Ethics in health care is an issue across every clinical discipline. All health care practitioners with direct access to patients are subject to following ethical standards, regulations and scopes of practice. In many cases, ethical issues are straightforward and can be determined by thoroughly examining what is right versus what is wrong. Other, more gray areas of ethics can be perplexing to health care providers. In some cases, varying value systems may contradict each other and create scenarios that can be potentially dangerous to both the provider and the patient.
Is It or Isn't It Ethical?
Major health care companies like hospitals and national treatment centers to small practices located across every city in the nation encounter ethical issues. A recent survey by Medscape identified some common problems with ethical standards, noting that not all health care providers agreed on what was ethical practice or what was not. The survey revealed the top three issues that caused differences of opinions as to what is or is not ethical: 1) withholding treatment to meet an organizational budget, or because of insurance policies; 2) accepting money from pharmaceutical or device manufacturers; and 3) upcoding to get treatment covered.
As we know, applying professional standards can give health care providers some guidance on ethical problems, but they do not address every issue. According to the Medscape survey, there are four critical values for deciding ethical issues:
- Autonomy: patients have the right to determine their health care.
- Justice: distributing the benefits and burdens of care across society.
- Beneficence: doing good for the patient.
- No misconduct: making sure you are not harming the patient.
For chiropractors, the industry has gone to great lengths to identify and define what is or is not considered and ethical issue. The Federation of Chiropractic Licensing Boards (FCLB) has numerous resources on its publication's webpage related to ethics and practice.
Ethical Code Violations & Relicensing
But what happens when an ethics code is broken and reported in chiropractic services? Well, it depends on the violation, the state an offense is committed, and the laws that govern that state. If your ethics violation crosses over into a criminal matter, then that will supersede – or delay – any disciplinary action or relicensing processes dictated by the chiropractic state regulatory board.
Barring an ethical violation that is criminal, the process of disciplinary action and potential relicensing is handled through the state chiropractic board. One of the elements a chiropractor may need to complete following an ethics violation is an ethics exam administered by the Ethics and Boundaries Assessment Service. EBAS strives to protect the public through effective ethics and boundaries assessment of licensed, regulated professionals. EBAS offers proctored essay exams that assess an individual's understanding of ethics and boundaries in a professional setting.
The ethics exam originated from the National Board of Chiropractic Examiners (NBCE) and was available to all chiropractic state licensing boards. Interestingly, there was interest in the exam outside of the chiropractic profession from other health profession boards and agencies, so the NBCE decided to spin off EBAS, making it available for all health care disciplines.
EBAS reports that aside from chiropractors, medical doctors (MDs), nurses and dentists rank highest in taking the exam. EBAS addresses a broad spectrum of ethical violations and has found that providers deal with a combination of issues, rather than a simple, singular violation; for example, substance abuse issues that lead to boundaries issues or a professional standard issue that lead to fraud.
Ethical Violations in Chiropractic and Health Care: Real-World Examples
Here are some real-world examples of ethical violations that have spawned the need for a professional ethics exam to gain relicensing.
Fraud / Unprofessional Conduct: Chiropractic physician disciplined for making misleading, deceptive, untrue, or fraudulent representations in the practice of chiropractic through signing and submitting claims to a third-party payor for a patient who did not receive all the services offered on the shares. The DC submitted one or more claims to the patient's insurer for services and supplies that were not provided to the patient.
Unprofessional Conduct: Respondent was convicted of retail fraud in the third degree, a misdemeanor not punishable by imprisonment for a maximum term of two years. Respondent was sentenced to 12 months' probation. The conviction stemmed from an incident in which law enforcement responded to a retail theft report. The respondent was observed stealing two pairs of sunglasses. Respondent failed to notify the state board of the conviction.
Boundaries/Unprofessional Conduct: The physician entered into a sexual relationship with a female patient. This relationship – and sexual engagement – continued while the physician was treating the patient.
Unprofessional Conduct: A physician left 183 pre-signed scripts at the pain management clinic for nurses to have available. The licensee stated that they did pre-sign the prescriptions and placed them into a locked cabinet. The respondent said that the reason for pre-signing the prescriptions was to save time when seeing 45-50 patients per day.
The licensee was also observed taking the prescription pads home and then directing their spouse to return the pads pre-signed to the clinic. The licensee was contacted by phone each time a pre-signed prescription was used, and permission was given to complete the prescriptions and give it to the patient.
Ethics Is the Responsibility of All
As we all know, members of the regulatory community are responsible for protecting and enhancing the public's health, safety and welfare. Still, it is incumbent to all licensed professionals, not just chiropractors, to adhere to and practice ethics and understand boundaries. State boards will typically hear disciplinary cases brought against a licensee for substandard practice and questionable ethics.
An essential part of the ethics rehabilitation process requires the licensee to acknowledge and understand the ethics violation, accept the consequences, and learn where the boundaries exist while offering safe, efficient patient care.
Dr. Karlos Boghosian is the current president of the Federation of Chiropractic Licensing Boards, a not-for-profit, 501(c)(3) organization whose membership is comprised of the U.S. chiropractic licensing boards, certain Canadian provincial registration boards, and the chiropractic licensing board of New Zealand. FCLB lessens burdens on state government by providing programs and services to its membership.