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Practical Office Ethics
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Introduction

Medical Ethics is subjective. Even the definition itself, "a system of moral principles that apply values and judgments to the practice of medicine" may result in multiple interpretations because morals and values vary so significantly between cultures and religions. For example, polygamy is generally frowned upon except for Mormons, who believe that having multiple wives constitutes a religious duty.

Because the spectrum of what is and what is not moral is so vast and ambiguous, chances are there are practices that each of us are doing that may not be medically ethical according to some. Thankfully, in order to have a license in this country to practice acupuncture, there are professional ethical standards that we are obliged to follow in order to practice in good standing. These governing bodies, like NCCAOM and the California Acupuncture Board, set these standards which we will discuss in the pages to follow.

Although we have these standards of practice (CAB) and Code of Ethics (NCCAOM) to guide us, they do not come close to covering all the intricacies of our practices and the issues that may arise. This course is designed to give you medical ethical parameters so that you will be able to create the ethical principle that defines your practice and then challenge you to live up to the code. It will give real examples of lawsuits against health care practitioners and ask you to identify what steps they missed a long the way to get them into their conundrum.


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Ethics, Morals, and the Law

Definitions
Ethics is derived from the Greek word ethikos, meaning displaying moral character. Morals are defined as a personal code of conduct. One's morals may be influenced by many factors including family, religion, or society. Professional ethics are standards of conduct held in place by licensing boards or certification entities. They provide mandatory guidance for members of a profession. Medical ethics, therefore, are outlines of personal code of conduct to be applied within one's medical practice.


Legal duties are laws that every citizen must obey. Violation of these laws result in fines or even jail.

Exercise 1.

Of the following scenarios, please identify which ones are violations of moral, medical ethical, or legal duties? Take a moment to think about your answer(s).
a. Not stopping for a stop sign
b. Cheating on spouse
c. Telling non-medical personnel the name and condition of your patient
d. Treating a blind person who was blind from birth who wants to start seeing
e. Billing for services you did not perform


Answers: a. Legal b. Moral/Legal c. Medical Ethical/Legal d. Medical Ethical e. Medical Ethical/Legal

Explanation: With the exception of the first and last scenario (a. and e.) the rest are actually subjective. Answers were given but there could be dissent. For example, would cheating on a spouse be a moral violation if the marriage was considered an open marriage? Or, could treating a blind person who wants to start seeing be justifiable if the practitioner truly believed they could cure that person?

Exercise 2.

A practitioner has an affair with a patient who is a minor. What moral, legal or medical ethical duties are violated?

Answer: Medical ethical and legal.
Explanation: Having an affair with a minor is illegal, regardless of whether or not they are a patient. However, certain acupuncture regulatory boards do not permit practitioners having an affair with any patient (regardless of age), so this would be a professional ethical violation as well. In addition, some people may find having an affair with a patient who is a minor a moral violation, while some others do not. (If, for example, the patient is 18 and the practitioner is 21.) The most important question, is what do you think?

As you can see, there are situations where multiple ethical principles are violated yet there may be disagreement as to which because we each have a unique moral compass.

Are you taking this course for NCCAOM credit? If so, please follow this link to your first worksheet question.








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Ethics, Morals and the Law continued

Example 3.

A practitioner goes to work sick knowing he has a contagious upper respiratory infection. What moral, medical ethical, or legal violations are occurring? Take a second to think about your response.

Answer: None.

To some this is considered a medical ethical violation, as a patient comes to treatment to heal from illness, not to be infected with illness. Furthermore, some may feel this is a moral violation as the incentive to work would be motivated financially and not in the best interest of the patient.

On the other hand, there are certainly highly moral people who pride themselves on never missing work, no matter how crummy they feel. They feel that the real medical ethical violation is to not fulfill their obligation to be there at the appointed time, putting their well being last.

Lastly, it is not illegal (although may be frowned upon) to come to work sick.

Example 4.

Charging Patient A less for the same supplement as Patient B. What medical ethical, legal or moral violations are taking place here? Take a second to think about your answer.

Answer: None.

This is a hotly debated topic. I gave this lecture at a doctor's office and I was surprised when the doctor did not find any moral or ethical violation in selling the same supplement for a different price depending on the patient. My moral compass says this is wrong, and it felt illegal as well (which it is not, by the way). He, on the other hand, likened this practice to having a sliding scale. Some of us regularly charge people different amounts for acupuncture services depending on whether or not they pay cash, if they are in financial hardship, etc. He pointed out that charging people a different price for the same supplement is the same as charging people a different amount for the same (or similar) treatment, like in an acupuncture sliding scale. I had to concede that there really isn't any difference. Ultimately, what do you think? (Email me to share: info@grasshoppereducation.com).

You may be starting to feel as if the entire subject of medical ethics is open for interpretation. How, then, do we as practitioners navigate these sticky waters?

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Principles of Biomedical Ethics

Most people still refer to this book as the bible of medical ethics. Originally released in 1978, the book is now in it's 7th edition and was written by Tom Beauchamp and James Childress. They define four main ethical principles in the practice of medicine.

The first guiding ethical principle is Respect to Autonomy. Autonomy means self-governing. In terms of medical ethics, this means that a patient has a right to refuse their treatment. The statement "I'm the boss of me" is a synonym for autonomy. For example, the following statements use Respect for Autonomy as the guiding ethical principle:

"If they don't agree with chemotherapy, they should not have to do chemotherapy."

"If they don't want to get a vaccine, they should not be forced to get the vaccine."

Historically the tradition within our healthcare system has been paternalistic. You did not question the doctor. If the doctor said you should vaccinate your kids, you did. For a multitude of reasons, the paternalistic nature of medicine has changed, perhaps due to WebMD and other internet outlets that provide patients with more information about their bodies and their diagnosis.

Many diseases are characterized by a loss of autonomy, like someone in a coma. How does the idea of patient autonomy conflict with someone who, for example, is suicidal? Can you think of another disease where a patient may lose his or her autonomy?

Principle #2: Beneficence

This means the practitioner takes actions that serve the best interests of patients. Inherently this can be problematic, because it assumes that the doctor knows what is in the best interest of the patient. He or she may have unconscious biases or religious beliefs which influence their decisions. Furthermore, a practitioner can always claim in their defense they were doing what they thought was the best thing for their patient at that time, which has very little recourse.

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The Principles of Biomedical Ethics, cont.

Non-malifecence is the third ethical principle.

This may seem like the flip side of the beneficence coin, but if you take a closer look that is not the case. Many consider non-malifecence the most important consideration; it is more important not to harm your patient than to do them good. The statement "The treatment was a success, but the patient died" exemplifies a violation of non-malificence.

Medical mistakes, like amputating the wrong leg, is another example of violating non-maleficence. Pharmaceutical drug prescription leading to abuse is yet another.

In regards to acupuncture, which has very little risks when compared to surgery or pharmaceutical drugs, the guiding principle of non-malifecence seems to fit well. It is very hard to hurt someone with acupuncture. Even if the chief complaint was not resolved in the acupuncture session, there are usually other positive changes that occur. When it comes to Chinese herbal medicine, the line becomes more blurred. Historically people have died from taking Chinese herbal medicine.

Are you taking this course for NCCAOM credit? If so, please follow this link to your second worksheet question.

The last ethical principle explored in this book is justice as it regards to health care. Justice asks the question: Who is entitled to health care? This idea challenges the notion that health care should not only be available to the rich. Socialized medicine implies an idea of justice in medicine. In their model everyone gets health care for free with everyone paying in. Health care becomes a right and not a privilege.

In your office, how do you see the concept of justice (or injustice) in health care in action? Some might say that only the patients who can afford acupuncture are wealthy, and thus their practice tends to be skewed towards treating only a middle to upper class cohort. Others might practice in acupuncture community clinics, where the sliding scale may allow justice to prevail in acupuncture health care.

Now that you have learned these four ethical principles, which one(s) aligns the most with your values?

Are you taking this course for NCCAOM credit? If so, please follow this link to your third worksheet question.


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Informed Consent

Let's move on to another ethical principle that may seem more like a requirement for our malpractice carriers than an ethical principle: Informed consent. Informed consent means a person must be fully informed and understand the potential benefits and risks of their choice of treatment. An uninformed person is at risk of mistakenly making a choice not reflective of his or her values or wishes. It does not specifically mean the process of obtaining consent.

In other words, obtaining consent, which means for most of us getting a signature at the bottom of a form, is not enough. It is incumbent upon the practitioner to make sure that the patient understand the risks of acupuncture. This means that we must tell them specifically (this list is not complete):

- Acupuncture may give you a bruise

-Acupuncture may cause a pneumothorax

-Acupuncture may puncture an organ

-Acupuncture might hit a superficial nerve and cause an electric-type pain upon insertion

-Acupuncture might make you sore in the area you were needled

How often do you tell your patient these risks before you needle them? If your answer is never, then technically they are not fully informed even if they signed the consent form.

This is because most patients do not read the entire document before signing it. Unfortunately even if they did read it, they could claim that they did not understand it. That is why it is crucial for you to make eye contact and make sure they know that although the risks are incredibly rare, they do exist. Next, get verbal and written confirmation that they understand.

Lastly, consider creating consent forms in multiple languages to give people the opportunity to read the form in their native tongue. Google translate is an excellent and easy resource for you to create consent forms in many languages.

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Confidentiality

The notion of confidentiality is applied to both treatments and conversations between doctors and patients. Legally, physicians are not allowed to reveal their discussions with patients even under oath in court. This is known also as patient-physician privilege.

As an acupuncturist running a clinic with staff, this concept of patient-physician confidentiality must also be upheld with the office staff you employ. Staff are not required to know the conditions for which your patients are being seen. However this is breached often, sometimes due to patient omission or staff having access to patient charts. If the office member divulged personal health information about one of your patients, you are responsible.

Many doctors do not train their staff on their medical ethical guidelines and assume they will keep information confidential about their patients. Never assume this. Make sure all office staff adhere to this strict policy of patient confidentiality.

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Conflicts of Interest
Conflicts of interest are the number one way well-intentioned practitioners get into trouble with medical and professional ethics.


Referral relationships
If a doctor is frequently referring patients to you, your unconscious bias might be to refer patients to her as well. Instead of acting in the best service to the patient, you could inadvertently be doing her a favor by sending her your patients. This can also manifest as giving discounts or appointment preferences to the patients of referring doctors.


At the clinic where I work, a doctor's office brought us lunch one day. How do you think the free lunch will influence referral patterns to this doctor?

Vendor relationships
Studies show that doctors can be influenced by drug company inducements like gifts and food. Studies also show that industry-sponsored continuing education programs influence prescribing patterns regarding Western medicine (continuing education is often sponsored by drug companies for doctors).


Do you know of any vendors of Chinese medicine products that offer "freebies" or other deals if you use their products? Do you think freebies influence your prescribing patterns or who you choose for vendors?

Treatment of family members or friends
Treating family or friends can be seamless or can be disasterous. The most common concerns with treating friends or family have to do with standard of care and payment. Perhaps you would charge your friend or family member less, or nothing at all. If nothing, do you think you would give them the same level of care you would to a paying patient? Would you still practice clean needle technique if you were treating a friend or family member on the couch at home? Would you remember to wash your hands and put your biohazard box in a secure location?

If you are taking this course for NCCAOM PDA's, please click here to be directed to the last worksheet question.
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Sexual relations
Both the California Acupuncture Board and the NCCAOM prohibit having sexual relations with a patient. According to NCCAOM dating a former patient is okay, as long as it has been six months since the treatments have terminated.

Complacency
Acupuncturists have a high level of integrity both personally and in their practice. I suspect medical ethical violations done by L.Ac.'s are very rare. The area I do see acupuncturists becoming susceptible to violations of medical ethics (and this is all health care providers, really), is complacency. When I say complacency, I really mean laziness. In particular:

- How many of us are brush scrubbing their hands before every patient, much less washing their hands before every patient?

-How many of us are keeping our patient's charts under lock and key?

-How many of us are taking the time to explain the risks of acupuncture before every single treatment?

-How many of us are changing the sheets in between patients or at the very least changing pillow cases? (Lice is easily spread, and contaminated pillow cases is a sure fire way to spread lice).

-How many of us check the treatment room after every patient to make sure there are no rogue needles that someone could step on?

Plenty of people make mistakes at work, but unfortunately for us mistakes can be considered medical ethical violations. Are there any areas that you may have been complacent about that you could improve upon?

Ignorance

Another area in which acupuncturists make mistakes is by simply not knowing the Standards of Practice (CAB) or the Code of Ethics (NCCAOM). By the end of this course, you should no longer be ignorant.

Your Turn

Now that you have learned the four principals of biomedical ethics, informed consent procedures, confidentiality procedures, and the various conflicts of interest that can get in the way, please take a moment and define which guiding principle(s) that resonate the most with you. Use that principle like a mantra, and set that intention every day in your practice. For example, if justice is what resonates the most with you, commit to treating all people who need your care even if they can not afford treatment. Or if doing no harm (non-malificence) is what you feel is the most important, keep that top of mind when choosing herbs, points or additional therapies.

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CASE STUDY 1

The following case history is about a physician who does prolotherapy in Santa Barbara, Ca. He is under investigation for spreading Hepatitis C among his patients. He is still under investigation. However, I thought this was an excellent and interesting study on medical ethics, especially since the case may have to do with infected needles.

"Dr. Thomashefsky Investigation Update
updated: Apr 27, 2015, 2:15 PM
Update: Results of Testing for Bloodborne Virus Exposure as Recommended by the Health Department

Source: Public Health Department
The Santa Barbara County Public Health Department is continuing an investigation of Dr. Allen Thomashefsky's medical office, and is recommending that former patients get tested for Hepatitis B, Hepatitis C and HIV. The Health Department has received and analyzed information associated with the laboratory test results of former patients. As of April 26, 2015, a total of 240 tests have now been reported with the following cumulative results:
- 1 patient tested positive for Hepatitis B and has been determined to be a prior, existing infection
- 6 patients have tested positive or are currently infected with Hepatitis

Of these 6 patients:
- 5 of these are believed to be a new, or acute, diagnosis of Hepatitis
- 1 is believed to be a prior, or chronic, infection of Hepatitis C

- 0 patients have tested positive for HIV
- 233 patients are negative or not infected with Hepatitis B and C, or HIV


As part of the investigation, the Health Department looks for possible causes and for any common characteristics among these cases. Four (4) patients testing positive for Hepatitis C had injection procedures performed by Dr. Thomashefsky on the same day. There were no other commonly identified elements between these 4 patients; and 3 of the 4 patients had no other known risk factors for Hepatitis C. An important part of the ongoing investigation will be further molecular genetic testing performed by the Centers for Disease Control and Prevention. This advanced testing can help determine if the hepatitis C virus found in these infected patients share common genetic pieces and therefore are likely to come from the same source.


In November 2014, the Santa Barbara County Public Health Department was notified of a new case of hepatitis C in a person with no previous risk factors. An immediate investigation revealed that this person had undergone a procedure involving multiple injections at Dr. Thomashefsky's medical office in Santa Barbara County. Two prompt inspections of this clinic (one announced, the other unannounced) revealed multiple infection control breaches, which led to closure of Dr. Thomashefsky's medical office on March 19, 2015.


The infection control breaches witnessed at the office of Dr Thomashefsky have the potential to expose patients to bloodborne viruses including hepatitis B, hepatitis C, and HIV. The new findings released today bring new urgency to the Health Department's recommendation that any patients of Dr. Thomasfekshy get tested for hepatitis B, hepatitis C and HIV. People infected with hepatitis C often have no symptoms. Testing is the only way to know if a person is infected."


Using the idea of autonomy, beneficence, non-malificence, justice, informed consent, patient confidentiality, conflicts of interest, and complacency, explain in medical ethical terms how, if convicted, this doctor violated medial ethics. What unsafe medical practices did he exemplify? Could this have happened in an acupuncturist office? If so, why?

https://www.edhat.com/site/tidbit.cfm?nid=151884
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CASE STUDY 2

The next case study is regarding a physician who had an affair with a patient. I used this case study because I believe this happens all the time without any real legal action. In this case, however, the doctor's license was revoked. The following is taken directly from http://www.nj.com/politics/index.ssf/2014/06/nj_ph....

"The state has revoked the license of a former neurologist at the world famous Kessler Institute who was accused of engaging in a sexual relationship with a 33-year-old woman he was treating for recurring seizures.

In a decision reached Wednesday, the state Board of Medical Examiners said Jonathan Fellus, of Glen Ridge, must transfer his patients to other doctors within 30 days and pay a $10,000 fine as well as $34,450 in court costs, according to Neil Buccino, a spokesman for the state Department of Consumer Affairs.

Buccino said the board determined that Fellus could reapply for his license in three years.

Fellus was director of the brain injury program at an unidentified "institutional rehabilitation center facility in West Orange" at the time of the affair in 2008 and 2009, according to the complaint the Attorney General's Office filed with the medical board in March.

In an earlier interview with The Star-Ledger and according to various online references, Fellus was described as being employed by the Kessler Institute for Rehabilitation in West Orange during that period.

Doctors are barred from having sexual relationships with their patients, "even if the patient solicited or consented to sexual contact," according to the complaint.

According to testimony cited in the complaint, during Fellus' first evaluation of the woman, the victim of a traffic accident, on August 2008, she asked if the office was open on weekends. Fellus smiled and replied with a question, "Are you asking me on a date?" She said no, and he appeared "annoyed," causing her to worry "that he might refuse to take care of her." She emailed him later saying she "wouldn't mind if you asked me out."

During her next visit in September 2008, the complaint said he massaged and kissed her neck. The affair began - with trysts at his home while his wife was away, and at the Kessler facility, according to the complaint.

The patient "continued to have seizure episodes" and on November 28, 2008, informed (Fellus) of a severe episode she had had days earlier. They met at the facility that day and in an examining room "engaged in sexual contact by hugging and kissing."

The last time they met, in March 2009, she came to him for treatment for recurring seizures and "collapses," the complaint said. "But instead . . . he requested she perform a sex act with him and she did so."

The patient later sued Fellus, who resigned in February 2011 after Kessler officials saw his written responses to a lawsuit, according to the complaint.

Fellus currently operates a private practice, Advanced NeuroCare in Flanders, and is the chief medical officer for the International Brain Research Foundation, an independent nonprofit organization that supports experimental research.

The doctor did not return a call to his home seeking comment, and his attorney, Joseph Gorrell, could not be reached."

In this case, the relationship was consensual. However he was still sued as all sexual relations are illegal between doctors and patients. What are you thoughts on this?


http://www.nj.com/politics/index.ssf/2014/06/nj_ph...

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Acupuncture Ethics

To obtain an acupuncture license in California, the following are professional ethical guidelines as listed in the California Acupuncture Board's website. Please read the following, and make note of any you are not adhering to (even if you are not licensed in California).

"Condition of Office
(a) Every acupuncture office shall be maintained in a clean and sanitary condition at all times, and shall have a readily accessible bathroom facility in accordance with Title 24, Part 2, Building Standards Code Sections 494A.1 and 1994 Uniform Building Code Section 2902.3.

1399.451. Treatment Procedures.
(a) The acupuncturist's hands shall be brush-scrubbed with soap and warm water immediately before examining patients or handling acupuncture needles and other instruments, and between patients.
(b) All instruments shall be sterilized before and between uses in a manner which will destroy all microorganisms. All needle trays which contain sterile needles shall also be sterile. Each time instruments are sterilized, the acupuncturist shall use a tape or strip indicator which shows that sterilization is complete.
(c) Acupuncture points, where needles are to be inserted, shall be cleaned with an appropriate antiseptic before insertion of the needle.
(d) In the event an acupuncture needle inserted in a patient breaks subcutaneously, the treating acupuncturist shall immediately consult a physician. An acupuncturist shall not sever or penetrate the tissues in order to excise such a needle.
(e) Any complication, including but not limited to, hematoma, peritonitis or pneumothorax arising out of acupuncture treatment shall be referred immediately to a physician or dentist or podiatrist, if appropriate, if immediate medical treatment is required.
(f) Acupuncture shall not be performed using hypodermic needles.
(g )All instruments to be discarded shall be disposed of safely.
(h) Needles shall be disposed of by placing them in a sealed, unbreakable container marked "Hazardous Waste" and disposed of in accordance with state and local law.

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Acupuncture Ethics Continued

Treatments outside the Office
(a) Any acupuncturist who provides acupuncture treatment outside the office shall carry the required sterile needles and other instruments in a sterile airtight container.
(b) All standards of practice applicable to treatment outside the office shall be adhered to by the acupuncturist providing such treatment.

Record keeping
An acupuncturist shall keep complete and accurate records on each patient who is given acupuncture treatment, including but not limited to, treatments given and progress made as a result of the acupuncture treatments.

Single Use Needles
An acupuncturist shall use needles labeled for single use only that meet the requirements of federal regulations 21 CFR Part 880.5580 (61 FR 64617, December 6, 1996). It shall constitute unprofessional conduct for an acupuncturist to use a needle more than once.
Advertising
(a) A licensed acupuncturist may advertise the provision of any acupuncture services authorized to be provided by such licensure in a manner authorized by Section 651 of the code so long as such advertising does not promote the excessive or unnecessary use of such services.
(b) It is improper advertising as provided in Section 4955 of the code to disseminate any advertising which represents in any manner that the acupuncturist can cure any type of disease, condition or symptom.
(c) It is improper advertising as provided in Section 4955 of the code to disseminate any advertising of a practice, technique or procedure which is not within the scope of the practice of acupuncture as defined in Section 4927 and 4937 of the code and which is the unlawful practice of medicine.

Use of the title "Doctor"
It is unprofessional conduct for an acupuncturist to use the title "Doctor" or the abbreviation "Dr." in connection with the practice of acupuncture unless he or she possesses a license or certificate which authorizes such use or possesses an earned doctorate degree from an accredited, approved or authorized educational institution as set forth under Article 4 (commencing with section 94760) of Chapter 7 of Part 59 which is in acupuncture, Oriental medicine, a biological science, or is otherwise related to the authorized practice of an acupuncturist as set forth in Sections 4927 and 4937 of the Code.
The use of the title "Doctor" or the abbreviation "Dr." by an acupuncturist as authorized above without further indicating the type of license, certificate or degree which authorizes such use, constitutes unprofessional conduct."


After reading the Standards of Practice, are there any mandates you may not be adhering to? Common errors include failure to brush scrub their hands (although they do wash them), or sterilize needle trays in between patients.

Another point of confusion is the title "Doctor". Unless the individual has earned a PhD in Chinese medicine in an accredited California institution, it is illegal to print on business cards or refer to oneself as a doctor if they are practicing in California. Even if the individual has a doctorate in Chinese medicine from another country like China or Japan, it is still illegal under the California's Standards of Practice to call themselves "Doctor." However, there are still L.Ac.'s who are using this title without the aforementioned credentials.

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NCCAOM Code of Ethics

NCCAOM does not have Standards of Practice like the California Acupuncture Board. Instead they have a Code of Ethics. It says on their website:

"All applicants and Diplomates must always abide by the NCCAOM Code of Ethics. Penalties for violations of the Code of Ethics may include denial of certification, probation, suspension, or revocation of certification. Disciplinary action is taken for various offenses, including cheating, boundary violations, fraud, non-license activity such as negligence and criminal conviction."

If you are NCCAOM certified you are required to abide by their Code of Ethics. This is provided on their website or you can access a printable version here. Take a moment to read through their Code of Ethics, even if you are not NCCAOM certified.

I encourage you to print a copy and frame it in your office. This demonstrates to your patients and staff that your practice has a set of outlined medical ethical principles that you adhere to.

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Conclusion

Medical ethics is not cut and dry, black or white, or any other cliche dichotomy. Applying ethics - which are personal codes of conduct - within a business setting (replete with its own expected behaviors) can be problematic. Thankfully we have NCCAOM's Codes of Conduct and California Acupuncture Board's Standards of Practice to follow. Following these guidelines is crucial because it maintains integrity in our profession which benefits us personally and collectively. Treat each and every patient by the guiding medical ethical principle you set for yourself, and watch your practice soar.

 

 
 
 
 
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