Section 5. Ethical Issues in Community Interventions

Learn how using your personal, moral, legal, and social standards can increase your program effectiveness and provide you with moral standing in the community.

 

You run a community violence prevention program, working with gang-involved and justice-involved youth. The youth trust you, and sometimes divulge information to you. The police also know you work with gang-involved youth, and often ask you for specific information about particular youth. What are you obligated to tell them, or to keep from them?

The right of a person to know what happens to information he reveals in the course of a community intervention falls under the heading of ethics. A participant in a community program -- a health clinic, an adult literacy class, a youth leadership initiative -- has a right to certain expectations relating to how she and the information she passes on are treated. The community has expectations as well about the reliability, competence, and honesty of a program that benefits its citizens. In this section, we'll discuss what some of those expectations are, and your and your organization's or initiative's moral and legal obligations to those you serve.

What do we mean by ethics?

Ethics is a code of thinking and behavior governed by a combination of personal, moral, legal, and social standards of what is right. Although the definition of "right" varies with situations and cultures, its meaning in the context of a community intervention involves a number of guiding principles with which most community activists and service providers would probably agree:

Do no harm. Hippocrates put this in words over 2,000 years ago, and it's still Rule Number One.

• Respect people as ends, not means: consider and treat everyone as a unique individual who matters, not as a number in a political or social or clinical calculation.
• Respect participants' ability to play a role in determining what they need. Don't assume that professional staff or program planners necessarily know what's best for a community or individual.
• Respect everyone's human, civil, and legal rights. This encompasses such issues as non-discrimination and cultural sensitivity.
• Do what is best for everyone under the circumstances. You're not necessarily going to be able to help everyone all the time, but you can try to get as close as possible.

• Don't abuse your position or exploit a participant to gain a personal advantage or to exercise power over another person. This refers to taking advantage of participants or others for political, social, sexual, or financial gain.
• Don't attempt an intervention in areas in which you're not trained and/or competent. This goes along with "do no harm," but it's not always possible. Just as there are times when no intervention may be preferable to doing something counterproductive, there may be times when any intervention is better than none at all. In those circumstances, you may have to learn as you go, getting all the help you can and hoping you don't do anything harmful. It's important to distinguish between doing what you can and getting in over your head to the point where what you're doing becomes truly unethical and harmful.
• Actively strive to improve or correct, to the extent possible, the situations of participants in your program and the community. In other words, it's incumbent on you to try to create the best and most effective program possible to meet the needs of participants, and to address underlying conditions or situations in a way that will benefit the community as a whole.

Why is ethical behavior important in community interventions?

In addition to its simply being the right thing to do, always acting ethically brings some particular advantages with it. It makes your program more effective; it cements your standing in the community; it allows you to occupy the moral high ground when arguing the merits of your program, and to exercise moral leadership in the community; and it assures that you remain in good standing legally and professionally.

• Program effectiveness. Consistent ethical behavior can lead to a more effective program. Considering ethical principles in all aspects of a community intervention will lead you to finding the most effective and community-centered methods, and will bring dividends in participation, community support and funding possibilities.
• Standing in the community. An organization that has a reputation for ethical action is far more likely to be respected by both participants and the community as a whole than one that has been known to be unethical in the past. An organization that's recognized as ethical is also apt to be seen as competent, and to be trusted to treat people with respect and to do what it says it will do. That community trust makes it easier to recruit staff, volunteers, Board members, and participants, and to raise money and public support.
• Moral credibility and leadership. If you work for the betterment of the world -- whether you see that as social change, social justice, the alleviation of suffering, the fostering of human dignity, or simply the provision of services -- it's consistent to act as you wish the rest of the world to act. Ethical action reflects why you started your community intervention in the first place. You have a moral obligation to yourself, the individuals you work with, and the community to be ethical in all you do, and to expect the same from others. If you fulfill that obligation, and everyone knows it, your voice will have greater impact when you speak out for what you believe is right, or against what you believe is wrong, and others will follow you.
• Professional and legal issues. Many of the health and human service professions often involved in community interventions are held to specific codes of ethics by their professional certification or licensure organizations. The American Medical Association, the American Bar Association, the American Psychological Association, the National Association of Social Workers -- these and many other professional associations have detailed ethical standards their members are expected to adhere to. If members of the profession violate these standards, they can be disciplined, or even lose their licenses to practice.

  Lawyers who mishandle funds entrusted to them, for instance, or who otherwise violate the law, are often suspended or disbarred. A Massachusetts obstetrician who was found to be sexually abusing patients immediately lost his license to practice medicine (and had to flee the state to avoid prosecution).

  Professional codes of ethics generally cover everything from the use of accepted methods to professional development to billing practices. People in a particular field are expected to be familiar with their professional code, and to adhere to it under all circumstances.

  The law requires certain standards of many professionals as well. Doctors and lawyers can be sued for malpractice if their substandard handling of a case results in harm to a patient or client. In rare cases (where someone feels that a competent therapist might have been able to prevent a suicide, for instance), a mental health professional might also be sued for malpractice. Medical professionals, psychologists, psychiatrists, and psychotherapists can lose their licenses, and may be sued -- or prosecuted for criminal sexual assault -- if they have sexual relations with clients, even in cases where the clients consent. Organizations and individual administrators may find themselves in legal trouble if they abuse participants or if they misuse or misappropriate money. In most situations, ethical and legal behavior go hand in hand.

Who is subject to a code of ethics in community interventions?

The short answer is that everyone -- who works in a community program of any kind, or who deals with other people in a professional or paraprofessional capacity -- is subject to a code of ethics in community interventions. There are, however, a number of formal ethical codes -- usually set down by professional organizations, but sometimes by law -- that apply to people in particular professional or other positions.

Here are some examples of people expected to adhere to a formal code of ethics:

• Medical professionals (i.e. doctors, nurses, EMTs). This category also includes such non-traditional medical workers as chiropractors and acupuncturists.
• Mental health professionals (i.e. psychiatrists, psychologists, psychotherapists, counselors)
• Social workers
• Clergy
• Public officials
• Educators
• Youth workers
• People who work with young children, or in child protective services
• Lawyers and paralegals
• Mediators
• Administrators of all types of community programs or their sponsoring organizations
• Non-professional line staff (home health aides, overnight staff at residential facilities and shelters)

What are the ethical issues that need to be considered, and how do they play out in community interventions?

Ethical behavior in community interventions relates to the treatment of people, information, and money, and to the general actions of the workers and the organization or initiative, even when they're not dealing directly with the community. Not all of the areas discussed below are covered by a specific legal or ethical code for every profession or community service, but are nonetheless related to ethical behavior for just about any program or organization. All should at least be considered as you define ethics for yourself and your program.

Confidentiality

Probably the most familiar of ethical issues -- perhaps because it's the one most often violated -- is the expectation that communications and information from participants in the course of a community intervention or program (including conversations, written or taped records, notes, test results, etc.) will be kept confidential. Programs' legal responsibilities in this area may vary, but as a general rule, confidentiality is the best policy. It protects both participants and the organization from invasion of privacy, and establishes a bond of trust between the participant and the program. Depending upon the program, the staff member's position, and the participant's needs, confidentiality may encompass a range of possibilities:

• No one but the individual working with a particular participant will have access to information about or records of that participant without her permission. At this level of confidentiality, records and notes are usually kept under lock and key, and computer records should be protected by electronic coding or passwords.

• Information is confidential within a program, but may be shared among staff members for purposes of consultation and delivering better services to the participant. Teachers in an adult literacy program, for instance, may confer about a student with a particular learning disability or problem.

• Information is confidential within a program or to a particular staff member, but may be shared with staff members of other programs in which the participant is involved, either to improve services for the participant, or to contribute to the other organization's reporting data. This kind of arrangement usually requires that participants be told about it from the beginning, and that they sign release forms giving the program permission to share records and information under appropriate circumstances.
• Information is confidential within a program, but is submitted to funding sources as documentation of services provided. This situation can lead to problems if participants have been promised complete confidentiality. In that case, especially if threatened with withdrawal of funds, the program has to decide whether the money is more important than participants' anonymity, or what level of anonymity is sufficient. Some organizations simply provide the requested documentation without informing participants, on the assumption that funders are not likely either to have actual contact with participants or to misuse an individual record; others feel they must honor their promise, and can't release anything without participants' permission.

• Information is not confidential, or is only confidential under certain circumstances. Participation in a program may be court-mandated or mandated by an agency as a condition of receiving benefits or services. Often, in those cases, participation implies an agreement to the sharing of records and information, and may even be a matter of public record.

In all circumstances, ethical treatment of participants demands that they be informed about the program's confidentiality policies. In most cases, they then have the choice of not participating if they are unhappy with those policies; in the case of court-mandated participation, at least they'll know what to expect. All of which brings us to the next two issues, which may intertwine with confidentiality and each other: consent and disclosure.

Consent

There are really three faces of consent: program participants giving program staff consent to share their records or information with others for purposes of service provision; participants giving informed consent to submit to particular medical or other services, treatment, research, or program conditions; and community members consenting to the location or operation of an intervention in their neighborhood.

• Consent to sharing of information. As we found in the discussion of confidentiality above, most participant records and information collected by program staff can only be passed on with the consent of the participant. In general, this consent is embodied in a standard form signed by the participant, granting permission to a program in which he was formerly or is currently enrolled to share his information with another organization, in which he is also a former or current participant. In some programs, a participant might sign a blanket form on entrance, but a separate form is usually needed for each separate instance of information sharing outside the program itself.
• Informed consent for services, treatment, research, or program conditions. In some situations, services might be significantly different from participants' expectations (being asked to enter residential drug treatment as a result of psychotherapy, for example). In others -- medical diagnoses, for instance -- there are no "normal" expectations. A third possibility involves participants enrolling in a community intervention which is also a study. In any of these instances, ethical practice demands that people be fully informed -- and can ask and have answered any questions -- about what they are about to take part in. An informed consent form is usually the vehicle by which participants give their permission to be involved in these interventions.

• Community consent. It's difficult to draw lines here, or to find the absolute ethical standard. Is it ethically necessary to gain the consent of a neighborhood to place a halfway house or homeless shelter there, for instance? What if neighbors' attitudes stop at "Not in my back yard"? Do you need the consent of a group -- or its president or director -- to survey its members? Do you need the consent of a majority of the members of a jobs-for-youth program to enforce a substance-free policy?

Both confidentiality and consent bring up the issue of privacy, one that has been much discussed in the past 20 years or so. Technology has made information far more accessible to far more people, and individual privacy has consequently become far more threatened. Much of what is discussed above and below has been the subject of legal wrangling or legislation (as in the case of the Buckley Amendment). While the question of the right to privacy, constitutional or otherwise, is much too broad to go into here in any detail, it is always lurking behind any decision about releasing information.

Disclosure

Like consent, disclosure in this context has more than one meaning.

• Disclosure to participants of the conditions of the program they're in -- program policies of confidentiality and when it might be breached, what kinds of services are available and what kinds are not, any time limits on the program, whether it will cost anything, etc. Participants have a right to know if they will be part of a research study if they enter the program, and to understand the purpose of that study, as explained above. Some organizations or individuals put these disclosures in writing, and make sure that every participant has a copy and that he understands what's written on it. It is ethically important both that participants know exactly what they're getting into, and that they be treated as adults who can decide what makes sense for them.

• Disclosure of participant information to other individuals, agencies, etc. The rules here are essentially those for confidentiality: information, except in cases of mandated reporting, potential harm to self or others, or court testimony, can only be disclosed with the participant's permission. Exceptions to this rule have to be spelled out to participants as they enter the program, so they can decide whether the services are worth any loss of privacy or anonymity.
• Disclosure -- by the program and by the affected individuals -- of any conflict of interest that the program represents to any staff or Board members. Disclosure here includes individuals disclosing potential conflicts to the program or organization, and the program disclosing potential conflicts to funders and other interested parties.

Competence

By offering services of any kind, an organization is essentially making a contract with participants to do the job it says it will do. Implied in that contract is that those actually doing the work, and the organization as a whole, are competent to accomplish their goals under reasonable circumstances.

It is obvious that no program or individual will succeed 100% of the time. Participants may be unready -- think about the long-term failure rates of many substance use treatment programs -- or resistant. Some community interventions may succeed less than half the time, and that may be the best anyone can do. But whatever the success rate, participants and the community have a right to expect that the program knows what it's doing and will make its best faith effort to provide effective services. That means that community services need to be offered by folks who are competent at what they do.

Competence means more than simply having the appropriate training and experience. A competent organization hires competent staff members, provides supervision and staff development, and does everything it can to assure that the services it offers are the best available. If service appears to be ineffective or harmful, it is the ethical responsibility of the program to seek out or develop and try more effective methods. If a staff member, even with help from supervisors and others, isn't able to do the job, that should be documented and she should be dismissed.

There are legal implications here as well. As explained earlier in this section, in some cases, service providers can lose their licenses or be sued for malpractice if they are found to be incompetent. It is up to a program to make sure that no one on its staff places himself in that position.

Conflict of interest.

A conflict of interest is a situation in which someone's personal (financial, political, professional, social, sexual, family, etc.) interests could influence his judgment or actions in a financial or other decision, in carrying out his job, or in his relationships with participants. In community interventions, conflicts of interest may change -- to the community's disadvantage -- how a program is run or how its money is spent.

Conflicts of interest are virtually always unethical, to the point where the mere appearance of a conflict needs to be avoided. Even if decisions or actions are not actually influenced by personal interest, people in conflict of interest situations in their public or professional lives should do everything possible to resolve them.

If you find yourself in such a situation, the ethical remedy is two-pronged:

•  Point it out to whoever needs to know -- your employer, a funder, the community, the participant you're working with -- and discuss possible solutions.
• Eliminate the conflict situation. Depending upon the situation, solutions might involve excusing yourself from taking part in a particular decision, refusing funding from a particular source, ceasing to work with a particular participant, or even changing jobs.

Some examples of conflict of interest (with possible solutions in parentheses):

• A decision by a program director to purchase office equipment for the program from a company his wife owns: the director has both a personal and a financial stake in the decision. (The director could remove himself and/or his wife's company from the purchasing process.)
• A staff member entering into a sexual relationship with an intern or someone they supervise. The supervisor has power over the other's employment and/or professional evaluation, which puts pressure on the subordinate to enter into and/or continue the relationship, even if he or she is reluctant, and may keep the supervisor from making objective decisions about the subordinate. (If the relationship is mutual and the attraction strong on both sides, this can present a very difficult situation. If the supervisor simply transfers her supervisory responsibility to someone else, there still remains her power in the program or organization itself. The best solution is probably to remove herself and wait until the internship period ends before approaching an intimate relationship.)
• A researcher financing a study with money from a company that stands to benefit from a particular result of that study. The researcher's conclusions could be influenced by what the company wants. (The ideal here is not to finance a study with funding from anyone who has a vested interest in the outcome.)
• A counselor or therapist providing services to a family member or ex-lover. The issues that exist between the two may reduce both the objectivity of the therapist and the effectiveness of the therapy. (Suggest one or more other therapists, and don't provide those services.)
• A youth program staff member working with a youth with whose family she has a personal conflict. (The staff member should remove herself from direct contact with that particular teen: her attitude toward his family is apt to influence her attitude toward and work with him.)
• A doctor in a community clinic owning an interest in a specialty medical practice to which he refers patients from the clinic. (The doctor could offer a number of choices for referral, not specifying which one she had an interest in.)

Grossly unethical behavior.

This is behavior far beyond the bounds of the normally accepted ethical standards of society. In some cases, grossly unethical behavior may stem from taking advantage of a conflict of interest situation. In others, it may be a simple case of dishonesty or lack of moral scruples. Both individuals and organizations can be guilty of some instances of it, and in both cases it is often a result of someone managing to justify the unjustifiable. Community programs need to be clear about their own ethical standards, and to hold individuals to them and to any other standards their professions demand. In most cases, staff members guilty of grossly unethical behavior should be dismissed as quickly as possible, and prosecuted where that is appropriate. Some of the more familiar types of grossly unethical behavior include:

• Having sexual relationships -- even consensual sexual relationships -- with people with whom you have a professional relationship in which you hold the power. Doctor -patient, therapist-client, teacher-student, supervisor-intern, and youth worker-teen are all examples of such relationships. In some of these cases, a sexual relationship both violates the professional's code of ethics (and is therefore grounds for losing professional certification), and may be the base for a sexual harassment or sexual assault lawsuit as well.
• Exploiting for financial gain people with whom you have a professional relationship. Moving someone to the head of a waiting list in return for free services he can provide (car repair, for instance), or accepting gifts or money -- essentially bribes -- to do something out of the ordinary (e.g. accept someone who normally wouldn't qualify for your program).
• Defrauding funders: billing for non-existent services, or inventing problems in order to deliver unnecessary services.
• Denying necessary medical services to those uninsured and unable to pay.
• Discriminating in service delivery by race, gender, ethnicity, etc.

• Outright criminal behavior: redirecting program funds for personal use, for instance, or sexually abusing children in a day care center. This can also include criminal behavior that a staff member engages in on his own time -- e.g., selling drugs or robbing a warehouse

General ethical responsibilities.

Ethical behavior for a community intervention is more than simply following particular professional codes and keeping your nose clean. It means actively striving to do what is right for participants and for the community, and treating everyone -- participants, staff members, funders, the community at large -- in an ethical way. By doing what you do in the community, you take on a number of responsibilities:

Responsibility to funders. You are responsible for being fiscally accountable, for using funds properly, and for trying to do what you promised to do when you took the money.

Responsibility to staff members. You are responsible for making sure everyone is treated fairly in all dealings with the program; that everyone is paid for the work she does; that everyone has a reasonable amount of control over her job; and that everyone has the opportunity to continue to develop her skills and effectiveness through staff development and/or supervision. You are also responsible for protecting staff from harm to the extent possible, and for warning and training them if some physical or other danger is part of their jobs.

You owe it to a youth gang outreach worker, for instance, to train him in such areas as the boundaries of different gang territories, colors or clothing that send particular signals, conflict resolution techniques, how to talk to gang members without creating problems, etc. You also owe him a clear explanation of the risks of the job and of how much and what kind of support he can expect from the program.

Responsibility to participants. You are responsible for trying, throughout the life of the program, to provide the best and most effective services possible. This means constantly searching for better methods and ideas; paying attention to participant feedback; building on program successes; and acknowledging, learning from, and correcting program weaknesses. You are also responsible for respecting participants' rights, and for treating all with the respect due them, not only as program participants, but also as human beings.

Responsibility to the community. You are responsible for trying to understand and meet the needs of the community; for being responsive to community attitudes and opinions (without compromising your own mission or philosophy); and for trying, through your intervention, to improve the quality of life in some way for both program participants and the community as a whole.

The participatory nature of community interventions that these obligations imply can also raise ethical questions. It usually makes both ethical and practical sense to involve the target population and/or the community at large in planning a community program. There are many good reasons for this involvement -- fostering community ownership of the program, having the input of people with a sense of community history, respecting people enough to pay attention to what they say they need, etc. -- but there can be drawbacks as well. What if you think the community's ideas are completely wrongheaded, or they want more control over the program than you'd feel comfortable with? What are the ethical solutions to these situations?

The reality is that there aren't specific answers to most ethical questions. It's important to consider the questions, but to understand that taking what you see as the ethical path can sometimes land you in a briar patch. It helps to have clear sense of what you believe is right, and to also consider carefully what will actually benefit the situation and the people involved.

In the case of community participants giving wrongheaded advice, for instance, is the principle of respecting the community's wishes more or less important than that of creating the most effective way to meet community needs? And which will be more likely to actually get the job done in the community? The answers will probably vary in different places and times.

In Summary

Ethical considerations are extremely important in community interventions. A program that itself behaves unethically or allows its staff to do so is both ignoring its mission and risking its credibility and effectiveness in the community.

Because ethical issues are not always cut and dried, community programs should work out their own ethical guidelines and policies before questions actually arise. If you can agree on standards for primary ethical issues -- confidentiality, consent, disclosure, competence, conflict of interest, grossly unethical behavior, and the overall ethical stance and actions of the program -- and create policies which will help you uphold those standards, you're on your way to community respect and outstanding service delivery.