Ethics: What Comes First?

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How do you balance contradictory demands and still arrive at an ethical decision? Ethics in O&P practice was the subject of a popular symposium during the recent Annual Meeting of the American Academy of Orthotists and Prosthetists in Orlando, Florida.

A panel headed by Wilton Bunch, MD, PhD, MBA, explored practical ethical issues; panelists included Gary M. Berke, CP, FAAOP; Wendy Beattie, CPO, FAAOP; and Tom DiBello, CO, FAAOP.

Bunch brings a unique background to questions of ethics in O&P practice. He has been a pediatric orthopedic surgeon, past president of the Scoliosis Research Society, dean of a major university, and holds a divinity degree and a PhD in physiology. He influenced the certification exams of the American Board for Certification in Orthotics and Prosthetics (ABC) when physicians administered the exams. Read an enlightening interview with Bunch, Ethics: What Choices Do I Make? . (Exclusively Online)

The Academy symposium was interactive: a series of cases illustrating ethical dilemmas, along with possible responses and solutions, presented both to the panel and to the audience. Audience members voted on their chosen solutions via electronic keypads and results were displayed on a giant screen.

Components of Moral Actions

Taking a moral action involves four factors, Bunch noted:

  1. Moral sensitivity: if a person does not recognize a moral issue in a decision, he will not make a moral judgment.
  2. Moral judgment: recognition of the moral issue and arriving at a moral decision, which is influenced by:
  3. Moral priorities, i.e., what comes first: the patient, the company, or legal responsibilities and accountability; and
  4. Moral character: the courage to implement a moral decision. Bunch commented on a university president he had known; "I used to fantasize a surgical operation that would give him a backbone."

Ethics involves three components: persons, actions, and consequences. The focus is generally on the person: What would a "good person" do in this situation? "A good person constantly strives to do the right thing," Bunch said. "If he makes a mistake, he makes every effort to correct it."

Actions can involve legal rights and responsibilities. Consequences, of course, are the results of decisions made and implemented.

Ethical Priorities

There is a hierarchy of ethical consequences, Bunch said. The catalyst is: "What does the good person do?" However, the most important question is, "What ethical system should I be working in?" A hierarchy of consequences includes legal requirements and responsibilities: what's best for the patient; what's best for the company; and what's best for other health care professionals involved. This hierarchy can produce ethical consequences.

An example given was an accident victim in a hospital emergency room who needed to be fitted with a halo right away. The doctor was inexperienced in halo-fitting and afraid to do it, so he asked the orthotist to do it. However, the orthotist was not legally qualified to do this. What ethical priority comes first? The patient's need? The physician's situation? Obeying the law?

Another scenario: A physician who sends the orthotist a large number of scoliosis referrals prescribes a nighttime brace for a particular patient. The orthotist knows from his training and experience that this brace will not be effective. He discusses his concerns and reasons with the doctor, who adamantly insists on the nighttime brace. What to do? Fit the brace anyway? Go to the family with your concerns? Take some other action?

The cases and possible solutions pointed to the complexity involved in practical ethical issues. One suggestion that emerged was to try whenever possible to avoid diminishing the doctor in the eyes of the patient. In addition to the business consequences of angering a referral source, there could be other long-range consequences that would be bad for the patient, such as a loss of confidence in the physician and perhaps the entire medical profession. Often other solutions are possible that are more beneficial to both patient and physician.

High-Tech? Yes or No?

High-tech versus low or mid-tech: This is a hot-button issue for many O&P professionals as they juggle the patient's wishes, their own business interests, and what the insurers will pay.

Some comments follow:

"As a taxpayer, I am against providing anything other than a standard simple prosthesis. I feel that if the patient is motivated to get a more advanced prosthesis, the patient can get employed or get into a program to become employable. I feel that it is unethical to ask society to line the prosthetist's pockets when the patient can do well with a much cheaper and simpler product." -Paul T. Webber, CO, FAAOP

"Ethics, like religion, means different things to different people. I personally believe that no man truly sets another man's ethics....I can be railed against for saying that the C-Leg-used as an example only-is the best component for a given patient. After all, I have a vested interest. On the other hand, I can be condemned for not giving that same patient the ability to rise above a level I might have decided he was capable of.

"Any one of us can credibly argue for or against the provision of either high-tech, high cost or low-tech, low cost components-and any one of us could play the devil's advocate.

"As professionals, we are charged with putting the patient first. This is as it should be. But, with the lack of true research and the amount of marketing that goes into each new product, which one of us can be right on every call, and which one of us is best equipped to judge the other's motives?

"'Ethics' is an extremely nebulous term. In the final analysis, maybe a religious phrase is suitable: 'Judge not, lest you be judged.'" -Jim Fenton, CPO, LPO

"Where I undertook my residency, my mentor was extremely ethical in this respect. He would never, ever provide anything that was not cost-effective for the patient and the insurer. He also believed in keeping the temporary prosthesis basic....We both suspect that he may be losing business because he takes the low-tech approach unless the patient is active and healthy and will make full use of-and benefit from-the high-tech features.

"Patients, irrespective of age and health, seem drawn to the promises of high-tech and practitioners who advertise their approach as high-tech, even though the technology may be overkill. I suspect the high-tech system produces a psychological benefit that may have little or no bearing on the outcome, i.e., 'They gave me the best system made, even if I don't need all of its features!'" -anonymous prosthetist

The Canons of ABC state, "It is the sole responsibility of the physician or other appropriately licensed health care providers to determine the medical appropriateness of the orthosis or prosthesis," noted Lance Hoxie, ABC executive director, in a post to the OANDP-L listserver. However, the Canons also address the responsibility of the orthotist or prosthetist in determining the wants and needs of the patient, he added.

Bunch emphasized the criteria of "What would a good person do in this situation?" He also expressed the idea of philosopher Immanuel Kant: Consider if your action were to become a universal law for similar situations, what effect would it have?

Many ethical choices are not clear or easy: practitioners need to consider the priorities involved- and make decisions that leave them comfortable when they look at the face in the mirror.