Dilemmas with duty care - Care Certificate

How to address and manage dilemmas between duty of care and an individual’s rights

This page is designed to answer the following questions:

Balancing duty of care with the rights of the individuals you support

Perhaps one of the most difficult things about working in adult health and social care is maintaining the equilibrium between an individual’s rights and your duty of care.

On the one hand, you must promote the safety and the wellbeing of the individual and do your best to ensure they do not come to harm.

On the other, you must also uphold the individual’s right to make their own life choices, even if you think they are making an unwise decision.

So, how can you respect their human rights whilst also ensuring that they are protected?

The short answer is that you can’t. In many situations the individual’s right to make their own decisions (even poor ones) will outweigh your duty of care obligations.

At the end of the day, the choice is theirs. However, you must still do your best to ensure their safety and wellbeing. You may do this by:

  • asking why they have made their decision
  • explaining the risks so that they can make an informed decision
  • following their care plan
  • completing a risk assessment
  • seeking advice from your manager or other professionals

There may be situations where you feel that an individual has made or is making a decision that they do not fully understand and it may be that they do not have the capacity to make such a decision. In these cases you should report it to your manager or other relevant person(s) in your organisation and advise that a Mental Capacity Assessment (MCA) may be required.

Other exceptions are if serious harm or injury could befall the individual or others directly from their decision or if you have suspicions that abuse is or could take place. These should be reported to a manager or relevant person(s) immediately as part of your safeguarding responsibilities.

Some typical dilemmas between duty of care and individual rights

Dilemma #1: A client won’t take his meds

The most common example usually given to demonstrate a dilemma between an individual’s rights and duty of care is that of medication administration.

Imagine you are supporting an individual with paranoid schizophrenia and it is time for their medication. You ask them to take their medication but they refuse because they believe that the pharmaceutical industry conspiring to poison them.

Even though you know the individual needs the medication, you cannot force them to have it. Neither can you try to give it to them covertly by grinding it into a powder and putting it in their food (this is a big no-no!).

The way that you manage the situation will depend on the individual and what is written in their care plan. It may be that you say “okay, no worries – come and see me if you change your mind” and then leave them alone knowing that (based on previous situations) they will request their meds again within half an hour. Or you could try to reassure them that there is no big conspiracy against them and logically list the flaws in their belief.

If the individual continues to refuse their medication despite your best efforts, you may have to call their GP or NHS Direct to seek further guidance. You should also report this your manager and fill in the required paperwork as per your organisation’s policies and procedures.

Dilemma #2: A vulnerable client gets a part-time job as  a drug runner

As another example, imagine that you support a man with a mild learning disability who has been befriended by a group of men at his local pub. They buy him drinks in exchange for him delivering suspicious packages for them. The man often comes home smelling of marijuana.

You are obviously concerned about his wellbeing but you also have to respect his right to make his own choices.

It would be your obligation under duty of care to talk to him about his actions and explain the associated risks (he could be arrested, he could be subjected to drug-related violence, he could put his family at risk etc.). But you could not tell him that he can’t continue to do it (although you may advise him not to).

It could be that he didn’t realise that the packages contained drugs. Or he may have known but didn’t fully understand the implications. By having these conversations, you may dissuade him from doing it in future.

It may be that you establish that he does not comprehend the implications and may not have the capacity to make this choice, in which case you would refer him to have an MCA.

In any case, you should report this information to your manager and whomever is responsible for safeguarding in your organisation. If you do not have a safeguarding lead, you or your manager may report it to your local authority’s social services safeguarding team or the individual’s social worker.

Dilemma #3: A recovering alcoholic fancies a beer

Consider that you support a recovering alcoholic. They haven’t had a drink for six weeks and are doing well. One day whilst walking past an off licence they say they want to buy a four-pack of lager to drink that evening.

You want to look out for their wellbeing but you understand that ultimately the decision of whether they have a beer or not is up to them.

You may remind them about how well they are doing and encourage them to keep it up. You may be compassionate and empathetic and tell them that you understand it is hard but they can do it and you are there to support them. You may remind them of what was discussed in their last AA meeting and highlight the risks of falling off the wagon. You could suggest going home to have a chat about it first or completing a risk assessment together and if they still want some cans to return later.

But if they still say “nah, i’m gonna get some booze”, you must respect their decision and let them get on with it. You have no legal right to stop them. By trying the things above, you have fulfilled your duty of care. Short of restraining them (which is illegal) unfortunately there is not a lot more you can do?

Managing conflicts and dilemmas: Do’s & don’ts

Now that you understand some of the difficulties that can arise as between human rights and duty of care, here is a list of DO’s and DON’TS when trying to balance the two.

Do’sDon’ts
✔️ Take reasonable steps to ensure the safety and wellbeing of others❌ Tell others what they can and can’t do
✔️ Do what you can to ensure individuals have all the info they need to make an informed decision❌ Embellish or exaggerate the facts
✔️ Inform responsible person(s) if there is a risk of harm to themselves or others❌ Keep quiet if there is a risk of harm
✔️ Inform responsible person(s) if you have a suspicion that abuse has occurred or is likely to occur❌ Worry about breaking confidentiality if there is a suspicion of abuse
✔️ Request an MCA referral if you believe that an individual may not have the capacity to make a decision❌ Assume that an individual does not have the capacity to make a decision (unless you have the relevant paperwork to back it up)

Seeking additional advice and support

If you are unsure about what to do in a particular situation, you should always ask.

In the first instance, you would want to get additional support and advice to resolve such dilemmas from your line manager. In most cases, they will be able to give you the guidance you need.

Your organisation may have people that have expertise in certain areas. For example, a Head of Safeguarding that can advise in safeguarding matters or a Learning Disability Nurse responsible for carrying out Mental Capacity Assessments. It will be useful for you to find out what the various employees in your organisation have specialism in and are responsible for so that you know the best person go to for advice.

Similar, you may be able to get some guidance from your organisations documented agreed ways of working, which can include policies, procedures and care plans.

Outside agencies may also be able to offer support. Social services, GP’s, psychologists, NHS Direct or even charities can be great sources of information.

Example questions & answers

Describe two situations which demonstrate a conflict or dilemma between exercising a duty of care and the rights of an individual.

Within my line of work, there are many times that there are conflicts or dilemmas between exercising my duty of care and the rights of an individual.

A typical example may be when an obese client wants to eat junk food or takeaways every day despite it being detrimental to their health. My duty of care obligations require me to encourage the client to have a healthy diet so that they don’t get poorly from overeating or not getting enough nutrition, however I also need to remember that all individuals have the right to make their own choices about what they eat.

Another example would be if an individual with paranoid schizophrenia refuses to take their medication. Everyone has the right to refuse medication and I should respect that, however my obligation to duty of care would require me to do everything I can to try to encourage the individual to take it because I know that it would be detrimental to their mental health if they didn’t.

Choose one of the situations above and describe how best to manage the risks involved, explaining the reasons why this would be best practice.

In the example above, where an individual is refusing to take their medication, it would be best practice to try to encourage the individual to take it because this would be in their best interests. Everyone is different and by knowing the individual or referring to their care plan and risk assessments, we can establish the best techniques to help them to agree to take their medication.

For some individuals, this may mean simply leaving them for a while and then coming back later to offer them their medication again. Or even waiting for the individual to come to you to request it. For others, it may be necessary to explain the reasons why they should take their medication and the potential ramifications of them not taking it. You could even remind them of the negative consequences that occurred last time that they refused their medication.

Asking the individual why they are refusing their medication may shed some light on the reason for their refusal. It could be that they think the medication is causing them harm and in this case I would be able to reassure that it will help them, rather than harm them.

Sometimes, it may be necessary to ask for assistance from another member of staff as some individuals may be more willing to comply with a different person’s request.

If medication is still refused then I would contact a senior member of staff for advice. I may also obtain advice from the individual’s GP or NHS Direct (out of hours).

Recording the refusal of medication is imperative. I would note on the MAR sheet that medication had been refused and write up a statement about what had happened. It may be necessary for me to write up a risk assessment for the individual refusing their medication with collaboration from the individual, their family, other staff and other professionals, which can be used in the future.

Explain where a social care worker can find advice, support and information relating to conflicts and dilemmas in adult social care.

Social care workers can find advice, support and information about conflicts and dilemmas from several sources.

Speaking to the individual themselves when they are in a calm state is perhaps one of the best ways of finding out ways to resolve or come to a compromise about any conflicts or dilemmas that affect their support. Speaking to their family or close friends can also be beneficial.

Conversing with other staff and my manager is also a good way to get guidance and new ideas as well as talking to other professionals that are involved in an individual’s care, such as their GP, social worker, psychologist etc.

I can also obtain guidance from my company’s policies and procedure as well as industry best practices such as CQC’s Key Lines of Enquiry. The Internet is also a useful resource.