A Lesson in Ethics

In the summer of 1977, I had a summer engineering internship at Texas Instruments (TI), which proved to be an interesting place to work. I have many fond memories of my time spent there. Recently, I have found even more reason to think highly of the company, particularly its stance on ethics. TI has received many accolades for its commitment to ethics.¹ Its first code of ethics was published in 1961 and in 1987, they established an Ethics Office, complete with an ethics director.

To help its employees determine what constitutes ethical behavior, TI came up with a fairly simple test, composed of four questions and three actions.² The test provides a valuable lesson in ethics, not only to the intended TI employees, but to every chiropractor as well.

The TI Ethics Quick Test

• Is the action legal?
• Does it comply with our values?
• If you do it, will you feel bad?
• How will it look in the newspaper?
• If you know it is wrong, don't do it!
• If you're not sure, ask.
• Keep asking until you get an answer.

Is the Action Legal?

Well, this seems simple enough. Avoid doing something that is illegal, which means not only violating statute, but also regulations. However, would someone who wants to sell an idea that is illegal actually tell you the truth? In 1986, I signed up to be a client of a practice-management firm. One of the firm's biggest strategies was to advertise NOOPE (no out-of-pocket expenses). For those of you who came into chiropractic after managed care superseded indemnity insurance plans, this will be quite foreign. Nevertheless, NOOPE meant that patients didn't pay their deductible or co-pay, which was typically 10 percent to 20 percent of the bill. I was assured that this was legal. However, I soon discovered on my own that, in fact, NOOPE was considered insurance fraud in the state of New York, where I practiced.

In previous articles, I have discussed the illegal MD/DC practices that were promoted by some practice-management gurus.³ If you read their advertisements, they all claimed this was completely legal. Chiropractors are still taught the UCCAFF (unlimited chiropractic care at a fixed fee) scheme. In many states, this is the unlicensed business of providing insurance and is flagrantly illegal. The NY Insurance Department even has a Web page discussing this in detail.⁴

Don't trust anyone who is teaching you about what is legal when they have a vested interest in getting you to do what they recommend. Don't trust an attorney they recommend - their duty may not be to you. I recommend doctors get outside legal counsel to determine if their business arrangements are legal, and make sure the lawyer knows their state laws concerning chiropractic practice. The general-practice attorney who did your will or your real-estate closing might not really have the specialized knowledge needed.

In teaching risk management around the country, I find that many doctors are ignorant about practice regulations, even in their own state. I can't stress this enough; please go to your regulatory authority's Web site and read carefully. In some cases, there are simple things that one can be doing wrong without knowing it. For example, in New York, every health care provider within a multidisciplinary practice needs a name tag including their licensed profession. Every time I present this in a talk, some doctor comes up to me and says they never knew about that mandate. The Web has made getting this information easier than ever, and of course, ignorance is no excuse under the law.

Does It Comply With Our Values?

Integrity is all about having one's behavior reflect one's values. One might think of integrity as the armor that protects our values. There are many ways that people "chip away" at our integrity armor. Often, it is done incrementally.

A colleague told me that when he was a new graduate, he worked for a doctor who had him slowly and progressively order unneeded tests and provide unneeded treatments. While working there, my colleague's integrity had become compromised so incrementally that he didn't notice it until his friend, a fellow college alumnus, applied for a job in his office. After an interview, the owner of the practice offered the new graduate a job. When the new doctor expressed that he had not yet received a license to practice, the owner said it didn't matter and to come to work on Monday. The new doctor declined the position, stating that he could never work for this doctor, because it was obvious that he was unethical. The colleague who related this anecdote to me quit shortly thereafter. He needed his friend to point out how his employer's morals, and thus, his policies, were incongruous with his values.

If You Do It, Will You Feel Bad?

A recent graduate told me about working for a MD/DC practice in which he was continually berated by the MD for not ordering enough diagnostic tests. He knew the patients didn't need the tests and felt guilty when he did order the extra tests. Eventually, his financial burden, compiled of student loans and supporting a family, couldn't outweigh his guilt from what he was required to do every day in practice.

How Will It Look in the Newspaper?

Think carefully about how your actions would look in the newspaper or on the evening news. Would your actions put our profession, as well as your appearance, in a positive or a negative light if seen on the front page? Think about some of the practice-management schemes you have heard of. How about the doctor whose goal is to see more patients per hour than the public might think appropriate? Imagine if the details of some of the disciplinary cases our regulators have adjudicated were the lead article. I thought about putting specific examples here but then thought, "Do I want to give those behaviors more exposure?"

If You Know It Is Wrong, Don't Do It!

This is as obvious as the first question in TI's Ethics Quick Test, but people often do something they know is wrong. They believe they won't get caught. While it might be true that one can "get away with it," as the criminals say, "Don't do the crime if you can't do the time." One really has to ask the question: Do the consequences of getting caught outweigh the "benefits" of the action? A friend told me that when he was in chiropractic college, his ethics teacher asked the class to consider if a few extra dollars or sleeping with a sexy patient was worth never practicing again. Assume you'll get caught doing everything you do and consider whether getting caught is OK.

If You Are Not Sure, Ask

It doesn't matter whether you are new in practice or a bit long in the tooth - getting advice from trusted colleagues can save you from great embarrassment and hardship. Make sure your trusted colleague doesn't suffer from ethical lapses, either; their advice isn't worth much.

Keep Asking Until You Get an Answer

TI obviously wants its employees to keep asking questions, going up the "chain of command" until they get an answer. For the professional in private practice, persistence in finding an answer may mean asking other professionals (e.g., lawyers, health professionals, clergy), as all professionals have the pre-eminent duty to the public. They could be good advisors. Finally, keep in mind that often, there is a double standard for our profession. What others can get away with, we can't. Too frequently, the badly behaved individual in our profession is seen as the model for chiropractic, while the well-behaved chiropractor is viewed as representative of themselves only.

References

1. Texas Instruments. "Ethics Overview." Available online.
2. Texas Instruments. "The TI Ethics Quick Test." Available online.
3. Perle S. "Two Wrongs Don't Make a Right." Dynamic Chiropractic, 2004;22 (22):28-9. Available at: www.chiroweb.com/archives/22/22/15.html.
4. State of New York Insurance Department. "Contracts for the Provision of Unlimited Chiropractic Services to Patients." Available online.