Ethical considerations of the financial cost of resources on harmful sexual behaviour services

 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.