Abstract
Preamble
The 2020 Occupational Therapy Code of Ethics (the Code) of the American Occupational Therapy Association (AOTA) is designed to reflect the dynamic nature of the occupational therapy profession, the evolving health care environment, and emerging technologies that can present potential ethical concerns in practice, research, education, and policy. AOTA members are committed to promoting inclusion, participation, safety, and well-being for all recipients of service in various stages of life, health, and illness and to empowering all beneficiaries of service to meet their occupational needs. Recipients of services may be persons, groups, families, organizations, communities, or populations (AOTA, 2020).
The Code is an AOTA Official Document and a public statement tailored to address the most prevalent ethical concerns of the occupational therapy profession. It sets forth Core Values and outlines Standards of Conduct the public can expect from those in the profession. The Code applies to all occupational therapy personnel 1 in all areas of occupational therapy and should be shared with relevant stakeholders to promote ethical conduct.
The Code serves two purposes:
It provides aspirational Core Values that guide occupational therapy personnel toward ethical courses of action in professional and volunteer roles.
2. It delineates ethical Principles and enforceable Standards of Conduct that apply to AOTA members.
Whereas the Code helps guide and define decision-making parameters, ethical action goes beyond rote compliance with these Principles and is a manifestation of moral character and mindful reflection. Adherence to the Code is a commitment to benefit others, to the virtuous practice of artistry and science, to genuinely good behaviors, and to noble acts of courage. Recognizing and resolving ethical issues is a systematic process that includes analyzing the complex dynamics of situations, applying moral theories and weighing alternatives, making reasoned decisions, taking action, and reflecting on outcomes. Occupational therapy personnel are expected to abide by the Principles and Standards of Conduct within this Code.
The process for addressing ethics violations by AOTA members (and associate members, 2 where applicable) is outlined in the Code’s Enforcement Procedures (AOTA, 2019).
Although many state regulatory boards incorporate the Code or similar language regarding ethical behavior into regulations, the Code is meant to be a freestanding document that guides ethical dimensions of professional behavior, responsibility, practice, and decision making. This Code is not exhaustive; that is, the Principles and Standards of Conduct cannot address every possible situation. Therefore, before making complex ethical decisions that require further expertise, occupational therapy personnel should seek out resources to assist with resolving conflicts and ethical issues not addressed in this document. Resources can include, but are not limited to, ethics committees, organizational ethics officers or consultants, and the AOTA Ethics Commission. For a full list of AOTA ethics resources, please refer to the AOTA website at https://www.aota.org/Practice/Ethics.aspx.
Appendix A describes the revision process for the 2020 Code. Appendix B summarizes the history of the AOTA Occupational Therapy Code of Ethics.
Core Values
The occupational therapy profession is grounded in seven longstanding Core Values: Altruism, Equality, Freedom, Justice, Dignity, Truth, and Prudence (AOTA, 1993). The seven Core Values provide a foundation to guide occupational therapy personnel in their interactions with others. These Core Values should be considered when determining the most ethical course of action (adapted from Core Values and Attitudes of Occupational Therapy Practice; AOTA, 1993):
Altruism indicates demonstration of unselfish concern for the welfare of others. Occupational therapy personnel reflect this concept in actions and attitudes of commitment, caring, dedication, responsiveness, and understanding.
Equality indicates that all persons have fundamental human rights and the right to the same opportunities. Occupational therapy personnel demonstrate this value by maintaining an attitude of fairness and impartiality and treating all persons in a way that is free of bias. Personnel should recognize their own biases and respect all persons, keeping in mind that others may have values, beliefs, or lifestyles that differ from their own. Equality applies to the professional arena as well as to recipients of occupational therapy services.
Freedom indicates valuing each person’s right to exercise autonomy and demonstrate independence, initiative, and self-direction. A person’s occupations play a major role in their development of self-direction, initiative, interdependence, and ability to adapt and relate to the world. Occupational therapy personnel affirm the autonomy of each individual to pursue goals that have personal and social meaning. Occupational therapy personnel value the service recipient’s right and desire to guide interventions.
Justice indicates that occupational therapy personnel provide occupational therapy services for all persons in need of these services and maintain a goal-directed and objective relationship with recipients of service. Justice places value on upholding moral and legal principles and on having knowledge of and respect for the legal rights of recipients of service. Occupational therapy personnel must understand and abide by local, state, and federal laws governing professional practice. Justice is the pursuit of a state in which diverse communities are inclusive and are organized and structured so that all members can function, flourish, and live a satisfactory life regardless of age, gender identity, sexual orientation, race, religion, origin, socioeconomic status, degree of ability, or any other status or attributes. Occupational therapy personnel, by virtue of the specific nature of the practice of occupational therapy, have a vested interest in social justice: addressing unjust inequities that limit opportunities for participation in society (Ashe, 2016; Braveman & Bass-Haugen, 2009). They also exhibit attitudes and actions consistent with occupational justice: full inclusion in everyday meaningful occupations for persons, groups, or populations (Scott et al., 2017).
Dignity indicates the importance of valuing, promoting, and preserving the inherent worth and uniqueness of each person. This value includes respecting the person’s social and cultural heritage and life experiences. Exhibiting attitudes and actions of dignity requires occupational therapy personnel to act in ways consistent with cultural sensitivity, humility, and agility.
Truth indicates that occupational therapy personnel in all situations should be faithful to facts and reality. Truthfulness, or veracity, is demonstrated by being accountable, honest, forthright, accurate, and authentic in attitudes and actions. Occupational therapy personnel have an obligation to be truthful with themselves, recipients of service, colleagues, and society. Truth includes maintaining and upgrading professional competence and being truthful in oral, written, and electronic communications.
Prudence indicates the ability to govern and discipline oneself through the use of reason. To be prudent is to value judiciousness, discretion, vigilance, moderation, care, and circumspection in the management of one’s own affairs and to temper extremes, make judgments, and respond on the basis of intelligent reflection and rational thought. Prudence must be exercised in clinical and ethical reasoning, interactions with colleagues, and volunteer roles.
Principles
The Principles guide ethical decision making and inspire occupational therapy personnel to act in accordance with the highest ideals. These Principles are not hierarchically organized. At times, conflicts between competing principles must be considered in order to make ethical decisions. These Principles may need to be carefully balanced and weighed according to professional values, individual and cultural beliefs, and organizational policies.
Principle 1. Beneficence
Occupational therapy personnel shall demonstrate a concern for the well-being and safety of persons.
The Principle of Beneficence includes all forms of action intended to benefit other persons. The term beneficence has historically indicated acts of mercy, kindness, and charity (Beauchamp & Childress, 2019). Beneficence requires taking action to benefit others—in other words, to promote good, to prevent harm, and to remove harm (Doherty & Purtilo, 2016). Examples of Beneficence include protecting and defending the rights of others, preventing harm from occurring to others, removing conditions that will cause harm to others, offering services that benefit persons with disabilities, and acting to protect and remove persons from dangerous situations (Beauchamp & Childress, 2019).
Principle 2. Nonmaleficence
Occupational therapy personnel shall refrain from actions that cause harm.
The Principle of Nonmaleficence indicates that occupational therapy personnel must refrain from causing harm, injury, or wrongdoing to recipients of service. Whereas Beneficence requires taking action to incur benefit, Nonmaleficence requires avoiding actions that cause harm (Beauchamp & Childress, 2019). The Principle of Nonmaleficence also includes an obligation not to impose risks of harm even if the potential risk is without malicious or harmful intent. This Principle is often examined in the context of due care, which requires that the benefits of care outweigh and justify the risks undertaken to achieve the goals of care (Beauchamp & Childress, 2019). For example, an occupational therapy intervention might require the service recipient to invest a great deal of time and perhaps even discomfort; however, the time and discomfort are justified by potential long-term, evidence-based benefits of the treatment.
Principle 3. Autonomy
Occupational therapy personnel shall respect the right of the person to self-determination, privacy, confidentiality, and consent.
The Principle of Autonomy expresses the concept that occupational therapy personnel have a duty to treat the client or service recipient according to their desires, within the bounds of accepted standards of care, and to protect their confidential information. Often, respect for Autonomy is referred to as the self-determination principle. Respecting the Autonomy of service recipients acknowledges their agency, including their right to their own views and opinions and their right to make choices in regard to their own care and based on their own values and beliefs (Beauchamp & Childress, 2019). For example, persons have the right to make a determination regarding care decisions that directly affect their lives. In the event that a person lacks decision-making capacity, their Autonomy should be respected through the involvement of an authorized agent or surrogate decision maker.
Principle 4. Justice
Occupational therapy personnel shall promote equity, inclusion, and objectivity in the provision of occupational therapy services.
The Principle of Justice relates to the fair, equitable, and appropriate treatment of persons (Beauchamp & Childress, 2019). Occupational therapy personnel demonstrate attitudes and actions of respect, inclusion, and impartiality toward persons, groups, and populations with whom they interact, regardless of age, gender identity, sexual orientation, race, religion, origin, socioeconomic status, degree of ability, or any other status or attributes. Occupational therapy personnel also respect the applicable laws and standards related to their area of practice. Justice requires the impartial consideration and consistent observance of policies to generate unbiased decisions. For example, occupational therapy personnel work to create and uphold a society in which all persons have equitable opportunity for full inclusion in meaningful occupational engagement as an essential component of their lives.
Principle 5. Veracity
Occupational therapy personnel shall provide comprehensive, accurate, and objective information when representing the profession.
The Principle of Veracity refers to comprehensive, accurate, and objective transmission of information and includes fostering understanding of such information. Veracity is based on the virtues of truthfulness, candor, honesty, and respect owed to others (Beauchamp & Childress, 2019). In communicating with others, occupational therapy personnel implicitly promise to be truthful and not deceptive. For example, when entering into a therapeutic or research relationship, the service recipient or research participant has a right to accurate information. In addition, transmission of information must include means to ensure that the recipient or participant understands the information provided.
Principle 6. Fidelity
Occupational therapy personnel shall treat clients (persons, groups, or populations), colleagues, and other professionals with respect, fairness, discretion, and integrity.
The Principle of Fidelity refers to the duty one has to keep a commitment once it is made (Veatch et al., 2015). This commitment refers to promises made between a provider and a client, as well as maintenance of respectful collegial and organizational relationships (Doherty & Purtilo, 2016). Professional relationships are greatly influenced by the complexity of the environment in which occupational therapy personnel work. For example, occupational therapy personnel should consistently balance their duties to service recipients, students, research participants, and other professionals, as well as to organizations that may influence decision making and professional practice.
Standards of Conduct
The AOTA Ethics Commission, under the Enforcement Procedures for the AOTA Occupational Therapy Code of Ethics (AOTA, 2019), enforces the Standards of Conduct listed in Table 1.
Standards of Conduct for Occupational Therapy Personnel
Authors
Ethics Commission Members, 2019–20 and 2020–21
Brenda S. Howard, DHSc, OTR, Ethics Chairperson, 2019–2023
Leslie Bennett, OTD, OTR/L, Member at Large, 2019–2021
Brenda Kennell, MA, OTR/L, FAOTA, Education Representative, 2015–2021
Kimberly S. Erler, PhD, OTR/L, Practice Representative, 2014–2020
Barbara Elleman, MHS, OTD, OTR/L, Practice Representative, 2020–2023
Jan Keith, BA, COTA/L, OTA Representative, 2017–2020
Marita Hensley, COTA/L, OTA Representative, 2020–2023
Donna Ewy, MD, FAAFP, MTS, Public Member, 2019–2022
Roger A. Ritvo, PhD, Public Member, 2018–2021
Mark Franco, Esq., Legal Counsel
Rebecca E. Argabrite Grove, MS, OTR/L, FAOTA, AOTA Ethics Program Manager
Revised by the AOTA Ethics Commission, 2020
Adopted by the Representative Assembly, November 2020
Note. This revision replaces the 2015 document Occupational Therapy Code of Ethics (2015) , previously published and copyrighted in 2015 by the American Occupational Therapy Association in the American Journal of Occupational Therapy, 69, 6913410030. https://doi.org/10.5014/ajot.2015.696S03
Copyright © 2020 by the American Occupational Therapy Association.
Citation. American Occupational Therapy Association. (2020). AOTA 2020 occupational therapy code of ethics. American Journal of Occupational Therapy, 74(Suppl. 3), 7413410005. https://doi.org/10.5014/ajot.2020.74S3006
Footnotes
1
The term occupational therapy personnel in this document includes occupational therapist and occupational therapy assistant practitioners and professionals (e.g., direct service, consultation, administration); educators; students in occupational therapy and occupational therapy assistant professional programs; researchers; entrepreneurs; business owners; and those in elected, appointed, or other professional volunteer service.
2020 Revision Process for the AOTA 2020 Occupational Therapy Code of Ethics
In Fall 2019, the Ethics Commission (EC) of the American Occupational Therapy Association (AOTA) began the process of reviewing the Occupational Therapy Code of Ethics (the Code) as part of the AOTA Representative Assembly’s 5-year review cycle. Although ethical principles are timeless, the issues to which they apply and the manner of application are constantly evolving, as are the health care and community environments in which occupational therapy personnel apply them. Therefore, the Code must change to remain applicable to the environments in which occupational therapy personnel work. The following paragraphs outline the changes made to the 2015 Code.
From August to November 2019, EC members reviewed codes of ethics from several health care professions and found that the organization of codes of ethics documents and online platforms had evolved. These professions had organized their codes not by bioethical principles, but by their relationship to areas of practice and professionalism. Moreover, the professions had organized their online platforms for greater interactive agility. The EC decided that a major revision of the Code’s organization was in order, although the majority of the content would remain unchanged.
EC members divided into work groups to reorganize the Code by dividing the 2015 Code into the following parts: Preamble, Core Values, Principles, Standards of Conduct, and Appendixes.
EC work group members reorganized the Standards of Conduct from the 2015 Code into behavioral categories. The work group reviewed and discussed the placement of the Standards until consensus was reached. The work group then presented the reorganization of the Standards to the full EC for discussion on February 25, 2020. The EC continued to review and reorganize the standards until June 9, 2020. The EC added a section on Professional Civility in response to a referred motion from the Representative Assembly. Once completed and reviewed on June 9, the EC sent the revised Code draft to content experts for further review and edits.
Content experts completed a survey for responding to changes in the Code using both Likert-type scale ratings and open-ended responses. The EC reviewed the feedback from the content experts on July 14, 2020, and incorporated revisions to create a draft of the Code for membership review.
In July and August 2020, the EC sent a survey to all AOTA members to garner feedback on the revised Code. Results of the survey indicated that among the 122 respondents to the survey, there was 80% or greater agreement that each part of the Code was both relevant and clear. EC members compiled qualitative feedback, carefully considered comments, and made edits to complete the final draft of the Code. The EC then submitted this final draft of the Code, and accompanying motion and rationale, to the Representative Assembly in September 2020. After online discussion, the Representative Assembly voted on November 4, 2020, to pass the motion to strike the Occupational Therapy Code of Ethics (2015) and replace it with the AOTA 2020 Occupational Therapy Code of Ethics.
History of the AOTA Occupational Therapy Code of Ethics
As society evolves, so must our understanding and implementation of ethical practices as occupational therapy personnel. The American Occupational Therapy Association (AOTA) 2020 Occupational Therapy Code of Ethics (the Code) continues to be a critical tool in the AOTA Ethics Commission’s quest to guide ethical conduct and elevate public trust in the profession. The Code must be a dynamic, living document that grows and develops to complement changes in occupational therapy delivery models, technology, and society.
The first official AOTA ethical code was established in 1975. Work to create this document, titled “Principles of Ethics,” began in 1973. Carolyn Baum, Carlotta Welles, Larry Peak, Lou Arents, and Carole Hayes authored this document. At that time, many professional associations began creating codes of ethics in response to the ethical issues being raised by the Tuskegee Syphilis Study, in which researchers studied the effects of syphilis on African-American men who had not given informed consent and were told that they were being treated for the disease (Centers for Disease Control and Prevention, 2016). The outcry after the public became aware of this violation, even after standards had been put in place after World War II and the Nuremberg Code of 1947, led many professions to establish ethics rules.
In April 1977, the AOTA Representative Assembly approved the “Principles of Occupational Therapy Ethics,” and AOTA distributed them in the American Journal of Occupational Therapy in November 1977. This first publicly circulated rendition of the Code of Ethics consisted of 12 principles, all starting with the words “Related to,” such as “Related to the Recipient of Service.”
The Code of Ethics underwent revisions in 1988, 1994, 2000, 2005, 2010, 2015, and 2020, with input from AOTA membership. The 1988 revision began to look like the modern Code, with headings called “Principles” and subheadings called “Standards.” In 1994, the members of the AOTA Ethics Commission added a focus on bioethical principles rather than professional behaviors, as in the previous two editions. The Principles included in the 1994 Code were Beneficence; Autonomy, Privacy, and Confidentiality; Duty; Justice; and Fidelity and Veracity. The Principle of Nonmaleficence was added in 2000, and Social Justice was added in 2010, then combined with the Principle of Justice in 2015.
There were 30 Standards of Conduct in 2000; this number increased to 38 in 2005 and to 77 in 2010, then decreased to 69 in 2015. These Standards, categorized under the various Principles, were expanded to promote ethical practice in a variety of areas, including the use of technology for telehealth, social media, Internet use, and health records. With the 2020 Code revision, the EC has grouped the revised 73 Standards of Conduct by behaviors rather than under the Principles, in order to return to the original concept of relating the Standards to desired professional behaviors, so that they are more easily accessible to the membership when using the Code. As charged by the Representative Assembly, the Ethics Commission added a section on Professional Civility in 2020.
The Representative Assembly mandates that the Code, as an official AOTA policy document, undergo review every 5 years. This continual review is especially important because some states use the AOTA Code as part of their licensure acts. In addition, some states require occupational therapy practitioners to obtain continuing education in ethics in order to maintain licensure. In updating the Code to meet the needs of members and society, the occupational therapy profession continues to reflect and lead change in health care.