Business and Professional Ethics In Prosthetics and Orthotics
Jack Armold, Ph. D. *
Introduction
The story of Oedipus in ancient history reveals the main focus of this article. Oepidus, who had been abandoned by his father, returned to Thebes, the city of his birth, after growing up in the wilderness. He found the city harassed by the Sphinx, a monster having a lion's body, wings, and the head and bust of a woman, who challenged travelers with a riddle. Those travelers who could not answer, were devoured by the Sphinx. When confronted by the Sphinx, Oepidus guessed the riddle, the Sphinx slew herself, and Oepidus became king of Thebes. The riddle: What creature walks in the morning upon four feet, at noon upon two, at evening upon three? The answer: Man, as a baby on hands and knees, later on his feet, and in old age with a staff.
Man as he relates to other men and his environment is the main concern of ethics. In this article we are concerned specifically with man in his business and professional relationships. Many have left the study of ethics to the philosophers, but ethics deals with practical questions of human behavior, which lie within the power of all men to discuss. Science does not admit to general discussion because the subject matter of science is based upon verifiable general laws or the operation of general laws.
The universality or popularity of ethical discussions may be seen in businesses and professions other than prosthetics and orthotics.
Ethics has always played a significant role in the professional lives of physicians. American technology has retooled itself with an eye toward moral, social, and ethical values. The world of financial investments has struggled in an upward move to practice loftier codes of professional and business ethics which would protect investors. Finally, there is a current rush of Senators to support a code of ethics for Senators and Senate employees as a result of the Bobby Baker scandal.
Importance of Ethics
Why study ethics? In the first place, men in business and professions should study ethics because it is economically sound. Judge Edwin B. Parker, Chairman of the Committee on Business Ethics, stated in the pamphlet issued by the United States Chamber of Commerce:
Business has formed and is forming habits of straight thinking and right acting because they are in the last analysis economically sound habits . . . Enlightened self-interest should prompt each class of persons in business to deal fairly with others, because to do so ultimately pays.
Secondly, the study of ethics is practical. This reason is illustrated succinctly by the story about the business man who had been deaf to all reasons for having an annual audit of his company's books. He suddenly changed his mind about the audit when he saw his new cashier wearing a new fur coat!
The third, and most important, reason for the study of ethics may be found in the statement of Socrates, the Grecian sage and teacher: "The unexamined life it not worth living."
A look at the birth of philosophy, reason, and ethics provides one with a background, or a frame of reference, for studying ethical questions in prothetics and orthotics.
The ancient Greeks showed man how to use his mind. Modern thinkers, striking out alone on what they believe are untrodden paths, nearly always sooner or later encounter the ghost of some ancient Greek returning from the same solitary journey. The Greek's creed is found in the famous dictum: MAN BY NATUBE DESIRES TO KNOW. Giorgio de Santillana, Professor of History and Philosophy of Science Department of the Massachusetts Institute of Technology, wrote, in The Origins of Scientific Thought, "The two greatest thinkers, Plato and Aristole, between them, laid the ground for worlds of thought as far apart as ethics and nuclear physics.
Definitions: Ethics and the Ethical Man
Ethics is the study of moral values and deals primarily with a choice involving human action, character, and ends. "Choice" is a key word in this definition because of our primary concern with business and professional relations. Wayne A. Leys, an expert on business ethics, contends that business and professional persons should "practice the habit of always seeing an alternative, of not taking the usual for granted, of making conventionalities fluid again, and of imagining foreign states of mind."
A study of ethics helps in making wise choices. Business and professional persons often have the impression that they are making important decisions, but wonder privately whether they really know what they are doing. An awareness of ethics will provide one with systems which stimulate proper questioning when analyzing actual cases and issues. The practical importance of ethics may be seen in the fact that decisions determine action—with major consequences or a long series of related actions.
Having defined ethics, we have yet to characterize the ethical man. The ancient philosophers considered him to be a man of character, competence, and good will.
Character may be defined as the result of the way in which a man exercises his capacities. The emphasis here upon "man exercising his capacities" makes this definition extremely relevant to a study of "public ethics." This study looks "horizontally" at man as he relates to others and his surroundings. On the other hand, "private systems of ethics" are chiefly concerned with man looking introspectively at himself; thus he may be characterized as "vertical."
Business Counselor Merrill C. Meigs states that success begins and ends with character. He writes:
To succeed, one must first build his character on sound fundamentals— honesty, loyalty, unselfishness. Then he must set his sights on a goal. If he attains it on that foundation—no matter what the goal, no matter what the monetary rewards—he is a success.
Competence is the second characteristic of the ethical man. A prosthetist or orthotist, for instance, fulfills this requirement when he demonstrates that he has had the special skills, knowledge, and ability necessary to meet the needs of the patient. The competence of the prosthetist or orthotist will be judged by the patient and other professionals.
Good will, the third characteristic of the ethical man, is that quality which goes beyond skills and knowledge. It is that quality which is best typified by the Greek word, agape, a sense of concern as an expression of one's being, humanness, and need to reach out beyond one's individual isolation to touch the spirit of others."
Business and Professional Considerations
The history of the professions is an excellent practical object study for anyone interested in plotting the possible course for prosthetics and orthotics towards higher ethical standards. For example, the medical profession worked itself through various stages of charlatanism and low commercialism. It is not so far advanced today that it does not still have to struggle with some of its legacies of the past. It, too, has its problems of competition and of consumers' rights closely paralled to those in other business and professional fields. Therefore, one concerned about the "old saw," business v. professionalism, should consider what the best members of the medical profession have done and are doing to move their ethical standards and practices upward.
An excellent definition of a profession appears in the Canadian Bar Review:
A profession is a self-selected, self-disciplined group of individuals who hold themselves out to the public as possessing a special skill derived from education and training and who are prepared to exercise that skill primarily in the interest of others.
Note the words, "the public" and "the interest of others." These words help to further clarify the nature of a "public" ethical system which is an integral part of any profession.
Historically, there were three professions—theology, medicine, and law. Their origins arose out of a need for competent individuals, acceptable by the community, to administer to the spiritual and physical needs of the individual and to regulate the practice of the community.
From the very beginning, the university was considered as an integral part of the preparation of men for the professions. The central creed of the university has been summed up by the Greek phrase—strive for excellence.
The role of the university has always been vital to the professions because it traditionally has been in the best position to organize a body of knowledge and transmit it by systematized instruction to its students. Three general purposes of the university are: (1) the conservation of knowledge through libraries and collections; (2) the dissemination of knowledge by teaching and publishing; and (3) the addition to knowledge through scholarship and research.
The University of California at Los Angeles, New York University, and Northwestern University are today, partially responsible for the preparation of candidates for full professional acceptance by their colleagues and the American Board for Certification in Orthotics and Prosthetics, Inc.
While the university has always been central to professionalism, many professionals have made outstanding contributions to society through private study and practice. For example, Ahraham Lincoln, Charles Goodyear, Henry Ford, and Thomas Edison had little formal education but their achievements are well known today.
Professionals are workers. Dr. McKinley H. Crabbe, of the State Medical Boards of the United States, said:
The licensed physician regards work as the fulfillment of personality.
He is usually overworked, worried and conscientious about some patient. He often has more patients than he can see properly. When work becomes an end, the drudgery leaves work. This is the mark of a professional person.
The professional person must also act according to written and unwritten codes of ethics. Prosthetists and orthotists have written a code of ethics and use this code as a measure of professional and ethical behavior. However, there are large grey areas where the written codes do not apply. All codes are blank in some areas. In the context of the first professions the candidate was required to show evidence of measuring up to an unwritten code of being a gentleman before being allowed into a profession. The implication of acceptable sociability and taste are still a requirement for professional conduct.
Finally, a profession is entered for its inherent value and not first for individual profit. The motive of service must be greater than the motive of service to one's self and one's own.
In short, professionalism adds up to: (1) the pursuit of excellence, (2) hard work, (3) written and unwritten standards of conduct, and (4) a high motive of service.
Ethical Systems
The organizing ideas of the philosophers, the thinkers of all times, complement the fact-hugging insights of business and professional men when ethical standards are expressed as questions. Standards must be stated as questions because ethics is an inexact study. Intelligent questioning may best be described by the word, "deliberation," which is taken from the Latin root, "libra" (scales).
A study of various ethical systems provides a means of weighing questions of practical human conduct. In listing some of the leading systems of ethics, the practical reader may not see their immediate relationships to every day problems of the business and professional world. Students of philosophy may accuse the writer of oversimplification. However, recognizing the dilemma, an attempt will be made to improve and systematize practical judgments by finding out whether the right questions are being asked when making decisions. The systems will raise questions which will serve as pointers and direction finders. The following systems of ethics turn our gaze to values in our situation which we might not otherwise see:
| Type of Ethical System |
Name |
Highest Good or Ethical Goal |
| Individual: |
Platonism
Stoicism
Cynicism
Epicureanism |
Moral Idealism
Rationality
Virtue
Pleasure |
| Group: |
Casuistry
Utilitarianism
Pragmatism
Historical "Logic"
Semanticism |
Precedents
Public Utility
Practical Consequences
Economic Equality
Understanding |
| Critical: |
Golden Mean |
Moderation |
Platonism, or moral idealism, asks: Can you bring various approved practices under a general rule? The ethical or Good Life is achieved when one lives by moral absolutes. E.g. Do unto others as you would have them do unto you.
Stoicism believes in keeping integrity by using reason as the measure for all decisions. The belief in Universal Reason above a society is central to stoicism. The stoic asks: Can you rationally follow your principles to point of sacrifice?
Cynicism is anti-materialistic. The cynic believes that virtue and freedom should be the object of man's pursuits. Since wealth is often equated with evil, a question might be raised: Is profit making wrong?
Epicureanism is diametrically opposed to cynicism, stoicism, or Platonism. Pleasure, not idealism, rationality or virtue, is the true measure of happiness. The epicurean asks: Does man work to be able to afford the thing he wants?
These four systems are labeled "individual" because they involve man looking at himself. The next five may be considered "group ethical systems" because they reflect man looking "outside himself."
Casuistry, which takes its name from the Latin word, case, makes decision on the basis of precedents and law. In weighing questions of human action, the casusist asks: What are the authoritative rules and precedents, the agreements and accepted practices?
Utilitarianism made "public utility" the main criterion of the rightness or wrongness of human actions. The worth of philosophic thought is to be measured by its fruitfulness in productive operations and techniques. The utilitarian asks: How many people would benefit from the alternative proposals?
Pragmatism William James' famous book (1907), was subtitled "A New Name for Some Old Ways of Thinking." James claimed that the ancient Greek thinkers, Socrates and Aristole, and the British philosophers, Locke, Berkeley and Hume, were forerunners of modern American pragmatism. The term "pragmatic" is derived from a Greek word which refers to practical affairs and actions. James made practical consequences the test of truth of moral and religious ideas. Ideas and theories, in this view, must make a difference in actual experience, otherwise they are empty and barren, and hence, meaningless. The pragmatist is not so worried that many commonly think of the practical or expedient as the not-so-ethical means of achieving riches, power, or pleasure. The pragmatist might ask when trying to improve the relevance of older systems: Will the policy work?
Historical "Logic" has been embraced by many liberal political economic thinkers. Marx, for instance, thought that all ethical problems related to economics and self-interest. Economic equality and classlessness should be the goals of every society. Related to the business world, he might ask: Are pay, prices, and profit at the base of all business and professional problems?
Semanticism upholds the idea that most ethical problems result from confused, inaccurate, and emotional language. The semanticist seeks proper meaning and understanding. He asks: Has the problem been confused by loaded language and verbal trickery?
Many kinds of investigations have been called ethics. No one should protend that he can systematize all of the varieties with one organizing idea. Common speech is no more consistent in the meanings assigned to ethics than it is in the meanings assigned to hills, fishes, and laws. So far, our listing of ethical systems has revealed a great spread in the value systems: moral idealism, rationality, virtue, pleasure, precedents, public utility, practicality, economic equality, and understanding. Each system turns our attention to values which are involved in most questions of conduct and expediency. These questions no more admit of hard and fast rules than questions of health.
In the business and professional world, a "critical" system of ethics is needed when deliberating about or weighing the alternatives of each question. The ancients called the system the "golden mean." It has been popularized by expressions like: "Moderation in all things," and "Nothing in excess." We will attempt to define the golden mean by looking at the word, "happiness." If for the sake of illustration, we could agree that the end for which all men more or less consistently strive is happiness, our differences in behavior would become immediately apparent because we have different notions of what happiness is. Whatever the definition of happiness might be, or the ethical system one follows to achieve it, his state and character should cause him to choose a mean of conduct between an excess and a defect. Either, excess or defect, would involve him in wrongdoing and eventual un-happiness. Justice, for example, is a fair balancing of claims between contending parties.
In short, the golden mean:
- Is the point between extremes,
- takes both into consideration in matters of practical human behavior,
- is neither too much nor too little; and,
- is not the same for everyone.
For example, let us consider our attitude towards property:
Prodigality ----- Liberality ----- Greed
Prodigality involves extravagant waste; greed is stinginess. We apply the term "greed" to people who care more than they should for property; the term "prodigality" we refer to people who are intermperate and spend their money in extravagant living. For most people, "liberality" would sum up the golden mean as it represents a point between waste and stinginess.
A final example of the golden mean will be used before making a direct application to prosthetics and orthotics. America is currently faced with a difficult problem which affects all business and professional persons. Example :
Complete Socialization ----- Unrestricted Personal Freedom
If, on the one hand, the American society moves toward the extreme of complete socialization there will be an inevitable restriction of personal freedom; if, on the other hand, the choice is for the opposite extreme of unrestricted personal freedom there would be a reluctance to enter the sphere of social planning. The extremes of these divergent paths are undesirable for the majority of Americans, rooted as we are in the Greek philosophy respecting the dignity and worth of the individual. In both extremes, the individual is sacrificed.
If there is a middle course, a golden mean, it does not lie with all-powerful government ultimately stifling all-important areas of personal and professional freedom. Also, if there is a middle way—a golden mean—it does not lie in the unrestricted power of business enterprisers to whom the burden of the distribution of social services becomes an intolerable restriction of profit.
The golden mean for most Americans would be found at varying points between the extremes. While the golden mean varies among individuals, such as Republicans, Democrats, and Independents, the importance of critically weighing the alternatives becomes immediately apparent in any consideration of business and professional ethics.
Ethical Questions in Prosthetics and Orthotics
Having defined terms and discussed various ethical systems, we will now turn our attention to their application to prosthetics and orthotics.
Professional Relationships
A profession must first practice policies of social responsibility and secondarily seek professional recognition. Recognition cannot be a cause; it can only be a result of professional service to others. Professions exist for people and not for professionals. Society supports a profession because it looks upon professional persons as contributors to human welfare.
In professional relations, an ethical question arises when an association, such as The American Orthotics and Prosthetics Association, seeks to gain professional recognition and at the same time project the image of social responsibility.
Professional Recognition ----- Social Responsibility
If the prosthetic-orthotic profession, either through a drive for status among professions or through a preoccupation with its own internal structure and politics, reduces the effort it can invest in research, teaching, and practice, it cannot best meet its first rsponsibility—service to the disabled.
A profession needs an association in order to function well. Prosthetists and orthotists should belong to the American Orthotics and Prosthetics Association, contribute to the benefit of other members, participate in meetings, and share information. However, too much organization is nonfunctional. So is too much concern for position in that organization. The golden mean is located at points between too much and too little organization.
An inter-professional spirit among men of different competencies engenders the understanding that the other man is working hard on an interesting and worthwhile job without knowing what the details may be. Carl Taeusch wrote: "The confidence which arises from membership in a recognized and dignified profession will contribute vitally to that sort of contentment and happiness which alone can be justilied in an ethical society."
Standards
Standards have the effect of making prosthetic and orthotic practice a career of distinction. Emphasis upon professional conduct and standards makes the practice honorable and dignified. The development of a professional morale has led to the founding of all professional societies.
The ancient Greeks felt that man could only discover bis own humanity, his true self, when he strained every resource to the limit. This relentless will to pursue excellence helps account for the wonders the Greeks accomplished. It was also the source of their sufferings. Standards should be striven for, but they should not lead to despair. One ethical question which a standard-setting body, such as the American Board for Certification, must continually consider is:
Realistic Standards ----- Absolute Standards
If one begins at the extreme of current practice and education, he will automatically lower standards in an effort to satisfy the realities of the current practice of prosthetics and orthotics and the actual educational achievement of practicing prosthetists and orthotists. If, on the other hand, one goes to the other end of the continuum and sets absolute standards of achievement, he will exclude many candidates for certification because of the arbitrary standards of measurement.
As discussed in the section on ethical systems, the Platonist would favor the absolute standard or ideal because it would result in the best qualified personnel and superior rare for the disabled. The pragmatist and utilitarian however, would probably lean more toward "realistic" standards which take into consideration current practice and education of prosthetists and orthotists. The) would contend that realistic standards bring a greater supply of certified personnel into the field and more patients would be served.
Certification in prosthetics and orthotics is dynamic and growing. As it continues to change and develop, the difficult question of excluding some applicants for certification by maintaining and elevating high standards of achievement will be raised by certifees and non-certifees in years to come. The golden mean takes into account both the realistic and absolute goods and attempts to choose standards which would have the beneficial results of offering quality care for the disabled and of encouraging prosthetists and orthotists to strive for achievement levels which do not lead to despair.
Education
As stated earlier, the development of professional responsibility had its birth in the university. Every professional person should have opinions about the role of education in his professional development. In prosthetics and orthotics, there is a change from apprenticeship training to educational programs. The apprentice learns by practical experience under skilled workers. The student learns by principles and practice through systematic instruction and supervised work projects. Leaders in the profession and educators are currently trying to organize educational programs which will meet the needs of the student and the industry-profession. The alternatives under consideration are:
Specialized Education ----- General Education
Specialized education contains those experiences which are clearly related to technical skills, professional competence, and economic considerations which future prosthetists and orthotists will need in the industry-profession. General education will develop those understandings, skills, values, and attitudes desirable for responsibile living in a contemporary society.
Specialized education is occupationally oriented and it is practical in nature: general education follows the liberal arts tradition and is theoretical in nature. The historical "logicians" and pragmatists might favor training which directly relates to job requirements. The traditional cynics and stoics would contend that the total man should be educated first, then his hands. The golden mean suggests that educational programs which meet the highest objectives of practical education and general education should be developed. To select either one and not the other would be a defect.
The four-year Bachelor Degree program and the two-year Associate in Arts Degree programs are modern attempts in our field to combine the extreme goods of a practical and general education. The curricula include specialized courses in prosthetics and orthotics as well as general education courses in the arts and sciences.
Cast
The supreme purpose of a profession is to make available to society, without reservation as to quality or any question as to remuneration, the very best services needed. The very difficult question in the business and professional world—the price that society, either collectively or individually, should pay for services—requires much more deliberation than space will allow here. However, since our main objective is to raise pertinent ethical questions in our field, it seems proper to discuss financial considerations here.
The services of the prosthetic and orthotic profession should be financially accessible to the public, but society at the same time should properly reward that motivation of service to it. The following continuum suggests the problem:
Accessibility to the Public ----- Remuneration to the Profession
No health profession should ever become so exclusive that all individuals, regardless of income, do not have access to the necessary health services. Historically, the professional person received not a salary nor a fee, but an honorarium. Until early in this century, physicians in England did not submit a statement of fees but were paid by their patients on a voluntary-basis that reflected the financial status of the patient rather than the service rendered. And today in spite of the generality of the fee-for-service basis of professional claims, there is a tacit understanding that neither the quantity nor the essential quality of the service is limited by the size of the fee.
Of greater importance than the technique of remuneration, whether by fee or salary, is this essential condition: the motivation of services to society, the hallmark of a true profession, should be properly rewarded. In 1961, the Rockefeller Panel Reports said:
We must recognize that one important factor in the unwillingness of youth to undertake certain critical tasks is due to a rather severe imbalance in our current system of incentives. The skills which we need most critically today are not those which we reward most highly.
Too often dedication to society has resulted in extreme personal sacrifice. Many prosthetists and orthotists have invested material goods, time, ability, experience, and education in businesses without success. Their contributions, including risk, must be considered a part of the total investment to dedication.
One corrective to the question of the method and amount of remuneration to the professional prosthetist and orthotist is the maintenance of high professional standards of service and a strong professional organization. The American Orthotics and Prosthetics Association should encourage its members to make their services accessible to all who require them, but, at the same time, its members can rightfully expect to receive a relatively equivalent return for services offered.
Conclusion
In this article, we have: (1) defined ethics and professionalism as well as related terms; (2) described briefly classical and popular systems of ethics; and (3) related these systems to a few ethical questions in prosthetics and orthotics. Our main objective has been to raise pertinent questions relating to practical human conduct; we have suggested the "answer" is a critical system of ethics which establishes a golden mean by considering the alternatives when making decisions.
Prosthetics and orthotics is as strong as its best practitioner and as weak as its worst. In ethical questions of professional relationships, standards, education, and cost, the prosthetists and orthotists should be free to commit responsibilities to a large measure in ways dictated by their own best wisdom and ethical systems. They must be free to act in accordance with their best considered judgment, provided these acts do not run counter to the human values embraced by the profession. The integral government of a profession must lie within its own membership, and it should be on the broadest possible democratic basis.
It is the duty of the government to see that that power is not abused but is used wisely and fairly in the interest of the patient and of society in general. It is not within the power of government to exercise this power within itself. Outside restraint will not be necessary in prosthetics and orthotics as long as its practitioners are able to demonstrate and regulate the dangers of extravagant notions and practices. The "critical" system of ethics, or the golden mean, suggests that professional organizations, such as the American Orthotics and Prosthetics Association and the American Board for Certification, become a bulwark against the invasion of individual freedom and public responsibility.
Fig. 1
References:
- Carl E. Taeusch, Professional Ethics, New York, 1926. p. 242.
- Life, January 4, 1963.
- Ibid., February 8, 1963.
- Wayne A. Leys, Ethics for Policy Decision, The Art of Asking Deliberative Questions, Englewood Cliffs, New Jersey, 1952, p. 9.
- Pamphlet, "What is Success," Chicago, National Boulevard Bank, 1963.
- Frederick A. Whitehouse, "The Rationale of Nursing," Rehabilitation Record, July-August, 1962, 12.
- Canadian Bar Association, Canadian Bar Review, Vol. 24 (1946), 705.
- Robert Bendiner, "Where is the Teacher?" Chicago Daily News, February 9, 1963.
- Chicago Daily News, March 14, 1962.
- Taeusch, op. cit., p. 361.
- Rockefeller Brothers Fund: Prospect for America, The Rockefeller Reports, New York, 1961, p. 352.
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