1 Compare and contrast the various sources of moral guidance.
2 Define three traditional approaches to applied ethics: principle, care-based, and virtue.
3 Apply one of the traditional approaches to ethics to a complex case to reach a morally justifiable resolution.
Health care is fraught with ethical issues, including questions about whether to tell clients disturbing and potentially harmful news, how to deal with impaired or incompetent colleagues, and how to distribute scarce and valuable resources. As one of the health professions, occupational therapy cannot help being involved in ethical problems and their resolutions. In fact, occupational therapists often find themselves caught between two moral goods. First is the desire to assist the client to function better with independence, and second is the client’s right to self-determination that may lead to noncompliance and less-than-satisfactory outcomes.
The purpose of this chapter is to define applied ethics and its application to occupational therapy practice, with a specific emphasis on the special types of problems encountered in splinting. Sources of moral guidance and values are explored, along with three traditional approaches to ethics. The three approaches (principles, care-based ethics, and virtue) are applied to complex clinical situations involving splinting in the latter sections of the chapter. Resources to assist in the resolution of ethical problems are also noted.
Ethics itself is hardly a new area of study. Its application to the practical problems of health care is a relative newcomer, beginning approximately in the late 1960s with questions about research on human subjects, vital organ transplantation, and hemodialysis [Jonsen 1998]. What was needed at that time was a detailed study of professional ethics aimed at establishing standards of conduct and moral behavior. The need for the guidance ethics provides continues to the present day.
Normative ethics is that branch of ethical inquiry that considers general ethical questions whose answers have a relatively direct bearing on practice [Solomon 1995]. The results of applied ethics have immediate consequences for action and policy. In recent years, this definition of normative or applied ethics has been expanded. Now it includes concerns about relationships and the particular experiences of those who are ill or injured, as opposed to abstract universal approaches.
These types of concerns fall under the heading of care-based reasoning. Thus, a complete definition of normative ethics encompasses an examination of principles and virtues. It also includes what we should nurture and sustain as human beings to achieve the most of what is best in human life. The focus of this chapter is on the moral life in occupational therapy, particularly in the area of splinting. To arrive at a clearer understanding of ethics, it is helpful to have a baseline of key terms. Three terms underlie the discussion in this chapter: ethics, morality, and values.
Ethics, as has already been explained, is the exploration of moral duty, principles, human character or virtue, and human relationships. In effect, ethics involves the study of right and wrong, good and evil, moral conduct on an individual and societal basis, rules, promises, principles, and obligations. Taken together, these constitute the important concerns of ethics.
From this broad definition of ethics, it might appear that all human interactions on some level involve ethics. Although this is true, it is important to be able to sort out and differentiate the ethical issues central to the question at hand from those that are merely the underpinning or backdrop for daily experience. A simple guide to determining whether a situation involves ethics involves answering the following three questions [Chater et al. 1993].
• Is there more than one morally plausible resolution?
• Is there no clear-cut best resolution?
• Is there direct reference to the welfare or dignity of others?
If the answer to any of these questions is yes, the situation in question involves ethics.
Human behavior or actions that are judged as either good or evil fall in the domain of morality. Although ethics can be thought of as the more formal and prescriptive of the two, many ethicists use the words morality and ethics synonymously. When we make a judgment about a person’s conduct, saying “That action is bad or wrong,” we are actually including a judgment about the act itself, the values attached to the action, and accountability for the action. If a therapist were to tell a lie, the very word we use to describe the action (lie) indicates that the action is wrong or at least opposed to the action of telling the truth. For example, suppose a client asked a therapist if she has any prior experience in fabricating a particular type of splint. Although the therapist has never made the specified splint before, she tells the client that she has made them on several occasions.
We can claim that the action is wrong only if we explore the values that support the worth or goodness of truth telling and why it is important to tell the truth. Telling the truth demonstrates respect for the other person and allows individuals to make decisions with accurate information. If we found while exploring the “liar’s” action that he or she was completely unaware that lying was wrong or bad we might excuse the person from moral wrongdoing because he or she did not know any better. When a person is unaware of the rightness or wrongness of actions, we consider him or her amoral.
Although it is difficult to believe that individuals would be unaware of the moral rules of the society in which they live, there are those who because of age or mental defect do not understand the moral implications of their actions. Persons who normally fall into this category are children, the mentally ill, or persons with severe cognitive disabilities. On the other hand, persons who know the difference between right and wrong conduct and yet choose to do the wrong thing are considered immoral and accountable for their actions.
In the brief discussion of morality, it is clear that values are an important part of ethics. Values are the internal motivators for our actions. When individuals value something, they invest themselves psychologically and spiritually. They also attach emotions (positive or negative) and importance to persons, places, objects, actions, ideals, or goals that seem to be most relevant to or intimate with the self. Basic values and a value system are developed during childhood. Of course, early established values can be changed under great spiritual or emotional distress.
Values can also be changed when it becomes apparent that an old value does not effectively resolve a present dilemma and a new, more attractive and applicable, value does. A conflict of values is often the genesis for an ethical problem in clinical practice. Regardless of the origin of a value, the resulting personal and professional values can profoundly affect the ethical decisions occupational therapists make. For example, a first-year occupational therapy student used to think elders over age 85 should not receive any type of splinting because it was too costly and life expectancy was probably minimal. However, after graduating from occupational therapy training and interacting with older adults in the clinical setting the new therapist now values the lives of elders and has resolved the bias against ageism.
The basic definitions of ethics, morality, and values set a foundation to help separate ethical concerns from other types of problems and issues an occupational therapist faces in clinical practice. Once it is clear that a situation or problem involves ethics, the next question is where you should look to determine what is right or morally correct. Are morals grounded in one’s own opinion? Or that of significant others? In the law and regulations that govern professional practice? In the opinions of one’s professional group or association? In the religious or philosophical beliefs of the individual or institution?
This section explores alternative sources of moral guidance. What is important is not so much to determine what the right thing to do is but to reflect on the various sources of moral authority that have particular impact on your professional practice and personal decision making. One should consider how these sources of authority shape one’s behavior and character.
One of the primary sources of support and guidance for moral decision making are peers and family members. In two separate national studies (one of registered nurses and the other of pharmacists) the majority of respondents stated that they would first turn to their spouse for moral advice or counsel, followed by a peer [Haddad 1988, 1991]. Seeking the advice of someone who is close and trusted is not too surprising, and it is likely that occupational therapists would respond in the same way their colleagues in nursing and pharmacy did.
Individuals who know us well and share the same perspectives and values are logically the first-line resource for most health professionals faced with a moral problem. However, even though it is understandable why an occupational therapist might turn to a peer for ethical advice there is no reason to believe that the peer will be able to provide justifiable resolutions to the problem. In other words, peers and significant others may be sympathetic but they are not necessarily in the best position to help sort through the complicated ethical issues encountered in clinical practice.
Furthermore, significant others and peers would probably not be considered the source of moral authority, even if they were skilled in analyzing ethical problems. We must look further than the individuals who make up our families and our colleagues for moral guidance. For example, a therapist is faced with an ethical decision: whether or not to fabricate splints for a person who was burned over 90% of her body. Instead of the therapist asking his wife about the decision, the therapist networks with professional peers who are members of the hospital’s ethics committee.
At times it is difficult to distinguish between the law and ethics. Former Chief Justice of the Supreme Court Earl Warren described the relationship between the law and ethics as follows.
In civilized life, Law floats in a sea of Ethics. Each is indispensable to civilization. Without Law, we should be at the mercy of the least scrupulous; without Ethics, Law could not exist. Without ethical consciousness in most people, lawlessness would be rampant. Yet, without Law, civilization could not exist, for there are always people who, in the conflict of human interest, ignore their responsibility to their fellowman [Warren 1962].
Thus, there is a delicate and changeable relationship between ethics and law. Laws and specific regulations that govern health care practice order our professional and institutional relationships. In an ideal world, the law would embody our ethical commitments. Yet, sometimes the law and ethics diverge.
It is possible that an occupational therapist could conclude that he or she should engage in civil disobedience to violate the law or public policy to do what is ethical. Of course, this sort of decision to disobey a law or regulation should not be taken lightly. If ethics sometimes requires civil disobedience, it implies that what is ethical is not determined solely by public policy or law. Therefore, this reasoning argues, the law is not a sufficient source of authority for determining proper ethical conduct for an occupational therapist.
Health professionals recognize that the question of what is moral has to do with professional ethics. Occupational therapists might turn to a professional code of ethics as a source of moral guidance. For American occupational therapists, this would be the current Occupational Therapy Code of Ethics of the American Occupational Therapy Association [AOTA 2005].
An occupational therapist faced with an ethical problem could turn to the Occupational Therapy Code of Ethics to see what guidance it offers regarding the specific issues at stake. Often the Code will provide direction and assistance. “Health care professionals typically specify and enforce obligations for their members, thereby seeking to ensure that persons who enter into relationships with these professionals will find them competent and trustworthy” [Beauchamp and Childress 2001, p. 6]. Most health care professions codify these rules of conduct into a formal code of ethics.
The purpose of professional codes is to set minimal expectations of those who practice within their respective profession. Professional codes can also be aspirational in nature in that they set more than minimal expectations for members of the profession. The AOTA Code of Ethics states that the code “is an aspirational guide to professional conduct when ethical issues surface.” One limitation of codes is that they tend to oversimplify moral responsibilities.
The occupational therapist is obligated to abide by the tenets of the Code of Ethics. It is possible that occupational therapists may believe that if they fulfill the requirements of the Code of Ethics they have done all they have to do, morally speaking. However, would an occupational therapist’s conduct be always correct just because it conforms to the Code of Ethics of the AOTA?
Another limitation of codes of ethics is that the perspectives of the recipients of health care may be absent. What might the public proclaim as the fundamental obligations of occupational therapists if given the chance?
Finally, how do we account for changes in professional codes? Although the first version of the AOTA Code of Ethics was approved in 1977, it has already undergone several revisions. Each time the Occupational Therapy Code of Ethics changed, did the ethically correct behavior for occupational therapists really change-or only what AOTA members believed was the correct behavior? It seems that the foundation for ethics in occupational therapy is something more basic than current professional agreement based on these changes in the Code of Ethics.
If an occupational therapist worked in a hospital or ambulatory care center sponsored by a religious organization, the institution’s ethical code may be derived from religious beliefs and ethical commitments of the sponsoring group. For example, if the institution were Catholic and located in the United States it would have to abide by the Ethical and Religious Directives for Catholic Health Care Services [U.S. Conference of Catholic Bishops 2001]. In addition, the occupational therapist may personally believe and hold to the beliefs and moral guidance of a religious tradition.
Should a religious tradition be considered a voice of moral authority? Religious traditions are a salient source of moral guidance on all-important matters of human life. Believers in a faith hold that a decision is right or morally correct because of divine authority. Thus, being a believer commits one to the ethical teachings of one’s faith. Some argue that religion alone is the sufficient and ultimate justification for moral guidance. However, there is often plurality of beliefs regarding what is moral and good within a single faith tradition.
What if the religious beliefs of the institution and the occupational therapist differ? If there are differences in religious beliefs, whose beliefs should take precedence? For example, a female therapist receives an order to splint a male Hasidic Jew. The therapist recalls some information about the Hasidic Jewish culture. She thinks it may be inappropriate for her to touch this man’s hand. The therapist is unsure what to do. She knows that this client needs her services and she is the only therapist in the clinic, but she also wishes to be culturally and religiously sensitive.
Because the moral authority for religious beliefs is by its very nature mutually exclusive, there would be no common language or set of ethical principles from which to engage in discussion. There is no common language because different people hold different religious beliefs. We would have to look for a view of ethics that is respectful and cognizant of religious beliefs but that exists outside individual belief systems in order to meet on common ground. In a pluralistic society, such as that encountered in the United States, secular ethical principles have great appeal because they are grounded on reason. Moreover, there is striking similarity among basic ethical principles and constructs held across diverse religious beliefs. This indicates that there is perhaps another, more basic source, of moral guidance. We now turn to three of these traditional approaches to secular ethics that allow us to talk across various faith traditions, cultures, and disciplines.
One way of discussing morality is to observe that it involves obligations. The principles approach to ethics recognizes these obligations or duties and the universal nature of their application to moral decisions. Another way of viewing the moral life is through a more subjective lens, with a concern for actual persons and their needs and relationships. Care-based ethics attempts to focus on the specific ethical issues that arise within the web of human relationships that nurture and sustain us as human beings.
Finally, we can view the moral life outside the moral problems encountered in clinical practice and instead focus on the character of the occupational therapist. When decisions have to be made in occupational therapy practice it is often in a climate of stress and perhaps urgency. The best tools an occupational therapist can have for dealing with situations such as this are not those provided by principles or care-based reasoning but by a fixed habit of character or virtue. This provides a generally reliable response to ethical challenges. Virtue ethics takes the view that a person with a developed moral character knows when and what type of a decision needs to be made and has the perseverance to follow through. A brief description of each of these traditional approaches to ethics follows.
Beauchamp and Childress [2001] are the architects of the four principles approach to ethics. Although there are more than the four ethical principles selected by Beauchamp and Childress, these four principles do provide a comprehensive framework for ethical analysis. The four principles are as follows:
• Respect for autonomy (respecting the decision-making capacity of autonomous persons)
• Nonmaleficence (the duty not to harm)
• Beneficence (the duty to do good)
• Justice (a group of norms or rules that assist in the fair distribution of burdens and benefits)
Each of these principles has played a central role in health care. Respect for autonomy requires that we not only respect other human beings but that we have a regard for their self-determination. Autonomous adults have the right to make decisions about their lives without undue interference or coercion from others. Therapists must be aware of the autonomy of their clients. For example, a therapist may want to provide a splint for an elder to retard deformity. The elder may explicitly state that he or she does not wish to have the splint made.
Nonmaleficence is sometimes referred to as the most basic of all ethical principles in health care. Nonmaleficence is a perfect duty because it is always binding and forbids harm to others. For example, a physician may write a prescription for a splint that you know will cause a client harm. The therapist’s duty of nonmaleficence guides the therapist to handle the situation for a different outcome.
Beneficence is an imperfect duty and one that is sometimes binding. Beneficence asserts that we should promote and do good for others. All of the occupational therapist’s efforts are directed to the patient’s good in the sense that treatment and therapy are directed to improving function and well-being. The very act of splinting is a beneficent act because it is for the patient’s welfare whether in the long or short term. In the relationship between health professionals and clients, the imperfect duty of beneficence takes on more weight and approximates the perfect duty of nonmaleficence.
Justice mediates the claims of self-interested individuals within communities. Distributive justice is of particular interest in health care because often there is not enough of a valuable resource for all those who need or want it, and decisions must be made about the fair distribution of such a resource. For example, a therapist knows that a client will benefit from a splint that is not covered by insurance. The therapist wishes to do good and refers the client to a pro bono clinic.
Generally speaking, principles are action guides to moral behavior. The principles approach responds most appropriately to the question of what is the morally correct thing to do. The principles are universally applicable (i.e., they apply to all people in all situations and provide a degree of impartiality to the decision-making process). Beauchamp and Childress emphasize that their four principles do not constitute a general ethical theory but provide a framework for identifying and reflecting on ethical problems [2001].
Principles must be specified to be of assistance in practical circumstances, especially when there is conflict between ethical principles. For example, a therapist is treating a client who is severely depressed and needs a splint to improve function. The client does not want the splint. The therapist must wrestle with the client’s need for autonomy and the principles of beneficence and nonmaleficence. After specifying what autonomy, goods, and harms mean in the context of this case, the therapist could then turn to a more sophisticated level of reasoning to a moral decision; that is, ethical theory that prioritizes or balances the demands of the principles in conflict.
Care-based reasoning emphasizes the particular and unique features of a situation. Care-based reasoning also emphasizes the moral relevance of such features as context, relationships, and power hidden in the more objective, universal view of the principles approach. A care-based approach to ethics recognizes that all persons are not situated so as to be independent decision makers of equal status. Many individuals (particularly clients) are disadvantaged, dependent, sometimes exploited, and often responsible for the care of others. All of these factors limit their ability to assert their rights in competition with the claims of others.
A care-based approach draws our attention to the actual persons involved in a case, and their needs, particular history, and connections. In addition, care-based theorists claim that a caring relationship is characterized by mutuality (recognition of the self in others) and transformation; that is, the relationship transforms or changes not only the recipient of care but the caregiver as well [Mayerhoff 1971, Gadow 1980]. The recognition and protection of relationships are of prime importance to care-based ethics.
The following example demonstrates the ethical dilemma arising from a situation in which relationships, context, and power are intertwined. A therapist may wish to honor a child’s goal to independently hold a crayon. To accomplish this goal, the therapist must provide the child with a splint. The child’s parents are adamantly opposed to the child’s wearing the splint because they wish to preserve the child’s “normalcy” and do not want equipment that calls attention to the disability.
Virtue is a morally good habit of one’s nature. Virtue makes work, interactions, and all types of human exchanges good and makes individuals good. The distinction between a habit and action is important if one is to understand virtue, as human beings are constantly required to make choices between good and bad alternatives and to discern the right and reject the wrong. We need a constancy of mind or will to adhere to right principles. All of this calls for a foundation of solid virtues. Thus, we do the right thing or are inclined to do good as a matter of habit or character. Goodness is a part of who we are and is evident in how we act. An occupational therapist must have the virtues of compassion, wisdom, justice, temperance, and fortitude—to name a few essential virtues—to be deemed a good occupational therapist.
According to Aristotle, virtue means doing the right thing in relation to the right person, at the right time, and in the right manner. In other words, we should strive for moderation in all things, not going to excess or falling short of the mark. For example, it is one thing to be courageous and another to take courage to the point of foolhardiness. If we exercise too little courage, we might be considered cowardly. Thus, to find the right balance is life’s greatest good or summum bonum of the moral life. Virtue holds us fast to the right course. For example, a therapist’s client tells her that her husband is abusing her and she is frightened to go home. The virtuous therapist makes the time to help this client and risk being reprimanded for low productivity units.
The three approaches to ethics provide different methods of analysis that highlight certain aspects of a case and minimize others. Each approach is applied to a different case dealing with occupational therapists involved in some aspect of splinting. The first case highlights the ethical principles of nonmaleficence and beneficence and an additional principle, proportionality, that helps balance the two.
Delaney, OTR/L, was somewhat surprised when she received an order for splinting for a client from the oncology service in the large medical center in which she worked. The occupational therapy department did not receive many referrals from oncology. Delaney was concerned that the order might be inappropriate when she noted the age and primary diagnosis of the client, Anne, who was dying of metastatic cancer of the breast. Anne is 82 years old and is no longer a viable candidate for any type of treatment for cancer. She had undergone surgery several years before. Surgery was followed by radiation and chemotherapy. However, the cancer had returned and metastasized to her bones.
Anne’s husband died of cancer, and thus Anne had first-hand knowledge of what dying could be like. She told her physician, “I saw how Frank died surrounded by tubes and equipment. That’s not for me. I don’t want to die in the hospital. I want my family and friends with me, and I don’t want to be in pain.” Recently, Anne returned to the hospital for surgery to excise a tumor on her arm. Unfortunately, the tumor caused radial nerve compression that was not resolved by the surgery. The order Delaney received today was for a dynamic extension splint.
After Delaney finished reviewing the medical record, she walked down the hall to assess Anne’s condition. Anne had fallen asleep in the chair in her room. As Delaney stood in the doorway and watched the slow rise and fall of Anne’s thin chest, she wondered if splinting made any sense in this case. What did Anne stand to gain from the splinting procedure? The dynamic extension splint could cause discomfort. It did not seem right to inflict discomfort on Anne in addition to what she was already experiencing. How should Delaney weigh the potential benefit to be gained from splinting against Anne’s overall prognosis?
There are at least two ethical questions raised by this case. The first is substantive: Is it ever appropriate to deliver care that offers little hope of benefit or is unduly burdensome to the client? The second is more procedural: What role should Delaney play in providing care to Anne? Clearly, the two are linked but separate issues.
Delaney is obligated by the principles of nonmaleficence and beneficence to avoid harm and to provide good. This statement appears fairly straightforward. Yet, we know that certain clinical procedures (splinting included) do cause harm in the form of inconvenience and discomfort. We justify this harm because of the potential benefit that will be realized through the present discomfort. It is worthwhile, in other words, to suffer some inconvenience and discomfort in the present for greater function from stretching of soft tissue in the long term.
The principle of proportionality recognizes the need to balance the goods and harms of all types of clinical care. The risks of harm must be constantly weighed against possible benefit. We not only have a duty to avoid harm and do good but to weigh and balance possible benefits against possible harms in order to maximize benefits and minimize harms. Normally, the provision of a dynamic extension splint would be considered a moral good. If the splint does its job, the client will have greater flexibility and use of the wrist and hand, adding to the overall quality of life.
In this case, however, Anne is already burdened with the pain and suffering of a terminal illness. It is unlikely that she will gain much benefit from the splint because there is little hope for an extended life span. In addition, the stretching provided by the splint will likely cause discomfort. Under other circumstances, the discomfort of the splint might be well worthwhile because of the benefits that would be gained in the long run. Anne made it clear that she did not want to be in pain while she was dying. Is the discomfort that will be caused by the splint the type of pain she meant?
Competent clients have the right, according to autonomy, to make decisions about the benefit and burdens of treatment. This is especially important when a client nears the end of life. A death with dignity is sometimes defined as a death that is not “unduly burdened” by the clinical environment and medical technology to prolong life [Catholic Health Association 1993]. The treatment or technology in this case is not “life-sustaining” (e.g., a ventilator or artificial nutrition and hydration). However, it does have an impact on the quality of life Anne will have until her death from other causes.
Clients are not obligated to undergo treatment that offers little hope of benefit or that involves excessive pain, expense, or other inconvenience. If the goals of treatment are not attainable (i.e., the use of particular therapy cannot or will not improve prognosis and recovery), the treatment need not be initiated or continued. The moral focus in this case is not on the type of disease or illness the client has, the state of medical science, or the type of treatment. In addition, questions of whether the treatment is customary, simple, inexpensive, or noninvasive are not the relevant ethical considerations. The true moral focus regarding any treatment, splinting included, is the proportion between the benefit to the client and the burden involved. Furthermore, health care professionals are not mandated by law or morally obligated to render treatment that is deemed useless.
Delaney must first decide whether she considers the splint as plausible treatment. If the treatment is at least plausible, she has a duty to give Anne the relevant information about the splint and its possible benefits and burdens. This should be done in a manner that Anne can understand so that she can make a decision about the treatment that is in keeping with her values and previously expressed wishes. If Anne decides that the burdens of the treatment are disproportionate to the benefits, she is not obligated to undergo the splinting procedure; nor is Delaney morally obligated to provide treatment that Anne deems overly burdensome.
It should be noted that the physician has ordered a specific splint for Anne and Delaney cannot ignore this additional obligation to a professional colleague. The physician has a right to expect that his orders will be carried out unless there is a good reason they should not be. Delaney should explain the outcome of her interaction with Anne to the physician and work toward a mutually agreeable solution. Delaney could also offer other methods of support to Anne such as stretching exercises to improve the quality of her life for whatever time she has left.
The next case involves a situation in which the therapist is advised to deceive both the client and the third-party payer. The act of deception runs counter to the principle of respect for autonomy, and therefore requires justification. Another way to sort through the ethical issues and decide what ought to be done in this particular situation is through a care-based approach.
The number of clients referred to the out-client rehabilitation clinic of Centerview Medical Center seemed to increase every week. Mark Petty, OTR/L, enjoyed the busy pace and the variety of clients he saw in the clinic. Mark was assigned a new client, Tung, a 28-year-old automobile manufacturing worker who had sustained a severe crush injury of his hand on the job. Mark noted that there were orders to evaluate and begin treatment. As Mark read further in Tung’s medical record, he saw that the physician specifically requested a certified hand therapist’s (CHT’s) services. Mark was not a certified hand therapist, so he approached his supervisor, Vivian, to discuss the problem. Mark explained that the physician’s orders specified a CHT.
“How soon can Tung see the CHT?” Mark asked Vivian. “She’s just too busy to take any new clients,” Vivian responded. “I’ll tell you what to do. I would hate to lose this case. It looks like it will take at least a year of service to rehabilitate Tung. Why don’t you just go ahead and provide services to him and have the CHT sign the notes? Who will know the difference?” Vivian then walked away.
Mark was left standing in the middle of the hallway with Tung’s chart in his hand and a perplexed look on his face. Provide services to a client and have someone else sign off on them? On the face of it, that seemed very wrong to Mark. Yet he, too, would hate to lose this interesting case. He had briefly met Tung and instantly liked him. Would anyone really know the difference if he provided care to Tung or if the CHT did? Mark wondered what the right thing to do was. The application of a care-based approach includes the following [Fry et al. 1996]:
• Identifying the moral conflict within the specific context, considering the others who are involved in the conflict and how they are interrelated
• Feeling concern for relationships and individuals, and identifying oneself in relation to the individuals and problems involved
Generally speaking, if Mark were to take a care-based approach to resolving the ethical issues in the case he would have to ask himself what it means to be “caring” within the context of this situation and its specific responsibilities. The moral conflict involves whether or not to provide services that are less-than-optimal to Tung, in that Mark is not a CHT. Could this be considered a “caring” action? The context of this case is a busy outpatient setting, perhaps too busy to handle the volume of clients and maintain quality. Because the physician specifically ordered that a CHT provide the care the first logical alternative for Mark is to transfer Tung’s care to a CHT. This is what Mark attempted to do and was told that the CHT caseload was backlogged.
If the beleaguered CHT at the Centerview Medical Center cannot see all of the clients who need her level of expertise, the clinic is obligated to either hire another CHT or to help support and prepare another therapist who is already a member of the staff (such as Mark). This would allow Mark to become eligible to take the certification examination to become a CHT. Both of these options are caring in several regards in that the special needs of all parties, including the overworked CHT, are considered.
The CHT would receive some assistance so that her work is more manageable, and probably less stressful, and clients would receive the level of care they deserve for their complex problems. However, these solutions are long term in nature and not immediately helpful to Mark. A caring, short-term solution could be to refer Tung to a CHT at another clinic or hospital. Alternatively, Mark could “trade” a patient with the CHT. In addition, Mark could work with the physician to see whether there is any room for negotiation about the requirement for the CHT. The latter option would be considered caring only if Mark truly believed he could deliver a quality of care approximating that of a CHT, perhaps under the indirect supervision of a CHT.
Vivian did not offer any of these alternative solutions to Mark’s problem but suggested that Mark lie. Could a lie ever be considered a caring action? Perhaps, but in this situation we have to ask who the lie benefits? It appears that the clinic benefits because they won’t lose reimbursement for a year’s worth of billable service. Mark might also benefit to a limited extent because he would get to work with a client he likes and would learn from the experience of treating him.
Those who would be harmed are the physician and Tung. If either the physician or Tung found out that they had been deceived, how might they react? If Tung’s care was insufficient, his function could be compromised. Of course, there are legal implications in the case, in that what Vivian has suggested is fraud. However, there are moral implications as well.
Care-based ethics also focuses on the relationship of the individuals involved. Lies have a way of eroding relationships because they damage trust. If Mark chose to follow Vivian’s recommendation, the entire time he was treating Tung he would be doing so in a deceptive manner. It is important to understand that deception includes withholding information as well as outright falsehoods. In addition, Mark now knows that Vivian condones deception and this knowledge can hurt their relationship. Vivian did not demonstrate caring behavior to one of her subordinates but chose to place him in a moral dilemma in which he will be forced to oppose her recommendation in order to do the right thing.
Finally, because Mark “likes” Tung he may be more inclined to resist actions that are deceitful. Affection for clients makes it easier for us to recognize that they are fellow participants in life, facing the human condition. Another of the characteristics of care-based reasoning, as you recall, is mutuality; that is, empathizing with the other’s position. If Mark were the client and had an injury similar to that suffered by Tung what sort of treatment would he want? As a client, would he accept the reasons for the deception Vivian has proposed? It is unlikely that any client would accept less than optimal care just so that the clinic could make a profit.
In the next case, an occupational therapist wrestles with the conflicting obligations often encountered in clinical settings between clients and colleagues. Everyone makes a mistake at one time or another, but what if the mistake of a colleague has serious implications for a client’s well-being? Should the therapist’s primary loyalty always lie with the client?
Douglas, OTR/L, was filling in for a colleague and friend (Melody) who was absent from work with a bad case of the flu. Douglas and Melody attended the same occupational therapy program, and after graduation both ended up working for the same health system in a large urban setting. Douglas made it a habit to review the medical records, treatment plans, and progress reports of the clients he treated, even if he worked with them for only a day. He believed it was important to be familiar with their care and present status.
The first client on the schedule, Ben, was recovering from a flexor tendon injury, status post two weeks. The chart review indicated that Ben was a cooperative client. Douglas began with an assessment of Ben’s condition before proceeding with therapy. Douglas immediately noticed that the tendon repair appeared to be ruptured. Douglas began to question Ben about his activities. Ben reported that Melody had removed the splint the previous day and engaged him in aggressive gripping exercises. “You know, I knew something was wrong right away with my hand last night when I was doing those gripping exercises on my own. Should the therapist have told me to do that?” Ben asked.
It appeared that Melody had not followed the protocol for flexor tendon injuries. Because she had given him a home exercise program with gripping exercises and put Ben through an inappropriate hand exercise regimen, the surgical repair was ruptured. Melody was responsible for the injury and the future pain and inconvenience Ben would have to undergo having surgical repair of the injury a second time. Ben’s question hung in the air as Douglas thought about his obligations to a friend and colleague in contrast to his obligations to the client. This case raises numerous questions.
• Is this therapist simply inexperienced?
• How does one gauge the competence of a peer?
• How far does loyalty to peers extend?
• Is competency a matter of aesthetics?
• Are there sufficient safeguards in place to protect the public from incompetent providers?
• What are occupational therapy’s obligations to society regarding the competence of its own practitioners and those in other fields?
It would be important to determine whether this was an isolated incident or a pattern in Melody’s behavior. Overall competence is related to client good. Regardless of the reason for this particular act of incompetence, to remedy the incompetent behavior Douglas must access the systems in place in the organization (such as Melody’s supervisor or the risk management department). To report a friend and colleague, Douglas must have the virtues of courage and perseverance. Douglas’s first obligation as a health care professional is to the best interests of clients.
Douglas must also have the virtue of honesty. He has made an implied promise to clients to serve their best interests. In this case, that involves supplying information about what Douglas suspects is the cause of Ben’s injury. It is possible that Ben injured his hand himself, although he denies it. However, even if that is so Melody should not have engaged him in inappropriate active hand exercises.
Douglas also has a general moral obligation to tell the truth. He should not lie. Before Douglas reveals the information about the ruptured tendon repair to Ben and the surgeon, who will also need to know, he would first want to speak to Melody and confirm what actually happened. The morally virtuous occupational therapist is straightforward, thoughtful, and well-meaning. Given all of these virtues, Douglas must make a decision (and quickly) as to how he will respond to Ben about his injury. He can be loyal to his peer and friend and still do the right thing, but he will need a strong moral character in order to act.
The Occupational Therapy Code of Ethics would support actions that maintain high-quality standards of care. In addition, balanced with this mandate of client benefit is Principle 7, which states, “Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity.” Douglas must make certain that Ben’s welfare is protected, but he should do so in a way that minimizes harms to Melody.
In addition to the resources already enumerated to assist occupational therapists when making ethical decisions, there are also resources within organizations or institutions. For example, policies and guidelines provide excellent support when they are thoughtfully written in keeping with the ethical norms provided herein and the values of the organization as a whole. Policies or guidelines should be available for commonly encountered ethical issues, such as informed consent, determination of decision-making ability, confidentiality, futility decisions, fair and safe distribution of staff and workload, and the role of surrogate decision makers.
Furthermore, personnel in specific areas of care (such as hand rehabilitation or burn care) could work together to establish mutually held values about the complex issues that comprise daily clinical experience. For example, what are the values regarding conflicts between religious values and those held by the institution regarding end-of-life treatment and pain management? Unless dedicated time is spent reflecting on issues such as these, it is likely that decisions will be made during highly emotional and urgent circumstances with less than satisfactory results.
Finally, another resource that is becoming more common is the institutional ethics committee. Occupational therapists should not only seek out the advice and support of ethics committees when problems seem beyond resolution; they should also offer to serve on such committees, as their expertise and perspective are often missing from the committee’s membership. Ethics committees offer the opportunity to discuss issues in a nonthreatening environment in a multidisciplinary manner. Although ethics committees do not make the decision for the individuals involved in an ethical problem, they do offer guidelines and affirm the values of the organization that form the parameters for decisions.
1. How does one know if a situation involves ethics?
2. What is the difference among moral, amoral, and immoral behavior?
3. What are the basic differences between the three traditional approaches to ethics: principles, care-based, and virtue?
4. What are the four ethical principles that underlie the majority of interactions in health care?
5. What question does the principle approach to ethics best answer?
6. What does the principle of proportionality require us to do?
7. Can virtues be learned, practiced, and cultivated?
8. How does care-based ethics view the moral life?
9. How does virtue provide us with immediate responses to ethical challenges?
10. What are some of the limitations of professional codes of ethics?
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Warren E (1962): Special address to the Lewis Marshall Award Dinner of the Jewish Theological Seminary of America, New York. Quote appears in the New York Times, November 12, 1962, pp. 1-2, in an article by Milton Bracker, ‘Warren Favors Profession to Give Advice on Ethics.’