Ethical Dilemmas in Action: RTP Decisions Regarding Back Injuries

1. Ethical Dilemmas in Action: RTP Decisions Regarding Back Injuries Kimberly S. Peer, EdD, ATC, LAT Program Coordinator Kent State University Gretchen Schlabach, PhD, ATC, LAT Program Director Northern Illinois University

2. Course Objectives • Provide Foundational knowledge regarding ethical principles and theories that guide clinical decision-making • Engage participants in considering the ethical elements associated with back care management and return to play • Challenge participants to actively engage in ethical problem-solving activities – including but not limited to – ethical reflection

3. The cornerstone in a sea of ambiguity? • COE • “-those standards and fundamental values that preserve the integrity of the profession, prevent misrepresentation among members, and protect against unethical practices or fraud”

4. If not just the code, then what is Ethics? ……. is branch of philosophy, and is a systematic inquiry and judgment about the moral dimensions of human conduct.

5. MORAL …of or relating to principles of right and wrong behavior… Merriam Webster Dictionary

6. And this has to do with the back…how?!!! We cannot ignore the moral dimensions of our lives; it is always and everywhere present. • Jackson, Boostrom, & Hansen

7. Ethics Defined • “What is right…what is good” • Trilogy (Kidder, 2003) • Values • Moral Reasoning and Ethical Decision Making • Moral Courage

8. How we ought to treat people. Values • Are moral in nature • Are intrinsic • Focus on human rights, integrity, welfare • In other words…..

9. Professional Values • Are easy to remember • Encourage ETHICAL BEHAVIOR • Encourage consistent patterns of behavior • Support a framework to facilitate excellence in clinical judgments • Support a spontaneity in practice • Encourage professional commitment • Give shape, meaning, direction to life

10. Professional Values • Impart Exclusiveness • Affect Professional Behavior and Influence Attitudes and Beliefs • At the Heart of Every Professional Decision and Action (Wilson, 1995) • Mark of Professional Excellence (Weiss, 2002)

11. Professional Core Values… • Beliefs that are intrinsically important • Foundation for Developing a Sense of Professional Commitment and Responsibility • Identification of Values = Professional Identity will emerge? • UNIFY US ACROSS SETTINGS?

12. Moral Reasoning & Ethical Decision Making • ETHICAL INQUIRY • Requires the decision maker to consider facts in light of important VALUES

13. MORAL COURAGER.M. Kidder, Moral Courage, 2003

14. “Being ethical also takes…courage. That courage, on occasion, demands resistance; on other occasions it demands persistence; and on other occasions, it may even demand assertiveness.”

15. “…While fostering courage, however, we have to avoid being self-righteous. Courage must be coupled with the humble acceptance that we will not always make the best decisions or the best choice, but we will keep trying, and we trust our colleagues and clients will help us by providing constructive criticisms”

16. Ethical Dilemmas • Right versus wrong • Right versus Right

17. Four Paradigms • Truth versus Loyalty • Individual versus Community • Short Term versus Long Term • Justice versus Mercy

18. Key factors in ethical dilemmas • Information • Public Exposure and Reputation • Personal Loss

19. An Ethical Dilemma? An athlete with a polynodal cyst is the starting shortstop for a baseball team. The cyst is causing considerable LBP. A major game is pending and the athletic training staff administers a continuous TENS treatment to allow the athlete to play without pain.

20. What information do you have? • What are the professional reputation and/or public exposure issues? • What are the personal losses? • Which paradigm defines your decision?

21. The artistry of professional practice ….Unfolds as professionals consciously grapple with those gray areas of professional practice in which the precise direction to be taken is not clear because the situation is shrouded in moral ambiguity, value conflicts, and ethical dilemmas. P. Clark

22. Let’s look at another case… An athletic trainer at a clinic is evaluating a patient experiencing considerable back pain. The patient is clinically obese, which is addressed in the assessment. During the course of treatment, the AT and patient establish a rapport. One day during treatment, the patient brings in her 9 year old daughter who consumes 2 sugary sodas and a bag of chips during the 1 hour treatment session. The AT takes the opportunity to talk to the mother about appropriate nutrition for her child and how obesity runs in families. Was this ethical? Cases adopted from Schlabach, GA; and Peer, KS. Professional Ethics in Athletic Training, Mosby-Elsevier Publisher, 2008.

23. Being Good and Doing Good How does one keep their footing and keep their professional balance in a challenging practice setting? It is abouttaking the high road…… It is about professional ethics………

24. ETHICS - APPROACHES Roles Ethics Ethical Equilibrium Rules Ethics Goals Ethics

25. ETHICS - APPROACHESTheory ROLE ETHICS/VIRTUE ETHICS …..is a moral theory that emphasizes character, rather than rules or consequences, as the key element of ethical thinking Roles Ethics Ethical Equilibrium Rules Ethics Goals Ethics ROLE ETHICS

26. ROLE ETHICS • Aristotle – Classic Values • Fortitude (perseverance) • Temperance (controlling human passions) • Prudence (practical wisdom) • Justice (fairness, lawfulness)

27. ETHICS - APPROACHESTheory GOAL ETHICS/TELEOLOGY ……… action-based moral theory that that deems the ends justifies the mean Roles Ethics Ethical Equilibrium Rules Ethics Goals Ethics GOAL ETHICS

28. ETHICS - APPROACHESTheory RULE ETHICS/DEONTOLOGY ……… action-based moral theory that deems the means justifies the end Roles Ethics Ethical Equilibrium Rules Ethics Goals Ethics RULE ETHICS

29. PROFESSIONAL ETHICS

30. APPLICATION of PROFESSIONAL ETHICS INATHLETIC TRAINING Roles Ethics Ethical Equilibrium Rules Ethics Goals Ethics

31. APPLICATION of PROFESSIONAL ETHICS inATHLETIC TRAINING

32. ETHICAL ANALYSIS

33. DILEMMAS IN ACTION • A male BKB player reports to campus with LBP and is not cleared for participation. A medical work-up reveals a HNP. The ATC discusses the injury with the coaching staff. If the athlete is not cleared, the coaches fear decreased scouting products from that particular region (which is a productive recruiting region) due to the DQ. If the athlete is cleared, he will likely not play and will need significant modifications to continue through the season. What is the ethical dilemma?

34. ETHICAL ANALYSIS WHO, WHAT, WHERE 1. What is the problem? 2. What are the facts of the situation? 3. Who are the interested parties? (facility, patient/client, other health care professionals, observer, payers, et.) 4. What is the nature of the interest? What is the problem? (professional, personal, business, economic, intellectual, societal)

35. ETHICAL ANALYSIS ETHICAL ISSUES 1. Does it violate your professional code of ethics (NATA Code of Ethics)? Which principle? 2. Does it violate any healthcare principle (autonomy, beneficence, nonmaleficence, justice)? LEGAL ISSUES 1. Is there a legal issue Practice Act/licensure law? 2. Other laws?

36. ETHICAL ANALYSISHealth Care Principles CLINICAL INSIGHT Respect for autonomy: respecting the decision-making capacities of autonomous persons; enabling individuals to make reasoned informed choices. Beneficence: this considers the balancing of benefits of treatment against the risks and costs; the healthcare professional should act in a way that benefits the patient Non maleficence: avoiding the causation of harm; the healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm should not be disproportionate to the benefits of treatment. Justice: distributing benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner

37. ETHICAL ANALYSISEthical vs Legal Clinical Insight

38. Case Two • Football player who has a PMHx of LBP reports to camp with increased LBP and stiffness. After 1 week of 2/day practices, the athlete can no longer go and has a full work-up which reveals HNP. The MD administers epidural injections and discusses with family decision regarding playing or not. The athlete decides to not play indicating that it is too painful. Two weeks later, the athlete decides he made a bad decision and wants to return back on the team and try more epidural injections. What are the ethical issues here?

39. ETHICAL ANALYSIS INFORMATION 1.What information do I need? 2. Is there a treatment, policy, procedure, law, regulation, or document that I do not know about? 3. Can I obtain a copy of the treatment, policy, procedure, law, regulation, or document in writing? 4. Do I need to research this issue any further? 5. Do I need to consult with a mentor, an expert in the area, or a lawyer?

40. ETHICAL ANALYSIS ACTION STEPS 1. Brainstorm possibilities. 2. Eliminate obvious wrong or impossible choices. 3. ROLE ETHICS Does the action compromise respect, truth/honesty, and integrity? Does the action compromise my personal values? 4. GOAL ETHICS Does the action compromise the NATA Strategic Direction? 5. RULE ETHICS Does the action compromise the NATA Code of Ethics Does the action compromise the universal Health Care Principles?

41. ETHICAL ANALYSIS ETHICAL REFLECTION 1. Have you found ethical equilibrium? ROLE:1) Have you honored professional values, e.g., respect, truth/honesty, and integrity? 2) Have you honored your personal values? GOAL: Have you honored the NATA Strategic Plan? RULE: Have you honored the NATA Code of ethics and other health care principles? 2. How do you feel about your course of action?

42. Let’s look again from a different angle… An athlete needs a bone scan for a suspected lumbar stress fracture. She is unable to return to play until she receives clearance, which will be based on the scan results. You receive the referral from the team physician and have set up an appointment and transportation to the appointment for the athlete. On the morning of the scan, the athlete calls to cancel the appointment 30 minutes before you are to leave to take her there. You reschedule the appointment for the following day; this time the athlete fails to show. When you see her that afternoon, she laughs and said she must have forgotten and asks you to reschedule the appointment. This time when you call to reschedule, you are given an appointment time 1 week away. You typically try to see if the bone scan staff can “squeeze you in sooner,” but you do not ask for that favor this time. Is this ethical? Cases adopted from Schlabach, GA; and Peer, KS. Professional Ethics in Athletic Training, Mosby-Elsevier Publisher, 2008.

43. Do values play a role here? • Were they professional values or personal values? • Was there a prominent paradigm you shifted to that was not used in the prior cases?

44. And Another… You work for a private physical therapy clinic as an athletic trainer. A worker who was recently injured is nearing time to return to his job. His progress has been fair, but it certainly falls within the marginal range. He has shared with you that during his time off he has been able to help his elderly father care for his mother, who has Alzheimer’s disease. He is always on time to the clinic and works hard during his rehabilitation. He states that his father cannot afford to institutionalize his mother and his help creates some relief from the situation. You are writing the report for his follow-up visit for the physician, which will determine whether he returns to work the next week or has his therapy extended another 3 weeks. You know the physician will ask what you think about his readiness to return to work. What do you do? Cases adopted from Schlabach, GA; and Peer, KS. Professional Ethics in Athletic Training, Mosby-Elsevier Publisher, 2008.

45. Your Cases… We are faced with challenges each day…feel free to share your cases yet ensure anonymity when reporting the case…no names, institutional ties, etc…

46. The Artistry of Professional Practice ….Unfolds as professionals consciously grapple with those gray areas of professional practice in which the precise direction to be taken is not clear because the situation is shrouded in moral ambiguity, value conflicts, and ethical dilemmas. P. Clark

47. Summary “Although this may sound odd, the purpose of ethics is not to make people ethical, it is to help people make better decisions.” – Brown, 1990, xi.

48. May you always keep your balance and footing on the high road of professional life.

49. Thank You • Kimberly Peer, EdD, ATC, LAT • ATEP COORDINATOR • KENT STATE UNIVERSITY • kpeer@kent.edu • Gretchen Schlabach, PhD, ATC, LAT • ATEP DIRECTOR • NORTHERN ILLINOIS UNIVERSITY • gas@niu.edu