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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
Introduction to Biomedical Ethics for Optometrists
Optometrists, like other health professionals, are entrusted with a great deal of responsibility for the health and well-being of their patients. Optometrists are primary care-givers, and, as such, have much broader and deeper roles in their patient's lives than simply taking care of refractive needs. Along with the recent expansion of optometric scope, this has led a number of states to mandate courses in ethics as part of their continuing education requirements.
What Ethics Isn't
As we begin this course, it is important to realize that ethics is not about being the "moral police," or about malpractice issues, or about "Polyannish" pledges.
The word "ethics" is likely to evoke a variety of responses amongst optometrists, many of which are understandable but incorrect. First, ethics is not about policing morality. The aim in this course is not to ferret out possible misdeeds of colleagues or call them to task. That is one of the many responsibilities of state boards.
Ethics and law are not the same thing, though they do overlap in some respects. Most optometrists have sound instincts about what is right and wrong - and by and large they choose what is right.
Another thing that ethics is not about is moral education. The instructor of this course does not have some special and heretofore secret moral knowledge that will be imparted to those taking the course. This course is not about how to behave morally; optometrists already know that. As Fulghum said in his book, "all you really need to know is what you learned in kindergarten." (All I Really Need to Know I Learned in Kindergarten, Robert Fulghum, Random House Press, 2003)
Finally, this ethics course is not designed to instill a sense of professionalism amongst optometrists. The AOA code of ethics is an inspirational document designed to give the broadest possible perspective regarding what it means to be an optometrist.
American Optometric Association Code of Ethics
It Shall Be the Ideal, the Resolve, and the Duty of the Members of the American Optometric Association:
The AOA code of ethics is an inspirational document which is designed to give the optometrist the broadest possible vision of what it means to be an optometrist. It is necessarily vague. It speaks of holding the welfare of the client or patient in mind at all times. It does not speak about all the circumstances that would constitute a fulfillment or violation of this principle. It is a vision statement. Not a rule book. It speaks about respecting patients without describing all the details of what it might mean to show or not show respect.
What is optometric ethics? It is systematic reflection on the values dimension of optometric practice. The optometrist is a human being. He or she does not cease to be a human being when they become an optometrist. All human beings have fundamental commitments; values and beliefs that guide their understanding of the world and their place in it. It is naïve to think that one's fundamental commitments do not have an impact, often a profound impact, on the way one thinks about and practices optometry. An ethics course provides the optometrist with an opportunity to set aside some time to reflect on this dimension of practice.
What Is Ethics?
The dictionary definition of "ethics" is: "The study and philosophy of human conduct, with emphasis on the determination of right and wrong." This definition is not very helpful because it leaves the reader to determine what is right and wrong in situations where choices might not be all right or all wrong. A Google search using the term "ethics' is also not especially helpful because it returns over eleven million hits. Even though ethics might be difficult to define, there is obviously considerable interest in the topic.
Defining "ethics" is further complicated by the fact that ethical judgements are always embedded in a context. Some might argue that certain ethical principles are absolute, e.g., thou shall not kill. Yet in time of war, soldiers are encouraged to violate this principle and kill the enemy. Thus, circumstances carry within themselves many factors which must be understood to arrive at a satisfying ethical conclusion.
All of us live by ethical principles, but most of them are situational. We exceed the speed limit when we drive even though we know it is wrong, and we would all steal or perhaps even kill under certain circumstances to protect our families in times of great peril.
In optometric practice, we make decisions
regarding how much information to give patients about their conditions,
and we may perhaps "fudge" a letter or two when determining
acuity. Are we being unethical when we make these decisions? Do
we need to take an ethics course as punishment for being unethical,
somewhat like people have to take traffic school for violating
a driving law? This is not the purpose of this course.
What is the purpose of this ethics course? It is designed to bring to the forefront decisions that optometrists are often called upon to make in which there is no clear right or wrong choice. Or, more specifically, choices in which the optometrist, the patient, a third party, and/or society will be hurt or disadvantaged no matter which alternative is selected. These choices need to be considered in advance of need so that decisions can be made based on well thought-out considerations rather than spur of the moment emotion or confusion.
Ethics and Dilemmas
Ethics explores the moral puzzles that arise during the course of daily living and practice. A moral puzzle is called a dilemma, and a dilemma exists when alternatives are presented to the optometrist which make him/her feel that something of importance must be sacrificed in deciding to go in one direction or another. Cold, hard logic does not always dictate the correct choice, so a decision must based on a set of ethical beliefs or principles and a process for applying them.
As a very simple example, do you tell your patients that their eyes will be touched by the probe when doing Goldmann tonometry? On one hand, there is a prima facie obligation to inform patients about the details of procedures that are about to be done and to obtain their informed consent. On the other hand, many patients feel very uncomfortable with the idea of their eye being touched. They might refuse the test thus depriving the optometrist of important information.
As an optometrist, you have sworn to keep the patient's welfare uppermost at all times. Is it in the patient's best interest to inform him or her of the test's true nature and risk the possibility that they might refuse it? One might argue that the potential risks of this procedure are miniscule when compared with the risks associated with the absence of accurate IOP information. This is classic example of a moral dilemma. Perhaps it is a fairly minor issue in most optometrist's lives, but it is a good illustration of the kind of questions explored in an ethics discussion. (During my last eye exam, a 3rd year student told me that the instrument would touch my "tears," not my actual eye. Is this an ethical resolution for the dilemma?)
A more interesting dilemma arises in the State of Oregon where a new law requires that health providers report to the Department of Motor Vehicles (DMV) any patient with severe and uncontrollable functional and/or cognitive impairments (e.g., attention, judgement, reaction time, impulsivity, etc.) that are likely to render the person unsafe to drive. This report results in automatic suspension of the patient's driving license. Is it ethical to allow (or encourage) patients to inform you about these conditions during the history portion of your exam without warning them that you will need to turn this information over to the DMV? Does your patient have an expectation of confidentiality when history information is volunteered? Will this law discourage patients from revealing vital history information to the doctor for fear of losing their drivers' licenses? Does the protection of society override the rights of a patient to a "confidential" disclosure of history to a doctor? Is this law fair to patients? Is this law parallel in severity to the required reporting of child of elder abuse? Interesting questions.
Ethical Dilemmas to Consider
Here is a rather lengthy list of questions that come up in ethics conversations with optometrists. I justify the length of this list by saying that it constitutes an excellent introduction to the domain of ethics in optometry. As you read this list, consider your intuitive responses and the "ethics" of each situation. The decisions you make in these situations are the one that can cost you a good night's sleep - or your license to practice.
- Knowing that patients have full access to all information in their charts, do you avoid entering some information or enter it in code?
- Are there circumstances under which you would pass a borderline patient sent to you by the DMV? What are these circumstances? One acuity letter, two letters, a line, two lines, etc.
- Even though HIPAA might not allow it, do you think that you should disclose a patient's positive HIV status to other health care providers who might work with the patient? Would you be tempted to disclose the positive HIV status of a patient to their spouse -- over their objections?
- Is it reasonable and justified to ask about your patient's gender orientation?
- When you take history, should you ask every patient about domestic abuse? What about asking an adult female patient with facial bruises?
- If you had a patient with RP who was going blind but did not want their family or fiancée to know, would you try to convince them to share the information? Regardless of what HIPAA required, who do you think should be entitled to know information in cases like this where third parties are affected by the situation?
- Does the same logic which led optometry to successfully expand its scope of practice into ophthalmologic turf justify opticians expanding their scope of practice into optometric turf? What are the criteria for expanding or shrinking the scope of practice? Are they more financial than patient care oriented?
- Would you ever consider keeping two files on some of your patients, one for your use and one for the insurance company?
- If you live in a TPA state, you are now in a position to examine more than just the eyes since some of the drugs you use affect other parts of the body. What are the ethical issues that go along with this kind of access to your patient's body?
- Insofar as you are now, in a sense, practicing medicine, are you not only bound by the AOA code of ethics but that of the AMA as well?
- Should insurance companies play the role of regulating the practice of optometry through selective reimbursement?
- Should you allow insurance companies force optometrists to reschedule patients for medical tests when these tests are called for during a routine exam? Would you consider doing the tests all on the same day and billing them as though they were done on different days?
- Should you give a patient their prescription even though they have failed to pay for their glasses or contacts in the past?
- If you see a patient with talc retinopathy, should you discuss the issue of drug abuse?
- Under what conditions would you feel morally obligated to report or intervene in cases of suspected spousal or elder abuse?
- How standard should the standard of care be? Are AOA standards guidelines or mandates?
- What is the appropriate use of technicians in optometric practice? Should they refract if they are properly trained? Is your answer based on financial or patient care concerns?
- What are the limits of one's obligation to treat patients irrespective of their financial means?
- Do you feel that you have a right to know if your patient is HIV positive?
- Do you feel your patient has a right to know if you are HIV positive?
- What are the moral considerations in dealing with a partner or colleague you suspect has become incompetent?
- If your practice is in deep need of cash, is it morally acceptable to encourage patients to have benign procedures done even though they may be of limited usefulness (e.g., having a picture taken of a normal retina just in case a problem might develop later)?
- Is the optometrist committed to a higher code of conduct in their daily affairs than the average person on the street?
- Should an optometrist be sanctioned for using marijuana recreationally on a vacation out of the country?
- Should being found guilty of driving under the influence of alcohol be of official concern to the professional organization or the state board?
- How much information is sufficient to get clear informed consent? And how do you KNOW when you have gotten consent?
- Do you have a ethical obligation to take Medicaid or Oregon Health Plan patients?- Should optometrists be required to be periodically re-licensed?
- Should participants in CE be required to take exams?
- Should refraction only exams be allowed? Do patients have a right to seek or request to this very limited kind of service?- Should state boards be allowed to regulate the number of optometrists practicing in their state by devising more or less difficult and idiosyncratic tests? Should all states have similar pass/fail rates? Should questions of a personal nature be allowed?
- Should a company be allowed to sell identical contact lenses at greatly differing costs to patients by packaging and marketing them differently?
- Are there kinds of vision therapy which you think should be more heavily regulated than at present? What criteria would you use in making this decision?
- What sorts of ethical issues are involved in the increasing dependence of the optometrist to be on group insurance panels?
- Is it always unethical for an optometrist to date his or her patients?- What are the ethical issues surrounding the practice of radio, TV, and print advertising?
- Just how current should an optometrist stay to maintain a minimal level of competency in the profession? Should this be regulated more strictly? What is a minimal level of competency
- Should opticians be allowed to fit contact lenses? Is you answer based totally on patient care concerns?
- Have you been tempted to upcode for services not covered by third party payers?
Some of these ethical dilemmas are relatively easy to resolve, but other are more difficult. One way to resolve the dilemmas is to become totally dogmatic and not allow for any gray areas in your considerations, i.e., use a set of absolute ethics and never deviate from your principles. Dating patients is always wrong, (even if both doctor and patient are single and willing), denying an older patient a driver's license is always right even though they are just one letter below the legal acuity standard, etc. We are all acquainted with strict moralists who always know the "truth" and thus never have to agonize over an ethical decision, but, for most of us, ethical dilemmas are very real and can be very problematic.
Ethicists can provide some guidelines regarding how we might consider our moral dilemmas.
Ethical Reasoning
There is a rather specialized set of tools that ethicists employ when we enter into conversations about ethical issues. One thing ethicists do is to listen carefully to "ethics talk" (a discussion of all aspects of the situation) and analyze the process revealing a kind of taxonomy of moral reasoning. Here are a few observations I can make after 15 years of listening to ethics talk.
Ethics Talk is not the same as Legal Talk
We can all think of activities which are illegal but not necessarily immoral from our own understanding of right and wrong. An example might be (but not necessarily), the recreational use of marijuana. Vice versa, we can all think of activities which are perfectly legal but which we are divided on the question of morality. A good example would be the case of abortion. Most of those who are opposed to abortion simply do not recognize the moral authority of the Supreme Court in Roe v. Wade.
Ethics Talk is not the same as Ethics Code Talk
This is true for the same reason that ethics talk is not the same as legal talk. Ethics codes, e.g., the AOA Code of Ethics, are designed to inspire the health care practitioner to aspire to a high code of conduct. However, it may be the case that the average optometrist may find the AOA Code of Ethics entirely useless as a guide for resolving an actual moral dilemma, or may decide, in good conscience, that the Code of Ethics is simply wrong about some matter of basic moral significance.
Ethics Talk often proceeds by analogy
This phenomenon is not peculiar to ethics. Science also proceeds by analogy. For example the model for the virus, before it was actually discovered, was the bacterium. In ethical discourse, one often tries to think of situations that one feels confident about that are similar to the situation in question and test an analogy with that situation.
Ethics reasoning tends to ask or address five types of questions
Factual Questions:
Disputes about facts often come up in moral discourse. These are fortunate types of questions to have since they are, by and large, questions which can be answered to everyone's satisfaction. Note that factual questions can sometimes confuse rather than clarify a conversation. Why? Because it is sometimes the case that a factual claim is true but not relevant. A good deal of time is wasted in debates about the truth of factual claims when the truth or falsity of such claims are, in fact, irrelevant to the ethics discussion. An example is the use of photographs or models in the abortion debate. Since the claim is that life begins at conception (when there are no discernable human features extant), the use of photos, videos or models by pro-life groups add nothing to their argument. They are what philosophers call "red herrings" leading the opponent astray from the actual argument being made that life begins at conception with everything then flowing from that claim.
Conceptual Questions:
Conceptual questions are more difficult than factual questions. The reason for this is that it is largely a matter of ratification in building into a concept a common set of ideas. For example we all have the concept of "bachelor" pretty well firmly a part of our understanding. If I were talk about a friend of mine who is a married bachelor you would probably think that I just don't have the concept of "bachelor" firmly in mind when I'm using the word. I've misused the word. However, not all words are as firmly entrenched in our common repertoire as "bachelor." For example consider "informed consent." How much information is needed for a patient to be sufficiently informed before having a procedure done in your clinic? And further, what do you need to have true "consent?" A signature on a form does not automatically insure that a patient has consented to anything. The concept of "informed consent" is an important one in medical ethics because it is a fluid concept which has produced a vast literature amongst philosophers and bioethicists.
Preference Questions:
Sometimes we confuse questions about our preferences with questions about morality. This is understandable. But it is important that we disentangle these types of questions or we may inappropriately bring to the debate issues which are really about ourselves and our preferences rather than anything related to an ethical issue. If you and I go into a Baskin and Robbins and order ice cream cones, it would be odd for me to say to you, "Look I couldn't help notice you ordered chocolate. You should have ordered strawberry. Strawberry is better than chocolate. It's wrong for you to order chocolate when strawberry is available. Sorry. I just had to get that off my chest." What makes the scene comical is that the "should" in the quote is a misapplication of a moral imperative. In the clinic you might prefer not to take Oregon Health Plan patients, but this preference is not the same thing as an ethical judgment. You may ALSO have an ethical judgment about taking Oregon Health Plan patients. But that ethical judgment is something quite different than your preference.
Metafactual Questions:
This one may seem somewhat esoteric. Perhaps it is. But it does come up explicitly in some case studies and I would make the case that it can be found in every case study in one shape or another. A metafactual claim looks very much like a factual claim, but with this difference: a metafactual claim does not have public criteria for settling disputes about it. It looks like a claim about the way the world is, but when pressed, is shown to be a claim which cannot be tested in the way factual claims can be tested. Religious beliefs are often of this sort. There is a community in the South Seas which practices systematic geronticide, that is at a certain point in life people in the community are killed. An anthropologist studying the community discovered the belief that supported this practice. They believed that you enter the next life in the condition you left this one. Now if I ask you the question, "do you go into the next life in the condition you left this one" how would you answer? These people do not live in a different moral universe than us (they are, after all, trying to 'honor their father and mother' to use language from the ten commandments). They live in a different metafactual universe and this makes a big difference. Problems in optometry which have this dimension as a prominent feature either involve metafactual beliefs on the part of the optometrist, the staff or patient which play a role in a situation or a pattern of situations that come up in the clinical setting.
Moral Weighting Questions:
The values question is only one of five types of questions that come up in moral reasoning. Sometimes it just is the case that the optometrist will have to choose between two competing principles in an ethical dilemma. For example, he or she may need to choose between beneficence (i.e., doing good, performing an act of kindness) and autonomy in the Goldman tonometry case presented below.
The Moral Reasoning Process
There is no formula or algorithm that leads from the facts to a certain valid and true ethical solution. The ethics dimension of human experience is necessarily fuzzy around the edges and requires a different set of skills than other types of reasoning. It requires a certain toleration of ambiguity and an attitude of skepticism concerning one's own moral intuitions.
Here are a few simple goals:
Clearly articulate your moral intuition about the case.
Test that intuition with systematic use of the questions above. This is difficult. The hardest work in ethics comes from developing a habit of skepticism about your own intuitions and putting them to the test through systematic analysis.
1. Is your intuition more about your "preferences" than your moral commitments?
2. How are you filling in the concepts at work in this case? Are using words and phrases in an idiosyncratic fashion?
3. Are there facts which, if you had them at your disposal, would make a moral difference to you in this case?
4. What are the values in tension in this case? What principles might you use to weigh them in relation to each other?
5. What do you know and what can you do about it?
6. Are you or is someone on your team or staff using an analogy to urge a particular point of view? TEST IT. What are valid points of analogy AND disanalogy.
When in doubt, discuss the situation with colleagues, an ethics committee, or ethics consultant.
Case Studies
The goals of this course are to prepare optometrists to make ethical decisions in advance of need and to hone their ethical reasoning skills. Here are a set of cases to practice on.
Case One: Informed Consent and the Principle of Beneficence
This is a situation we have discussed previously.
The patient has a family history of glaucoma. Upon observation
unequal cupping is observed. Goldman tonometry is clearly indicated.
The patient has exhibited an unusual degree of nervousness throughout
the exam and has repeatedly asked whether anything would be touching
her eyes. You believe that if you tell the patient that the probe
will, in fact, touch her eye she would refuse the test.
Assuming you believe that doing Goldman tonometry is important
to obtain a diagnosis, is it ethical to proceed with obtaining
full informed consent? How much information did the patient need
to make a decision about whether to allow the procedure to go
forward? Do you inform the patient of the risks, however small,
of corneal abrasion? Could you inform the patient of the small
risk without informing them that the instrument will actually
touch the eye? Given the unreasonableness of this patient's fear
of having her eye touched should the student take this into account
and find creative ways to deceive the patient?
In this moral dilemma, one could use absolute ethical principles and tell the patient the probe will touch her eye. After all, it is her right to refuse the test and her right to have undiagnosed glaucoma. Or you could use situational ethics and "shade" your description of the test a bit. But, if this the one in a million times that the probe damages the cornea, you have a potential legal problem.
As with most ethical dilemmas, the use of absolute ethics protects you absolutely because you never do anything that could hurt yourself. The patient might suffer, but you are in the clear.
Case Two: Public Safety versus Patient Needs
You have just bought a small practice in Ten Sleep, Wyoming from Dr. Brown, who has been there for 35 years. Your second week there, Daryll Johnson, an 82 year old widower, rancher comes in. He has a broken frame. He was in for a visit 3 years ago. All he wants is a new frame. You have some time and invite him in for a free Rx. You find a best corrected far VA 20/100 OD, OS, OU
Daryll still drives 2 miles/day into town to have coffee with his friends. He also drives around the ranch. He is still sharp as a tack mentally, but is no longer legal to drive in Wyoming.
Later in the day, you get a call from Mrs. Schwartz who tells you that she is bringing her 78 year old dad in for a vision exam. She relates to you that he has had 2 auto accidents (rear enders) in the last 4 months. She would like you to fail her dad on the vision test so that he loses his license for his own safety and the safety of others.
When you examine Mr. Schwartz you find he has 20/30 VAs, 100" stereopsis, and full fields. Mr. Schwartz is legal to drive in Wyoming.
How do weigh your obligations to the state against the psycho-social needs of your patient? Do your moral obligations as an optometrist extend to these kinds of concerns? Is it any of your business what the social impact of the free Rx check you did for Daryll was? To what extent is the question of your legal liability part of your thinking about this case? Are there circumstances under which you would be willing to accept some liability to do what you believed to be the morally right thing to do? How close would the Rx readings need to be before you might be willing to 'fudge' and either not inform the DMV or chart a slightly different Rx?
Here again the doctor using absolute ethics
would have no problem with these patients. He would report both
patients to the DMV and have them called in for a drivers test
thus absolving himself of any responsibility for the patients.
On the other hand, both of them might lose their independence
and wind up in nursing homes because of his actions.
An optometrist is never a clinician only. He or she is embedded
in a complex set of social relationships. These two cases illustrate
multiple layers of responsibility that the optometrist has
to his/her patient's health and eye care, to his patient's well-being,
to the state, and to the patient's family. An optometrist is in
a position of power and knowledge relative to the patient and
cannot help but feel the weight of his/her decision-making in
these cases.
Case Three: Third Party Payment Dilemma
Willie, a 30 year old myope, is a prime candidate for vision therapy to resolve his convergence insufficiency. His state health plan does not pay for vision therapy, but will pay for Rx checks. You decide to have Willie in for therapy, but bill each visit as diagnostic tests and not vision therapy. To cover yourself, you check VA on each visit.
How do you weigh the bona fide clinical needs of your patients and the prima facie obligation to tell the truth to the insurance company?
This case is just one of many we could have used to illustrate a dilemma produced by our current health care system. On the one hand, every optometrist is sworn to provide the best vision-related healthcare possible. He/she has been trained to do so and is highly skilled to provide such care. On the other hand, the covered services that can be billed for are tightly regulated by insurance plans.
Different optometrists respond differently to scenarios like the one described above. It is not a difficult case for optometrists using absolute ethics because billing for one service and providing another involves deception and could, in fact, create a risk for a lawsuit and the loss of licensure. However, if we separate the ethical issues from the legal issues, we find a deep dilemma, one which many doctors find problematic.
Some readers might see in the case of Willie nothing more than a fairly coarse attempt to rationalize "ripping off" the insurance company. Others might see a much more difficult question concerning competing deeply held principles, namely the principle of beneficence (i.e., just being nice to Willie) versus the principle of truth-telling.
Case Four: Romantic Interests
You are single, a new doctor in a small North Dakota town, and you are a little lonely. Jim comes into your office. He's single, smart, good looking, and he needs some corneal rehab work. After a couple of sessions, he asks you to dinner.
Forgetting about what you think the AOA code of ethics says or doesn't say about dating patients, do you have a moral obligation to say, "no?" If Jim agreed not to see you as an optometrist any longer, would that change the situation from an ethical perspective? What if Jim were a member of your staff, say a technician. Is the general rule about mixing romance with business an absolute one? Is it anyone's business with whom you develop personal relationships?
There are numerous case studies which illustrate the problems that can arise when relationships of sexual nature crop up in the clinic. But, it is unrealistic to think that romantic interests in one form or another will not come up in clinical environments. One does not stop being a human being when one becomes an optometrist.
It is worth reflecting on sex and the clinic as part of an ethics discussion. The roles one plays in the clinic complicate any sexual relationship. Many people initially have absolute rules for themselves forbidding such relationships. But, some of these rules go out the window when a particular situation arises. Clearly the optometrist must remind him/herself of the powerful position they hold vis-à-vis patients and staff.
Case Five: Scope of Practice
You suspect that your patient Susan has chlamydia. You decide to check it out further by palpating the sub-mandibular lymph nodes. You think you might be feeling something, but it is ambiguous. You then decide to palpate the lateral axillary lymph nodes to get a better check on your suspicions. Indeed the nodes are swollen and you refer your patient to an M.D. A few weeks later you are informed by the state board of optometry that Susan has filed a complaint against you for sexual misconduct saying that you fondled her breasts while palpating her lymph nodes.
Is it acceptable practice for an optometrist to palpate lymph nodes? If you say above the clavicle only, why? If optometrists are trained to do physical exams and physical exams can give useful clinical information, why should such exams be restricted? Are O.D.'s more likely than M.D.'s to engage in sexually inappropriate behavior? Would palpating the lateral axillary lymph nodes of a male patient be acceptable? Even if you were a female doctor? And if you were a female doctor, would palpating the lateral axillary lymph nodes of a female patient be acceptable?
Has the practice of optometry expanded too far into the medical realm? For example, has the move from the diagnostic to the therapeutic use of drugs produced a new set of ethical problems we have not yet fully understood?
This case may or may not be about sex, but it certainly raises questions about scope of practice. In an actual case similar to this, the accused optometrist brought in an expert witness who testified that while palpating the lateral axillary lymph nodes is unusual, it is not outside the scope of practice, and is, in fact, demonstrated in some schools of optometry. With optometrists on the front lines of primary care and expansions of scope of practice based on the premise that humans are not "eyeballs on a stick," we can imagine a whole class of ethics questions which were not thought of even a decade ago.
Case Six: Confidentiality and the Duty to Protect
Mr. Jackley is a male in his forties. He has been a regular patient of Dr. Daniels for over twenty years. They also know each other through Rotary. Mr. Jackley has come to Dr. Daniels for a routine eye exam. His fiancée is in the waiting room. While performing binocular indirect ophthalmoscopy, Dr. Daniels sees what he believes to be Cytomegalovirus retinopathy. He knows that CMV is associated with the conversion of HIV into AIDS. He steps away, thinks for a moment, and decides to ask Mr. Jackley about this possibility directly. "Mr. Jackley, is it possible that you are HIV positive?" Mr. Jackley looks uncomfortable and asks, "Why?" Dr. Daniels explains what he sees and its implications. Mr. Jackley pauses for a moment and says, "Yes, I am HIV positive." He then goes on to say that he does not want this information to go on his chart. He says he is afraid he might lose his insurance. Mr. Jackley also says that he does not want his fiancée, Janet, to know. It would devastate her, he says. Mr. Jackley, now in tears, tells Dr. Daniels that he contracted the virus through a homosexual encounter some years ago. Revealing this information might destroy his otherwise good relationship with his fiancée.
Should Dr. Daniels have discussed Mr. Jones' potential HIV status with him? How should he handle the insurance concern? Should he simply record the finding of CMV and refer Mr. Jackley? Should he now mention AIDS in Mr. Jackley's file?
Now that Dr. Daniels has reason to believe that Mr. Jackley is HIV positive, should he take any further precautions while examining him? This is a controversial issue among optometrists.
What about Janet, Mr. Jackley's fiancée? As Mr. Jackley's doctor, you are bound by your HIPAA duty to keep information about your patients confidential--yet you have a legitimate fear for Janet's safety. If Mr. Jackley refuses to talk to Janet about it, should you tell her and risk legal action?
Assume you are an active member in a church that condemns homosexuality. Does this make any difference to you in your dealings with Mr. Jackley? Often our basic life perspectives DO affect our perceptions in very subtle ways and you might never be able to think of Mr. Jackley again with out condemning him. Would you suggest he find another optometrist?
Do patients have a moral obligation to inform their physicians if they are HIV positive? Would you dismiss a patient from your practice if you found out from another source that they were HIV positive?
What if you were homosexual and HIV positive; or heterosexual and HIV positive? Do you, as a physician, have a moral obligation to inform your patients? Would you want to know if your physician, dentist, physical therapist, or ophthalmologist were HIV positive? The universal precautions approach is controversial. If HIV is not of serious concern to you, consider the virulent strains of tuberculosis, which is turning up with increasing frequency in AIDS patients.
This case always produces intense conversation and often ends in a very mixed response to the questions. On the one hand, the optometrist is bound by very strict rules of confidentiality concerning his/her patients. On the other hand, there is a very powerful intuitive principle at work in many people that would dictate that measures should be taken to protect the basic safety of the fiancée.
This case illustrates the ethics formula K + P = R (Knowledge + Power = Responsibility). Whatever roles the optometrist take on in his/her practice, he/she remains a human being with basic values and fundamental commitments. It just turns out to be the case that if we know something and have the power to do something about what we know, we hold ourselves morally responsible for what we decide to do (or not to do).
This formula sometimes works with the rules and sometimes works against them. The legal background for this scenario is the famous Tarasoff case in which the parents of a young woman who was murdered successfully sued a psychiatrist (and the Board of Regents of the University of California) for failing to protect her after a patient told his psychiatrist that he planned to kill her.
Case Seven: Patient Beneficence and Patient Autonomy
Mary Farmer is a new patient with a known history of non-compliance and corneal ulcers. Upon examination, Dr. MacDonald finds that she is -4.00 DS in both eyes. She dispenses a trial of two week disposable contact lenses. Ms. Farmer is cautioned against sleeping in lenses because of the previous ulcers. She does not return for any follow-up care. Three months later, Ms. Farmer returns as a walk-in patient without the lenses on. She tells Dr. MacDonald that she needs another contact lens because one ripped. Her glasses are broken and are being repaired, and she needs the contact lens to drive her car and do her work. Concerned that this patient might not return for follow-up care due to the history of non-compliance, Dr. MacDonald gives her another lens, but makes it -3.50 to increase the probability that she will return.
Should Dr. MacDonald have given any lenses to this patient in the first place? Does Dr. MacDonald have an obligation to continue to treat Ms. Farmer, despite her non-compliance? What do you think of the strategy of intentionally under correcting a patient to encourage compliance?
This is a good illustration of emphasizing the principle of beneficence over autonomy. It is also a good illustration of situations that can occur when the optometrist thinks he/she is there to do one thing (provide eye care) and the patient thinks he/she is there to do another (correct vision).
(I have had one optometrist say this is a fairly common practice with non-compliant patients. Another said they have never heard of it and consider it to be completely immoral. Situational versus absolute ethics are very nicely illustrated by these two comments.)
Despite the slogan, "the customer is always right," we know that our patients vary widely in their level of maturity and capacity to act in their own best interest. This case illustrates the tension between autonomy and beneficence. Generally speaking, we normally want to give patients the most autonomy possible which is compatible with fulfilling the obligations of beneficence. We often attenuate our respect for autonomy the more we believe that the patient, for whatever reasons, is not competent to exercise his/her autonomy responsibly.
This is called the "reasonableness" principle. There is a range of patient behavior which we tolerate as roughly "reasonable." Outside of that range we begin to deploy strategies to either persuade (manipulate?) the patient into reasonable behavior or find ways to "work around" the unreasonable behavior to achieve your beneficent goals. What you view as ethical in this case depends in some measure on how you view the tension between autonomy and beneficence, how you assess the "reasonableness" of your patients, and the degree to which you are willing to in a sense "trick" your patient into doing what is clearly in his or her own best interest.
Summary
Ethics in optometry is the process of reflecting on the sometimes complex moral dimension of clinical practice. It deploys a set of tools for engaging in moral reasoning and aims at finding solutions that satisfies the practitioner wanting to do the right thing and preserves the integrity of the profession. Absolute, blind adherence to "the rules" might, in some cases, not lead to the most ethical solution to a dilemma.
Optometrists are occasionally called upon to make decisions in which there is no clear right or wrong choice, and he or she, the patient, and/or a third party will be hurt or disadvantaged no matter which alternative is selected. This course has discussed some of these situations and provided optometrists with an opportunity to consider them, hopefully in advance of need, by analyzing the dynamics that underlie the various alternatives.
As should have become clear, ethics is not an exact science in the sense that physiology or optics is exact, but ethical considerations and decisions can be just as important in a practice as those associated with lens optics or medications.
Contact this author:
Marc Marenco, D. Phil.
Department of Philosophy
Pacific University
2043 College Way
Forest Grove, OR 97116
mm@pacificu.edu
Pacific 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.
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