What distinguishes audiologists and other health care professionals from those in the business world? Should the rules that govern retail sales apply to audiologists? Can business practices and altruism coexist? Let's examine these issues in the context of the ASHA Code of Ethics and a growing effort among health care organizations to remind professionals of the centrality of ethical behavior in their daily activities.
Free Market vs. Professional Rules
Most of us have friends or family members who work in the business world, often involving sales of one kind or another. Part of their compensation may include "perks" such as bonuses for meeting sales quotas, manufacturer's rebates for selling their brand of a product, gifts from industry to encourage brand loyalty, and industry-subsidized training to demonstrate the features and functions of that manufacturer's product. The latter may be their primary (or even exclusive) source of information used to sell the product to consumers.
The consumer seeks value, which is perceived as a combination of quality and cost. In a truly free market with multiple brands of similar products, competition can improve both of these for the consumer. Since the consumer is making the choice of what to purchase, or even whether to purchase, advertising is widely used to persuade consumers that they need a specific product and that a particular brand (i.e., theirs) is best. Advertising is intended to increase sales of a particular brand and product and is regulated by consumer fraud laws.
Consumers interested in independent analyses of various brands of the same product don't expect to obtain it from manufacturers or retailers of those products. One source claiming to provide an independent analysis is Consumer's Union, publisher of Consumer Reports, a monthly magazine that rates different brands of similar commercial products and makes recommendations. Although it is nonprofit, it must have sufficient revenue if it wishes to remain in business.
What if you learned that a supposedly independent source wasn't free of bias? How would you react if you learned that the manufacturer of the highest rated product in Consumer Reports had given substantial gifts to Consumer's Union? What if you discovered that the judge hearing your case in court received gifts from the attorney representing the other party? Would you have any concerns about a basketball referee who had a close relationship with the team your daughter was scheduled to play for the championship?
Should the same set of rules that govern those working in retail sales apply to health professionals? What distinguishes the original three professions of medicine, law, and ministry-or subsequent ones, such as audiology-from free-market commerce? Professionals who earn recognized credentials by completing an approved educational program are given a special monopoly to provide certain services and, when appropriate, to dispense related products. In return, health professionals are expected to restrict themselves to a defined scope of practice, follow practices based on good science, and adhere to the principle of beneficence (i.e., patient welfare is the primary concern). On the other hand, those working in the world of free-market commerce may face major competition from anyone who wishes to try to sell that same product.
In recent years, several prominent organizations for health professionals have increased their efforts to remind their members and students about the significance of ethical behavior and professionalism. For example, the American Medical Association's (AMA) Web-based training modules address relationships between physicians and industry, with most of the focus on the issues of gifts, objectivity, and conflicts of interest. The AMA's criteria for gifts and industry-subsidized educational activities are shown in the box on page 5.
Codes of Ethics
The self-governance that professions also enjoy requires self-discipline if they wish to retain the public's trust and its special privileges. Clearly stated and fairly enforced codes of ethics, with sanctions proportional to the magnitude of the violation, provide an assurance to the public that this commitment is taken seriously by the respective professional organizations. Professional organizations and credentialing bodies in audiology typically require a commitment to follow their code of ethics as a requirement for maintaining membership or a credential. Most audiologists are governed by multiple codes, and many of the rules of these various codes overlap. All are subject to change in order to adapt to change, such as technological advances. It is our individual responsibility to be aware of all of the current ethical standards to which we have committed ourselves. Just as regular weight resistance training maintains muscular strength, regular exposure to potential ethical scenarios in our professional lives, and appropriate responses, is necessary to maintain our moral strength. This resistance training will be enhanced if we go beyond mere awareness and examine our professional heritage and inherent obligations.
Approximately 15,000 audiologists are currently under the jurisdiction of the ASHA Code of Ethics. This code originated in 1930 and has undergone several changes to its current form, most recently in 2003 to address ethical issues of researchers. All of its 37 current rules are based on four fundamental principles:
- holding paramount the welfare of persons served
- achieving and maintaining the highest level of professional competence
- promoting public understanding of the professions, supporting the development of services designed to fulfill the unmet needs of the public, and providing accurate information in all communications involving any aspect of the professions
- upholding the dignity and autonomy of the professions, maintaining harmonious inter-professional and intraprofessional relationships, and accepting the professions' self-imposed standards
The ASHA Board of Ethics is charged with updating the code, enforcing it by adjudicating complaints against those covered by it, and educating members about professional behavior and responsibilities. In addition to the Code of Ethics, the board created a variety of "Issues in Ethics" statements, which are available on the ASHA Web site.
Some of the reasons given by audiologists opposed to current ethical principles and rules include:
- "I wasn't familiar with the ethical rules governing my professional conduct." The accrediting body for academic clinical programs, the Council on Academic Accreditation, currently requires inclusion of relevant codes of ethics to be in the curriculum. Additional measures aimed at improving not only awareness, but understanding of professional ethics might include significant references in student recruitment materials to the privileges, opportunities, and responsibilities in audiology, beyond just employment and income statistics; creation of a national exam on ethics which must be passed prior to beginning practice; and online training modules and recommended readings in professional ethics. The need for exemplary professional role models throughout our careers can't be understated. Just as a parent's observable actions under fire leave a deeper imprint on a child than handing the child a rule book, the same is probably true for those entering the profession.
- "I can maintain objectivity even in the face of attempts by industry to influence me." In 2000, the pharmaceutical industry spent $15.7 billion on promotion and employed 87,000 sales representatives. If this kind of investment did not result in measurable influence on physicians to recommend their product, it would discontinue. Hawkins (2002) reported that 32% of audiologists approved of things like rebates, gifts, and learning activities subsidized by industry, but only 5% of consumers concurred.
- "Professional practice is a business, and rules prohibiting 'perks' from industry place audiologists at a disadvantage and reduce their already low incomes." If hearing aids and other devices are simply retail products, then anyone should be allowed to dispense them. The transition to the entry-level clinical doctorate should create the opportunity to include coursework in contemporary business practices. This should increase the likelihood of graduates' ability to start and maintain successful practices and reduce/eliminate reliance on relationships that can undermine the public's trust in the profession. Joint efforts by professional organizations and industry to curb longstanding practices that jeopardize the profession could help pave the way for changes without economic consequences.
There is a tendency when addressing this subject to argue that business practices and altruism cannot co-exist. We must find ways to employ and embrace the highest standards of each. Audiologists work in physicians' offices, private practices, hospitals, universities, industries, and/or schools-each setting with its own set of challenges and traditions. No work setting is devoid of ethical dilemmas, and no professional is immune to the allure of placing self-interest above that of the people we have committed to serve as our first priority. If we are to maintain the public's trust, we must be on guard for such situations and have mentally practiced a plan of action in advance in order to increase the likelihood of responding in a trustworthy manner. We must regularly remind ourselves that we are responsible for preserving the future well-being of this profession as our legacy to the next generation of audiologists. Jacobson's (2002) editorial in the American Journal of Audiology on "Our Great and Noble Profession" eloquently addressed the rewards of being an audiologist, our common ancestry, and the responsibilities we have to the public we serve, and West's (1961) Hippocratic Oath remains relevant and inspiring. It is incumbent upon each of us to be aware of, and live by, the principles and rules to which we have pledged as professionals, from our various professional organizations and credentialing agencies, and from one generation to the next.