Sources of Moral Guidance

The basic definitions of ethics, morality, and values set a foundation to help separate ethical concerns from other types of problems and issues an occupational therapist faces in clinical practice. Once it is clear that a situation or problem involves ethics, the next question is where you should look to determine what is right or morally correct. Are morals grounded in one’s own opinion? Or that of significant others? In the law and regulations that govern professional practice? In the opinions of one’s professional group or association? In the religious or philosophical beliefs of the individual or institution?

This section explores alternative sources of moral guidance. What is important is not so much to determine what the right thing to do is but to reflect on the various sources of moral authority that have particular impact on your professional practice and personal decision making. One should consider how these sources of authority shape one’s behavior and character.

Family and Peers

One of the primary sources of support and guidance for moral decision making are peers and family members. In two separate national studies (one of registered nurses and the other of pharmacists) the majority of respondents stated that they would first turn to their spouse for moral advice or counsel, followed by a peer [Haddad 1988, 1991]. Seeking the advice of someone who is close and trusted is not too surprising, and it is likely that occupational therapists would respond in the same way their colleagues in nursing and pharmacy did.

Individuals who know us well and share the same perspectives and values are logically the first-line resource for most health professionals faced with a moral problem. However, even though it is understandable why an occupational therapist might turn to a peer for ethical advice there is no reason to believe that the peer will be able to provide justifiable resolutions to the problem. In other words, peers and significant others may be sympathetic but they are not necessarily in the best position to help sort through the complicated ethical issues encountered in clinical practice.

Furthermore, significant others and peers would probably not be considered the source of moral authority, even if they were skilled in analyzing ethical problems. We must look further than the individuals who make up our families and our colleagues for moral guidance. For example, a therapist is faced with an ethical decision: whether or not to fabricate splints for a person who was burned over 90% of her body. Instead of the therapist asking his wife about the decision, the therapist networks with professional peers who are members of the hospital’s ethics committee.

Laws and Regulations

At times it is difficult to distinguish between the law and ethics. Former Chief Justice of the Supreme Court Earl Warren described the relationship between the law and ethics as follows.

In civilized life, Law floats in a sea of Ethics. Each is indispensable to civilization. Without Law, we should be at the mercy of the least scrupulous; without Ethics, Law could not exist. Without ethical consciousness in most people, lawlessness would be rampant. Yet, without Law, civilization could not exist, for there are always people who, in the conflict of human interest, ignore their responsibility to their fellowman [Warren 1962].

Thus, there is a delicate and changeable relationship between ethics and law. Laws and specific regulations that govern health care practice order our professional and institutional relationships. In an ideal world, the law would embody our ethical commitments. Yet, sometimes the law and ethics diverge.

It is possible that an occupational therapist could conclude that he or she should engage in civil disobedience to violate the law or public policy to do what is ethical. Of course, this sort of decision to disobey a law or regulation should not be taken lightly. If ethics sometimes requires civil disobedience, it implies that what is ethical is not determined solely by public policy or law. Therefore, this reasoning argues, the law is not a sufficient source of authority for determining proper ethical conduct for an occupational therapist.

Professional Codes of Ethics

Health professionals recognize that the question of what is moral has to do with professional ethics. Occupational therapists might turn to a professional code of ethics as a source of moral guidance. For American occupational therapists, this would be the current Occupational Therapy Code of Ethics of the American Occupational Therapy Association [AOTA 2005].

An occupational therapist faced with an ethical problem could turn to the Occupational Therapy Code of Ethics to see what guidance it offers regarding the specific issues at stake. Often the Code will provide direction and assistance. “Health care professionals typically specify and enforce obligations for their members, thereby seeking to ensure that persons who enter into relationships with these professionals will find them competent and trustworthy” [Beauchamp and Childress 2001, p. 6]. Most health care professions codify these rules of conduct into a formal code of ethics.

The purpose of professional codes is to set minimal expectations of those who practice within their respective profession. Professional codes can also be aspirational in nature in that they set more than minimal expectations for members of the profession. The AOTA Code of Ethics states that the code “is an aspirational guide to professional conduct when ethical issues surface.” One limitation of codes is that they tend to oversimplify moral responsibilities.

The occupational therapist is obligated to abide by the tenets of the Code of Ethics. It is possible that occupational therapists may believe that if they fulfill the requirements of the Code of Ethics they have done all they have to do, morally speaking. However, would an occupational therapist’s conduct be always correct just because it conforms to the Code of Ethics of the AOTA?

Another limitation of codes of ethics is that the perspectives of the recipients of health care may be absent. What might the public proclaim as the fundamental obligations of occupational therapists if given the chance?

Finally, how do we account for changes in professional codes? Although the first version of the AOTA Code of Ethics was approved in 1977, it has already undergone several revisions. Each time the Occupational Therapy Code of Ethics changed, did the ethically correct behavior for occupational therapists really change-or only what AOTA members believed was the correct behavior? It seems that the foundation for ethics in occupational therapy is something more basic than current professional agreement based on these changes in the Code of Ethics.

Religion

If an occupational therapist worked in a hospital or ambulatory care center sponsored by a religious organization, the institution’s ethical code may be derived from religious beliefs and ethical commitments of the sponsoring group. For example, if the institution were Catholic and located in the United States it would have to abide by the Ethical and Religious Directives for Catholic Health Care Services [U.S. Conference of Catholic Bishops 2001]. In addition, the occupational therapist may personally believe and hold to the beliefs and moral guidance of a religious tradition.

Should a religious tradition be considered a voice of moral authority? Religious traditions are a salient source of moral guidance on all-important matters of human life. Believers in a faith hold that a decision is right or morally correct because of divine authority. Thus, being a believer commits one to the ethical teachings of one’s faith. Some argue that religion alone is the sufficient and ultimate justification for moral guidance. However, there is often plurality of beliefs regarding what is moral and good within a single faith tradition.

What if the religious beliefs of the institution and the occupational therapist differ? If there are differences in religious beliefs, whose beliefs should take precedence? For example, a female therapist receives an order to splint a male Hasidic Jew. The therapist recalls some information about the Hasidic Jewish culture. She thinks it may be inappropriate for her to touch this man’s hand. The therapist is unsure what to do. She knows that this client needs her services and she is the only therapist in the clinic, but she also wishes to be culturally and religiously sensitive.

Because the moral authority for religious beliefs is by its very nature mutually exclusive, there would be no common language or set of ethical principles from which to engage in discussion. There is no common language because different people hold different religious beliefs. We would have to look for a view of ethics that is respectful and cognizant of religious beliefs but that exists outside individual belief systems in order to meet on common ground. In a pluralistic society, such as that encountered in the United States, secular ethical principles have great appeal because they are grounded on reason. Moreover, there is striking similarity among basic ethical principles and constructs held across diverse religious beliefs. This indicates that there is perhaps another, more basic source, of moral guidance. We now turn to three of these traditional approaches to secular ethics that allow us to talk across various faith traditions, cultures, and disciplines.

Classic Approaches to Ethics

One way of discussing morality is to observe that it involves obligations. The principles approach to ethics recognizes these obligations or duties and the universal nature of their application to moral decisions. Another way of viewing the moral life is through a more subjective lens, with a concern for actual persons and their needs and relationships. Care-based ethics attempts to focus on the specific ethical issues that arise within the web of human relationships that nurture and sustain us as human beings.

Finally, we can view the moral life outside the moral problems encountered in clinical practice and instead focus on the character of the occupational therapist. When decisions have to be made in occupational therapy practice it is often in a climate of stress and perhaps urgency. The best tools an occupational therapist can have for dealing with situations such as this are not those provided by principles or care-based reasoning but by a fixed habit of character or virtue. This provides a generally reliable response to ethical challenges. Virtue ethics takes the view that a person with a developed moral character knows when and what type of a decision needs to be made and has the perseverance to follow through. A brief description of each of these traditional approaches to ethics follows.

Principles Approach

Beauchamp and Childress [2001] are the architects of the four principles approach to ethics. Although there are more than the four ethical principles selected by Beauchamp and Childress, these four principles do provide a comprehensive framework for ethical analysis. The four principles are as follows: