by Marc Marenco, D.Phil.
Course List | Take This Exam | CE Home | Optometry's Home
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.
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.
Click here to View Response Sheet (you can print to use with the section below)
Ethical Problems/Considerations
Most religions, codes, and laws absolutely prohibit killing another person but there are often exceptions and ambiguities that allow the application of situational ethics. For example, the Judeo-Christian Bible says "thou shall not kill," but it also says "an eye for an eye."
Consider the following situations and evaluate what you think about the ethics of each one. Although verbal anchors are only provided for scale numbers 1, 5, and 10, feel free to use the entire 1 through 10 scale for your responses. Do not fight with the details of the situations or try to find ways around them. Just indicate your responses to them. Remember to use the entire 10 point scale and write down your answers for later comparison to responses from a group of optometry students and faculty members.
1). Is killing another person who is trying to kill you ethical?
2). Is killing another person who has food and will not share if you or your family is starving ethical?
3). Is killing another person preemptively because you believe that the person might be a threat to you in the future ethical?
As the human genome project progresses, it will soon be possible to determine the probability that a person will develop specific diseases or conditions, e.g., cancer, diabetes, alcoholism, obesity, mental illness.
4). Is it ethical to require genetic testing of each newborn to determine the probability that the newborn will develop certain diseases or conditions during his or her lifetime?
5). Is it ethical to tell a person (and the parents in the case of in infant) about these probabilities?
6). Assuming that the patient does not provide the information, is it ethical for a patient's health care providers to know these probabilities?
7). Assuming that the patient does not provide the information, is it ethical for a patient's spouse to know these probabilities?
8). Assuming that the patient does not provide the information, is it ethical for a potential spouse, i.e., a person considering marriage, to know these probabilities?
9). Assuming that the patient does not provide the information, is it ethical for a patient's health care insurance provider to know these probabilities?
10). Assuming that the patient does not provide the information, is it ethical for the government to know these probabilities?
11). Assuming that the patient does not provide the information, is it ethical for a patient's employer to know these probabilities?
12). Assuming that the patient does not provide the information, is it ethical for an optometry or medical school to know these probabilities and thus deny admission to a person who has a high probability of developing a condition that might be dangerous to patients, e.g., mental illness, alcoholism, or pedophilia?
13). Assuming that the patient does not provide the information, is it ethical for everyone to know these probabilities from the time the person is an infant?
14). Assume that the genes for antisocial behavior, i.e., criminal behavior, have been found, and it is possible to prevent the conception of individuals who are likely to demonstrate criminal behavior. Is it ethical to prohibit conception of such individuals?
15). Assume that the gene for criminal behavior is present in strong association with a particular race (which race is irrelevant to the issue), and that it is possible to prevent the conception of individuals who are likely to demonstrate criminal behavior. But it will also mean preventing the conception of many members of a particular race. Is it ethical to prohibit conception of these individuals?
16). Assume that the gene for Best's disease, which leads to early blindness, has been discovered, and it is possible to prevent the conception of individuals who will have Best's disease. Is it ethical to prohibit conception of these individuals?
17). Assume that the gene for myopia has been discovered, and it is possible to prevent the conception of individuals who will be 6 diopters or more myopic. Is it ethical to prohibit conception of these individuals?
18). A recently televised football game featured the University of Utah playing the United States Air Force Academy. On the uniforms of the Utah and Air Force players there was a rather large Nike Swoosh logo. There was also a large Swoosh logo on the football. Is it ethical for state university and Air Force teams to wear advertising logos?
19). Recently, an ophthalmic corporation donated white clinic coats to all third year students at a school of optometry. Each of the coats had a small company logo on the sleeve cuff. Is it ethical for optometry students to wear coats with company advertising logos?
20). Many medical and ophthalmic companies provide lunches or dinners to doctors in exchange for listening to a product/sales presentation. Is it ethical for doctors to accept these free meals?
21). Some medical and ophthalmic companies provide cash, equipment, rebates, and other significantly expensive perks to doctors who use or prescribe their products. Is it ethical to accept these perks assuming that the doctor passes the perks along to the patients in the form of reduced fees?
22). Now consider the perk issue above but assume that the doctor does not pass along the perks to patients. Instead, he or she uses the perk for personal benefit. In addition he or she does not let patients know that there are perks associated with certain products or prescriptions. Is this ethical?
23). An ophthalmic corporation invites optometry faculty members to its headquarters all expenses paid to learn how to give presentations about their products. It then pays them to give these presentations, which are based on scripts or PowerPoint slides furnished by the company. The faculty member speakers do not reveal that they are company trained or paid. Is this ethical?
24). Consider the issue above regarding company training and pay for faculty member speakers, but now assume that the speakers declare at the beginning of the presentation that they are company trained and paid. Is this now ethical?
25). Assume that your spouse has a simple but very painful corneal abrasion. OTC pain relief products have not helped. Oregon law prohibits the prescribing of category III drugs to family members but you use a category III pharmaceutical sample from your office for pain relief. Is this ethical?
26). Physicians do not typically sell the drugs they prescribe. However, it has been suggested that they should begin selling drugs at a profit. Would it be ethical?
27). Optometrists typically sell lenses at a profit. Is this ethical?
28). Is it ethical to deny medical school admission to individuals with disabilities such as poor color vision that would potentially reduce the ability to make diagnoses?
29). Is it ethical to deny optometry school admission to individuals with disabilities such as poor color vision or reduced binocularity if they would potentially reduce the ability to make diagnoses?
30). A health plan has been developed that essentially rations care for patients with limited incomes. Diseases and conditions, including those related to the eyes, are ranked in order of expense to treat, probable outcome, etc., and a line is drawn on the list below which treatment will not be paid for by the state. Is this ethical?
31). A health plan has been developed that essentially rations care for all patients regardless of income or ability to pay. Diseases and conditions are ranked in order of expense to treat, probable outcome, etc., and a line is drawn on the list below which treatment will not be provided even if the patient can pay. Is this ethical?
32). You have contracted a contagious disease, e.g., AIDS or TB. You observe all required precautions with your patients to prevent transmission, but is it ethical not to tell your patients about your disease?
33). Your patient has contracted a contagious disease, e.g., AIDS or TB. You observe all required precautions with your patient to prevent transmission, but is it ethical for the patient not to tell you about their disease?
34). Some believe that optometrists must be held to a higher code of conduct in their daily affairs than the average person. Is it ethical for an optometrist to use marijuana recreationally on a vacation out of the US where use of the drug is legal?
35). You are romantically attracted to a patient who seems to return your feelings. Neither of you are involved in another serious relationship. Is it ethical to date a person and have him/her still remain your patient?
36). You are romantically attracted to a member of your staff who seems to return your feelings. Neither of you are involved in another serious relationship. Is it ethical to date a person and have him/her still remain on your staff?
37). A senior colleague has grown out-of-date in his treatment and diagnostic skills. The colleague is not dangerous to his patients because he has years of experience and makes referrals when he is unsure. Yet he is not practicing up to the current standard of optometric care in the community. Is it ethical to contact the state board with your concerns?
38). You have hired an office assistant who turns out to be incompetent. When you try to dismiss her, she threatens action against you for racial discrimination, age discrimination, sexual harassment, or whatever. However, she agrees to leave quietly if you will give her a good letter of recommendation. Is it ethical for you to do this?
39). You have hired an office assistant who you believe is stealing from you but you have no hard evidence. When you try to dismiss her, she threatens action against you for racial discrimination, age discrimination, sexual harassment, or whatever. However, she agrees to leave quietly if you will give her a good letter of recommendation. Is it ethical for you to do this?
40). You have hired an office assistant who is stealing from you and you have hard evidence of this. You decide to avoid calling the police because of all the scandal, but when you try to dismiss her, she threatens action against you for racial discrimination, age discrimination, sexual harassment, or whatever. However, she agrees to leave quietly if you will give her a letter of recommendation. Is it ethical for you to do this?
41). Touching your patient or performing an "invasive test" without informed consent can be considered assault. You feel a strong need to perform a test for the benefit of the patient, but he/she is resisting out of fear, e.g., fear of having the Goldmann probe touch the eye. You tell a "little white lie" and explain to the patient that the probe will not touch the eye. (Do not avoid the intent of the example by arguing that you could use another test.) Is it ever ethical to lie to a patient?
42). In parts of Canada, "Sight Testers" provide refractions and glasses (no health testing is done) to adults who meet certain criteria and who specifically request this service. Notwithstanding any laws or regulations to the contrary, would it be ethical for optometrists to provide only refractions and glasses to adults who specifically request that no other testing be done?
43). Notwithstanding any laws or regulations to the contrary, would it be ethical for opticians who have been adequately trained by optometrists to provide only refractions and glasses to adults who specifically request that no other testing be done?
44). A laboratory with which an optometrist does business sends a holiday gift with a certain value. At what value, if any, does it become unethical to accept the gift. Let the scores of 2 through 9 represent gift values in $100 increments, e.g., 3 would be $300, etc.
45). A doctor or practice group with which an optometrist does business (i.e., sends or receives referrals sends a holiday gift with a certain value. At what value, if any, does it become unethical to accept the gift. Let the scores of 2 through 9 represent gift values in $100 increments, e.g., 3 would be $300, etc.
Conclusion
Ethics is a very complex concept and what is ethical in any given situation can be difficult to determine. Certainly adhering to an absolute code of ethics, laws, oaths, etc., can make life and professional practice relatively simple, but there are cases when common sense or special circumstances make this adherence difficult or questionable. In these cases, most people rely on situational ethics in which they evaluate all aspects of the situation to reach the best possible conclusion.
It can occur, however, that an evaluation of the situation/dilemma does not reveal an ethical solution. In these cases, consultation with trusted colleagues can help. Colleagues can often see a situation more rationally than those actually involved in it and can at least provide a consensus of opinion regarding how to handle the situation ethically.
Many organizations provide ethics advisory committees for their members who need help in dealing the ethical dilemmas. These committees are separate from ethics enforcement committees so that confidential questions can be posed without fear of reprisal. The Oregon Board of Optometry does not currently provide a confidential ethics advisory committee.
Another source of help can be a professional ethicist. Some large organizations employ ethicists and most universities have faculty members who specialize in ethics. Consultations can usually be arranged, sometimes for a nominal fee. Typically, professional ethicists do not actually solve problems, but they help to place the relevant variables into perspective so that the problem can be solved by those involved in it.
Courses on ethics taken later in life will probably not change a person's basic ethical perspectives, i.e., courses cannot change a fundamentally unethical person into an ethical one, and vice versa. Indeed, many believe that basic ethical perspectives are developed early in life. However, ethics courses help to develop strategies to use in dealing with ethical dilemmas and can help those who take courses to formulate their ethical perspectives in advance of need.
Even though it might not be possible to change a person's basic ethical perspective or conscience, it is certainly possible to alter behavior. Using the freeway-driving example, speed can be changed by altering the situation. Placing a police officer every quarter mile along the road or increasing the speeding penalty to $1,000,000 would certainly alter behavior. Placing black boxes in cars to constantly monitor speed and rewarding non-speeders with lower insurance premiums could also have this same effect.
In the same way, the behavior of optometrists can be influenced by increased monitoring and ethics violation penalties, but peer pressure and recognition of positive role models might be equally or more effective ways to enhance ethical behavior.
Compare Your Responses Or Take Exam
To compare your responses to those from 34 randomly chosen optometry students and faculty members (and take the course exam) later click here: Compare responses
To skip the comparison and just take the course exam, click here: Take exam
Acknowledgement: Robert Yolton, PhD, OD, assisted in the preparation of this course.
Contact this author:
Marc Marenco, D. Phil. Department of Philosophy Pacific University 2043 College Way Forest Grove, OR 97116Pacific University College of Optometry provides On-Line CE as a service to optometrists. The college does not endorse or recommend any products, equipment, or services that might be discussed in the courses. Courses are prepared by individuals believed to be experts in their areas of specialization who are compensated for their efforts. The College relies on their expertise to produce accurate and timely courses. Questions or concerns about courses should be directed to the individual authors and/or the Continuing Education Department at the College of Optometry at kundart@pacificu.edu.
© Copyright 2006,