This chapter explores in more depth the range of ethical issues related to reflection, and the ways in which practising reflectively can help in unravelling dilemmas. It will take the Neo-Aristotelian stance introduced in chapter 1 to look at issues of personal morality and will use reports of conduct hearings published by professional bodies and licensing authorities. These will be used to explore and critique situations in which practical wisdom is needed and to look at how reflection may help. Using the Reflective Timeline, it will ‘unpick’ the moment when the first bad decision was made and how that event was compounded by others. This chapter will develop your analysis beyond your own immediate practice. Through studying this chapter and engaging in the exercises, you will be able to:
• reflect on ethical dimensions of your own professional practice
• critically review your professional accountability
• develop your reflective practice to manage difficult situations
As you are reading this book, you are probably studying to join a health, medical or social care profession, or undertaking post-qualification study. In chapter 2, we said that reflective practice is useful for improving practice, and for moving difficult situations forward. We have then looked at the many ways in which you may reflect – alone and in groups, in writing and other media. We know that reflection is often hard; it may seem to be simply a chore that must be done, particularly when it’s required to pass a course. We want to convince you that it is much more than that: a hard-wired way of thinking and behaving that sets you en route to being a successful professional.
We aim in this book to be positive and to encourage you to be courageous and confident in your skills. We want to show how, no matter what may go wrong – even if it makes you question your own abilities or threatens your career – reflective practice can be a helpful, essential life-line to ethical, professionally strong practice.
What does it mean to be a professional?
In chapter 2, we explored in detail different descriptions of professional behaviour (Litchfield et al., 2010; Pau & Croucher, 2003), but what does this mean to you? Being called a ‘professional’ may simply identify whether a person is paid or not – such as amateur and professional sportspersons. However, for health and social care professions, the distinction historically has usually been between ‘profession’ and ‘vocation’. Many medical practitioners were not paid for their services and social or health care was provided by religious orders or by women who did so from religious conviction rather than to earn a living (Hallam, 2000; Hudson Jones, 1988). This left a cultural legacy that views engaging in caring work for money as less worthy than doing so because of a vocation. People reading this book will most likely share many of the ideals held to be vocational – for example, a belief that their work is worthwhile and that it is of value beyond the salary that can be earned. However, for the vast majority of you, your profession will be important to you not just as a worthwhile occupation, but as your source of financial stability.
Thus, to be a professional today usually indicates that someone is at a particular level of skill, or capability. If you hire a professional to do work on your house, for example, you expect them to do a ‘good job’. So a social care or health professional needs to be able to do well whatever aspect of care for people they are engaged in.
Professional status related to these behaviours brings with it privileges, but also duties. Privileges may include better salaries and conditions of work, as well as being held in higher regard than the average member of the population. Such status is also often associated with privileged rights to information, for example confidential facts about a person’s life or their health status. Finally, it may permit you to undertake specific tasks. Examples might be prescribing and/or administering medicines; the completion of medical or other procedures; the implementation of legal acts that control behaviour related to mental or public health, and the safety of vulnerable children and adults (Purlito, 2011).
Duties clearly follow from this: if you know something confidential about someone, you need to keep that information to yourself, not to share it with others who do not have a right, or need, to know. If you have legal powers to restrict someone’s freedom, or to prevent them from caring for their own children, your assessment of the situation must be absolutely clear and fair. If your professional status allows you to do anything to people’s bodies, from requesting access to their homes or touching them to give care through to prescribing medications and carrying out invasive procedures, you have a duty to know what you are doing and the best, evidence-based way to proceed (Beauchamp & Childress, 2013; O’Hagan, 2007). These privileges and duties are more significant for professionals who have power and control over others: whilst you would expect the person who mends your roof or cooks a meal for you in a restaurant to be trustworthy in doing their job well, the level of their ethical integrity will probably be of less significance to you than for the person who is responsible for the wellbeing of your child or elderly relative.
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A search for ‘professional rights and duties’ will bring forward a wealth of material on this subject; you might want to narrow this down to look at aspects relevant to your country or profession, including human rights acts and other legislation.
Regulating the professions
Such freedom, power and responsibility means you are held ethically and legally accountable to a higher level than the average person. You are subject to additional laws, including the registration or licensing of your profession within your own country. The specific ways in which you are legally accountable will vary depending on your profession, your level of practice and the country you are working in. However, a useful overall guide to accountability is offered by Dimond (2008), who outlines the four arenas of accountability that apply to all (see figure 7.1). In this chapter, it is the fourth level – accountability to your profession – that will be the main focus for reflection.
Accountability
Accountability to criminal law includes serious crimes such as assault or murder.
Accountability to civil law includes, for example, disputes around negligence or breaches of privacy and confidentiality.
Accountability to your employer includes your contractual rights and obligations as an employee. This might, for example, include expected behaviour and confidentiality. It may include a ‘gagging’ clause related to whistle blowing.
Accountability to your profession for registered or licensed practitioners – this is an additional level of accountability that governs your behaviour. By accepting the privileged role of your profession, you also accept this set of added expectations.
Figure 7.1 The four arenas of accountability (Dimond, 2008)
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Do you know your Code of Practice? Find the site for the body that regulates and licenses your profession. Your Code will be published there. Bookmark this as you will need it regularly!
Have you found your Code? Whilst each profession may vary, there are three universal aspects.
(1) To protect the public from harm: for example, from physical danger, from breaches of confidentiality, from theft of their belongings or from poor practice.
(2) To protect the good name of the profession: each profession wishes to be held in high regard and to be respected by other professions and by the public. Someone who, for example, steals, cheats, or treats members of the public or other colleagues badly will cast doubt over the quality of the whole profession if this behaviour is not questioned.
(3) To set standards for that profession: Codes generally set out clearly what is expected of each professional. This Code then becomes the benchmark against which each person’s behaviour and actions can be measured
The practical skills and knowledge expected will be different for each profession. The burden of responsibility for protecting and safeguarding children is present for all health and social care professions, but a higher level of knowledge, skills and responsibility may be expected for children’s nurses, for midwives or in social work. A pharmacist or a doctor will have specific aspects of the management of medicines as part of their Code which would not be applicable to those working in social care. Despite these variations in detail, universal behaviours can be identified.
• responsibility
• good relationships with and respect for patients
• probity and honesty
• self-awareness and capacity for reflection
These have a strong ethical bias and so seem to be a good summary of the universal nature of professional responsibility, harmonizing with the ‘professional wisdom’ of ethical practice (care, respectfulness, trustworthiness, justice, courage and integrity) introduced in chapter 1 (Banks & Gallagher, 2009).
What happens if you break your Code?
To illustrate the link between ethical professional practice and reflection, we will be using published cases, rather than the narrative stories we have constructed in other chapters. Our seven case studies are drawn from different regulators in Britain, Australia, New Zealand and Canada, and they concern people registered with seven different professions. (These countries were chosen because they publish more detailed accounts of cases, offering a more complete narrative. Other countries only publish the name of the professional, what they have done and the outcome – this means that it is not possible to have any insight into their feelings and motivations, or what might have influenced the decisions made regarding their right to continue practising their profession.) You will see that the mistakes they made, and the way their profession investigated and sanctioned their behaviour, are universal. In all seven cases, the allegations about them were upheld and their practice was limited or controlled as a result. As you will see if you search for cases from your profession, names are published, but we have chosen not to leave the actual names in the case studies we are using.
Anyone can contact your registration or licensing authority, reporting behaviour that they think falls below the standard for your profession. This can be anything from a formal police report when a major crime has been committed, through to an individual member of the public saying that you have treated them unfairly or dangerously. The allegation will always be investigated, and if your profession thinks that there is a case to answer they will hold a hearing. Unless the poor practice is related to a health problem, hearings are usually held in public and the outcome is reported openly on the internet.
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