An Issue of Ethics: Fall 2005

Understanding Our Code of Ethics Documents
Cidalia Paiva
August 31, 2005
By Cidalia Paiva
Origins of Code of Ethics Documents
Probably the best known and most famous Code of Ethics document in recorded history is the Hippocratic Oath. Written by celebrated Greek physician Hypocrites, in the fourth century B.C., the Hippocratic Oath provided the ethical foundation for the practice of western health care.

As a time-honoured ideal and strong moral force co-ordinating health care practice, the oath falls into two parts. The first part of the Hippocratic Oath outlines the duties of the physician to his teacher and his obligations to transmit medical knowledge. The second part specifies ethical guidelines to be observed in the treatment of disease.

The durable contribution of the oath lies in its articulation of the medical covenant which addresses patient dignity, the confidentiality of the therapeutic relationship and the physician’s responsibility to guard against abuse or corruption of his knowledge and art.

Why does Massage Therapy need a Code of Ethics Document?
As Regulated Health Care professionals we recognize that our profession must conduct itself in a framework of relevant laws, regulations and policies. But we also recognize that these do not govern all behaviours. As members of our profession we are accountable for all our behaviours not just those which fall under the purview of the law. We are also and equally accountable for our ethical behaviour. As members of a health care profession massage therapists are accountable to society.

Our accountability arises out of the professional promise made to society to look after the best interest and well-being of all those entrusted to our care in exchange for the privilege of self-regulation and the status of being a health care profession as opposed to a health service industry.

Specifically, massage therapists have promised society that they will: Always and invariably act in the public interest;conduct themselves according to highest standards of professionalism;adopt a code of ethics that governs the ethical conduct of its members.

What do Code of Ethics Documents consist of?

Code of Ethics documents, in the 21st century at least, typically consist of some kind of preamble statement which identifies the profession as an organizational body including its mission and or goals, usually followed by a values statement which explicitly identifies the professions values. 

The professions values statement in turn is followed by a statement of the ethical principles that ground the practice of health care for all professional healthcare providers and concluded with an explicit statement of the specific standards negative and positive that embody our values and the principles of medical ethics.

What does our Code of Ethics tell others about us?
Ideally our code of ethics document will tell others who we are and what we believe in. As such, a Code of Ethics document is integrally linked to a profession’s values. Some Code of Ethics documents will include a preamble that explicitly articulates the professions value system. Others will expound their value systems implicitly and the reader is required to infer and deduce these from specific standards of behaviour.

However it is difficult and perhaps even impossible in the absence of some kind of statement about professions values to gage the importance of particular values and to link values and specific behavioural standards in a meaningful way.

Massage Therapy does not function in a vacuum as a regulated health care field. Massage therapists like  doctors, nurses, physiotherapists and other regulated health care professionals, fall under the umbrella of medical ethics.

For example, the behavioural standard of keeping patient confidentiality in the absence of the value of respecting our patient’s rights is like putting the cart before the horse and does not explain or tell us why we ought to respect patient confidentiality. However, if indeed respecting patients is a value of our profession, it follows logically and necessarily that we can be required to maintain patient confidentiality given the fact that we respect our patients. In other words, our values tell us why we do what we do and why it is important.

Massage therapy does not function in a vacuum as a regulated health care field. Massage therapists, like doctors, nurses, physiotherapists and other regulated health care professionals, fall under the umbrella of medical ethics.

As such, a code of ethics document as a professional document in a health care discipline must demonstrate its relationship and relevancy to the principals of medical ethics that are applicable to all health care professions.

The three broadest and most encompassing of these being: Respect for Persons; Non Malfeasance (do no harm); and Beneficence (do good).

“Respect for Persons”

Respect for persons refers to the ethical obligations to treat each person as having dignity and value him or her as a person and never simply as a means to someone else’s purposes. If a treat my wealthy patient with respect in order to secure a hefty fee I am violating the principle of respect for persons because I am not treating him or her with respect because I value him or her as a person but rather because I see them as a means to securing an exorbitant fee for my services.

Non Maleficence or “Do no Harm”
Non maleficence or do no harm is central in discussions of the ethical responsibilities of health care professionals. Human beings have an impulse to help those in need. Throughout history and across cultures individuals have devised ways to prevent illness and cure diseases. The difficulty though rests in the fact that sometimes these well meaning interventions have resulted in harm. Exactly what does not doing harm involve?

The duty of non malficence encompasses not only actual harms but also the risk of harm. In other words, this duty does not just include avoiding the infliction of harm (such as exacerbating or triggering a migraine) but also includes not placing someone at risk by failing to forewarn them that the treatment provided could in fact trigger or exacerbate an existing migraine.

The duty of meleficence also requires that therapists be thoughtful and act carefully. Not all harms or even risks of harm are intentional. It is possible to violate the duty of malifcense without acting maliciously. The violation may involve omission as well as commission. If, for example, I fail to warn my patient with high blood pressure that hydrotherapy may be contraindicated when he asks about a pre-heat, I am not acting from malice but still neglecting to communicate the risk to him.

Beneficence or “Do Good”
The duty of beneficence requires not only that we treat people with respect and refrain from harming them but also that we contribute to their welfare, including their health. In ordinary English, the concept of beneficences includes among its meanings “mercy, kindness and charity.” However, ethically speaking beneficence is regarded as a duty and is therefore a requirement imposed upon us beyond simple acts of mercy, kindness and charity. In its most general form the principle of benificenc holds we have a duty to help our patients further their interests.

The duty of benevolence is often expressed in Codes of Ethics documents in the form of the obligation to benefit our clients through scientific research, preventative medicine and public health initiatives to cite a few typical examples. The duty to confer benefits and actively to prevent and remove harms is especially important in health care. Firmly entrenched in the history of ethics and health care is the belief that the failure to benefit others when we are in a position to do so violates our professional commitment to our patients.

Finally, a code of ethics will list specific behavioural standards that clearly tell us what it is that we are required to do in order to avoid harming our clients as well as what it is that we are required to do in order to benefit them. The focus or structure of these standards can vary from profession to profession however the vast majority of these documents will typically organize these standards under the headings of responsibilities to self, clients/patients, the profession including our colleagues and society.

How does a health care profession enforce its code of ethics?
Typically practitioners who violate a professions code will be subject to disciplinary actions which can range from letters of warning to fines, suspension or revocation of license and even imprisonment depending on the gravity of the offence.

The most significant and in the end the most reliable enforcement mechanism is personal conscience. Ultimately, even when no one else is looking, someone is still bearing witness to our behaviour. That person is us.

Whether we have failed through commission or omission to be faithful keepers of our integrity in touch we can hold ourselves accountable. Why would we choose to do so? Because we are people of integrity who choose to keep our professional promise.

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