1. Chapter 4 Ethical Decision Making in Military Social Work

2. Some Key Conflicts With the NASW Code of Ethics That Have No Clear Answer
Is the client the airman or the Air Force?
Do we have an obligation to ensure the Marine is ready for combat and, if cleared, can we handle his or her subsequent combat death because we sent him or her back to duty?
Do commanders have the authority to order our clinical decisions to slant the “desirable” way?
Should a social worker who opposes the war work with a veteran who has gone to war?

3. Some Dominant Themes Within the Military Culture
Image is crucial and self-control is expected.
The military takes care of its own.
Mission is first priority.
Hierarchy dictates social convention.

4. Dual Loyalty Issues
Are you a military officer first or a social worker first?
For example:
Social worker recommends that a soldier is unfit for duty due to PTSD, but the commanding officer rejects the recommendation, orders the soldier back to duty, and pressures the social worker as he needs “every soldier in the fight.”
Social worker successfully treats a self-referred military client. The client is promoted and requires a security clearance. Social worker is required to complete the clearance as the only mental health provider available. The report is read by the executive officer, who denies the clearance due to the mental health diagnoses revealed in the report.
What happens if treatment of veterans with PTSD improves their symptoms, but they do not want the results recorded as the findings would reduce their disability pay? Should the therapist not record the improvement in the record?

5. Confidentiality and Privacy Issues
It’s a fine line between protecting the client’s right to privacy and the “need to know” for commanders.
In the 70s several authors jolted the profession with reviews of research indicating that direct social work practice was not effective. These studies were later criticized for failing to evaluate specific, clearly described interventions. Later studies provided grounds for optimism by addressing this problem and demonstrating the effectiveness of well-explicated interventions.

6. Some Recommendations for Navigating Stormy Ethical Waters
Assume that every member of the community is a future client.
Provide immediate informed consent to all clients.
Use stringent interpretations of “need to know” policies and especially “be conservative when determining what information is crucial to the question posed by a command.
Avoid significant self-disclosure.
Consider alternative mental health resources when complicated or awkward situations occur.
Actively collaborate with clients regarding management of nonclinical interactions so you and client know how to respond in informal contact.
Carefully document uncomfortable multiple relationships and your efforts to carefully document awareness of the problem, ethical reasoning, and clear efforts to resolve the dilemmas in the most expeditious and elegant fashion possible.

7. Neutralizing the Hierarchical Power Structure When It Prevents Appropriate Care
Fight rank with higher rank.
If the commander is shutting down your clinical judgment, you go up your chain of command until you can have a higher-ranking medical officer discuss the importance of clinical input.

8. Triad Model of Ethical Dilemmas

9. The ETHIC Model: Step 1
“Examine relevant personal, societal, agency, client and professional values.” Related to military social work, this step implies the social worker needs a clear understanding of the military context, culture, and chain of command and an in-depth awareness of the client’s rights to appeal or negotiate decisions directly impacting the client’s best interest.

10. The ETHIC Model: Step 2
“Think about what ethical standard of the NASW code of ethics applies, as well as relevant laws and case decisions.” Related to military social work, this step implies the need for a thorough understanding of the code of ethics and when it clashes with the current military issue you are facing. You should have a detailed awareness of the UCMJ and should consult with military (and possibly civilian) attorneys on the issue.

11. The ETHIC Model: Step 3
“Hypothesize about possible consequences of different decisions.” Related to military social work, the pros and cons are based on understanding of the issues in the first two steps. The key point is to prevent rushing to a decision without working out all choices and consequences.

12. The ETHIC Model: Step 4
“Identify who will benefit and who will be harmed in view of social work’s commitment to the most vulnerable.” Related to military social work, this step is most challenging because the military is committed to the mission, not to the most vulnerable.

13. The ETHIC Model: Step 5
“Consult with supervisor and colleagues about the most ethical choice.” Related to military social work, consultation is sound advice and can include going up the chain of command and seeking legal advice from Judge Advocate General (JAG) officers. The complex issue could be not being able to share sensitive military information when consulting with civilian counterparts who could be naïve to the military context.

14. NASW Ranking of Ethical Principles
Ethical Principle 1: Protection of life
Ethical Principle 2: Equality and inequality
Ethical Principle 3: Autonomy and freedom
Ethical Principle 4: Least harm
Ethical Principle 5: Quality of life
Ethical Principle 6: Privacy and confidentiality
Ethical Principle 7: Truthfulness and full disclosure

15. Six Strategies for managing Ethical-Legal conflicts
“Determine whether the dilemma constitutes a tension or a conflict.” Social workers should use negotiation skills and chain of command to reduce the tension and clarify the concern so the issue can be navigated legally and ethically. For example, a lawful order to release mental health records can be clarified to see what specific issue (i.e. security concerns) may be complied with without releasing the whole record.
“Know your ethical code and relevant federal laws.” The NASW Code of Ethics is well-known. The primary legal document to familiarize yourself with is the Uniform Code of Military Justice ( The best way to understand the UCMJ is to chat with a Judge Advocate General (JAG) officer about possible situations that you are likely to face.

16. Six Strategies for managing Ethical-Legal conflicts (Continued)
3. Develop a process for ethical decision making.” The authors do not detail the process but do emphasize a slow process of researching your options and rights and avoiding impulsive or naïve reactions to legal requests. 4. “Recognize that military service does not overrule or negate one’s identity and obligations as a health professional.” The authors reaffirm our allegiance to our code of ethics and warn against “ ‘drift’ in the direction of primary allegiance to military tradition and regulations at the expense of adherence to professional ethics”(p. 552).

17. Six Strategies for managing Ethical-Legal Conflicts (Continued)
“Seek to balance client best interests with DOD regulations.” Basically, the authors advocate to carefully minimize harm to the client if feasible and be sure to discuss the options with the client at each step. Document what steps you are taking and the client’s involvement.
6. “Work to reduce conflicts between ethical guidelines and federal law.” Advocate for legal changes to laws and policies and educate people in power about the conflicts when they occur.

18. Discussion Questions
Do you believe that you can balance the military as a client and the service member as a client? Which would you choose as your primary client? Can you see a situation where the military needs to be your primary client? Can you see a situation where the service member needs to be your primary client?
Do you believe the situation is ethical if a service member wants you to support the military family’s request for approval of an overseas assignment if the services for their autistic child are not adequate in your judgment? What would you do?
Do you believe the situation is ethical if the veteran with posttraumatic stress disorder makes significant improvement but wants you to not record the improvement as the veteran would have his service-connected disability check reduced? What would you do?
Using the PSPIDD model of ethical decision making, what ways can you think of to slow down the decision making and allow to you work out your options? Often you will receive pressure from the commander or designee to act the way they desire. How do you take the time needed?