Chapter 23 - Ethical And Professional Conduct Of Health Care Providers

3-23.1  INTRODUCTION

1. Purpose.  This chapter establishes the policy, procedures, and responsibilities for Indian Health Service (IHS) personnel, supervisors, and management officials regarding the conduct of health care providers (hereinafter "providers") in the IHS.  Providers should be knowledgeable of, and are subject to, certain discipline-specific ethical standards of conduct to which they must adhere.
2. Background.  Providers come from a variety of professional and training backgrounds, and most disciplines have a published code of ethical and professional conduct.  However, because the codes differ among disciplines and some disciplines have no explicit ethical standards, this chapter on ethical and professional conduct for IHS providers has been developed.

   This chapter serves as an adjunct to and not as a substitute for "The Standards of Ethical Conduct of Employees of the Executive Branch," the Department of Health and Human Services "Supplemental Standards of Ethical Conduct for Employees," and the Commissioned Corps "Standards of Conduct."

   This chapter takes into account the rural practice setting of many IHS facilities particularly where providers must treat colleagues or family members in situations where no other providers of physical or behavioral health services are available.

3. Definitions.
   1. Health Care Providers.  Anyone who provides physical or behavioral health treatment to patients, e.g., physicians, nurses, dentists, podiatrists, optometrists, physician assistants, pharmacists, psychologists, counselors, etc.
   2. Patients.  Any customer of an IHS/Tribal/Urban (ITU) facility for whom clinical services have been provided.
4. References.
   1. 5 Code of Federal Regulations 263.101, "Standards of Ethical Conduct of Employees of the Executive Branch," revised January 1, 2003.
   2. Department of Health and Human Services (HHS), "Supplemental Standards of Ethical Conduct for Employees," July 30, 1996.
   3. Commissioned Corps Personnel Manual "Standards of Conduct," July 14, 1981.
   4. American College of Physicians, "Ethics Manual," 1998.
   5. American Medical Association, "Principles of Medical Ethics," June 2001.
   6. Encyclopedia of Bioethics, 3rd Edition, Volume 4, "Professional-Patient Relationship," 1995.
   7. Journal of Psychosocial Nursing & Mental Health Services, "Professional Boundaries," April 2002.
   8. Social Work, "Dual Relationships and Professional Boundaries," March 1994.
   9. Federation of State Medical Boards of the United States, Inc., Ad Hoc Committee on Physician Impairment, "Report on Sexual Boundary Issues," April 1996.
5. Responsibilities.  All IHS clinical staff must be familiar with and abide by the specific ethical codes published by the national organizations of their discipline or profession as well as Federal and State mandatory reporting requirements.
   1. Director, Office of Clinical and Preventive Services, IHS Headquarters.  The Director, Office of Clinical and Preventive Services, shall provide guidance and technical assistance to local and Area personnel in the implementation of or the supplementation of this chapter.
   2. Area Director.  The Area Director is responsible for ensuring that:
      1. assistance and training are provided to local clinical supervisors, managers, and staff regarding the implementation of this chapter;
      2. direct guidance is provided to a local investigation of any complaints or allegations of unethical behavior or misconduct by providers;
      3. reports of conduct involving legal issues and/or practices are referred to the Program Integrity and Ethics Staff (PIES) and/or the Office of Inspector General (OIG); and
      4. any violations of ethical standards are reported to the PIES and/or the OIG and the appropriate professional organization and State licensing/certification boards.
   3. Chief Executive Officer.  The Chief Executive Officer shall:
      1. provide training on ethical standards and policies to all local IHS clinical staff on a regular basis; and
      2. report all allegations, written or oral, to the Area Office, the OIG, and/or PIES.
   4. Clinical Supervisors and Managers.  Clinical supervisors and managers must report all allegations, written or oral, to the appropriate senior leadership of the facility, and/or the Area Office.
   5. Clinical Staff.  Clinical staff must follow the requirements outlined in this chapter and immediately report allegations, written or oral, of misconduct or possible violations of ethical standards to their supervisor or other appropriate official.  It is strongly recommended that verbal reporting he followed up with written documentation.  It is unethical not to report known violations of misconduct or violations of ethical standards.

3-23.2  BASIC PRINCIPLES

The following are the basic ethical principles from which the subsequent specific ethical conduct policies are derived.  These basic principles may be used for ethical decision making when a situation is encountered that is not covered specifically by the requirements of this chapter.

1. The most basic consideration of each IHS staff member in the performance of his/her duties and obligations is that the primary responsibility is to the patient/client and that no harm must occur to the patient/client as a result of the action or inaction of that staff member.
2. It is the responsibility of all IHS staff to ensure that each patient receives the best possible treatment under the circumstances of the setting as well as the available resources.
3. The IHS staff shall respect a patient's wishes regarding treatment and testing alternatives.  Whenever possible, Tribal customs and/or rituals shall be honored.
4. The IHS providers must follow all rules, regulations, laws, and policies related to performance and conduct.
5. The provider-patient relationship is a special relationship based upon trust by the patient in the provider.  This relationship must never be used by the provider to exploit a patient or former patient.
6. It is unethical for any staff member to use alcohol, illicit drugs in violation of the law, or medications in a manner that places them in violation of the law or in any way harms patients.

3-23.3  SPECIFIC ETHICAL CONDUCT

1. Relationships Between Providers and Patients.
   1. Respect and maintain appropriate provider-patient boundaries.
   2. At no time is it justifiable to have sexual contact or to develop a sexual relationship with a patient, client, or the parent/guardian of a pediatric patient or client.
   3. Professional relationships shall not be used to further the personal, sexual, political, religious, business, or other financial interests of the provider.
   4. Except in emergency situations, it is usually inappropriate to provide treatment to a person with whom the provider has had a previous sexual or close personal relationship.
   5. It is unethical for staff to encourage patients to use alcohol, illicit drugs in violation of the law, or medications in a manner that in any way harms them or places them in violation of the law.
   6. Social contacts and dual relationships with active patients should be kept to a minimum, insofar as is possible.
   7. Consistent with many State medical boards and prescribing practices, except for minor and self-limited medical conditions or emergencies, providers should not treat their immediate family members or themselves Professional objectivity may be compromised when an immediate family member of the provider or the provider is the patient; the provider's personal feelings may unduly influence his or her professional medical judgment, thereby interfering with the care being delivered.
2. Confidentiality.  Confidentiality about patients and their families shall be maintained under the guidelines of the Privacy Act of 1974; the Health Insurance Portability and Accountability Act (HIPAA) of 1996 Privacy Rule; Tribal, State, and Federal law; and published codes of professional ethics.
   1. Exceptions to the confidentiality of the provider-patient relationship may be made in the following circumstances:
      1. When the patient has granted specific and written authorization for the release of specific information.
      2. When there is danger of harm to the patient or to others.  In this case, there is an ethical duty on the part of the provider to share with legal authorities and other appropriate parties only such information that is necessary to prevent or curtail the threatened harm from taking place.  Providers are required to follow Federal and State mandatory reporting requirements.
      3. When the health care provider staff is required by an appropriate party to perform an evaluation of a patient for a specific purpose and identifies that purpose prior to beginning the evaluation.  Examples would be when the provider is asked to perform an evaluation of a patient or client for legal purposes to determine competency or the evaluation of a child or family for a child custody hearing, etc.  The patient or client should be informed of his/her right to refuse to participate in the evaluation.
   2. For further information regarding exceptions to the confidentiality of provider-patient relationships, see the IHS Circular No. 2003-02, "HIPAA Privacy Rule Implementation Guidelines," at:

      This Circular has been superseded by Indian Health Manual Part 2 Chapter 7 HIPAA

   3. Provider staff must not discuss patients in public places or in a manner that might allow information about the patient to be disclosed to someone who does not have the need for and/or right to know that information.
3. Relationships Between Coworkers/Colleagues.
   1. All health care staff should treat coworkers/colleagues with respect, courtesy, and honesty.
   2. Except for minor and self-limited medical conditions or emergencies, the provision of services to supervisors and direct subordinates is discouraged.
   3. The provision of behavioral health care to colleagues may be undertaken only if there is no reasonable alternative available, and then only if professional role conflicts between the role of provider and colleague are determined to pose no threat to the ability of the provider or the patient/colleague to otherwise provide patient care or maintain their professional working relationship. A note documenting the health services provided to a colleague should be maintained in the colleague's medical record.
   4. Behavior toward colleagues that is routinely disrespectful, harassing, intimidating, coercing and/or inappropriately unpleasant is unethical and a violation of several policies regarding conduct and the consideration of others.
   5. It is the ethical responsibility of provider staff members to share appropriate information with other staff members about the care of patients within the constraints of the Privacy Act, HIPAA Privacy Rule, and the confidentiality of the provider-patient relationship in the provision of ongoing care.
4. Relationships Between Providers and the Administration.  All staff must work to ensure quality patient care and effective delivery of services in the health system.  In this context, it is the duty of all staff members to bring programmatic issues that interfere with patient care (and possible solutions) to the attention of the appropriate administrators.  It is the responsibility of the administrators to address these issues in a timely manner.
5. Treatment and Assessment Modalities.  Clinical staff shall utilize and promote treatment and assessment modalities that have a basis in technical and scientific literature or that are accepted as part of traditional ritual or custom by the Tribal culture of the American Indian or Alaska Native person being served.
   1. Staff shall explain the reason and purpose of the treatment and assessment procedures in terms that are understood by the patient.  When necessary, the use of an interpreter is recommended.
   2. The use of treatment or assessment modalities that degrade patients or primarily use humiliation or harm to the patient's self esteem as a supposed tool of therapy or assessment are unethical.  It is the responsibility of health care providers to encourage the termination of such treatment or assessment modalities.
   3. Fostering inappropriate dependence by the patient on the provider is unethical and inappropriate.
6. Non-IHS Clinical Consultants.
   1. It is inappropriate for non-IHS clinical consultants to assume the principal care responsibilities for a patient in an IHS facility if the contacts with that patient occur too infrequently to provide adequate continuity and quality care.
   2. Service consultants shall not, without the permission of the facility to which they consult, divert a patient seen in that facility into their private practice or to another facility with which the service consultants are associated.
7. Consequences for Inappropriate conduct.
   1. Substantiated allegations of unethical behavior or misconduct may lead to disciplinary action.
   2. When the provider is determined to have engaged in unethical behavior due primarily to an impairment that is remediable, a program of treatment shall be offered to the provider.