Defining the Problem
Michael A. Gillette, Ph.D.

One of the most important tools for doing applied ethics well is the ability to define in concrete terms the specific function of activities or services that are offered. Many ethical disputes develop out of the fact that different people, either staff or clients, have distinct sets of expectations for what they must provide or what they can reasonably demand to receive. This lack of clarity regarding expectations is generally a function of divergent concepts of exactly what is being offered, rather than an indication that one party is being reasonable while the other party is not.

Imagine a circumstance where a child is driven to Florida on a "vacation". From the child's perspective, the purpose of the trip is to go to Disney World. Why else, after all, would anyone ever drive all the way to Florida? For the child, the fact that great-grandparents happen to live in Delray Beach is secondary - although perhaps lucky - to the fact that Disney World is located in Orlando. From the perspective of the parents in this story, however, the grandparental visit is of paramount importance, and the trip to Disney World is the lucky, although expensive diversion.

No problem exists in this scenario until the schedule for the trip is developed. If the trip is primarily to Disney World, then five out of seven days should be spent there. If the trip is primarily a family visit, then the ratio of time should be reversed. The first move that one might make in analyzing this problem is to assume that adults know best, and that the immature desires of the children can be discounted. In this case, however, the desire to spend additional time in Disney World may not be a function of immaturity. It is entirely plausible that the adults in the story would also like to spend the lion's share of their vacation in Disney World rather than in Delray.

While extraneous factors (e.g. available financial resources) may seem to have impact on the resolution of this situation, we can only really settle the above outlined dispute by clarifying the purpose of the trip to Florida. It is important to determine what the motivation for the excursion is. If the purpose of going to Florida is to make sure that the great-grandchildren have sufficient time with their great-grandparents, then more time should be spent in Delray. If the purpose of the trip is to provide bonding time for the nuclear family, then Disney World becomes the primary target. If the goal of the trip is to provide bonding in a low-key, relaxed and inexpensive environment, however, then Florida should be forgotten, and hiking in the Smokies would be best.

How, one might ask, does this all relate to medical ethics? Imagine the case of Ms. L. She is a 28 year old resident at a group home who has successfully worked at a sheltered workshop for 18 months. She has done very well and enjoys the work, but evaluations indicate that she would most likely succeed in a more competitive work environment. Ms. LÌs case manager wants to move her out of the sheltered workshop so that space can be made available for another client who needs the close support offered by sheltered industries. Both Ms. L and her family do not want Ms. L to leave her present employment, however, because they feel that the protective and supportive environment is the safest place for her. Should Ms. L be forced to leave her comfortable work setting?

Although the decisions involved in Ms. L's case are much more serious than those in the Disney World choice, the format for decision making is identical. In determining our responsibilities to Ms. L and the other unnamed client, we must ask: what is the primary goal that drives Ms. L's placement in sheltered employment? Is this work experience simply a job? Is it a service? Is it part of a treatment plan? Or is it a transitional episode in a process by which some more ultimate goal is achieved?

Although a single experience may answer to multiple descriptions, it will only be possible to determine whether Ms. L has a right to remain in her present work environment once we understand what the primary function of her work is. If sheltered industries is a 'job', then she cannot be fired for as long as she continues to satisfy her job description. She also would have no deep right to the job, however, as people lose jobs all the time to down-sizing and reorganization.

If the work experience is to be considered a service, then it becomes clear that services are offered only to those who satisfy certain criteria. We do not offer special assistance to those who do not have special needs. Therefore, one of the criterion to be met if we understand the work in this way, might be inability to work in an alternate environment.

If the work is understood as a therapeutic intervention or treatment, then it would also only be made available to those with special needs. In addition, there would be pressure to apply the therapeutic remedy that is least invasive. This work option would only be made available to Ms. L if she truly needs it, and if there is no other less restrictive method available for satisfying her needs.

Finally, if sheltered industries are considered transitional opportunities, then no expectation of permanence should ever have been allowed to develop, as it should have been made clear at the outset that work settings are temporary.

It is not my goal this month to complete a case study. Rather, I wish to demonstrate the fact that many ethical disputes are based on misunderstandings. Many people erroneously believe that moral disagreements are always the result of disagreements over moral values. It is my thesis, however, that moral disagreements can grow up out of misunderstandings of a much more simple sort. If clarity in the goals of action is available, then clarity in moral responsibility can be generated.