Morals are related to character and behavior from the point of view of right and wrong. Morals develop as a result of background, values, religious beliefs, and the society in which a person lives. Thus, OT practitioners bring their individual morals to situations and those morals may or may not be in agreement with the client’s morals. Professional decisions may or may not agree with the practitioner’s morals; rather, decisions are based upon ethics. Practitioners are required to comply with professional ethics and legal mandates.¹³

Ethics is the study and philosophy of human conduct. Ethics is “a systematic reflection on and an analysis of morals.”¹² Ethics guide how a person behaves and makes decisions so that the best or “right” conduct is carried out. Law is defined as “a binding custom or practice of a community: a rule of conduct or action prescribed or formally recognized as binding or enforced by a controlling authority.”¹¹ Laws are established by an act of the federal or state legislature. Laws are intended to protect citizens from unsafe practice, whereas ethics compel the professional to provide the highest level of care.

Ethics and laws are closely intertwined. However, ethics differ from laws and rules in that ethical standards are more general, and their intent is to give positive guidance rather than impose binding and negative limits to specific situations. However, because ethics are blended with laws to form professional standards, ethical misconduct may also constitute a violation of the law.¹³

In this chapter, the Occupational Therapy Code of Ethics and an approach to ethical decision-making are described. State licensure laws and regulations of the profession are also discussed, including potential sanctions when a practitioner violates the regulations.

Practicing Ethically

Frequently, OT practitioners encounter situations in which they must weigh alternatives and make decisions about a course of action. Some situations are easy to resolve, whereas others may challenge one’s decision-making abilities. Clinicians frequently rely on their own values and morals when deciding a course of action. However, professional decision-making relies on a systematic ethical problem-solving process.

Clinical reasoning involves understanding the client’s diagnoses, strengths, weaknesses, prognosis, and goals. Practitioners use clinical reasoning to develop and provide intervention to address goals and make necessary adaptations. Clinical reasoning requires problem-solving and professional judgment; therefore, it improves with experience, reflection, and critical analysis. Practitioners use clinical reasoning along with morals and ethics when making professional decisions.

A professional code of ethics provides direction to members of a profession for mandatory behavior and protects the rights of clients, subjects, their significant others, and the general public.¹³ For example, the code of ethics dictating that OT practitioners treat each client equitably describes a basic principle of the occupational therapy profession. Ethical codes provide guidelines for making correct or proper choices and decisions of health care practice in the field.^4,¹² These guidelines are usually stated in the form of principles.

American Occupational Therapy Association Code of Ethics

The American Occupational Therapy Association (AOTA) Occupational Therapy Code of Ethics⁴ was initially adopted by AOTA’s Representative Assembly in April 1977 (see Appendix A). This code provides guidelines to practitioners to help them recognize and resolve ethical dilemmas, to practice at the expected standard using guiding principles, and to educate the public (see Appendix A). The Code of Ethics is meant to inspire professional conduct for quality and empathetic occupational therapy while respecting the diversity of clients. The Code of Ethics is based upon the core values of the profession.⁹

The Occupational Therapy Code of Ethics consists of seven principles, each addressing a different aspect of professional behavior.⁴ Following is a brief description of each principle and an example to illustrate professional application.

Principle 1: Beneficence

In general terms, the principle of beneficence means that the OT practitioner will contribute to the good health and welfare of the client. Principle 1 of the Occupational Therapy Code of Ethics has four parts, each of which is related to the well-being of the recipient of services. This principle highlights the need for OT practitioners to (1) treat each client fairly and equitably, (2) advocate for recipients to obtain needed services, (3) promote public health and safety and well-being, and (4) charge fees that are reasonable and commensurate with the services provided.⁴

Mr. Parker can no longer pay for occupational therapy services. His occupational therapist (OT), Karen, started a daily self-feeding program for Mr. Parker prior to his funds running out. Karen visits Mr. Parker at mealtime and explains the proper use of the adaptive equipment to the aide. She discusses how to work on independence and what assistance may still be needed upon discharge. The therapist does not bill for this instructive visit, knowing that Mr. Parker will receive better care after she has personally addressed the issues.

This example illustrates the principle of beneficence in that the OT practitioner shows concern for the client by ensuring that the aide is properly trained in feeding techniques. The OT practitioner advocates that the client receive the services he needs.

When serving as a consultant to a residence facility for individuals who have severe intellectual disability, Judy, the OT, becomes aware that another therapist, Sam, is billing for one-half-hour individual intervention sessions. In reality, Sam only passes through the unit and briefly talks with the clients and does not provide treatment. After observing the pattern for several weeks, Judy speaks with Sam, who brushes off the inquiry, “Look, we all have plans on file, but these kids aren’t going to progress no matter what we do.” Judy documents the situation and brings the matter to the attention of the administrator.

In this case, Judy must address the breech of ethical conduct by Sam. Sam is financially exploiting the client by charging for intervention services that do not take place.

Principle 2: Nonmaleficence

The principle of nonmaleficence means that the practitioner should not inflict harm on the client. This principle ensures that OT practitioners maintain therapeutic relationships that do not exploit clients physically, emotionally, psychologically, socially, sexually, or financially. Furthermore, the OT practitioner is obligated to identify and address problems that may impact professional duties and bring concerns regarding professional skills of colleagues to the appropriate authority.⁴ In that OT practitioners work with a variety of clients, it is the practitioner’s responsibility to address concerns and foresee possible harmful situations so that harm can be avoided. The principle of nonmaleficence requires practitioners avoid any relationships, activities, or undue influences that may interfere with services.⁴

Tonya, a 15-year-old teen attending an outpatient group for eating disorders, becomes exceptionally at-tached to the OT practitioner, Mark. The teen calls Mark at home to discuss her intervention plan, telling Mark she got his phone number from her cousin, whom Mark knows from school. Mark limits the call and speaks to Tonya the next day at group, explaining to Tonya that it is inappropriate to call him at home and reiterating the professional nature of their relationship. Tonya is upset, but agrees that she will not call him. Mark asks a colleague to work with Tonya. He does not completely stop working with Tonya because he does not want her to feel rejected, but rather reinforces professional boundaries.

This example illustrates nonmaleficence (i.e., do no harm). Mark believes the relationship between himself and the teen may be harmful to the teen’s intervention plan. Tonya has become too attached and is unsure of the boundaries. Mark is truthful with the teen and brings the situation up with the team so that no emotional harm will come to Tonya. The team supports him in continuing to serve on the team so that he does not completely reject Tonya. The team fears that complete rejection may harm Tonya emotionally and result in slower progress or regression in her treatment.

Principle 3: Autonomy and Confidentiality

Principle 3 protects the client’s right of autonomy and confidentiality. Autonomy is the freedom to decide and the freedom to act.¹¹ Confidentiality refers to the expectation that information shared by the client with the OT practitioner, either directly or through written or electronic forms, will be kept private and shared only with those directly involved with the intervention (under conditions expected by the client).^2,¹² Confidentiality also stipulates that the client will determine how and to whom information may be shared. This principle requires OT practitioners to respect a client’s right to refuse treatment, and it protects all privileged communication.¹²

According to Principle 3, the OT practitioner (1) collaborates with clients and caregivers to determine goals; (2) informs clients of the nature, possible risks, and outcomes of services; (3) receives informed consent for services; (4) respects a client’s decision to refuse treatment; and (5) maintains confidentiality concerning information.⁴

Informed consent refers to the “knowledgeable and voluntary agreement by which a client undergoes intervention that is in accord with the patient’s values and preferences.”¹² Thus, clients have the right to refuse intervention and the right to be made aware of the risks, benefits, and cost of occupational therapy intervention.

Mrs. Jones, who is indigent and lives in a nursing home, resists going to occupational therapy but rather constantly asks to return to her room. The therapist, Andrea, learns that Mrs. Jones is afraid someone will steal her things. Andrea deals with the issue by making an intervention plan to address Mrs. Jones’s fear that she will lose her hairbrush, an old mirrored compact, a brocade change purse, a bottle of toilet water, and a pair of underpants. Mrs. Jones does not want to tell anyone, but with her consent Andrea obtains a wheelchair carrier. Part of Mrs. Jones’s intervention plan is the use of a checklist to pack her carrier with these treasured belongings each morning and to unpack it at the end of each day. The staff is informed that using a daily checklist is part of her occupational therapy program. Now Mrs. Jones goes to activities and therapy without protest.

This example illustrates a respect for the rights of both au-tonomy and confidentiality. The therapist allowed Mrs. Jones the freedom to choose to keep her treasures with her. This autonomy gave Mrs. Jones the assurance and comfort to participate in occupational therapy activities. The therapist respected her confidences by being careful to only discuss the contents of the carrier with Mrs. Jones, but informing the team of the intervention plan. The therapist respected Mrs. Jones’s right to decide if and how she will participate in therapy and allowed her to contribute to the intervention planning process. The practitioner respected Mrs. Jones’s right to confidentiality by not discussing with others the reasons she refused to go to therapy.