Preamble: Ethics is defined as “…the science of moral duty or the science of ideal human character and the ideal ends of human action. The chief problem with which ethics deals concerns the nature of the summum bonum, or highest good, the origin and validity of the sense of duty, and the character and authority of moral obligation.” Webster’s New International Dictionary, 2nd Edition.
We exist in a world that is filled with uncertainty. In order to bring more meaning to our short existence, we humans have sought to bring control to our lives and thus reduce this element of uncertainty. In the activity of health care and its delivery to our fellow humans, chaos can lead to worsening health, rampaging disease and death. Thus, we have developed intricate financial plans, marvelous educational systems, brilliant research techniques and well-defined laws to order this most vital of human efforts.
Despite all of these attempts to control the uncertainty, human character itself undermines and degrades the outcome. In an attempt to control this last and most errant aspect of human action, the science of ethics has taken a vital position in our culture. Ethics under girds all aspects of our enterprise of health care, the financing of it, the education of its practitioners, the growth and development of its knowledge and how it is to be adjudicated.
The American Association for Respiratory Care is a living, breathing and growing organization dedicated to improving all aspects of the science of respiratory care. As evidence of its evolutionary nature, the Association has seen fit to initiate a process which will continuously amplify its ethical statements in order to meet the growing complexity of what the profession of respiratory care is asked to accomplish.
This “Statement” is part of this process of growth and is to be passed on to generation after generation of practitioners who will wisely see the importance of remolding, restating and adding to these statements as the field of respiratory care expands and evolves.
| Co-chairs: | Richard L. Sheldon, MD, FAARC |
| Carl P. Wiezalis, MS, RRT, FAARC |
Committee members responsible for writing this statement:
| G. Andrews | J. Lee | B. Rogers | R. Weilacher |
| C. Brooks | P. Mathews | T. Watson | E. Rodriguez |
| P. Doorley | S. Mikles | L. Van Scoder | H. Hedrick |
| F. Hill | M. Prewitt | S. Bastable | E. Rodriguez |
| J. Hughes | R. Edge | C. Durbin |
In the conduct of their professional activities respiratory therapists shall be bound by the following ethical and professional principles. Respiratory therapists shall:
1. Demonstrate behavior that reflects integrity, supports objectivity, and fosters trust in the profession and its professionals. Actively maintain and continually improve their professional competence and represent it accurately.
It is incumbent upon the respiratory therapist to exhibit actions and carry our activities in a scrupulously honest manner, unbiased and free from personal feelings or prejudices. In so doing, personal, peer and public confidence is promoted in the individual practitioner and in the profession. This behavior pattern is maintained and sustained for the life of one’s professional career through continuing education. Patient care continues to improve as scopes of practice change, new technologies and disease management strategies emerge and learning is validated.
In the process of continuing education, the respiratory therapist will be aware of the required Continuing Education Units (CEUS) required by their state’s license laws and will comply with these requirements. In so doing, they will choose only the highest quality CEU programs which will address the topics that represent new, proven techniques and knowledge. Areas of known weakness may require educational attention.
References/Suggested Reading
2. Perform only those procedures or functions in which they are individually competent and which are within the scope of accepted and responsible practice.
Respiratory care is a life-supporting, life-enhancing health care profession practiced under qualified medical direction. Any respiratory therapist providing cardiorespiratory care to patients, regardless of the care setting and patient demographics, shall successfully complete formal education and training and demonstrate initial and continuing competency via appropriate national or state certification, registration, or licensure prior to assuming their duties.
The practice of respiratory care encompasses activities in: diagnostic evaluation, therapy, research, infectious diseases and epidemiology, and education of the patient, family, and public. These activities are supported by education, research, and administration.
The respiratory therapist is expected to possess a recognized ability to render competent and efficacious care across the entire health care delivery spectrum, including, but not limited to: physician’s offices; inpatient or outpatient clinics; acute and critical care settings; transport by land, sea, or air, subacute, transitional, skilled nursing, and long-term care venues; and home and self-care settings.
In light of the burgeoning explosion in healthcare science, each respiratory therapist is responsible to maintain knowledge and skills commensurate with the advances in the cardiorespiratory milieu. Today’s respiratory therapist is a dedicated life-long learner. This requires a mind open to, in search of, and absorbent of new techniques and new and expanded applications of all aspects of cardiorespiratory care. Failure to stay abreast of the constantly changing nature and character of cardiorespiratory science and practice may result in a failure to perform competently in an ever-expanding scope of practice.
References/Suggested Reading
3. Respect and protect the legal and personal rights of patients they treat, including the right to informed consent and refusal of treatment.
Respect for patients’ autonomy is vital to the practice of respiratory therapy. Respiratory therapists must accept that self-determination defines a patient’s right to choose or refuse treatment. Essential to a patient’s ability to exercise autonomy is informed consent. Respiratory therapists have a responsibility to provide the patient with a clear understanding regarding therapeutic interventions and outcomes. In those cases where patients do not have the capacity for autonomous choice, decisions may be made by advance directive or by a legal guardian.
The respiratory therapist must inform the attending physician in the event that the patient does not fully understand and has not fully consented to the proposed treatment or diagnostic procedure.
References/Suggested Reading
4. Divulge no confidential information regarding any patient or family unless disclosure is required for responsible performance of duty, or required by law.
In the performance of their duties, respiratory therapists have access to confidential medical information. Respiratory therapists have an ethical duty as professionals to respect the patients’ trust and safeguard the privacy and security of this information. The obligation of confidentiality prohibits practitioners from disclosing patient information to other parties and encourages respiratory therapists to exercise caution with such information to ensure that only authorized access occurs.
When respiratory therapists exchange information with other staff for diagnostic, treatment, or for educational purposes, precautions must be taken to limit the ability of others to hear, view, or authorize access to confidential information. It is vital that Respiratory therapists follow prescribed policies related to security and disclosure whether oral, written, by telephone, or electronic transfer of information.
Respiratory therapists may only breach confidentiality when mandated by law or code such as when abuse is suspected or concern for public health arises. In such cases, the duty to protect the individual or public health outweighs the duty to maintain confidentiality.
References/Suggested Reading
5. Provide care without discrimination on any basis, with respect for the rights and dignity of all individuals.
In order to assure the highest quality care to all patients, the ethical caregiver must have a clear idea of the potential for abuse when discrimination occurs within the areas of class, color, race, gender, age, handicap, culture, religion, creed, ethnicity, sexual orientation, national origin, politics or any other factor that will make a human-being unique. Personal biases shall not allow them to stand in the way of a patient’s right to the best care possible. Any lessening of the dignity of a patient in these areas during the course of treatment is below the ethical standard and should not be tolerated.
If a respiratory therapist is unable to provide care without discrimination, they have an ethical responsibility to request that they be assigned other duties so as to not lessen the rights or dignity of the patient in question.
6. Promote disease prevention and wellness.
Respiratory therapists shall follow a system of personal health care that fosters and leads to optimal attainment of the physical, mental, emotional, social and spiritual aspects of health. Respiratory therapists need to look at the whole person, including analysis of physical, nutritional, environmental, emotional, social, spiritual, and lifestyle values. Practitioners must accept responsibility for their own level of well-being and for the everyday choices made which affect their own health.
By optimizing their own wellness, the respiratory therapist can best participate in programs that promote disease prevention and wellness in others.
7. Refuse to participate in illegal or unethical acts, and shall refuse to conceal illegal, unethical or incompetent acts of others.
In the conduct of their professional activities, respiratory therapists will not engage in any illegal acts and shall adopt a zero tolerance approach to the illegal behavior of others. Knowing that when a minor infraction is tolerated, the door is open for further and more serious breaches, and any witnessed or suspected event must be promptly reported to an immediate supervisor and/or appropriate authority. These infractions include, but are not limited to, illegal behaviors such as theft, falsification of records, fraud and causing the injury or death of a patient.
Respiratory therapists shall resolve that they will neither engage in nor tolerate unethical behaviors in their coworkers including, but not limited to poor quality patient care, wasteful practices, destructive attitudes, sexual harassment, vulgar speech, and customer service failures.
Permitting illegal or unethical behavior to go unreported and uncorrected maligns the integrity of other respiratory therapists in the workplace and reflects badly on the profession at large. Respiratory therapists must resolve to personally promote organizational policies that detail reporting mechanisms for the identification and remediation of illegal, unethical, or incompetent behaviors. Within our current professional world of “blame and punishment”, the respiratory therapist has the right to protection by the organization for which he works, should they take the extremely difficult step of reporting illegal, unethical or incompetent behavior.
References/Suggested Reading
8. Follow sound scientific procedures and ethical principles in research.
Through the centuries there have been methodologies developed by which truth in science can be found. These methods include but are not limited to the concepts of the “randomized, prospective, double-blind, studies” which help to remove bias and other tendencies to arrive at conclusions that will help the researcher more than expand the body of scientific truth.
The current scientific world is now filled with great incentive to arrive at conclusions which can be marketed and thereby allow the researcher to achieve financial and personal gain. The ethical approach to research does not disallow these kinds of gain, but does require that before information is released under the concept of “proven scientific data” the researcher(s) have scrupulously identified and removed bias, reported outlying data, and drawn conclusions which are supported by the data developed.
A primary purpose of science is the formulation and testing of hypotheses about the world around us, and the purpose of a scientific investigator is to report and explain the results of tests of these hypotheses. Data published by an investigator and the interpretation of those data must be the truth, and to the extent that an investigator’s work deviates from what is strictly true, it fails its mission and its readers. Anything that distorts the testing of hypotheses, or the interpretation of the results of this testing, is considered to be a form of bias, and is therefore antithetical to the fundamental nature of science.2
Dorland’s Medical Dictionary3 defines bias as “deviation of results or inferences from the truth.” The potential for bias is everywhere in science. A lack of appropriate controls, inadequate sample sizes, and other defects in study design introduce bias, as do the selective reporting of data and the use of inappropriate statistical tests. Bias on the part of investigators, authors, or manuscript reviewers can stem from family and personal relationships, academic pressure, politics, religious beliefs, and a host of other sources. The form of bias that tends to receive the most attention in scientific publishing, though, especially from the general public, is that involving money, in which reported results deviate from the truth as a result of a financial relationship between the author and the product studied.
A major part of this activity focuses on the identification of conflicts of interest. In its Uniform Requirements for Manuscripts Submitted to Biomedical Journals, the International Committee of Medical Journal Editors (“The Vancouver Group”) states that “conflict of interest for a given manuscript exists when a participant in the peer review and publication process, author, reviewer, or editor has ties to activities that could inappropriately influence his or her judgment, whether or not judgment is in fact affected.”1
References/Suggested Reading
9. Comply with state or federal laws which govern and relate to their practice.
Respiratory therapists must be aware of and responsive to the requirements for practice in their locale of practice, that their actual scope of practice be within the bounds set by local, state and federal regulations and laws, actions that they perform required by legally determined and promulgated rules, regulations and laws.
Laws are decisions of national, state or local legislative bodies that set conditions under which regulated activities can be practiced and detail the criteria which define the education, testing and scope of the practice of those permitted to practice. These laws may also define breeches of legal practice, establish and empower oversight boards for the regulated profession and set boundaries defining the limits of these boards to collect monies, investigate activities of the profession and determine limits of sanctions and punishment for breach of the law and board regulations and rules.
Regulations are descriptions of actions and activities promulgated and defined and enforced by the professional practice board under its legislative empowerment. Regulations are sometimes referred to as Administrative laws. Regulations set for requirements for practice under the law. Regulations also define the board’s powers to control areas of practice.
Rules are developed by the board to operationalize the broader mandates of the Laws and Regulations.
The Therapist Must:
Respiratory Therapists May Not:
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Case Report –
Tara Z. Someliynski has been practicing as a Registered Respiratory Therapist for 7 years. Prior to that she practiced for 3 years in an adjacent state. Licensure became a requirement in her state this year. As a condition for licensure each practitioner must submit a copy of their current drivers license, her NBRC registration card and an application containing, among other information, a notarized statement attesting that all the information submitted to the Board is true.
Upon submission to the board and during application processing J.H., MS, RRT and appointed member of the board became curious about Ms. Someliynski. He stated to other board members “You know, this is very strange. I went to RC school with a Tara Z. Someliynski, but about eight years ago she was killed in an automobile accident three days after passing her RRT exams. What are the chances that someone with that exact same name would also be an RRT from my home state?” The rest of the board agreed that it was an exceptionally strange circumstance and referred the matter to the investigative branch.
Upon examination it was discovered that Ms. Someliynski was actually Billie Sue Renfrew, a former roommate and co-worker of Tara Someliynski’s. Billie Sue had been dismissed near the end of her training for attitude problems and poor grades from the same school that Ms. Someliynski and Mr. Hernandez attended.
It was discovered that Ms. Renfrew had intercepted Ms. Someliynski’s NBRC card from the mail and had altered her driver’s license by switching photos. When these actions were successful Billie Sue moved to her current state under her newly switched identity.
What ethical and legal issues arise from this case? How could this situation have been avoided? (By the employer, by the NBRC, by the state and federal government?) Is Billie Sue the only one at fault? What sanctions should be leveled?
References/Suggested Reading
10 Avoid any form of conduct that creates a conflict of interest and shall follow the principles of ethical business behavior.
The vast majority of respiratory therapists are honorable and dedicated professionals who are themselves harmed and diminished by conflict of interest, breaches of confidentiality, or fraudulent practices of those in their peer group.
Conflict of interest has been defined by Thompson1 as “a set of conditions in which professional judgment concerning a primary interest (such as patient’s welfare or the validity of research) tends to be unduly influenced by a secondary interest (such as financial gain.)”
The bond of confidence and the standard of confidentiality are hallmark attributes to guarantee trust between the respiratory therapist and his/her patient, and others directly or indirectly involved in the patient’s care. The careless word or comment may bring as egregious harm to the patient-therapist relationship as a knowing over breach of confidence for personal or professional gain.
Fraud or fraudulent practice is conduct intended to deceive. A practice is equally fraudulent if practiced or witnessed, and may come by means of commission or omission.
Fraudulent practices violate the trust, which should exist between patients, their caregivers, and payers, and present an image of non-professionalism, lack of compassion, and overpowering greed. Fraudulent practices undermine legitimate practices and add to the burden on the nation’s already financially stressed health care system.
Fraudulent practices may include, but are not limited to, submitting claims for payment for services not provided; falsification of documentation to indicate that services were provided which were not, in fact, provided; falsification of patient services or reimbursement or for other reasons; providing services which are not medically necessary, or which have not been ordered; or using/reporting improper billing codes and/or inflating service charges for selected patient groups to enhance reimbursement.
Under no circumstances should any respiratory care practitioner engage in any activity which compromises the motive for the provision of any therapy procedures, the advice or counsel given patients and/or families, or in any manner profit from referral arrangements with home care providers or others within the healthcare environment.
In the realm of conflict of interest and fraudulent practice, vigilance is the watchword. Actively participating in conflict of interest and fraudulent practice is only level of transgression. To witness or suspect conflict of interest or fraudulent practice and not report it makes the practitioner as culpable as having performed the act or practice.
References/Suggested Reading
11. Promote health care delivery through improvement of the access, efficacy, and cost of patient care.
Respiratory therapy practitioners shall act in the manner that will indicate a proactive stance toward better access to a more effective and affordable health care system.
This suggests that the respiratory therapist is:
These responsibilities rise from duties to serve the public, to conserve scarce resources, to do good (beneficence) and to use our knowledge and skills in a just and humane manner. Services rendered should neither be distributed nor restricted due to race, gender, ethnicity, religion or economic status, or other factors or attitudes.
In order to do these things respiratory therapists must always use our skills,
knowledge and resources in as efficient, effective and economical a manner as
possible. Respiratory therapists must advocate for quality over quantity
where the two are opposed. Respiratory therapists must be the champions
of high quality patient focused care utilizing systems such as evidence-based
medicine and outcomes analysis to guide our practice.
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Case Report –
H.M. is a 43-year-old HIV positive patient who has an admitting diagnosis of bronchial pneumonia and pneumothorax. He is hepatitis A, B, C negative. His body temperature is 98.6 F (37 C) with respirations which are 24 breaths per minute and shallow. He is cyanotic and tachycardic with a normal blood pressure. His oxygen saturation is 89% and he has a Pa02 of 65 mm Hg on a 40% Venturi mask. The patient has a 25% pneumothorax seen on chest X-ray. His CD-4 T cell counts are very low and he has a positive sputum culture for Pneumocystic carini. He has been HIV positive for 11 years and reports a weight loss of 40 lb over the last three months.
The patient is admitted to the ICU where a chest tube is inserted which results in a slight improvement in his oxygenation. The patient is awake, lightly sedated, but able to answer questions appropriately. Discussion ensues regarding further therapeutic steps. The patient declines intubation should he proceed to full respiratory failure. This statement is well-documented on the medical record. Previous medical records indicate the presence of a “durable power of attorney” which excludes “heroic efforts” and the use of “life support equipment”. The patient’s life partner of eight years states he has seen the document and affirms that in the course of much discussion, the patient has said he does not want “life support and all that goes with it”. The patient’s family, who has been out of contact for ten years, cannot be located for confirmation.
One week later the patient has clinically deteriorated to the degree that he is comatose and hear death. The mother suddenly appears and is devastated to learn of her son’s illness and demands that he be immediately intubated and fully resuscitated. The mother insists he is not to be “put behind the barn and let die” regardless of the Durable Power of Attorney which can not be found among the patient’s records at home. However, the patient’s will is found which leaves large sums of money to his life partner.
The case is immediately referred to the hospital’s ethics committee. They rule that the patient’s statements, as documented on the charge before he becomes mentally incompetent from his acute illness, has precedence and because of the futility of aggressive care, the patient is not to be aggressively treated as demanded by his mother. Soon thereafter the patient dies. Because of the large sums of money in the patient’s estate, the mother brings a lawsuit for wrongful death against the hospital, the physicians and the patient’s life partner.
The court subsequently dismisses the hospital and the physicians as defendants due to their use of the hospital’s ethics committee for consultation and careful documentation of the patient’s premorbid statements. The mother and the life partner settle out of court.
References/Suggested Reading
12. Encourage and promote appropriate stewardship of resources.
Respiratory therapists will be good stewards of health care resources. They will develop and follow standards of care based on sound science. They have an obligation to advance the quality of respiratory care by using the best available science in support of individual care decisions. They will participate in implementing changes in care that reduce costs without compromising quality and share ideas about “best practices”.
A practical demonstration of this principle is the implementation of patient-driven protocols. These evidence-based guidelines reduce variation in patient treatment, improve quality, and often reduce costs. Another example of good stewardship is using a less expensive, equally effective device in place of more expensive technology.*
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* Adherence to this principle is demonstrated by substituting a metered-dose
inhaler for small volume nebulizer treatments in appropriate patients.
Ethical arguments related to cost-conscious distribution of resources involves
the concept of distributive justice.
Reference
AARC Special Committee on Ethics and Professional Behavior
Ethics Coverage in Current Respiratory Care Texts
The authors, book titles, publishers and chapter/page numbers of the reviewed texts are listed below: