Jan 29, 2015
The Right Call

If an ethical dilemma were to present itself tomorrow, would you be prepared to handle it properly? We asked athletic trainers who have been there for their expertise.

By Mike Phelps

Mike Phelps is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected].

Within her first few months on the job at Fairfax (Va.) High School, Associate Athletic Trainer Amanda Rolik, MS, LAT, ATC, was confronted with a dilemma. A Fairfax wrestler was recovering from a concussion and had not yet been cleared to return to activity, but his coaches were discussing having him participate in an upcoming match.

While it seems like an open-and-shut case–any concussed athlete shouldn’t participate until medically cleared to return–this one came with a twist: The opposing team didn’t have a competitor in the injured wrestler’s weight class. He could simply walk to the center of the mat, have the referee raise his arm above his head, and he would earn a forfeit victory for his team.

Although the athlete was at no risk for injury, Rolik and others on the school’s athletic training staff still took issue with the idea. “He wasn’t medically eligible to participate, and even though he would have been fine walking onto the mat, had there been an opponent, no one would have ever considered allowing him to participate,” Rolik says. “We turned the situation around to the coach and asked how he would feel if the other team had an athlete in the same situation. We would have been taking advantage of the situation in an unfair way.”

In the end, the head coach agreed with the athletic training staff’s assessment, the wrestler was held out, and the match resulted in a double forfeit. Like many decisions that athletic trainers face on a day-to-day basis, the correct or ethical choice isn’t always the easiest one to make. In this article, we talk to a number of athletic trainers about ethical issues–how to detect them, think through them, and make the right decision.

SPOTTING A PROBLEM

The first step to understanding how to make ethical decisions is to recognize when you may be facing one. Unfortunately, this can be more difficult than it seems.

“Athletic trainers can be placed in situations where they may not have the ethical awareness to recognize that how they act could have some moral underpinning,” says Kimberly Peer, EdD, LAT, ATC, Athletic Training Education Program Coordinator and Associate Professor at Kent State University, and co-author of the book Professional Ethics in Athletic Training. “Understanding the core values of the profession is imperative for us to survive, especially since the ethical issues are not always obvious.”

One area of athletic training Peer says can be difficult to immediately recognize as a potential hot spot for ethical issues deals with resources. Athletic training staffs are often not large enough to cover all games and practices, so they are put into the compromising situation of having to decide which teams are most important.

“Do you cover the collision sports? Contact sports? High-profile sports?” Peer asks. “Those questions have some real ethical edges to them and a lot of athletic trainers don’t realize it. They just say, ‘I’m going to do the best I can with the resources I have and provide the athletic department with something rather than nothing.’ However, ‘something’ might not always be better than nothing.”

Equitable coverage for male and female athletes is an important ethical issue to Kathy Schniedwind, retired Head Athletic Trainer at Illinois State University and an NATA Hall of Famer. “Making sure the women’s teams have the same coverage as the men’s teams can be a huge challenge,” she says. “When you have a top men’s program, all the medical staff wants to be at those events and it can be harder to get the same coverage for the women’s teams.”

Pressure from coaches can also force athletic trainers to make tough calls. “If you work at a school where one or two sports get a higher level of media exposure and those coaches make more money, you tend to be pushed to spend more time with those sports,” Schniedwind says. “At smaller schools, there often aren’t enough people on staff to devote one athletic trainer to every sport. We tried very hard at Illinois State not to have a student-athlete in a lower-profile sport feel like they weren’t important.

“For example, I would never make an athlete from a lower-profile sport wait for an MRI just because a higher-profile athlete also needs one and their coach thinks they should get priority,” she continues. “That’s not always an easy stance to take.”

Peer draws a much bolder line. “When you don’t have enough staff to cover all sports equally, simply saying that you’ll cover just some sports isn’t right,” she says. “Instead, I believe you have to take a stand and make it clear to the athletic department that if you’re going to treat all athletes the same, then you need to have more staff or a different system.”

Another key issue lies in return-to-play decisions. Considering the ethical ramifications of these scenarios often comes down to who you are most loyal to.

“We’d hope that all athletic trainers would practice the philosophy that the injured athlete is put back into play only when he or she is objectively ready to return,” Peer says. “But what happens a lot of times is that athletic trainers are put in tough places by coaches or athletic directors–or even the athletes themselves–who say, ‘Do whatever you need to do to get them back in the game.’

“Do you stay loyal to yourself and hold the athlete out, or stay loyal to the coach and try to do whatever you can to return the athlete to play?” she continues. “You hear about athletes getting injections in the locker room at halftime and returning to play. Is that truly the best way to treat them?”

Ethical dilemmas can creep up in everyday conversations within the athletic training room as well. When multiple athletes are in the whirlpool or getting their ankles taped at the same time, they tend to speak freely with each other about whatever is on their mind–either forgetting or not realizing the athletic trainer is present. So what do you do when those side conversations reveal a potential problem?

“You might hear about plans for a wild, unsupervised party or something similar,” says Joe Iezzi, MS, ATC, PES, Head Athletic Trainer at Downingtown (Pa.) High School West. “It would be easy to just look away and pretend you didn’t hear anything, but it’s our responsibility to do something. The important thing is to do it discretely and have the coach or athletic director take care of the situation. If you go blowing the whistle right away, the kids will never trust you again.

“Once, when I was working at the college level, I heard about a party going on the day before a game, and then we lost the next night,” he continues. “I told the coach about it, but he was smart enough to not say anything to the team right away. Then a few games later, the night before, the coach told the team, ‘We can win this game, but if you guys go out and party like last time, we won’t.’ Their eyes almost popped out of their heads.”

Ron Carroll, MS, LAT, ATC, Head Athletic Trainer at Arkansas State University, agrees that an athletic trainer has the duty to act on any potential issues he or she hears about a student-athlete. “Any problem you learn about needs to be dealt with, especially if it might be something illegal, like they’re taking some type of amphetamines,” he says. “Even hearing something like a racial slur needs to be talked about. Another example is if you have any inkling that an athlete is suffering from an eating disorder–maybe you hear they’ve been throwing up after meals–you have to pass that on to your superiors.”

Carroll, who joined the staff at Arkansas State in 1976, has encountered numerous under-the-radar ethical dilemmas in his career. They include football players trying to injure opposing players using casting material or unnecessary braces, or trying to gain an advantage by using cleat spikes longer than the rules allow.

He also says athletic trainers should be aware of what does and does not fall under the scope of their practice. “It’s important to have knowledge of your state practice act and understand the role delineation of athletic training,” he says. “If an athlete comes into the athletic training room and asks you to pop his back, that may seem like something innocent, but is that within the scope of practice of athletic training? It’s not. Knowing what’s ethical and what’s not also comes from knowing your practice act and what the NATA Board of Certification says.”

THINKING IT THROUGH

Once you’re able to recognize ethical situations, the next step is making a decision. But the correct call is often a difficult path to take. So how do you ensure you’re acting in an ethical manner? Peer believes athletic trainers need to develop moral courage, a term that comes from author Rushworth Kidder, founder of the Institute for Global Ethics.

“It’s about being able to dig in your heels and have the endurance to go the distance with a tough decision,” Peer says. “If it’s what you believe in and what you know is right, you need to be tough and stand up for change. That’s hard to do, but it’s the only way to make things better.”

One way to build moral courage and develop the ability to take a stand is to seek guidance from others. Peer believes looking for help is not a sign of weakness.

“It’s okay to not have the answer for something and to consult a colleague,” she says. “It’s important not to think that you’ve failed or are not knowledgeable just because you talked over a sticky situation with someone else.”

Schniedwind adds that even if you know what your decision will be, sometimes it helps to have a second opinion. “When you’re under stress, it’s always nice to have somebody to bounce ideas off of,” she says. “You have to pick and choose who you trust and what information you can talk about with them, but sharing your thoughts is better than keeping them bottled up.”

Schniedwind also believes it can be helpful to step back from any situation before taking action, especially if the call you make directly affects another person. “It’s usually best to not make your decision based on the immediate emotions you feel,” she says. “One of the things I always tried to do was wait 24 hours before discussing an issue with someone. By then, your emotions have come down and you can look at the situation more objectively.”

While having time to contemplate a decision is nice, it isn’t always possible. If you’re receiving pressure from a coach on the sidelines during a game, you’ll likely have to recognize the ethical situation, think through your options, and choose one on the spot. To do that, you need to have laid out the groundwork for your decisions in your mind ahead of time.

“The first and most important thing is to understand your personal and professional values,” Peer says. “The second is to have some type of moral framework to anchor your decisions in. There are a lot of them out there, so you have to go out and find one that makes sense to you.

“Then test that framework by looking at ethical cases and thinking about what you would do in those situations,” she continues. “That way, when you eventually encounter a similar scenario, you can make a quick decision.”

Here’s one example of a case study Peer has presented when she talks about ethics:

You work for a private physical therapy clinic as an athletic trainer. A worker who was recently injured is nearing time to return to his job. His progress has been fair, but it certainly falls within the marginal range. He has shared with you that during his time off he has been able to help his elderly father care for his mother, who has Alzheimer’s disease. He is always on time to the clinic and works hard during his rehabilitation. He states that his father cannot afford to institutionalize his mother and his help creates some relief from the situation. You are writing the report for his follow-up visit with the physician, which will determine whether he returns to work the next week or has his therapy extended another three weeks. You know the physician will ask what you think about his readiness to return to work. What do you do?

According to Peer, this is a situation in which the right thing to do isn’t cut and dried. She asks, what would you do if you didn’t know the patient’s family history? If coming to a conclusion is difficult, Peer advises thinking about how you make clinical decisions in the field.

“We train ourselves to think through clinical cases very quickly,” she says. “We can look at a downed athlete and decide in a very short period of time whether to move the athlete or not and whether he or she can return to play. We’re good at processing this scenario quickly because we practice it often. But we don’t practice ethics much because people don’t want to talk about it. Look at cases with your peers and say, ‘I would solve it this way.’ Maybe your colleague would say, ‘Well, did you ever think about it from this perspective?’ Then when a similar situation occurs, you have something to go back to.”

WORKING WITH OTHERS

Often, when a difficult ethical decision presents itself, you need to convince more people than yourself of the correct course of action–especially when it comes to return-to-play decisions. If an injured athlete should be held out but a coach is pressuring you to put him or her back in, the key is to come to the conversation armed with evidence, not emotion.

“You have to go one-on-one with the coach who is pressuring you to go the other way and be able to present facts and reasons why that athlete shouldn’t be playing,” Schniedwind says. “It doesn’t help to yell and scream, because that will put the coach on the defensive. Nobody thinks clearly when on the defensive.”

Carroll advises that athletic trainers avoid attacking the coach or making him or her think you’re challenging their authority. “No one wants to be challenged,” he says. “You have to say, ‘Coach, this came up. Here’s all the research behind it’ or ‘Here’s the official rule.’

“It comes down to communicating and educating,” Carroll continues. “What does the research show, what does the law say, and what are the rules? You’re not saying no. You’re saying, ‘This is putting me in a tough position. I will not do this.'”

Sometimes, though, the best thing may be to ignore the coach and make sure what you know is right gets done. “You may have to blot out the coach in your left ear saying, ‘You know, we could probably win this championship if Johnny is okay,'” Iezzi says. “As athletic trainers, we need to think with the knowledge we’re given and block out the outside influences. You can’t be swayed by whether it’s a big game or a rivalry. It’s about the athletes first.

“To make those decisions easier, I pretend the injured athlete is my own son or daughter,” he continues. “That puts everything into perspective.”

PASS IT ON

Most athletic trainers readily admit that it’s easier to recognize ethical situations, stand up for your beliefs, and make the right call when you’re a veteran in the field with experience to draw from. But what about those who are just getting their start in athletic training?

Carroll recalls how early in his career it was tougher to stand his ground with a coach who didn’t agree with his point of view. “You earn your respect every day,” he says. “You do that by doing your job well. If you show effort, people will have more confidence in you and respect you.

“But I think something young athletic trainers can do before earning that respect is to go over situations with their supervisor ahead of time so they’re prepared for any scenario,” Carroll continues. “I also think ethics is a good topic to bring up in your job interview. Ask what kind of respect you can expect to receive from the coaches.”

Schniedwind believes veterans can help younger athletic trainers by clearly laying out the rules and continually discussing them. “When you bring in athletic training students or new athletic training staff members, make sure they know right away what is expected of them and what is considered unethical behavior,” she says. “Spell it out immediately so it’s not hazy and if something happens, they know the correct course of action.

“I liked to talk to my staff and students throughout the year and tell them when they did something well or when they did something I didn’t like,” Schniedwind continues. “If a situation was handled poorly, I would bring that person in as quickly as I could to go over what happened and make sure it didn’t happen again.”

It’s also vital–at all times–to remember the importance of the subject. Whether you’re new to the athletic training room or an NATA Hall of Famer, ethics should always be at the forefront of everything you do.

“Ethics are huge to me,” Schniedwind says. “A big part of that is how I was raised. You do things the right way. I always say to myself, if you can look in the mirror every day and you’re comfortable with who you see, then what you’re doing is okay. If you can’t, then something’s not right.”

Sidebar: ETHICS IN OTHERS

In addition to monitoring one’s own ethics, athletic trainers may find themselves in the predicament of witnessing another athletic trainer engaging in unethical behavior. When this happens, what is your role? Should you report the behavior, or simply brush it off as none of your business? The best answer might be somewhere in between.

As part of the research for her thesis at Montana State University-Billings, Amanda Rolik, MS, LAT, ATC, now an Associate Athletic Trainer at Fairfax (Va.) High School, was looking up the license status of athletic trainers in Montana when she encountered a problem: two individuals who were listed as high school athletic trainers did not have licenses on file. Rolik wondered if she should immediately report them to the state board of athletic training. Instead, she decided to first reach out to the two athletic trainers in question.

“I wanted to contact them first, just to make sure I wasn’t missing something, like a misspelled name,” Rolik says. “I wanted to give them the opportunity to explain the situation to me first.”

Rolik never succeeded in getting in touch with one of the athletic trainers. The other, however, had simply never turned in his Board of Certification card. In retrospect, Rolik is happy with how she handled the situation.

“I went back and forth about what I wanted to do, but it came down to the fact that practicing without a license is against the law,” she says. “I then looked a little more into the NATA code of ethics and found a whole list of reasons why it was my responsibility as an athletic trainer–even though I was still in school–to uphold the standards and integrity of the profession.”

Kathy Schniedwind, retired Head Athletic Trainer at Illinois State University, agrees with Rolik’s course of action and adds that sometimes what you should do depends on the severity of what you’ve observed. “When you see something unethical, it’s important to consider the consequences of what is happening,” she says. “If you don’t say something, will people suffer or be hurt from what is happening? Every situation is different.”

Ron Carroll, MS, LAT, ATC, Head Athletic Trainer at Arkansas State University, adds that you should be prepared for the athletic trainer in question to possibly not be receptive to your inquiry. “If the individual is doing something against the law, obviously you need to report that,” he says. “But if it’s using a hard pad or something else that’s not against the law but still unethical, you need to make sure you approach the person with some diplomacy. You have to be careful, because they might get defensive and tell you to mind your own business. But if you do say something, you can go to sleep at night and know you did the right thing.




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