When Social Work is Wrong: Self-Determination
No profession is perfect. My thoughts on this and future topics are not a critique of my profession, but rather thoughts on where we can and should do better. Issues of public health and safety often morph and evolve as new challenges arise and must be faced. I do not believe that the NASW Code of Ethics is a perfect document (nor do I believe the Constitution of the United States is either). Ethics (and rights) are time-focused and are subject to interpretation; often, they are also conceived with mean human preferences, beliefs, and behaviors in mind as well. I believe that it's again time to re-evaluate the Code of Ethics, specifically, and have not confidence that will never happen.
A Nuanced Issue
In saying this, I'm not trying to tear down a long-standing value of social work. I am, however, raising a critical eyebrow at the fact that this value has not seen meaningful revisions in decades; a long enough time, in fact, for the state of the world and the challenges today's social workers face to have materially changed in substantial ways. The drugs of abuse that are available today are far more potent and powerful than was anything available in 1960, when the NASW first published the original Social Work Code of Ethics. Today's drugs of abuse not only create previously unseen levels of intoxication, they often carry the side effects of temporary AND permanent psychosis. The impacts these substances create on short-term and long-term decision making bring the idea of self-determination into newly questionable territory.
Standard 1.02 of the Code limits self-determination when risk is "serious, foreseeable, and imminent." I'm unsure that today, that language goes far enough. What does that mean? What does a "limit" entail? Who enforces it? How does a social worker actively hold the limit? Having reviewed several past versions of the Code, I can say whatever else has changed across the revisions, the self-determination standard today asks only about imminent risk, not whether the client can actually make the decision. The language does not go far enough.
It's Not Illegal to Be Mentally Ill
I heard this recently and it struck a chord with me. The statement was made in response to a police interaction with a mentally ill person, and a member of the public was expressing frustration that nothing could be done. Sadly, it's true. Sadly, it is also true that this person was not only behaving in a way that would be considered a "nuisance," but also in ways that were very likely to bring the police back for an arrest (the dreaded callback). Without intervention, this person will likely continue to create great difficulty for others until someone is grossly impacted or even hurt.
But who intervenes? Social workers seem well positioned to do some of this work, and here's the dilemma: Standard 1.02 allows limits only for imminent risk and never mentions capacity. Standard 1.14 assumes someone, somewhere, has already determined that a client lacks decision-making capacity. As long as that remains someone else's job, nothing changes. In Utah and many other states, that someone is a medical or mental health professional, and the determination often comes only after a self-harm attempt, a crime against others, or some material circumstance has already proven the risk, which is a hindsight view. Simply put: social workers treat self-determination as the default unless someone else has already labeled the person ill or incapable.
Dignity of Risk
The idea that self-determination and the right to take "reasonable risks" carry personal dignity really does not apply here, though it is an oft-cited defense of allowing people to persist in an inhumane state. However, the challenge is that many individuals in this state of mind are incapable of understanding what decisions may mean or their possible impacts and implications. Again, I feel that this idea is outdated and may have even been originally perpetuated by people with little experience working with anyone so impaired and at a time when far fewer people lived in public with such impairments.
Symptom Intensity Isn't the Same as Risk
As I move about the Salt Lake Valley on my bike, I see many likely homeless and possibly mentally ill individuals; some of these folks appear to be very mentally ill. They often are responding to internal stimuli, are clearly disheveled, and are unclean to the point of offensiveness. Now, I understand my passing observations of severity have no bearing on whether they are a risk. It's likely they aren't a danger to themselves or others, and I can't see imminent risk as I pedal by. But I can see some evidence at a glance that capacity may be greatly impaired. Should we allow our fellow humans to suffer in their incapacity? Is there "inherent dignity" in that? Does the dignity of risk justify leaving people to suffer in this state? I say no.
Clearly, the case for intervention is easier to make when one poses a risk to themselves or others, but what happens when such risk isn't present? Would a suffering person, in their "sane" state of mind (I'll call it "healthy"), choose to continue to suffer and go without intervention? Would a choice made by that person in their "healthy mind" carry more weight than one made in an unhealthy state of mind? Terminally ill patients create advance directives so their wishes carry weight if they later can't speak for themselves. The same idea exists for mental health, called a psychiatric advance directive, where a person records during a healthy period what they'd want in a crisis. It's an imperfect tool. It only helps people who had a healthy window and engaged enough to use it, and how much weight it carries varies by state. That said, it shows the question isn't hypothetical: what a person would choose in a healthy state is something we can ask, and sometimes record.
The Disease of Choice
In his video Pleasure Unwoven, Dr. Kevin McCauley discusses addiction as "the disease of choice." This is not to say that it is one's "choice" to be addicted; rather, the addiction actually impairs the mechanism of choice, namely the prefrontal cortex. I argue that there are analogues for serious mental illnesses, usually deeply impaired insight, whether born of addiction or not. Once a person's ability to "choose" becomes highly impaired, the argument of self-determination is harder to substantiate.
Going Further
When risk is high and capacity is low, "respect their choice" stops being an answer. So what is?
I'm not asking the Code to change, and I wouldn't wait for it to. There is work practitioners can do now, inside the standards we already have.
Start with the trigger. Imminent risk shouldn't be the only thing that opens a capacity conversation. Observable signs that a client can't understand, weigh, or appreciate a decision, in someone with serious mental illness or substance use, should be enough. That doesn't mean a social worker decides capacity. It means we notice, document, and refer to whoever our state designates (in Utah, designated examiners play that role in the commitment process). Self-determination stays the default, but a documented concern can rebut it, in place of waiting for someone else to raise it.
Next, what makes an intervention ethical? A few ideas already exist. Soft paternalism says stepping in is justified when a choice isn't substantially voluntary, which is different from overriding an informed one. Drane's sliding scale says the higher the stakes, the more capacity a decision requires, so low capacity and high risk is where autonomy has to give the most ground. When we can't ask the person, we start with substituted judgment, meaning what they would choose in a healthy state, and fall back on their best interests. Advance directives are one way to know that, when someone had a healthy window to write one.
Guardrails matter as much as the trigger. Use the least restrictive option that works. Make it time-limited and reviewable. Treat the impairment so capacity can return. And send formal decisions through an independent process instead of one worker's call.
The strongest objection is that coercion can damage trust and push people away from care, and the evidence on involuntary outpatient treatment is mixed. That's fair, and it's why the guardrails exist and why I'm arguing for assessment and referral, not for more force. That said, a hands-off default isn't neutral either. It has costs, and they land on the person we decided not to help and the systems with which they interact.
Capacity should be a second lens next to risk. We're good at asking how dangerous a choice is. We should be just as willing to ask whether the person can make it.