Occupational Therapy Ethical Dilemma Essay

This essay explains a classical example of an ethical dilemma that can be encountered when practicing as an occupational and physical therapist. It involves an 85 year old female covered by Medicare who was receiving treatment at home. The ethical dilemma was triggered due to several factors such as the expectations of the client (client/ consumer rights), organisational expectations (employer, governmental and payer-source regulations) and my own personal values (one's moral principles, social responsibilities, sense of professional duty) and how they all interact with each other. The ethical dilemma in the case discussed below involved whether or not to continue treating a client who undoubtedly needed occupational therapy services based on medical necessity, yet the payer-source (Medicare) coverage conditions for services to be delivered at home was questionable. This essay highlights the various ethical theories and resolutions involved in the ethical dilemma. Decisions taken were derived from; The Australian Association of Occupational Therapist code of ethics (2001)

and the American Occupational Therapy Code of Ethics and Ethics Standards (2010) documents. This essay concentrated on, subsection c under Respecting Patients’ and Clients’ Rights on Page 3 of The Australian Association of Occupational Therapist code of ethics (2001) and 5 out of the 7 principles mentioned in the American Occupational Therapy Code of Ethics and Ethics Standards (2010) was referred to as well. Consideration were also based on Medicare's Benefit policy manual for home health services, under section 30.1 with title ‘Confined to the Home’, in subsection 30.1.1. This document stated the criteria for homebound services.
My dilemma was based upon different ethical theories. My case, as with most occurrences in health care, had elements of ethical theories. The theories affecting my decisions were; utilitarianism, my pursuit to make the choice that will yield the greatest benefits to the most people. The second was egoism, to act exclusively to promote my self-interest. Thirdly I was faced with the ethic of reciprocity (the golden rule) and virtue based ethics which will require me to strive for my client to receive the care that I or any human may hope for. Fourth was the ethic of care because of the therapist-client relationship I had developed and my concern for my client's care. Nevertheless, resolutions to my dilemma was mostly dependant on rule based. Rule based focuses on highest sense of principle and is regarded as the absolute moral rules. It focuses on the action and its process and emphasises that one must act in accordance with rules and principles of ethics.
Ms TE, an 85-year-old woman, was referred to me (an occupational therapist) after a debilitating stroke affected her right side. Ms TE was accepted under home health after running out of Medicare allowable days at a nursing facility. Ms EH needed considerable assistance with all activities of daily living and was mostly wheelchair-bound because of her inability to walk alone. She lived with her 89 year old husband Mr. DH, who was also not in the best shape of health. Due to financial constraints, the couple picked against long-term assisted living at the nursing facility in favour of their home. Ms TE demonstrated good rehabilitation progress with all her house health services. One night, approximately four weeks after her return from the nursing home, Mr. DH suffered an infarction. He got hospitalised. Tests results showed a blockage of multiple vessels and the doctors considered him a poor candidate for surgery. Subsequent medical interventions proved abortive. He was afterwards transferred to a nursing home. Ms TE apparently became depressed and worried about the situation of her husband. She devoted about four to six hours visiting Mr. DH every day at the nursing home with the aid of her family members and friends. Soon after her husband's admission to the nursing home, Ms TE began to have difficulty keeping up with her appointments with me and the other home health providers.
This case presents an ethical dilemma, a situation which arises when one has to choose between mutual alternatives (Beauchamp & Walters, 2003). Medicare's guidelines for clients to receive home health under Part-A Insurance Plan requires them to meet certain "homebound" criteria. The criteria for Medicare homebound status states that, there must exist a normal inability to leave home such that leaving his or her home is medically contraindicated. The beneficiary may however be considered homebound if the absences from the home are infrequent or for periods of relatively short duration. Ms TE was clearly homebound based upon her physical limitations; however, her daily absences did not exactly fit the "infrequent" or "short-duration" requirements for Medicare coverage. Much of the ethical confusion was also caused due to the inability of the coverage guideline to exactly define the terms "infrequent" and "short duration". The client's expectation and what could be perceived as her right to receive health care at her home, based on her medical necessity (client/consumer rights), and my moral duty to provide treatments and my obligation toward her well-being (my personal beliefs) were thus in conflict with the organisational interpretation/ procedures based on regulations that set criteria for services (rules of practice, possible legal issues involved).

The Code of Ethics for occupational therapist is founded on the bio-ethical principles of beneficence, non-maleficence, honesty, fidelity, veracity, confidentiality, justice, respect and autonomy and it is the responsibility of an occupational therapist to protect these bio-ethical principles in their professional practice. Hence my resolution was based on the code of ethics for Australian Association of Occupational Therapists (AAOT) and The American Occupational Therapy Association (AOTA) code of ethics.
The Australian Association of Occupational Therapists code of ethics (AAOT) under the Relationships with, and Responsibilities to, Patients and Clients in sub-section, Respecting Patients’ and Clients’ Rights, implies that patients and clients and carers are active participants in any decision regarding their involvement in services.

The American Occupational Therapy Association (AOTA) under autonomy and confidentiality principle 3, described autonomy as a duty to treat the client according to the client’s desire. According to Beauchamp & Childress, 2009, Autonomy is based on a person’s right to hold views, to make choices, and to take actions based on personal values and beliefs. Autonomy in this scenario, gives the client (Ms TE) the right based on her self determination to receive occupational therapy at home while still respecting her personal rights and values which was visiting her

husband.
Veracity from The American Occupational Therapy Association (AOTA) is based on the virtues of truthfulness, candour, and honesty. The principle of veracity in health care refers to comprehensive, accurate, and objective transmission of information (Beauchamp & Childress, 2009). This scenario obligates me to speak and act truthfully regarding the client’s inability to follow homebound. This however interfered with my respect for the client’s autonomy.
Honesty, referred to as fidelity in The American Occupational Therapy Association (AOTA) describes fidelity as maintaining good-faith relationships between various service providers and recipients. I viewed this principle as my ability to be honest to all parties involved including as the client, my organisation, and the government (via Medicare regulations) and myself as a moral agent.
Beneficence includes all forms of action intended to benefit other persons by protecting and defending the rights. The client strongly believed that she needed home occupational therapy services and in my professional judgement, the client certainly would benefit with continued services. Yet, this beneficence seemed to conflict with the legal and ethical aspects of delivering services.
Justice is concerned with making unbiased decisions that follows policies, regulations and laws. Although I felt a sense of duty of care for my client, I absolutely knew my client did not satisfy all the Medicare coverage criteria.
In my resolution, I would consider whether or not to continue services even though there is a medical necessity, as well as my client’s inability to meet the coverage criteria for payment as a result of her visit to her husband. After much consideration, I would ensure I have detailed discussions with the client and her family about the short comings and implication, then, I would propose to Ms TE the option to receive services under Medicare Part-B plan at an outpatient rehabilitation clinic or other qualifying health care facilities including the one where her husband is being admitted. Upon her agreement and consent, I will discontinue the home-based occupational therapy services and refer her for outpatient rehabilitation.
My decision was taken after I had reflected on both the ethical and legal issues. I analysed these issues to see if a law has been violated or is at risk, or if there was just an ethical problem with no legal implications. With what I had gathered concerning ethical-legal aspect, I decided to gear my actions towards ethical resolutions since there were no legal violations and no separate legal actions were warranted other than those implied by ethical actions. My resolution was approached using the rule based principles. The principles in the documents also ensured that I did what was required of me in my professional duty as well as in Medicare and state practice. Subsequently, it gave me the option of not interfering with the regulation with my own interpretations which would have resulted to further dilemmas. This also upheld the cause of justice, veracity and my fidelity towards the law that governs my professional practice. In addition, the ability of my client to visit her husband at the nursing home at will, upheld the clients autonomy.