By Sophie King-Hill, Ph.D., University of Birmingham
In many harmful sexual behaviour (HSB) services for children
and young people (CYP) how resources are funded, developed, and delivered is
coming under increasing scrutiny as frontline and third sectors organisations
are having budgets cut and services reduced. Given this context, is it ever
ethical to charge for these resources?
Preventing and responding to (HSB) in children and young
people forms a significant proportion of the work social services, the third
sector and social justice organisations carry out. Due to this there are many
tools, assessments and interventions (referred to as resources) that have been
developed that make a tangible and positive difference to the lives of CYP and
their families. This, and the other points made in this article, also hold true
for the adult criminal justice field, but it is beyond the scope of the authors
expertise to discuss these in-depth and the focus will be on HSB services for
CYP.
When considering HSB the moral philosophy appears to be
underpinned by the reduction and prevention of sexual abuse and harm and the
promotion of well-being and recovery. So the reduction of harm and the
maximising of benefits. Ethics are often highlighted in practice in terms of
work carried out with CYP and their families and of the practice that is delivered,
and the research that is conducted. Yet these ethical considerations are sparse
when considering products that are commissioned and used.
At face value the ethical principles of HSB work may appear
clear-cut (i.e., work in a trauma informed way, do no harm, protect the
patient/service user). However, after scrutiny, the lines seem blurred. This
field is inhabited by professionals from a range of specialisms and fields
(i.e., sociology, psychology, criminology, social work, police, probation,
prisons, social care); therefore, HSB services are a multi-disciplinary,
multi-agency area that exist at a crossroads between practices, policies, and
processes. This means that the ethical considerations are somewhat complex as
no core set values and principles exist as they do in medicine, law or criminal
justice for instance. In social work for example, there is an explicit
commitment to human dignity and worth. In medicine there is a framework that is
built around doing good and no harm, free choice, justice and fairness. These
are ethical principles in which professions are bound - being built around
trust and held to account by bodies such as the General Medical Council.
Whilst a multi-agency approach is clearly needed for HSB, a
by-product of this way of working is that no steadfast and explicit ethical
principles exist due to the range of specialisms involved. This lack of a sense
of measure, accountability and consistent public pledge has perhaps created an
environment where profitable endeavours have gained traction and power without
the rigour of adequate ethical questioning. Given that preventing and responding
to HSB is both social justice and social care work, and given the rise of
health approaches and thinking in the HSB field there is a strong argument that
work, including tools and interventions, needs to be framed by social not
private enterprises. Therefore, profitability,
in its purest form does not seem to align when considering the field of HSB and
the underpinning principles of minimising harm and suffering and supporting
recovery.
The impact of the financial costs of resources on practice
and provision in harmful sexual behaviour services
Consideration needs to be given to the impact of the
financial costs of resources. If the
costs of resources is not equitable and is the same for all, in HSB services it
risks failing CYP and their families for a number of reasons, for example:
If some professionals can access the resource
and others can’t then this can result in miscommunication and misunderstanding
between the differing agencies. Research tells us that multi-agency work is a
crucial aspect of positive HSB outcomes, so this has the potential to cause
conflict in this space.
If, because of the cost, only a few
professionals in one agency can access certain resources then this may also
risk the dilution and misuse of what has been paid for. This points to a flawed
and unsustainable model – and may also indicate that in social welfare contexts
a model based purely on profits may make the overall issues worse, not better.
Training costs will always have to be ongoing if
there is a commitment to a certain resource, which again may be unsustainable
for agencies with small budgets. High staff turn-over may result in resources
not being used adequately as the trained experts will have left. Additionally,
when the case loads of those who are trained are full, what then happens to CYP
who need support.
The exclusion of CYP and families from accessing
services if professionals aren't trained or have knowledge is also
inadvertently causing them harm. This runs the risk of a two tier model – even
in the same service with some CYP and their families getting good support and
others not. When something exists that can make a tangible positive difference
to the lives of CYP and their families in an area as damaging as HSB, with no
equitable approach, can be measured against ethical principles as inherently morally
wrong.
The financial cost of resources can,
inadvertently, create a postcode lottery of service delivery and interventions.
For example, services in poorer socio-economic areas may not have the resources
to pay for resources and therefore CYP and their families maybe excluded from
accessing services.
Additionally, consideration needs to be given as to how resources
are commissioned and adopted by services and how this is supported by them as
well as by government and local authority budgets and spending. If resources are
shown to be working and making a measurable difference to the lives of CYP, and
their families, then large-scale funding and commissioning should be
considered. This may negate the issues with the profiting from damaging social
welfare issues that have gained traction.
What can be done?
It is important to consider the role, impact, and purpose of
charging for resources on the HSB sector has. If the purpose is to positively
support CYP who have sexually harmed or been harmed in an evidence-based way to
reduce harm, then of course the materials used need to be based on research as
well as expertise. The reality is that costs need to be covered, this is not
unrealistic. And to protect their fidelity through this should always be
considered. However, questions need to be asked in terms of the level of
profitability over social good and where this is ethically situated. A pure profitability perspective still
appears ethically flawed in this field and considerations of revenue sacrifice,
when bearing in mind the positive impact on people’s lives, should be made.
Perhaps a case could be made for a ‘robin hood’ model of working when charging
for services in this arena. In its simplest form this means charging those that
can afford it more and providing subsidies, resources and free services, to those
who can’t. This model emerged in the 1970s as can be seen in the work on
cataracts by the Aravind Eye Care Hospital in India at this time. Other
businesses have followed suit such as Warby Parker (buy one, give one for
glasses) and Cotopaxi (donating money for social good from profits) and is
underpinned by increasing social responsibilities of profit-making businesses.
With the right policy transfer frameworks in place this application of values
and approach can work in the field of resources and interventions that are
being charged for in the field of HSB.
Work in field of prevention of and response to HSB is a
moral and ethical issue, it is carried out by professionals who, in the main,
deeply care and are motivated to help the people they work with, and therefore
should be given access to the best resources available, regardless of cost.
This is even more relevant in working with children and young people in this
space. Therefore, should businesses that trade in this arena be held to account
and be bound to shared ethical principles, standards, and safeguards. These
principles could be set out in a charter mark for example, that has a clear
ethical criterion when making profit in this field that is underpinned by the
aim of maximising benefits and minimising harm to CYP and their families. The aim should be geared around considering
where they can make profitable sacrifices to maximise benefits and reduce harm
- being held to account when this is not evidenced, via an ethical framework.
It can be argued that in this field that the outcomes for CYP and their families
should be paramount and a recognition first and foremost for the lives of the
people who can benefit from services should be at the forefront of any business
considerations. That public benefit, as outlined by the Charity Commission, is
a key component of work in this area, especially in frontline services (i.e.,
social work, policing, child protection) that are publicly funded. The
landscape, when explored through the lens of ethics, provides a concerning
picture of an environment where the lack of consistent ethical principles means
there is no bar to measure against. Therefore, when considering maximising
benefits and minimising harm, in the field of HSB this lack of accountability
runs the risk of becoming incredibly dangerous.
