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Chapter

48

Ophthalmology ethics
Alex V Levin

CHAPTER CONTENTS
Introduction 767
Informed consent 768
Confidentiality 769
Truth telling 769
Boundary issues 770
Multiculturalism 770
Vulnerable populations 770
Pediatric ethics 770
Futility 771
Medical error 771
Impaired physicians and ophthalmic
professionals 772
Resource allocation 772
Research ethics 772
Innovation 773
Genetics ethics 773
Advertising 774
Fee splitting 774
Medical industry 775
Cosmetic surgery 775
Financial issues 776
Trainees in patient care 776
Resolution of ethical dilemmas 776

INTRODUCTION
Issues that challenge our ethical and moral value systems
have been part of medicine throughout recorded history.
2013 Elsevier Inc

As early as the 5th century bc, Hippocrates recognized the


role of ethics, virtue, and moral compass in the practice of
medicine in what has since become known as the Hippocratic oath, which physicians in many countries pledge
upon receiving their medical degrees. In 1241, Frederick
II, the King of Naples, recognized the risks of conflict of
interest when physicians engage in business relationships
with apothecaries in his Law for the Regulation of the
Practice of Medicine. Sir William Oslers 1906 treatise,
Equanimities, is filled with commentary on many examples
of the ethical issues that physicians face in their daily lives.
The 1960s brought an accelerated evolution of medical
technology. Medicine was now able to prolong the end of
life, engage in heroic surgical interventions, and save the
lives of infants born at increasingly earlier ages of prema
turity. With this progress also came increased attention to
the ethical issues that attended such advances. The field of
bioethics began to take shape and has since undergone
remarkable growth to the point where it has become a
fundamental part of undergraduate, graduate and continu
ing medical education as well as everyday practice.
In 1993 the American Academy of Ophthalmology pub
lished its manual, The Ethical Ophthalmologist: A Primer. In
1995, the Royal College of Physicians and Surgeons of
Canada mandated that ethics education must be part of
all residency program curricula regardless of the medical
or surgical specialty. Later, the Royal College would
develop the Core Competencies of the CanMEDS pro
gram for physicians: Medical Expert (the central role),
Communicator, Collaborator, Health Advocate, Manager,
Scholar, and Professional. Each role has components that
involve ethical considerations. Many training programs in
ophthalmic assisting and other ophthalmic fields now
include ethics in their curricula. Today, most professional
societies, including the American Academy of Ophthal
mology and the American Academy of Optometry, have
published codes and/or guidelines for ethical behavior.

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Role of Assistants in Eye Care

Every individual who plays a role in the ophthalmic care


of patients will face ethical dilemmas. In trying to resolve
these moral quandaries, each of us brings our own set of
moral values and knowledge to the process of resolving
the issue at hand. Given the almost infinite variety in our
religious, family, cultural, and experiential backgrounds, it
seems impossible to have a set of right answers that could
dictate our response to ethical dilemmas when they arise.
This is further complicated by the intricate details of each
situation and the rich context of the lives of our patients,
each with their own unique background and circum
stances. The writings of philosophers and bioethicists rep
resent many schools of thought (which are well beyond
the scope of this chapter), which attempt to give us for
mulae or orientation of our thought processes to address
our ethical challenges. Policy makers have laid out for us
guidelines that prescribe acceptable and unacceptable
actions and decisions as judged by peers and colleagues in
the same institution or field. The law, reacting to events
that question our actions within the context of our
societys regulations on behavior, places further boundar
ies on our actions and decisions. Figures 48-1 and 48-2

Ethics

Law

Policy

Fig. 48-1 A simplified model for ethical consideration


recognizing the intersection of ethics, policy and law.
Clinical experience/Research

Ethics

Law

Moral
Foundations

Philosophy

Policy
Fig. 48-2 A more complex model for ethical consideration
that is perhaps more applicable to a person with a deeper
interest in bioethics.

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offer diagrammatic approaches one more simple and


workable (48-1) and the other perhaps more complex and
attuned to the deliberations of the person with a deeper
interest in bioethics (48-2) to how these circles of con
siderations in our lives might intersect to help us address
ethical issues in our minds and in our practice.
This chapter is not intended to be a prescription of
correct answers to every ethical issue that might confront
eye care professionals; each issue below could itself
become an entire chapter or book. Rather, it offers identi
fication of issues, and a context in which they might be
considered, and raises questions one might ask in trying
to bring to consciousness those variables that should be
addressed in trying to resolve a moral quandary. The
readers of this textbook will likely come from many juris
dictions, professions, and societies, so the following dis
cussion must be interpreted within each specific context.

INFORMED CONSENT
Gone are the days when physicians simply told their
patients what must be done to their bodies to treat their
disease. Rather, we have developed a healthy recognition
of the importance of autonomy: the right of persons to
make their own decisions about what they will and will
not allow. Informed consent represents a partnership
between medical professionals and their patients. Doctors
have a fiduciary duty to ensure that each patient under
stands the treatment recommendations. Admittedly, this
is not always entirely possible as patients rarely can achieve
the same level of understanding as the doctor. In some
cases, the patient may have such strong feelings of trust
towards their physician that they make little effort to attain
the knowledge level of truly informed consent and instead
wish for the doctor to do whats best for me. Yet the obli
gation of the physician remains to at least attempt to
demonstrate that the patient does indeed have some com
prehension of the medical plan.
Informed consent is more than the signed piece of paper
entitled consent form. Informed consent is a process,
documented in the patients health record, wherein the
physician or a trained delegate (e.g., the ophthalmic assis
tant) educates the patient and asks for his or her participa
tion in the decision-making process. When the physician
delegates this process, there should be an opportunity for
the patient to ask questions of the physician and speak
directly to the physician if desired. Some situations require
little more than the patients action. When a patient sits
at the slit lamp and puts their head forward, it is an
implied consent to be examined. But when the medical
encounter is to involve aspects of risk, in particular risks
of bodily harm as in surgery or laser treatment, then more
formal informed consent, preferably documented by the
patients signature, is required. Performing a procedure

Ophthalmology ethics
without consent may be considered as battery. Clearly
there will be situations usually those surrounding emer
gency medical issues when the informed consent process
must be either abbreviated or abandoned, assuming rea
sonable effort has been made.
The eye doctor must inform the patient of all common
risks, no matter how small (including those that might
result not only in changes in function but also appear
ance), and also all serious risks, no matter how uncom
mon. The disclosure of risk should be considered in the
context of what a reasonable patient would want to know.
Although the risks are very small, reasonable people
would likely want to know about the risk of death from
general anesthesia or the risk of blindness from cataract
surgery.
Comprehension is another foundation of informed
consent. Patients may refuse treatment, even if their deci
sion will result in death or blindness, if they are deemed
to have the capacity to do so. If the decision-making capac
ity of the patient is in question (e.g., in Alzheimer disease),
then a substitute decision maker must be found. In some
jurisdictions this is a legal designation by power of
attorney, whereas in other cultures it may be a family
designation by virtue of marriage, age, or sibship. Informed
consent for children is discussed below.
Even when the patient is deemed capable, the ophthal
mologist must ensure that the necessary information for
decision making is presented in an understandable way.
Risks may be described in relative terms rather than with
incidence data. For example, one might say that the risk
of an entirely well young adult dying from general anes
thesia is less than the risk of dying in a road traffic acci
dent. Although written information is helpful, it must be
readable, preferably on a grade 68 level. Consent forms
with many pages have become common, yet one can ques
tion whether they are likely to be read and understood by
an average patient. No document can fully replace the
conversation between physician and patient. The patient
must be given the opportunity to ask questions and receive
answers before making a voluntary decision without influ
ence or coercion.

CONFIDENTIALITY
The ophthalmic health care team, like all medical profes
sionals, has a duty to protect the confidentiality of the
patient. The fulfillment of this duty enhances the trust
relationship with and respects the autonomy of the
patient.
Sharing of health records with other medical profession
als is just one aspect of the confidentiality issue. One
should remember that, although the chart itself belongs
to the physician or the health care institution, the informa
tion in the chart belongs to the patient. Information

Chapter | 48 |

should not be shared with others, especially those outside


the patient care team, without the patients documented
consent.
Ophthalmic professionals must also guard against acci
dental violations of confidentiality that can occur through
the discussion of cases in public places such as elevators
and registration desks or in easily overheard phone con
versations. Patient charts should not be left in accessible
view and computer screens with patient information
should be protected by password or screen saver. The use
of e-mail will be governed by a variety of jurisdictionspecific law and policy as society is still addressing the
challenge such communication imposes in our world
of increasing electronic interaction. Portable electronic
devices and even hard-copy documents taken out of the
patient care setting may be easily lost or stolen. Identifi
able patient information should not leave the patient
care setting in either form unless appropriate safeguards
are in place (e.g., remote access to a secure server via a
handheld device).
The medical professional may also be faced with situa
tions in which there is a conflict between the patients
desire for confidentiality and the medical professionals
desire to transmit information about the patient to other
individuals. A patient may disclose to an ophthalmic assis
tant that the cause of their periocular ecchymosis was an
assault by their spouse, but then ask that the ophthalmolo
gist not be told. The ophthalmologist may become aware
through evaluation of ophthalmic findings that a patient
is infected with HIV, but the patient does not wish to tell
their sexual partner. Sometimes these situations can be
anticipated and the patient forewarned that disclosure will
obligate the physician to make the necessary transmittal
of information either to public authorities (e.g., reportable
communicable disease) or private persons who may be at
risk. Yet this obligation may hold even if the patient dis
closed without being forewarned. In a landmark United
States case, Tarasoff v. Regents of the University of California,
where a psychiatrist came to know that a patient was likely
to murder, the court ruled that the physician did have a
duty to warn and protect by either notifying the intended
victim or informing the police. The most desirable
outcome in such difficult cases would be the resolution of
conflict through a trusting partnership between patient
and physician, perhaps with the assistance of nursing,
counseling, and social work support, but if the ophthalmic
professional feels that such partnership is not reasonably
achievable in a satisfactory time frame then the duty to
breach confidentiality may apply.

TRUTH TELLING
Truth telling is another fundamental tenet that underlies
the ethical practice of medicine. It is a foundation to the

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Role of Assistants in Eye Care

resolution of many issues discussed in this chapter (e.g.,


informed consent, duty to warn). Truth telling enhances
trust and partnership and also aids the patient in under
standing their disease. Sometimes, however, the ophthal
mic team will receive requests to withhold the truth. The
daughter of a 75-year-old man with ocular melanoma
might say, Please dont tell my father he has cancer.
Although the physician may empathize with the daugh
ters sentiment and truly feel that such information might
do more harm than good if disclosed to the patient, it
should be recognized that the courts in the Western world
have found this principle of therapeutic privilege to be
tenuous at best. Research studies have shown repeatedly
that in general, patients do want to be told the truth about
their condition and the health care team should endeavor
to do so. Much has been written about patient communi
cation and the breaking of bad news. It would benefit the
physician to become skilled in these techniques. Exploring
the reasons for the request of nondisclosure will likely lead
to a strengthening of the doctorfamilypatient relation
ship and easier resolution of the ethical dilemma.

BOUNDARY ISSUES
Respect for persons also entails that their bodies not be
violated in nonconsensual ways such as sexual advances
or touching. This principle applies not only between
co-workers in an ophthalmology office or clinic but also
between health care professionals and their patients. Vio
lation of boundaries may also come in the form of
personal affronts without actual physical touching. Exam
ples might include comments with inappropriate sexual
content, or aggressive and condescending behavior. The
field of organizational ethics addresses many of these sce
narios and the relationships between co-workers in various
roles. In general, it is advisable for health care profes
sionals to similarly avoid such behaviors, gestures, and
advances towards their patients, including activities such
as dating or sexual liaison.

MULTICULTURALISM
Many societies represent a rich blend of ethnicity, religion,
and culture. With this variety in the patient population,
ophthalmic professionals will likely encounter behaviors
that seem foreign, if not objectionable. One must respect
that there are a wide variety of behaviors to which the
terms right and wrong do not apply. Rather, tolerance
and understanding, often reached simply through dia
logue, become the basis of therapeutic success and patient
compliance. For example, there are ways for a patients
appointment to be altered to a time that does not conflict

770

with a religious holiday rather than demanding compli


ance with the original date.
There may be times when a cultural belief is not consis
tent with the laws or policies that govern the society in
which the patient lives. If a mother has used her urine to
treat her childs red eye and in doing so caused the child
to contract gonorrhea conjunctivitis, then education to
avoid this practice (in addition to bacterial culture and
treatment for gonorrhea in the family as well as commu
nicable disease reporting) is certainly indicated. To do so
in a culturally sensitive way may be challenging. All
medical professionals working in culturally diverse com
munities are encouraged to read Anne Fadimans book,
The Spirit Catches You and You Fall Down (Farrar, Straus and
Giroux, New York, 1997).

VULNERABLE POPULATIONS
One must be particularly careful when addressing ethical
dilemmas where the patient is part of a vulnerable popula
tion such as children (see below), prisoners, minorities,
and other groups who may, by virtue of their position
in society, prejudice, and prior unjust treatment, have
impaired decision-making capacity or a lack of proper
empowerment. Illness and infirmity may in themselves
make the patient more vulnerable and less able to engage
in capable decision making. The ophthalmic team must
guard against bias and parentalism in these cases and
maintain a healthy respect for the autonomy of these indi
viduals. It is easy to become blinded by our beneficent
parentalistic desires to benefit the patient and in so doing
ignore the importance of autonomy for all patients. One
might argue that extra care is required in order to ensure
the rights, boundaries, privileges, and autonomy of such
patients.

PEDIATRIC ETHICS
The ethical issues surrounding the care of children have
enormous scope that extends well beyond the reaches of
this chapter. Children are indeed a vulnerable population
yet they do have a right to respect for their autonomy,
which, even if they are not currently able to express it, will
eventually blossom.
It is recommended that children be involved in their
health care as much as possible, including discussions
about their disease and proposed treatment. Infants and
young children may not have the ability to participate
meaningfully in the informed consent process so their
parents/guardians become substitute decision makers,
although the physician must ascertain that the decisions
of these individuals are indeed in the best interest of

Ophthalmology ethics
the child. Although adults have the right to refuse treat
ment for themselves, even though such refusal could
lead to death or blindness, they do not have the right to
make such decisions for their children in most jurisdic
tions in North America. In such cases, if the health care
team is unable to form a partnership with the family that
would lead to a satisfactory resolution of the conflict,
then the physician may be obligated to approach the
child protection or legal system for intervention on behalf
of the child. Before resorting to these means, attempts to
resolve conflicts with the use of social workers, clergy,
mental health professionals, and other mediators can be
helpful.
Likewise, parents may not harm their children and there
is a firm legal obligation to report a suspicion of child
abuse or neglect to child protection authorities. This is a
legal as well as a moral obligation. Some physicians fail
to report because of a lack of confidence in the system, a
fear that parent and child will be separated unjustly, uncer
tainty over the diagnosis, a feeling that a well-known good
family could never abuse or neglect their child, a fear of
lost patient referrals, or a disinclination to have to take
time to go to court to testify. In reality, the facts suggest
that these fears and concerns are largely unjustified and
inaccurate. In all cases, the health professionals legal obli
gation to report is the primary responsibility.
Older children may have some ability to participate in
their own care decisions even if they are not mature
enough to give full consent. In these situations, one should
try to obtain the childs assent, or agreement, to proceed
with the medical plan. This can be done by involving
the child in the decision-making process with the
parents/guardians, asking the child directly about their
questions or concerns and even documenting in the chart
that this process occurred, with or without the childs
signature. Ascertaining when a child is able to give consent,
separate from that of the parents, may be defined by law
(and varies by jurisdiction) or simply by the assessment of
the ophthalmic team. In Ontario, there is no legal age of
consent. Older children and adolescents may have wishes
that differ from those of their parents. Taking a familycentered approach to care, which attempts to find thera
peutic alliance, will require time, patience, and perhaps
the support of other professionals in the field. The health
care team is advised to maintain a manifest respect for the
childs autonomy, confidentiality, and right to know the
truth about their care.

FUTILITY
Just as the adult patient may decide against treatments
proposed by the physician, the physician may refuse to
give a treatment requested by the patient if, in the best
judgment of the physician, the treatment is unlikely to

Chapter | 48 |

result in any benefit. If an eye is hopelessly blinded by


glaucoma and the entirely asymptomatic patient (i.e., with
no pain) desires another surgery to bring the pressure
down from 30, the doctor may refuse. Of course, there
should be ample evidence to support the physicians posi
tion. If this difference in viewpoint leads to an irresolvable
conflict between the doctor and patient, then the doctor
can attempt to find an alternative care provider for the
patient. Indeed, physicians may do this under any circum
stance in which they feel they can no longer provide a
therapeutic alliance with the patient, provided that the
decision is not made on the basis of class or cultural dis
tinction, prejudice, or malicious intent.

MEDICAL ERROR
Error is part of medicine. Much attention has been paid to
error in medicine, with large studies confirming its high
incidence and prevalence. Every ophthalmic team member
will at some time make an error that may or may not lead
to patient harm. Of course, we must always strive to reduce
error and many strategies have evolved to encourage this,
including the systems approach, which attempts to prevent
error by adapting the environment in which we work. For
example, if two eye drop bottles are so similar that they
could easily be mistaken for each other, it may be desirable
to place colored tape around one bottle or move the two
different medications to different locations in the office.
Marking the eye to be operated before surgery and preop
erative time outs are system interventions to avoid per
forming surgery on the wrong eye or patient.
Another approach to error, which has been unfortu
nately all too prevalent in medicine, is that of individual
blame, punishment, and secrecy. The aviation industry
has been a leader in the recognition that a nonpunitive
approach and the encouragement of error reporting with
team problem solving is the most productive path towards
error reduction. Likewise, disclosure to patients is a fun
damental part of an ethical response. Research studies
continue to show that patients do want to know when
errors are made.
Disclosure of error leads to a reduction in malpractice
claims and judgments as well as an increase in the trusting
partnership between doctor and patient. Disclosure may
present difficult challenges. Is a rupture of the posterior
capsule during cataract surgery by a skilled surgeon a com
plication (i.e., a known adverse event with a known fre
quency that accompanies any procedure) or an error? If
the outcome of surgery is not influenced (i.e., intraocular
lens in the bag, no vitreous loss, quiet eye), does the
patient need to know? Some would argue that disclosure
of such an event would be too complicated for the patient
to understand even though this same patient was pre
sumed to understand enough to give consent for surgery.

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Role of Assistants in Eye Care

Others would wish not to worry the patient unnecessarily,


although the principle of such therapeutic privilege, as
discussed above, is tenuous and runs contrary to what
patient-based research would recommend. Indeed, the
outcome for posterior capsule rupture may include a
higher risk of retinal detachment and glaucoma. The
surgeon may take special actions (e.g., dilated postopera
tive examination, more frequent postoperative visits) to
guard against such complications. The patient may wonder
why their care is different from other patients who were
befriended in the pre- or postoperative waiting areas
before surgery and are seen again at follow-up visits.
Disclosure of error is difficult for physicians and all
members of the health care team. It is recommended that
the health care team address error in a positive alliance
designed to identify error and the risk factors that led to
its occurrence as well as the measures that can be taken to
prevent its reoccurrence. Patients will want to know what
the expected outcome of an error might be and what
measures are being taken to prevent or address those com
plications should they arise.

IMPAIRED PHYSICIANS AND


OPHTHALMIC PROFESSIONALS
Patients have the expectation that their ophthalmic care
takers are competent. To violate this entrustment by allow
ing the practice of professionals who are under the
influence of drugs or alcohol, or otherwise impaired by
medical illness or knowledge deficiency, would be an
unethical breach of our duty to do no harm (nonmaleficence). Most professional regulatory bodies have mecha
nisms by which such professionals can find supportive
help designed to achieve reentry into the medical care
system once the individual is deemed competent to prac
tice again.
Difficulties arise when a member of the team is unsure
about the status of a colleagues competence, in particular
with regards to deficiencies of knowledge, suboptimal
skillsets (e.g., the surgeon with bad hands), or unsatisfac
tory decision making. Older professionals may be felt to
be not with the times. One must be careful that such
determinations are made without prejudice and not by
individual observations. Some practitioners, such as
the retinal surgeons who are asked to retrieve dropped
pieces of lens matter from the vitreous, may occasionally
or even regularly see what at first appears to be the error
or incompetence of another ophthalmologist. They must
be careful to remind themselves that the true story of the
events that led to the occurrence is not known and may
have a satisfactory explanation. Assuming the incompe
tence of another surgeon, and in particular reporting this
to the patient, is fraught with danger on many levels.
Consultation with co-workers and even frank discussions

772

with the individual about whom there is concern are


advisable. If there is sufficient evidence that incompetency
to practice exists, then delay in intervention will inevitably
lead to patient harm. It is highly recommended that these
issues be addressed before such events occur.

RESOURCE ALLOCATION
The allocation of scarce resources has become an increas
ingly frequent ethical challenge as the cost of ophthalmic
care continues to rise as a result of remarkable technologic
advances. Should only those with the means to afford
it have access to multifocal intraocular lenses? Should
limited operating theater time be allocated to the surgeons
who do the most expensive operations with remarkable
powers to restore vision on patients with uncommon
diseases or to the surgeons who do much less expensive
operations on larger numbers of patients with less pro
found impacts on vision? Should we use the most expen
sive suture in keeping with the surgeons preference even
if there is no demonstrable benefit to the patient? Should
the donor cornea go to the 1-month-old infant with uni
lateral Peters anomaly or to the 70-year-old person with
bilateral pseudophakic bullous keratopathy?
Resolution of these issues is often difficult, complex
and far removed from the patient, yet still impacting
their care. A full discussion of these issues is beyond the
scope of this chapter, but perhaps the starting point
is recognition of the best interest of the patient (beneficence), if not all patients, in the resource allocation
decision-making process. There is also an ethical duty
to best represent the interests of society which can at times
compete with the interests of an individual patient. Clearly
we cannot provide every possible aspect of medical care
to every patient but we can use a utilitarian approach to
achieve the greatest good. For an excellent discussion
of this and other ethical issues in a practical format,
the reader is referred to Bioethics at the Bedside provided
by the Canadian Medical Association Journal (http://
www.collectionscanada.gc.ca/eppp-archive/100/201/300/
cdn_medical_association/cmaj/series/bioethic.htm).

RESEARCH ETHICS
In academic health science centers, and sometimes in
community ophthalmic practice as well, there is a desire
to achieve advancement in ophthalmic care through
research. The researcher has certain ethical responsibilities
towards the research subject, which include informed
consent, confidentiality, disclosure, and respect for persons.
There is also a duty to ensure that the patient is not

Ophthalmology ethics
enrolled in a frivolous project unlikely to yield meaningful
results, a project where the potential benefits are out
weighed by potential harm, or a project that enhances
discrimination toward the patient or the group they rep
resent. Refusal to participate must not influence the care
or the access to care that a patient receives.
Recognizing the difficulties in honoring these obliga
tions, all research should be evaluated in advance and
approved by a research ethics board (REB, also known as
institutional review board, IRB) the membership of
which should be multidisciplinary, with representation of
the lay public as well. REBs are available both inside and
outside academic institutions. Research done in the com
munity is not an excuse for avoidance of REB review. Most
jurisdictions are now requiring even retrospective chart
reviews to obtain such approval. REBs may try to stream
line these processes. Although the process of REB approval
may seem arduous, its objective is to facilitate good
research rather than impede progress, while protecting
both the researcher and the patient.

INNOVATION
Ophthalmology is a highly technologic field. It is not
uncommon for ophthalmologists to find themselves
trying something new. Such presumed advances may
come as the result of publications in the peer-reviewed
literature, a throw-away publication, a presentation at a
meeting, conversations with colleagues, or de novo from
the creative mind of a thoughtful practitioner. The innova
tion may be as simple as a new way of tying a knot during
surgery or as complex as a piggyback intraocular lens
implanted into a neonate to deal with aphakic high
hyperopia with a predicted removal of the second lens at
a later date. Other examples include new intraocular
lenses, new techniques for refractive surgery, and smaller
instrumentation for retinal surgery. Some innovations are
applications of technology and experience from one
patient population to another (e.g., intraocular lenses in
children) and others are new only to that physician (e.g.,
switching to smaller gauge phacoemulsification). Should
innovation be allowed to proceed outside that purview of
the research paradigm with involvement of an REB?
Research is designed to answer questions and improve
the care of patients. Research studies are constructed to
follow the scientific method, which allows these questions
to be answered in a fashion that minimizes bias and the
influence of chance. Research is also distinguished by the
informed consent, which allows a patient to understand
the level of evidence base for the intervention in the
context of their care, and the REB-mandated monitoring,
which protects participants from unintended harm as early
as possible. Unfortunately, there are many examples of
innovation that proceeded without a research protocol

Chapter | 48 |

and led to disaster; anterior chamber closed loop intraocu


lar lenses are but one example. Some would argue that a
better understanding of innovation would arise if we
instead referred to it as nonvalidated intervention. One
might doubt that patients would have much interest in
being subjected to nonvalidated care. Yet patients are
attracted to the sexy innovations that they read about in
the media (e.g., small sutureless incisions); they want
to be cared for by ophthalmologists who are on the
cutting edge. Others would argue that innovation is part
of clinical care and an intrinsic part of medicine, especially
the surgical subspecialties, and therefore not a form of
research.
Some innovations occur in emergency settings where
REB review is not possible. When faced with an expulsive
hemorrhage, the surgeon will use any reasonable means
they can think of at that moment to close the eye. Other
situations require somewhat urgent innovation, but
perhaps with enough time to get an expedited review and
compassionate approval from an REB with not much
more effort than a letter to the REB chair. The majority of
major practice changes are done with sufficient fore
thought that REB approval could indeed be sought, with
the aim of ensuring the optimal outcome while protecting
the best interests of patient and researcher. Some authors
have recommended a system parallel to the REB specifi
cally for innovation a system designed to be more expe
ditious and attuned to the unique nature of surgical
practice. Institutions may adopt procedures where peer
review is a minimum, perhaps in the form of approval by
the departmental chief, before proceeding.
All of these considerations have in common a desire to
enforce some regulation of the current freedom of oph
thalmologists to do whatever they want and thus respect
the rights of the patient to informed consent, truth telling
and protection from harm while facilitating the progress
of ophthalmic care.

GENETICS ETHICS
Genetics has become an increasingly prominent part of
virtually every aspect of medicine. Ophthalmic profession
als must have a working knowledge of genetics in almost
every aspect of the field, from age-related macular degen
eration and cataract to steroid-induced glaucoma and con
genital malformations. Advances in genetics are already
bringing to ophthalmology the possibility of gene-based
therapy for a variety of diseases.
Recognition of the role of genetics in eye disease brings
with it some special ethical challenges. There may be con
fidentiality issues with the sharing of information within
families and the need to obtain such information to give
appropriate genetic counseling. Insurance companies may
have a desire to obtain information about patient risk for

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Role of Assistants in Eye Care

diseases not yet developed and then classify the asymp


tomatic disorder as preexisting, and therefore uninsurable
in the United States; the Genetic Information Nondis
crimination Act of 2008 prohibits insurance companies
from using genetic information in this fashion.
Parents may ask about prenatal testing for ocular disease
and consider terminating pregnancies of otherwise
healthy infants. They may ask for presymptomatic predic
tive testing of their children for genetic disease that is
unlikely to develop until the child is an adult. There is
some evidence that there may be harmful psychosocial
effects to both positive and negative predictive test results.
Perhaps a child identified as having the gene mutation for
retinitis pigmentosa in the family will be steered away
from certain career options only to find that, when they
become of age to pursue a career, there is a cure for their
disease and they have missed the opportunity to prepare
for the field they desire. Depression and even suicide may
follow a positive predictive test. A negative test in a highly
affected family with a disease-based identity may result in
the child being ostracized as not one of the group.
Ultimately, ophthalmologists might even have to
contend with the issue of eugenics as we become capable
of weeding out gene defects from society through sperm
and egg selection or gene repair. Should parents be allowed
to choose the iris color of their children? There is a primate
model for correction of X-linked recessive redgreen color
deficiency. Is this a disease? With the recent successful
treatment of Leber congenital amaurosis using intraocular
gene therapy we are beginning to see the power and poten
tial of this technique. With that must come a careful
appraisal of the potential ethical implications.
It would be unreasonable to expect all ophthalmologists
to be up to date with every genetics advancement; however,
the ophthalmic team must be cognizant of these ethical
issues in genetics. When faced with such dilemmas, it is
useful to call on the support and intervention of genetics
professionals such as ocular geneticists, genetic counsel
ors, or medical geneticists. They can act as consultants and
partners to help address the concerns brought forward by
the patient or anticipated by the team.

ADVERTISING
Physician advertising is now legal in many jurisdictions.
Some ophthalmologists have rejected this as an affront to
the profession that degrades our field to a business no
different from auto sales. Others have embraced advertis
ing as a means of public education at a time when
informed consent has received so much attention.
The main ethical principle that applies to this and the
financially related issues that follow below is that of con
flict of interest. Rarely do physicians advertise solely for
the altruistic benefit of disseminating information to

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patients. Advertising presents a conflict of interest wherein


the physicians motive of financial gain, practice advance
ment, and perhaps ego enhancement could potentially
result in techniques that are either coercive or even
untruthful. This would likely violate our duty to do no
harm. Of course, physicians can choose not to advertise,
at which point the ethical issue is moot. But if they do
choose to advertise they should do so in a way that may
remedy some of these concerns.
Advertisement should be truthful and not misleading.
Advertising does not replace informed consent. Some
jurisdictions prohibit patient testimonials or acrimonious
comparisons with other colleagues. Some professional
societies review and regulate advertising to ensure that
the potential patient is not influenced by style rather
than content. Catchy radio jingles or print slogans may
unduly influence and coerce patients into uninformed
choices. Consultation with professional regulatory bodies
is advised to ensure that the undesired effects of the
conflict are minimized and the benefits to the patient
maximized.

FEE SPLITTING
There are several forms of fee splitting. In the most typical
arrangement, one caretaker (e.g., an ophthalmologist)
pays back the referring professional (e.g., an optometrist)
as a demonstration of gratitude for a referral and presum
ably to provide an incentive for further referral. This
reward is referred to as a kick back or profit sharing and
may take the form of cash or other benefits such as tickets
to a sporting event, free meals, gift certificates, or even
cash. Another arrangement might involve a shared practice
wherein members of the group all benefit from the aggre
gate activity of the group and therefore encourage referrals
to each other. An example might be the multispecialty
ophthalmology group where all cataract patients are sent
to the retina specialist within the group for preoperative
examination. Lastly, fee splitting may take the form of
co-management. The ophthalmologist delegates the post
operative care of patients to another provider, often an
optometrist, and provides a payment in cash or in kind
for that service. Alternatively, the optometrist may bill the
patient directly for services that would otherwise fall under
the care of the surgeons postoperative care and as such
may not have been billable.
Although some may perceive these arrangements as
beneficial to the patient, providing continuity of care and
improved access to care, others have identified the conflict
of interest that may be inherent, particularly if the patient
is unaware of the arrangement. Research has shown that
patients are, in general, unhappy with these relationships.
Some jurisdictions have policy or law which proscribes
against these arrangements. Health care providers should

Ophthalmology ethics
initiate and sustain referral practices based on the best
interest of the patient rather than their own financial gain.
The American Academy of Ophthalmologys stance has
been to encourage ophthalmologists to provide postop
erative care for their own patients unless there are com
pelling reasons why this cannot be accomplished (e.g.,
surgeon leaving town for holiday) and only if the patient
is informed in advance. In situations where the conflict of
interest persists, physicians are encouraged to disclose
these relationships to the patient in a further attempt to
avoid any illusion of impropriety.
One must recognize that disclosure of a conflict of
interest does not remove the conflict. Patients may not
be empowered, especially when made vulnerable by
status, illness, or age to act in response to such disclosures
as they may feel that to do so would deny them access
to the provider they want and to whom they were
referred. This may leave the patient uncomfortable, suspi
cious, and more likely to be a dissatisfied participant in
their care.

MEDICAL INDUSTRY
Medical industry provides us with our therapeutic agents,
diagnostic agents, medical technology, and surgical equip
ment. It is a necessary and integral part of medicine. In
addition to the use of these products, physicians will
have direct interaction with representatives of medical
industry in the form of sales representatives wanting to
give information about new products, opportunities to try
new products, invitations to participate or lead industrysponsored educational events with or without social
components, invitations to become a spokesperson for
industry products, invitations to write papers/conduct
research/write monographs sponsored by industry, offers
of grants to support research activities or program devel
opment, gifts of free samples of medications or gifts
ranging from items of nominal value for medical use
(e.g., note pads with the drug company name on each
page), to more significant gifts such as sporting event
tickets, free meals, and even all-expenses-paid trips to
lovely locations with or without a sometimes nominal
educational component.
As the reasonable patient would likely expect that the
medical decisions of their ophthalmologist are free from
influence and conflict of interest, it is not difficult to see
why multiple studies have shown that patients generally
object to such relationships between physicians and
medical industry. Research also indicates that, despite the
often-heard claims of physicians to the contrary, these
practices do affect our prescribing patterns. It is then not
surprising to learn that medical industry spends billions
of dollars on advertising and such contacts with physi
cians, presumably not out of purely altruistic motives but

Chapter | 48 |

rather in recognition of the positive effect such expendi


tures have on company profit.
Most ophthalmic and other medical professional societ
ies, as well as the institutions in which physicians work,
now have policies regarding interaction with medical
industry. These policies grew out of the recognition of the
potential for influence on the decision making of medical
personnel if they stand to benefit from the largesse of
industry in a personal way. Some physicians have rejected
restrictions out of a feeling of entitlement, especially in
times when physician fees are dropping and other restric
tions on practice are increasing. Physicians may assert that
their own autonomy to conduct their lives as they see fit
is no less important than that of the patient. This conflict
rages on and is most apparent at large meetings, where
companies present enormous and elaborate displays and
every conference participant may be given a tote bag and
a neck strap for their identification badge emblazoned
with drug company logos.
The pharmaceutical industry has also recognized the
ethical dilemmas these relationships and activities engen
der. As a result they have implemented voluntary restric
tions. Companies may contribute much in the way of
information and financial support for medical meetings and
claim that they have not influenced the scientific content
(although there are many drug company-sponsored talks
on exhibit floors in addition to the official scientific
program). The risk of the public perception of impropriety
and the potential for adverse manifestations of conflict of
interest in direct patient care remain to be resolved.

COSMETIC SURGERY
As discussed above, patients have the autonomous right to
choose what they will and will not allow to be done to
their bodies (with the exception of futile interventions; see
above). Cosmetic surgery acts on a patients wish to have
something normal about their body changed to another
normal variant, often at large cost. Proponents of cosmetic
surgery would argue that the patient does not perceive the
condition as normal and therefore making the change, so
that the patient feels more normal, is well within the
helping nature of the medical profession. Analyzing the
philosophical differences on this topic is beyond the scope
of chapter, but the ethical issue of conflict of interest is
again worthy of consideration.
Laser refractive surgery has proliferated worldwide. In
many communities, as a procedure not covered by insur
ance plans, surgeons may charge sizeable fees and perform
the surgery exclusively in private clinics. People have
flocked to have this surgery, allowing enormous numbers
of patients to abandon their contact lenses and glasses. But
interviews of the lay public suggest that many go for the
procedure because they believe that the surgery will fix

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Role of Assistants in Eye Care

their bad eyes. Most of these people have normal healthy


eyes, seeing 6/6 with their preoperative refractive correc
tion. Their eyes are just a different shape from the average.
If the surgery were presented as a procedure which cuts
their healthy eyes to allow them to go without glasses,
would there be as much interest?
The laser refractive surgery field has gone to enormous
lengths to achieve informed consent, with some practices
offering documents in excess of 10 pages for the patient to
sign a practice that may raise some questions about truly
informed consent (see Informed consent above). Yet, if a
surgeon stands to reap exceptional financial benefit for a
procedure that is not medically necessary (although some
cosmetic surgeons would argue that the patients desire for
surgery is a compelling indication), is there not a potential
for bias, conflict of interest and incentive, for the surgeon
to recommend or even advertise (see above) the proce
dure. This conflict may not be readily apparent to the
patient despite assumptions by the physician to the
contrary.

FINANCIAL ISSUES
In addition to the ethical issues discussed above, many
of which have financial implications for the physician
(e.g., fee splitting, advertising, medical industry, cosmetic
surgery), all medical practitioners are also faced with
moral challenges related to charging and collecting fees for
services rendered. Although altruism is an ethical principle
that should pervade much of medicine, there will in
almost every setting be a business component: expenses
must be covered, employees must be paid, and the physi
cian deserves an income commensurate with their skill,
training and success. Opportunities abound for making
minor, or even major, manipulations in billing practices
that will further increase income while staying within the
law and out of detection by the patient.
This potential conflict of interest and the ethical issues
that such practices raise, have long been troubling to the
ophthalmic profession and served as the basis over the last
century for the emergence of the American Academy
of Ophthalmologys increasing interest in ethics with
the establishment of a Code and an Ethics Committee.
The potential conflict of interest was also recognized
in the United States in the form of safe harbor legislation
that put restrictions on potentially unethical arrange
ments. More subtle billing practices may also raise similar
concerns that profit motives conflict with the best interest
of the patient. In the past, in some Canadian provinces,
ophthalmologists got paid more if the patient was referred
from a physician as opposed to an optometrist even
though the same service is performed. Some ophthalmol
ogists were very creative in getting around this rule by
writing consultation letters back to the patients family

776

doctor or refusing referrals from optometrists. The former


act is a type of deception, whereas the latter causes the
patient inconvenience and potential care delays in having
to seek an alternative referral route. This is but one example
of bending the billing rules, other forms of which range
from illegal to legal but questionably ethical. In the United
States there is an entire industry devoted to advising physi
cians on how to best code for patient visits and surgery to
achieve the greatest reimbursement. Although all illegal
acts are not within the ethical and moral acceptability
of the practice of medicine, some legal acts may also
challenge our ethics boundaries. Creative billing
also tends to raise the cost of health care to society,
creating yet another conflict of interest and potential
nonmaleficence.

TRAINEES IN PATIENT CARE


When trainees (e.g., medical students, ophthalmology
residents, ophthalmic assistant students) are participating
in the care of patients, there may be a reluctance to inform
the patient for fear that the patient may reject this arrange
ment. In fact, research shows that patients do want to be
told about the nature of such arrangements and, if prop
erly informed and assured that appropriate supervision is
in place, usually welcome this interaction and may even
feel that they are making a positive contribution to the
health care system. Some authors have argued that patients
have a moral obligation to participate in the training of
future professionals, particularly in a publicly funded
health care system such as Canada, but this does not nec
essarily abrogate our truth-telling duties. The ethical prin
ciples of truth telling and disclosure play a strong role in
this setting. A utilitarian approach, seeking the greatest
good for both the patient and society, would argue that
the success of these relationships, largely through the
graded allocation of responsibility to trainees and the pro
vision of appropriate supervision, is supported by the high
functioning of the training system and its lack of demon
strable negative outcome impact on patient care. In fact,
the highest level of care is often delivered at the academic
centers where trainees are routinely part of health care
delivery.

RESOLUTION OF ETHICAL DILEMMAS


The ophthalmic team is confronted by a wide variety of
ethical issues. This chapter has attempted to identify many
of those issues and offer some pertinent points for reflec
tion and consideration when attempting to resolve the
dilemmas. Although there may not be a perfect right
answer in each case, ophthalmic professionals should

Ophthalmology ethics
consider the relevant key ethical principles, institutional
policies and societal law. Multidisciplinary conversations
with peers and colleagues can be particularly helpful. Dif
ficult situations arise when an employee (e.g., ophthalmic
assistant) has a different viewpoint on an ethical issue
from the supervisor or employer. Open conversation
can often resolve these conflicts. Consultation may be
sought from bioethicists or other professionals who have
had formal training in the field. Many written resources
are now available; ethical issues have found their way
into hundreds of journal articles on virtually every topic
as well as the resources mentioned above, books,
and internet-based courses and case discussions. The
University of Toronto Joint Centre for Bioethics website
(www.jointcentreforbiothics.ca/) is another useful resource
that can link readers to a wide variety of information on
bioethics and case management.
Each reader of this chapter and every professional in the
field of ophthalmic care will be faced with the task of
resolving ethical dilemmas. The word ethics is indeed a

Chapter | 48 |

plural word. There is more than one ethic depending on


the specifics of the situation at hand and the background
of the professional. Understanding the rich context of the
patients situation their culture, family, disease, progno
sis, education level, religion, support systems, alternative
health care practices, and wishes is perhaps the first step
in laying the foundation for understanding and conflict
resolution. Practitioners must also understand their own
orientation and bias when dealing with these issues. Each
of us may make different decisions, but we must do so in
a comfort zone that lies within the policy guidelines and
law that govern our practice as well as the ethics boundar
ies beyond which most reasonable people would recog
nize transgression. Within those boundaries is a wide zone
of possible pathways to resolution of an ethical quandary.
Choosing the resolution that best suits the needs and
desires of the patient is paramount, and finding a solution
that is agreeable to the ophthalmic team and the indi
vidual practitioner responsible for the patients care is
most desirable.

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