Ethical Dilemmas in Occupational Therapy

Whether you’re an experienced occupational therapist or a new OT practitioner, we all remember taking an ethics course in OT school. The vast majority of us who decided to become occupational therapy practitioners are intrinsically good people who want to help others, so it’s tough to think about difficult situations we may encounter at work that could blur our ethical boundaries.

Depending on the occupational therapy setting, our field sometimes feels like it has become increasingly harder to adhere to our Code of Ethics due to the for-profit healthcare companies many of us are working for.

It can feel like it’s getting harder to find an OT position in an ethical rehab placement, since the turnover at these jobs is typically lower. As a new grad or fieldwork student, you may feel stuck taking a job in a less-than-ideal placement, and you will more than likely see these issues come up at some point in your career.

If you do end up in one of these positions, here is some insight on how to deal with some of the most common ethical dilemmas in occupational therapy. I know from experience how hard being put into an unethical work situation can be, so I truly hope these pointers can give you some confidence and strength to manage these situations. 

First, What is the Research on Ethics and Occupational Therapy?

There isn’t a lot of research about ethics and occupational therapy currently. I imagine as more OT practitioners are able to voice their experiences with unethical practices in OT via various social media platforms and OT-related forums, this may increase over time.

One interesting article (that is a bit older) that is worth checking out is titled “Ethics, occupational therapy and discharge planning: Four broken principles” (Atwal & Caldwell, 2003).

In the article, the researchers state that common ethical issues include “ineffective treatment, unethical/incompetent colleagues, priorities in treatment, causing pain and discomfort, treating patients despite refusal, and misleading the patient and confidentiality.”

The researchers focused their article on how occupational therapists can complete discharge planning “following the four fundamental bioethical principles of respect for autonomy, beneficence, non-maleficence and justice.” 

To check out a few older articles related to ethical dilemmas published in the 1990’s, you can do a quick Google Scholar search using the terms “ethics [and] occupational therapy.” 

I hope to see more current research coming out in the near future and will add to this post as I continue to discover it.

Common Ethical Issues Clinicians Face

We did an informal poll in several of the Occupational Therapy Facebook groups and asked for the members’ anonymous unethical practices they see on a consistent basis.

These were the most prevalent:

• Treating patients that are inappropriate for therapy. This happens pretty frequently in certain adult rehab settings unfortunately. Included in this is having to treat patients with excessive treatment times (previously known as ultra-high RUGs) that cannot tolerate these high amounts of therapy. As the patient’s clinician, you have the right to confront your manager about this issue.

• Seeing patients past the point of progress. If the patient has plateaued, is not making any more gains, or has met their prior level of function, it is time to discharge them from therapy if you believe it is time, regardless of what management is telling you.

• Billing patients for documentation time when you aren’t providing intervention. With unreasonably high productivity requirements of SNF settings, this is unfortunately fairly common in the field. 

• Documenting and billing your services accurately for what you did for your treatment. Complete your documentation in a timely manner (same day is best) so you don’t accidentally leave anything pertinent out that you may forget. 
• Certain OTs or DORs requiring COTAs in adult rehab settings to complete documentation (such as discharges and progress notes) on patients they’ve never personally treated before, particularly without any collaboration from the treating OTR. OTs are also sometimes being requested to complete progress notes and discharges on patients they’ve never treated. 

Not-So-Obvious Situations

You will also come across situations that may seem “fine” if you’re a new clinician but are actually unethical. It can be harder to realize that you may be violating the Code of Ethics, so I wanted to include these as well to protect yourself.

Providing a treatment that you aren’t adequately trained to perform.

An example of this could be using a modality (like e-stim) without getting any training on its proper use beforehand. Some states do require you to be modality certified, while others do not. If you’re in a state that does not require training, make sure you’ve had enough training to feel competent using the modality. The worst thing that could happen is that you unintentionally harm your patient.

Prolonging discharging the patient or discharging too early.

I’ve read multiple accounts of for-profit rehab companies pushing their therapists to keep patients as long as possible, even after the patients’ goals are met and patients have met their max potential. On the other hand, some patients are only approved for one week but need significantly more time in the rehab setting. If they are sent home because of their payer source, this is really unfortunate but out of our control as therapists.

Billing for unskilled treatment.

This can be easy to do by accident if you’re a new therapist. If you’re billing for treatments where patients are independent in all ADLs, or you complete dependent dressing/bathing/self-feeding regularly for a dependent patient that a CNA could do, it technically isn’t skilled. Medicare or other insurance providers may deny their rehab services if this occurs. 

Blurring the lines of personal and professional relationships.

Becoming romantically involved with patients, professors, clinical instructors, etc. happens and is of course frowned upon. You want to use good judgement avoiding a complicated situation.

For more on how to avoid crossing professional boundaries with patients, clinical instructors, professors, even your own friends/family in the treatment setting, check out this helpful document from the Occupational Therapy Board of New Zealand. 

Companies Committing Unethical Practices

While the last section covered what you as a therapist can do to avoid committing unethical acts, oftentimes the company is the primary offender. This is because many companies are putting profits before patients and quality care.

You may be given unrealistic productivity standards, which forces many therapists and COTAs to work off of the clock. This is not only terrible for the therapists forced to do this regularly, but it is also illegal in many states.

It can become a slippery slope since documenting off the clock is the only way therapists are able to achieve the goals set out by the “higher ups” in rehab companies. The expectation is that 90%, 95%, or even 100% productivity is possible and productivity goals will continue to increase as long as the current goals appear to be met.

Other common practices of unethical settings include being urged to provide therapy to individuals that do not actually need therapy. This includes high level individuals that are independent with all basic and instrumental ADLs, as well as very sick, frail people with ultra-high minutes that would not benefit from skilled therapy.

What Can You Do To Avoid Unethical Practices?

The best solution I can offer to this is to get out of there and find a different setting or employer.

It’s definitely easier said than done for me to tell you to find a new job with more ethical practices. I totally get that it’s hard to find a good OT job, especially as a new grad. 

But even so, I still want to encourage you to try to get to a place where you feel confident and comfortable as a clinician every day. You became an OT practitioner to love and enjoy your career, and I don’t want you to be miserable!

If your company is blatantly committing fraud or unethical practices, you can also become a whistle-blower. That may initially seem like a scary task, but it is an important one to help keep companies honest.

For more in-depth information on becoming a whistle-blower with step-by-step instructions, you’ll definitely want to check out the article “So You Wanna Blow the Whistle: How to Report Fraud and Abuse in Health Care” from WebPT. You can also report any unethical activities directly to AOTA’s Ethics Commission here as well as your state OT board if you feel inclined to do so.

If you have any specific questions at your workplace that you aren’t sure about, you can consult with your facility’s legal team or your own attorney if that feels more appropriate.

Most hospitals have lawyers on staff to help consult with you to prevent any issues. Your professors from OT school may also be willing to lend you words of advice if you’re concerned but are understandably hesitant to discuss matters with your employer’s legal team.

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At the end of the day, we all should be advocating for our profession, our patients, and our licenses. We have the right to stand up to the unethical behaviors of corporations.

Do you have any tips you would share with new occupational therapists regarding how to advocate for themselves during unethical dilemmas? Have you been faced with difficult situations in the past?

We would also would love to hear any positive stories about ethical OT settings that you work in to show new grads and students that not every therapy setting is unethical, and that quality patient care still does come first in most settings.

This post was originally published on November 12, 2016 and last updated on July 23, 2023.