Dear Ethics Consult,
I work in a pediatric private practice in a semi-management position. As the practice has been growing the owner has been asking me, with increasing frequency, to say or take actions with families that I feel are unethical—or maybe illegal. Some of these requests have been to manipulate the schedule so that private-pay clients have preferred time slots and to pair new clinicians with lower-paying in-network clients, while the more experienced staff gets to work with out-of-network clients. I’m growing more and more uncomfortable but I’m not sure what to do. Overall, I really like my position, but this is starting to worry me.
—Not Okay With This
Dear Not Okay,
The difference between law and ethics is a tricky intersection to navigate. Something can be legal but not ethical, and laws aren’t always based on ethics. Legal standards are based on written law, while ethical standards are based on a shared understanding of professional rights and wrongs.
While I understand that your practice owner needs to strike the balance between running a successful business and serving clients, one of the core ethical standards is this: Advocate for the best interests of your client, including their ability to receive fair treatment. This core standard is what most state boards and professional ethics codes hold licensed professionals to.
It doesn’t sound like the owner is asking you to do anything technically illegal. But the requests may violate the terms of the practice’s contracts with insurance companies. Those contracts may have clauses related to scheduling preference and assigned clinicians that are designed to ensure that their members are treated equally with other patients or clients.
In any case, the owner’s requests certainly seem to be putting you in an ethically complicated position. When in doubt, you can always contact your state board or professional association, or your professional liability insurance carrier.
But as I said, just because something is legal doesn’t mean it’s ethical. In other words, just because something is allowed doesn’t mean that it’s right. If you’re uncomfortable carrying out the tasks your practice owner has set you, you’re within your rights to say something. You may have the initial instinct to downplay or ignore these situations as they arise, but that may not be the best course of action for you here. Many clinicians likely know this feeling—something happens that we know feels wrong, and want to speak up to make it right. But we can’t quite figure out how to do it. Then the moment passes, and we find ways to justify that it was okay to act as we did—or didn’t.
It’s not uncommon to imagine we might act one way in these situations, and then act differently in reality when they arise. But based on your letter, it does sound like you feel you need to act. And if you don’t say anything, the owner’s behavior and requests are likely to continue. Initiating potentially challenging conversations can make anyone feel anxious and uncomfortable, particularly when they’re with a supervisor. Try to use any discomfort you feel as an internal signal to be forthright, and a cue for action rather than inaction.
By bringing up your concerns in private with the owner, you’ll accomplish two important things. First, you’ll rule out the possibility of any misunderstanding or miscommunications about what they’re actually asking you to do. It’s possible that by citing specific reasons for your concerns, you’ll help them see why the request is compromising for you. It also might solidify that they really do want you to do something you’re not comfortable doing, in which case you’ll need to consider whether it’s time for a change.
Second, the fact that you have this concern, to me, affirms your commitment to your practice and profession. If you didn’t care, you wouldn’t feel conflicted. Opening up this conversation might help the owner reframe the requests they’re making of you, and you might be able to offer ethical alternatives that produce similar results. Of course, if the conversation doesn’t go well, or if the owner takes steps to punish you for bringing it up, that also can be useful in guiding your next steps.
Many of us have memories in our work lives where we should have done something or spoken up in the moment, and for whatever reason, didn’t. If you feel strongly that what you’re being asked to do is against your ethical standards, you should address it now, rather than wishing you did later. In doing so, you’ll make sure you’re staying true to yourself, while also ensuring your clients are getting the care they deserve.