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Ethical Considerations for Health Care Providers

Marc Marenco, D. Phil.

 

Contents

Introduction from the Oregon Board of Optometry

The Oregon Board of Optometry has promulgated an administrative rule that requires all optometric physicians to have 1 hour of continuing optometric education in ethics or Oregon law and administrative rules for license renewal beginning in 2005.

The Board made this decision for the following reasons: (1.) Our society has seen what occurs when those in positions of leadership whether in business, political life or healthcare fail to act ethically. There is now a demand that there be assurances and institutional safeguards to ensure that leaders act responsibly. (2.) Licensing boards, professions and professional associations have all begun to renew the allegiance to ethical standards for their members. Particularly in healthcare - where doctors make decisions that can intimately impact patients' lives - it is vital that they have a framework on which to base those decisions. Society holds optometric physicians and other medical professionals to high standards of conduct; ethical decision making plays a large role in helping physicians to meet those standards. (3.) The increased scope of practice for optometric physicians puts them in situations that would not have been contemplated even a few years ago. This is part of the ongoing knowledge and increased sophistication with which optometric physicians need to practice. The use of oral medications now make it imperative that optometric physicians are even more aware of the laws and requirements that come with increased responsibility.

The increasing choices and implications in healthcare decision making are becoming more complicated and nuanced. Knowledge of Oregon law and administrative rules and ethical guidelines help optometric physicians make the critical decisions that keep their patients - the citizens of Oregon - safe and well served.

March 8, 2004

David Plunkett, Executive Director

Oregon Board of Optometry

Course Introduction

According to the dictionary, ethics is defined as, "The study and philosophy of human conduct, with emphasis on the determination of right and wrong." This is not an especially helpful definition because it begs the question of what is right and what is wrong.

Right and wrong can be very easy or very difficult to determine depending on the individual making the determination and the circumstances. Some people follow absolute ethical codes and their behavior is precisely regulated by these codes, others utilize more flexible ethical codes and adjust their definitions of what is right and wrong depending on the situation.

Absolute Versus Situational Ethics

Absolute ethical codes are easy to describe because they provide no choices for a person. Laws and regulations are deemed to be absolute and are never violated. Often there is a document that specifies the laws, e.g., the Bible or Koran, or an authority figure who pronounces rules, e.g., the Pope, and no departures from the rules are tolerated. The absolute definitions of right and wrong are typically based on the authority of some higher power, e.g., God, the government, or a state board of optometry.

Persons who follow a set of laws absolutely are often given significant comfort from the laws because they remove the need to make decisions. However, discomfort can sometimes arise if the validity of the laws is questioned, if the authority of the lawgiver is questioned, or if there are contradictory laws within the code being followed.

In distinction to those who have absolute definitions of right and wrong, many people use more flexible definitions. They operate with a few absolutes in their lives, but mostly they analyze each situation pragmatically before making a decision regarding what is right and what is wrong.

As an example, consider the speed with which a person drives down the freeway. On one hand, some people use absolute ethics and never exceed the speed limit no matter what (usually they drive in the left lane too). On the other hand, there are the reckless drivers who greatly exceed the speed limit and endanger others on the freeway.

Imagine a line or a continuum between these two extremes. Most people set their speed somewhere along this line with the speed determined by various situational factors. These might include traffic conditions, weather, and certainly the number of law enforcement officers on the road, i.e., the probability of getting caught. Even if there is significant officer presence on the road, many people "fudge" a few miles per hour over the speed limit believing that it is all right to do this because everyone else is doing it and that officers will allow a certain range over the speed limit before they will write a ticket.

How does this relate to optometry? Optometrists are presumably bound by very absolute sounding oaths, codes of ethics, state board regulations, etc., and to follow these "laws" absolutely is deemed to be "professional." And yet many situations arise in which the optometrist is tempted to "go a few miles per hour over the speed limit" because it seems to make sense to do so and besides everyone else is breaking the law too. Optometrists are frequently tempted to abandon the absolute ethics of laws, etc., and utilize situational ethics, which often seem logical and rational. How far they move along the continuum between absolute ethics and recklessness typically depends on peer behavior, perceived patient needs, the "bottom line," and the probability of getting caught.

A classic example of demonstrating the situational ethics continuum features Mrs. Jones who is living in poverty and who has just had a complete vision examination. If she is charged for a routine examination, her insurance will not cover the costs and she will have to decide between paying your bill and eating for the next week. Of course the bill could be simply written off, but what about those suspicious lenses or the mildly elevated (but still within the normal range) IOPs? If Mrs. Jones has a medical problem, her insurance will pay for the exam and everyone (with the possible exception of the insurance company) would be happy. Certainly this would violate the absolute ethics of the profession, but does the situation justify moving just a few miles per hour along the situational ethics line?

As another example, a recent Wall Street Journal article described a very common practice used by physicians in which lab specimens were sent out to a private lab for analysis. In one of the cases cited, the laboratory did the analysis for $30, but the physician charged the insurance company a full fee of $100 and pocketed the difference. Presumably, charges for acquiring the specimen and interpreting the lab results were billed separately. The absolute ethical position is spelled out by the American Medical Association code of ethics which states that a, "physician should not charge a markup, commission, or profit on the services rendered by others." But there is a loophole for situational ethics consideration: doctors are permitted to levy a "processing fee." This "referral-sharing," as it is called, seems fairly far along the continuum toward recklessness, but it is apparently a legal and widespread practice.

Course Goals

This course is designed to stimulate thinking about ethics and to allow reflection on some potential ethical problems. To aid in making ethics-based decisions, it is helpful to have considered as many ethical problems as possible before the problems actually arise. In this way, problems can be considered without the sometimes overwhelming emotional overlay of the moment.

As a very simple example of how pre-consideration works, a doctor could decide that the office will absolutely not extend credit to anyone. This would make the decision easy when a patient asks for credit (at least until the situation arises in which a patient with a real hard luck begs for credit).

To provide some mental exercise in ethical analysis, a number of situations are presented below. For each situation, determine where your personal ethical values would fall on the 10-point scale from "Totally Ethical" to "Totally Unethical." To start with, some situations involving global ethical concerns are presented. They are followed by others that are more specific to health care.

At this time, click the Print Response Sheet button below to display and print a response sheet with your computer. Use the sheet to record your responses for comparison at the end of the course with responses from optometry school faculty members and students. After you have printed the response sheet, click the button to return to this course.