (NASW, 1999). If I, as the field liaison, want my students to think critically about the NASW Code of Ethics, then I need to hold meaningful discussions with my students about the inherent values and ethics of social work in the field. Critical thinking around ethics, according to Banks and Williams (2005), involves asking ‘What should I/we do?’ in terms of how individuals should treat each other and their environment and if certain actions should be regarded as right or wrong.

An Ethical Dilemma in Research in a Psychiatric Hospital

The ethical situation that challenged me as a field liaison occurred at a psychiatric hospital where one of my students was interning. From my perspective, the situation involved routine experimental research protocols so deeply embedded in the hospital’s culture that it seemed unlikely that either the field instructor or the student was aware of the ethical implications of these protocols. The student, completing her last semester of her Master’s in Social Work (MSW) program, was interning three days a week at an inpatient psychiatric hospital, where she was also doing a research project. I met with the student and her field instructor midway through the semester. The field instructor conclusively noted that the student was making terrific progress in her assignments and was well-liked by staff and patients. The student was assigned group and individual work, and was an effective part of the treatment team. Additionally, the setting gave the student plenty of opportunities to work with issues related to socioeconomic, racial, and ethnic diversity.

As we talked, I became aware that the hospital participated in drug trials. The hospital had an active Institutional Review Board (IRB) that monitored ongoing research, carried out in collaboration with pharmaceutical entities, on patients receiving treatment at the hospital. For the most part, these patients were receiving treatment for serious and chronic psychiatric conditions, such as schizophrenia and bipolar disorder. The student, as part of her MSW program, was doing a research project at the hospital which involved a review of records. I questioned the field instructor and the student regarding the question of whether one could obtain informed consent from patients who have severe psychiatric conditions. My challenge to the student and field instructor subsequently led to a discussion of the extensive research conducted at this hospital. The student’s project had been approved by the hospital’s IRB; the field instructor reported that this was the first time he had been involved with the time-consuming IRB process. The student reported that she had successfully completed the National Institute of Health’s web-based training course “Protecting Human Research Participants” (2008) as required by her university. The student, upon recognizing my concern about patients’ rights to informed consent, quickly acknowledged the difficulties involved in obtaining informed consent from individuals who are of diminished capacity because of mental illness.

Many concerns came to my mind as I sought to understand the IRB process. My questions centered on the issues of informed consent, payment for participation in research, and clarification of risks and benefits. The first concern was whether these patients could give informed consent to participate in a research study. Thomlison and Corcoran (2008) provide a detailed discussion about the importance of informed consent. They delineate the procedures to be used to inform clients about the risks involved in the procedures, and alternative procedures and their concomitant risks. They describe how clients may acquiesce because of undue influences, noting that a trusting and confidential relationship between a social worker and a client may prevent the client from refusing to participate in the trial. These authors suggest that the “ideal” of informed consent may be lacking because a client may not be intellectually capable of understanding, or because the client may feel pressured to agree. Thomlison and Corcoran (2008) also examine the inherent conflict between protecting the client’s interest and the interests of those providing pecuniary resources, noting that this “conflict cannot be resolved simply” (p. 82).

I wanted to know how to protect the rights of these clients. I speculated that there might be a number of reasons that hospitalized psychiatric clients might sign informed consent for trials involving participation in pharmacological research. Dolgoff, Loewenberg, and Harrington (2009) suggest that individuals with mental illnesses are vulnerable and that this vulnerability undermines their consent. They also note that the client’s trust in the practitioner may result in diminished participation in decision-making process. Additionally, I wondered whether some of the medications that clients were already taking might be helping to make them compliant.

My intern suggested that it was possible that researchers at the hospital spoke with “proxies,” people who are appointed to act independently for individuals who may not be deemed competent to sign consent forms. The student and the field instructor, though, were unsure if proxies were obtained or if patients signed informed consents. I didn’t know how proxies work for individuals with mental health issues, and I wondered if proxies were expensive and cumbersome to implement. I suspected that the investigators probably had found a way to limit the need for proxies, and I doubted if there were objective criteria that investigators used to determine a need for proxies.

A second issue that concerned me was the suggestion that the medical expenses of the participants in these pharmaceutical studies were paid for by the parent pharmaceutical companies. The Belmont Report, from The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1979) states that undue influence can occur through an offer of an excessive, unwarranted, inappropriate, or improper reward to obtain compliance, especially an offer to vulnerable patients (http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.html). Pharmaceutical companies’ payment for the patients’ hospital treatment implied that the patients’ medical insurance carriers were not paying for these patients’ hospital expenses. Since most medical insurance plans in the United States have only limited coverage for mental health treatments, it would certainly seem to benefit the patient financially if a pharmaceutical company paid for the patient’s hospital expenses. Having a pharmaceutical company pay for treatment may allow a patient to continue to have insurance coverage if further medical treatment is needed for mental health issues. As I started to think in greater depth about the level of compensation that patients receive for their participation in a study, my wariness of pharmaceutical companies’ involvement in hospital research studies increased. Psychiatric hospitalizations are expensive. Is participation in studies really voluntary if the compensation is so great that the patient feels that he or she must participate for financial reasons? If a patient doesn’t have health insurance coverage and therefore is not eligible for treatment, is participation in the study the only way the patient will receive treatment? If an individual has medical insurance coverage, does participation ensure that the patient will not use up all of their benefits for this hospitalization? Are these studies contributing to the institutionalization of medication as the preferred treatment, rather than other forms of intervention that might be just as effective and less biologically intrusive? If most of the studies on treatment for psychiatric illnesses involve psychiatric medications, is it likely that the outcomes will recommend psychiatric medication? If more of the studies recommend medication, will this result in patients being treated with medication?

A third issue of concern was whether patients really understood the risks and benefits of research studies. My student referred to the concept of beneficence. As the Belmont Report (1979) puts it,

The obligations of beneficence affect both the individual investigators and society at large…. Investigations are obliged to give forethought to the maximization of benefits and the reduction of risk that might occur from the research investigation… In the case of scientific research, in general, members of the larger society are obliged to recognize the longer term benefits and risks that may result from improvement of knowledge. The principle of beneficence often occupies a well-defined justifying role in many areas of research involving human subjects (para 17).

Clearly, mentally ill patients could benefit if research discovers new and effective treatments. However, studies may also have negative consequences for patients. Pharmaceutical studies may cause subjects side effects that are harmful and long-lasting. The propagation of biologically-based interventions rather than other less intrusive interventions may lead to long-term financial cost to patients. Patients need to be apprised of the risks and benefits of interventions in language that they can understand.

An important question is, “Who benefits from the research?” There may be even more benefits to researchers and hospitals than to patients. Researchers benefit from using psychiatric patients because of their “easy availability, their compromised positions, or their manipulability…” (Belmont Report, 1979, para. 21) Pharmaceutical companies benefit financially from research that reaches positive conclusions about the companies’ medications. Kutchins and Kirk (1995) note that drug companies reap enormous profits from the expanding market for psychiatric medications, and that these companies have a direct financial interest in increasing the number of people who might be treated with their products. In order to get approval to sell medication, these companies need to demonstrate the drug’s effectiveness through studies. Hospitals that participate in studies provide a venue to demonstrate the effectiveness of specific treatment protocols. I wondered how the hospital benefitted from participation: for example, does the hospital receive reimbursement from pharmaceutical companies for each patient enrolled in a study? Are higher hospital rates approved by insurers for hospitals participating in research studies? Social work interns, like their clients, need to understand the risks and benefits of research studies for all involved parties, not just to their clients.

What Can Interns Do When Faced with an Ethical Dilemma?

It is not unusual for social work students to be placed in internships where there are ethical dilemmas. In this example, while students might not be directly involved in research occurring at their facilities, this lack of involvement does not preclude students and field instructors from exploring the ethical ramifications of this type of research. How can interns respond to such ethical dilemmas?

Interns should start by examining their own values, as well as reviewing the National Association of Social Workers’ Code of Ethics, and, if applicable, their Institutional Review Board’s standards for research. Clear understandings of one’s professional values guide an individual’s professional actions, which includes knowing the legal and moral responsibilities of social workers. Before taking any action, interns should assess the mission and values of the organization in which they are practicing, and the values of the different professionals within the organization. At this point, interns can choose from a number of options, including informing clients of their rights, asking thought-provoking questions, and implementing social action initiatives.

Social work students who are placed in settings like this hospital where there are issues around social justice should first clarify their own personal values. Bryan (2006) states that social work students enter placements with already-established personal values, and suggests that these initial values can change to accommodate different contexts. Addressing ethical issues involving organizations may give rise to the need for social workers to think about their role in ensuring equality and justice. As an advisor, I tried to ask my student and her field instructor thought-provoking questions about research ethics; I could have also asked her to imagine herself as a client in this psychiatric hospital, or explored possible roles in ensuring equality and justice.

Social work students placed in hospital settings need to be sensitive, both to their role as a student and to the context of social work in their particular hospital. Students are generally in a host setting where the primary mission is intervening medically, rather than managing issues that pertain to social justice. Banks and Williams (2005) suggest that social workers need to pay attention to the relevant organizational context of actions, and to the reasons, motives, and emotions of others in the organization. Other professionals may hold values that differ from those of social work. When social work students are placed in host facilities such as hospitals, there are many differing professional values systems and organizational constraints in place that students need to take into consideration.

Abramovitz and Lazzari (2008) describe social justice in social work practice. Social justice is concerned with the systematic marginalization and exclusion of people with disabilities, and unequal and unjust distribution of power and resources. Hardina (2002) views social workers as “change agents” who engage in a variety of activities to obtain justice. The first step towards social justice is to empower the client. While individuals with mental illnesses may be vulnerable, these individuals still have an array of strengths. Individuals with mental illnesses can and ought to be part of any process that involves changes in systems that affect their well-being. Social workers can help facilitate these individuals’ access to the information needed to make decisions with respect to participation in research. Grobman (2002) outlines a number of ways that students in field placements can identify and promote direct involvement in social change. Gathering data, drafting letters, and organizing meetings are a few of the many ways in which interns can advocate for change.

Students examining the need for change in how research is undertaken in hospitals might start by asking a series of questions. How does the hospital ensure patients’ meaningful participation in decisions around whether or not to take part in pharmaceutical studies? How does the hospital ensure that patients understand all of the ramifications of a study? Are patients given the resources and services to be able to refuse to participate in a study? Are proxies effective in ensuring patients are treated fairly?

If interns are concerned about inequality of service or unfair practices in an organization, there are several options available to them. Ward and Mama (2006) suggest that they should discuss the problem in supervision, and that they have the right to leave the agency if the situation is not remedied. I hoped that this intern and her field instructor would discuss possible action plans within the hospital, and inform themselves of legislative initiatives, like the Affordable Care Act, that may insure patients’ mental health as well as their health coverage.

Addressing Ethical Dilemmas in the Classroom

After expressing my concerns to the student and the field instructor, I solicited input from the students in my field seminars. Students could share information and feelings about their field experiences and could highlight relevant topics, such as values and ethics. I described my uneasiness with research involving individuals with serious mental illnesses, because of the potential for unfair manipulation of a vulnerable population. This discussion led to a brief dialogue on the difficulties in obtaining informed consent from individuals with impairments and individuals receiving involuntary services. The focus of this discussion was based on Loewenberg, Dolgoff, and Harrington’s (2009) principles of least harm: choosing the option that will result in the least harm, least permanent harm, or the most easily reversible harm. I reviewed the controversies surrounding pharmaceutical studies on prisoners in the Philadelphia area involving researchers at the University of Pennsylvania (Hornblum, 2007). Hornblum (2007) notes that, despite the 1961 World Medical Association Code of Ethics declaration that persons detained in prison should not be used as subject of human experiments, research in prisons thrived through the early 1970s because of payment to prisoners to cover everything from toiletries to bail money. The Institute of Medicine and of the National Academy of Sciences presented a report in 2006 that claimed that, despite past abuse in biomedical research in prisons, research affords the potential of great benefit and will help craft responses to the myriad health problems faced by prisoners. These examples of research dilemmas brought to life the students’ discussions of social work ethics.

After having obtained feedback from the students, I asked faculty members how they integrate values and ethics into field assignments. Faculty members reported that discussion of ethics was included in student field seminars and integrated in class discussions. Ethical issues frequently raised included issues around confidentiality, boundaries, the importance of relationships, and competence of clients. Ethical dilemmas, like that of informed consent for research, should be discussed in all social work classes, especially capstone courses like our school’s final semester community practice class.

My sense was that material on broader ethical issues is more likely to be covered at an abstract level in the community and policy courses, rather than systematically in field settings. While I saw broaching this subject as an opportunity for myself and other faculty members, I had some misgivings about bringing it up at a faculty meeting. Yet I was hopeful that by sharing my experience I would get constructive feedback that might also be beneficial to other faculty members. While I had no direct evidence that anything was amiss, I was uncomfortable with this situation and the moral standards involved in doing research on individuals with serious mental health problems. Faculty members were supportive and validated my uneasiness about the situation. We briefly discussed the important role that pharmaceutical interventions have had in helping individuals with mental illnesses and how this role was complicated by the profits that the pharmaceutical companies made from the sale of medications. As I shared my concerns with other faculty members, I was reassured about my interventions. I became convinced that the discussion of ethical dilemmas in field placement created a unique opportunity for elaboration of the principles of ethical social work practice.

Conclusion

One of the limitations of this paper is that my discussion of questionable research practices in a hospital setting is not intended to provide an integrated framework for what should be happening in a field practicum. I see students’ learning experiences as constituted by reflection on values, by direct practice experience and by the social life of the institutions in which these experiences occur. However, this potential dilemma in research opened up an invaluable conversation with my student and her field instructor, and with fellow faculty. Discussions about dilemmas like informed consent, payment for participation in pharmacological studies, and clarification of risks and benefits of research highlights important social justice concerns and is, therefore, an integral part of the professional development of students in field as well as in class.

Abramovitz, A., & Lazzari, M. (2008). What is social justice? Updates from the council on social work education commission for diversity and social and economic justice. BPD Update Online, Spring 2008. Retrieved from http:/www.bpdupdateonline.org/spring2008/id98.html retrieved 5/22/2008

American Psychiatric Association. (2006). The principles of Medical Ethics with annotations especially applicable to psychiatry. Arlington, VA: American Psychiatric Association.

Banks, S., & Williams, R. (2005). Accounting for ethical difficulties in social welfare work: Issues, problems and dilemmas. British Journal of Social Work, 35, 1005-1122.

Barretti, M. (2004). The professional socialization of undergraduate social work students. The Journal of Baccalaureate Social Work, 9(2), 9-30.

Birkenmaier, J. (2002). Promoting social justice within the practicum. In Grobman, L. (Ed.), The field placement survival guide: What you need to know to get the most for your social work practicum. Harrisburg, PA: White Hat Communications.

Bauman, R. (1992). Story, performance, and event: contextual studies of oral narratives. Cambridge: Cambridge University Press.

Bryan, V. (2006). Moving from professionally specific ideals to the common morality: Essential content in social work ethics educations. Journal of Teaching in Social Work, 26(3/4), 1-17.

Dolgoff, R., Loewenberg, F., & Dolgoff, R. (2009). Ethical decisions for social work practice (8th edition). Belmont, CA: Thomson Brooks/Cole.

Goodban, N. (1985). The psychological impact of being on welfare. Social Service Review, 59, 403-422.

Grobman, L. (2002). The field placement survival guide: What you need to know to get the most for your social work practicum. Harrisburg, PA: White Hat Communications.

Hardina, D. (2002). Analytical skill for community organization practice. New York: Columbia University Press.

Holosko, M., & Skinner, J. (2009). Shaping the implicit curriculum through student voice in a BSW program. Invited presentation at the Baccalaureate Program Directors Annual Meeting, Phoenix, AZ.

Hornblum, A. (2007). Sentenced to science: One black man’s story of imprisonment in America. University Park, PA: The Pennsylvanian University Press.

Horner, R., & Kelly, T. (2007). Ethical decision-making in the helping profession: A contextual and caring approach. Journal of Religion & Spirituality in Social Work, 26(1), 71-88.

Kutchins, H., & Kirk, S. (1995). Should DSM be the basis for teaching social work practice in mental health? Journal of Social Work Education, 31(2), 148-169.

Lowenberg, F., & Dolgoff, R. (2005). Ethical decisions for social work practice (7th edition). Itasca, IL: F.E. Peacock Publishers.

National Academy of Sciences. Institute of Medicine. Ethical consideration for research involving prisoners. July 12, 2006, xii.

National Association of Social Workers (1999). Code of ethics. (Rev. ed.) Silver Spring: Author.

The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (April 18, 1979). The Belmont Report Office of the Secretary Ethical Principles and Guidelines for the Protection of Human Subjects of Research. Washington DC: U.S. Government Printing Office. Retrieved from http://www.hhs.gov/ohrp/humansubject/guidance/belmont/htm

Manning, S. (1997). The social worker as a moral citizen: Ethics in action. Social Work, 42, 223-230.

Miller, S. (2010). A conceptual framework for the professional socialization of social workers. Journal of Human Behavior in the social Environment, 20, 924-938.

Siporin, M. (1985). Deviance, morality, and social work therapy. Social Thought, 11( 4), 11-24.

Thomlison, B., & Corcoran, K. (2008). The evidence-based internship: A field manual. Oxford: Oxford University Press.

Ward, K., & Mama R. (2007). Breaking out of the box: Adventure-based field instruction. Chicago, IL: Lyceum Books, Inc.