Ethics North Carolina Occupational Therapy
Ethics – North Carolina Occupational Therapy
Goals & Objectives
Course Description
“Ethics – North Carolina Occupational Therapy” is an online continuing education
program for North Carolina licensed occupational therapists and occupational therapist
assistants. The course focuses on defining moral, ethical, and legal behavior of North
Carolina licensed occupational therapy professionals. The information presented
includes discussions on the theoretical basis for ethical decision-making, the AOTA
Code of Ethics and hypothetical case studies.
Course Rationale
This course was developed to educate, promote and facilitate ethical and legal behavior
by North Carolina licensed occupational therapists and occupational therapist assistants,
and is intended to meet the Ethics requirement as mandated by 21 NCAC, Chapter 38.
Course Goals & Objectives
At the end of this course, the participants will be able to:
1. Define the meaning of ethics and recognize the various theories that promote
ethical behavior.
2. Apply a systematic approach to ethical decision-making.
3. Recognize the principles of ethical conduct as defined by the established and
accepted Occupational Therapy Code of Ethics
4. Assess their current professional practices to ensure ethical conduct
5. Apply the concepts of ethical practice to clinical situations to determine
appropriate professional ethical behavior.
Course Provider – Innovative Educational Services
Course Instructor - Michael Niss, DPT
Target Audience - Occupational therapists and occupational therapist assistants
Course Educational Level - This course is applicable for introductory learners.
Course Prerequisites - None
Method of Instruction/Availability – Online text-based course available continuously.
Criteria for Issuance of CE Credits - A score of 70% or greater on the course post-test.
Continuing Education Credits - One (1) hour of continuing education credit
AOTA - .1 AOTA CEU, Category 3: Contemporary Issues & Trends
NBCOT – 1.25 PDUs
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Ethics North Carolina Occupational Therapy
Ethics – North Carolina Occupational Therapy
Course Outline
page
Goals and Objectives
Outline
Ethics Overview
Why Ethics are Important
Ethics vs. Morals
Ethical Questions
Ethics Theories
Utilitarianism
Social Contract Theory
Deontological Theory
Ethical Intuitionism
Ethical Egoism
Natural Law Theory
Virtue Ethics
How to Make Right Decisions
Occupational Therapy Code of Ethics
Principle 1 - Beneficence
Principle 2 - Nonmalficence
Principle 3 - Autonomy & Confidentiality
Principle 4 – Social Justice
Principle 5 – Procedural Justice
Principle 6 - Veracity
Principle 7 - Fidelity
Case Studies
Case Study #1 – Confidentiality
Case Study #2 – Informed Consent
Case Study #3 – Medical Necessity
Case Study #4 – Conflict of Interest
Case Study #5 – Relationships / Referral Sources
References
Post-Test
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Ethics North Carolina Occupational Therapy
Ethics Overview
The word “ethics” is derived from the Greek word ethos (character), and from the
Latin word mores (customs). Together, they combine to define how individuals
choose to interact with one another. In philosophy, ethics defines what is good
for the individual and for society and establishes the nature of duties that people
owe themselves and one another. Ethics is also a field of human inquiry that
examines the bases of human goals and the foundations of “right” and “wrong”
human actions that further or hinder these goals.
Why Ethics are Important
Ethics are important on several levels.
 People feel better about themselves and their profession when they work
in an ethical manner.
 Professions recognize that their credibility rests not only on technical
competence, but also on public trust.
 At the organizational level, ethics is good business. Several studies have
shown that over the long run ethical businesses perform better than
unethical businesses.
Ethics vs. Morals
Although the terms “ethics” and “morals” are often used interchangeably, they
are not identical. Morals usually refer to practices; ethics refers to the rationale
that may or may not support such practices. Morals refer to actions, ethics to the
reasoning behind such actions. Ethics is an examined and carefully considered
structure that includes both practice and theory. Morals include ethically
examined practices, but may also include practices that have not been ethically
analyzed, such as social customs, emotional responses to breaches of socially
accepted practices and social prejudices. Ethics is usually at a higher intellectual
level, more universal, and more dispassionate than morals. Some philosophers,
however, use the term “morals” to describe a publicly agreed-upon set of rules
for responding to ethical problems.
Ethical Questions
Ethical questions involve 1) responsibilities to the welfare of others or to the
human community; or 2) conflicts among loyalties to different persons or groups,
among responsibilities associated with one’s role (e.g. as consumer or provider),
or among principles. Ethical questions include (or imply) the words “ought” or
“should”.
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Ethics North Carolina Occupational Therapy
Ethics Theories
Throughout history, mankind has attempted to determine the philosophical basis
from which to define right and wrong. Here are some of the more commonly
accepted theories that have been proposed.
Utilitarianism
This philosophical theory develops from the work of Jeremy Bentham and John
Stewart Mill. Simply put, utilitarianism is the theory that right and wrong is
determined by the consequences. The basic tool of measurement is pleasure
(Bentham) or happiness (Mill). A morally correct rule is one that provides the
greatest good to the greatest number of people.
Social Contract Theory
Social contract theory is attributed to Thomas Hobbes, John Locke, and from the
twentieth century, John Rawls. Social contract theories believe that the moral
code is created by the people who form societies. These people come together
to create society for the purpose of protection and gaining other benefits of social
cooperation. These persons agree to regulate and restrict their conduct to
achieve this end.
Deontological or Duty Theory
Under this theory you determine if an act or rule is morally right or wrong if it
meets a moral standard. The morally important thing is not consequences but the
way choosers think while they make choices. One famous philosopher who
developed such a theory was Immanuel Kant.
Ethical Intuitionism
Under this view an act or rule is determined to be right or wrong by appeal to the
common intuition of a person. This intuition is sometimes referred to as your
conscience. Anyone with a normal conscience will know that it is wrong to kill an
innocent person.
Ethical Egoism
This view is based on the theory that each person should do whatever promotes
their own best interests; this becomes the basis for moral choices.
Natural Law Theory
This is a moral theory which claims that just as there are physical laws of nature,
there are moral laws of nature that are discoverable. This theory is largely
associated with Thomas Aquinas, who advocated that each thing has its own
inherent nature, i.e. characteristic ways of behavior that belong to all members of
its species and are appropriate to it. This nature determines what is good or bad
for that thing. In the case of human beings, the moral laws of nature stem from
our unique capacity for reason. When we act against our own reason, we are
violating our nature, and therefore acting immorally.
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Ethics North Carolina Occupational Therapy
Virtue Ethics
This ethics theory proposes that ethical behavior is a result of developed or
inherent character traits or virtues. A person will do what is morally right because
they are a virtuous person. Aristotle was a famous exponent of this view. Aristotle
felt that virtue ethics was the way to attain true happiness. These are some of the
commonly accepted virtues.
Autonomy: the duty to maximize the individual’s right to make his or her own
decisions.
Beneficence: the duty to do good.
Confidentiality: the duty to respect privacy of information.
Finality: the duty to take action that may override the demands of law, religion,
and social customs.
Justice: the duty to treat all fairly, distributing the risks and benefits equally.
Nonmaleficence: the duty to cause no harm.
Understanding/Tolerance: the duty to understand and to accept other
viewpoints if reason dictates.
Respect for persons: the duty to honor others, their rights, and their
responsibilities.
Universality: the duty to take actions that hold for everyone, regardless of time,
place, or people involved.
Veracity: the duty to tell the truth.
How to Make Right Decisions
The foundation for making proper ethical decisions is rooted in an individual’s
ability to answer several fundamental questions concerning their actions.
Are my actions legal?
Weighing the legality of one’s actions is a prudent way to begin the decisionmaking process. The laws of a geopolitical region are a written code of that
region’s accepted rules of conduct. This code of conduct usually defines clearly
which actions are considered acceptable and which actions are unacceptable.
However, a legitimate argument can be made that sometimes what is legal is not
always moral, and that sometimes what is moral is not always legal. This idea is
easily demonstrated by the following situation.
It is illegal for a pedestrian to cross a busy street anywhere other than at the
designated crosswalk (jaywalking). A man is walking down a street and sees
someone fall and injure themselves on the other side of the street. He
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Ethics North Carolina Occupational Therapy
immediately crosses the street outside of the crosswalk to attend to the injured
person. Are his actions legal? Are they moral? What if by stepping into the
street he causes a car to swerve and to strike another vehicle?
Admittedly, with the exception of law enforcement officers and attorneys, most
people do not know all of the specific laws that govern their lives. However, it is
assumed that most people are familiar with the fundamental virtues from which
these laws are based, and that they will live their lives in accordance with these
virtues.
Are my actions ethical?
Professional ethical behavior as it is defined in this context relates to actions that
are consistent with the normative standards established or practiced by others in
the same profession. For occupational therapists and occupational therapist
assistants, these ethical standards are documented in the AOTA’s Code of
Ethics. All OTs and OTAs, even those who are not members of the AOTA, are
bound to these guidelines. This is because The AOTA Code of Ethics is the
accepted and de facto standard of practice throughout the profession.
Are my actions fair?
I think most people would agree that the concept of fairness is often highly
subjective. However, for these purposes, we will define fairness as meaning
deserved, equitable and unbiased. Fairness requires the decision-maker to have
a complete understanding of benefits and liabilities to all parties affected by the
decision. Decisions that result in capricious harm or arbitrary benefit cannot be
considered fair. The goal of every decision should be an outcome of relative
equity that reflects insightful thought and soundness of intent.
Would my actions be the same if they were transparent to others?
This question presents as a true reflection of the other three. Legal, ethical, and
fair are defined quite differently by most people when judged in the comfort of
anonymity versus when it is examined before the forum of public opinion. Most
often it is the incorrect assumption that “no one will ever find out about this” that
leads people to commit acts of impropriety. How would your decisions change, if
prior to taking any actions, you assumed just the opposite; “other people will
definitely know what I have done”. One sure sign of a poor decision is debating
the possible exposure of an action instead of examining the appropriateness of it.
AOTA Code of Ethics
The following is an abridged version of the most current AOTA Code of Ethics. It was originally published in 2010 in the American
Journal of Occupational Therapy, 64 (November/December Supplement. To read the AOTA Code of Ethics in its entirety, please go
to: http://www.aota.org/consumers/ethics/39880.aspx
The profession of occupational therapy remains grounded in seven core concepts, as
identified in the Core Values and Attitudes of Occupational Therapy Practice (AOTA,
1993): altruism, equality, freedom, justice, dignity, truth, and prudence. Altruism is the
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Ethics North Carolina Occupational Therapy
individual’s ability to place the needs of others before their own. Equality refers to the
desire to promote fairness in interactions with others. The concept of freedom and
personal choice is paramount in a profession in which the desires of the client must
guide our interventions. Occupational therapy practitioners, educators, and researchers
relate in a fair and impartial manner to individuals with whom they interact and respect
and adhere to the applicable laws and standards regarding their area of practice, be it
direct care, education, or research (justice). Inherent in the practice of occupational
therapy is the promotion and preservation of the individuality and dignity of the client, by
assisting him or her to engage in occupations that are meaningful to him or her
regardless of level of disability. In all situations, occupational therapists, occupational
therapy assistants, and students must provide accurate information, both in oral and
written form (truth). Occupational therapy personnel use their clinical and ethical
reasoning skills, sound judgment, and reflection to make decisions to direct them in their
area(s) of practice (prudence). These seven core values provide a foundation by which
occupational therapy personnel guide their interactions with others.
The Occupational Therapy Code of Ethics and Ethics Standards (2010) is a guide to
professional conduct when ethical issues arise. Ethical decision making is a process that
includes awareness of how the outcome will impact occupational therapy clients in all
spheres. Applications of Code and Ethics Standards Principles are considered situationspecific, and where a conflict exists, occupational therapy personnel will pursue
responsible efforts for resolution. These Principles apply to occupational therapy
personnel engaged in any professional role, including elected and volunteer leadership
positions.
The specific purposes of the Occupational Therapy Code of Ethics and Ethics Standards
(2010) are to
1. Identify and describe the principles supported by the occupational therapy profession.
2. Educate the general public and members regarding established principles to which
occupational therapy personnel are accountable.
3. Socialize occupational therapy personnel to expected standards of conduct.
4. Assist occupational therapy personnel in recognition and resolution of ethical
dilemmas.
Principle 1 - Occupational therapy personnel shall demonstrate a concern for the
well-being and safety of the recipients of their services. (Beneficence)
Beneficence includes all forms of action intended to benefit other persons. Forms of
beneficence typically include altruism, love, and humanity. Beneficence requires taking
action by helping others, in other words, by promoting good, by preventing harm, and by
removing harm.
Occupational therapy personnel shall
A. Respond to requests for occupational therapy services (e.g., a referral) in a timely
manner as determined by law, regulation, or policy.
B. Provide appropriate evaluation and a plan of intervention for all recipients of
occupational therapy services specific to their needs.
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C. Reevaluate and reassess recipients of service in a timely manner to determine if
goals are being achieved and whether intervention plans should be revised.
D. Avoid the inappropriate use of outdated or obsolete tests/assessments or data
obtained from such tests in making intervention decisions or recommendations.
E. Provide occupational therapy services that are within each practitioner’s level of
competence and scope of practice (e.g., qualifications, experience, the law).
F. Use, to the extent possible, evaluation, planning, intervention techniques, and
therapeutic equipment that are evidence-based and within the recognized scope of
occupational therapy practice.
G. Take responsible steps (e.g., continuing education, research, supervision, training)
and use careful judgment to ensure their own competence and weigh potential for
client harm when generally recognized standards do not exist in emerging
technology or areas of practice.
H. Terminate occupational therapy services in collaboration with the service recipient or
responsible party when the needs and goals of the recipient have been met or when
services no longer produce a measurable change or outcome.
I. Refer to other health care specialists solely on the basis of the needs of the client.
J. Provide occupational therapy education, continuing education, instruction, and
training that are within the instructor’s subject area of expertise and level of
competence.
K. Provide students and employees with information about the Code and Ethics
Standards, opportunities to discuss ethical conflicts, and procedures for reporting
unresolved ethical conflicts.
L. Ensure that occupational therapy research is conducted in accordance with currently
accepted ethical guidelines and standards for the protection of research participants
and the dissemination of results.
M. Report to appropriate authorities any acts in practice, education, and research that
appear unethical or illegal.
N. Take responsibility for promoting and practicing occupational therapy on the basis of
current knowledge and research and for further developing the profession’s body of
knowledge.
Principle 2 - Occupational therapy personnel shall intentionally refrain from
actions that cause harm. (Nonmaleficence)
The principle of nonmaleficence is grounded in the practitioner’s responsibility to refrain
from causing harm, inflicting injury, or wronging others. Nonmaleficence also includes an
obligation to not impose risks of harm even if the potential risk is without malicious or
harmful intent.
Occupational therapy personnel shall
A. Avoid inflicting harm or injury to recipients of occupational therapy services, students,
research participants, or employees.
B. Make every effort to ensure continuity of services or options for transition to
appropriate services to avoid abandoning the service recipient if the current provider
is unavailable due to medical or other absence or loss of employment.
C. Avoid relationships that exploit the recipient of services, students, research
participants, or employees physically, emotionally, psychologically, financially,
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Ethics North Carolina Occupational Therapy
D.
E.
F.
G.
H.
I.
J.
K.
L.
socially, or in any other manner that conflicts or interferes with professional judgment
and objectivity.
Avoid engaging in any sexual relationship or activity, whether consensual or
nonconsensual, with any recipient of service, including family or significant other,
student, research participant, or employee, while a relationship exists as an
occupational therapy practitioner, educator, researcher, supervisor, or employer.
Recognize and take appropriate action to remedy personal problems and limitations
that might cause harm to recipients of service, colleagues, students, research
participants, or others.
Avoid any undue influences, such as alcohol or drugs, which may compromise the
provision of occupational therapy services, education, or research.
Avoid situations in which a practitioner, educator, researcher, or employer is unable
to maintain clear professional boundaries or objectivity to ensure the safety and wellbeing of recipients of service, students, research participants, and employees.
Maintain awareness of and adherence to the Code and Ethics Standards when
participating in volunteer roles.
Avoid compromising client rights or well-being based on arbitrary administrative
directives by exercising professional judgment and critical analysis.
Avoid exploiting any relationship established as an occupational therapist or
occupational therapy assistant to further one’s own physical, emotional, financial,
political, or business interests at the expense of the best interests of recipients of
services, students, research participants, employees, or colleagues.
Avoid participating in bartering for services because of the potential for exploitation
and conflict of interest unless there are clearly no contraindications or bartering is a
culturally appropriate custom.
Determine the proportion of risk to benefit for participants in research prior to
implementing a study.
Principle 3 - Occupational therapy personnel shall respect the right of the
individual to self-determination. (Autonomy and confidentiality)
The principle of autonomy and confidentiality expresses the concept that practitioners
have a duty to treat the client according to the client’s desires, within the bounds of
accepted standards of care and to protect the client’s confidential information. Often
autonomy is referred to as the self-determination principle.
Occupational therapy personnel shall
A. Establish a collaborative relationship with recipients of service including families,
significant others, and caregivers in setting goals and priorities throughout the
intervention process. This includes full disclosure of the benefits, risks, and potential
outcomes of any intervention; the personnel who will be providing the intervention(s);
and/or any reasonable alternatives to the proposed intervention.
B. Obtain consent before administering any occupational therapy service, including
evaluation, and ensure that recipients of service (or their legal representatives) are
kept informed of the progress in meeting goals specified in the plan of
intervention/care. If the service recipient cannot give consent, the practitioner must
be sure that consent has been obtained from the person who is legally responsible
for that recipient.
C. Respect the recipient of service’s right to refuse occupational therapy services
temporarily or permanently without negative consequences.
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D. Provide students with access to accurate information regarding educational
requirements and academic policies and procedures relative to the occupational
therapy program/educational institution.
E. Obtain informed consent from participants involved in research activities, and ensure
that they understand the benefits, risks, and potential outcomes as a result of their
participation as research subjects.
F. Respect research participant’s right to withdraw from a research study without
consequences.
G. Ensure that confidentiality and the right to privacy are respected and maintained
regarding all information obtained about recipients of service, students, research
participants, colleagues, or employees. The only exceptions are when a practitioner
or staff member believes that an individual is in serious foreseeable or imminent
harm. Laws and regulations may require disclosure to appropriate authorities without
consent.
H. Maintain the confidentiality of all verbal, written, electronic, augmentative, and nonverbal communications, including compliance with HIPAA regulations.
I. Take appropriate steps to facilitate meaningful communication and comprehension in
cases in which the recipient of service, student, or research participant has limited
ability to communicate (e.g., aphasia or differences in language, literacy, culture).
J. Make every effort to facilitate open and collaborative dialogue with clients and/or
responsible parties to facilitate comprehension of services and their potential
risks/benefits.
Principle 4 - Occupational therapy personnel shall provide services in a fair and
equitable manner. (Social justice)
Social justice, also called distributive justice, refers to the fair, equitable, and appropriate
distribution of resources.
Occupational therapy personnel shall
A. Uphold the profession’s altruistic responsibilities to help ensure the common good.
B. Take responsibility for educating the public and society about the value of
occupational therapy services in promoting health and wellness and reducing the
impact of disease and disability.
C. Make every effort to promote activities that benefit the health status of the
community.
D. Advocate for just and fair treatment for all patients, clients, employees, and
colleagues, and encourage employers and colleagues to abide by the highest
standards of social justice and the ethical standards set forth by the occupational
therapy profession.
E. Make efforts to advocate for recipients of occupational therapy services to obtain
needed services through available means.
F. Provide services that reflect an understanding of how occupational therapy service
delivery can be affected by factors such as economic status, age, ethnicity, race,
geography, disability, marital status, sexual orientation, gender, gender identity,
religion, culture, and political affiliation.
G. Consider offering pro bono (“for the good”) or reduced-fee occupational therapy
services for selected individuals when consistent with guidelines of the employer,
third-party payer, and/or government agency.
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Principle 5 - Occupational therapy personnel shall comply with institutional rules,
local, state, federal, and international laws and AOTA documents applicable to the
profession of occupational therapy. (Procedural justice)
The principle of procedural justice is based on the concept that procedures and
processes are organized in a fair manner and that policies, regulations, and laws are
followed.
Occupational therapy personnel shall
A. Be familiar with and apply the Code and Ethics Standards to the work setting, and
share them with employers, other employees, colleagues, students, and researchers.
B. Be familiar with and seek to understand and abide by institutional rules, and when
those rules conflict with ethical practice, take steps to resolve the conflict.
C. Be familiar with revisions in those laws and AOTA policies that apply to the
profession of occupational therapy and inform employers, employees, colleagues,
students, and researchers of those changes.
D. Be familiar with established policies and procedures for handling concerns about the
Code and Ethics Standards, including familiarity with national, state, local, district,
and territorial procedures for handling ethics complaints as well as policies and
procedures created by AOTA and certification, licensing, and regulatory agencies.
E. Hold appropriate national, state, or other requisite credentials for the occupational
therapy services they provide.
F. Take responsibility for maintaining high standards and continuing competence in
practice, education, and research by participating in professional development and
educational activities to improve and update knowledge and skills.
G. Ensure that all duties assumed by or assigned to other occupational therapy
personnel match credentials, qualifications, experience, and scope of practice.
H. Provide appropriate supervision to individuals for whom they have supervisory
responsibility in accordance with AOTA official documents and local, state, and
federal or national laws, rules, regulations, policies, procedures, standards, and
guidelines.
I. Obtain all necessary approvals prior to initiating research activities.
J. Report all gifts and remuneration from individuals, agencies, or companies in
accordance with employer policies as well as state and federal guidelines.
K. Use funds for intended purposes, and avoid misappropriation of funds.
L. Take reasonable steps to ensure that employers are aware of occupational therapy’s
ethical obligations as set forth in this Code and Ethics Standards and of the
implications of those obligations for occupational therapy practice, education, and
research.
M. Actively work with employers to prevent discrimination and unfair labor practices, and
advocate for employees with disabilities to ensure the provision of reasonable
accommodations.
N. Actively participate with employers in the formulation of policies and procedures to
ensure legal, regulatory, and ethical compliance.
O. Collect fees legally. Fees shall be fair, reasonable, and commensurate with services
delivered. Fee schedules must be available and equitable regardless of actual payer
reimbursements/contracts.
P. Maintain the ethical principles and standards of the profession when participating in a
business arrangement as owner, stockholder, partner, or employee, and refrain from
working for or doing business with organizations that engage in illegal or unethical
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business practices (e.g., fraudulent billing, providing occupational therapy services
beyond the scope of occupational therapy practice).
Principle 6 - Occupational therapy personnel shall provide comprehensive,
accurate, and objective information when representing the profession. (Veracity)
Veracity is based on the virtues of truthfulness, candor, and honesty. The principle of
veracity in health care refers to comprehensive, accurate, and objective transmission of
information and includes fostering the client’s understanding of such information
(Beauchamp & Childress, 2009)
Occupational therapy personnel shall
A. Represent the credentials, qualifications, education, experience, training, roles,
duties, competence, views, contributions, and findings accurately in all forms of
communication about recipients of service, students, employees, research
participants, and colleagues.
B. Refrain from using or participating in the use of any form of communication that
contains false, fraudulent, deceptive, misleading, or unfair statements or claims.
C. Record and report in an accurate and timely manner, and in accordance with
applicable regulations, all information related to professional activities.
D. Ensure that documentation for reimbursement purposes is done in accordance with
applicable laws, guidelines, and regulations.
E. Accept responsibility for any action that reduces the public’s trust in occupational
therapy.
F. Ensure that all marketing and advertising are truthful, accurate, and carefully
presented to avoid misleading recipients of service, students, research participants,
or the public.
G. Describe the type and duration of occupational therapy services accurately in
professional contracts, including the duties and responsibilities of all involved parties.
H. Be honest, fair, accurate, respectful, and timely in gathering and reporting fact-based
information regarding employee job performance and student performance.
I. Give credit and recognition when using the work of others in written, oral, or
electronic media.
J. Not plagiarize the work of others.
Principle 7 - Occupational therapy personnel shall treat colleagues and other
professionals with respect, fairness, discretion, and integrity. (Fidelity)
In the health professions, fidelity refers to maintaining good-faith relationships between
various service providers and recipients.
Occupational therapy personnel shall
A. Respect the traditions, practices, competencies, and responsibilities of their own and
other professions, as well as those of the institutions and agencies that constitute the
working environment.
B. Preserve, respect, and safeguard private information about employees, colleagues,
and students unless otherwise mandated by national, state, or local laws or
permission to disclose is given by the individual.
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C. Take adequate measures to discourage, prevent, expose, and correct any breaches
of the Code and Ethics Standards and report any breaches of the former to the
appropriate authorities.
D. Attempt to resolve perceived institutional violations of the Code and Ethics Standards
by utilizing internal resources first.
E. Avoid conflicts of interest or conflicts of commitment in employment, volunteer roles,
or research.
F. Avoid using one’s position (employee or volunteer) or knowledge gained from that
position in such a manner that gives rise to real or perceived conflict of interest
among the person, the employer, other Association members, and/or other
organizations.
G. Use conflict resolution and/or alternative dispute resolution resources to resolve
organizational and interpersonal conflicts.
H. Be diligent stewards of human, financial, and material resources of their employers,
and refrain from exploiting these resources for personal gain.
Ethics Case Studies
Case Study #1 - Confidentiality
John Jones OTR, Sue Brown (therapy receptionist), and Mary Smith (Director of
Managed Care Contracting), are in a private OT office discussing the fact that
they are treating Jessica McDonald, an award winning actress. John says, “I
can’t believe that I’m actually treating Jessica McDonald.” Mary asks, “How bad
do you think her injury is?” John replies, “I saw her MRI report, it looks likes she
is going to need surgery to repair her wrist.”
Is this a breach in confidentiality?
The information contained in each patient’s medical record must be safeguarded
against disclosure or exposure to nonproprietary individuals. The right to know
any medical information about another is always predicated on a sound
demonstration of need. Frequently, many individuals require access to
information contained in a patient’s medical record. Their right to access this
information is limited to only that information which is deemed necessary for
them perform their job in a safe, effective, and responsible manner.
The first questions we must ask are “What information is being disclosed and do
the three individuals engaged in the conversation have a need to know this
information?”
John’s first statement discloses the name of person receiving care, and his
second statement reveals private patient medical information. Certainly, as the
primary therapist, John would need to know the patient’s name and therapy
related diagnosis in order to provide care. Sue, the receptionist, may also need
this information to schedule appointments and perform other essential clerical
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Ethics North Carolina Occupational Therapy
tasks. Mary, whose job it is to contract with managed care organizations, most
likely has no compelling reason to know either the patient’s identity or any of her
medical information. Therefore, the disclosure to Mary of the patient’s identity
and medical information is a breach of patient confidentiality.
Case Study #2 – Informed Consent
Sam Smith OTR has just received orders to begin therapy with a 75-year-old
woman who is s/p right humerus ORIF. He goes to her hospital room to evaluate
her and begin therapy. She says she does not want therapy today because she
is in too much pain. Sam explains to her that the doctor has left orders for her to
begin using her right arm. The patient refuses. Sam leaves and returns the next
day to try again. Again, she declines treatment and he leaves.
Under the guidelines of informed consent, were the therapist’s actions adequate?
Informed consent is the process by which a fully informed patient can participate
in choices about their health care. It originates from the legal and ethical right the
patient has to direct what happens to their body and from the ethical duty of the
therapist to involve the patient in her health care.
The most important goal of informed consent is that the patient has an
opportunity to be an informed participant in their health care decisions. It is
generally accepted that complete informed consent includes a discussion of the
following elements:








the nature of the decision/procedure
reasonable alternatives to the proposed intervention
the relevant risks, benefits, and uncertainties related to each
alternative
the consequences on non-treatment
the goals of treatment
the prognosis for achieving the goals
assessment of patient understanding
the acceptance of the intervention by the patient
In order for the patient’s consent to be valid, they must be considered competent
to make the decision at hand and their consent must be voluntary. It is easy for
coercive situations to arise in medicine. Patients often feel powerless and
vulnerable. The therapist should make clear to the patient that they are
participating in a decision, not merely signing a form. With this understanding, the
informed consent process should be seen as an invitation for them to participate
in their health care decisions. The therapist is also generally obligated to provide
a recommendation and share their reasoning process with the patient.
Comprehension on the part of the patient is equally as important as the
information provided. Consequently, the discussion should be carried on in
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layperson’s terms and the patient’s understanding should be assessed along the
way.
The therapist’s actions in this case were not sufficient. None of the required
information was offered to the patient. The most important thing the therapist
failed to explain to the patient was the consequences of non-treatment. The
patient cannot make an informed decision regarding therapy without this
information. It could be argued that her decision to refuse therapy may have
changed had she known that one of the consequences of this decision could be
the development of secondary complications. (i.e. increased risk of morbidity or
mortality).
Case Study #3- Medical Necessity
Steve Smith is an occupational therapist who owns his own therapy clinic. He
recently signed a contract with an HMO to provide OT services. The contract
stipulates that Steve will be compensated on a case rate basis. (A fixed amount
of money based on the patient’s diagnosis) Steve has performed a thorough
cost analysis on this contract and has determined that the financial “breakeven”
point (revenue equals expenses) for patients with this diagnosis is 5 visits. He
informs his staff that all patients covered by this insurance must be discharged by
their fourth visit.
Is limiting care in this manner ethical?
Therapists are obligated to propose and provide care that is based on sound
medical rationale, patient medical necessity, and treatment efficacy and
efficiency. It is unethical to either alter or withhold care based on other
extraneous factors without the patient’s knowledge and consent.
In this instance, the decision to limit care is not ethical. The quantity of care is
not being determined by the medical necessity of the patient. A therapist must
be able to justify all of their professional decisions (such as the discharging of a
patient from clinical care) based on sound clinical rationale and practices.
Case Study #4 – Conflicts of Interest
Debi Brown OTR works in an acute care hospital. She is meeting with a vendor
whose company is introducing a new brace onto the market. He offers her 3 free
braces to “try out” on patients. The vendor states that if Debi continues to order
more braces, she will qualify to receive compensation from his company by
automatically becoming a member of its National Clinical Assessment Panel.
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Does this represent a conflict of interest?
Yes, there exists a conflict of interest in this situation. Debi has two primary
obligations to fulfill. The first is to her patient. It is her professional duty to
recommend to her patient a brace that, in her judgment, will benefit them the
most. The second obligation is to her employer, the hospital. As an employee of
the hospital it is her responsibility to manage expenses by thoroughly and
objectively seeking effective products that also demonstrate economic efficiency.
The conflict of interest occurs when she begins to accept compensation from the
vendor in direct or indirect response for her brace orders. Even if she truly
believes it is the best brace for her patient, and it is the most cost effective brace
the hospital could purchase, by accepting the money she has established at least
an apparent conflict of interest. Under this situation she is obligated to disclose
to all parties her financial interest in ordering the braces. This disclosure is
necessitated because the potential for personal gain would make others rightfully
question whether her objectivity was being influenced.
A conflict of interest is a situation in which a person has a private or personal
interest that influences the objective exercise of his or her professional duties. As
a professional you take on certain responsibilities and obligations to patients,
employers, and others. These obligations must take precedence over a
therapist’s private or personal interests.
In addition to avoiding all real instances of conflict of interest, therapists must
also avoid any apparent or potential conflicts as well. An apparent conflict of
interest is one in which a reasonable person would think that the professional’s
judgment is likely to be compromised, and a potential conflict of interest involves
a situation that may develop into an actual conflict of interest.
How do you determine if you are in a conflict of interest, whether actual,
apparent, or potential? The key is to determine whether the situation you are in
interferes or is likely to interfere with your independent judgment. A good test is
the ‘trust test’: Would relevant others (my employer, my patients, professional
colleagues, or the general public) trust my judgment if they knew I was in this
situation. Trust is at the ethical heart or core of this issue. Conflicts of interest
involve the abuse, actual or potential, of the trust people have placed in
professionals. This is why conflicts of interest not only injure particular patients
and employers, but they also damage the whole profession by reducing the trust
people generally have in therapists.
Case Study #5 – Relationships with Referral Sources
Larry White OTR owns a private practice. Business has been poor. He decides
to sublease half of his space to an orthopedic surgeon. Larry’s current lease is at
$20/sq ft. The doctor wants to pay $15/sq ft. They come to a compromise of
$17/sq ft. Larry also agrees that if the doctor is his top referral source after 3
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Ethics North Carolina Occupational Therapy
months, he’ll make him the Medical Director of the facility and pay him a salary of
$500/month.
Is this an ethical arrangement?
No, this agreement is not ethical. The most notable infraction involves offering to
designate (and compensate) the physician as the Medical Director contingent
upon the number of referrals he sends. It is perfectly acceptable (and required in
some instances) to have a physician as a Medical Director; however,
compensating the Medical Director based on their referral volume is unethical.
Another area of concern is the rent. At first glance, the rent amount of $17/sq ft
seems fair because it was a compromise between the two parties. However,
closer scrutiny reveals this to be unethical. The fair market value for rent has
been established as $20/sqft. (Larry’s current rental agreement with his landlord)
By discounting the doctor $3/sq ft on his rent, Larry is giving a referral source
something of value.
It is unethical for a physical therapist to offer anything of value to physicians or
any other referral source in direct response for the referral of patients or services.
This includes cash, rebates, gifts, discounts, reduced rent, services, equipment,
employees, or marketing. Many mistakenly believe that it is a normal acceptable
business practice to offer these things to referral sources. It is not. In most
states, the practice is not only unethical, but it is also illegal. Exchanges of
valued items or services between therapists and referral sources must never
have any relationship to the referral of patients. Goodwill gifts of nominal value
are acceptable provided that no correlation can be made between the magnitude
or frequency of the gift giving and referral patterns. All business agreements and
transactions should always be well documented and most importantly, reflect fair
market value.
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References
American Occupational Therapy Association.. Occupational therapy code of ethics and ethics standards. American Journal of
Occupational Therapy, 2010, 64(Suppl.)
Carpenter, C. Moral distress in physical therapy practice. Physiotherapy Theory & Practice. 26(2):69-78, 2010 Feb.
Delany CM. Edwards I. Jensen GM. Skinner E. Closing the gap between ethics knowledge and practice through active engagement:
an applied model of physical therapy ethics. Physical Therapy. 90(7):1068-78, 2010 Jul.
Drummond-Dye R. Matters of Integrity PT in Motion. Alexandria: May 2011. Vol. 3, Iss. 4; p. 37
Edwards I. Braunack-Mayer A. Jones M. Ethical reasoning as a clinical-reasoning strategy in physiotherapy. Physiotherapy. 2005
Dec; 91(4): 229-36. (45 ref)
Geddes, Lynne E. BScPT MRE. Salvatori, Penny MHSc(OT). Eva, Kevin W. PhD. Does moral judgement improve in occupational
therapy and physiotherapy students over the course of their pre-licensure training?. Learning in Health & Social Care. 8(2):92-102,
2009 June.
Kenny, B., Lincoln,M., Balandin.S. Experienced Speech-Language Pathologists' Responses to Ethical Dilemmas: An Integrated
Approach to Ethical Reasoning; American Journal of Speech - Language Pathology (Online). Rockville: May 1, 2010. Vol. 19, Iss. 2;
p. 121
Kenny, B., Lincoln,M., Balandin.S. A dynamic model of ethical reasoning in speech pathology; Journal of Medical Ethics. London:
Sep 2007. Vol. 33, Iss. 9; p. 508
Kirsch NR. Ethics in action. Improper conduct: case two. PT--Magazine of Physical Therapy. 2007 Jun; 15(6): 34-7
Kirsch NR. Ethics in action. Issues of professional integrity: analysis. PT--Magazine of Physical Therapy. 2006 Jul; 14(7): 38-42.
Kirsch NR.. Matter of Vitals Concern. PT in Motion. Alexandria: Jul 2010. Vol. 2, Iss. 6; p. 44
Kirsch.NR. Unsatisfying Satisfaction. PT in Motion. Alexandria: Sep 2010. Vol. 2, Iss. 8; p. 44
Kuczewski MG. Fiedler I. Ethical issues in physical medicine and rehabilitation: treatment decision making with adult patients.
Critical Reviews in Physical and Rehabilitation Medicine. 2005; 17(1): 31-52.
Marietta C. McGuire AL. Currents in contemporary ethics. Journal of Law, Medicine & Ethics. 37(2):369-74, 2009.
Nalette.E. Constrained Physical Therapist Practice: An Ethical Case Analysis of Recommending Discharge Placement From the Acute
Care Setting. Physical Therapy. Washington: Jun 2010. Vol. 90, Iss. 6; p. 939
Nalette E. Physical therapy: ethics and the geriatric patient. Journal of Geriatric Physical Therapy. 2001; 24(3): 3-7.
National Center for Ethics in Health Care. Informed Consent Dos & Don’t for Best Practice. In Focus, Aug 2006
National Center for Ethics in Health Care. "Teach Back": A Tool for Improving Provider-Patient Communication. In Focus, April
2006
National Center for Ethics in Health Care. When Patients Refuse Treatment. In Focus, Dec 2005
National Center for Ethics in Health Care. Gifts to Health Care Professionals from the Pharmaceutical Industry. October 2003
National Center for Ethics in Health Care. Ethical Boundaries in the Patient-Clinician Relationship. July 2003
Swisher LL. Moral reasoning among physical therapists: results of the Defining Issues Test. Physiotherapy Research International.
15(2):69-79, 2010 Jun.
Swisher LL, Hiller P. The Revised APTA Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical
Therapist Assistant: Theory, Purpose, Process, and Significance. Physical Therapy. Washington: May 2010. Vol. 90, Iss. 5; p. 803
US Department of Health & Human Services. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and
Security Rules. http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/privacysummary.pdf. Accessed 1/1/2013
Veterans Health Administration. VHA Handbook 1004.01: Informed Consent for Clinical Treatments and Procedures. August 2009
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Ethics North Carolina Occupational Therapy
Ethics – North Carolina Occupational Therapy
Post-Test
1. Which statement regarding ethics theories is INCORRECT?
A. Utilitarianism is the theory that right and wrong is determined by
consequence.
B. Social Contract Theory proposes that moral code is created by the people
who form societies.
C. Ethical Egoism is based on the theory that each person should do
whatever promotes their own best interests.
D. Natural Law Theory proposes that ethical behavior is a result of inherent
character traits.
2. Which of the following statements is TRUE?
A. All actions that are legal are also morally right.
B. All actions that are morally right are also legal.
C. Occupational therapy ethics vary state by state.
D. The AOTA Code of Ethics establishes ethical behavior for all occupational
therapists; including those who are not members of the AOTA.
3. Which of the following is NOT one of the seven core concepts of occupational
therapy practice?
A. Professionalism
B. Altruism
C. Freedom
D. Prudence
4. Which of the following is NOT one of the stated purposes of the AOTA’s Code
of Ethics?
A. Identify and describe the principles supported by the occupational therapy
profession.
B. Establish rules that define lawful occupational therapy practice.
C. Educate the general public and members regarding established principles
to which occupational therapy personnel are accountable.
D. Socialize occupational therapy personnel to expected standards of
conduct.
5. As per the principles of the AOTA’s Code of Ethics, it is unethical for an
occupational therapist to have a sexual relationship with ________.
A. their patient
B. a COTA working under their supervision
C. their occupational therapy student intern
D. All of the above
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Ethics North Carolina Occupational Therapy
6. Which of the following is NOT a listed requirement of procedural justice?
A. Refer to other health care specialists solely on the basis of the needs of the
client.
B. Hold appropriate national, state, or other requisite credentials for the
occupational therapy services provided.
C. Be familiar with revisions in those laws and AOTA policies that apply to the
profession of occupational therapy.
D. Maintain high standards and continuing competence
7. An occupational therapist providing pro bono services is an example of
A. Procedural justice
B. Social justice
C. Veracity
D. Fidelity
8. Which of the following is NOT generally considered to be a requirement of
Informed Consent?
A. Discussion of consequences of non-treatment
B. Discussion explaining the treatment goals and the prognosis for attaining
those goals
C. Assessment of patient understanding
D. Patient’s signature of acceptance on a written plan of care
9. The “Trust Test” is relevant for helping to establish ___________.
A. confidentiality
B. informed consent
C. conflict of interest
D. medical necessity
10. Which of the following is unethical?
A. Having a physician serve as your facility’s Medical Director.
B. Showing your appreciation to your top referral source by inviting them to
stay for a week at your mountain cabin
C. Taking a case manager out to lunch to inform her about the new therapy
services you have available
D. Subleasing office space to an attorney.
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