Jan 29, 2015
A Moral Compass

As an athletic trainer, you will undoubtedly face ethical decisions. Luckily, there is a source of help.

By Dr. Greg Frounfelter

Greg Frounfelter, DPT, SCS, ATC, CSCS, is an Athletic Trainer and Physical Therapist in the Physical Medicine Department at Agnesian Healthcare-Waupun Memorial Hospital in Waupun, Wis. He can be reached at: [email protected]

Personal ethics are like snowflakes—no two are alike. What one person sees as just and right, another may view as unfair or immoral.

Professional ethics, however, are different. Many professions—especially in healthcare—have established ethical standards for their practitioners. Most likely, you are already familiar with the National Athletic Trainers’ Association Code of Ethics. This is a powerful document with many ramifications for the ways athletic trainers practice.

Once you become a Certified Athletic Trainer, the words in this code will take on greater meaning. No longer will they address purely theoretical concepts. They will become a tool to guide you through the ethical and moral decisions we all encounter in our profession.

At its core, the NATA code is based on four principles:

Principle 1: Members shall respect the rights, welfare, and dignity of all.

Principle 2: Members shall comply with the laws and regulations governing the practice of athletic training.

Principle 3: Members shall maintain and promote high standards in their provision of services.

Principle 4: Members shall not engage in conduct that could be construed as a conflict of interest or that reflects negatively on the profession.

By becoming an athletic trainer, you agree to follow this Code of Ethics and use it as your moral compass as an athletic trainer. Even athletic trainers who are not members of the NATA are bound by our Code of Ethics, because if an athletic trainer’s decision results in litigation, one of the questions at hand will be whether he or she acted in accordance with accepted professional standards, including the NATA Code. There is no way around it. Every athletic trainer needs to understand and follow the NATA Code of Ethics.

It should also be mentioned that individual state practice acts, where appropriate, are another important tool in ethical decision making. Principle 2 of the NATA Code makes it clear that these guidelines should be followed at all times. However, state practice acts vary in approach and detail, so we will limit this discussion to the NATA Code of Ethics.

Transport yourself to the time when you have passed your NATA-BOC Examination and are a full-fledged athletic trainer. Congratulations! You can now wrestle with ethical questions that come up in our profession. Here are four scenarios presenting ethical quandaries and how the NATA Code of Ethics can be applied to make the proper decision.

Case A: The quarterback of the high school football team is injured during a game. As you make your way to the locker room, a booster stops you and asks about his status.

Resolution: You are faced with a request for privileged medical information from someone who has no need to know the information. Section 1.3 of the NATA Code states: Members shall preserve the confidentiality of privileged information and shall not release such information to a third party not involved in the patient’s care without a release unless required by law.

As harmless as it may seem, you should not share patient information with a person who is not involved in his care unless you have received approval from the athlete, and in the case of a high school player, his parents. In addition, Federal HIPAA requirements may come into play here, which could make such disclosure illegal.

Case B: In an effort to save on the cost of supplies, a freshman basketball coach asks you to tape the ankles of only players in the starting line up. He says the other players can use braces instead.

Resolution: You face several ethical considerations here. First, Section 1.1 of the NATA Code states: Members shall not discriminate against any legally protected class. This means everyone on the team should receive the same level of care whether they’re starters or not.

Section 1.2 states: Members shall be committed to providing competent care. So you have to determine whether taping or bracing would be the best treatment for each player.

In addition, Section 3.4 states: Members shall recognize the need for continuing education and participate in educational activities that enhance their skills and knowledge. Searching for research in regard to this issue will help strengthen your position should you have to defend your decision to tape or brace.

Case C: You know a fellow athletic trainer who is also employed as a physical therapist at a local clinic. You note that all of the injured student-athletes at her high school are being sent to the clinic where your friend then treats them as a physical therapist. This occurs even with injuries that could easily be addressed within the confines of the high school athletic training room.

Resolution: Principle 4 makes clear that any conflict of interest should be avoided and an athletic trainer referring patients to themselves to treat as a physical therapist could certainly qualify as a conflict. While it may seem to be good business, Section 4.3 states: Members shall not place financial gain above the patient’s welfare and shall not participate in any arrangement that exploits the patient. In addition, Section 3.3 states: Members shall provide services, make referrals, and seek compensation only for those services that are necessary, which would not include services that could be handled in the athletic training room.

Even if the referral is made without regard to financial considerations, there is still an ethical problem, since Principle 4 speaks of “construed conflict of interest” not just an actual conflict of interest. Though everything may be legitimate, an athletic trainer referring athletes to a clinic they work for could appear to be a conflict of interest and should be avoided. This is often addressed by being open about your professional relationships with your employer and giving the athlete the choice of where he or she would like to go for further follow-up care.

There’s another ethical consideration here—what action you should take. Section 2.3 of the Code says: Members shall report illegal or unethical practices related to athletic training to the appropriate person or authority. The NATA Web site includes instructions for reporting violations of its Code of Ethics. Reports can be made anonymously, if desired.

Though it may be difficult to report a fellow athletic trainer, our profession relies on self-policing. Turning a blind eye to an athletic trainer who acts unethically can put the profession’s reputation at risk.

Some athletic trainers may prefer to talk with the offending party first in an attempt to get them to change their ways. But if the problematic behavior continues, it should be reported.

Case D: You are covering a wrestling match at a new high school. You find the coach has been using a soft splint and taping to help a varsity wrestler with a sprained hand for the last four weeks. The wrestler shows signs that strongly indicate a fifth metacarpal fracture, and says he is experiencing decreased hand function. But the coach is adamant that he not see a doctor because if the hand is fractured, the wrestler, who is ranked second in the state, will miss the state tournament.

Resolution: In this scenario, there are a variety of ethical issues, and sometimes they may even conflict with each other. Principles 2 and 3 of the Code of Ethics speak to the need to maintain high standards in providing athletic training services. Pertinent sections of the NATA Code of Ethics include:

Section 3.1: Members shall not misrepresent, either directly or indirectly, their skills, training, professional credentials, identity, or services.

Section 3.2: Members shall provide only those services for which they are qualified through education or experience and which are allowed by their practice acts and other pertinent regulation.

Section 4.1: Members should conduct themselves personally and professionally in a manner that does not compromise their professional responsibilities or the practice of athletic training.

By not arranging adequate medical follow-up, there is a breach of duty to the athlete. An athletic trainer who allows this to continue and tries to nurse the athlete through the season could even be accused of practicing medicine without a license. Plus, if permanent injury or disability occurs as the result of competing with the injury, the school, coaches, or athletic trainer could be held liable.

Ethics require that the athletic trainer explain to the coach and athlete—and if he’s a minor, to his parents—the seriousness of the injury and the importance of having it evaluated by a doctor. The athletic trainer also needs to make it clear that he or she will not participate in any plan to keep the wrestler in action without a physician’s approval.

However, the athletic trainer cannot force the athlete to seek treatment. In the high school setting, this decision will usually be up to the parents. If they decline your guidance, all you can do is reiterate your concerns and have them sign off on their refusal to follow your instructions.

These scenarios, all of which are based on ethical questions I have faced during my career, may seem to require little more than common-sense solutions. But anytime you get into a discussion of ethics, you will be amazed by some of the arguments you will hear. Some athletes and parents may feel a chance to win a state title is worth taking the risk of permanent injury, and some people will never understand why an athlete’s medical information is none of their business.

As an athletic trainer, you will be judged by the NATA Code of Ethics and state practice acts. By using these as the basis for your professional ethics, you will always be able to justify your decisions from a moral and legal perspective. They provide the tools needed to be an allied health professional who can make the best decisions on a consistent basis.

The National Athletic Trainers’ Association Code of Ethics, and instructions for reporting an ethics violation, can be found on the NATA Web site at: www.nata.org/codeofethics/index.htm.


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