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Social Justice: To Be or Not to Be?

AOTA members debate one of the hottest issues expected to come before the 2011 RA

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Vol. 27  Issue 7  Page 8

2011 RA

When the Representative Assembly approved the new 2010 Code of Ethics and Ethics Standards last April in Orlando, it included a section on social justice, an already controversial addition even then.

You can read the code on the AOTA website at http://www.aota.org/Practitioners/Ethics/Docs/Standards/38527.aspx.

Motion 2, coming up on the 2011 Representative Assembly spring meeting agenda in Philadelphia next month, would delete the section on social justice and place some aspects of Principle 4 into other sections of the code. Two of the subsections would simply be deleted. We asked representatives of the Ethics Commission who helped write the code and the authors of Motion 2, who would change it, to debate the social justice issue for our readers. Here are their responses.

Q: Would eliminating the 'social justice' principle in AOTA's Code of Ethics - and replacing it with an upgraded concept of 'altruism' - have the unintentional effect of downgrading the degree of commitment the profession means to offer its clients? How or why not?

ETHICS COMMISSION RESPONDERS

A: Yes, downgrading would occur. The two concepts are entirely different and based on different moral principles.

Altruism is a form of beneficence. Beneficence is concerned with services rendered to identified clients. Social justice is concerned with the equality of moral worth of all persons.

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The principle of social justice does not require that persons involved are actually or potentially our clients, but that they be considered morally equal, e.g. not lesser citizens, regardless of any disability that may exist. Altruism is defined as a commitment to serving the needs of others. It is from the Latin alter, "another."

The term justice has been around for 3,000 years. The word for "justice" is the Hebrew term "mishpat." Its most basic meaning is to treat people
equitably.

The term social comes from a Hebrew term "tzadeqah," which refers to a life of right relationships.

The two words appear together scores of times in the Hebrew text. Therefore, social justice is the correct terminology because it puts it into the context of relationships with clients and the world in a social justice way.

Much of the language under Principle 4 reflects occupational therapy's commitment (in the Code and Ethics Standards as well as other AOTA documents) to and interaction with groups and populations, which is consistent with other health professions (and their own codes of ethics).

MOTION 2 ORIGINATORS

A: Using the term "altruism" would in no way downgrade the degree of commitment the profession offers to our clients or our community. The unselfish regard for the welfare of others has always had a major presence in the AOTA Core Values and Code of Ethics... Beneficence includes altruism such as acts of mercy, kindness and humanity; ...beneficence has been a long-standing aspect of the Code. The engagement of client-centered occupational therapy services is the underlying rational for our behavior. Social justice takes on vague and broad interpretations, referencing service areas beyond... occupational therapy.

In a time when the profession of occupational therapy is striving to define itself clearly to consumers, it is counterproductive to add a principle that has multiple interpretations outside the context of occupational therapy. Altruism has no political implications or vagueness. In fact, for that very reason, the inclusion of social justice terminology was "the only point of debate" prior to the passage of the 2010 Code of Ethics as noted in ADVANCE, May 14, 2010 (https://occupational-therapy.advanceweb.com/News/Daily-News-Watch/RA-Approves-Action-on-Ethics-Fieldwork-Re-entry.aspx).

All principles of the Code of Ethics are pragmatic with the exception of Principle 4, Social Justice. For example, in the statement from Principle 4 "uphold the professions' altruistic responsibilities to help ensure the common good," the common good is not defined anywhere. One factor in ongoing deliberations is whether the common good is synonymous with an individual's good and whether there is a universal decent minimum.

Q: Principle 4 now states, '.While opinions differ regarding the most ethical approach to addressing distribution of health care resources and reduction of health disparities, the issue of social justice continues to focus on limiting the impact of social inequality on health outcomes.' What do you think this statement means?

ETHICS COMMISSION RESPONDERS

A: The EC (Ethics Commission) purposefully included this statement to be clear about the intent of this principle. The concept of social justice is imbedded in the tradition of practice. Thoughtful people have and will argue about which is the most effective way to help those in need of social justice (equal opportunity for health care). To use the term "distribution" and use it in another context is using it inappropriately and is fear spreading. Not every one gets the same medical care - that is the nature of giving health care. However, people have a right to needed health care to maintain their normal functioning. "People have a right to needed health care to provide an opportunity for a level of health equal as far as possible to the health of other people." This does not mean "redistribution of wealth." Nowhere in Principle 4 or the advisory opinion does it use the word wealth. Social justice cannot be tied to any one political system or economic policy.

The statement in Principle 4 recognizes that ethical dilemmas exist regarding how health outcomes will be achieved. Our society differs frequently on how best to appropriate resources, which are typically limited. Social justice, as an ethical principle, should guide our behavior and decision-making. Motion 2 appears to be written based on absolutism, where something is either right or wrong, yet this is often untrue of many situations in life: complex issues can result in ethical dilemmas which require thoughtful consideration. Moral principles have longevity, which is independent of current political interpretation by certain individuals. Occupational therapy was founded on social justice and has always advocated for the moral worth of all citizens, an ideal which should be perpetuated.

MOTION 2 ORIGINATORS

A: This statement recognizes that there is no consensus on how to determine a fair and equitable distribution of health care services, appropriate access to needed services, or how to remediate health disparities. The ethical responsibility of the OT practitioner is equally unclear. However, stating that the inclusion of social justice focuses on limiting the impact of social inequality on health outcomes implies that this is the lone role or objective of social justice. It has a far broader context, including religious and political platforms. Such broad contemporary utilization of the term makes it difficult to find a workable place for "social justice" within a professional Code of Ethics.

When considering health outcomes, social inequalities are significantly influenced by a multitude of circumstances such as predisposition to disease, personal habits and access to primary care providers. These issues are not within the control of the OT practitioner, but are broad societal issues that require structural and systemic improvements in general education, parenting skills, and the ability to find and retain sustainable employment. While OT may have a tangential role in some situations, to imply that practitioners should be held to a standard on broad societal issues is aspirational and impossible to quantify.

Q: Subsection F under the Social Justice Principle lists specific factors that might affect occupational therapy delivery: "economic status, age, ethnicity, race, geography, disability, marital status, sexual orientation, gender, gender identity, religion, culture and political affiliation." Motion 2 would replace that list with a single statement under Principle 1 - Beneficence: 'to provide client-centered OT services that reflect consideration of an understanding of the multiple differences that each unique individual is, and the circumstances that they have.' What affect, if any, might this move to more general wording have on the standard of behavior expected of OTs?

ETHICS COMMISSION RESPONDERS

A: The subsection is a list (but not a complete list) of possible factors that may be addressed under the principle of social justice where equality of moral worth may be denied. The fact that the list may also be used as considerations to providing service (beneficence) does not change the usefulness of the list as possible issues for occupational therapists and assistants to consider under the principle of social justice. The list could be considered equally useful under both principles (beneficence and social justice). Language in Principle 4 relates to OT interaction with groups and populations (common terminology in other official documents) to expand access to services. Relocating it solely to Principle 1 which is focused on providing client-centered services to individuals is inappropriate as it also applies to groups and populations. OT personnel have responsibilities both to individual clients as well as to the larger community, as do all health care professionals. One does not preclude the other.

MOTION 2 ORIGINATORS

A: The language revision in Motion 2 would set a focus on addressing diversity beyond the limited examples currently spelled out in the Code of Ethics. This language is more inclusive because everything listed in the current Code would be covered in the proposed revision but it does not limit the characteristics by which diversity would be identified. It gives occupational therapists a structured guide for providing client centered services in individual, group and population-based models. There are too many differences in people and circumstances to have a comprehensive listing. An OT should be seeking to identify those traits of diversity in the individual or group they are working with. As part of the OT process, the occupational therapist seeks to identify all of the issues that impact a person's ability to participate fully and remove or modify those which are barriers to their success. The intent of the language change is not to limit the issues being considered, but to be more inclusive in identifying an individual's diverse characteristics and circumstances in order to provide client-centered services.

Q: Subsection G of the Social Justice Principle allows, but does not encourage, OTs to consider offering pro-bono services to those who cannot afford care, when 'consistent with the guidelines of the employer, third-party payer and/or government agency.' Under Motion 2, this subsection would be eliminated completely. What do you believe this part of the motion is trying to achieve? Do you agree with that goal?

ETHICS COMMISSION RESPONDERS

A: Pro-bono is a recognized service-delivery method in several professions, including law and medicine. Deleting the statement diminishes the support for social justice, which is the intent of the motion. The originators state, "Guidelines are not necessary for a practitioner who has the time to provide charity work for an individual. This is a personal choice." This is incorrect and a misrepresentation of the statement, as organizational policies are also a factor in this decision. The intent of the statement is that OT personnel should be knowledgeable about alternative options to assist clients in accessing needed services. The statement is a moral guide for behavior, not a requirement for every OT/OTA to provide pro bono services. It is based on the understanding that inequities exist and pro bono is one method of addressing them, where feasible.

The language about pro-bono/reduced fees in Subsection 4G, which the originators want to eliminate, has been part of previous Codes consistent with promoting access to services. Likewise, the suggested addition (in Motion 2) of "funding of services" to the statement in Principle 2B mixes up two different points. The intent of 2B is to address patient abandonment, which has come to AOTA as a member concern a number of times. Funding, while it may also result in cessation of services, is a different issue.

MOTION 2 ORIGINATORS

A: "Consider" is not a quantifiable term, making this portion of the current Code vague. Consideration is an internal process that may or may not result in any action, so it is difficult to ascertain when consideration has been given to any issue. The system for which an OT practitioner works will determine whether or not their employees can provide pro-bono services, in what circumstances and to what extent. Requesting approval for pro-bono status for a client or advocating for pro-bono services as a policy option is an action that may be taken following consideration, but the lack of these activities does not mean that the OT practitioner has not given consideration to the situation.

In the case where an OT practitioner is in private practice, pro-bono service is truly charity, as they are foregoing customary payment for appropriate and valid services. This may be an admirable activity, but the profession does not need a principle to allow individual decisions regarding charitable donations in a professional Code of Ethics.

This is pragmatically covered in Principle 2, Non-maleficence, subsection B, through Motion 2's revision to "Make every effort to ensure continuity of services and/or options for transition to appropriate services to avoid abandoning the service recipient if the current provider is unavailable due to medical, other absence, loss of employment, or funding of service is an issue."

Q: Section D under Principle 4 is also being eliminated. This section encourages occupational therapists to 'advocate for just and fair treatment' of all, and to 'encourage employers and colleagues to abide by the highest standards of social justice.' Should this be re-worded rather than deleted? How great an obligation do therapists have to risk their job security in standing up for ethical practice?

ETHICS COMMISSION RESPONDERS

A: The principle of social justice is based on equality of moral worth of all individuals. At the same time beliefs regarding moral behavior do not require us to put our life on the line. Example: While people with kidney failure may benefit greatly from a kidney transplant, ethical behavior does not require us to donate both our kidneys to help them. Likewise, advocating for social justice does not require us to give up, willingly or unwillingly, our livelihood. There is a failure here to understand that advocacy of social justice involves the behavior of the organization (AOTA) as much as it does the behavior of individuals. Ethical dilemmas occur.

The welfare of one's family must be considered as well as the welfare of clients, or potential clients when making a moral decision to advocate for social justice. Further, the intent of the Code and Ethics Standards is for colleagues to educate each other as they strive to create an ethical culture in the workplace, which will ultimately benefit their clients and enhance the work environment.

MOTION 2 ORIGINATORS

A: This is not standing up for ethical practice. It is standing up for social justice at the interpretation of the individual OT. As such, it is not consistent. That is why subsection D under Principle 4 should be deleted. We have to work within our circle of control, and that does not include the behavior of our professional colleagues.

As an OT, are we to advocate for everyone in every situation? This is not advocating for a client or group in the realm of occupational therapy but moves from advocacy within our scope of expertise into activism. Participating in activities that forcefully support or oppose an issue, policy or legislation is a personal choice, not a professional obligation. Motion 2 places the role of OT as advocate back where it had previously been located, under Principle 1, Beneficence ("Make efforts to advocate for recipients of occupational therapy services to obtain needed services through available means." 2005).

In addition, the concept of OT as advocate can be found under Principle 5, Procedural Justice ("Actively work with employers to prevent discrimination and unfair labor practices, and advocate for employees with disabilities to ensure the provision of reasonable accommodations." 2010).

Q: One rationale for changing the Code is that Principle 4 is 'vague,' and that at least 12 licensure boards that include it in their practice acts put therapists in danger of violating it unintentionally. Do you agree or disagree?

ETHICS COMMISSION RESPONDERS

A: Disagree: originators of the motion claim that it would be "legally binding to uphold this Principle" because some state regulatory boards (SRBs) reference the Code and Ethics Standards. In fact, some SRBs also take the Code language without citation and others have their own professional conduct language, which is quite similar to the Code. SRBs are legal bodies that are empowered to enforce their regulations based on investigation of evidence. This is their legal issue (and right) if they choose to adopt the Code language and use it as a basis for disciplinary action. There is no indication that it has been (or will be) an issue or result in revocation of licensure for any individual.

Ethics is desired behavior; law is required behavior. Ethics recognizes that ethical dilemmas exist and that desired behavior may have two alternative actions, both of which are equally desirable but only one action can be performed. A person (or group) that understands the ethical dilemma and makes a decision based on that understanding is not violating intentionally or unintentionally the action or behavior not performed. Law, on the other hand, makes no exceptions, although courts of law occasionally allow for "mitigating circumstances."

Ethics is designed to guide behavior as a moral compass. Occupational therapy was founded on social justice and has always advocated for moral worth of all citizens. Turning our backs on our heritage because some people do not agree with the idea at the present time does not make a good decision in my opinion. Political thinking changes frequently. Moral principles should last a long time. In the case of a professional organization, the moral principles should outlast the lives of the current stakeholders.

MOTION 2 ORIGINATORS

A: The aspirational character and ambiguous wording of this new section of our Code raises a very real risk of multiple interpretations. For example, the parent of a student with disabilities could allege impropriety under this section of the Code as a result of how a practitioner decided to use limited treatment time available to serve the diverse range of students on their caseload because her daughter did not receive the same amount of service as another student. It would be difficult to prove that services were distributed fairly, no matter what decision the practitioner made.

According to AOTA's state policy department, at least 12 states have included the Code of Ethics into their licensure rules and regulations by reference, making it a binding requirement of licensure to uphold all aspects of this Code. In these states, any person may bring a complaint against a licensed OT practitioner based on their interpretation of Principle 4, and it would be up to the state regulatory board for OT to investigate and, if warranted, sanction the offending practitioner, up to and including loss of their license to practice OT. While this is not highly likely, it is possible. How this section may be interpreted and adjudicated by state regulatory boards is something that is not controlled by AOTA.

ETHICS COMMISSION RESPONDERS

 Barbara J. Hemphill, MS, OTR, FAOTA, Chair, EFC

 Kathlyn Reed, PhD, OTR, FAOTA, former Chair, EC

Also for References:

 Deborah Slater, MS, OT/L, FAOTA, AOTA Staff Liaison

MOTION 2 ORIGINATORS

 Kathleen Grace, MS, OTR/L-qath@sbcglobal.net

 Roseanne DiZazzo-Miller, DrOT, OTR/L-ar7975@wayne.edu

 Claudette Stork Reid, OT/L-claudot@chartermi.net




     

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