Ethics in Hearing Health Care: Strategies for Ethical Solutions Presenter: Suzanne Lindsey-Henderson, MA Senior Educational Specialist Beltone Hearing Care

From the desk of our Attorney

The views expressed in presentations made at International Hearing Society (IHS) educational events are those of the speaker and not necessarily of IHS. Presentations at IHS events, or the presence of a speaker at an IHS event, does not constitute an endorsement of the speaker's views.

Objectives • Defining the terms • Principles of ethics • Strategies and how they apply to hearing instrument fittings • Code of Ethics • Q&A

Defining the Terms • • • • •

Ethics Morality Law Bioethics Ethical dilemma

Ethics and Morality • Ethics is a set of moral principles and a code for behavior that govern an individual’s actions with other individuals and within society. • Morality is what people believe to be right and good, while ethics is a critical reflection about morality.

Ethics and Morality  In the end:  Ethics and morality are about the same  They are both about what you ought to be doing with your life

 If an act is immoral, then you ought not to be doing it  If an act is unethical, then you ought not be doing it either

Ethics and Morality  To make things clear:  Science tries to figure out the way the world is, was, or will be  Ethics is about the way the world ought to or should be

Ethics and morality  Science would ask:  What will be the effect of detonating a nuclear weapon in a major city?  What led to the extinction of the dodo bird?  Is there a beer in the fridge?

Ethics and morality  Ethics would ask:  Ought we be detonating nuclear weapons around large numbers of people?  Should endangered species be protected from human hunting?  Should I really have that last beer in the fridge before driving home?

Law • Laws are brought about by tension, agitation and conflict by dramatic situations. • • • • •

Amber Hagerman Adam Walsh Jacob Wetterling Pam Lynchner Megan Kanka

Law • Laws are societal rules or regulations that are obligatory to observe. • Laws protect the welfare and safety of society, resolve conflicts, and are constantly evolving. • Laws have governed the practice of medicine for over one hundred of years.

Comparing Law and Ethics • Law, ethics, and bioethics are different but related concepts. • Laws are mandatory to which all citizens must adhere or risk civil or criminal liability.

• Ethics relate to morals and help us organize complex information and competing values and interests to formulate consistent and coherent decisions.

Law  Keeping in mind that we must obey the law:  OHIO  It is illegal to fish for whales on Sunday  It is illegal to get a fish drunk

Law  FLORIDA  If an elephant is left tied to a parking meter, the parking fee has to be paid  Men may not be seen publicly in a strapless gown  Unmarried women cannot parachute on Sunday

Law  TEXAS  It is legal to drive without a windshield, but illegal to drive without windshield wipers  It is illegal to milk another person’s cow  It is illegal for one to shoot at a buffalo from a second story window

Last, but not least…  WASHINGTON  Harassing Big Foot, Sasquatch or any other unidentified species could lead to jail time

Let’s talk about ethical vs. legal…  Scenario 1 – the poorly fit user  Scenario 2 – managed care  Scenario 3 – national news

Scenario 1- Poorly Fit User A woman wearing a set of digital hearing aids comes in complaining that they don’t work very well. They were fit by the HCP who worked in your office previously. You discover the following: • • • • •

•  •

They are less than 1 year old They are entry level, 3-channel digital hearing instruments with basic noise reduction, anti-feedback, and omni mics Style is ITE No speech testing The woman is very disappointed because she reveals that the dispenser said this was top technology and she paid what amounted to her life savings getting these Was what the other dispenser did legal? Was what the other dispenser did ethical? What is your next step?

Scenario 1  Was what the fitter did legal?  Was what the hearing instrument specialist did ethical?

Ethical?

Legal?

Scenario 2 – Managed Care  A man comes in with a moderate to severe s/n loss and a very active lifestyle with lots of difficult listening environments. He has a hearing aid benefit from his company. Under the contract, you can fit him with budget hearing instruments and you cannot upgrade him and charge him the difference for the more advanced hearing instrument. You are also not allowed to charge him for assistive listening devices.

Scenario 2  Is fitting an entry level hearing instrument on this patient legal?  Is it ethical?  What do you do?

Scenario 3– National News So hard not to bring up politics…     

Hilary Clinton – e-mails Ted Cruz – robo-call re Ben Carson John Kasich – staying in the race to the end Bernie Sanders – everything will be free The Donald – building a wall

Scenario 3 – National News  Pot laws in Colorado  Colorado law allows the sale and distribution of recreational marijuana  Marijuana remains illegal under federal law  Rules of professional conduct in Colorado prohibit lawyers from assisting clients to engage in conduct that is criminal (Colorado Bar Association)

Scenario 3  Is it legal for attorneys in Colorado to provide legal services to clients re marijuana-related conduct permitted under state law?  Is it ethical?

Bioethics • Bioethics refers to the moral issues and problems that have arisen as a result of modern medicine and medical research.

• Issues in bioethics are usually life-and-death issues! • Ethical and bioethical principles can be personal, organizational, institutional or worldwide.

Ethical Dilemma

Value conflicts, no clear consensus as to the “right” thing to do. A conflict between moral obligations that are difficult to reconcile and require moral reasoning.

Ethical Dilemma

Situations necessitating a choice between two equal (usually undesirable) alternatives.

Ethical Questions • Should a parent have a right to refuse immunizations for his or her child? • Does public safety supersede an individual’s right? • Should companies/organizations be forced into healthcare plans that go against their beliefs? • Should a woman be allowed an abortion for any reason?

Ethical Questions • Should terrorists be tortured to gain information possibly saving hundreds of lives?

• Should healthcare workers be required to receive the H1N1 vaccination? • Who should get the finite number of organs for transplantation?

Bioethical scenario  17 year old with Hodgkin’s lymphoma refuses to continue her chemotherapy. Mother upheld her right to refuse treatment  Generally, parents are the final decision maker for treatment on minors  The hospital took them to court to appoint a guardian to make the decision

Bioethical Scenario  Was the medical staff and hospital acting in an ethical manner?  Was the patient and mother’s decision legal?

Bioethical scenario  Would it change your mind if:  The minor was younger?  You knew the chance of a cure was 90% with continued chemotherapy?

Ethical Action Strategies • Deontology (duty) • Consequentialism (actions) • Virtue ethics/intuition (morals and values) Beliefs • Rights ethics (individuality and the American culture)

Ethical Theories Deontology /Nonconsequentialism: Derived from the Greek word, Deon, meaning duty. Considers that some acts are right or wrong independent of their consequences. Looks to one’s obligation to determine what is ethical and answers the question:

What should I do and why should I do it?

An Example Deontology: A duty Zelda, a practitioner, believes she has a duty to give cardiac clients detailed information on the pathology involved in their condition even though the client has indicated that they are not ready or may be terrified to hear the information causing the client distress.

Ethical Theories Continued

Consequentialism: Also called Teleological, Greek word, Telos, meaning end or consequence. Actions are determined and justified by the consequence of the act.

Consequentialists consider all the consequences of what they are about to do prior to deciding a right action. This also answers the question: What should I do and why should I do it?

An Example Consequentialism: Action Had Zelda respected the wishes of her clients, she would have given them only the information which would have been a benefit to them and not caused them undue stress. She would have been motivated by her desire to do good (beneficence), rather than her sense of duty. This is a deontological betrayal.

Ethical Theories continued • Utilitarian Ethics: Considers the greatest good for the largest number of people. Also answers the question: What should I do and why should I do it? • Intuitionism: Resolves ethical dilemmas by appealing to one’s intuition, a moral faculty of a person which directly knows what is right or wrong. (A gut feeling of knowing what is right).

Ethical Theories continued Rights: This popular American theory resolves ethical dilemmas by first determining what rights or moral claims are involved and take precedence, (consider the abortion debate- personal – mom vs. fetus/child, societal- women’s choice vs. murder.)

Ethical Theories continued Virtue Ethics: Contrary to other ethical theories, virtue ethics tells us what kind of person one ought to be, rather than what they do. The focus is on the character (goodness) of the person.

Two Questions When Faced with a Dilemma

• Behavior: What should I do?

• Motivation: Why should I do it?

The Identity Argument • Premise 1: What is understood to be morally right depends (at least in part) on one’s identity as a moral person. • Premise 2: Ones’ race ethnicity and culture is central to one’s identity as a moral person. • Conclusion: Thus, what is understood to be morally right by an individual depends (at least in part) on that person’s race, ethnicity and culture.

Race, Ethnicity and Culture What exactly do we mean by race, ethnicity and culture? Race – Genetically there is only one race, which is the human race. Society makes judgments about the varieties of biological characteristics. Eventually, biological characteristics are seen as socially constructed which often leads to stereotyping.

Race, Ethnicity and Culture What exactly do we mean by race, ethnicity and culture?

Ethnicity - An individual’s identification with a particular cultural group to which they are biologically related.

Race, Ethnicity and Culture What exactly do we mean by race, ethnicity and culture?

Culture - A set of beliefs, values and traditions that are socially transmitted from one generation to another. It defines a group’s norm’s or community’s identity.

Cultural Differences May include: • Value the family over the individual. • Engage and expect the family’s support in their self-care. • Value the institution’s that are sensitive to their cultural needs.

Moral vs immoral across cultures USA • Eating beef • Drinking alcohol, gambling • Women wearing shorts, face uncovered

Immoral elsewhere • India • Middle East/Islamic cultures • Iran, Saudi Arabia, Sudan

And the reverse… Immoral - USA • Killing newborn females • Female genital mutilation • Bribery • polygamy

Moral or acceptable • China, India • Many African nations • Many countries • Iraq, Malawi, Namibia, Uganda and others

The Dangers of Stereotypes 

Are oversimplifications to conceptions or images of what a particular group or person should look like, or how they should act by disregarding each person’s uniqueness.



Represent the end-point of one’s understanding (all members of a particular group fit the same pattern or mold).

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Do not encourage further exploration of the individual or assimilation into the majority group.

Generalizations • Generalizations – Statements that represent common trends in a group with the understanding that further information needs to be gathered to verify its application to a particular person. • Represent a starting point and have been used by anthropologists whenever they see a broad pattern of similarities among groups of people. • May lead to inaccuracies in their application to a specific client.

Organizational Ideas and Actions • AKA – Group think • Cultural relativism: “Everyone does it.” • Cheating • Taking office supplies for personal use • Conducting personal business at work

Ethical Principles What are ethical principles, and how do they help with decision making?

Ethical Principles

Conflict is inevitable. Ethical principles provide the framework/tools which may facilitate individuals and society to resolve conflict in a fair, just and moral manner.

Ethical Principles • Autonomy/Freedom • Veracity

• Privacy/Confidentiality • Beneficence/Nonmaleficence

• Fidelity • Justice

Autonomy • The right to participate in and decide on a course of action without undue influence. • Self-Determination: which is the freedom to act independently. Individual actions are directed toward goals that are exclusively one’s own.

Veracity

The duty to tell the truth. Truth-telling, honesty.

Privacy/Confidentiality • Respecting privileged knowledge.

• Respecting the “self” of others.

Beneficence/Nonmaleficence • The principle and obligation of doing good and avoiding harm. • This principle counsels a provider to relate to clients in a way that will always be in the best interest of the client, rather than the provider.

Fidelity • Strict observance of promises or duties. • This principle, as well as other principles, should be honored by both provider and client.

Justice The principle that deals with fairness, equity and quality and provides for an individual to claim that to which they are entitled. • Comparative Justice: Making a decision based on criteria and outcomes. ie: How to determine who qualifies for one available kidney. 55 year old male with three children versus a 13 old girl.

• Noncomparative Justice: ie: a method of distributing needed kidneys using a lottery system.

Ethical Dilemma: Deciding People’s Fate

Ethical Dilemma: Deciding People’s Fate

You are on a sinking ship and there is only ONE lifeboat available. Posted on the side of the lifeboat is a sign which reads, “Maximum Occupancy” - 8 persons…this boat will sink if over occupied.” Standing on the deck and waiting on board the lifeboat are nine adults and one child.

You must decide who dies.

Ethical Dilemma: Deciding People’s Fate People on deck • • • • •

• • • •

You A young mother and her infant son A 75 year old retired physician His 68 year old wife A 17 year old, pregnant girl (this counts as one person) A professional athlete (male) A member of the clergy A middle aged school teacher and Her husband, a banker

Ethical Dilemma: Deciding People’s Fate Who would go on the lifeboat first? • The young mother with her infant • The pastor • The professional athlete Who would be second? • You • The retired physician and his wife • The teenager who is pregnant

Making This Work How do we make this work for our business?

An Example of a Decision Making Model (ADPIE) Assessment, Diagnosis, Plan, Implementation, Evaluation • Assessment  Gather the facts/collect information from a variety of sources

• Diagnosis  Identify the problem or issue

ADPIE continued Plan • Explore alternatives and/options. • Identify the consequences of actions/non-actions. • Analyze the values and professional issues at stake. • Select the course of action/make a decision. • Justify the decision.

ADPIE continued Implementation • Carry out the plan.

Evaluation • Determine how this ethical problem could possibly have been prevented. • Lessons learned. • Assessment of outcomes.

Besides being ethical…. Laws to protect consumers

Illinois

HEARING INSTRUMENT CONSUMER PROTECTION ACT

Purpose & Benefit  The purpose of the act is to protect consumers from dishonest sales practices  People who purchase hearing instruments in the state of Illinois will benefit

What does the act cover?  Applies to the sales of all devices that are designed, intended, or offered to improve a person’s hearing  Hearing instruments  Parts and attachments  Accessories (includes earmolds)

 Does not apply:  To batteries or cords or to devices offered by a telephone or other utility company in connection with providing telephone or other communication services  To medical or osteopathic doctors

Who must comply  Any hearing instrument dispenser doing business in Illinois  Any person who is not a properly trained professional, but who advertises or displays a sign or represents himself as someone who tests, fits, selects, services, dispenses or sells hearing instruments

What legal protections are provided by the act?

 Before the sale (purchase price over $50)  Dispenser must give you a written statement containing the following:  Dispenser’s name, license number, business address and phone number, and signature  Hearing instrument manufacturer’s name, and the model and serial numbers; and date of purchase  The full amount of the charges required to complete the sale

What legal protections are provided by the act?

 Medical exam before the sale  The act recommends seeing an ENT before buying a hearing instrument – dispenser may not sell you a hearing aid unless you present a statement from your doctor showing an exam w/in the last 6 mos and that you could benefit from hearing aids  However…the patient can sign a waiver stating that you have been informed that it is in your best interest to see a doctor and you’ve chosen not to do so

What legal protections are provided by the act?

 Sale of used hearing instruments  Dispenser must clearly mark the receipt and the container as “used” or “reconditioned” and clearly state the terms of the guarantee, if any

What legal protections are provided by the act?

 Cancelling the sale  Entitled to return the hearing aid(s) and receive a refund during the first 30 days following the sale. Mail order = 45 days  If the hearing instrument is returned to the manufacturer for adjustment/repair during that period, the refund period will be extended by the number of days that the h.a. was out of your possession

What legal protections are provided by the act?

 Cancelling the sale  At the time of the sale, the dispenser must give you a written notice. The notice must:  Inform you of your right to cancel the sale  Include the address and phone number of the seller  As a dispenser, you can charge a restocking or dispensing fee if it is clearly stated in the sale document

What if my rights are violated?  You can file a complaint with the Illinois Dept. of Public Health w/in 3 years from the date the dispenser violated the act  Complaint must be in writing  Should attach a copy of the contract and other relevant documents

What happens then?  DPH will investigate the complaint  If there is a violation, DPH will encourage the dispenser to voluntarily correct the matter  Department has the authority to revoke or suspend your license or impose a fine

 If found that the act was violated, the Attorney General has the authority to file a lawsuit against the dispenser

Other remedies  Private lawsuits  You have a right to file a lawsuit if:  The dispenser has violated the act  The dispenser has failed to honor the warranty or otherwise violated the contract

CODE OF ETHICS

Conduct and Relationship with Patient  Continuing Education  It is in the best interest of the patient that the IHS member engage and participate in continuing education during each year of active practice

 Referrals  Member shall utilize all resources available, including referral to other specialists as needed

 Services Rendered  Member shall accept full responsibility for the exercise of judgement within, but not limited to, the areas of his/her expertise. These services include the testing of human hearing and the selection, fitting dispensing and servicing of hearing instruments and counseling patient. Member shall not guarantee outstanding results from the use of hearing instruments, products, services or counseling when such is not the case. He/she shall exercise caution not to mislead patients to expect results that cannot be predicted.

Conduct and relationship with patient  Confidential aspects of patient relations  Member shall hold in professional confidence all information and professional records concerning a patient and use such data only for the benefit of the patient or as the law demands

 Conduct in regard to colleagues and hearing healthcare professions  Member must keep the welfare of the patient uppermost at all times. He/she shall avoid disparaging, pejorative, and/or inaccurate remarks or comments about professional colleagues or members of the hearing healthcare professions. Shall conduct him/herself at all times in a manner which will enhance the status of the profession. Shall be supportive to individuals and organizations with whom he/she is associated to their mutual benefit. Shall not agree to practice under terms or conditions which tend to interfere with or impair the proper exercise of his/her professional judgment and skill, which tend to cause a deterioration of the quality of his/her service, or which require him/her to consent to unethical conduct.

Conduct and relationship to patient  Maintenance of records  Member shall initiate and maintain records of services provided to patients. All laws or rules and regulation pertaining to keeping of records must be carefully observed.

 Fees and compensation  Member shall not participate with other health professionals or any other person in agreements to divide fees or to cause financial or other exploitation when rendering professional services

 Delay in providing service  Member shall not delay furnishing care to patients served professionally w/o just cause

Conduct and relationship to patient  Discontinuance of service  Shall not discontinue services to patients without providing reasonable notice of withdrawal, providing all contractual agreements have been satisfied

 Safety and sanitation  Practice accepted standards of infection control and exercise reasonable precaution to maximize patient safety

 Mail order/internet sales  Do not sell hearing aids to a patient via mail order or internet without establishing direct, face-to-face contact

Responsibility to the profession and colleagues

 IHS member has the duty to observe all laws, rules, and regulations applicable to the dispensing of hearing instruments; to uphold the dignity and honor of the profession; and to accept its ethical principles. Member shall not engage in any activity that will bring discredit to the profession and shall expose, without fear or favor, illegal or unethical conduct in the profession  Members are encourage to report violations of the code  Members shall not pursue any course of action that may be harmful or detrimental to the Society, its members or the public we serve  Member holding an official or elective position in HIS or an affiliate chapter shall not use that position for self-aggrandizement  If you have served on an exam-writing committee or have knowledge of the contents of the exam, you cannot hold a pre-test class or review course to prepare candidates for the exam for not less than five years

Advertising  Member who chooses to advertise his/her services shall use only material considered ethical and complying with laws, rules and regulations governing advertising. Member shall endorse the following statements of principle that assure protection of the hearing impaired and the public in general.       

Truth Responsibility Taste and Decency Disparagement Bait Advertisements Guarantees and Warranties Mail order/ Internet

Standards  Maintenance of high standards by all IHS members is in the best interest of persons served professionally, the IHS member, and the profession.  Unethical for a member to willfully and knowingly violate any law, rule, or regulation applicable to the dispensing of hearing instruments.  Unethical to represent yourself as something you are not or to use symbols or depictions which connote the medical profession  Unethical to use any terms that may be said to confuse the public that you have some relationship to a governmental or nonprofit medical, educational, or research institution

Suzanne Lindsey-Henderson [email protected]