Key Considerations
Understanding and respecting the client’s or client system's right to refuse services is crucial for ethical social work practice. Social workers must ensure clients are informed, respect their autonomy, and document decisions accurately. Both legal and ethical guidelines must be taken into account. This approach empowers clients and supports their right to make decisions about their own lives--even decisions that may not be in their own best interest.
Informed Consent
- Clients must be provided with all relevant information about the services, including potential benefits, risks, and alternatives, to make an informed decision. This is spelled out in the first section of the NASW Code of Ethics.
- The process should ensure that the client fully understands the information provided and the implications of their choices.
Autonomy and Self-Determination
- Clients have the right to make their own decisions about their care and services, even if those decisions differ from the recommendations of professionals.
- Social workers must respect clients’ choices and support their right to self-determination.
Legal and Ethical Boundaries
- Social workers should be aware of legal requirements and ethical guidelines surrounding the right to refuse services.
- In some cases, there may be legal constraints, such as court-ordered treatments, which can limit this right.
Capacity to Decide
- Assessing the client’s capacity to make informed decisions is crucial, especially in cases involving mental health issues, cognitive impairments, or minors.
- If a client lacks capacity, social workers must work with legal guardians or representatives to ensure decisions are made in the client's best interest.
Documentation and Communication
- Documenting the client's decision to refuse services, along with the information provided and the client's understanding, is essential.
- Clear communication with the client about their rights and the potential consequences of refusing services is important.
Examples
Here are examples of situations where clients or client systems may exercise their right to refuse various services. It's not hard to imagine any of these shaped into a vignette question on the social work licensing exam:
Medication
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Psychiatric Medication:
- A client with a diagnosis of schizophrenia decides to stop taking antipsychotic medication due to side effects.
- A teenager diagnosed with ADHD refuses to continue taking stimulant medication because it makes them feel anxious.
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Pain Management:
- A terminally ill patient with cancer refuses to take prescribed opioids for pain management, preferring to manage pain with alternative methods.
- A client with chronic pain refuses prescribed pain medication due to concerns about addiction.
Medical Treatment
Counseling
Placement
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Residential Placement:
- An elderly client with mobility issues refuses to move to a nursing home, preferring to stay in their own home with support from home health aides.
- A child in foster care refuses to move to a new foster home, expressing a desire to stay with their current foster family.
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Inpatient Treatment:
- A client with severe bipolar disorder refuses inpatient psychiatric treatment during a manic episode, insisting they can manage their condition with outpatient care.
- A young adult with an eating disorder refuses admission to an inpatient treatment facility, preferring outpatient therapy and support groups.
End-of-Life Care
Law Involved
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Court-Ordered Treatment:
- An individual on probation refuses court-ordered anger management counseling, preferring to complete their sentence without participating in the program.
- A parent involved in a custody case refuses to undergo a court-ordered psychological evaluation, believing it is unnecessary and intrusive.
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Mandatory Reporting:
- A social worker encounters a client who refuses medical treatment for a child that may constitute neglect, requiring the social worker to report the situation to child protective services despite the refusal.
TL;DR: Except where mandated or immediate harm to self and others is in play, clients’ rights to refuse services eclipses other concerns.
On the Exam
Test questions on this topic may look something like this:
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A client with a chronic mental health condition refuses to take prescribed medication. The social worker should:
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A social worker is working with a client who has been court-ordered to attend counseling sessions but refuses to participate. What should the social worker do?
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An elderly client with cognitive impairment refuses to be placed in a nursing home, even though it is recommended for their safety. The social worker should FIRST:
Get practice questions like these when you take SWTP's full-length practice tests.
Next up on our ASWB exam journey: The client's/client system's right to refuse services (e.g., medication, medical treatment, counseling, placement, etc.). This is material that is likely to show up on the licensing exam since it straddles several different broader topics. Let's take a look and then examine how the material might appear on the big test.