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Ethics Case Studies—Learning Application
of the 2009 ADA/CDR Code of Ethics for the
Profession of Dietetics
Case Study #1: A registered dietitian (RD) is newly employed as part of a treatment team in an
ambulatory care setting. After several counseling sessions, one of the clients he is counseling for obesity
discloses that she is being physically abused by her spouse and is experiencing depression. The RD
continues to have the client come in for nutrition counseling sessions in an attempt to better understand
the relationships among her current domestic situation, psychological state and weight issues. During a
treatment team meeting, the RD reports on the client and is questioned by one of the team members
about why he did not refer the client to the mental health professional. What should be done in this
situation?
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to Clients.
Indicate the Principle(s) of the Code of Ethics: Principle#8 - The dietetics practitioner recognizes
and exercises professional judgment within the limits of his/her qualifications and collaborates with
others, seeks counsel, or makes referrals as appropriate.
Explain how/why this relates to the Category and Principle: This principle relates to the ADA
value of social responsibility and the dietitian’s ability to recognize boundaries between nutrition
treatment and medical nutrition therapy versus psychotherapy, and when it is appropriate to refer
clients to mental health professionals.
Key Points to Consider:
 RDs must differentiate between client problems in their professional scope, such as issues related to
food, eating patterns, and weight, versus those that are beyond the scope of nutrition practice, such
as suicidal tendencies, physical abuse, severe marital difficulties, feelings of depression, past
unresolved sexual abuse, and other severe problems.
 RDs should understand the policies and procedures in the ambulatory practice setting regarding
treatment of various types of clients and especially those who need a team approach to treatment.
 RDs should understand what it means to be part of a treatment team and the roles of other health
care professionals.
 Since the RD is new in this position, he could discuss the situation with a colleague who works in a
similar setting, she could meet with his direct supervisor, if available, or he could go directly to the
treatment team for advice.
 RDs need to engage in self-reflection and evaluation of professional roles, reassess interactions with
clients, and recognize that each client and each setting require their own scope of counseling theory
and skill.
 This scenario has important implications for academic programs and their role in educating students
on scope of practice issues and state licensure laws.
 To prevent similar future ethical dilemmas, the dietitian could take graduate coursework in
counseling, participate in continuing education in the area of counseling, or complete a certification
program in counseling.
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Case Study #2: A Didactic Program in Dietetics (DPD) student, who is a student member of ADA, is in
a computer lab at the university taking an online examination for one of his courses. The course
syllabus specifically states that the exam is to be taken without the use of the textbook or class notes.
One of the student’s classmates observes the student referring to the text and class notes while
completing the online exam. What should be done in this situation?
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles.
Indicate the Principle(s) of the Code of Ethics: Principle#1 - The dietetics practitioner conducts
himself/herself with honesty, integrity and fairness.
Explain how/why this relates to the Category and Principle: This principle relates to the ADA
value of integrity and addresses attributes that should characterize all professionals, including
students who are preparing to become food and nutrition professionals.
Key Points to Consider:
 The student needs to recognize that he/she is being dishonest and is cheating.
 The student may not view his behavior as violating ethical principles and the Code of Ethics.
 This situation points out the important role of faculty who need to review acceptable ethical
behaviors in all classes and discuss consequences of professional misconduct, both during academic
preparation and after graduation.
 This scenario points out the importance of putting the institution’s academic honesty policy in all
course syllabi, reviewing the policy and consequences of violating the policy with students, and
providing students with specific examples of dishonesty, such as cheating on online exams.
 The student should be disciplined based on academic honesty policies of the institution.
 The student’s letters of recommendations /should/could disclose this infraction and the action could
jeopardize his/her ability to obtain a dietetic internship.
 A student who is dishonest and cheats his/her way through the DPD and Dietetic Internship (DI)
programs, may not pass the RD exam or could become an incompetent dietetics practitioner,
possibly causing potential harm to the public and clients.
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Case Study #3: A registered dietitian (RD) is employed in a hospital-based outpatient clinic and her
major role is to counsel clients with diet-related chronic diseases with the goal of changing their dietary
behaviors, successfully managing their chronic diseases, and improving their health status. During
counseling sessions, the RD routinely provides clients with the rationale for the prescribed medical
nutrition therapy, a written list of foods to include and exclude, and tips for menu planning, grocery
shopping, and food preparation. After several counseling sessions, one of the clients expresses her
dissatisfaction with the progress she is making to institute dietary changes. The client requests
assistance in development of a different plan. However, the RD continues to provide the same types of
information and advice. After several more appointments with the RD, the client contacts the director of
nutrition services to express her dissatisfaction with the counseling sessions and her frustration with not
being able to successfully change her dietary behaviors. What should be done in this situation?
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue.
But, this could be considered a business dispute since there is no clarity on whether the client’s
outcomes were established and agreed upon.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to the Profession
Indicate the Principle(s) of the Code of Ethics:
Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and
current information.
Principle #14 - The dietetics practitioner assumes a lifelong responsibility and accountability for
personal competence in practice, consistent with accepted professional standards, continually
striving to increase professional knowledge and skills and to apply them in practice.
Explain how/why this relates to the Category and Principle: These principles relate to the ADA
values of integrity and social responsibility and the dietitian’s ability to engage in self-reflection and
self-evaluation and to seek opportunities to improve effectiveness by utilizing counseling theories
and strategies that are current and evidence-based.
Key Points to Consider:
 The RD needs to differentiate between nutrition education and nutrition counseling and be familiar
with the literature that states that providing information and advice alone do not lead to behavior
change. Also, the RD needs to recognize that each client has unique needs and ways of achieving
success.
 The RD has the responsibility to engage in self-reflection and evaluation and to recognize that
he/she is not currently effective as a nutrition practitioner within the current setting.
 The RD should seek out opportunities to improve his/her skills in the area of counseling through
continuing education, academic coursework and/or certification programs.
 If the RD does not believe he/she is making progress with the client after a period of time, it would
be appropriate for him/her to refer the client to another RD counselor, if available.
 The director of nutrition services should have policies and procedures for the institution which
include standards and expectations regarding the use of appropriate counseling theories and
strategies.
 The director of nutrition services should adequately supervise and evaluate the RD staff to be sure
they are using current practices based on evidence-based information and, if not, make suggestions
for improvement.
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Case Study #4: A faculty member (PhD, RD) asks a graduate doctoral student (ADA RD member) to
assist with a paper she is writing. She asks the graduate student to update the paper’s literature review,
add additional data to the analysis and do a draft revision to the results section based on the additional
data. The, the primary author prepares the discussion and methods section. The graduate student
decides to discuss this with a junior faculty person and with her encouragement, she asks to be listed on
the paper as an author. The primary author replies no, as student contributions to a paper do not merit an
author byline. The PhD, RD agrees to an acknowledgement. The student feels compromised as he/she
cannot refuse to do the work and must accept the professor’s decision. The junior faculty member
agreed with the student and also felt she could not address her colleague on the issue. When the article
is published in Journal of the American Dietetic Association, the student is highly disappointed and
reflects on this compromising situation as a very unpleasant professional encounter early in her
academic career.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue, not a
business dispute.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles and Colleagues and other
professionals.
Indicate the Principle(s) of the Code of Ethics:
Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity, and
fairness.
Principle #19 - The dietetics practitioner demonstrates respect for the values, rights, knowledge and
skills of colleagues and other professionals.
Explain how/why this relates to the Category and Principle: All RDs are accountable for
adhering to the Code of Ethics including professional writing in an area of dietetics practice.
Key Points to Consider:
 Authorship guidelines are published by journals and need to be reviewed by all individuals involved
in the process.
 Collaboration on the dissemination of the research is necessary.
 Issues of honesty and fairness are key components in collaborative authorship.
 Addressing issues of authorship when collaborating with other RDs should be incorporated into the
initial discussions of a research publication. In this situation, the graduate doctoral student and
senior faculty member should have discussed the issue of authorship and/or acknowledgment of
contribution at the time that the assignment was made.
 To avoid similar situations in the future, there should be clear expectations and policies established
for research authorship within an institution. Merely updating the literature, adding data to analysis
and drafting a simple revision may not constitue authorship.
 It is critical to avoid any bias in student evaluations based on unrelated disagreement and hierarchy.
 It is important that misleading and inappropriate educational/academic practices should be avoided.
 Although difficult, it might be beneficial for the student to discuss this issue with the dean.
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Case Study #5: A clinical registered dietitian (RD) is working with oncology patients in a large
medical facility. A reputable pharmaceutical company supplies nutrition-related products to the
hospital, and has done so for over 20 years. In fact, the medical center is the company’s largest account.
A few years ago the company developed a product that can speed up the process of wound healing after
surgery and it is currently being used by the RD’s hospital. The product has recently been found to
promote the building of muscle tissue, and the company is interested in marketing it to cancer patients
and their caregivers in a new and exciting way: an infomercial. The company wants a RD to support the
product in the infomercial and has asked the clinical nutrition/manager for his support. The clinical
nutrition manager agreed and asked the RD, as the only oncology RD, to represent the hospital and
speak in favor of the product in the infomercial.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is possibly both an ethical
issue and business dispute.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to the Public.
Indicate the Principle(s) of the Code of Ethics:
Principle #3 - The dietetic practitioner considers the health, safety and welfare of the public at all
times.
Principle #6 - The dietetics practitioner does not engage in false or misleading practices or
communications.
Explain how/why this relates to the Category and Principle:
The situation involves mass media/communication as a means to endorse/promote a product to the
public. This relates to the ADA value of integrity.
Key Points to Consider:
 The oncology RD may sense a threat that his relationship with the clinical nutrition manager is in
jeopardy if he does not cooperate.
 The clinical nutrition manager needs to determine if he has the authority to accept the offer
presented by the pharmaceutical company on behalf of the hospital and what policies and procedures
should be reviewed.
 Even though the clinical nutrition manager agreed on behalf of the hospital, it does not mean that the
individual RD should feel pressured to accept this role if he is uncomfortable doing so.
 Does scientific evidence exists to support the use of this product in a new patient population (eg.,
oncology patients)?
 If the RD is convinced that enough scientific evidence exists to support the use of this product in
oncology patients, how much control will he have over the delivery of the message (“script”) so that
he can make sure the message is not delivered in a false or misleading manner?
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Case Study #6: An RD colleague voiced his opinion on several occasions about organic versus
conventional produce. During an outpatient counseling session, you overhear this colleague strongly
encouraging the use of organic produce despite the client protesting about the lack of availability of
organic produce in her nearby grocery store and the higher cost associated with these products. As the
conversation continues, the RD suggests to the client that purchasing smaller amounts of produce will
ensure that the organic varieties can be obtained within the family budget.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is appears to be a practice
dispute on how to counsel clients. However, there is an element of ethical behavior related to providing
clients with information that will empower them to make a decision.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to Clients and Responsibilities to
the Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration.
Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and
current information.
Principle #13 - The dietetics practitioner presents reliable and substantiated information and
interprets controversial information without personal bias, recognizing that legitimate differences of
opinion exist.
Explain how/why this relates to the Category and Principle: This scenario represents both
responsibilities to the client and to the profession. RDs and DTRs must show respect and
consideration for clients and allow them to make their own informed decisions. In addition, the
RD/DTR should present information to client that is based on evidence-based principles.
Key Points to Consider:
 A RD/DTR has a right to his own opinion, such as the personal preference to select organic foods
for use at home.
 RDs/DTRs must allow clients to make their own informed decisions. The RD’s behavior is
inconsiderate and disrespectful, especially when the client voices legitimate concerns (eg, cost and
availability).
 Current scientific evidence supports increased consumption of fruits and vegetables to decrease
chronic disease risk; it does not specify that these foods must be organic.
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Case Study #7: A 45-year old man was referred to the Lipid Disorders Clinic with a plasma triglyceride
of 16,000 mg/dL. The physician prescribed medical nutrition therapy (MNT) for a 10% fat diet. When
the RD asked about his level of motivation for making changes in his eating or exercise habits, he
replied, “Exactly zero!” The RD responded, “Then we have nothing to talk about.” He replied, “What
do you mean?” The patient and the RD then had a 30-minute conversation. The patient set a goal to
order Big Macs (29 grams fat) instead of the Bacon Ultimate Cheeseburgers (77 grams fat). This goal
was not in keeping with a 10% fat diet. At the end of the session, the RD gave the patient an analysis of
his eating habits, his goal sheet, practical information about the 10% fat diet, and a return appointment.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This situation could be an
ethical issue. But, it may not be an ethical issue as the RD assisted the patient to achieve some changes
toward the desired MNT treatment. It could also be a business dispute in reference to the patient and RD
agreeing to change only one behavior.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to Clients.
Indicate the Principle(s) of the Code of Ethics:
Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration.
Principle #9 b - The dietetics practitioner respects the client’s right to make decisions regarding the
recommended plan of care, including consent, modification, or refusal.
Explain how/why this relates to the Category and Principle: The principle relates to the ADA
value of social responsibility.
Key Points to Consider:
 This could be an ethical issue related to the RD accepting a goal not in keeping with the physician’s
MNT prescription for a 10% fat diet. However, regardless of the need for the patient to eat as little
fat as possible in order to reduce his plasma triglycerides to a safer level, it was essential for the
dietitian to meet the patient “where he was.”
 The fact that she respected and accepted the client’s goal which was not in keeping with his diet
prescription may have encouraged him to ultimately consider making goals more in keeping with a
10% fat diet.
 It is highly likely the physician had already informed the patient about his high risk for developing
acute pancreatitis.
 The RD should communicate with the physician about the approach taken and document it
appropriately.
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Case Study #8: A registered dietitian (RD), who lived in a state with a voluntary licensure law (title
act) with no scope of practice, became licensed. The RD then failed to renew her license but continued
to use the LD credential. This came to the attention of the executive secretary of the licensure board
who apprised the board members of this violation. The chair of the licensure board appointed a
committee to investigate. The committee determined that the RD had, in fact, filed a renewal
application, but that it had been returned because of missing information. The RD thought she had sent
in the missing information but had not. The RD moved during this time and the mailing disappeared.
This all occurred within two to three months. The licensure board decided not to discipline the RD, but
to provide education about potential consequences related to this violation and reinstate the license after
provision of the missing information.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue. It
could be a business dispute, as not all information may have been given about practices of the board for
the renewal process and acceptance of funds for renewal.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibility to the Public.
Indicate the Principle(s) of the Code of Ethics:
Principle #4 - The dietetics practitioner complies with all laws and regulations applicable or related
to the profession or to the practitioner’s ethical obligations as described in this Code.
Principle#4c - The dietetics practitioner must not commit an act of misfeasance of malfeasance that
is directly related to the practice of the profession as determined by a court of competent jurisdiction,
a licensing board, or an agency of a governmental body.
Explain how/why this relates to the Category and Principle: This principle relates to the
responsibility of each licensed and credentialed practitioner to maintain current licensure status with
the state and national agencies responsible for ensuring the protection of the public.
Key Points to Consider:
 The licensure board could have disciplined the RD, which would then have been reported to the
ADA Ethics Committee. Because the lapse in licensure was determined to be unintentional and was
of short duration, the licensure board decided to inform the RD of the potential legal consequences
that could occur if she referred to herself as an LD when she was not.
 The RD put her facility in violation of Centers for Medicaid & Medicare (CMS) rules for which the
facility could have been fined. CMS facility rules specify that licensure or certification must be
current for all employees. Therefore, all RDs working in facilities, whether or not they provide
Medicare MNT are affected.
 Licensure is voluntary, but since the RD has applied and accepted the regulations for use of the
credential, it is the RD’s responsibility to ensure that her licensure/certification credential is current
and active.
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Case Study #9: An out-patient registered dietitian (RD) also consults part-time with worksite wellness
programs. Weight management guidance has become a major part of her practice. She recognizes that
having the CDR Weight Management Certification would be usefull, but cannot afford the cost and has
no support from her employer. A friend who represents a company that makes and sells weight loss
products suggests that the firm would fund her enrollment fees and travel expenses to the course in
exchange for her meeting with their team to learn more about their products. Currently, she does not
endorse any products and is generally against such products.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue:
perceived or real. It is a potential conflict of interest and potentially a violation of the Code for
accepting a gift.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities of the Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #18 - The dietetics practitioner does not invite, accept or offer gifts, monetary incentives,
or other considerations that affect or reasonably give an appearance of affecting his/her professional
judgment.
Explain how/why this relates to the Category and Principle: If one works for a company or is
contracted as a consultant, a similar arrangement would not be an ethics issue. However, the RD has
placed herself in a position of appearing to endorse the company supporting the trip.
Key Points to Consider:
 Is this likely to affect the viewpoint of the RD toward the products? What are the companies’
reasons for providing this “gift”?
 Serving as a consultant to the company implies you ascribe value to their product should be
disclosed at appropriate times (eg, speaking engagements, submitted articles).
 Conducting an in-service to the company’s staff within the boundaries of science, licensure and
business practice is acceptable and part of the role of a consultant.
 Evaluating the products before you accept funding for the trip is necessary. Also, it important that
the RD discuss her perspective on promotion of products with the company.
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Case Study #10: A dietetics technician, registered (DTR) works for a supermarket chain. He is invited
to attend a 2- day seminar offered by a not-for-profit industry support group that represents a segment of
major commodity (dairy, fruits, vegetables, meat, grains). Funding for the support group is by growers
and producers. The theme is “from farm to table,” and the program is approved for continuing education
units. The program includes visits to farms, producers and a food processing plant, presentations by
researchers and marketing staff, and a culinary demonstration. The plant visit is to the headquarters of a
nationally known company that produces both a nationally known brand and store brands. His
transportation, lodging, meals, educational materials and presentations are being paid by the industry
support group. The location is a resort in a part of the country that is known for growing and producing
the commodities being featured.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? Since the DTR is working
for a supermarket, this is not an ethical issue, provided his employer does not see it as a conflict of
interest or as a gift that might be perceived as affecting his professional judgment. However, it could
become one if the DTR does not follow ethical lines when making decisions on the products that are
being showcased in this educational program.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles and Responsibilities of the
Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity, and
fairness.
Principle #18 - The dietetics practitioner does not invite, accept or offer gifts, monetary incentives,
or other considerations that affect or reasonably give an appearance of affecting his/her professional
judgment.
Explain how/why this relates to the Category and Principle: Depending on the employment
status, this DTR may be expected to make recommendations for products.
Key Points to Consider:
 The DTR should discuss this with his employer to clarify business directives and any appearance of
unethical behavior.
 The DTR should research the commodity group, their mission, and their funding so he is aware of
the funding for the opportunity. If the reasons for the program, mission statements of the funders, or
funding disclosure are unclear, it may be best to decline.
 The DTR should discuss with the funder/planner any questions before accepting the invitation.
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Case Study #11: A university professor who teaches clinical dietetics is provided with glucose testing
supplies including meters, samples of supplements for persons with diabetes, and computer programs by
the local representative of a pharmaceutical company. Amounts provided are sufficient for use in
student demonstrations and for use at the school’s sponsored health fairs conducted for its employees
and the community. This is welcomed because of the lack of budget for these at the university.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It has the potential for being
unethical.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities of the Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #18 - The dietetics practitioner does not invite, accept or offer gifts, monetary incentives,
or other considerations that affect or reasonably give an appearance of affecting his/her professional
judgment.
Explain how/why this relates to the Category and Principle: Although such tools are welcomed,
the perception of product endorsement comes when only one product is featured. Knowing
expectations that come with the “gift” and limitations that might come if competitors were
introduced is important.
Key Points to Consider:
 The university’s policy should be reviewed and understood.
 Support from more than one source, if acceptable to department policy, should be sought out.
 Expectations should be discussed with the pharmaceutical representative.
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Case Study #12: A client fails to pay for the final session of a private practice appointment ($150
outstanding). Three invoices are sent and the registered dietitian (RD) leaves 3 voicemail messages.
The client’s credit card number is on file. The RD does not have authorization to use the credit card for
this specific payment. The RD is considering the use of the credit care to charge for the previously
provided final session.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is both an ethical issue
and a business dispute. Payment practices for services must be made clear to clients prior to initiation of
services to prevent disputes and should be provided in writing. If provider RD charged the card for the
service it would be both an ethical and legal issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles.
Indicate the Principle(s) of the Code of Ethics:
Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity and fairness.
Explain how/why this relates to the Category and Principle:
Although the RD has the credit card number, it is unclear if it’s fair to charge the card without
approval. It is clear that the RD does not have authorization to charge credit card for service.
Key Points to Consider:
 The client owes $150 for service rendered, but did not sign any contract or authorization forms
allowing the RD to charge for those services.
 In the future, the RD needs to obtain authorization for payment prior to rendering services.
 Billing policies should be disclosed during initial appointment.
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Case Study #13: A registered dietitian (RD) is reading blogs posted by colleagues in dietetics. He
finds nutrition misinformation written by an RD; her posting is not in agreement with a non-government
organization’s recommendations and current scientific evidence. He is familiar with the topic because
he consults for a food company that relies on the information to support their brand messages. He
knows that the RD is incorrect and perpetuating myths, but he worries that it could also be considered a
conflict of interest for him to correct the RD on the site.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibility to the Public; and, Responsibility to
the Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #3 - The dietetics practitioner considers the health, safety and welfare of the public at all
times.
Principle #6 - The dietetics practitioner does not engage in false or misleading practices or
communications
Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and
current information.
Principle #13 - The dietetics practitioner presents reliable and substantiated information and interprets controversial
information without personal bias, recognizing that legitimate differences of opinion exist.
Explain how/why this relates to the Category and Principle:
The blogger is providing misinformation. The RD, on the other hand, may have a conflict of interest
in that he benefits from the correct message being posted.
Key Points to Consider:
 Consider if the RD is expressing his opinion or professional advice/knowledge.
 Consider if the research is conclusive.
 What do the non-government organizations and professional health organizations (e.g., ADA)
recommend?
 Based on the scenario, discuss whether the RD should disclose his relationship with the food
industry. And, if so, is the RD permitted to speak on their behalf?
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Case Study #14: At a regional dietetic educator’s meeting there is a discussion about how to meet some
of the didactic program in dietetics (DPD) and internship competencies. A DPD director has a
disagreement with an internship director about how some of the competencies can be met. That year the
DPD director discourages all students who want to apply to that internship and tells them not to apply
because it is of poor quality. The internship director, who had previously talked to one of the potential
applicants, runs into the applicant and asks the student why he did not apply. He tells her he was advised
against it because of the “dubious” quality of the program.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? An ethical issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles (Principle #1);
Responsibilities to the Public (Principles #5 and #6); and, Responsibilities to Colleagues and Other
Professionals (Principle #19).
Indicate the Principle(s) of the Code of Ethics:
Principle #1 - Conducts himself/herself with honesty, integrity and fairness.
Principle #5 - The dietetics practitioner provides professional services with objectivity and with
respect to the unique needs and values of individuals.
Principle #6 - The dietetics practitioner does not engage in false or misleading practices or
communications.
Principle #19 - The dietetics practitioner demonstrates respect for the values, rights, knowledge and
skills of colleagues and other professionals.
Explain how/why this relates to the Category and Principle
Principle #1: The DPD director has not been fair to the student, the internship director and the
program.
Principle #5: The DPD director has not provided the student professional services with objectivity
and with respect to the unique needs and values of the student.
Principle #6: The DPD director has provided unsupported and perhaps false information.
Principle #19: The DPD director has violated the rights of a colleague.
Key Points to Consider:
For Principle #1, consider the following questions related to the case.
 Did the DPD director provide evidence or facts to support the statement of “dubious quality?” What
evidence is needed to be provided to support that statement?
For Principle #5, consider the following points related to the case.
 What should the DPD director consider when providing the student guidance about what internships
would be most appropriate based on individual needs, values, and desires?
For Principle #6, consider the following questions related to the case.
 What false or misleading communications did the DPD director provide and how did that impact the
behavior of the students, their opinion of the accused internship and its director?
For Principle #19, consider the following questions and points related to the case.
 Consider whether the behavior of the DPD director has been appropriate. Consider if the DPD
director violated the internship director’s personal rights (and that of the program’s). How could
the DPD director have handled the disagreement and student desires to apply to the internship?
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Case Study #15: A registered dietitian (RD) in an ICU unit has been working with two very different
clients. Mr. Jones is a client who is very angry over an unexpected heart attack, the “unfairness of life”
and the ensuing dietary restrictions. As a result, he telephones the RD a couple of times a day with
issues about the food or if he is not feeling well. Next door is Mr. Smith, who is very personable,
patient, and friendly. The RD has seen the telephone ring twice, noticed it was from Mr. Jones room,
and ignored the call. The telephone rings again and it is Mr. Smith. The RD answers the telephone, and
agrees to go see Mr. Smith. The RD decides he’ll go see Mr. Jones after talking with Mr. Smith.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? An ethical issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles (Principle #2); and,
Responsibilities to Clients (Principle #9).
Indicate the Principle(s) of the Code of Ethics:
Principle #2 - The dietetics practitioner promotes and supports high standards of professional
practice.
Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration.
Explain how/why this relates to the Category and Principle
Principle #2: The RD did not use high standards of professional practice in working with the clients
and providing equal and timely care in the order or sequence required.
Principle #9: The RD did not treat all clients with respect and equal consideration.
Key Points to Consider:
For Principle #2, consider the following questions related to the case.
 Does the failure to answer the telephone not support the provision of high standards for professional
practice?
 Does choosing to visit Mr. Smith before Mr. Jones violate the principle of high professional
practice?
For Principle #9, consider the following questions related to the case:
 Does not answering Mr. Jones’ two telephone calls, constitute a failure to treat the client with
respect and consideration?
 What could the RD have done to respect Mr. Jones calls and minimize the annoyance that was felt
by the client’s frequent demands?
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Case Study #16: A registered dietitian (RD) has a follow-up appointment with a client who is on a
weight loss diet. This client failed to come to the last two meetings. The RD decides to call the client to
remind her about the appointment. When the answering machine comes on, the RD leaves a message
for the client. The RD reminds the client about the appointment, states the importance of a weight
check, and asks the client to call back to confirm the meeting.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is both an ethical issue
and a business (legal) issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles (Principle #2); and,
Responsibilities to Clients (Principle #10).
Indicate the Principle(s) of the Code of Ethics:
Principle #2 - The dietetics practitioner promotes and supports high standards of professional
practice.
Principle #10 - The dietetics practitioner protects confidential information and makes full disclosure
about any limitations on his/her ability to guarantee full confidentiality
Explain how/why this relates to the Category and Principle
Principle #2: The RD has failed to practice in accordance with the standards of the profession.
Principle #10: The RD has not protected the patient’s information and treated it confidentially.
Key Points to Consider:
For Principle #2, consider the following points related to the case.
 Consider the standards of practice related to confidentiality.
 Consider some of the legal implications of this RD’s actions, both for the RD and the employing
institution.
 HIPAA laws prevent leaving confidential medical/nutrition information on a voicemail without prior
authorization. It is appropriate for the RD to do reminder calls.
For Principle #10, consider the following points related to the case.
 Discussing general business practices or operating procedures can be implemented to deal
proactively with appointment compliance.
 Consider options for how the RD deal with the appointment-keeping issues related to this client.
These options should limit the purpose of the call to avoid presenting confidential information.
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Case Study #17: A registered dietitian (RD) who works in a clinical setting recently lost her significant
other. Since the death, she has had trouble concentrating, sleeping, decision making or putting focus
into life. This is something that is evident when she is counseling clients, reading records and charting.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This has the potential to be
an ethical issue. The professional is continuing to practice when he/she may have impaired judgment.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles.
Indicate the Principle(s) of the Code of Ethics:
Principle#7 - The dietetics practitioner withdraws from professional practice when unable to fulfill
his/her professional duties and responsibilities to clients and others.
Explain how/why this relates to the Category and Principle: Stress is an issue that can impair
one’s judgment. Identification, treatment and support are important but it is not known if this RD
has sought any of these. If the role of this professional is making decisions that affect the health and
safety of others, and if there is no check and balance on decisions, the potential for the public to be
harmed is increased.
Key Points to Consider:
 Important to know if the practitioner has identified there is a problem and sought help.
 What types of decisions are being made by this professional? Nutrition support, recommendations
for rehabilitation, serving as the dietetics practitioner on a team can put additional stress on RDs. On
a management side, employee negotiations and supervision, and budget management are stresses
where concentration and quick response are important. Regardless of the position, there is potential
for clouded judgment.
 Removing oneself from a high-level decision position is difficult but is a part of ethical behavior.
 Having support from coworkers and those who supervise the professional is important.
 Although the protection of the public is the prime concern, the protection of the RD is also a point to
consider. A compromised decision can end up with loss of life and all the costs that come with
liability lawsuits. Not withdrawing from the work environment could lead to these actions.
However, depending on the contract with the employer and the way the withdrawal from
responsibility is handled, there is also protection of the rights of the RD.
 Possible disability requirements as it relates to the Americans with Disabilities Action should be
discussed with the employee.
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Case Study #18: A registered dietitian (RD) has constant back pain, something the doctors have been
unable to treat. Biofeedback, physical therapy, and pain medication are the current means to control.
The current level of pain medication, although prescribed by his physician, is at such a level that he has
been advised not to drive after taking the medications for at least 4 hours. In addition, the side effects
include drowsiness, shortening of attention span and memory. His current job requires office hours in 3
different sites a week and involves home visits to patients in critical need. The RD believes the situation
is under control by limiting his appointments to control drive time and home visits. In the past month,
the dependence on the pain medication for relief has increased.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This is a potential ethical
issue. Personal responsibility to fulfill the needs of the employer and to provide service to the public.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibility to the Public.
Indicate the Principle(s) of the Code of Ethics:
Principle#7 - The dietetics practitioner withdraws from professional practice when unable to fulfill
his/her professional duties and responsibilities to clients and others.
Explain how/why this relates to the Category and Principle: The RD has a condition that
interferes with his ability to provide effective service. In addition, the situation is escalating to be
potential malpractice considering the side effects of the medication.
Key Points to Consider:
 Need to consider if this is a “cover-up” by the RD to maintain a position that he is unable to fulfill.
 Is there a back-up plan for covering patients who need nutrition care?
 Where is the employer, including Human Resources, in this scenario? Do they know the issues and
the potential liability they are assuming by allowing the RD to perform duties that may not be safe
for the patient or the individual?
 What is the risk of misuse of the medication and the potential damage?
 What can be done to “protect the public” depending on this professional providing service without
the risks of a drug (even legal) dependency? And, what can be done to protect the other players (the
employer and the RD)?
 Possible disability requirements as it relates to the Americans with Disabilities Action should be
discussed with the employee.
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Case Study #19: A registered dietitian (RD) works in an outpatient care center. Her patient discloses
he is pursuing complementary and alternative therapies. The client has a family history of diabetes and
heart disease. He has been diagnosed with Type 2 diabetes and is under control with one oral
medication, diet and exercise. In addition he is on a low dose medication for hypertension. He asks the
RD’s opinion on several supplements and therapies she is already taking or thinking of using. The RD is
not familiar with these supplements or therapies and dismissed the comments.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue if the
RD gives an opinion about the supplements without adequate scientific knowledge of its benefits or side
effects.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to Clients.
Indicate the Principle(s) of the Code of Ethics:
Principle #8 - The dietetics practitioner recognizes and exercises professional judgment within the
limits of his/her qualifications and collaborates with others, seeks counsel, or makes referrals as
appropriate.
Explain how/why this relates to the Category and Principle: Supplements and their interaction
with drugs is an issue that requires specific knowledge. The fact that the client admits to already
taking some is a trigger for more information.
Key Points to Consider:
 By dismissing the request for an opinion without research or without providing an appropriate
referral, the door is opened for harm to the client.
 Decisions of this type require assessment of the person’s family and health history (perhaps
genetics), current meds and potential interactions, diet and activity. Risks will vary.
 Referral to an RD familiar with complementary and alternative medicine, or at least a referral to
legitimate Web sites, may be appropriate.
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Case Study #20: A consultant registered dietitian (RD) has a worksite wellness account. Her usual
programming includes group classes on basic nutrition, nutrition for those with diabetes, heart-healthy
eating, and coping with food allergies. She also provides personal coaching to the company’s
employees. She is approached by one of an employee who is training for marathons and has specific
interests in sports nutrition, nutrition during training and pre-/post-event. Although the RD is
comfortable with the role of exercise and nutrition in basic health and general needs, competitive
athletics is not an area of expertise.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? To decide on giving advice
without adequate knowledge would be an ethical issue if the client is accepting your advice believing
you are an expert in sports nutrition.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to Clients.
Indicate the Principle(s) of the Code of Ethics:
Principle #8 - The dietetics practitioner recognizes and exercises professional judgment within the
limits of his/her qualifications and collaborates with others, seeks counsel, or makes referrals as
appropriate.
Explain how/why this relates to the Category and Principle: Recommendations on fitness and
activity for an elite athlete or someone seeking that distinction is, by nature of the case study
outside the limits” of this practitioner’s expertise.
Key Points to Consider:
 There is the potential to work with the client after disclosure of the RD’s limitations and willingness
to research the necessary information.
 Sports nutrition for the “elite athlete” is an area that is best addressed by a RD with the appropriate
certification/training. This is a specialty certification.
 How much time would it take to research the questions, seek counsel and from a business side,
would it be a better decision for all to refer to another practitioner?
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Case Study #21: The Professional Development Portfolio (PDP) process has become a stumbling block
to retaining a dietetic technician, registration (DTR) who wishes to retain her registration status. She
submitted the initial portfolio and is close to the end of the 5-year period. Although she has attended
meetings that offered continuing professional education (CPE), most of them were not specific to her
approved plan for continuing education. The reminder notices from Commission on Dietetic
Registration (CDR) continue to come. Registration is a requirement to remain licensed and employed.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical dilemma
that was set up by the DTR not putting emphasis on responsibilities to the profession.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to the Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #14 - The dietetics practitioner assumes a life-long responsibility and accountability for
personal competence in practice, consistent with accepted professional standards, continually
striving to increase professional knowledge and skills and to apply them in practice.
Explain how/why this relates to the Category and Principle: The Portfolio Process is built on
assessment and planning. It is a personal responsibility.
Key Points to Consider:
 Does the submitted plan meet the needs for the DTR to meet competencies of practice and reflect
increasing professional knowledge and skills?
 Within the time frame, what opportunities are available within the submitted and approved plan (or
amendments if possible)?
 Attempting to make CPE “fit” the learning plan is taking a risk for the CPE not being accepted in the
portfolio process, with loss of registration and the reciprocity of licensure in this case.
 Submitting CPE that “fits” but was not completed is fraudulent and is definitely unethical.
Potentially, this places the dietetics practitioner at risk in the case of an audit.
 Review the reason for the portfolio process. CDR offers guidance and this should be sought.
 What opportunities are available that meet needs (online, academic coursework, book or journal
based articles, intensive seminars)?
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Case Study #22: A group of registered dietetics practitioners, who are friends and co-workers have
decided it will be easier (and less expensive) to meet continuing professional education (CPE)
requirements if as a group, they decide on a plan with minor variations for each person to submit as their
own. This, they rationalize will allow discussion and planning for helping those who are not sure of
their plans. Further, the attendance at the CPE events will be split among the group with designated
members taking responsibility for attending, taking detailed notes, taping speakers and duplicating any
handouts, and CPE proof. This is rationalized as a form of “self-learning” with the idea that group
members not attending will be able to ask questions of those who did as well as study the handouts.
While discussing this as a group, several of the group members question if this is ethical.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to the Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #14 - The dietetics practitioner assumes a life-long responsibility and accountability for
personal competence in practice, consistent with accepted professional standards, continually
striving to increase professional knowledge and skills and to apply them in practice.
Explain how/why this relates to the Category and Principle: The Portfolio process is built on
assessment and planning. It is a personal responsibility.
Key Points to Consider:
 Copying a group plan is clearly a breach of ethics.
 Copying a group plan is not only unethical but also crosses the ethics line of personal competence in
practice. Planning for continuing education is a personal issue that takes into account skill and
knowledge level, experience, interest and professional responsibilities; both present and in the
future. The goal of CPE is to meet competencies of practice and reflect increasing professional
knowledge and skills. This is unlikely and the submission of a single plan essentially “copied”, is
another breach of ethics.
 It is clearly unethical to record attendance at a CPE event that was not attended. Take the
opportunity to review the purpose of the CDR portfolio process.
 There are programs that are preapproved for group sharing and discussion, but the intent of this
group to “share” is fraudulent and is definitely unethical. Potentially, this places each of the dietetics
professional at risk in the case of an audit.
 If practicality and convenience is the driver in this case study, think about the potential of one of the
group deciding to report the actions to CDR or ADA. What then?
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Case Study #23: A skilled long-term facility patient with severe dementia tells a registered dietitian
(RD) that she no longer wants to be fed via her gastrostomy feeding tube. She has no advanced
directive. The daughter wants the mother fed. What is the RD’s role in this situation and what should
be done?
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical and legal
issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Responsibilities to Clients; Responsibilities to the
Profession.
Indicate the Principle(s) of the Code of Ethics:
Principle #8 - The dietetics practitioner recognizes and exercises professional judgment within the
limits of his/her qualifications and collaborates with others, seeks counsel, or makes referrals as
appropriate.
Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration.
Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and
current information.
Explain how/why this relates to the Category and Principle: The RD must recognize and exercise
their professional judgment when determining what is best for the client. Client and patient
preferences must be balanced with scientific judgment and legal considerations.
Key Points to Consider:
 RDs are frequently called upon for their expertise regarding long-term and end-of-life nutrition
issues. Is the RD knowledgeable about these specific nutritional issues? If not, the ADA position
paper on this topic could be of assistance.
 If the RD has been working with the patient for a period of time, she may have had previous
discussions about feeding. If the RD has this knowledge, she has an ethical duty to report this
information to the physician.
 If there were no discussions and no advance directives, the daughter may be the person designated to
make these decisions. State laws vary widely and would need to be strictly followed to avoid
liability to the institution or the individual health practitioners.
 If there are additional family members, their input could also be sought.
 If there is a bioethics committee, the RD needs to be an active participant, sharing her nutrition
expertise.
 A discussion with the daughter about the probable futility or lack of benefit of the tube feeding
needs to be addressed.
 If the decision is made to continue feeding the patient and the RD does not agree, she has a duty to
get another RD to take over the care.
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Case Study #24: A registered dietitian (RD) says that she had expenses paid by ADA to attend a
conference. Her job also pays for the expenses to attend the meeting. She decides to submit for
reimbursement to each group. She explains that the ADA expenses can be considered a honorarium for
work done at the meeting. She shares this information with a colleague RD.
Questions for Discussion
Is the situation described an ethical issue? Or, is it a business dispute? The situation is an ethical
issue.
What principle(s) of the Code of Ethics does it relate to and how/why?
Indicate the Category for the Code of Ethics: Fundamental Principles; Responsibilities to
Colleagues and Other Professionals.
Indicate the Principle(s) of the Code of Ethics:
Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity and
fairness.
Principle: #19 - The dietetics practitioner demonstrates respect for the values, rights, knowledge
and skills of colleagues and other professionals.
Explain how/why this relates to the Category and Principle: The fundamental actions of the
practitioner are a personal responsibility to act ethically with accountability. The RD colleague has
a responsibility to act ethically.
Key Points to Consider:
 It is a two-fold ethical issue. The ethical conduct of both individuals is called into question.
 The practitioner who decides to double-dip is violating Principle #1.
 The practitioner falsely claiming reimbursement for expenses, regardless of her rationale, is
dishonest and double-dipping from the professional association and employer.
 While RDs cannot regulate the conduct of others, the colleague who hears about situation should
confront the individual to discuss the ethical issue.
 The colleague could decide to ignore the breach of ethics or decide if the rationale is acceptable.
How does the RD demonstrate respect for the values, rights and knowledge of her colleague?
 If the practitioner goes ahead with the submission, is it the responsibility of the RD colleague to
report the issue to the ADA or the place of employment or both?
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