Exploring the Ethical Issues in Family Therapy

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

Ethical Issues: Worker’s intuitive moral (Kitchener, 1984) sense didn’t provide a decision lead to the protection of both the wife and husband. Worker came up with the following considerations: Keep this confidential as requested by Mrs. Chan. This would keep the work relationship with the couple. But this may take the risk if Mr. Chan really did it and would do it again and it might lead to the worst scenario, homicide. Persuade Ms. Chan, to have her consent to disclose this to Mr. Chan, explore if this was true, his intension because this might due to the unbearable stress level caused by taking caring of his wife. If he did it in purpose, need to consider if this needed to be reported to the police. But this would totally break the trust and work relations with both the wife and the husband. And worker seems not supporting the caregiver, instead, she might take him to jail and at the same time, the caregiver stress would be overlooked.

In option a, worker could keep the request of Mr. Chan, confidentiality issue is not violated. By being faithful to Mrs. Chan, keeping secret for her can uphold the principle of Fidelity. The relationship with both the wife and husband will not be damaged. This might help in future support to their needs since one of the service objectives is to provide support to the caregivers. If worker choose option b, it might break the relationship with Mrs. Chan since worker didn’t have her consent to talk to Mr. Chan on the issue. The relationship between the couple might be spoiled because this may expose Mr. Chan’s intention of his very special action. He might no longer be regarded as a good husband, a good caregiver nor a good father. This would harm the worker client relationship which would not be beneficial to any subsequent care plan.

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

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

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

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

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

Fidelity: Since the underlying issue was the care burden, efforts in taking care of a late stage wife should be honored and commitment in resolving or eliminating the caring stress should be promoted among the family. Ah Fai should also be invited to join interviews and his effort for support can sure mitigate the tense relationship between the couple. Referring to the Universalizability Theory (Kitchener, 1984, p.53), worker answered the 3 important questions as follows:

1. If I were in a similar situation, I would want my therapist to reveal my husband’s action such that he learned to protect himself, even though I might have been killed.
2. If my family were in a similar situation, I would want the therapist to verify the husband’s intension and let him know the best way to protect his wife and himself when his stress resilience level is due.
3. If other people were in a similar situation, I want the therapist to disclose the situation, too. This would prevent tragedy like “homicide the beloved, with one killed and one put in jail consequently”.

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

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