Ethical Dilemma Paper

The Case
By Lorena R Salcedo

1. Values
a. Professional Values
i. Service. Individuals with dementia and their spouses have private and
personal needs that deserve social workers' attention and advocacy.
ii. Social Justice. Individuals with dementia face challenges that are difficult
to understand by family members and society, and as a result of their
mental capacity, it makes them more vulnerable to discrimination and
oppression. Social workers should work towards preventing social
injustice.
iii. Dignity and Worth of the Person. Individuals with dementia, with mental
decline, are human beings with needs and feelings. Social workers should
work towards promoting autonomy and respecting the inherent worth of a
person.
iv. Importance of Human Relationship. Connections with others provide
meaning and purpose to life. As life evolves, so do the connections
amongst people making those connections equally important. Social
workers should promote the importance of healthy human contact in spite
of an individual’s cognitive decline.

b. Personal Values
i. Equality for Everyone. Society implies treating everyone equally and
fairly, but that is not always the case. If I were an individual with dementia
and desired to connect with others or my spouse, I would hope I would
have that right to do so.
ii. Respect for people who lack the capacity to make decisions. People with
dementia are often restricted in their decisions, and at times, their
decisions are not respected. If I were an individual with dementia, I would
want others to respect my decisions and allow me to feel loved and
protected, providing me with the autonomy I deserve.
iii. Protection for those that are unable to. Suppose a loved one (family
member, spouse, partner, or caregiver) is unable to reduce the level of
harm or increase the overall well-being of a dementia person; in that case,
social workers should act in the person’s best interest to protect them from
harm and increase their overall well-being.
iv. Legal protection from abuse. Individuals with dementia may be taken
advantage of due to their lack of capacity or shift in decision-making from
one moment to another. If I were a person with dementia and someone
hurt me (physical, emotional, financially), I would want the law to protect
me from further harm.
 c. Societal (“American”) Values
i. Restriction of Self-determination. Every individual, including an
individual with dementia, has the right to decide how to live their life to
the extent that they can make those choices. To avoid unwanted harm
(physical, emotional, financially), actions should be taken when necessary,
to limit that person’s right to self-determination.
ii. Social connectedness. Individuals with advanced dementia may
experience a decrease in mental capacity but are still able to build
meaningful relationships.
iii. Loss. Life often involves loss, and loss is hard. Individuals need to
understand this, and they need those around them to understand this.
iv. Protection of the law. Society does not have the right to intrude upon
another its values, views, culture, or traditions, but it should serve to
protect society, and the vulnerable population from unwanted physical or
mental distress, harm, danger, or deprivation.

2. Minimize/Reduce Conflicts Between Professional, Personal, and Societal Values

a. Professional Values and Personal Values.
i. Areas of Agreement. Professional values of service, dignity, and worth of
the person and the importance of human relationships agree with my
personal value of protection for those who are unable to, and respect for
people who lack the capacity to make decisions.
ii. Areas of Disagreement. My personal value of equality for everyone has
the potential to conflict with the professional value of Service. Equality for
everyone states equal treatment for everyone with or without dementia
which means that an individual with dementia has the right to make their
own decisions with whom or how they want to connect (sexually) with a
spouse or someone else without anyone intervening or advocating for
them. The professional value of Service implies that for a client and their
spouse to have that right, others will have to advocate for them to enjoy
that right.
iii. Using Areas of Agreement to Minimize/Reduce Impact of Areas of
Disagreement. Incorporating into the policy, my personal values of
respect for people that lack capacity to make decisions, and protection for
those that are unable to with the professional values of dignity and worth
of the person, and importance of human relationship will reduce the areas
of disagreement and could help minimize the impact of areas of
disagreement.

b. Professional Values and Societal Values.

i. Areas of Agreement. The professional value of the importance of human
relationship is in agreement with the social values of social connectedness.
ii. Areas of Disagreement. The area of disagreement is the societal value of
restriction of self-determination with professional value dignity and worth
of the person. Social workers seek to promote the dignity and autonomy of
people, including people with dementia, and the societal value of
 restriction of self-determination aims to promote autonomy and respect a
person's inherent worth.
iii. Using Areas of Agreement to Minimize/Reduce Impact of Areas of
Disagreement. Incorporating the professional value of the importance of
human relationship and the societal value of social connectedness into the
policy will help reduce the disagreement between the restriction of self-
determination and the dignity and worth of the person. The professional
values seek to help vulnerable populations meet their needs while
empowering them to have a voice and be heard, which is vital for this
population. On the other hand, the societal value aims to limit that person's
right to self-determination, making it challenging to have some of their
personal needs meet; however, using both value systems increases that
possibility for enjoyment.

c. Personal Values and Societal Values.

i. Areas of Agreement. My personal value of legal protection from abuse is
in agreement with the societal value of the protection of the law.
ii. Areas of Disagreement. My personal value of equality for everyone and
the societal value of the restriction of self-determination may create
conflict because equality for everyone is freedom everyone should enjoy.
However, the societal values do apply a restriction on that freedom to do
so.
iii. Using Areas of Agreement to Minimize/Reduce Impact of Areas of
Disagreement. Incorporating my personal values of legal protection from
abuse and the societal value of the protection of the law into the policy
may help minimize the impact between areas of disagreement. Both values
(personal and societal) are designed to protect an individual with
dementia, provide them with the autonomy to love and be loved, and also
allows them to build a meaningful relationship with whomever they decide
with the protections offered by the laws.

3a. Alternative Policy Options for Resolving the Dilemma

a. Option 1 (O1): The We Care Nursing and Rehabilitation Center physician or social
worker will not authorize a patient with advanced dementia to engage in sexual
activity (touching of external or internal genitals, including touching of breast under
clothing, oral sex, sexual intercourse), regardless of the relationship status or sexual
orientation, and only handholding, touching shoulders, rubbing back, hugging and
kissing will be allowed. The We Care Nursing and Rehabilitation Center does not
provide alternative options to families, partners, and spouses to meet those needs.
And if the patient does not have a diagnosis of advanced dementia, this policy does
not apply to them.

b. Option 2 (O2): The We Care Nursing and Rehabilitation Center physician or social
worker will not authorize a patient with advanced dementia to engage in sexual
activity (touching of external or internal genitals, including touching of breast under
clothing, oral sex, sexual intercourse), regardless of the relationship status or sexual
 orientation, and only handholding, touching shoulders, rubbing back, hugging and
kissing will be allowed. The We Care Nursing and Rehabilitation Center physician’s
staff can provide alternative ways to enable patients with advanced dementia to feel
loved and protected.

c. Option 3 (O3): The We Care Nursing and Rehabilitation Center physician or social
worker will render the decision for a patient that has been diagnosed with advanced
dementia to decide on whether an advanced dementia patient can consent to sexual
activity (touching of external or internal genitals, including touching of breast under
clothing, oral sex, sexual intercourse). We Care Nursing and Rehabilitation Center
physician or social worker will determine if the relationship (civil union, married),
whether heterosexual or gay, is one that was established prior to the onset of
advanced dementia. If the relationship (civil union, married), whether heterosexual or
gay, was established prior to the onset or diagnosis of advanced dementia, then the
We Care Nursing and Rehabilitation Center social worker will evaluate (based on an
objective assessment) if the patient with advanced dementia is able to demonstrate
their disapproval of sexual activity (touching of external or internal genitals,
including touching of breast under clothing, oral sex, sexual intercourse), after that, a
determination will be made by the We Care Nursing and Rehabilitation Center
physician or social worker. If the We Care Nursing and Rehabilitation Center
physician or social worker determines that the patient can engage in sexual activity
(touching of external or internal genitals, including touching of breast under clothing,
oral sex, sexual intercourse), then the staff will monitor the client for distress or
disapproval on the day of the visit. If the patient with advanced dementia does not
meet the criteria above, then the We Care Nursing and Rehabilitation Center
physician's staff can provide information (literature, counseling, psychoeducation) on
how to build a healthy, meaningful relationship that does not harm the person
financially, physically, or emotionally and allow the patient with advanced dementia
to feel loved and protected.

d. Option 4 (O4): The We Care Nursing and Rehabilitation Center physician or social
worker will render the decision for a patient that has been diagnosed with advanced
dementia to decide on whether an advanced dementia patient can consent to sexual
activity (touching of external or internal genitals, including touching of breast under
clothing, oral sex, sexual intercourse). We Care Nursing and Rehabilitation Center
physician or social worker will determine if the relationship (civil union, married),
whether heterosexual or gay, is one that was established prior to the onset of
advanced dementia. If the relationship (civil union, married), whether heterosexual or
gay, was established prior to the onset or diagnosis of advanced dementia, then the
We Care Nursing and Rehabilitation Center social worker will evaluate (based on an
objective assessment) if the patient with advanced dementia is able to demonstrate
their disapproval of sexual activity (touching of external or internal genitals,
including touching of breast under clothing, oral sex, sexual intercourse), a
determination will be made by the We Care Nursing and Rehabilitation Center
physician or social worker. If the We Care Nursing and Rehabilitation Center
physician or social work determines that the patient can engage in sexual activity
 (touching of external or internal genitals, including touching of breast under clothing,
oral sex, sexual intercourse), then the staff will monitor the client for distress or
disapproval. If the patient with advanced dementia does not meet the criteria above,
then the We Care Nursing and Rehabilitation Center physician’s staff may link the
spouse to community service providers for ongoing services.

3b. Ethical Rules Screen

a. Code section 1.01: Commitment to Clients. "Social workers' primary responsibility is
to promote the well-being of clients." While social workers recognize the needs of
advanced dementia patients in relationships, their goal is to promote the client's
overall well-being.
b. Code section 1.02: Self-Determination. “Social workers respect and promote the
right of clients to self-determination and assist clients in their efforts to identify and
clarify their goals…Social workers may limit clients’ right to self-determination when
… actions or potential actions pose a serious, foreseeable, and imminent risk to
themselves or others.” While social workers promote clients' right to self-
determination, there are times where a social worker may limit that right to reduce
unwanted harm. Therefore, the qualifying criteria for a relationship must be met,
excluding those that met after the onset of advanced dementia and are not in civil
union or marriage. That type of relationship may pose serious or foreseeable harm
(physical, emotional, or financial) to a patient.
c. Code section 1.14: Clients Who Lack Decision-Making Capacity. “When social
workers act on behalf of clients who lack the capacity to make informed decisions,
social workers should take reasonable steps to safeguard the interests and rights of
those clients.” Social workers understand that some couples who have not been in a
relationship prior to their advanced dementia diagnosis can make them susceptible to
harm.
d. Code section 6.01 Social Welfare. “Social workers should promote the general
welfare of society, from local to global levels, and the development of people, their
communities, and their environments. .." While it is essential to promote social
welfare, it is not the focus of this section of the code; however, supporting the
established law may reduce the harm to those patients in the facility who may require
protection of the law.
e. Code section 6.04 (b) Social and Political Action. “Social workers should act to
expand choice and opportunity for all people, with special regard for vulnerable,
disadvantaged, oppressed, and exploited people and groups.” The goals provide
choices for everyone in the facility. While some patients may have the opportunity to
engage in sexual activity, others can still build a meaningful, healthy relationship
without sexual activity that does not harm the person financially, physically, or
emotionally and allow the patient with advanced dementia to feel loved and
protected.
f. Code section 6.04 (c) Social and Political Action. “Social workers should promote
conditions that encourage respect for cultural and social diversity within the United
States and globally. Social workers should promote policies and practices that
demonstrate respect for difference, support the expansion of cultural knowledge and
resources, advocate for programs and institutions that demonstrate cultural
 competence, and promote policies that safeguard the rights of and confirm equity and
social justice for all people.” The goals to consider are that the above includes
heterosexual and gay relationships (married or in a civil union), which does not
exclude someone based on their sexuality.
e. Code section 6.04 (d) Social and Political Action. “Social workers should act to
prevent and eliminate domination of, exploitation of, and discrimination against any
person, group, or class on the basis of race, ethnicity, national origin, color, sex,
sexual orientation, gender identity or expression, age, marital status, political belief,
religion, immigration status, or mental or physical ability.” This code does not
address advanced dementia patients, but it does allow social workers to participate in
the decision-making process of permitting an advanced dementia patient to engage in
sexual activity and monitor the patient for distress or disapproval to prevent
exploitation.

3b (2). The codes provide guidance for ensuring patients with advanced dementia are protected
from harm and discrimination, and they promote choices for others. Although it does not
mention individuals with advanced dementia, it identifies individuals who lack the
capacity to make decisions and provide sufficient guidance to select a particular policy.

3c. Ethical Principles Screen

a. Principle 5 (Quality of life) – Although my Option 1 (O1), in 3a does not take into
consideration the importance of building a meaningful relationship with the advanced
dementia client nor does it provide alternative resources for couples, therefore the
lack of support for those in the patient and partner may have a negative impact on the
patient and the partner that may contribute to their deterioration and quality of life.

b. Principle 4 (Least harm) – In an attempt to reduce the possible level of harm to the
partner and the patient, Option 1 (O1) may be perceived as causing the most harm to
a couple because it only allows minimal interaction and does not provide any
additional, on-site, options to maintain a healthy and meaningful relationship which
therefore leads me away from it being a viable option. Although Option 2 (O2) offers
an information component to the couple, Principle 4 leads me away from Option 2
(O2) because the information provided to the couple, along with the level of
interaction permitted, may not be sufficient to create a meaningful and healthy
relationship contributing to the deterioration of the patient’s mental health causing
harm. Option 4 (O4) does appear to decrease the level of harm; however, it does deter
me from this option because the facility does not provide additional services on-site
for those that do not qualify to engage in sexual activity, exposing the patient to rapid
deterioration of their mental health and exposing the client to other types of harm
(physical, emotional, and financial).

c. Principle 3 (Self-determination, Autonomy, & Freedom): Principle 2 leads me away

from Option1 (O1), Option 2 (O2), Option 3 (O3), and Option 4 (O4). Option 1(O1)
and 2 are the most restrictive, not allowing the patient with advanced dementia to
enjoy an opportunity to engage in sexual activity if the patient has a diagnosis of
advanced dementia. However, Option 3 (O3) and Option 4 (O4) will allow the
 patients to use some of their capacity. Even though it is limited to assenting to or
expressing distress and disapproval of sexual contact, it is limited to people who had
a prior relationship. Option 3 (O3) and Option 4 (4) does maximize those patients in a
previous relationship a level of self-determination, autonomy, and freedom, although
it may appear restrictive.

d. Principle 2 (Social Justice): The Principle of social just leads me away from Option 1
(O1) and Option 2 (O2) because it does not allow anyone to engage in sexual activity
in the facility, which discounts the patient with advanced dementia and their partner
the opportunity to meet their basic human needs, which is having a meaningful,
healthy relationship with sexual activity. However, Option 3 (O3) and 4 (O4) allow
the advanced dementia patient the opportunity to engage in specific sexual activity
people as long as the patient with advanced dementia is not being hurt. Although
Option 3 (O3) and Option 4 (O4) does allow the client to engage in sexual activity, it
does create some risk of sexual abuse, but the way they are structured, they work to
protect against that possibility of abuse while allowing a couple a level of autonomy
in their relationship. On the other hand, Option 4 (O4) is more restrictive and does not
provide a fair distribution of services in the facility. It isolates those that do not meet
the criteria to engage in sexual activity to outside resources.

e. Principle 1 (Protection of life): Principle 1 leads me to Option 3 (O3) because it is

the best fit, it provides the patient with advanced dementia, that is married or in a civil
union, the opportunity to engage in sexual activity while being monitored to ensure
their protection of life, and it also provides for those that do not meet the criteria to
engage in sexual activity the opportunity to receive services on-site with their partner
ensuring the safety of the patient. Option 3 (O3) reduces the likelihood of negatively
impacting a patient’s well-being because it allows them an opportunity to nurture a
meaningful relationship with their partner. The consequence of preventing a couple
from neutering a meaningful relationship may be life-threatening in some instances.

4. Which of the alternative options will:

a. Minimize conflicts between your client's, others, and society's rights? My Option 3
(O3) minimizes conflict between the client’s, other’s, and society's rights. My Option
3 (O3) minimizes the area of disagreement as presented in 2a(iii) by incorporating my
personal values of respecting people who lack the capacity of making decisions and
protecting those that lack the ability to protect themselves from physical, emotional,
and financial harm. It allows for the patient with advanced dementia to still be able to
participate in some sexual activity and at the same time be protected from potential
harm. The incorporation of 2b(iii) recognizes that even though the patient with
advanced dementia struggles with making decisions, they still have a voice to
communicate their needs or disapproval. The patient is monitored to ensure
prevention and protection of harm from those who are supposed to be caring for
them. Item 2c(iii) provides the facility the right to determine who is eligible to engage
in sexual activity. It allows them to protect the patient from harm while allowing
them to build a healthy and meaningful relationship by implementing the facility's
rules.
 b. Protect rights/Welfare

My Option 3 (O3) provides the patient with advanced dementia the protection of their
rights and welfare while also providing their partners (married, in a civil union, or
friends) to build a meaningful and healthy relationship, whether it is through
consensual sexual activity or through of other means as provided by the facility (see
3c(c)).

c. Be efficient. My Option 1 (O1) and Option 2 (O2) appear to be most efficient;

however, from my perspective, the cost of that efficiency may be too high as it might
impact the facility in other areas. While Option 3 (O3) and Option 4 (O4) are not as
efficient, they do have additional benefits as described above. The services provided
in-house outweigh the financial cost of providing services to those that do not meet
the criteria to engage in sexual activity.

d. Be effective. My Option 3 would be most effective in obtaining results because it

provides an opportunity for a couple to engage in sexual activity, it offers a patient
protection from harm through monitoring of the patient’s distress level or
disapproval, and Option 3 (O3) provides other onsite resources to continue to meet
patients personal needs in a secure setting for those that do not meet the criteria for
engaging sexual activity or are no longer to meet the criteria to do as a result of a
patient’s decrease in their mental health.

e. Result least harm. My Option 3 provides a patient with an option to go through the
process for approval to engage in sexual activity with their loved one if they wish to.
It also protects the patient from possible harm (sexual, physical, emotional, financial)
through the ongoing evaluation and assessment of the client’s mental health and well-
being. Even though not everyone at the facility may enjoy that benefits, they offer
additional onsite services with their partner, which increase a patient's safety and
well-being, as stated above.

5. The use of technology involves keeping electronic records. The accessibility of the client's
electronic record will allow any new or existing staff member to retrieve information on the
patient. It can include retrieving information on the outcome of the assessments, track
changes of a patient’s decline, make modifications in their plan, and make referrals to other
departments within the facility. The electronic record-keeping system can also be used to
track a patient's reactions to each visit. Technology can also be used to track individuals that
are not permitted to visit the patient due to abuse and can be used to ensure that the visitor is
not a sexual offender. Technology can also be used to track all releases of information to
primary care doctors, family, executor of the estate, and attorney if needed, and keep track of
permitted visitors. Technology can also be used to scan the visitor for weapons to ensure the
safety of staff, other residents, and patient.

6. In the short term, my Option 3 (O3) provides couples that have been together before a
patient's advanced dementia diagnosis an opportunity to engage in sexual activity. However,
this opportunity is limited, and reassessment is necessary to reduce harm to the patient. In the
 long-term, the couple and others in that facility can learn ways to nurture a meaningful,
healthy relationship on site. There is a likelihood that those that need a more intimate level of
affection (sexual activity as defined above in Option 3) may suffer from other mental health
illnesses, but with the ongoing services and therapist on-site, their mental health can be
addressed to avoid future harm.

7. I consulted with fellow co-worker, Paola Ortiz, Housing Specialist for the Housing,
Homelessness Prevention and Workforce Solutions, and Amanda Avila, Social Worker, DPSS
Children Services Division. Their key comments were:

a. Having a conversation about elderly people having sex is important but very “taboo” in
many cultures, would like to have seen a cultural component being considered in the
policy.

b. The policy does allow patients with advanced dementia a level of autonomy, and the
limitation on autonomy and self-determination are appropriate. Individuals in a facility
are not the best decision-makers and are unable to determine what they really want, so
assessing their understanding and willingness to engage in sexual activity is essential
because the patients do have rights and are protected under the law.

c. Would like to have seen a component on evaluating a dementia patient’s nonverbals

after a visit (not getting out of bed, not wanting to eat, refusal to bathe, lack of
excitement in the visit) because, at times, a patient may not be able to communicate
how they feel due to the violation.

d. The policy should not restrict the level of partnership; it should be more inclusive.

e. The definitions of sexual activity, relationship, and staff roles are clearly stated.

f. Did a "great job on examining the NSAW Code of Ethics and connecting to criteria
identified in the values section and options section."

8. Is (are) your final option(s):

a. Impartial? My Option 3 (O3) is impartial because it provides those patients that had
been in a relationship (married or in a civil union) prior to the diagnosis an
opportunity to engage in sexual activity until the patient discloses that they are in
distress or disapproval of the sexual activity with their partner. It may exclude other
advanced dementia patients from having sexual activity. However, they are given
other resources on-site to continue building a healthy, meaningful relationship with
another person while at the same time providing protection from harm.

b. Generalizable? Yes, my preferred Option 3 (O3) is generalizable. It allows patients

with advanced dementia to nurture a healthy and meaningful relationship despite the
individual cognitive decline. It also provides a similar opportunity for those who do
 not meet the criteria for sexual activity to develop and nurture a healthy relationship
with their partner through on-site resources.

c. Justifiable? Yes, my preferred Option 3 (O3) is justifiable. See discussion above.

9. As stated in 1 (b) (i), “If I were an individual with dementia, and desired to connect with
others or my spouse, I would hope I would have that right to do so." However, if I was
not married or in a civil union, I might have feelings of discrimination, but the good thing
is that we all have options. Furthermore, if I were married, I would be willing to go
through the facilities process to determine if I met the criteria necessary to engage in
sexual activity. I would hope to have some level of comprehension to understand why I
was not allowed to engage in sexual activity. I would respect the preferred option because
I know they would be acting in my best interest. If I can no longer identify my spouse
and feared him, I would want someone to set healthy boundaries for me. Also, if I no
longer qualify to engage in sexual activity with my spouse, having an alternative option
on site would be ideal for us. And if I were a rich widower who had been befriended by
someone after my onset of advanced dementia, I would like someone to protect my estate
and me from foreseeable harm.

10. I propose the implementation of Option 3 (O3): The We Care Nursing and Rehabilitation
Center physician or social worker will render the decision for a patient that has been
diagnosed with advanced dementia to decide on whether an advanced dementia patient
can consent to sexual activity (touching of external or internal genitals, including
touching of breast under clothing, oral sex, sexual intercourse). We Care Nursing and
Rehabilitation Center physician or social worker will determine if the relationship (civil
union, married), whether heterosexual or gay, is one that was established prior to the
onset of advanced dementia. If the relationship (civil union, married), whether
heterosexual or gay, was established prior to the onset or diagnosis of advanced
dementia, then the We Care Nursing and Rehabilitation Center social worker will
evaluate (based on an objective assessment) if the patient with advanced dementia is able
to demonstrate their disapproval of sexual activity (touching of external or internal
genitals, including touching of breast under clothing, oral sex, sexual intercourse), after
that, a determination will be made by the We Care Nursing and Rehabilitation Center
physician or social worker. If the We Care Nursing and Rehabilitation Center physician
or social worker determines that the patient can engage in sexual activity (touching of
external or internal genitals, including touching of breast under clothing, oral sex, sexual
intercourse), then the staff will monitor the client for distress or disapproval on the day of
the visit. If the patient with advanced dementia does not meet the criteria above, then the
We Care Nursing and Rehabilitation Center physician's staff can provide information
(literature, counseling, psychoeducation) on how to build a healthy, meaningful
relationship that does not harm the person financially, physically, or emotionally and
allow the patient with advanced dementia to feel loved and protected.