One of the most challenging situations that a social worker can face involves making a decision about whether he or she should disclose information revealed by one client that could be emotionally or physically harmful to another patient; the dilemma can be still more difficult when the clients in question are two people who are involved with each other romantically. Imagine, for instance, that a male client who reveals to the clinician that he is HIV+ has asked the clinician to keep that information a secret from his partner, as he is afraid that she will end their relationship if she learns of his seropositivity. Such situations, not at all uncommon in social work, may create confusion and conflict within the social worker, whose personal ethics and moral values may call for one type of response. While the situation can indeed be uncomfortable, there are actually clear guidelines for reporting information that has been requested to remain confidential. Legal stipulations and ethical regulations that have been set forth in the Code of Ethics of the Canadian Association of Social Workers provide support and guidance for handling situations like these; however, it is crucial that the social worker know these legal and ethical standards before such a situation ever arises
In the case scenario described above, the social worker is seeing a man and a woman for couples counseling. Couples therapy can be among the most difficult kinds of clinical work, especially for a novice social worker, because the client is not viewed as the individual, but as the unit, and the needs of each individual within that client unit may be divergent (Edwards, 2003; Lee, 2005). This point is critical for resolving the ethical dilemma of the present case. It is not uncommon for each of the partners to draw the clinician into their drama as a couple by attempting to force a scripted role onto the social worker as an advocate, mediator, or secret-keeper (Lee, 2005). While these dramas of transference are unconscious to the client, they must be negotiated and balanced by the clinician, who is simultaneously assessing the real physical risks that may be at stake in a situation such as the one described in this case. At the same time, the social worker must be aware of his or her own countertransference and how personal values, beliefs, and experiences may influence the impulse to insist, for instance, that no such secret can be maintained in a relationship that is physically and emotionally healthy (Knobloch-Feders, Pinsof, & Mann, 2004).
In any clinical situation in which an ethical dilemma is raised, the social worker should review the profession’s Code of Ethics to ensure that he or she understands the obligations, responsibilities, and commitments of the social worker as outlined in the code. In this case, the social worker would want to review Section Six of the Canadian Association of Social Workers’ Code of Ethics, which is the section on the subject of confidentiality. Specifically, the social worker would want to examine Section 6.7.8., which addresses issues of disclosure in family therapy work. The Code makes clear provisions for handling the kind of situation presented by the case: “Disclosure of information that one client has requested be kept confidential from his or her partner will not be made without the informed consent of the person providing the confidential information" (Canadian Association of Social Workers’ Code of Ethics, 1983, n.p.). This section, then, seems to suggest a thoughtful course of action in which the social worker discusses the matter of disclosure with the male partner and evaluates the reasons and implications for non-disclosure. The social worker should invite the client to reflect on issues of transparency in intimate relationships, thereby promoting insight into the implications of non-transparency. In the best case scenario, the male partner would decide to disclose the information voluntarily to his partner, perhaps with the assistance and support of the social worker, who would then address the couple’s needs as a unit.
There is another section of the Code of Ethics, however, that is deserving of attention in this case, and that is Section 6.7.10, in which the caveat of non-disclosure is articulated: “Disclosure of information necessary to prevent a crime, to prevent clients doing harm to themselves or to others is justified" (Canadian Association of Social Workers’ Code of Ethics, 1983, n.p.). The harm implied by this section of the code is physical, and is generally interpreted to mean immediate physical harm threatened by an act against the self (a suicide attempt, for example) or against others (homicide attempt or physical abuse, for instance). HIV is clearly a physical harm that could compromise the health of the female partner and, eventually, could even result in her death. One might think, then, that the social worker has an immediate obligation to disclose to the female partner the information that the male partner has shared. The social worker must be cautious in interpreting this guideline, however. First, he or she should determine what physical threats actually exist in this particular case. Is the couple physically intimate? What are the real risks, both immediate and long-term, to the female partner if she is not told of her partner’s seropositive status? Second, he or she should continue to work with the male partner on self-disclosure, which is always preferable. If the social worker decides to disclose the man’s status to the female partner, however, she or he must do so only after informing the male partner that the disclosure will be made. Furthermore, the social worker must make a tangible plan of action and support that will assist the couple—the identified client—to cope with the aftermath of the disclosure.
The Canadian Association of Social Workers’ Code of Ethics (1983) provide the ethical foundation for crafting a response and intervention in this particular case, but the legal stipulations related to HIV reporting in Canada must be taken into account as well. Reporting requirements for physicians, counselors, and people diagnosed with HIV were updated in 2005 and were approved in the piece of legislation known as the Health Protection Act (CanLII, 2006). Sections 74 and 106 of the Health Protection Act establish the provisions and guidelines which must be consulted and put into effect when an individual learns that he or she is HIV+ or discloses that information in counseling. Like the Canadian Association of Social Workers’ Code of Ethics (1983), the Health Protection Act acknowledges that both current and former partners of an HIV+ individual have a right to know that they may be at risk of infection. The partner’s right to know, however, does not supersede the right of patient confidentiality under any circumstances according to the Health Protection Act (CanLII, 2006). As one begins to see, confidentiality is always the highest order value in social work and in public health.
The insistence upon clinicians’ commitment to confidentiality does not, however, free them from the responsibility to discuss the importance of disclosure and the implications of non-disclosure with the client. In fact, the disclosure and partner notification guidelines of the Health Protection Act explain what procedures should be activated by the social worker or other mental health clinician who speaks with the client during the compulsory pre- and post-counseling sessions that are held with an individual who is receiving an HIV test. Regardless of whether the test being performed is done under the condition of anonymity versus the condition of confidentiality (CanLII, 2006), the client must receive counseling, and in those cases when a client is HIV+, he or she is briefed about the responsibility that he or she has to notify all past and present partners that they may have been exposed to HIV (CanLII, 2006). The counselor explains this responsibility and while the follow-up on the part of the patient is not enforced by the counselor or by public health officials, the client is provided with the option of transferring notification responsibility to a physician or public health nurse (CanLII, 2006). The ethical and professional obligations of the clinician are then considered to be fulfilled.
It is clear, then, that the social worker is not compelled to disclose the male partner’s HIV status to the female partner; furthermore, it is clearly articulated, both in ethical and legal standards, that the social worker is not permitted to do so unless he or she has the full and informed consent of the client. The protection of privileged information in such a case may conflict with a social worker’s own personal morals and ethical values, as he or she may feel an understandable discomfort about the fact that the female partner could be at physical and psychological risk if she is unaware of her partner’s HIV status and is thus unable to take effective precautions. This case study is one of many different types of situations in which a social worker must make difficult and even painful decisions that are determined by professional values as opposed to personal beliefs and preferences. While some social workers call for an ethical practice that is determined more by the judgment of the clinician than by what they view as a rigid code of ethics (Banks, 2002), the profession and the people whom it serves need and deserve consistency in the application of standards to navigate them through difficult decisions.
Finally, while the preservation of the value of confidentiality may seem to be a less worthy preoccupation than the potential preservation of someone’s life, it is important to recall that social work is a profession that was founded upon the belief and goal that individual autonomy and personal decision-making power should be enhanced so that each person can be an accountable member of society functioning at his or her best. Often, in challenging ethical circumstances, it is important that social workers step back to look at the bigger picture and remember the core values of the profession. The maintenance of these core values, including—and especially—confidentiality—is important both on the macro-level and on the micro-level of responsible and ethical social work practice.