Ethics

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Ethical Boundaries in Community-based Care

Carlo’s father needs a place to stay

By Karen E. Faith, BSW, MEd, MSC

Albert has found the sacrifice and devotion shown by Carlo’s parents to be truly inspiring. They have faced considerable difficulties in caring for their son and his ongoing health challenges. Albert has a good rapport with both of his client’s parents and is particularly friendly with Carlo’s father, whose family, like Albert’s, had emigrated from Columbia. Early on, both men discovered that their extended families even attended the same church.

On one of Albert’s visits to Carlo’s home, Carlo’s father confided to him that he and his wife were not getting along. (Carlo’s mother had discovered that her husband had resumed gambling and had lost a considerable amount of money, which the family could ill afford.)

When Albert arrived for his next visit with Carlo, he found luggage in the front hall. Carlo’s father was in tears. He told Albert that his wife had asked him to leave. He explained to Albert that his extended family had also closed their doors to him. He then asked Albert if he could stay at his place that night.

An overlap of home and work environments
As this example shows, a client’s home environment is the work setting for home care providers such as Albert. Within a client’s home, care providers are often exposed to the intimacy and complexity of family relationships and family life . This is a very different work setting from other, more structured health care settings such as hospitals. Therefore, addressing ethical boundaries in the training and supervision of home care providers becomes more important. In home care, relationships are built over time within the realities of day-to-day circumstances.

“Ethical boundaries” refers to ethical guidelines that ought to govern caregiving relationships making them distinct from personal, intimate or business relationships.  The ethics  literature makes a distinction between boundary violations and boundary crossings. According to Reamer, a boundary violation involves a conflict of interest in the actions or behaviours of the care provider, resulting in harm or a burden to the client.1 More egregious boundary violations might involve the care provider exhibiting sexual behaviour toward or financially exploiting clients. Boundary crossings can involve a care provider entering into a dual relationship with a client without the intention to exploit, manipulate or unduly influence the client. Such dual relationships can be entered into unintentionally and vary in the extent to which the caregiver–client relationship is harmed, or the extent to which the client is actually exploited or harmed.

Boundary crossingrccm-ethics1b
One common example of boundary crossing discussed in the literature is that of a care provider who discloses personal information to a client. In the example above, Albert has disclosed to his client’s father that the two men share the same country of origin and that their families attend the same church. Was this a boundary crossing? In community-based care relationships, it is very common for long-term care providers, such as Albert, to share some personal information with clients. The central concern from an ethics perspective is whether such actions or behaviours serve the best interests of the client.2 It could be argued that in sharing his similar cultural background and religious practice to Carlo’s father, Albert crossed a boundary. However, the extent to which this is an ethical violation depends upon the harm or burden that disclosing this information may have placed on the client or the client’s family. Harm or burden cannot be subjectively determined by the care provider alone. Harm or burden, just like best interests, are better determined from the client’s perspective. It is unlikely that the type of dual relationship or boundary crossing between Albert and Carlo’s father would harm or burden Carlo in any significant way. Therefore, boundary crossings are not always ethically compromising or harmful.

Carlo’s father had shared very personal information, and that marked the point where the ethical boundaries became more problematic for Albert. Did Carlo’s father see his relationship with Albert as a quasi-friendship? Albert was Carlo’s PSW meaning his primary duty was to fulfill the service plan that was developed to meet Carlo’s home care needs. In this situation, Albert would be well advised to receive supervision or seek advice from an experienced and trusted colleague. In addition, he is obliged to give thoughtful consideration to the ethical boundaries in question, as part of his professional duties in daily practice.

Taking things further
Let’s imagine that Albert agreed to provide Carlo’s father with a place to stay for the night. This decision would constitute a serious boundary crossing, even if Albert had the best of intentions. This situation involves a family in turmoil, whose son requires continuity of care. In providing shelter to Carlo’s father, Albert would become triangulated into the family’s problems. Perhaps Albert would be serving the needs of the father at the expense of his client’s best interests. Such an action would probably impede Albert’s ability to sustain his role as Carlo’s care provider. It would also call into question Albert’s ability to maintain professional boundaries and keep the confidence of both parents. Losing a trusted long-term care provider such as Albert is certain to result in a burden to Carlo.

Questions to think on
The following questions have been adapted from Professional Boundaries in Health-Care Relationships, published by The College of Psychologists of Ontario.3 These questions are intended to help care providers reflect upon ethical boundaries and to support ethical decision-making in daily practice.
Is this in my client’s best interests?
Whose needs are being served?
Will this have an impact on the service I am delivering?
Should I consult with my supervisor or a colleague?
How could this be viewed by the client’s family?
How would I feel telling my supervisor or a colleague about this?
Am I treating this client differently (as if this client is “special” to me) to how I treat other clients?
Am I taking advantage of this client?
Will I be comfortable documenting my actions or behaviour in the client file?
Am I acting in accordance with the code of conduct, values and ethical standards of my organization, college or association?

References
1. Reamer F. Boundary issues in social work: Managing dual relationships. Social Work 2003;48(1).
2. Pope K, Keith-Spiegel P. A practical approach to boundaries in psychotherapy: Making decisions, bypassing blunders, and mending fences. J Clin Psychol 2008;64(5):638–652.
3. College of Psychologists of Ontario (CPO). Professional Boundaries in Health-Care Relationships. Toronto: College of Psychologists of Ontario, The Bulletin, Vol 25, No 1, July  1998.

Karen E. Faith, BSW, MEd, MSc, is a bioethics consultant and speaker.

*This is not an actual case. However, elements of this case reflect actual circumstances and the experiences of care providers in community care.

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