‘Dilemmas, Conundrums, and Quagmires.’ Tracing the Threads of Ethical AMHP Practice

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By Alan Bristow

Inspired by John Mitchell's seminar on the 6th June this year and further buoyed by Robert Lewis’ impassioned comments towards the end of the talk, I have undertaken an informal review of the blog site considering the fundamental question that was posed during the seminar-‘What type of AMHP do you wish to be?’

In reviewing all twenty blogs published since September 2022, a number of threads or conceptual themes begin to emerge that may assist us in formulating something of an answer. Of all the blogs published on the site, by my rough assessment, somewhere in the region of three quarters of them are primarily concerned with navigating difficult ethical terrain and the moral or ethical challenges AMHP work throws up in respect of (amongst other things): interviewing style, the assessment process itself, service user perspectives, the draconian nature of detention as well as issues pertaining to heavy handed approaches from the police, time scales for conveyance, out of area beds and of course the use of 135 warrants.

Maybe not too much of a stretch to say that for a blog site that's been publishing critical reflections on AMHP practice for just shy of a year, a 75 per cent return on ethical concerns would suggest not only is it a pressing issue, but it could be argued to be the central issue or foundational concern for wider AMHP practice.

I doubt there is anything new in this realisation for any AMHPs worth their salt. Many of us will be keenly aware of the fundamental problematic that all AMHPs have to operate around and within. Namely, how to practice ethically in the face of a statutory mental health system that may be coercive and potentially anti-therapeutic in its effects, whilst also continually evidencing structurally racist, patriarchal and heteronormative practices. Essentially, it all boils down to how one can practice ethically within a system that has more than its fair share of unethical or unjust socio-cultural interventions.

This is something I’ve grappled with numerous times over recent years. To add my own two pennies-worth to this emerging ethical debate, I too have found myself struggling considerably with the unexpected, unaccounted for or altogether unwanted effects of my actions as an AMHP, particularly within the custody environments I complete the majority of my MHA assessments within.

Specifically, I’m tasked with completing MHA assessments for those in custody within a busy central London Magistrates court. Inevitably, due to beds or lack thereof, anyone requiring diversion via the MHA 1983 from custody in a magistrates’ court will require the use of the Bail Act 1976 to remand them for a period of time until any such bed becomes available (unlike police custody, defendants cannot stay overnight in cells).[1]

Now before everyone screams at me to say that prisons should never be used as a place of safety (they shouldn’t!) and that every single piece of governmental guidance from the Department of Health over the past two decades states the need to divert from custody as quickly as practically possible, the reality of my job means that anyone I deem to be in need of an application for diversion away from custody will then require me to be on my feet in court advocating for a course of action that may well see my client remanded to prison for a number of days. This is not the kind of intervention I foresaw myself undertaking when I embarked on a career as a social worker or AMHP.  I’m not sure where within my training asking Judges to send people to prison was covered. It feels alien, wrong and fundamentally opposed as to why I became a social worker and AMHP in the first place. An ethical quagmire indeed!

So, what are we to do with such ethical issues, those thorny experiences that really challenge our views, our politics and our deepest held values and beliefs? How do we reconcile the need to undertake statutory work with attendant risk assessments and care plans in the face of a massively under-resourced and increasingly broken NHS system?

Cast your minds back to your social work training (apologies to nursing and OT colleagues although I imagine you covered an ethics module as well). You may recall a fairly standard exercise used to illustrate the ways in which different ethical frameworks reveal to us different courses of action that may be pursued in light of any given ethical problem. It goes something like this:

Firstly, Identify the ethical problem. We’ll stick with the example I have just given;- the ‘dual role function’ of practitioners employed in criminal justice/forensic institutions who are tasked with care and support in those very settings that actively work against the interests of care and support. Once we have our problem, we then articulate it through the main ethical frameworks employed in professional practice. These frameworks roughly correlate to:

Deontological- A normative ethical theory which states that the morality of an action should be based on whether that action itself is right or wrong under a series of rules and principles, rather than based on the consequences of the action. So, with regard my ethical conundrum (advocating for remand in the context of diversion away from custody), a deontological perspective would state that provided I stick to the code and statutory guidance and am mindful of the ethical charter I signed up to as a social worker, then all is well. My actions are in keeping with the procedures and rules of my discipline, therefore ipso facto, I’m behaving ethically. Hmmmm, doesn’t feel too convincing I must admit. So how about…

Kantian - Derived from German idealist philosopher, Immanuel Kant, the easiest way to describe this framework would be as a set of universal moral principles that apply to all human beings, regardless of context or situation. Kant refers to these principles as ‘Categorical Imperatives’. His most famous categorical imperative being ‘do unto others as you would have them do onto you.’ Similar to a degree with those deontological perspectives above. Again, if I practice in accordance with these moral principles (do no harm, unconditional positive regard, etc) then I should be fine. But, we quickly encounter the same problem. Even if I do practice by agreed protocols and societal conceptions of just action, it still doesn’t get me out of the issue I originally came with. Maybe because my ethical conundrum depends so much on context, something that Kant does away with altogether. Let’s move on then.

Utilitarian- Formulated by 19th century philosopher Jeremy Bentham, in reply to Kant’s categorical imperative we get Bentham’s consequentialist framework which states that ethical action arises when we pursue courses of action that benefit the greatest amount of people (Or as Bentham says, the greatest good for the greatest number). So, with regard my problem, we can reason our way out of it by stating that remanding an individual to prison is ethical as the greater good will be felt by society at large. Once more, I’m not left altogether convinced that Mr Bentham’s argument for ethical behaviour will make me feel much better as I watch my client leaving for prison in a SERCO van. Where does that leave me?[2] Well, to close I want to introduce ‘Virtue ethics’ as a means to resolve (or at least find peace with) the ethical dilemma identified, and to assist us with some of those taxing ethical problems covered in the wider blog site.  

Virtue- Concerns people’s ethical values, beliefs, and actions in contrast to meta-ethics or normative ethics which prescribe what people should do in terms of ethical principles, rules and specific actions. They attempt to move beyond these statements of purpose and lists of standards contained within professional codes such as those offered by BASW. These principle-based approaches do not take into account individual actors and their emotional or moral stance when adhering to such standards. Nor do they compensate for the context in which such ethical dilemmas are navigated, or decisions made. In reply to Kantian and deontological positions have come various recent trends. They include, Virtue Ethics (Webb, 2010), an Ethics of Care (Featherstone, 2010), Identity and Narrative Ethics (Wilks, 2005) and postmodern ethics focusing particularly on the work of Foucault and Bauman (Hugman, 2003), Habermas and proportionist ethics (Lovatt and Gray, 2008) and discursive ethics (Houston, 2010).

Broadly speaking they all move away from prescriptive standardised approaches to focus on individual relations and the possibilities for contextual difference. Virtue ethics, for example, highlights “the need for “the cultivation of character, and thus to the precedence of the quality of the actor over his action.” (Webb, 2010, p.115). Postmodern approaches stress the importance of fragmentation and identity, whilst denouncing the possibilities for an all-encompassing meta-ethical frameworks. In keeping with this, Michel Foucault (2000) - one of the central figures in continental philosophy and critical social work theory - argued for ‘the ethics of the self and technologies of the self’ towards the end of his career. The focus here is, likewise, on the practice of self-scrutiny and critical reflection as a means to achieve ethical forms of subjectivity.  Essentially then, for frameworks that correspond to virtue ethics and this ‘care of the self’, the spotlight is firmly placed on the nature of the social worker and who they are, rather than what they do.

In truth, ethical frameworks go well beyond those mentioned in standard social work textbooks and the brief discussion above. Ethics pertains to a fundamental branch of philosophy (western and eastern) are arguably comprises one of the major components of most belief systems. Our discussion on virtue ethics and related frameworks only scratches the surface. I introduce it though to try and reorientate practice to show that there is a way to adhere to ethical positions in the face of unjust social institutions or practices.

If we feel somewhat disenfranchised from social or political action that is required to reform these institutions and practices, then virtue ethics, which offers the cultivation of character and a critically reflective mode, may still allow for ethical forms of AMHP practice.  For some, this may feel like a language game, a trick of perspective that pulls the rug from under us and then says we were ethical all along so there was no dilemma at all! Perhaps, but in the face of such massive disparities within the welfare state and a perceived lack of ability to affect change on a societal level, maybe a renewed focus inward, on character, offers us something tangible at the very least, something which we are able to take control over and exert some influence. What type of AMHP do I wish to be? Well, in keeping with many of the blogs already published, I wish to practice ethically and engage in forms of critical reflection as a means to strengthen my character. If only there was a website collating such reflections that could assist me…..

References

Featherstone, B. (2010) ‘Ethic of Care’, in Gray, M & Webb, S, A (eds), Ethics and Value Perspectives in Social Work. Basingstoke: Palgrave Macmillan

Foucault, M. (2000) Ethics: Subjectivity and Truth: Essential Works of Michel Foucault 1954-1984: vol 1. London: Penguin.

Houston, S. (2010) ‘Discourse Ethics’, in Gray, M & Webb, S, A (eds), Ethics and Value Perspectives in Social Work. Basingstoke: Palgrave Macmillan.

Hugman, R. (2003) Professional Values and Ethics in Social Work: Reconsidering Postmodernism? British Journal of Social Work, 33 p.1025-1041.

Lovat, T & Gray, M. (2008) Towards a Proportionist Social Work Ethics: A Habermasain Perspective. British Journal of Social Work. 38, p.1100-1114.

Webb, S, A. (2010) ‘Virtue Ethics’, in Gray, M & Webb, S, A (eds), Ethics and Value Perspectives in Social Work. Basingstoke: Palgrave Macmillan.

Wilks, T. (2005) Social Work and Narrative Ethics. British Journal of Social Work. 35 p.1249-1264.

1] The use of the bail act is only undertaken for civil sections. For forensic sections (s.37 etc) undertaken in a crown court the use of the bail act is not required. However, as many will know, it still requires the use of remand to facilitate transfer to forensic inpatient units. The ethical dilemma I advance above is in respect of civil sections within magistrate’s court solely.

[2] In fairness to Utilitarian approaches, they have been instrumental to wider Social Work practice, and one could frame the welfare state and the NHS in their entirety as examples of services being delivered for the benefit of the greatest good. Indeed, individual interventions that comprise large parts of AMHP and Social Work practice, such as applications for detention, can explicitly be framed as instances of utilitarian action. My brief comments here are not intended to suggest that such utilitarian positions have no relevance to overall AMHP work.