Code of Ethics Resources 2011
Table of Contents
Purpose of the Code of Ethics
Background on the Code of Ethics
Responsibilities of Therapists
COTM Code of Ethics - Values
A. Accountability
B. Individual Autonomy
C. Competent, Caring and Ethical Services
D. Dignity and Worth
E. Trusting and Respectful Practice Environment
F. Fairness
G. Confidentiality and Privacy
H. Honesty and Transparency
Pg. 3
Pg. 3
Pg. 4
Pg. 5
Pg. 6
Pg. 7
Pg. 9
Pg. 10
Pg. 11
Pg. 12
Pg. 13
Pg. 14
Appendices:
Appendix I: A Framework for Ethical Decision-Making, Michael
McDonald
Pg. 15
Appendix II: Scenarios
Scenario 1: 81 year old male; discharge planning;
acute medicine
Scenario 2: 52 year old female; neuro; out-patient
Scenario 3: 14 year old female; cancer; in-patient
Scenario 4: 43 year old female; depressed; in-patient
psychiatry
Pg. 19
Pg. 23
Pg. 26
Pg. 29
Appendix III: Glossary
Pg. 33
Appendix IV: Other supporting documents and resources
(e.g. websites, links)
Pg. 36
Appendix V: Bibliography
Pg. 37
Code of Ethics, October 2010
Page 2 of 28
Preamble
The Code of Ethics of the College of Occupational Therapists of Manitoba outlines the values
and obligations of occupational therapists practicing within the province. It does not, however,
provide direction for problem solving in specific situations with clients. It is recognized that
there are often times in the complex practice of occupational therapy where the Code of Ethics
is a starting point to decision-making and that other resources and guidance is required. This
resource package was developed to provide occupational therapists with further resources to
aid in the ethical practice of occupational therapy.
The Framework for Ethical Decision Making (Framework) (McDonald, 2001) has been used
locally and nationally as a resource to assist health providers approach ethical dilemmas and
decisions thoughtfully and consciously. Permission has been obtained from its author for
inclusion in this document. Following this Framework are four case study scenarios, developed
by the Practice Issues Committee with an initial application of the Framework to the scenario.
These applications are by no means to be thought of as complete or exhaustive, only a starting
point to demonstrate how the Framework can provide guidance in seeking information,
resources and clarification. In reading through the scenarios you may find that you disagree
with the analysis completed by the Committee and that is to be expected. These are provided
not as the “right” way of doing things but as a way of encouraging occupational therapists to be
conscious of how they are making decisions about their practice. We encourage you to use the
Framework both with the scenarios provided and with your own dilemmas in practice.
Beyond the Framework and scenarios is a glossary of terms which provides clarification of
some of the terminology used within the Code of Ethics to ensure clarity of language. The
Other Resources page provides useful links to consult for further access to resources on
ethics, within occupational therapy and in the broader health context. Finally, the Bibliography
provides a list of references consulted and considered in the creation of the Code of Ethics and
its supporting documents. Many of these may also be of value to occupational therapists
needing further guidance in their practice.
Code of Ethics, October 2010
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PART I - A Framework for Ethical Decision-Making:
This model has been reprinted with permission from Dr. Michael McDonald, June, 2011. Dr. McDonald is
an ethicist and philosopher in the Center for Applied Ethics at the University of British Columbia.
MacPherson et al., (2004) have written a chapter in the advanced ethics textbook edited by Storch,
Rodney and Starzomski (2004) with the use of case studies to demonstrate the application of this model
to practice.
A Framework for Ethical Decision-Making:
Version 6.0 Ethics Shareware (2001)
by Michael McDonald[1] with additions by Paddy Rodney and Rosalie Starzomski[2]
1. Collect information and identify the problem.
1.0
Be alert; be sensitive to morally charged situations.
Look behind the technical requirements of your job to see the moral dimensions. Use
your ethical resources to determine relevant moral standards [see Part III]. Use your
moral intuition.
1.1.
Identify what you know and don’t know.
While you gather information, be open to alternative interpretations of events. So within
bounds of patient and institutional confidentiality, make sure that you have the
perspectives of patients and families as well as health care providers and
administrators. While accuracy and thoroughness are important, there can be a tradeoff between gathering more information and letting morally significant options
disappear. So decisions may have to be made before the full story is known.
1.2.
State the case briefly with as many of the relevant facts and circumstances as you can
gather within the decision time available.
• What decisions have to be made?
• Who are the decision-makers? Remember that there may be more than one
decision-maker and that their interactions can be important.
• Be alert to actual or potential conflict of interest situations. A conflict of interest is "a
situation in which a person, such as a public official, an employee, or a
professional, has a private or personal interest sufficient to appear to a reasonable
person to influence the objective exercise of his or her official duties; "These
include financial and financial conflicts of interest (e.g. favouritism to a friend or
relative). In some situations, it is sufficient to make known to all parties that you are
in a conflict of interest situation. In other cases, it is essential to step out a decisionmaking role.[3]
1.3.
Consider the context of decision-making.
Ask yourself why this decision is being made in this context at this time? Are there
better contexts for making this decision? Are the right decision-makers included?
1.4.
Consider the following questions.
Clinical Issues
• What is the patient’s medical history/ diagnosis/ prognosis?
• Is the problem acute? chronic? critical? emergent? reversible?
• What are the goals of treatment?
Code of Ethics, October 2010
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• What are the probabilities of success?
• What are the plans in case of therapeutic failure?
• In sum, how can the patient be benefited by medical, nursing, or other care, and
harm avoided?
Preferences
• What has the patient expressed about preferences for treatment?
• Has the patient been informed of benefits and risks; understood, and given consent?
• Is the patient mentally capable and legally competent? What is evidence of
incapacity?
• Has the patient expressed prior preferences, e.g., Advanced Directives?
• If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate
standards?
• Is the patient unwilling or unable to cooperate with treatment? If so, why?
• In sum, is the patient’s right to choose being respected to the extent possible in
ethics and law?
Quality of Life/Death
• What are the prospects, with or without treatment, for a return to the patient’s normal
life?
• Are there biases that might prejudice the provider’s evaluation of the patient’s quality
of life?
• What physical, mental, and social deficits is the patient likely to experience if
treatment succeeds?
• Is the patient’s present or future condition such that continued life might be judged
undesirable by him/her?
• Are there any plans and rationale to forego treatment?
• What are the plans for comfort and palliative care?
Contextual Features
• What chapter is this in the patient’s life?
• Are there family/cultural issues that might influence treatment decisions?
• Are there provider (e.g. physicians and nurses) issues that might influence treatment
decisions?
• Are there religious, cultural factors?
• Is there any justification to breach confidentiality?
• Are there problems of allocation of resources?
• What are the legal implications of treatment decisions?
• Is there an influence of clinical research or teaching Involved?
Code of Ethics, October 2010
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2. Specify feasible alternatives.
State the live options at each stage of decision-making for each decision-maker. You then
should ask what the likely consequences are of various decisions. Here, you should remember
to take into account good or bad consequences not just for yourself, your profession,
organization or patients, but for all affected persons. Be honest about your own stake in
particular outcomes and encourage others to do the same.
3. Use your ethical resources to identify morally significant factors in each
alternative.
3.0 Principles
These are principles that are widely accepted in one form or another in the common
moralities of many communities and organizations.
• Autonomy: Would we be exploiting others, treating them paternalistically, or
otherwise affecting them without their free and informed consent? Have promises
been made?
• Non-malfeasance: Will this harm patients, caregivers, or members of the general
public?
• Beneficence: Is this an occasion to do good to others? Remember that we can do
good by preventing or removing harms.
• Justice: Are we treating others fairly? Do we have fair procedures? Are we producing
just outcomes? Are we respecting morally significant rights and entitlements?
• Fidelity: Are we being faithful to institutional and professional roles? Are we living up
to the trust relationships that we have with others.
3.1
Moral models
Sometimes you will get moral insight from modeling your behaviour on a person of great
moral integrity.
3.2 Use ethically informed sources.
Policies and other source materials, professional norms such as institutional policies,
legal precedents, and wisdom from your religious or cultural traditions.
3.3 Context
Contextual features of the case that seem important, such as the past history of
relationships with various parties.
3.4 Personal judgments
Your judgments, your associates, and trusted friends or advisors can be invaluable. Of
course in talking a tough decision over with others you have to respect client and
employer confidentiality. Discussion with others is particularly important when other
decision-makers are involved, such as, your employer, co-workers, clients, or partners.
Your professional or health care association may provide confidential advice.
Experienced co-workers can be helpful. Many forward-looking health care institutions or
employers have ethics committees or ombudsmen to provide advice. Discussion with a
good friend or advisor can also help you by listening and offering their good advice.
3.5 Organized procedures for ethical consultation
Consider a formal case conference(s), an ethics committee, or an ethics consultant.
4. Purpose and test possible resolutions.
4.0 Find the best consequences overall.
Propose a resolution or select the best alternative(s), all things considered.
4.1 Perform a sensitivity analysis.
Consider your choice critically: which factors would have to change to get you to alter
your decision? These factors are ethically pivotal.
4.2 Consider the impact on the ethical performance of others.
Think about the effect of each choice upon the choices of other responsible parties. Are
you making it easier or harder for them to do the right thing? Are you setting a good
example?
4.3 Would a good person do this?
Ask yourself what would a virtuous person – one with integrity and experience – do in
these circumstances?
4.4 What if everyone in these circumstances did this?
Formulate your choice as a general maxim for all similar cases?
4.5 Will this maintain trust relationships with others?
If others are in my care or otherwise dependent on me, it is important that I continue to
deserve their trust.
4.6 Does it still seem right?
Are you and the other decision-makers still comfortable with your choice(s)? If you do not
have consensus, revisit the process. Remember that you are not aiming at “the” perfect
choice, but a reasonably good choice under the circumstances.
5. Make your choice.
5.0 Live with it.
5.1 Learn from it.
This means accepting responsibility for your choice. It also means accepting the
possibility that you might be wrong or that you will make a less than optimal decision. The
object is to make a good choice with the information available, not to make a perfect
choice. Learn from your failures and successes.
Postscript
This framework is to be used as a guide, rather than a “recipe”. Ethical decision-making is a
process, best done in a caring and compassionate environment. It will take time, and may
require more than one meeting with patient, family, and team members.
Feel free to share this framework with others. If you reprint or distribute it, please let the author
know. Comments are welcomed. All substantive comments and requests to the author at:
mcdonald@ethics.ubc.ca.
[1] The W. Maurice Young Centre for Applied Ethics, University of British Columbia
[2] School of Nursing, University of Victoria
[3] See “Ethics and Conflict of Interest” by Michael McDonald at
http://www.ethics.ubc.ca/people/mcdonald/conflict.htm
PART II - Scenarios
COTM Code of Ethics, 2010
Application of McDonald’s Ethical Decision Making Framework
by McDonald, 2006 (used with permission)
The four scenarios that follow are intended to demonstrate how Michael McDonald’s Ethical
Decision-Making Framework (2001) may be used through ethical dilemmas. The scenarios
have been developed to cover several areas of occupational therapy practice, with clients of
differing ages and diagnoses.
Scenario 1: 81 year old male; discharged planning; acute medicine setting
Scenario 2: 52 year old female; neuro; out-patient setting
Scenario 3: 14 year old female; cancer; in-patient setting
Scenario 4: 43 year old female; depression; in-patient psychiatry setting
These four examples only provide a small representation of the full range of occupational
therapy practice and they are not intended to be comprehensive or exhaustive. Each scenario
is described using questions and considerations from McDonald’s framework to guide the
therapist. The terms used in the scenarios are defined in the glossary in Appendix III.
Therapists using the scenarios may have other perspectives that may fit equally well into the
Ethical Decision-Making Framework (2001), or they may disagree with the content expressed
here. These scenarios are not intended to be prescriptive in nature. Rather, they provide
therapists with examples of how the framework may be used to facilitate the process of
exploring the complexity of ethical dilemmas in occupational therapy practice.
Scenario 1: 81 year old; discharge planning; acute medicine
1. Information, problem identification
State the case briefly with as many of the relevant facts and circumstances as you can
gather within the decision time available.
81 year old male, admitted to hospital for rehab following a fall. He is a widower, who lives
alone in house, in squalor. He wants to return to home post discharge. He still demonstrates
impaired mobility with high risk for falls, neglects personal hygiene, unsafe use of stove, unsafe
smoking habits with no intention to stop smoking, history of alcohol abuse with no intention to
stop drinking. After course of therapy and OT reassessments, in terms of safety, you feel that
the client is not safe to live independently. You are particularly concerned about his smoking
safety, cooking safety, risk for fires, and poor judgment when drinking alcohol. His function has
improved somewhat during admission (when he has not been drinking alcohol). His
competence to make decisions has not been tested formally, but when sober, in hospital, he
demonstrates mild decreased short term memory. Home care is refusing to put in services
because of safety concerns. He has no money to pay for private services, and has no social
supports. He is somewhat estranged from his only daughter, who would like to see him in a
nursing home. Team and daughter want to pressure client into accepting PCH. Client states he
would rather die than go to nursing home. Client states he has always felt this way, and
daughter confirms that client has stated this “anti-nursing home” value throughout his life.
Code of Ethics, October 2010
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Values to consider from COTM Code of Ethics:
• Individual Autonomy (client’s wishes are known)
• Competent, Caring & Ethical Services (beneficence) (protect client from harm)
• Accountability (fidelity) (remain faithful to professional roles)
Decisions to be made:
• Decisions regarding supports.
• Decision to discharge.
Home
PCH
Alternative
• Does competence need to be assessed?
Is there a valid trigger?
Is there evidence of lack of competence?
Public Health issues?
Legislation?
Who are the decision makers?
• Therapist/team
• Client
• Physician
• Substitute Decision Makers
Is there a conflict of interest?
• Possibly a daughter?
• Determine daughter’s situation; perspective.
Consider the context of the decision-making:
• Is this the best time to make this decision?
• Are there any features of coercion in the current decision-making setting?
• Could it be better done once client is established at home, with information from
• community resources?
• Who are the best people to make this decision?
Consider the clinical issues:
• Chronic problems
• Not cooperative with treatment
Preferences:
•
•
•
•
Client is wanting to live at home
Has clearly expressed preference not to go to PCH in the past
If client is not competent, can we still respect his preferences?
Who is his substitute decision maker? Will her decisions be based on client’s
expressed preferences?
Code of Ethics, October 2010
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Quality of life:
•
•
His quality of life will likely go down significantly in his estimation if he goes to
PCH (withdrawal, no smoking or alcohol)
The team’s values biases our acceptance of his value on his current QOL in
squalor
Contextual features:
• Social-cultural features: we have a hard time accepting his lifestyle
• Legal Implications: concerns regarding possible litigation
• Provider Issues: home care, OT
2. Specify some feasible alternatives (there could be others):
1. Allow client total independence to decide (and send him home as is)
2. Negotiate with client re D/C home with environmental changes, supports
3. Negotiate with client re D/C home with environmental changes, supports, with a
view to reviewing the decision in the community
4. Negotiate with client re D/C to other alternative housing (E.G. Jack’s)
5. Request an assessment of competency. If not competent, defer to daughter for
decision, which will mean he goes to PCH.
3. Use your ethical resources to identify morally significant factors in each alternative
1. Allow client total independence to decide (and send him home as is)
• Respects autonomy;
• does not prevent harm;
• may be seen as not being true to our professional obligation (fidelity)
2. Negotiate with client re D/C home with environmental changes, supports
•
Respects autonomy to some degree;
•
prevents harm to some degree;
•
more faithful to professional roles
3. Negotiate with client re D/C home with environmental changes, supports, with a
view to reviewing the decision in the community
•
Respects autonomy to some degree;
•
prevents harm;
•
faithful to professional roles
4. Negotiate with client re D/C to other alternative housing (E.G. Jack’s)
• Respects autonomy to some degree;
• prevents harm;
• faithful to professional roles
Code of Ethics, October 2010
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5. Request an assessment of competency. If not competent, defer to daughter for
decision, which will mean he goes to PCH.
• Does not respect autonomy of client;
• Daughter, as substitute decision-maker, also does not respect autonomy as
she is not respecting his previously declared wishes;
• Does prevent harm
Use ethically informed sources
Consider legal obligations (issues of litigation if client is harmed; concept of legal competence)
4. Purpose and Test Possible Resolutions, considering the following questions:
4.1.
What would be the best consequence overall?
4.2.
Which factors would have to change for you to change your opinion?
4.3.
Consider the impact on the ethical performance of others.
4.4.
Would a good person do this?
4.5.
What if everyone in this circumstance did this?
4.6.
Will this maintain trust relationships with others?
4.7.
Does it still seem right?
Scenario 2: 52 year old female; neuro; out-patient
1. Information, problem identification
State the case briefly with as many of the relevant facts and circumstances as you can
gather within the decision time available.
You work in neuro out patient setting. You have a single female client, aged 52, who has had a
mild stroke, with mild L hemianopsia and L UE hemiparesis. She was never hospitalized, and
was initially very reluctant to attend the day program. After much work you have finally
engaged her co-operation and participation. Your treatment is focused on L UE function and
learning compensatory techniques for her mild hemianopsia and she is making good progress.
She was an active woman and wants to resume her previous employment in sales. One day
during your time off on the week-end, you see your client driving into the parking lot of the
shopping mall, and parking the car. The little you see of her driving is safe, and uneventful.
However, she had previously told you, her neurologist, and her family physician that she was
not driving, so a letter was never sent to motor vehicles department informing them of her
diagnosis. This issue has not been addressed in therapy as she had never indicated that she
wanted to drive. Her hemianopsia and hemiparesis are mild but you do have concerns about
her safety driving. Knowing her personality, however, you also are aware that if you bring up
the issue, tell her not to drive until she is tested, or report her driving to MPI and her physician,
she will likely be very angry and terminate the therapy.
Values to consider from COTM Code of Ethics:
• Individual Autonomy (client wants to make her own decision vs. need to protect
the public)
• Accountability (fidelity) (trust relationships with colleagues)
• Confidentiality & privacy (to whom can you report?)
Decisions to be made:
• Discuss driving issue with client?
• Report client’s stroke to MPI?
• Report client’s driving to family physician and neurologist?
Who are the decision makers?
• Therapist
• Client
• Physician
• MPI
Is there a conflict of interest?
• None, except the knowledge that informing authorities regarding her driving will
likely mean she will be angry and terminate her therapy with you.
Code of Ethics, October 2010
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Consider the context of the decision-making:
• This decision is being made at this time because you saw the client driving the
car. You previously did not know that she was driving and therefore did not
realize that a decision had to be made. You saw her driving outside of your
working hours, so technically, there is no “proof’, other than your private
observations, that she is driving.
Consider the clinical issues:
• Progressing well with stroke rehab
• Mild hemianopsia and hemiparesis; concerns about ability to drive safely
• Risk of clinical harm if client terminates therapy (not achieving goals that could
have probably been achieved)
Preferences:
•
Client is wanting to drive
Quality of life:
•
•
Her quality of life will likely go down, in her estimation, if her license is revoked
or if she has to wait for re-testing
Relationship with therapist will be harmed if you report her.
Contextual features:
• Social-cultural features for a middle-aged entrepreneurial woman who cannot
drive (socially and economically limiting)
• Legal Implications: Physician must report her to MV if she/he is aware
• Moral features: You know that others may be at risk with her driving
2. Specify some feasible alternatives (there may be others):
1. Report driving to family MD and neurologist
2. Report driving directly to MPI
3. Discuss issue with client, with plan of incorporating driving into treatment plan,
then proceed with reporting, either to family MD/neurologist, or directly to MPI
4. Do nothing
5. Report to MPI anonymously, as a concerned citizen.
3. Use your ethical resources to identify morally significant factors in each alternative
1.
2.
Report driving to family MD and neurologist:
• respects non-malfeasance by protecting public from harm
• respects fidelity by being faithful to our professional role, live up to trust
relationship with MD’s
• MD has legal responsibility to report
• Does not respect her autonomy
Report driving directly to MPI
• respects non-malfeasance by protecting public from harm
• respects fidelity by being faithful to our professional role, live up to trust
relationship with MD’s
Code of Ethics, October 2010
Page 14 of 28
•
•
•
3.
4.
goes beyond legal requirements of our role, as MD has legal responsibility
to report
Does not respect her autonomy
Concern re breeching confidentiality
Discuss issue with client, with plan of incorporating driving into treatment plan,
then proceed with reporting:
• some respect for autonomy by discussing and informing her; and by
including driving as a treatment goal
• respects non-malfeasance by protecting public from harm
• respects justice through an honest approach
• respects fidelity by being faithful to our professional role, live up to trust
relationship with MD’s
Do nothing:
respects autonomy
compromises non-malfeasance, justice, and fidelity to our professional
roles
•
•
5.
Report driving to MPI as a concerned citizen:
respects non-malfeasance by protecting public from harm
does not respect her autonomy;
compromises justice through secrecy and dishonesty
compromises fidelity by not being faithful to our professional roles, but
does allow client-therapist relationship to continue
•
•
•
•
Use ethically informed sources
Consider “duty to warn”/legal obligations (MD’s have legal obligation to report her stroke)
Consider PHIA/confidentiality issues (reporting to MD’s is not a breech)
Consider highway traffic act
4. Propose and Test Possible Resolutions, considering the following questions:
4.1.
What would be the best consequence overall?
4.2.
Which factors would have to change for you to change your opinion?
4.3.
Consider the impact on the ethical performance of others.
4.4.
Would a good person do this?
4.5.
What if everyone in this circumstance did this?
4.6.
Will this maintain trust relationships with others?
4.7.
Does it still seem right?
Code of Ethics, October 2010
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Scenario 3: 14 year old female; cancer; in-patient
1. Information, problem identification
State the case briefly with as many of the relevant facts and circumstances as you can
gather within the decision time available.
You are an inpatient therapist treating a 14 year old female who was admitted for a hip and two
wrist fractures. The girl has cancer and is aware of that, but during her admission it becomes
clear that her cancer has metastasized and that she only has a prognosis of 6 months to a
year. The girl is not aware of this, and her mother has threatened to sue the doctor and the
hospital if this is divulged to her. The doctor on the unit has reluctantly agreed and you and
your team have all been instructed not to tell the girl about her diagnosis. You understand the
mother has decision- making authority as the girl is not yet 18; and that her mother believes it
is not in her daughter’s best interest to know, but you feel that the girl is old enough to
understand, and to have the option of preparing for her death. The mother is not willing to
discuss this issue with the team. You do not want to cause distress to the girl’s mother; you do
not want precipitate a crisis for the girl and her mother at this time in her life; but you do not feel
that it is right for your team to withhold this information from the girl.
Values to consider from COTM Code of Ethics:
• Honesty and Transparency (wish to provide client with truth about prognosis)
• Dignity and worth (maintain trust of mother vs. allow client a dignified death)
• Trusting and respectful practice environment (going against team instruction;
team being asked to withhold truth)
Decisions to be made:
• Should the child be told about the change in her prognosis?
Who are the decision-makers?
• This is the heart of this scenario. The mother is the surrogate decision-maker
as the child is a minor.
• The doctor could also be a decision-maker.
• The child may have some capacity to make decisions depending on the
situation.
Is there a conflict of interest?
• There is no apparent conflict of interest.
Consider the context of the decision-making:
• The decision to not tell is being made at this time as the child has had a change
in prognosis and the mother does not feel that it is in the child’s best interests to
know. Until this point the child has been aware of her diagnosis. This new
information has changed the context for you, and possibly the team.
Code of Ethics, October 2010
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Consider the clinical issues:
• The child’s cancer has progressed and metastasized and her prognosis has
changed to terminal.
• While the child was previously aware of her diagnosis, she is not aware of this
change.
Preferences:
•
•
We are not clear about the child’s preferences at this time.
The mother’s preference is that the child would not be told.
Quality of life:
•
The mother believes that the knowledge of the change in prognosis would
affect the child’s quality of life, possibly by causing stress and grief.
Contextual features:
• The child is legally a minor and the law indicates that parents are considered
the surrogate decision-makers as a matter of course.
• There is precedent for a minor child who is considered to be mature to be
allowed to make their own decisions and be informed of all treatment options.
• Telling the child without the mother’s consent would be harmful to your
relationship with the family and could have a negative impact on the
relationship between the mother and the child
2. Specify some feasible alternatives (there could be others):
1. Do nothing: you could accept the decision of the parent and not tell the child
2. Discuss with the team and convince the physician to tell the child: It appears
from the scenario that the physician is a reluctant participant in this decision.
You may be able to work with the team to change his/her mind.
3. Tell the child yourself: You could tell the child contrary to the mother’s wishes
4. Talk to the mother with the team to discuss the reasons that you believe it is
important to tell the child: You could hold a team meeting to discuss the pros
and cons of with-holding the information from the child.
3. Use your ethical resources to identify morally significant factors in each alternative
1. Do nothing:
• respects the autonomy of the mother to make decisions for the child;
• does not respect the autonomy of the child is she has the capacity to make
informed choice;
• the concepts of beneficence and non malfeasance may or may not be
respected depending on whether you are considering the mother’s
perspective or the therapists perspective;
• compromises justice because of secrecy and dishonesty
2. Discuss with the team and convince the physician to tell the child:
• does not respect the autonomy of the mother;
3. Talk to the mother with the team to discuss the reasons that you believe it is
important to tell the child:
Code of Ethics, October 2010
Page 17 of 28
•
•
Respects the autonomy of the mother, although she is not presently
interested in discussing the issue;
does not consider the autonomy of the child;
Use ethically informed sources
Consider the legal definition of mature minor
Consider issues of informed consent
Contact other resources that may be able to provide guidance such as the Child’s Advocate
Office.
4. Propose and Test Possible Resolutions, considering the following questions:
4.1.
What would be the best consequence overall?
4.2.
Which factors would have to change for you to change your opinion?
4.3.
Consider the impact on the ethical performance of others.
4.4.
Would a good person do this?
4.5.
What if everyone in this circumstance did this?
4.6.
Will this maintain trust relationships with others?
4.7.
Does it still seem right?
Code of Ethics, October 2010
Page 18 of 28
Scenario 4: 43 year old female; depressed; in-patient psychiatry
1. Information, problem identification
State the case briefly with as many of the relevant facts and circumstances as you can
gather within the decision time available.
You are a therapist working on an adult in-pt psychiatry unit. One of your OT colleagues is
treating a client, a 43 year old female with depression and anxiety disorder, with a recent
suicide attempt. You know this client quite well from a former admission. You accidentally
overhear a conversation between the client and your colleague. Your colleague is challenging
and confronting the client about her current functional and behavioural issues. After he leaves,
you hear the client crying in her room. Based on your former knowledge of this client and your
experience in this area, you felt that his approach is too direct and likely to be harmful to the
client. Later that day, you privately approach your colleague and tell him of your knowledge of
this client and your concerns. He becomes defensive, and states that he is her therapist and he
knows best what he needs. He continues to regularly interact with this client in this manner.
You are concerned that she may become suicidal again, and that his interactions with her are
detrimental to her progress. Your colleague is a strong, outspoken team member who exerts
considerable influence on the team.
Values to Consider from COTM Code of Ethics
• Competent, Caring & Ethical Services (beneficence & nonmalfeasance)(client’s best interest)
• Accountability (fidelity, justice) (professional role and distribution of services)
• Trusting and Respectful Practice Environment (team relationships)
Decisions to be made:
• Validity of perception of therapist’s approach re: client’s self-injurious behaviour
• What level of risk is this behaviour?
• What is acceptable risk in this situation?
• Does one non-treating professional have an obligation to take corrective or
preventative action to protect clients?
• Under what circumstances?
• What would be acceptable behaviour from colleague who is providing
treatment?
• How does one determine if care being provided is incompetent, unethical, or
unsafe?
• At what level of concern for client does treating therapist’s actions have to be
explored further or action taken?
Code of Ethics, October 2010
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Who are the decision-makers?
• Therapist
• Client
• Team
• Inpatient
• Community Mental Health
• Supervisor
• College
Is there a Conflict of Interest?
• Previous therapist; why is she not current therapist?
• Motive? Consider strong, outspoken, influential team member.
• Are there any transference and/or counter-transference issues?
Consider the context of the decision-making
• What is the problem?
• Whose problem is it?
• Why is decision being made at this time? Chance? Happen to be passing by?
• Consider risk/harm reduction. How out of line is this behaviour?
• What are my feelings? Examine own motivation.
• Is this truly behaviour unbecoming, image of profession?
• Are right decision makers present? Consider others.
• Consider, is the previous therapist a member of the team?
• Does the previous therapist have access to the client’s records If not a member
of immediate treatment team?)
• Is the previous therapist aware of new treatment model and goals for current
admission?
Consider the Clinical Issues
• What would be appropriate clinical practice?
• Is there real risk of suicide or self injurious behaviour?
• Is confrontation or challenge the appropriate response in this scenario?
• What is incompetence in this case? Consider best practice, standards, and
treatment goals.
Preferences
•
Has client expressed any preference regarding style of treatment?
Quality of Life
•
Given what was witnessed, how does treating therapist justify his approach or
technique?
Contextual Features
• Do professionals need to maintain positive collegial relations? At what cost to
the client?
• Question regarding allocation of resources? [Can we justify taking time away
from our own clients to pursue clients other than ours, when we have
obligations to our own clients?]
• Legal implications? [Consider – therapists do not have legal access to clients’
charts/medical records if not on treatment team].
• Ramifications of successful suicide on unit?
• Mental Health Act, PHIA, institution policies, protocols, guidelines, best
practice, professional standards.
• How does therapist influence without overstepping ethical boundaries?
2. Specify some feasible alternatives (there could be others):
1.
2.
3.
4.
5.
Therapist does nothing
Therapist does nothing now, and monitors the situation
Therapist reads the current literature, and holds judgment until more
comfortable
Therapist re-approaches other current therapist, team members, Supervisor,
as indicated and discusses the issue again
Therapist discusses with the team, current therapist’s Supervisor, College
3. Use your ethical resources to identify morally significant factors in each alternative
1. Therapist does nothing
• Respects autonomy.
- For client – May be consistent with client’s informed consent
- For therapist - Acknowledges and respects that other therapists may
choose to do their jobs differently
• Justice/Accountability.
- Distributes service fairly. Therapist too busy with his case load to devote
to the client of another therapist
• Ethical service/practice/care. May or may not prevent harm
2. Therapist does nothing now, and monitors the situation
• Non-malfeasance. Monitors situation to minimize potential harm. May be a
one-time occurrence, so monitoring seems appropriate
• Trusting and respectful practice environment.
• Beneficence. May not need to intervene now. Monitor for potential
intervention should situation deteriorate
3. Therapist reads the current literature and holds judgment until more
knowledgeable about possible treatment options
• Beneficence. Client benefits from increased knowledge, best practice, etc.
learned from literature. Therapist charged with doing no harm, but requires
learning WHAT is harmful.
• Competent care. Consistent with standard of care within profession.
• Trusting and respectful practice environment. Therapist needs to be
confident that treating therapist is doing something harmful, before makes
comment to the contrary
4. Therapist re-approaches other current therapist, team members,
Supervisor, as indicated and discusses the issue again
• Non-malfeasance. Discussion/steps to minimize harm
• Beneficence. Client benefits if team negotiates new treatment as deems
current therapist’s treatment harmful.
• Fidelity. Consistent with professional obligations
• Accountability. Communicate risks involved in truthful, open manner in an
attempt to avert probable harm to client
5. Therapist discusses with the team, current therapist’s Supervisor, College
•
Justice. Identifies vulnerable client that may be affected by actions of
therapist and mediate/correct.
•
Beneficence. Prevents prolonged infliction of psychological discomfort which
may lead to incapacitation or worse
•
Fidelity. If therapist’s actions inconsistent with standards of care, best
practice within profession, inconsistent with informed consent, and satisfies
both principles of malfeasance and beneficence this step required.
•
Accountability. Is this a situation that relates to whistle blowing?
•
Non-malfeasance. Refrain from doing long term damage by having
Supervisor/College initiate remedial measures as needed
Use ethically informed sources
Consider legal obligations (e.g. issues of litigation if client is harmed)
4. Propose and Test Possible Resolutions, considering the following questions:
4.1
What would be the best consequence overall?
4.2
Which factors would have to change for you to change your opinion?
4.3
Consider the impact on the ethical performance of others.
4.4
Would a good person do this?
4.5
What if everyone in this circumstance did this?
4.6
Will this maintain trust relationships with others?
4.7
Does it still seem right?
Code of Ethics, October 2010
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PART III Other Resources
Alberta Provincial Health Ethics Network http://www.phen.ab.ca/
Canadian Association of Occupational Therapists Professional Practice and Ethics Resources
http://www.caot.ca/default.asp?pageid=34
College of Occupational Therapists of Ontario decision making and practice resources
http://www.coto.org/pdf/Concsious_Decision-Making.pdf
http://www.coto.org/pdf/Principled_OT_pratice.pdf
Health Canada Ethics Resources http://www.hc-sc.gc.ca/sr-sr/advice-avis/reb-cer/ethires/index-eng.php
Joint Centre for Bioethics at University of Toronto http://www.jointcentreforbioethics.ca/
Manitoba Provincial Health Ethics Network http://www.mb-phen.ca/
University of British Columbia’s Ethics website http://www.ethics.ubc.ca/
University of Manitoba Office of Research Ethics http://umanitoba.ca/research/orec/index.html
World Health Organization Ethics and Health http://www.who.int/ethics/en/
Code of Ethics, October 2010
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GLOSSARY
The glossary does not necessarily provide formal definition of terms and is intended to provide
Occupational Therapists with a common language for their reflections and discussions about
OT ethical practice.
Accountability: The state of being answerable to someone for something one has done.
(Burhhardt et al, 2002)
Advance Directives: Clients’ written wishes about how and what decisions should be made if
they become incapable of making decisions for themselves. Also called, "living wills" or
"personal directives".
Advocate: Actively supporting a right or good cause; supporting others in speaking for
themselves or speaking on behalf of those who are unable to speak for themselves.
Assent: The agreement by a child or incapacitated person to a therapeutic procedure; or
involvement in research following the receipt of good information. Assent from the individual
concerned/affected is encouraged in addition to informed consent from the guardian or parent.
Autonomy: Self-determination; an individual’s right to make choices about one’s own course of
action. (AARN, 1996)
Beneficence: Action that is done for the benefit of others. The obligation to do good, not harm,
to others. Beneficent actions can be taken to help prevent or remove harm or to simply improve
the situation of others. (Pantilat, 2008)
Care: (caring) Generic provision of OT services in a variety of environments and settings.
Client: Individuals, families, groups, populations, communities receiving or accessing OT
services.
Collaborate: Building consensus and working together on common goals, processes, and
outcomes. (RNAO, 2006)
Competence: The integrated knowledge, skills, judgment, and attributes (attitudes, values,
beliefs, etc) required of an OT to practice safely and ethically in a designated role and setting.
Confidentiality: Ethical obligation to keep clients’ private and personal information secret or
private (Fry et al, 2002); the duty to preserve a person’s privacy.
Conflict of Interest: Occurs when personal or private interests interfere with the interest of
clients’ or OTs’ professional responsibilities. (CRNBC, 2006)
Dignity: The right of an individual to be treated with respect as a person in his own right (WHO,
2001). The quality of worth and honor intrinsic to every person. This establishes basic
entitlements that are the right of every human. Dignity is the threshold level of status required
to meet basic human needs. It establishes the basic boundaries of humanity.
Ethical: Formal process for making logical and consistent decisions based upon ethical values.
Ethics: Moral practices, beliefs, and standards of individuals and/or groups. (Fry et al, 2002)
Fair: Equalizing a person’s opportunities to participate in and enjoy life, given his
circumstances and capacities (Caplan et al, 1999) and society’s equitable distribution of
resources; equitable treatment. The attitude of being just to all. (WHO, 2009)
Family: In care giving, people identified by the person receiving care or in need of care
providing familial support, whether or not there is a biological relationship. (CNA, 1994)
Note: In matters of legal decision-making, provincial legislation includes an obligation to
recognize family members in priority, according to their biological relationship
Fidelity: Refers to the concept of keeping a commitment. Fidelity is the concept of
accountability. (Silva & Ludwick, 1999)
Health: A state of complete physical, social and mental well-being, and not merely the absence
of disease or infirmity. Health is a resource for everyday life, not the object of living. It is a
positive concept emphasizing social and personal resources as well as physical capabilities.
(WHO, 2001)
Health Care Team: Regulated and unregulated health care providers from different disciplines
working in collaboration to provide care for individuals, families, groups, populations, and
communities.
(Regulated) Health Professions Act: Governing legislation that delegates the authority of the
COTM to regulate the practice of occupational therapists in Manitoba.
Informed Consent: Client’s agreement to authorize occupational therapy services on a full
disclosure of the facts required to make an informed decision (about care, treatment, and
involvement in research). The obligation to obtain informed consent is a legal and professional
duty. (COTBC, 2006) An ethical principle of respect for an individual’s right to sufficient
information
Informed Decision-making: (See informed consent above) In the COE, primarily used to
emphasize the choices involved.
Justice: Is closely tied to the legal system and refers to the obligation to be fair to all. (Silva &
Ludwick, 1999)
Occupational Therapist (OT): Refers to a registered occupational therapist practicing in
Manitoba.
Non-malfeasance: Means to “do no harm.” It is the concept of preventing intentional harm or
evil and may include protecting clients by reporting unsafe, illegal, or unethical practices by any
person. The pertinent ethical issue is whether the benefits outweigh the burdens. (Silva &
Ludwick, 1999)
Occupational Therapy Services: May include direct care, research, education, consultation,
care coordination, program development, administration, or a combination thereof. (COTBC,
2006)
Code of Ethics, October 2010
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Personal Information: Any recorded information, collected by an occupational therapist, that
would identify an individual is considered personal information in the context of OT practice.
(COTBC, 2006)
Privacy: Physical – right or interest in controlling/limiting the access of others to oneself.
Informational – right of an individual to determine how, when, with whom, and for what
purposes any of his personal information will be shared.
Professional Boundary: Limit of what constitutes appropriate professional conduct. Boundaries
make relationships professional and safe for the clients. (COTBC, 2006)
Public Good: The good of society or community; often termed the “common good”.
Quality Practice Environments: Have the organizational and human support allocations
necessary for safe, competent, ethical care. (CNA, 2001)
Values: Standards or qualities that are esteemed, desired, considered important or have worth
or merit. (Fry et al, 2002)
Well-Being: Person’s state of being well, level of contentment, and ability to make the most of
his abilities.
Whistle-blowing: Speaking out about unsafe or questionable practices affecting people
receiving care or affecting working conditions. This should be used only after unsuccessfully
accessing appropriate organizational channels and has a sound moral justification. (Burkhardt
et al, 2002)
Code of Ethics, October 2010
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BIBLIOGRAPHY
Burkhardt, M. et al (2002). Ethics and issues in contemporary nursing (2nd ed).
Toronto: Delmar.
Burkhardt, M. et al. (1998). Ethics and issues in contemporary nursing. Toronto:
Delmar.
Canadian Nurses Association. (2006). Social justice: a means to an end, an end
in itself. Ottawa: Author
Canadian Nurses Association. (2003). Ethical distress in healthcare environments. Ethics in
practice for registered nurses, 1-8. Ottawa: Author.
Canadian Nurses Association. (2001). Quality professional practice
environments for registered nurses. [Position Statement]. Ottawa: Author.
Canadian Nurses Association. (1994). Joint statement of advance directives.
[Position Statement]. Ottawa: Author
Caplan, R. et al (1999). Benchmarks of fairness: A moral framework for assessing
equity. International Journal of Health Services, 29(4), 853-869.
Center for the Study of Ethics in the Professions at IIT. (2009). Codes of Ethics. Chicago:
Illinois Institute of Technology.
College of Nurses of Ontario. (2005). Practice standard: ethics, 1-22. Toronto: Author.
College of Occupational Therapists of Ontario. (2002). Conscious decision making in
occupational therapy practice. Toronto: Author.
College of Psychologists of British Columbia. (2009). Code of conduct. Vancouver: CPBC.
College of Registered Nurses of British Columbia. (2006). Practice standard: Conflict of
interest. Vancouver: Author.
College of Occupational Therapists of British Columbia (COTBC). (2006). Code of
ethics for Occupational Therapists. Author: Victoria, BC.
Fry, S. et al (2002). Ethics in nursing practice: A guide to ethical decisionmaking (2nd. Ed). International Council of Nurses. Oxford: Blackwell
McDonald, M. (2003). Ethics and conflict of interest. Retrieved from
http://www.ethics.ubc.ca/people/mcdonald/conflict.htm>mcdonald@ethics.ubc.ca
Pantilat. S. (2008). Ethics facts. University of California: San Francisco
Registered Nurses Association of Ontario. (2006). Collaborative practice among nursing teams.
Healthy work environments best practice guidelines. Toronto: Author.
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Seedhouse, D. (1991). Against medical ethics: a philosopher's view. Medical Education.
25(4):280–282.
Silva, M., & Ludwick, R. (1999, July). Interstate Nursing Practice and Regulation: ethical issues
for the 21st century. Online Journal of Issues in Nursing 4(2). Retrieved 10 May 2010 at
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ableofContents/Volume41999/No2Sep1999/InterstateNursingPracticeandRegulation.as
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World Health Organization (WHO) (2001). WHO: Evidence for health policy (Glossary).
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