The American Occupational Therapy Association (AOTA) Code of Ethics is a “statement of principles used to promote and maintain high standards of conduct” in all occupational therapy (OT) practice. It serves as a “guide to professional conduct when ethical issues arise.”⁴ Inevitably, ethical issues and the need to establish the best outcome to a dilemma arise in practice, because OT practitioners have intimate contact with and a profound influence on the lives of the individuals, groups, and populations they serve. Although each OT practitioner has a personal set of values, he or she represents the profession as a whole when interacting with clients, caregivers, colleagues, authority figures, and subordinates. An understanding of the AOTA Code of Ethics⁴ is essential for carrying out one’s professional responsibilities.

After providing a brief description of ethical theory, the chapter outlines the ethical decision-making process and clearly presents the principles of the AOTA Code of Ethics.⁴ Providing case scenarios specific to OT practice helps to reinforce the concepts. The chapter concludes with a discussion of the enforcement and resolution process.

Ethical Theory

Morals are the personal values, principles, and beliefs that determine what is right and wrong for the individual.¹³ Many theories of moral development exist. Freud proposed that the child’s relationship with his or her parents affects moral development. Kohlberg, Piaget, and Gilligan link moral development to cognitive and physical development. They hypothesize that the child moves through stages of value acquisition as he or she develops. Gilligan theorizes that males and females differ in this respect.⁶ Massey attributes the development of morals to events that take place during childhood and adolescence that result in a group or generation that subscribes to a similar morality.⁶ Social learning theorists like Bandura view moral behavior as learned through modeling and reinforced by rewards and punishments.⁹

Ethics are a “system for decision making in the arena of moral values.”⁶ Both morals and ethics are culture based and influenced by factors such as age, ethnicity and race, religion, gender, gender identification, environment, social milieu, personality, emotional makeup, intelligence, physical health, economic status. The degree of control that an individual perceives himself or herself as having influences the ethical position.¹⁰ Ethical theories provide the framework for decision making and help define ways to solve professional dilemmas. These theories can be categorized as follows:

Virtue ethics examine the characteristics of the individual and theorize that the individual with certain traits (such as compassion) behave in an appropriate way.⁸

Divine command ethics postulate that there is a set of rules created by a divine source for directing of moral behavior.¹³

Teleologic theories hold that an action is ethical or unethical depending on its consequence. In practice, teleologic theories look for a solution to a dilemma that will achieve the best outcome for the most number of people.⁸

Deontologic theories hold that an action itself is either ethical or unethical with no regard for its consequence. When applied, deontologic theories hold that there is a universal duty to obey rules and follow principles.⁸

Professional organizations such as AOTA provide its members with guidance in dealing with ethical dilemmas.3,4,13 The establishment and enforcement of the code of ethics ensure maintenance of the standards of the profession. Practitioners rely on professional ethics as opposed to moral beliefs. The ethical decision-making process involves a systematic reasoning structure to enable practitioners to make professional decisions.

Ethical Decision Making

OT practitioners facing potential ethical dilemmas use a process to guide their analysis and subsequent actions. Purtilo ¹¹ lists six steps to assist OT practitioners to arrive at a “caring response” (Box 13-1). The “caring response” includes meeting client needs and performing professional responsibilities.

BOX 13-1 Steps to Ethical Decision Making ¹¹

Step 1: Gather relevant information.

What is the context of the dilemma?

What is the situation?

What are the associated facts?

Who are the involved players?

Step 2: Identify the type of ethical problem.

Ethical distress is the discomfort experienced when the OT practitioner is prevented from doing what is believed to be right.

An ethical dilemma occurs when the practitioner is required to choose between conflicting alternatives.

The locus of authority problem questions who should resolve ethical issues.

Step 3: Use ethical theories or approaches to analyze the problems.

Examine the AOTA Code of Ethics, Standards of Practice, and laws and regulations.

Define the principles involved according to the Code of Ethics.

Step 4: Explore the alternatives.

Who will benefit?

Will anyone be hurt?

Step 5: Complete the action.

Step 6: Evaluate the process and outcome.

AOTA, American Occupational Therapy Association; OT, occupational therapy.

Adapted from Purtilo R. (2005). Ethical Dimensions in the Health Professions, ed 5, St. Louis, Saunders.

These steps provide a method to thoughtfully act on ethical issues as they arise, staying in agreement with the AOTA Code of Ethics. Some situations cross legal boundaries. Thus, when gathering data and considering alternative courses of action, practitioners examine laws or regulations for practice.⁸

The OT practitioner should reflect on the outcome using the following questions as guides 5,8,11:

1. Is it the truth?

2. Is it fair to all concerned?

3. Will it build goodwill and better friendships?

4. Will it be beneficial to all concerned?

Reflection facilitates professional growth and provides the practitioner with tools for resolving subsequent situations.

Aota Code of Ethics—Principles

The AOTA Ethics Commission (EC) informs and educates OT personnel regarding ethical matters and ensures compliance with the ethical standards.2,3 The ethical standards of OT can be found in three documents: Occupational Therapy Code of Ethics⁴, Guidelines to the Occupational Therapy Code of Ethics², and Core Values and Attitudes of Occupational Therapy Practice.¹ The procedures to enforce the Code of Ethics are described in “Enforcement Procedures for the Occupational Therapy Code of Ethics and Ethics Standards.^”3 The Code of Ethics is based on the core values of the OT profession (Box 13-2). Table 13-1 presents the principles of the AOTA Code of Ethics.

BOX 13-2 Core Values and Attitudes of Occupational Therapy Practice ¹

Altruism: caring, an unselfish concern for and desire to help others

Equality: fairness in all interactions and seeing all people as having equal rights

Freedom: respect for the client’s personal choice and self-direction

Justice: being impartial in all interactions and adhering to laws and standards

Dignity: treating all clients with respect and assisting them to participate in meaningful occupations

Truth: honesty in all written and verbal communication

Prudence: self-discipline; moderation; and the use of reasoning, judgment, and reflection in making decisions

TABLE 13-1

Ethical Principles ⁴

Principle 1: Beneficence	Occupational therapy personnel shall demonstrate a concern for the well being and safety of the recipients of their services.
Principle 2: Nonmaleficence	Occupational therapy personnel shall intentionally refrain from actions that cause harm.
Principle 3: Autonomy and Confidentiality	Occupational therapy personnel shall respect the right of the individual to self-determination.
Principle 4: Social Justice	Occupational therapy personnel shall provide services in a fair and equitable manner.
Principle 5: Procedural Justice	Occupational therapy personnel shall comply with institutional rules; local, state, federal, and international laws; and AOTA documents applicable to the profession of occupational therapy.
Principle 6: Veracity	Occupational therapy personnel shall provide comprehensive, accurate, and objective information when representing the profession.
Principle 7: Fidelity	Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity.

AOTA, American Occupational Therapy Association.

Data from American Occupational Therapy Association (2010) Enforcement procedures for the Occupational Therapy Code of Ethics Standards. American Journal of Occupational Therapy, 64(Suppl.), S4-S16

Ethical dilemmas occur when there is a struggle to decide what course of action to take in a difficult situation. The “Occupational Therapy Code of Ethics and Ethics Standard”⁴ provides standards to guide practitioners in making the right choice to protect the public and the profession. The following scenarios are based on real-life situations that we have encountered and serve to illustrate a range of ethical dilemmas presented in OT practice. OT practitioners rely on knowledge of ethical decision making and the Code of Ethics when deciding the best course of action.

Beneficence

Principle 1: “Occupational therapy personnel shall demonstrate a concern for the well-being and safety of the recipients of their services.”⁴

The term beneficence refers to the act of producing good, as in an act of charity.¹⁰ Beneficence is consistent with the OT core value of altruism. AOTA interprets this principle as meaning that OT personnel need to take action to not only provide service that is for the good of their clients but to also protect their clients from harm.⁴ Working in a service profession such as OT does not automatically make a person altruistic. Being altruistic involves an attitude of doing good for every client. Beneficence requires OT personnel to put the needs of the client above personal needs or the needs of the facility.

To carry out this principle, OT personnel must have an understanding of the scope of OT practice and remain competent. Thus, practitioners use current equipment and provide evidence-based intervention. Responses to referral, completion of evaluations, and periodic reassessment should be completed in a timely manner to ensure that the client is receiving the best possible care and that services are terminated when the client is no longer able to benefit from them. The OT practitioner must be able to determine when the client could benefit from the services of another discipline and make necessary referrals. Finally, OT personnel must report behavior that is unethical when it is observed.3,4

CASE SCENARIO

Adam, a new OT graduate, accepts his job in a hand clinic where he is promised mentoring during his first year of employment. In his first week, the clinic receives more than the normal number of referrals and one of the practitioners is out sick. The supervisor asks Adam to complete an evaluation on his own, stating that someone will review it with him during the next week. Adam feels unsure of his ability to complete the evaluation effectively, but he does not want to disappoint the supervisor and he wants to demonstrate a helping attitude. What should Adam do?

Application: The principle of beneficence suggests that Adam should not do the evaluation if he does not have the competency to complete it independently because he could make an error that would cause harm to the client. However, Adam may demonstrate his helpful attitude in other ways. One suggestion may be that he could pair up with a more experienced OT to help with the evaluation. He could then independently complete the parts of the evaluation in which he is competent; the experienced OT could complete the rest of it. He could also offer to cover client interventions, allowing the experienced OT time to do the evaluations.

Nonmaleficence

Principle 2: “Occupational therapy personnel shall intentionally refrain from actions that cause harm.”⁴

Nonmaleficence is an “ethical principle of doing no harm.”¹⁶ On the surface, this may seem like a simple principle because it seems obvious that an OT practitioner would not want to harm any client. However, there are inherent risks in some aspects of OT intervention that can cause harm regardless of the intent to do good. Before starting treatment, the OT practitioner must identify the risk of the intervention and proceed only if the benefits outweighs the potential risks.¹¹ For example, the practitioner may consider taking a risk with a client to increase his or her independence, or the practitioner may decide to limit the client’s independence because of safety concerns.

AOTA outlines circumstances that have the potential to cause harm and cautions OT practitioners to avoid any relationship or activity that could exploit the recipient of services; compromise the therapeutic relationship; or inhibit making clear, objective decisions.2,4 These activities include conflicts of interest, sexual relationships, personal problems, or anything that blurs the boundaries of the relationship between the client and OT practitioner. It is important to understand the differences between a friendship and a therapeutic relationship. Friendships are give-and-take relationships that are beneficial to both parties involved. A therapeutic relationship is intentional and the client is always the focus.¹⁴ Having a friendship with a client can cloud judgment and result in a violation of this principle. This concept suggests that practitioners resolve their own personal problems so they are equipped to work with a variety of clients. Personal problems can result in the practitioner being intolerant, mentally unavailable, or treating the client as a sounding board, all of which can be potentially harmful.

Nonmaleficence includes the practitioner’s duty to avoid abandoning the client when the OT services can no longer be provided by helping the client transition to appropriate services.⁴ This may be especially difficult when working with a client who has limited financial or human resources available. The OT practitioner needs to be aware of resources offered in the community and work closely with other disciplines to arrange for the best possible outcome.

CASE SCENARIO

Dena is a certified occupational therapy assistant (COTA) working in a school-based practice. During an individualized education plan (IEP) meeting, the team decides that the child will not be afforded treatment over the summer. The mother is hesitant but eventually agrees to the plan. (Figure 13-1A) After the meeting, the mother speaks to Dena privately and offers to pay Dena $100 per week to provide OT services in their home (Figure 13-1B, 13-1C). Dena explains that she cannot provide services without an OT supervisor. The mother states that it does not need to be called “OT” and that no paperwork will be required. Dena feels uncertain but she really needs the money. What should she do?