Ethics In Occupational Therapy

Editor's note: This course was presented by Fawn Carson, OTD, OTR/L, ATP.

This content was created by Continued with AI assistance.

Learning Outcomes

• After this course, participants will be able to:
  • Identify the seven core principles of the AOTA Occupational Therapy Code of Ethics.
  • Recognize common ethical dilemmas across pediatric, geriatric, and mental health settings.
  • List the steps of a structured ethical decision-making framework for occupational therapy practice.

Course Overview

This course provides a comprehensive and in-depth exploration of ethical principles and decision-making for occupational therapy practitioners. Using the American Occupational Therapy Association (AOTA) Occupational Therapy Code of Ethics as a foundational document, this text-based module will guide you through the seven core principles, common ethical dilemmas, and a systematic framework for resolving conflicts. Through practical case examples and self-reflection questions, you will enhance your ability to identify, analyze, and navigate complex ethical challenges in various practice settings, ensuring the highest standards of professional conduct and client care.

Module 1: Foundational Ethical Principles

The AOTA Occupational Therapy Code of Ethics is the cornerstone for our professional conduct. It is a set of enforceable principles and standards that guide the behavior of occupational therapy practitioners. Understanding and internalizing these principles is the first step toward ethical practice. This module will provide an in-depth review of the seven core principles outlined in the Code.

Principle 1: Beneficence

Beneficence means that occupational therapy personnel shall demonstrate a concern for the well-being and safety of the recipients of their services. Essentially, it is about acting in the client's best interest and promoting good. This principle requires us to provide high-quality, effective services, prevent harm, and advocate for our clients' needs. It is the foundation of our therapeutic relationship. This is not simply about avoiding harm, but actively working to promote health, well-being, and a positive outcome. This can manifest in various ways, from selecting the most evidence-based interventions to advocating for a client's access to services.

Case Example 1.1: Beneficence vs. Productivity

Maria, an occupational therapist, works in a skilled nursing facility. Her manager has set a new productivity quota of 95%, which means she must spend 95% of her time in billable activities. Maria has a client, Mr. Jones, who has recently had a stroke. Mr. Jones is experiencing significant emotional distress and frequently needs extra time to process information and express his feelings. Maria knows that spending a few extra minutes with him to build rapport and provide emotional support would greatly benefit his engagement in therapy. Still, it would cause her to fall short of her productivity target. She feels conflicted between her duty to provide the best care (Beneficence) and her employer's policy.

• Ethical Analysis: Maria's primary ethical obligation is to her client's well-being, as mandated by the principle of Beneficence. While she is responsible to her employer, this must not come at the cost of providing clinically necessary and compassionate care. Her ethical dilemma is prioritizing the client's holistic needs or her employer's productivity demands. A rigid focus on the quota could lead to a less effective intervention, a strained therapeutic relationship, and ultimately, a poorer outcome for the client. The ethical path for Maria is to find a way to meet her client's needs while also addressing the systemic issue. She could document the emotional support as a therapeutic intervention (e.g., "therapeutic use of self to address psychosocial barriers to participation") and initiate a discussion with her manager about how the quota may negatively impact client-centered care.

Case Example 1.2: Balancing Beneficence and Resource Allocation

A home health occupational therapist, Carlos, works with an elderly client, Mrs. Rodriguez, who has severe arthritis. Mrs. Rodriguez's insurance plan only covers a limited number of therapy visits annually. After a few sessions, Carlos realizes that Mrs. Rodriguez could greatly benefit from more frequent and intensive therapy. However, providing this would use up her allotted visits very quickly, potentially leaving her without treatment later in the year if her condition declines. Carlos must decide whether to provide intensive, short-term care for maximum immediate benefit or to spread the visits over to entire year to ensure she has some coverage.

• Ethical Analysis: This scenario presents a direct conflict of Beneficence. Providing more intensive therapy would be highly beneficial in the short term, but it could cause long-term harm by depleting her resources. Carlos's responsibility is to act in the long-term best interest of his client. He must discuss this with Mrs. Rodriguez, explaining the pros and cons of each approach. The ethical solution involves collaborative decision-making that respects her Autonomy while guiding her toward a plan that maximizes her long-term well-being.

Case Example 1.3: Beneficence and the Use of Unproven Interventions

Laura, a pediatric occupational therapist, works in a private clinic. A new client, a child with autism, has parents who have extensively researched alternative therapies online. They are insistent that Laura use a specific, unproven "sensory diet" protocol they found on a forum. This protocol lacks any evidence in peer-reviewed literature and conflicts with Laura's clinical judgment and professional training. The parents state they will seek another therapist if Laura refuses to use the protocol. Laura feels a conflict between her professional duty to provide evidence-based, beneficial care and the family's strong desires.

• Ethical Analysis: Laura's primary obligation is to Beneficence, which includes providing effective and safe interventions. The AOTA Code of Ethics states that practitioners must use judgment and sound reasoning. Laura's ethical duty is to educate the parents about the evidence base (or lack thereof) for the protocol and to explain her rationale for using a different, clinically-supported approach. She should use the opportunity to build a trusting relationship based on professional expertise. While she may risk losing the client, compromising her professional judgment and potentially providing a non-beneficial or even harmful intervention would violate her core ethical responsibility.

Case Example 1.4: Beneficence and Technology Obsolescence

Sarah, an occupational therapist in an outpatient neurological rehabilitation center, continues to use a 15-year-old virtual reality system for cognitive training, primarily because it's familiar and covered by insurance with minimal paperwork. However, she has read several recent research articles demonstrating that newer, commercially available systems are three times more effective at improving executive function. Acquiring the newer technology would require significant administrative effort, grant writing, and justification to the facility director. She is currently prioritizing her convenience and ease of billing over the superior benefit to her clients.

Ethical Analysis: Sarah's actions violate the principle of Beneficence by failing to provide the most effective treatment available, which is an implicit duty under this principle. While administrative burdens are real, they cannot ethically supersede the obligation to maximize client outcomes. The ethical path requires Sarah to actively advocate for the superior, evidence-based technology, demonstrating a commitment to high-quality care, even when it requires personal or administrative effort.

Principle 2: Nonmaleficence

Nonmaleficence means that occupational therapy personnel shall refrain from actions that cause harm. This principle obligates us to avoid physical and psychological injury to our clients. It is the counterpoint to Beneficence: while Beneficence requires us to do good, Nonmaleficence requires us to avoid harming. This includes not only direct harm but also avoiding negligence, abandonment, or inappropriate interventions. This principle requires high clinical competence and constant vigilance to ensure that our interventions, tools, and environments are safe.

Case Example 1.5: Nonmaleficence and Intervention Choice

David, an occupational therapy assistant, is working with an elderly client with a history of heart disease. The client's doctor has cleared them for moderate exercise. David wants to use a new, high-intensity balance training program he learned at a recent conference, believing it will lead to faster progress. However, the client is visibly fatigued after the first five minutes of the exercises and reports feeling lightheaded. David is concerned that the intensity may be too much, but he is excited to try the new protocol.

• Ethical Analysis: David's actions could violate the principle of Nonmaleficence if he continues the intervention despite the client's distress. Even though he intends to help (Beneficence), his primary obligation is to "do no harm." He must recognize the potential for injury and immediately modify or stop the intervention. The ethical choice is to prioritize the client's safety, document the adverse response, and adjust the treatment plan to a lower intensity.

Case Example 1.6: Preventing Harm and Reporting Unsafe Conditions

You are a contract occupational therapist working at a new school. You notice that the sensory gym equipment has not been properly maintained for years. The swings have fraying ropes, the crash pads are torn and have exposed foam, and the climbing wall has loose holds. You have reported this to the school administration, but they have told you there is no budget for new equipment or repairs. You are concerned that a child could be seriously injured, but you also fear losing your contract if you push the issue.

• Ethical Analysis: Your duty to Nonmaleficence is paramount. You are ethically obligated to protect the students from harm. While your job security is important, it cannot come at the expense of a child's safety. The ethical path is to refuse to use the unsafe equipment, document the condition of the gym, and reiterate your concerns in writing to the school administration. If they do not act, you may have a duty to report the unsafe conditions to your professional association or state board, depending on the regulations.

Case Example 1.7: Nonmaleficence and Abandonment

A home health occupational therapist, Jessica, has a heavy caseload and is feeling overwhelmed. A client she has been seeing for several months, Mr. Peterson, has made significant progress and is nearing discharge. However, Mr. Peterson's family calls to cancel his next appointment, and Jessica, seeing an opportunity to reduce her workload, decides not to follow up. She does not formally discharge him or refer him for alternative services. Later, she learns that Mr. Peterson had a fall, and the family is distraught, feeling abandoned by her lack of follow-up.

Ethical Analysis: This scenario constitutes a clear violation of the Principle of Nonmaleficence due to professional abandonment. By failing to discharge or transition care formally, Jessica has left her client in a vulnerable position. While she was not the direct cause of the fall, her actions contributed to a situation of neglect. Her ethical responsibility was to ensure continuity of care, either by completing a proper discharge, providing a referral, or following up to ensure the client's safety and well-being. Her personal desire to reduce her workload does not supersede her duty to her client's well-being and safety.

Case Example 1.8: Nonmaleficence and Improper Delegation

An occupational therapist, Alex, is supervising an Occupational Therapy Assistant (OTA) who is new to the facility. Alex delegates a complex, custom dynamic splint fabrication procedure, a task that the OTA has only done once in school, to the OTA for a high-risk client. Alex provides minimal, rushed supervision. The nursing staff later finds the splint to have a sharp, unrolled edge near the wrist crease that causes a minor skin abrasion on the client. The client complains of pain and requires intervention from a physician.

Ethical Analysis: This constitutes a direct violation of the principle of Nonmaleficence, resulting from negligence and improper supervision/delegation. The OT is ultimately responsible for ensuring the competence of the personnel they supervise and the safety of the intervention provided. By delegating a complex, high-risk task without adequate verification of competence or direct supervision, Alex risked and ultimately caused harm to others. The ethical duty was to either fabricate the splint herself or provide dedicated, on-site supervision until the OTA demonstrated full competency.

Principle 3: Autonomy

Autonomy means that occupational therapy personnel shall respect the individual's right to self-determination, privacy, confidentiality, and consent. This principle respects the client's right to make their own choices regarding their care, even if we as professionals disagree. It also mandates that we protect a client's privacy and ensure their information remains confidential. This includes the right to informed consent, the right to refuse services, and the right to control their personal health information. We must always communicate with clients in a way that allows them to make informed decisions about their care.

Case Example 1.9: Autonomy and Client Refusal

Jennifer, an OT, is providing home health services to an adult with a traumatic brain injury who needs assistance with meal preparation. Jennifer has created a detailed plan to teach the client to use adaptive equipment for cutting and chopping. However, the client refuses to use the equipment, stating, "I don't need help. I can do it myself." The client attempts to chop vegetables with a regular knife, doing so in an unsafe manner. Jennifer worries about the client's safety but wants to respect their wishes.

• Ethical Analysis: Jennifer is facing a conflict between Autonomy and her duty to ensure safety (Nonmaleficence). While she must respect the client's right to refuse therapy, she also has a duty to educate the client about the risks associated with their actions. The ethical path is to find a balance by respecting the client's choice while offering alternative, safe strategies and thoroughly documenting the client's refusal and the discussion. She must ensure the client fully understands the risks and the rationale behind her recommendations.

Case Example 1.10: Autonomy and Confidentiality

You are an OT working in an outpatient mental health clinic. Your teenage client has been making good progress on their social participation goals. During a session, the teen confides that they have been engaging in self-harm. They ask you not to tell their parents, fearing they will be angry and will not allow them to continue therapy. You are bound by confidentiality and the principle of Autonomy, but you are also concerned for your client's well-being.

• Ethical Analysis: While Autonomy requires you to respect the client's wishes for confidentiality, the potential for serious harm invokes the principle of Nonmaleficence. In most jurisdictions, self-harm is an exception to confidentiality rules. You have a legal and ethical duty to break confidentiality to ensure the client's safety. The ethical course of action is to explain this duty to the client in a supportive and non-judgmental manner, and then to involve the parents or other necessary parties.

Case Example 1.11: Autonomy and End-of-Life Decisions

A therapist, Michael, works in palliative care with a client who has a terminal illness. The client, who is alert and oriented, has expressed a wish to decline further occupational therapy services. The client's family, however, is insistent that Michael continue providing care, believing it will prolong their loved one's life. The family pressures Michael to continue with the treatment plan, even though the client has repeatedly expressed their desire to stop.

• Ethical Analysis: This situation presents a direct conflict between the client's Autonomy and the family's desire for what they perceive as Beneficence. Michael's ethical duty is to the client. He must respect the client's right to self-determination, regardless of the family's wishes or the potential outcomes. He should respectfully but firmly communicate the client's wishes to the family and educate them on the principle of Autonomy. The ethical path is to document the client's decision and cease services as requested, while offering supportive services to the family.

Case Example 1.12: Autonomy and Coercive Consent

A school-based occupational therapist, Kenji, receives a parent referral for a child exhibiting significant challenges with attention and emotional regulation. During the initial meeting, Kenji tells the parent that if they do not immediately sign the consent form for OT services, the child will not be able to participate in a highly desired after-school sports program, which the parent knows is crucial for the child's self-esteem. Kenji is attempting to leverage the parents' desire for the sports program to ensure compliance with the OT referral.

Ethical Analysis: Kenji's actions are a clear violation of Autonomy because he is using coercion and misrepresentation to gain consent. Consent must be voluntary and fully informed, without undue pressure or the withholding of unrelated privileges. By tying OT consent to an unrelated activity, Kenji has violated the parents’ right to self-determination regarding healthcare decisions. The ethical solution is to present the benefits and risks of OT services truthfully and allow the parent time and space to make a voluntary decision.

Principle 4: Justice

Justice means that occupational therapy personnel shall promote fairness and objectivity in providing occupational therapy services. This principle extends beyond individual client care to encompass social Justice. It requires us to advocate for equitable access to therapy, fair treatment of all individuals, and non-discriminatory practices. This applies to allocating resources, managing our caseloads, and engaging with the broader community. Our responsibility is to recognize and address systemic barriers that may prevent individuals from receiving the care they need.

Case Example 1.13: Justice and Resource Allocation

A public school district has a limited budget for special education services. Two of the district's schools have significantly higher numbers of children with complex needs requiring intensive occupational therapy. The school-based OT, Chris, is assigned to both schools and has to decide how to divide his time. If he spends more time at one school, the other school's students may not receive the frequency of services listed in their Individualized Education Programs (IEPs).

• Ethical Analysis: Chris is facing a systemic ethical dilemma related to the principle of Justice. He cannot ethically shortchange one group of students to benefit another. His responsibility is to advocate for additional resources for the district. The ethical course of action is to communicate the resource deficit to his supervisors, document the impact on service provision, and work collaboratively to find a solution that ensures all students receive the services they are legally and ethically entitled to.

Case Example 1.14: Advocating for Justice in a Managed Care Setting

An occupational therapist, Tanya, works for a managed care organization that requires strict pre-authorization for all services. She has a client with a progressive neurological disorder who needs daily therapy to maintain functional skills. The insurance company's policy only allows for two therapy sessions per week. Tanya knows that this frequency will not be sufficient to prevent functional decline, so she is pressured to work within the limits of the insurance authorization.

• Ethical Analysis: This scenario highlights a conflict between the client's needs (Beneficence) and the limitations imposed by a third-party payer. The principle of Justice requires Tanya to advocate for fair access to care. Her ethical duty is to appeal the insurance company's decision, provide comprehensive documentation of medical necessity, and educate the client on their rights to appeal the decision. The ethical course of action is to exhaust all avenues to secure the necessary care, rather than simply accepting the insufficient authorization.

Case Example 1.15: Justice and Cultural Competence

An occupational therapist named Mia works in a community clinic that serves a highly diverse population. A new client, a recent immigrant, speaks a different language and comes from a culture where traditional healing practices are highly valued. The family expects Mia to incorporate these practices into her treatment plan. Mia has no training in these practices and is unsure how to proceed. She believes that providing services without integrating these practices may be unjust, as it would not constitute a truly client-centered approach that respects their culture and beliefs.

• Ethical Analysis: This case highlights the intersection of Justice and cultural competence. While Mia is not expected to be an expert in every cultural practice, she has a duty to provide fair and equitable services that are respectful of the client's values and cultural background. Her ethical obligation is to explore ways to collaborate with the family and a qualified interpreter or cultural broker. It would be unethical to either force her own cultural norms on the family or to dismiss their values as irrelevant. The just course of action is to engage in a respectful dialogue, seek guidance from colleagues, and find a way to honor the client's beliefs within the scope of safe and effective occupational therapy.

Case Example 1.16: Justice and Implicit Bias in Scheduling

Lisa, an occupational therapist in a large outpatient facility, manages her own schedule. She finds herself consistently scheduling clients who have premium, high-paying private insurance, or those she perceives as easier cases, in the desirable morning slots when she is freshest. She tends to schedule clients who require interpreters, have complex diagnoses, or rely on government-funded insurance in the less desirable late-afternoon or evening slots. She rationalizes this by arguing that the "easier" cases help her meet her productivity goals quickly.

Ethical Analysis: Lisa is violating the principle of Justice by allowing implicit bias and perceived financial benefit to dictate her allocation of resources (her time and energy). By systematically providing superior access to preferred time slots based on insurance status or perceived client ease, she is engaging in discriminatory practice. The ethical requirement is to schedule clients fairly and objectively, ensuring that all clients, regardless of their background or payer source, have equitable access to quality care during optimal times.

Principle 5: Veracity

Veracity means that occupational therapy personnel shall provide comprehensive, accurate, and objective information when representing the profession. This principle requires us to be truthful and honest in all our professional interactions. This includes accurate documentation, honest reporting of research, and clear communication with clients and colleagues. It is the foundation of trust. This principle applies to all forms of communication, from written documentation to verbal conversations.

Case Example 1.17: Veracity and Documentation

Jane, an OTA, is documenting a recent therapy session with a client. The client had a difficult day and refused to participate in the planned activities. Instead, Jane spent the session providing emotional support and conversing with the client. Her supervisor has a strict policy that all therapy notes must reflect goal-oriented, skilled interventions. Jane feels pressure to fabricate or exaggerate the note to make it appear as though it was a productive session, to order to avoid a negative review from her supervisor.

• Ethical Analysis: Jane's dilemma directly conflicts with the Veracity principle. Fabricating or exaggerating documentation is dishonest and constitutes unethical practice. The ethical choice is to document the session accurately, explaining the client's refusal and the rationale for providing emotional support as a therapeutic intervention. This is a truthful representation of what occurred, and if the supervisor has an issue, it opens a discussion about the importance of accurate documentation versus productivity standards.

Case Example 1.18: Misleading Advertising and Veracity

You are a business owner of a private occupational therapy clinic specializing in sensory integration. You have developed a marketing brochure that promises to "cure" sensory processing disorder and features testimonials from clients who report dramatic improvements. While you believe in your services, you know that there is no "cure" for SPD and that these testimonials may be misleading to the public. You are considering whether to use the brochure as is or to revise it.

• Ethical Analysis: The principle of Veracity requires you to be truthful in your advertising. Promising a "cure" for a complex disorder is a misrepresentation of what occupational therapy can achieve and is therefore unethical. While your intent may be to attract clients (Beneficence), doing so through deception violates Veracity. The ethical course of action is to revise the brochure to accurately reflect the goals of therapy, such as "improving sensory modulation" or "enhancing participation in daily activities," rather than promising a "cure."

Case Example 1.19: Veracity and Research Reporting

A researcher and occupational therapist, Dr. Lee, is conducting a study on a new therapeutic modality. The preliminary results are not as strong as he had hoped, and the data is inconclusive. Dr. Lee has funding from a large company that is eager for positive results. He feels pressured to "massage" the data to show a statistically significant improvement. He justifies this by thinking that a positive outcome would lead to more funding and ultimately benefit more people in the future.

• Ethical Analysis: This is a severe violation of Veracity. Dr. Lee's actions would not only be dishonest but would also undermine the integrity of the entire profession. Research must be reported accurately and without bias, regardless of the desired outcome. The ethical path is to report the inconclusive findings honestly and to publish the research as it stands. He can then seek additional funding or re-evaluate the study design to explore the modality further. The ends do not justify the means, and a commitment to truthfulness is a non-negotiable ethical obligation.

Case Example 1.20: Veracity and Misrepresentation of Title

An occupational therapist, Carter, who holds a non-clinical Doctor of Education (EdD) degree, introduces himself to clients and other healthcare providers at the hospital as "Dr. Carter, the occupational therapist," without clarifying that his doctorate is not in a clinical field related to his practice. He does this to increase the perceived authority of his recommendations during team meetings and with clients who question his plan of care.

Ethical Analysis: Carter is violating the principle of Veracity by using an academic title to misleadingly suggest a higher level of clinical expertise than is warranted by his degree. While technically holding a doctorate, using "Dr." in a clinical setting without clarification can compromise transparency and manipulate the client's trust. The ethical requirement is to use titles accurately and avoid misrepresentation of credentials, ensuring clarity in all professional communications.

Principle 6: Fidelity

Fidelity means that occupational therapy personnel shall treat clients, colleagues, and other professionals with respect, fairness, discretion, and integrity. This principle refers to our duty to honor our commitments and maintain professional integrity in our relationships. It embodies our commitment to our clients, colleagues, and the profession. This includes respecting confidentiality among colleagues, refraining from personal or professional conflicts of interest, and maintaining a professional demeanor in all interactions.

Case Example 1.21: Fidelity and Professional Relationships

Susan, an OT, works in a hospital and observes her colleague, Mark, consistently arriving late and taking long breaks, which causes client delays. Susan and Mark are friends outside of work, and she feels torn. She knows that reporting Mark's behavior could jeopardize their friendship. Still, she also recognizes that his actions negatively impact client care and place an unfair burden on the rest of the team.

• Ethical Analysis: Susan's ethical obligation is to Fidelity, which requires her to maintain a professional commitment to her clients and colleagues. While Fidelity prioritizes loyalty to her friend, her primary duty is to the integrity of her professional relationships and the well-being of her clients. The ethical course of action is to address the issue with Mark privately first, and if the behavior continues, to follow the established reporting procedures within her organization.

Case Example 1.22: Honoring Professional Commitments

You are a fieldwork educator for an occupational therapy student. Due to a recent staffing shortage at your clinic, you have been assigned an exceptionally heavy caseload. You find yourself cutting corners on the supervision of your student, often leaving them to complete tasks without proper guidance or feedback. The student is struggling and has expressed concerns, but you feel your hands are tied due to your workload.

• Ethical Analysis: Your commitment to your student as a fieldwork educator is a core component of Fidelity. You have a duty to provide proper supervision and mentorship. By failing to do so, you are compromising the student's learning experience and potentially endangering future clients they will treat. Your ethical obligation is to address your workload with your supervisor and advocate for a reduced caseload or for another therapist to assist with the student's supervision. You must not allow your professional commitment to the student to be compromised by workplace pressures.

Case Example 1.23: Fidelity and Professional Boundaries

An occupational therapist, Ben, has a side business as a life coach. A client he has been seeing for hand therapy mentions that they are looking for a life coach and asks for a referral. Ben is tempted to offer his services, thinking it would be a great way to help the client and earn some extra income. He knows that he could offer a "discount" to the client.

• Ethical Analysis: This scenario is a classic example of a dual relationship and a clear conflict of interest. Ben's duty to Fidelity and professional integrity requires him to maintain clear boundaries. Offering his life coaching services to a current or former therapy client would violate the trust of the therapeutic relationship and could exploit the client's vulnerability. The ethical course of action is to decline to offer his services and instead provide a list of other qualified life coaches. He must maintain a clear distinction between his professional roles.

Case Example 1.24: Fidelity and Whistleblowing Conflict

A new occupational therapist, Becca, witnesses her senior colleague and mentor, who is highly respected in the facility, accidentally leave a client unsecured in a wheelchair, resulting in a minor, but observable, forward tip and near-fall. The client was quickly stabilized and sustained no injuries. Still, the mentor immediately apologized to the client and then quietly asked Becca to omit the incident from the documentation to avoid a mandatory hospital safety report. Becca feels intense pressure to protect her mentor's reputation.

Ethical Analysis: Becca faces a conflict between her personal sense of loyalty (Fidelity to her mentor) and her professional duties to Veracity (accurate documentation) and Nonmaleficence (protecting client safety/reporting hazards). The ethical obligation is to the client and the institution's safety process. She must document the near-miss accurately and follow the facility's reporting policy. Protecting a colleague's reputation must never take precedence over client safety and professional integrity.

Principle 7: Dignity of the Person and the Profession

This principle, often regarded as the seventh overarching principle in many ethical discussions, emphasizes the inherent worth and unique identity of each individual. It is about treating clients and colleagues respectfully and promoting the profession as a valuable and respected service. While not one of the six core principles in the AOTA Code, its importance is reflected throughout all the other principles.

• Self-Reflection: How do I ensure that my actions and communication uphold the dignity of every person I encounter, regardless of their background, ability, or beliefs?

Case Example 1.25: Dignity and Stigmatizing Language

A group of occupational therapists is discussing their shared caseload during a lunch break in an open office area. One therapist, without using names, refers to a client with a substance use disorder as "the addict" and complains loudly about "the frequent flyer" who has multiple readmissions for self-neglect. The language is dismissive, judgmental, and dehumanizing, reflecting an evident lack of respect for the clients' inherent worth.

Ethical Analysis: The use of stigmatizing, label-based language is a direct violation of the dignity of the person. While the discussion was private among colleagues, such language in a professional environment erodes the commitment to client-centered care and fosters a culture of disrespect. Furthermore, allowing such language to persist violates the Dignity of the Profession, which is founded on compassion and respect. The ethical duty of listening colleagues is to intervene privately and gently remind the therapist of the necessity for professional and respectful language.

Module 2: Common Ethical Dilemmas

Ethical dilemmas are complex situations in which a practitioner must choose between two or more conflicting ethical principles. There is no single correct answer in these situations, and the practitioner must carefully weigh the competing values. This module will explore five common and challenging ethical dilemmas that occupational therapy practitioners face.

Dilemma 2.1: The Productivity Paradox

Productivity quotas are a widespread challenge in many healthcare settings. While they are intended to ensure efficiency, they can create significant pressure on practitioners, leading to ethical compromises. This dilemma often pits the principles of Beneficence and Veracity against the employer's demands.

Case Study 2.1: The Productivity Paradox

You work in an outpatient clinic with a set productivity target of 85%. You have a new client, Ms. Chen, a 75-year-old with osteoarthritis. She is a widow, lives alone, and is very social. Her therapy sessions frequently include long conversations about her life and feelings of loneliness. While these conversations are not billable, you know they are crucial for her emotional well-being and willingness to participate in therapy. Your manager has noted your lower-than-average productivity and has warned you that if it does not improve, you may face disciplinary action. You feel caught between providing holistic, client-centered care and meeting the financial demands of your workplace.

• Ethical Questions:

  • Does the principle of Beneficence require you to spend non-billable time on emotional support?

  • How can you balance your duty to your client with your responsibility to your employer?

  • What are the potential consequences of meeting your productivity target at the expense of client well-being?

Dilemma 2.2: Dual Relationships and Professional Boundaries

Dual relationships occur when a professional is involved in a relationship with a client that extends beyond the therapeutic one. These personal, financial, or social relationships can compromise professional judgment and exploit the therapeutic relationship. This dilemma often involves a conflict between Beneficence and Fidelity, with the added risk of violating Nonmaleficence if the client is harmed.

Case Study 2.2: Dual Relationships

A new client, a successful graphic designer, starts therapy with you for hand rehabilitation following a car accident. Over the course of therapy, you discover that you share a passion for art and design. The client offers you a freelance project to design a new logo for their business, offering to pay you a significant amount for the work. You are currently struggling financially and could really use the money. You see it as a great opportunity and a way to build a personal relationship.

• Ethical Questions:

  • What are the risks of accepting the freelance project?

  • How could this dual relationship impact your professional judgment and the client's progress in therapy?

  • Does your client, who is in a vulnerable position, have the power to truly give uncoerced consent to this arrangement?

  • What is the most ethical way to respond to the client's offer?

Dilemma 2.3: Interprofessional Collaboration and Scope of Practice

In a multidisciplinary team, practitioners from different disciplines often have overlapping responsibilities. This can lead to conflicts over the scope of practice, the range of services a professional is authorized to provide. This dilemma can involve conflicts between Justice (fairness in collaboration) and Fidelity (loyalty to one's professional role and boundaries).

Case Study 2.3: Interprofessional Conflict

You are a pediatric occupational therapist working in a school district. A physical therapist, who is new to the district, suggests that you perform a gait analysis and provide recommendations for orthotics for one of your shared clients. While you have basic knowledge of gait, you know that this is primarily within the physical therapist's scope of practice and that a thorough analysis requires specialized training you do not have. You are concerned that providing a recommendation would violate professional boundaries and could lead to a less-than-optimal outcome for the child. The physical therapist insists that you have the skills to do it and that it would save the district time and money.

• Ethical Questions:

  • Does a request from a colleague supersede your professional duty to stay within your scope of practice?

  • What are the potential consequences for the client if you perform an intervention outside of your expertise?

  • How can you address this situation with your colleague while maintaining a positive and collaborative relationship?

Dilemma 2.4: Confidentiality and Social Media

The rise of social media has introduced new and complex ethical challenges related to confidentiality and professional boundaries. Practitioners must be vigilant to protect client information in all online and offline interactions.

Case Study 2.4: Social Media Confidentiality

You are an occupational therapist working in an outpatient clinic. You have a close relationship with one of your clients, a young adult with a chronic pain condition. The client's mother sends you a friend request on a social media platform. You have a public profile with many personal photos and posts. You are unsure whether accepting the request is the appropriate course of action. You also notice that a former colleague has posted a generic, but recognizable, story about a "difficult client" with a similar condition. You are concerned that the post, even without a name, could compromise the client's privacy.

• Ethical Questions:

  • What are the ethical implications of accepting a client's or a family member's friend request on social media?

  • What is your ethical duty when you see a colleague's post that could violate a client's confidentiality, even if it is not yours?

  • How can you maintain Fidelity to your colleague while upholding the principle of confidentiality?

Dilemma 2.5: Competence and Continuing Education

The ethical principle of Beneficence requires us to provide the most effective, evidence-based care. This is impossible without a commitment to lifelong learning and maintaining professional competence. An ethical dilemma arises when a practitioner fails to stay current with the best practices.

Case Study 2.5: The Outdated Practitioner

You are an OT working in a long-term care facility. A new client, Mr. Smith, has been referred for therapy following a recent hip replacement. Your colleague, a veteran therapist, is Mr. Smith's primary OT. You observe your colleague using outdated manual handling techniques and interventions no longer considered evidence-based. While you know they are a kind and caring therapist, their methods could be less effective and even potentially unsafe. You feel a conflict between your Fidelity to your colleague and your duty to Beneficence and Nonmaleficence to the client.

• Ethical Questions:

  • Do you have an ethical duty to address your colleague's outdated practice?

  • What are the potential risks to the client if you do not intervene?

  • How can you approach this situation in a respectful and professional manner while ensuring the client receives the best possible care?

Module 3: Ethical Decision-Making Framework

A systematic approach is crucial when faced with an ethical dilemma. Relying on intuition alone can lead to poor decisions. The following is a step-by-step framework adapted from various models to guide you through ethical reasoning.

Step 1: Identify the Ethical Question

The first and most critical step is to define the ethical issue clearly. This is not about the logistics or the emotions involved, but about pinpointing the core conflict of values. The ethical question is not "What should I do?" but "Which ethical principle is in conflict with another?" Taking the time to articulate the central dilemma clearly ensures you are addressing the right problem.

• Example from Case Study 2.1: The ethical question is, "How can I balance the principle of Beneficence (acting in the client's best interest) with the potential conflict of Fidelity (my responsibility to my employer) and Veracity (the pressure to document inaccurately)?"

Step 2: Gather All Relevant Information

Before you can make a decision, you must have all the facts. This includes information about the client, the practice setting, relevant policies, and professional standards. Be thorough and objective in your information gathering.

• Relevant Information for Case Study 2.1:

  • Client's medical and social history (Ms. Chen's diagnosis, living situation, and emotional needs).

  • Your workplace policies (the 85% productivity quota and the disciplinary process).

  • AOTA Code of Ethics principles (Beneficence, Veracity, Fidelity).

  • The specific benefits of the non-billable time (building rapport, emotional support, and improved engagement).

  • The risks of not spending this time (decreased engagement, poor therapeutic outcome).

Step 3: Clarify Ethical Principles and Professional Duties

Next, identify the ethical principles from the AOTA Code of Ethics that apply to the situation. Analyze which principles are in conflict and which are most relevant. This step helps you move from a feeling of conflict to a clear understanding of your professional obligations.

• Analysis for Case Study 2.1:

  • Beneficence: This is a core principle at stake. Your duty is to promote Ms. Chen's well-being, which includes her emotional health.

  • Veracity: This is also at stake. You must be honest in your documentation. Fabricating notes to meet productivity would be a direct violation.

  • Fidelity: Your loyalty to your employer must be balanced with your duty to your client and the profession.

Step 4: Identify and Analyze Alternatives

Brainstorm all possible courses of action. For each alternative, consider the potential benefits, risks, and consequences for all parties involved: the client, the practitioner, the employer, and the profession. Be creative and think outside the box; don't limit yourself to only two choices.

• Alternatives for Case Study 2.1:

  • Alternative A: Do not spend non-billable time with the client; focus only on billable activities to meet the quota.

    • Pros: Meets employer demands, avoids disciplinary action.

    • Cons: Potential harm to the client's emotional well-being and therapy engagement. Violates Beneficence.

  • Alternative B: Continue spending non-billable time, risking disciplinary action.

    • Pros: Upholds Beneficence and provides the best care for the client.

    • Cons: Could lead to termination or other disciplinary action from the employer.

  • Alternative C: Discuss the situation with your manager.

    • Pros: It demonstrates honesty and professional responsibility. It educates the manager on the importance of holistic care and the potential conflict created by the quota. It could lead to a change in policy or a solution.

    • Cons: May be perceived as a complaint. Might not result in a solution.

  • Alternative D: Re-frame the non-billable time as a skilled intervention (e.g., "therapeutic use of self" or "psychosocial support") and document it as such.

    • Pros: Meets productivity and is a truthful reflection of the work.

    • Cons: Could still be a grey area depending on documentation standards, and be seen as deceptive.

Step 5: Determine the Desired Action

After analyzing the alternatives, choose the action that is most ethically defensible. The ideal solution upholds the greatest number of ethical principles and minimizes harm.

• Desired Action for Case Study 2.1: The most ethically defensible action is a combination of Alternatives C and D. You should first have a conversation with your manager (Alternative C), advocating for a more flexible policy for client-centered care. Simultaneously, you should accurately document the therapeutic value of the non-billable time (Alternative D), reframing it within the scope of occupational therapy and Veracity. This approach prioritizes Beneficence and Veracity while also fulfilling Fidelity to your employer by attempting to work within the system.

Step 6: Act and Review the Outcome

Implement your chosen course of action. After acting, reflect on the outcome. What did you learn? Did your decision lead to a positive result for the client? This final step is crucial for professional growth and continuous ethical development.

• Review for Case Study 2.1: By talking to your manager and documenting accurately, you may have avoided disciplinary action while providing the best care for Ms. Chen. This experience would inform future decisions about work environments and documentation.

Module 4: Professional Responsibility and Accountability

Ethical practice is not a one-time event but a continuous commitment to professional accountability. This final module discusses practitioners' ongoing responsibilities to maintain ethical standards and contribute to a healthy profession.

The Role of Self-Reflection and Continuing Competence

Ethical practice begins with self-awareness. We must regularly reflect on our values, biases, and professional conduct. Questions to ask yourself include:

• Am I acting in the best interest of my clients?

• Are my actions guided by the AOTA Code of Ethics?

• Am I being transparent and truthful in my interactions and documentation?

• Do I have any potential conflicts of interest?

• Do I need to consult a colleague or mentor about a problematic situation?

A critical component of this is continuing competence. The principle of Beneficence demands that we provide the best possible care, which requires us to stay current with new research, techniques, and technologies. This is a lifelong ethical obligation that goes beyond the minimum requirements for licensure.

Case Example 4.1: The Duty to Report

You are a new occupational therapist at a hospital, and you notice a veteran therapist frequently cutting corners during therapy sessions and using unsterile equipment. Although you have a good relationship with this therapist, you are concerned about patient safety and the department's reputation.

• Ethical Analysis: Your primary duty is to nonmaleficence—protecting clients from harm. While you feel a sense of Fidelity to your colleagues, your obligation to the clients and the profession is greater. The ethical course of action is to follow your hospital's established protocol for reporting unsafe or unethical practices.

Ethical Leadership

Ethical leadership is about creating a culture where ethical practice is expected and supported. This is a shared responsibility among all practitioners, regardless of their position. Ethical leaders mentor new practitioners, advocate for systemic changes that promote ethical practice, and model integrity in their conduct.

Case Example 4.2: Ethical Leadership

You are a manager of an occupational therapy department. You notice that some of your therapists are burned out due to heavy caseloads and administrative demands. You are aware that this can lead to a reduced quality of care and potential ethical lapses. You must decide whether to maintain the status quo or to advocate for changes that would enhance the work environment and promote ethical practice.

• Ethical Analysis: Your ethical duty as a leader extends to your team and the clients they serve. Allowing burnout to continue violates the principles of Beneficence and Nonmaleficence for your clients and Fidelity to your staff. The ethical course of action is to advocate for more staffing, implement more efficient administrative processes, or find ways to reduce the administrative burden on your therapists.

Module 5: Ethical Challenges in Specific Practice Settings

While the core ethical principles remain constant, their application can be nuanced in different practice settings. This module explores specific ethical challenges that arise in three common practice areas.

Ethical Issues in Pediatric Practice

Pediatric practice involves not only the client but also their family and caregivers. This introduces new layers of complexity, particularly regarding Autonomy and Beneficence.

Case Study 5.1: Pediatric Client Autonomy vs. Parental Wishes

You are a pediatric OT working with a 14-year-old client with autism. The client has made it clear that they no longer want to attend therapy sessions, stating that they feel they are "too old for it" and would prefer to spend their time with friends. However, the client's parents are adamant that therapy is necessary and are threatening to take the client's phone away if they do not comply. You feel a conflict between respecting the client's Autonomy and adhering to the parents' wishes, who believe they are acting in the client's best interest (Beneficence).

• Ethical Analysis: While a minor's Autonomy is not absolute, it is crucial. You must act as a mediator between the client and their parents. The ethical course of action is to educate the parents on the importance of the client's buy-in and to find a way to make therapy more meaningful to the client. This might involve changing the focus of therapy to social skills with peers or incorporating more age-appropriate and engaging activities.

Ethical Issues in Geriatric Practice

Geriatric practice often involves clients with cognitive decline, which can complicate the principle of Autonomy. Practitioners must also navigate complex family dynamics and make informed decisions regarding end-of-life care.

Case Study 5.2: Autonomy and Cognitive Decline

You are an OT in a long-term care facility. Your client, an 85-year-old with early-stage Alzheimer's, refuses to participate in showering or other hygiene activities, stating she wants to stay in bed. Her daughter, who holds a power of attorney, insists that she be showered daily, citing the risk of skin breakdown and infection. The client becomes extremely agitated when you attempt to provide care. You feel caught between respecting the client's immediate wishes (Autonomy), ensuring their long-term health (Beneficence), and fulfilling the family's directives.

• Ethical Analysis: This is a classic conflict between Autonomy and Beneficence. In this case, the client's cognitive impairment complicates their ability to make a fully informed decision. The ethical path is not to force the client but to find alternative approaches. This could involve scheduling hygiene at a different time of day, using a different care approach, or engaging the client in an activity that makes them more receptive to care. You must also educate the daughter about the ethical complexities and the importance of preserving the client's dignity.

Ethical Issues in Mental Health Practice

Mental health practice involves unique ethical considerations regarding confidentiality, risk assessment, and therapeutic boundaries.

Case Study 5.3: Confidentiality and Risk to Others

You are an OT working in a community mental health setting. A new client, a young man with a history of anxiety and depression, confides in you that he has been having intrusive thoughts about harming his younger brother. He clarifies that he would never act on them, but is concerned about their presence. You are faced with a conflict between confidentiality and the duty to protect a third party (nonmaleficence).

• Ethical Analysis: While confidentiality is a core principle in mental health, it has limits when there is a risk of harm to the client or others. Your ethical and legal duty is to protect the younger brother. The ethical course of action is to follow your organization's protocol for reporting a threat of harm to a third party. This would involve a discussion with your supervisor, and possibly involving the parents or the authorities, while explaining your rationale to the client in a calm and supportive manner.

Conclusion & Key Takeaways

The culmination of this course is not simply the acquisition of knowledge, but the commitment to an ongoing professional stance: the ethical life of an occupational therapist. Ethical practice is fundamentally a journey, not a destination. It is the conscious, continuous application of moral principles to the realities of client care, institutional pressures, and systemic injustice. This final module serves to anchor the knowledge you've gained in a call to continuous action.

We began by reviewing the foundational principles—Beneficence, Nonmaleficence, Autonomy, Justice, Veracity, and Fidelity—and the overarching theme of Dignity. These are the pillars of our profession. We then moved to the decision-making framework, recognizing that when principles conflict, resolution requires more than good intentions; it demands a systematic, analytical approach. The greatest ethical challenges rarely involve choosing between good and evil; they involve choosing between two goods, or navigating situations where external pressures compromise your ability to deliver ethical care.

The professional courage required to practice ethically cannot be overstated. It means having the clarity to question a policy that prioritizes profit over patient well-being, the empathy to respect a client's autonomous choice even when it conflicts with your clinical opinion, and the diligence to document honestly, even when it affects billing or productivity scores.

Ethical practice is not about rigid rules; it is an ongoing process of reflection, analysis, and action. It requires a deep understanding of our professional principles and the courage to make difficult choices. By internalizing the AOTA Code of Ethics, utilizing a systematic decision-making framework, and committing to ongoing self-reflection and professional accountability, you will be equipped to navigate any ethical challenge that comes your way.

Remember these key takeaways:

• Know the Code: Familiarize yourself with the AOTA Occupational Therapy Code of Ethics and its core principles.

  This knowledge is your first line of defense. Knowing the precise language of the Code allows you to frame dilemmas objectively, moving the conversation from a personal dispute to a professional obligation. Use the Code as leverage when advocating for a client or challenging an unethical administrative directive. Your authority stems directly from your commitment to these established professional standards. Continuous, active study of the Code, particularly its interpretive guidelines, is essential for every year of your practice.

• Act Proactively: Identify and address ethical issues before they escalate.

  Ethical vigilance is a preventive measure. It means anticipating the conflicts inherent in specific practice settings. In a busy clinic, it's anticipating how productivity pressures could tempt an OTA to cut corners. In a school setting, it's about proactively identifying resource disparities between different student populations. Being proactive also involves setting clear, defensible professional boundaries with clients and colleagues from the outset, thereby minimizing the risk of dual relationships or conflicts of interest that compromise Fidelity.

• Use a Framework: Apply a systematic decision-making process to resolve complex dilemmas.

  The six-step framework presented in Module 3 is your procedural safeguard against impulsive or emotionally driven decisions. When you feel "stuck" or emotionally charged by a situation, return to the framework: 1) Identify the Question, 2) Gather Information, 3) Clarify Principles, 4) Analyze Alternatives, 5) Determine Action, and 6) Act and Review. This structured approach ensures that you consider all stakeholders, analyze the short- and long-term consequences of your choices, and can ultimately defend your decision with clear ethical reasoning.

• Consult and Collaborate: Do not hesitate to seek guidance from colleagues, mentors, or professional organizations.

  Ethical dilemmas are rarely solved in isolation. Collaboration is a form of risk management and a demonstration of professional maturity. When faced with a serious dilemma, seeking consultation provides an objective, external perspective that can identify biases or overlooked alternatives. Utilize your formal mentorship networks, clinical supervisors, and the AOTA Ethics Commission as resources. Confidential, peer-to-peer consultation strengthens your analysis and reinforces the principle of Fidelity to your profession.

• Document Accurately: Your documentation is a reflection of your ethical practice. Be honest and transparent.

  Accurate documentation embodies Veracity. It is your professional narrative. Every entry must reflect the truth of the skilled service provided, the client’s response, and the rationale for intervention. Avoid documenting services not rendered or exaggerating patient progress to justify continued coverage. Your notes are both a clinical record and a legal document; their integrity is non-negotiable and represents your ethical commitment to your clients and the payment systems that fund their care.

• Embrace Accountability: Your professional life is a continuous journey of ethical growth and responsibility.

  True ethical accountability entails accepting responsibility for one's actions, learning from mistakes, and actively participating in the self-regulation of the profession. This involves maintaining your professional competence through ongoing education and reflection, engaging in ethical dialogue with peers, and actively shaping a work environment where ethical conduct is the norm, not the exception. The commitment to ethics is the most profound way you honor the dignity of the person you serve and the profession you represent.

Your enduring commitment to these principles ensures that occupational therapy remains a trusted and vital profession, continually dedicated to promoting health, participation, and justice for all individuals.

Thank you for being dedicated to ethical practice and commitment to your clients' well-being.

Resources

• AOTA Occupational Therapy Code of Ethics

• AOTA Ethics Commission

• Ethical Decision-Making in Occupational Therapy

• State Licensure Board Ethics Requirements

References

See additional handout.