The Welfare Office
Lu Chen, a 53-year-old, recently widowed housewife living in East Oakland, California, has applied for income support, including Temporary Aid to Needy Families (TANF), food stamps, and other public assistance programs. Lu, an immigrant, relied exclusively on her husband prior to his death for her financial support. She has several adult children, each of whom lives close to their mother. East Oakland is an ethnically diverse city of about 88,000 persons with an African American population approximately 51 percent of the total. Its Asian residents, representing about 4 percent of the overall population, are also diverse and include Chinese, Vietnamese, Laotian, and other southeast Asian persons residing mainly in East Oakland’s downtown area. East Oakland’s Latino population is the fastest growing, with a rate of increase exceeding 100 percent since 2000.
Lu is primarily a monolingual Chinese speaker, but does understand some common English phrases. At the time of her application for benefits, Lu is given informational materials relevant to her case that explain generally her rights and obligations under each program. Some of the materials are in comic book form and all are translated into Mandarin Chinese. A posted sign on one of the walls of the welfare office outlines the rights of the applicant, such as, for example, the right to appeal a denial of benefits. The sign’s information is translated into several languages, including Chinese. Detailed administrative rules and regulations describing income and other program conditions are not provided, but they are made available through the Internet, also translated into a number of languages, and are also made obtainable at the welfare office in printed form by request. The applications Lu has to complete require, among other things, her verification of income and attestation as to the amount of property she owns. These applications are translated as well into Chinese. A case worker who speaks some Chinese is on staff at the welfare office, but he is the only staff member who does so; basically, all Chinese clients who enter the office for services are referred to him.
This case example represents a nontraditional application of the informed consent doctrine in the sense that it involves the delivery of human services, rather than health or mental health care. Nevertheless, informed consent governs the professional relationship here every bit as much as it does the affiliation between a clinical provider and a client. The decision maker who recognizes the application of informed consent in this case example will obtain useful assistance in identifying responsibilities that apply to health and human service professionals, including all of the administrative tasks of practice, including client intake, assessment, and claims processing.
In this scenario, the requirements of informed consent are challenged by language barriers that may seriously impede Lu’s understanding of her rights and obligations under government programs. Can dissemination of general information about Lu’s rights and obligations be presented to Lu in a form that reasonably ensures her comprehension of what she is receiving and what her responsibilities are for receiving it? The answer will depend in large measure not only upon the clarity of the paperwork Lu is required to sign, but also on the quality of the dialog between Lu and her case worker before, during, and after her application for benefits. If a fully bilingual professional is not provided to Lu at the time of her intake, then her informed consent to receive services cannot reasonably be obtained. The time-limited, bureaucratic atmosphere of a typical welfare office does not justify the avoidance of this responsibility. If it is provided, then informed consent must continue throughout Lu’s involvement with the government programs, and cannot cease with the application process. It must even include competent advice to Lu concerning possible alternatives to some of the public assistance programs that Lu is to consider. Considering the demographics of the community in which Lu lives, a culturally-conscious welfare worker should be reasonably familiar with the role of extended family involvement in Chinese-American tradition, and especially the custom of financial support of older parents by their adult children. Such information may appropriately be used by the welfare worker to help Lu to contemplate her reliance on family assistance in preference to one or more of the government programs to which she may apply.
The program rules and regulations that are posted by the agency on the Internet are also likely to have an impact on Lu’s expectations and ability to conform to the requirements of the welfare programs. Lu cannot, however, be reasonably expected to access this information without ongoing professional assistance from the agency worker. Nor can Lu be expected to request a copy of program rules and regulations on her own initiative; she certainly is not likely to understand any part of this material without additional, personalized aid from the worker. Therefore, the agency’s promotion of Internet use as a means of conveying program information may be high-tech and inexpensive, but it is not an appropriate way, either culturally or realistically, to seek informed consent from clients.
Courts have demonstrated that a failure to honor informed consent by government employees can be legally enforced. Indeed, government agencies and their employees have suffered civil sanctions for professional misconduct in connection with their failure to provide sufficient assistance to clients during the welfare application process. In 1999, New York City welfare workers—evidently pressed by new state legislation imposing financial cutbacks—acknowledged turning away applicants for assistance and failing to provide prompt access to food stamps and Medicaid; in response, a federal judge ordered the city to retrain workers, revise benefit applications, and increase the visibility of posted signs outlining applicant rights.