Introduction
The current health care system has changed in recent years from a model where health care relationships were defined primarily by the provider and patient, to a more complex model where the organization in which the health care professional practices has a direct impact on the care provided to patients. The role of the organization in the delivery of care has introduced business, financial, and management pressures into the health care environment, often leading to ethical conflict between delivery, access, and reimbursement for service. As stated by the American Society for Bioethics and Humanities, “Ethical issues in organizational behavior have become more evident in recent years with the emergence of a more explicit market approach to medicine” (1998, p. 24). The market approach has resulted in the need for integrating organizational ethics into the health care environment. This integration has led to speculation regarding how business ethics and clinical ethics will coexist within the infrastructure of the health care institution. However, organizational ethics is more than clinical ethics and business ethics combined. Organizations must take into account values and moral positions that are defined both internally and externally (Spencer & Mills, 1999), including the professionals and the codes that shape their behavior and guide practice.
Strategies for shaping an ethical organization must include health care values and codes of ethics. Health care professionals have always been held to a high ethical standard; therefore, organizations that provide health care services also must be held to this standard. Ethics in organizations are often complicated by business pressures. Health care organizations have become more complex and more involved in managing care, especially in times of limited resources. There are ethical tensions resulting from pressures to do more with less. Health care organizations are expected to improve quality and expand access, while reducing cost (Veterans Health Administration, 2002). However, these pressures do not excuse organizations from their primary purpose of caring for people. In addition, if a health care professional works for an organization, ethical or otherwise, he or she cannot hide behind the policies or administration of the institution; his or her professional code and values must continue to guide practice. Ethical action requires the organization and the health care provider to demonstrate “integrity in the face of patients’ exploitable vulnerability, [and] loyalty even to the point of personal sacrifice” (Emanuel, 2000, p. 155).
The Issues
Occupational therapists are not immune to these market-based pressures. Most clinicians are familiar with the pressure to do more with less, whether manifested in lack of resources or increased productivity standards. Constraints in time and money will continue to exist in health care; therefore, occupational therapy practitioners must understand how to handle these problems ethically while addressing the needs of the patients and the communities they serve. Practitioners may work within an organization, but they also belong to a profession with core values based on concepts of altruism, equality, freedom, justice, dignity, truth, and prudence.
Health care providers are finding themselves emeshed in relationships that extend beyond the provider and patient. These providers “interact on matters of accountability over many different domains and mechanisms [creating] what we might call a complex reciprocating matrix of accountability” (Emanuel & Emanuel, 1996, p. 231). The organization in which a health care professional practices often acts as a domain that influences the behavior of the practitioner. If the practitioner is an employee of the organization, then a level of accountability to that organization’s culture, standards, and viability is subsumed. Although the focus of accountability is often limited to the dynamic of the provider–patient relationship, service delivery is influenced by relationships external to this dyad. The occupational therapy practitioner may be placed in situations where it is difficult to protect and maintain the provider–patient relationship. In some circumstances, occupational therapy practitioners will be pressured to provide services that conflict with their personal or professional code of ethics, in order to support decisions made by individual physicians or made within the organization.
Ethics focuses on choices in at least three domains: [1] choices about what we ought to do or not do, that is, the actions we might undertake; [2] choices about the kind of persons we ought to be or not be, that is, the kind of character we ought to have or develop; [3] and, more abstractly, choices about the conditions of doing and being, which are perhaps best illustrated in the context by the organizational cultures, structures or policies that influence but do not determine what we do and who we are as persons. (Heller, 1999, p. 346)
It is this influence of the organization that often leaves practitioners in the difficult position of attempting to respect the patient’s rights, while also attempting to support the organization’s policies, procedures, and financial viability. Organizations are dominant moral actors in today’s health arena, not only influencing policies within the hospital but also creating role expectations for health care providers that influence how they perform professionally within the organization (Goold, 2001).
In years past, relationships in health care were arguably less complicated. Practitioners’ ethical obligations were primarily limited to the patient, and acting within that patient’s best interest (Gervais, 1998). Practitioners’ roles and accountabilities were outlined by oaths and professional codes of ethics. These codes are designed to address conflict specific to the patient–provider relationship, but are lacking when used to address more complex ethical dilemmas that extend beyond the bedside and encompass organizational ethics issues. With growing changes in health care, and with the shift in focus from health care providers to corporate institutions, “greater attention must be paid to the moral content or moral character of the actions of health care organizations” (Goold, Kamil, Cohan, & Sefansky, 2000, p. 69). In particular, one must be aware of the impact an organization’s moral character has on its practitioners. Although organizations must consider the relationships between “institutions and patients, patient populations, professionals, and other institutions” (Khushf, 1998, p. 133), the organization cannot undermine the integrity of the provider–patient relationship.
[Organizations must take into] account interaction among individuals, health care workers, institutions, integrated delivery systems and the entire health care environment. Any account of organizational ethics that focuses only on one level of the environment, such as the team or the institution, without examining and accounting for interaction among the levels of the environment, is inadequate. (Boyle, DuBose, Ellingson, Guinn, & McCurdy, 2001, p. 8)
This goal of organizations to meet individual as well as comprehensive societal needs may at times seem to conflict with the provider’s responsibility to the patient. When this conflict occurs, the provider is often presented with a dilemma to support either the organization’s goals or the patient’s rights. An ethical dilemma will be encountered when a morally correct course of action requires the therapist to support both the organization and the patient, but the supporting actions are mutually exclusive, meaning that the therapist cannot do both (Purtilo, 2005).
Although the organization is responsible for responding to all of these levels of the environment, the occupational therapist working within the organization cannot be accountable to all of these groups without risking an erosion of the provider–patient relationship. This dynamic appears to be a conflict between organizational ethics and those of the practitioner. A health care organization must be accountable to multiple parties and the community, but this extended accountability should not detract from the provider’s relationship with the patient. The organization, therefore, cannot ethically require a practitioner to engage in decision making or actions that will undermine the provider–patient relationship. “Any social, organizational, administrative and financial arrangement with practice settings that contribute to distancing [providers] from their patients will result in tendencies to dehumanize them and will ultimately diminish the [provider’s] competence to heal” (Scott, Aiken, Mechanic, & Moravcsik, 1995, p. 81). Therefore, although organizational and clinical ethics may seem to conflict initially, the care of the individual patient is the common tenet in both areas of ethics, and ultimately the destruction of the provider–patient relationship detracts from delivery of care and patients’ outcomes (Mills, Spencer, Rorty, & Werhane, 2000). Unfortunately, not all health care organizations recognize the role the institution plays in sustaining the provider–patient relationship, and inevitably the provider encounters situations in which he or she must choose to act as directed by organizational administration or on behalf of the patient.
The conflict that arises from the health care professional’s complex matrix of accountability often leads to lack of trust between patients and providers. These conflicts have resulted in eroded trust between health care provider and patient (Haskell, 2000). Trust is a necessary component of the health care relationship between therapist and patient. “The need for trust and the reliance on trust are especially important in health care because of the patient’s acute vulnerability to suffering, lost opportunity, and lack of power” (Goold, 2001, p. 26). Within the provider–patient relationship, the occupational therapy practitioner has more power, and how he or she wishes to use that power can quickly degrade the trust of a patient. One potential abuse of that power presents itself in the form of paternalism. Practitioners who independently define the patient’s best interest and provide care based on their assumptions of best interest—without the consent, or worse, against the will of the patient—are acting in a paternalistic manner. Health care in the United States has shifted away from a paternalistic manner that affords the professional the power to make decisions in the health care environment and has moved toward a focus on patient autonomy (Quill & Brody, 1996).
Case Scenario and Discussion
An occupational therapist has received a referral to see a patient on the Cardiac floor of a community hospital. When the therapist enters the room to complete her evaluation, the patient refuses occupational therapy services. The occupational therapist continues to see the patient over the course of the next week. On all occasions, the patient refuses to participate in therapy. During each visit the therapist explains to the patient and her family the importance of occupational therapy services, why her physician has referred her for treatment, and the risks of minimal activity after cardiac surgery. In addition, the occupational therapist speaks with nursing staff to determine whether the patient has been seen by a psychiatrist to rule out depression, or any other emotional state that may be affecting participation. The nurse refers the occupational therapist to a report compiled by the psychiatrist, indicating that the patient is slightly depressed but has full decision-making capacity and is therefore able to make health-care-related decisions. The occupational therapist decides to contact the physician to tell her why she will be discharging the patient from services, due to the patient’s informed refusal of treatment. During this discussion, the physician states to the therapist that she will need to continue treatment and that she should “not allow the patient to refuse services,” and then abruptly hangs up the phone.
When the occupational therapist arrives to work the next day, she has another written physician referral on her desk stating, “Evaluate and treat for occupational therapy services, do not allow the patient to refuse.” This new order places the occupational therapist in a difficult position and she does not know how to proceed. She wants to respect the patient’s autonomy, and yet she feels a responsibility to maintain a positive working relationship with the physician. Her confusion is complicated by her obligation to the health care organization for which she is working, fearing that aggravating the physician may result in a decrease in referrals for patients who may benefit from occupational therapy services, and subsequent decreased revenue for the department.
Occupational therapists often work under the direction of a physician and within a health care organization. Organizations drive care, because they have a vested interest in services provided and in ensuring continued physician referrals that support the financial solvency of the institution. This situation is especially true in communities where the physicians are not employed by the facility itself, but also have privileges at competing hospitals within the same town. Of the three relationships—patient, physician, and organization—the patient relationship is often seen as the one to whom the occupational therapy practitioner is most responsible. There are serious questions about what accountability occupational therapy practitioners have to the organizations that employ them. Do employees have a fiduciary responsibility to support the organizations that employ them as well as other health care professionals within the organization, even if that relationship conflicts with their patient relationship?
Occupational therapy practitioners may perceive that the organization would support a team environment, which favors the physician, because there may be a negative financial fallout if physician relationships are strained. However, it is in the organization’s best interest to support provider–patient relationships that build trust, because these relationships make for better medical care (Goold, 2001). Ethical health care organizations should not require a practitioner to compromise standards in the delivery of care. Organizations that place providers in situations that jeopardize the patient–provider relationship are also jeopardizing the organization’s relationship with the customer. In the case scenario above, if the occupational therapist were to violate the trust of the patient by forcing her to participate in therapy against her will, the therapist would inadvertently make the institution less trustworthy in the eyes of the patient. Because of this need to support individual provider–patient relationships, most organizations have policies and resources in place that can support the provider in making ethical choices.
In the case scenario, the occupational therapist should utilize her supervisor to help her in communicating with the physician. If a supervisor is not available there is generally a medical director or administrator who can facilitate communication with the physician. Often organizational management can communicate with physicians in a way that minimizes power imbalances. In addition, a supervisor or administrator should be familiar with and able to locate patients’ rights policies that objectively identify patient and provider roles, and can assist the employee in identification of other organizational resources. The hospital ethics committee or consultation services may help resolve conflict between health care providers within the confines of the organization. In addition, organizational structures, such as incident reporting systems or safety hotlines, can be used to influence behavior of providers in order to protect patient rights, while keeping the reporting source anonymous so as to avoid strained relationships among team members. The occupational therapist walks a difficult line in balancing these team relationships with her responsibilities to the patient.
Helping patients to exercise their autonomy effectively in today’s health care environment has become more and more complicated. However, Principle 3 of the Occupational Therapy Code of Ethics (2005) requires occupational therapy personnel to respect their patients and assure that their rights are being upheld (American Occupational Therapy Association [AOTA], 2005). Due to the complex matrix of accountability faced when practicing in health care organizations, practitioners often find themselves not only in a relationship with the patient, but also in collegial relationships with other health care providers and the institution. Although the provider–patient relationship is typically the theoretical focus for conflict resolution, other relationships also must be maintained by the provider to ensure safe, effective, and ethical delivery of health care services. This concept of fidelity is also present in the Code under Principle 7: “Occupational therapy personnel shall treat colleagues and other professionals with respect, fairness, discretion, and integrity” (AOTA, 2005, p. 641). However, an occupational therapist need not compromise a relationship with a patient in order to maintain other relationships. In fact, respecting the patient’s right to refuse—thus maintaining the integrity of the provider–patient relationship—is ethically mandated, in order to ensure ensure ethical practices that support the moral structure of the health care environment.
In the case scenario above, the occupational therapist does have options for justifying a course of action. The therapist should pursue opportunities for communication with the physician; however, if the physician continues to rebuff the therapist’s attempts at dialogue, the therapist should pursue another avenue for communication, involving the administration. Depending on the organization’s understanding of its role in fostering relationships between providers and patients, the therapist may or may not encounter a supportive advocate for resolution of the ethical dilemma. If this option does not resolve the conflict, the therapist may ultimately decide to: transfer care of the patient to another therapist; refuse to treat the patient, which may result in termination of employment; or continue treating the patient. Continuing to treat a patient who is refusing services and has decision-making capacity would not be ethically justifiable. This option could lead to many adverse outcomes, including: a decline in trust between patient and provider; the potential harm—both psychological and physical—imposed on the patient; the lack of benefit incurred when treating a patient against his or her will (Note: This is also a legal issue because it can be construed as assault and battery); and, ultimately, a decline in trust between health care providers, organizations, and the individuals served.
Although the previously mentioned options are viable, it is important to actively advocate for the patient, but in a respectful manner that is least damaging to relationships between physician and therapist. Although patient trust is essential, one must also work to maintain trust between colleagues and team members.
Conclusion
Research demonstrates over and over again that patients most highly value having a strong relationship with their health care provider (Gervais, 1998). The humanistic characteristics of the occupational therapy profession, in which emphasis is placed on the patient’s view of meaningful life, morally require respect for the patient’s wishes, even when these wishes seem to conflict with clinical reasoning and their own benefit. It is not that autonomy-based obligations trump beneficence-based obligations; however, when there is no compelling beneficence-based obligation to consider, as demonstrated in the case study, a health care provider has no morally based option but to adhere to the patient’s informed choice (Chervenak & McCullough, 1991). Although other health care professionals are often apprehensive about sharing decision-making powers with the patient (Henderson, 2003), occupational therapists rely on patient input to help identify the direction intervention should take. AOTA acknowledges that “ethical decision making is a process that includes awareness regarding how the outcome will impact occupational therapy clients in all spheres” and encourages the implementation of core occupational therapy tenets that require the active participation of the client (2006, p. 5). Occupational therapy is a traditionally holistic profession with humanistic roots implying a “theoretical and practical commitment to treating patients in a caring, respectful and holistic manner that appreciates their dignity, individual needs and meaningful life circumstances” (Lohman & Brown, 1997, p. 11).
The occupational therapy practitioner has an ethical responsibility to maintain the integrity of the provider–patient relationship in the face of organizational pressures. Whether this relationship is maintained through respect for autonomy or advocating for patient rights and needs with regard to care, occupational therapists must be aware of their responsibilities to the well-being of the patient. Within the AOTA Occupational Therapy Code of Ethics (2005), the first principle calls practitioners to act with beneficence. Although the therapist cannot disregard or neglect his or her relationships within an organization, a practitioner must remember that undermining the patient’s trust promotes neither the integrity of the organization nor the integrity of the patient–provider relationship.
References
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Author
Lea Cheyney Brandt, OTD, OTR/L
Member at Large, AOTA Ethics Commission
