Editor’s note: Over the last 3 years, Codes of Ethics and ethical practices have been a focus of several hearing care organizations. Like politics and religion, professional ethics is a complex subject that often yields strong differences of opinion. The opinion expressed below represents the perspective of one professional who has run a practice and served as an educator in the hearing care field for over 30 years. HR welcomes other perspectives and viewpoints on this issue.

Over the years, I have been fortunate to have had wonderful teachers. One of those was a Benedictine nun named Sister John Mary. She spent a good deal of her time talking about what she called “the near occasions of sin.”

In a lifetime of reflecting on her words, I’ve come to realize that she didn’t mean a “mortal” sin—and she probably didn’t even mean a “venial” sin. Rather, she was talking about something far more insidious. This type of sin has something in common with the proverbial duck: If it looks like one, and quacks like one, and walks like one, it probably is one.

Reality is in the eye of the beholder. We undervalue our work and complain when others “charge more.” I don’t have a problem with what other people charge. They know what their work is worth.

We all adhere, to a greater or lesser degree, to the “Code(s) of Ethics” articulated by the organizations to which we belong. Moreover, because “philosophy dictates practice,” that behavior is all overseen by our own, inherent, ethical standards.

Your Actions Determine Who You Are
One of the most exciting movements in philosophy during the last 150 years is existentialism. Unlike a lot of philosophies that, to paraphrase Nietzsche, tend to build giant castles of logic only to have their architects occupy the ramshackle outbuildings beyond the structure’s unfathomable and impractical walls, existentialism puts forth a simple correlation between action and personal accountability. It posits that every one of us, as an individual, is responsible for what we do. And, in fact, what we choose to do makes us who we are.

Although chance, circumstance, upbringing, and nature (and/or a higher power) may have provided the stage on which your life unfolds, it is up to you to write and act out your role in the play. In short, existentialism puts forth the unsettling premise that “there are no excuses.” Every minute, we make conscious (and unconscious) choices about what we do, who we are, and who we will become, and we are singularly responsible for those choices. It matters far less what you think, or how you might seek to justify your actions, than what you do and the end results. Good intentions don’t mean much in this context. The sum of your character is wrapped up in what your actions yield.

Like many dispensing professionals, I am licensed by several boards in both audiology and hearing instrument dispensing, as well as national organizations like the American Speech Language Hearing Association (ASHA), the International Hearing Society (IHS), and the National Board for Certification in Hearing Instrument Sciences (NBC-HIS). I used to belong to many more but have “triaged” that number down in recent years. In each organization, there is a Code of Ethics to which I adhere, but there is enough disparity between the Codes that I have been forced to “meld” them together into the resulting most stringent code with which to overtly govern my practice.

While it is true that our professional obligation is to practice in an ethical manner, the conscious personal choices we make in this regard are, more precisely, the differences between professionalism and personal heresy. I am convinced that the vast majority of people know the difference between “right” and “wrong,” or between the ethical and the unethical paths. This is true both for themselves as well as for their businesses. I am also convinced, however, that if you find an individual who is systematically inclined to perform unethical (or immoral) acts, it is probably impossible to prevent them from doing so. All you can do is catch them at it! Relative to existentialism, their actions are the result of who they are or who they choose to be. The proverbial scorpion carried across the river by the frog is, by nature and character, bound to sting the frog—even if both drown from it.

The existence of Code(s) of Ethics1-3 is to establish a set of rules for an organization used in judging the professional ethical behavior of one of its own members, and help define the characteristics of a “good professional.” It has no authority over anyone who is not a member of the organization. It can only act through “the consent of the governed.”

One of the things that concerns me is that (in many cases) it is the most “acetic” and “pure” among us who are the loudest and most vocal in declaring the need for “standards” in response to the perceived behavior of others. It is never our own activities that are in question. As with color, we frequently can’t “define” an exact moral or ethical obligation, but we can always point to it when we see it (or don’t see it). It is always something that “someone else” does, and that we do not do, that meets with our disapproval.

In my opinion, the recent publication of the revised Code of Ethics by the American Academy of Audiology (AAA)1 takes on something of this tone. I would find it difficult to speak so didactically for (or on behalf of) my colleagues, and many of the approbations in the new code beggar the imagination. It cannot be, however, the definitive list of (member) audiologists’ potential sins; it is clearly limited only by time, space, and imagination.

Further, there are differences between actions that are (un)ethical and those that are professionally (un)acceptable. For example, it is considered to be unethical to perform a test (or procedure) in which one is not fully qualified. That includes administering or interpreting the test and its results. This is part of the Code of Ethics for both audiology groups (AAA and ASHA). But, no one answers the critical next question: “Who decides the meaning of ‘qualified’?” Even if a test and its results would be in the best interests of the patient, if you are not qualified to conduct the test, it would be considered unethical to perform it. That is very different than deciding not to learn to do something and, therefore, deprive the patient of higher quality care and/or not believe yourself to be fully competent. It is also different than choosing not to buy the newest equipment because you cannot afford it—even if it were in the patients’ best interests to have that technology available.

The new technologies in hearing instrument dispensing have a steep learning curve, even though most hearing devices can be fit using a first-fit program. But if we, as a profession, are to utilize this technology and provide the consumer with its full benefits, then there is a great deal of educational work ahead for us to “practice ethically.” If one is satisfied to simply use these devices in the traditional manner, then this “ease of programmability” is little more than appalling laziness and can be viewed as unethical. Unfortunately, the recent return rates may reflect a cavalier attitude or blind faith in technology across all professions.

Additionally, when considering the important debates taking place relative to “evidence-based audiology” and “best practices” (which are very positive discussions in the view of the author), the waters become even murkier. As experienced professionals, we know the value of performing such things as real ear measurement, verifying the performance of hearing instruments, assessing loudness and defining the client’s dynamic range, using the HINT and other measures to understand unaided versus aided performance in noise, using validation tools to assess benefit and customer satisfaction, etc. But, where is the evidence for using these tools? To what level of “epidemiological evidence” should we aspire before we incorporate these tools into our armamentarium—and charge the patient for them?

These kinds of dilemmas are fairly common and not completely esoteric or without gravity. Additionally, the ethical codes of conduct require a covered member to pursue facility and expertise in a plethora of areas. This may be a vestige of the early days of the “speech and hearing generalist,” a time when we pretended that it would be possible to know it all.

Practically Speaking
It is certainly not “moral” (or ethical) for us to lie to the patient. Yet, some 85% of us routinely do when we say that “the hearing test is free.” It is not! Hearing tests are paid for by the next person who purchases a hearing instrument. Similarly, Sweetow4 has pointed out that returning a hearing aid and getting refunded is also anything but a “free service.” That “free” hearing aid is paid for by the rest of your clients, along with all of the other purchasers of hearing instruments in the US.

The justification here seems to be that, if it is imputed to be “free,” people will make an appointment who would not otherwise do so if there was a fee. That reasoning is incorrect, and we all know it. The truth is that, if something is really free, then we—as participants in a capitalist system—have apparently assigned no value to it. Consciously (or unconsciously), this fact does not escape our patients. We may only charge a very minimal amount (which it is our prerogative to do), but “free” is an inappropriate term that would make George Orwell squirm.

Before any of my audiological colleagues begin to suffer from swollen heads because they unbundle their charges for service, let’s talk about the “discounted” price off the manufacturer’s suggested retail price (MSRP). Unless one regularly sells hearing instruments at MSRP (I am not aware of anyone who does), this discount is as implicit an untruth as any.

I find myself agreeing with K. Ray Katz5 on this issue: pretending that MSRPs are the same thing as the actual retail price is hogwash. In particular, knocking 20% off the MSRP of a hearing aid and then crowing about it in an advertisement should give all hearing care professionals pause.5

These types of untruths have the potential to erode consumer confidence and to contribute to the reluctance of the patient to believe us when we tell them the truth about the seriousness and the lifelong negative impact of their hearing problem. In truth, for many patients, if their vision was as poor as their hearing, they would never be permitted behind the wheel of a car. It would be illegal and dangerous for everyone if these people drove a vehicle, and our actions could fall under the general rubric of “reckless endangerment.” If these same people provide transportation for their own or others’ children or grandchildren without the assistance and the support of effective hearing instruments, while it might well be legally permissible for them to do so, the question “Just how safe are they (and the children)?” needs to be asked.

Yet, we rarely confront our patients with these truths, opting instead to downplay both the seriousness of their disability and the potential consequences of their “right not to choose.” And then we feel good about ourselves for not applying any pressure to purchase a hearing device that our tests show they desperately need! In this way, our professional behavior could be considered highly questionable—ethically and morally.

Trying to Offer Honest Answers to Tough Questions
Organizationally, we are bound by the Codes of Ethics to which we subscribe. Morally, we must answer to our own internal code—which is hopefully more stringent, practical, and accessible.

In a recent article in the ASHA Leader, Roy Shinn, PhD, wrote a cover story on “Ethics and Audiology.”6 In the article, he refers to a marvelous idea which he calls the “Centrality of Ethics.” He believes that this kind of behavior is the “linchpin” of our profession and sets us apart (some might say above) from most others. He believes that decision-making using ethics as your guiding principle can, and should, be taught.

He points to the ASHA Code of Ethics document as being dynamic and evolving, having been first instituted in the 1930s and receiving its most recent revision in 2003. Currently, approximately 15,000 audiologists are covered by its 37 rules which are divided into four categories. Shinn calls for the recently initiated clinical doctorate in audiology (AuD) to emphasize and devote coursework to the study of Ethics. He quotes one study as showing that, while a mere 32% of practicing audiologists had ethical problems with the “perks” offered by manufacturers, only 5% of consumers were similarly unconcerned.6

Dr. Shinn6 likens audiology and other healthcare professions to medicine, the law, or the ministry. I would maintain that audiologists and hearing instrument specialists are not like physicians, attorneys, or ministers because they share a fairly common Code of Ethics; rather, they have a fairly common Code of Ethics because they see themselves and the mission of their professions as very much alike. As members of the hearing healthcare team, all dispensing professionals must also adhere to the philosophical prime directive of the Hippocratic Oath: First, do no harm.

A few years ago, Barbara Weinstein, PhD, authored a superb book called Geriatric Audiology.7 In the preface, she maintains that the field of audiology has changed. In traditional terms, it has become a “laboratory service” for medicine. It is only through the dispensing of hearing instruments and aural rehabilitation, says Weinstein, that the audiologist can be the “independent case manager” he/she desires to become.

This makes counseling the patient and providing exemplary audiological services a prerequisite for any professional hearing care program. Like physicians, ministers, and attorneys (jokes aside), a basic component in our service is to understand and appropriately deal the patient’s situation. And that also extends to how the patient/client views us as the professional dealing with them.

Recently, The Hearing Journal and Audiology Online conducted an interesting survey concerning four potential “ethical dilemmas.”8 Each question posed a scenario in which the dispenser/audiologist was faced with choices or inducements to promote specific products, etc. In each case, the question of whether it was “not unethical,” “possibly unethical,” “clearly unethical,” or “not sure” was asked. However, I believe a more pertinent question concerning these scenarios would have been about whether or not they represented acceptable behaviors for a hearing care professional. Further, it may have been interesting to see how one’s work environment influenced the answers to these questions. Professionals in a private practice/business setting may have markedly different opinions on subjects involving dispensing than those professionals who are primarily involved in diagnostics (eg, a hospital, nonprofit, or agency setting).

Finally, in each case, we should not have been concerned with whether the scenario represented an ethical choice; clearly, each represented unacceptable behavior and was almost certainly unethical. The real question should have been the concept of “partial ethics.” I am afraid that, like partial pregnancy, this doesn’t exist in a truly professional, ethical practice. If someone accepts a gratuity (eg, gift, bribe, payoff, or perk) or an inducement by any other name, it could be considered graft by the patient. Choosing to do less than the best for our patients is always unacceptable, and in some cases immoral or even illegal.

Examples of Ethical Concerns
I would like to pretend that I really believe that ethics is a straightforward subject well suited to didactic teaching. Unfortunately, I do not. I believe that it is possible for one to be an appropriate exemplar of such behavior, but that it is unlikely that one could be an ideal discussion leader in it—particularly when you’re judging someone in a part of the field in which you do not practice.

Ethical dilemmas are not simply theological exercises from some ephemeral catechism class. They are life choices with significant consequences. Both professionally and personally, many of the choices encountered in private practice have nothing to do with legality. In general, they are simply choices that may be dis-approved of by those who do not, or cannot, make them.

Here are four examples of current ethical concerns that may or may not merit our attention:

• The “seductress” frequently mentioned in hearing care ethics lectures are the hearing instrument manufacturers. Apparently, we hearing care professionals are so innocent and childlike that we can be tempted by the perks, trips, educational opportunities, and the co-oping of equipment and technology that some offer.

How ethically upright would we have to be to resist this Siren’s song? It has always interested and amused me that the most vocal of the opponents of these practices are frequently those to whom they are not offered. Without question, there have been (and will continue to be) unethical dealings involving manufacturers rewarding dispensing professionals with substantial gifts or money in exchange for their business. But, in these egregious cases, both parties are completely aware of the fact that they are not working in the best interests of the client. They are the scorpions and the Codes of Ethics are the doomed frogs.

In other cases (eg, continuing education opportunities that involve paid travel and accommodations, etc), there are legitimate gray areas that, in my view, need to be looked at with caution by the dispensing professional. Whether you accept a notepad, pen, key chain, dinner at a nice restaurant, or a trip to Hawaii, it is like the policeman who accepts the cup of coffee, the free doughnut, or the lunch from a proprietor: each represents a slippery slope toward compromising your reputation and your values. However, I do have some concern if “propriety” becomes equivalent to “purity,” or worse, “piety.” Many of these are choices are for the dispensing professional him/herself to make.

• As another example, there may be about 100 hearing instrument manufacturers worldwide. If the Codes of Ethics require “facility and expertise” with all of the circuits, shell technologies and related modification/venting methods, cables, software, remotes, peripherals, and programming options appropriate to each of them to forestall any accusation of preferential treatment, the organizations have lost their understanding of what we do and of the meaning of the word “choice.”

In fact, according to the HR Annual Survey,9 about half (46%) of all dispensing professionals offer 2-4 brands of hearing aids, but the most popular brand is prescribed in 78% of the cases. This is a reflection of common sense: you find something that works and you use it. I am not aware of any professional who, knowing better, would deliberately make an inappropriate decision for their patient in order to stand a better chance of qualifying for a higher discount. Anything else is why they make both Fords and Chevrolets. Obviously, I do not object to volume discounts, but I consider it fundamentally shallow and questionable when the objections to them are made by those who have never qualified for them.

• There is, in my view, a problem with professionals who have flocked to some distance-learning AuD programs because the degrees offered are cheaper, faster, or easier to obtain. There are even instances in which the individual’s partner did the coursework to obtain a degree for the family practice. This, presumably to be called “doctor” and theoretically command a higher price for services, is clearly unethical and immoral. The choice of programs based—even partially—upon the real or presumed lack of intellectual rigor demeans us all.

• There may be a problem with Codes of Ethics that require anyone subject to the code to report another member (likewise subject to it) for suspected violations. This is different from being “your brother’s keeper”; it forces every member to be their “brother’s cop.” I am not, nor do I wish to be, the ethics police. It is not in my nature, and simply on the basis of “casting the first stone,” I am not qualified to judge others. I have a full-time job just making sure that my own actions satisfy my personal, ongoing, internal “night court.” Again, scorpions will act like scorpions, and this may be adequate reason alone to teach ethics in our universities and encourage our organizations to produce Codes of Ethics so they can hold up the documents and proclaim “that’s plainly wrong.” However, except in the most egregious cases of ethical misdeeds, I am reluctant to cry thief on my neighbor until I’m absolutely 100% certain that I understand the entire situation.

Codes of Ethics in a Practical and Historical Context
Living an ethical life, or the running of an ethical and moral business, is not about a Code of Ethics or about a Scope of Practice. It is not about the fear of being caught. We agree to act in the best interests of our patients. We believe that, upon submitting our professional and business behaviors to the light of public scrutiny, the fair consumer would approve as “reasonable” all our strategies, methods, and practices.

Likewise, we should agree on the Centrality of Ethics of which Dr Shinn wrote about so eloquently.6 You will either embrace it as a raison d’etre, or you will never understand it. It is about deciding who and what you are, and how you want to live and practice.

It is not inconsistent to act in the best interests of our patients and, at the same time, operate a successful business. It may not always be easy, but it does not mean giving away our services as some sort of act of charity or contrition. I have no problem with what others charge for what they do. They know what their work is worth for their particular geographic region and for the demographic they serve. In my experience, few of us dispense hearing aids for the money; it is too hard, and there is not enough money in it. We do it for the self-actualization—the “high” you get when being able to do it well and being able to problem solve at elevated levels with meaningful, positive consequences for your patients.

Our work is a fantastic challenge and opportunity in which to serve people. Patients want you to “still be available” when they need your services again. That means that you must—unless you are independently wealthy or in a totally endowed environment—make a profit.

Years ago, when we served our patients less and our own pristine traditions more, an audiologist could (and did) give hearing instruments away. As long as no money changed hands, the patient only had to “qualify” for a hearing aid. No money could change hands, on pain of a charge of violation of the Code.

We practiced in this manner in the VA, through the Public Health Service, and even through the Bureau of Indian Affairs. Everyone was self-congratulatory about the purity of our motives, even though many of our methods and results left much to be desired. There was wholesale denigration of those professionals who sold hearing instruments—as if that act alone negated their worth or value to a population we didn’t (and arguably still don’t) understand.

It was considered unethical under the ASHA Code of Ethics to sell hearing devices until the late 70s, on pain of loosing one’s CCC-A (the equivalent of excommunication for an audiologist). To me, it seemed the definitive example of situational ethics that the dispensing rule was changed in response to a threatened revolt at an ASHA meeting in Detroit. It might also be pointed out that, during the ASHA convention in San Francisco, the organization officially changed its dispensing rule—just as the first meeting of the Academy of Dispensing Audiologists (ADA) was convened a few blocks away.

Everyone Gets the War That He Deserves
When I was a child, my father taught me that “If you always tell the truth, you never have to remember what you said.” Additionally, I learned that it is not practice that makes perfect; it is perfect practice that makes perfect.

One of existentialism’s leading voices, Jean Paul Sartre, said “everyone gets the war that he deserves.” What he meant is that everyone has their own particular demons and obstacles in life, and it is up to each individual to overcome those circumstances, for that is what determines character. Sartre was a soldier in the French Resistance. Risking his life on many occasions, he came to disdain anyone who sympathized or collaborated with the Nazis—or who passively sat by in the face of the Nazi occupation. After the war, Sartre was brutal in his assessments of those who chose not to join the Resistance—even when some of those people faced withering circumstances of life or death concerning the fates of family and friends.

Sartre’s was a philosophy of no excuses where free will reigns, the individual is completely responsible for the actions he/she chooses, and a person’s character and legacy is defined by those actions—particularly in trying or tempting circumstances of duress. One of life’s serious lessons is that “You don’t have to stand tall when called upon, you just have to stand up.”

Every day we are confronted with professional choices that relate directly to ethics and morals, and we know that the only real choice is the one that the patient would view as being in his/her best interests. Moreover, we have a higher moral obligation to ourselves, our profession, and our family and friends in which to strive, as much as possible, for perfection and a superlative legacy as a caregiver.

 Jay B. McSpaden, PhD, BC-HIS, is an audiologist who retired from private practice and who is currently practicing as a hearing instrument specialist in Jefferson, Ore.

References
1. American Academy of Audiology (AAA). Code of Ethics. Alexandria, Va; AAA; 2003.
2. American Speech Language Hearing Assn (ASHA). Code of Ethics. Rockville, Md: ASHA; 2003.
3. International Hearing Society (IHS). Code of Ethics. Livonia, Mich: IHS; 2003.
4. Sweetow RW, Bratt LA, Miller M, Henderson-Sabes J. A time-cost analysis with patients who purchase, return and exchange hearing aids. The Hearing Review. 2004; 11(1):26-30.
5. Katz KR. Viewpoint: “What’s Ethical? Who Decides?” Hear Jour. 2003;56(3):39-42.
6. Shinn R. Ethics and audiology. ASHA Leader. 2003;9(4).
7. Weinstein B. Geriatric Audiology. New York: Thieme Medical Publishers; 2000.
8. Kirkwood DH: Survey of dispensers finds little consensus on what is ethical practice. Hear Jour. 2003.56(3):19-26.
9. Strom KE. HR 2004 dispenser survey. The Hearing Review. 2004;11(6):14-32,58,59.

Other Resources
Decker FN. Ethics. Seminars in Hearing 2000;21(1).

Correspondence can be addressed to HR or Jay B. McSpaden, PhD, PO Box 1043, Jefferson, OR 97352; email: [email protected].