Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

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If you have any questions on ethics, please submit them to EthicsQuestion@aoa.org. The AOA Ethics and Values Committee will respond to your questions as soon as possible. If you have an ethical challenge you wish to share, please feel free to submit a case description to ethics@aoa.org. The case description will be reviewed by the AOA Ethics and Values Committee and may be featured in a future Ethics Forum.

Impaired Colleague

By Adrienne Ari, O.D.

Case Study #3

You are in a group practice with Dr. Bob Jones and Dr. Charlie Smith in a large city. You and your colleagues are good friends and often socialize together with your spouses. While out, Bob typically drinks more alcohol than the others. Two months ago, Bob went through a rather ugly divorce. Since that time, you've noticed that Bob has been going to a local bar after work most nights after seeing patients. He also seems rather distant and has "disappeared" a few times for long lunches as well. You suspect that Bob is drinking at lunch though you have not noticed any obvious signs of impairment while in the clinic. You are hesitant to say anything because Bob's patients love him, and he is a friend and business partner. What are the ethical and legal considerations that the optometrist must address?

Discussion

This case is representative of an issue that can arise in today's optometric practice. The dilemma should be further examined in order to determine the best course of action. As reported in JAMA in 2014, it is estimated that approximately six percent of physicians have drug use disorders and that 14 percent have an alcohol use disorder-figures that mirror addiction in the general population1.

The standard definition in all states for being legally drunk is a blood alcohol content (BAC) of 0.082.  A person's blood alcohol content is determined by his or her weight and the number of drinks he or she consumes over a period of time. Someone can also be considered legally impaired at a BAC of less than 0.08. Because of individual differences in alcohol sensitivity, there is no clear-cut relation between the concentration of alcohol in the blood and mental performance3. So is even one drink OK?

According to the American Optometric Association's (AOA's) Code of Ethics, optometrists should conduct themselves as exemplary citizens and professionals with honesty, integrity, fairness, kindness and compassion4.  But is having one or two drinks with lunch cause for concern or in conflict with how a professional must function?  After all, drinking alcohol is socially acceptable in most cultures.  However, according to the AOA's Standards of Professional Conduct of "Do No Harm," optometrists who are impaired because of the use of controlled substances, alcohol or other chemical agents should remove themselves from patient-care activity5.

In the above scenario, you must consider the following before coming to a conclusion.

"Do No Harm"

  •  Any situation that limits the optometrist in his or her ability to provide the highest level of care to his or her patients should be evaluated. In Section B of the AOA's Professional Conduct, optometrists who are impaired because of the use of controlled substances, alcohol or other chemical agents should remove themselves from patient-care activity5.

Business

  •  What is the liability for the practice if there is a bad outcome for a patient related to Bob's impaired judgment? You are partners with Bob and Charlie. Anything affecting the practice, due to the actions of one of the partners, affects all of the partners.

Friendship versus working relationship

  •  What if your assumptions about Bob's drinking are wrong? How will confronting Bob impact your business relationship? What are the risks if you do nothing? Would it be better for you and Charlie to confront Bob together as a "unified front?" In an effort to protect patients and encourage help for impaired providers, optometrists should assist impaired colleagues in seeking professional help and/or identify impaired colleagues to appropriate state agencies or licensing boards5. Most physicians endorse a commitment to report impaired or incompetent colleagues in their medical practice, but when faced with this situation, some do not report6.

Reputation

  •  Does Bob's behavior have any impact on the practice? In business, the reputation of your practice is an important consideration. It is important to set a good example daily.

Whatever course of action is taken, it is important for the optometrist to carefully evaluate all of the aspects of the situation and consider action if harm exists for any of the parties involved. The reality is that a few drinks at lunch could be the beginning of a much larger problem.

REFERENCES

1. REGIER DA, FARMER ME, RAE DS, ET AL. COMORBIDITY OF MENTAL DISORDERS WITH ALCOHOL AND OTHER DRUG ABUSE. JAMA. 1990;268:1012-1014.

2. DRIVING LAWS [CITED 2015 NOV 2]. AVAILABLE FROM URL: HTTP://DUI.DRIVINGLAWS.ORG/DRINK-TABLE.PHP

3. CRESSEY, DM. ETHANOL, EMERGENCIES, AND ETHICAL DILEMMAS, BMJ 1998 MAY 16; 316(7143): 1515-1517

4. AOA CODE OF ETHICS, WWW.AOA.ORG, ABOUT THE AOA, ETHICS AND VALUES

5. AOA STANDARDS OF PROFESSIONAL CONDUCT, WWW.AOA.ORG, ABOUT THE AOA, ETHICS AND VALUES

6. DESROSCHES DM, RAO SR, FROMSON JA, BIRNBAUM RJ, IEZZONI L, VOGELI C, CAMPBELL EG. JAMA. 2010;304:187-197,210-211.

7. HTTP://WWW.NCBI.NLM.NIH.GOV/PUBMED/17242598