Ethics: The Glue That Holds Us Together

Kudos to the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) for creating a code of ethics for the nationwide profession and for deciding to make courses in ethics a requirement for certification renewal. Yes, starting in 2016, every NCCAOM Diplomate will have to do at least two hours of study in approved ethics courses. This replaces the previous renewal requirement of four hours in safety and/or ethics. Although neither a code of ethics nor a renewal requirement may seem significant, they both signal that the profession is exiting adolescence and entering adulthood. An industry-wide code of ethics brings legitimacy to the profession, provides consistent standards, and is the glue that holds us, the practicing acupuncturists, together.

It is also noteworthy when state acupuncture associations around the country establish a code of ethics for their members. I practice in Florida and am proud to say the Florida State Oriental Medical Association (FSOMA) established a code of ethics two decades ago. Similar to NCCAOM's, FSOMA's code of ethics is comprehensive and contains all the key elements and topics shared by medical professions of size and integrity.

State regulatory boards aim to accomplish something similar to codes of ethics via regulations and by enforcing laws made by legislators. However, laws and regulations are not enough, as many things cannot be spelled out, nor fully monitored or disciplined, by state boards. So while the legal and regulatory systems focus on larger, more egregious behaviors, codes of ethics serve to provide structure and guidelines for the finite aspects of clinical practice.

Four Pillars

Many concepts form the foundation of ethics in the practice of acupuncture. There are four concepts I consider "ethical pillars," meaning they are the deepest, most relevant root principles that many other aspects of ethics sit upon. Once known, we can use and apply them in many ways, helping us day by day, situation by situation. Like the saying, "Rather than give someone a fish to eat, teach them how to fish," I prefer to teach the foundation and reason for ethics versus writing a litany of individual do's and don'ts.

Authority

As much as our patients are our equals as humans, society views the patient/practitioner relationship as hierarchical, meaning it has layers of authority. In this structure, we the practitioners, are above the patient. Though this is a subtle distinction, it is actually quite powerful and profound. This aspect of the patient/practitioner relationship is often identified as the premiere reason to have a written code of ethics. Knowing and honoring this distinction requires us to pay attention to our methods and behaviors, as to not exploit or benefit from the inherent power of our position in this hierarchy.

Strong, controlling, or dogmatic rules or policies by practitioners, or their offices, such as selling unneeded or excessive products to patients, are examples of abuse and take advantage of the patient/practitioner relationship. Patients trust we are providing the best recommendation for their well-being, not ones that line our pockets.

Another example of a conflict with this authority is becoming over-friendly or flirtatious with patients. Dating a patient is a huge ethical violation. Most states have strong and clear language on this topic. The NCCAOM specifically addresses this in their code, "Maintain professional boundaries in relationships with patients and avoid any relationships that may exploit practitioner/patient trust."

Touch

Unique across almost all of society is the fact that professionals in medical fields, including acupuncture, are granted the right and ability to touch people. Touch is a powerful tool for good, but it can also do great damage if not honored and used properly. Touch crosses peoples' boundaries of space and intimacy. This is particularly true for those violated in one way or another through touch.

In the medical and healing fields, all touch should only occur within a therapeutic context. It is crucial for us to watch carefully for cues to how our touch is perceived. Do not assume everyone has the same desire for, or tolerance of, touch. Keep it professional and with proper timing and nuances. Equally important, always adhere to impeccable draping methods with patients. Remember, it is a privilege to have a license, literally, to touch another person for healing purposes, and it is critical to honor that privilege.

Need

Patients come to us because they have a problem and need help. Because of our knowledge and experience, they need us and believe in what we can offer. Sometimes this need is very significant. Many patients are suffering a great deal and may feel desperate. This is a key reason why society expects so much of certain professions like medicine, law and finance. Society does not want the adage "buyer beware" to be necessary when people have these needs and seek help. An ethical practitioner understands and honors this principle, and establishes conduct that does not take advantage of the vulnerability inherent in the patient stemming from their need.

Several ethical codes of the profession focus on the awareness of a patient's fundamental need. These codes include the elements of: the obligation to treat all patients, avoid discrimination, continuity of care, requirement to adhere to scope of practice, requirement to provide accurate information and to secure consent, and the requirement to refer to anyone else that can also help the patient.

Intimacy

The high quantity and quality of time we spend with our patients is a similar to that of the counseling and psychology professions. Hour after hour, week after week, we spend quiet face-to-face time with our patients. We ask incredibly personal questions and talk about all aspects of patients' lives. Patients tell us very confidential things. Trust and professional intimacy occurs with all this detail and shared time. This factor actually magnifies the three principles mentioned above. Certainly, this is a fundamental reason for the ethical requirement of confidentiality. Yet it is so much more than this. It is why the concepts of respect, dignity, professionalism, boundaries, not "over sharing" our own personal details, and not exploiting trust are so often included in codes of ethics.

Profession's Authority to Self Regulate

On the American Medical Association's History of AMA Ethics page, there is a statement I want to share, "The Code [of Medical Ethics] ... defines medicine's integrity and the source of a profession's authority to self-regulate." This is the simplest, yet most profound statement regarding ethics. It describes the most important reason for, and necessity of, the creation of codes of ethics. It is the foundational "why" for the establishment of codes of ethics by professional organizations, and their subsequent enforcement of ethical principles.

Certain professions have great latitude to create their own standards, and thereby given the expectation to be the first pair of eyes and ears to observe and uphold those standards. Society expects those closest to any individual or group within the profession to watch for damaging behavior, and to step forward and report that behavior in an effort to maintain the professions' ethical codes. Despite its newer and less recognized presence in the U.S. healthcare system, acupuncture and Oriental medicine is included in this expectation of self-regulation. For practitioners in states where acupuncture and Oriental medicine is given "primary care" status, this is even more so the case.

A benefit of ethical codes is that, whether intended or not, they increase safety, lower the risk of patient complaints and decrease civil lawsuits. Without them holding us accountable, the professional legitimacy we've worked so hard to establish will be lost. Our code of ethics is the glue that binds us all together.