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.

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.

Ethical Considerations for Optical Sales Incentives
By Satya B. Verma, O.D., FAAO, DPNAP, Diplomate & Hilary L. Hawthorne, O.D.

Case Study No. 14

Two doctors attended a course that focused on ways to implement practice management strategies to achieve maximum sales performance. Our case looks at how they shared a casual conversation on two different ideas. The two doctors exchanged thoughtfully presented, contrasting viewpoints.

Dr. Point was so enthused that she planned to make an announcement during her next office meeting and introduce distinct changes according to the lecturer’s guidelines. She concluded that revenue generated from patients who choose to purchase multiple pairs of eyewear from her optical dispensary and/or who ordered anti-reflective lens coatings on new and additional pairs would quickly increase her bottom line. From the lecture, Dr. Point was particularly focused upon directing her staff to emphasize two topics during each patient encounter:

  1. the benefits of owning an extra pair of eyeglasses; and
  2. the benefits of protecting the eyes from glare. 

Dr. Point determined that such changes would generate a higher yield in optical sales, particularly if the sales involved higher-margin products. To achieve this task, Dr. Point’s employees would begin receiving money as an incentive payment whenever they sold any of these items.

She believed wholeheartedly in the merits of rewarding staff who increase the bottom line by promoting products.  Learning from other experiences, she knew staff training would be needed to incorporate the clearly identified objectives. The business tools presented in the practice management course seemed highly complementary to her practice; she had always been doing a little bit of everything to market her practice via cooperative advertising with frame vendors and optical laboratories. 

Dr. Counterpoint, while equally interested in improving his bottom line, felt uncomfortable using staff financial incentives to increase product sales. Even though the use of incentives is an accepted technique in the sales world to improve revenues, using incentives might raise an ethical concern in the healthcare arena. Although he likes the idea of increasing his revenues, he is not comfortable with the lecturer’s advice to incentivize staff as he believes this approach may lead to sales staff behavior that may be perceived as aggressive by some patients.   

Who is right? They both are depending upon your vision, marketing and pursuit of strategic ideas, as well as your confidence in your ability to train staff on the appropriate way to interact with all patients whether they purchase products from your practice or not.

Potential Discussion Topics

On the surface, this conversation depicts how differently doctors tend to perceive what may seem like straight forward business propositions and marketing presentations.  Dr. Point’s course of action will earmark funds for her staff who sell more advanced or higher-end materials. Introducing the customer to higher-end products, upgrades or other add-ons may lead to a more profitable sale.  Is there any ethical concern? 

Doctors of optometry have an obligation to act ethically at all times regardless of operating dispensaries and are also obligated to be fiscally responsible for the financial health of their practice. The practitioner can neither ignore the need for financial sustainability, nor ignore his or her professional ethical responsibility. Offering patients products that can enhance their lives is not inappropriate. However, patients who elect not to purchase products from the practice must receive the same level of care as those who do. A patient’s treatment must never be impacted by the amount of money he or she might spend on products and services in a doctor’s practice. This is a fundamental tenet of physician ethics.  

It is also enshrined in the law - Eyeglass Rule (1) and the Contact Lens Rule (2), along with numerous similar state laws, set the expectation that the examination and treatment of the patient’s eyes and optical dispensing be distinct processes. Doctors of optometry embrace a patient care-first approach and are experienced in operating their practices in this regulatory environment. However, in implementing an incentive program, care must be taken not to unwittingly confuse staff regarding the legal and ethical requirements and the expectations set for them.      

Our case looks specifically at the two incentives Dr. Point intended to utilize.

  1. Staff are incentivized to promote the benefits of purchasing a second pair of glasses. 

    1. Dr. Point would say her patients can always use a second pair in case they misplace or break their eyeglasses. Her staff may also market the second pair as a fashion option to a style-conscious patient. 
    2. On the other hand, Dr. Counterpoint feels his patients may never make use of a spare pair of eyeglasses and may even lose track of where they’ve been stored. He does feel a fashion-conscious patient on the other hand may use the second pair more often compared to other one. He fully concurs that a second pair of eyeglasses makes sense for children. He does not view it as a necessity to promote to every patient. 
  1. Staff are instructed to offer the option of anti-reflective (AR) coating to every patient purchasing eyeglasses.  

    1. Many would agree with Dr. Point’s strategy for making sure that every patient is counselled about the benefits of premium, high-quality lens coating to meet the challenges of everyday life. AR coatings increase the light transmitted by the lens, resulting in better vision that could certainly help elderly patients with cataracts and symptoms of glare sensitivity. Patients should not feel pressured to add lens coatings, but the doctor would be doing a disservice if he or she did not educate patients about the benefits of coatings.  
    2. Dr. Counterpoint does not refute these lens coatings are beneficial; the option should definitely be discussed with patients, more so with symptomatic patients. However, in Dr. Counterpoint’s opinion, proposing that all patients should receive AR is not justified. The out-of-pocket expense may be too costly for some patients. Dr. Counterpoint’s preference is to train his staff using a comprehensive selling system tailored to identify and understand a patient’s individual lifestyle, needs and budget constraints and provide them with choices that best meet their needs.

An optometrist author writes, “(f)or many optometrists, the more patients seen, the more services, tests, and procedures rendered to the patient, the greater the practice’s income will be.” (3) This is true for other physicians as well. In addition, for doctors of optometry who operate a dispensary for glasses and lenses, the volume of sales through the dispensary will also of course impact the practice’s income.

Do you align your mode of practice with either opinion? Which approach is right for you? 

The ethical issue is not that the office should refrain from marketing and selling second pairs of eyeglasses, AR coatings or other lens option treatments. Incentives on individual items to an individual patient may be considered a “gray” area in ethics, due to the risk – real but addressable – that such incentives could encourage “high pressure” sales behaviors by staff that are inappropriate in a health care setting. The question largely boils down to the doctor’s confidence in his or her ability to train staff on the proper conduct of patient interactions in the optical shop. The office staff should be trained to educate patients about every option that can benefit the patient based on their needs, medical and visual health history. Staff must also understand that they must never under any circumstances place pressure on patients to purchase unwanted products. A good way to illustrate this principle is to explain that advice regarding the benefits of particular products should be particular to the patient and given without any consideration as to where the patient ultimately chooses to purchase products. In this same vein, staff should be trained in the requirements of the Eyeglass Rule and Contact Lens Rule and the importance of strict compliance with those regulations. Finally, staff must be properly overseen to make sure that they are following their training.  

Dr. Point is confident that she can provide such training and oversight and that sales incentives will not lead to inappropriate behaviors by staff.  Dr. Counterpoint feels optical sales should not be tied to an incentive plan. He contends that incentives sometimes are needed but should be based on the overall growth of the practice and not tied to the sale of a given item. This approach is more comfortable for Dr. Counterpoint. However, it does not eliminate the need to train and oversee staff regarding the ethical aspects of patient interactions.  

The American Medical Association Journal of Ethics states, “(a)lthough Physicians have an obligation to consider the needs of broader patient populations within the context of the patient-physician relationship, their first duty must be to the individual patient. This obligation must override considerations of the reimbursement mechanism or specific financial incentives applied to a physician’s clinical practice”. (4) Doctors of optometry maintain similar obligations to their patients and should always ensure that use of financial incentives is distanced from clinical decisions. 

The American Optometric Association’s Standards of Professional Conduct states that, “optometrists have an obligation to conduct themselves with integrity and without conflicts of interest in all of their professional relationships”. (5) It should be added that diligence in the supervision of staff ensures that your practice actually operates at all times according to the high standards you set for it.


Every practitioner who offers eyeglasses, contact lenses and other merchandise should keep in mind these concerns and make financial and marketing management decisions carefully. A broad sales training technique that includes ethical considerations should be considered. If individual staff incentives are employed, then staff training and oversight on appropriate sales practices are even more critical.      
Whenever adopting new strategies for your staff who dispense optical products, it is wise to be clear on the sales-program guidelines and explain what goals you hope to achieve. Form a partnership with your staff thoughtfully, maintain transparency and carefully monitor progress against the pre-defined goals. 

After reading this case, it is hoped that readers have a deepened understanding of the opportunities and risks of partnering with office staff to incentivize sales and are encouraged to create a dialogue to develop the best practices for their organizations.


  1. 16 CFR 456
  2. 16 CFR 315
  3. Klinger, Brian S. “Shared Responsibility in Patient Care.” An Optometrist’s Guide to Clinical Ethics, Edited by Bailey N., and Heitman E. and Published by American Optometric Association, 2000. pp 31-32.   
  4. https://journalofethics.ama-assn.org/article/ama-code-medical-ethics-opinions-physician-businessperson/2013-02
  5. https://www.aoa.org/documents/about/Standards-of-Professional-Conduct_Adopted-June-2011.pdf

About the Authors:

Dr. Verma is a member of the AOA Ethics and Values Committee and is an Associate Professor at Pennsylvania College of Optometry/Salus University. Dr. Verma was awarded the Life Fellowship Award from the American Academy of Optometry in 2014. Dr. Verma was named AOA Optometrist of the Year in 1998 and was awarded O.D. of the year by the Pennsylvania Optometric Association in 1986 and 1997. He was awarded the Dr. Jerry Davidoff Memorial Award from the Pennsylvania Optometric Association in 2015. Dr. Verma has a life membership in the American Optometric Association.

Dr. Hawthorne works at Community Eye Center Optometry and since 2011 has maintained her certification as a Diplomate of the American Board of Optometry. Dr. Hawthorne was one of only five optometrists awarded Young O.D. of the Year by the California Optometric Association in 2000.