Ethical decision making

Throughout the year, the CCOA will present an ethical or conduct scenario. The guidance provided on how to respond to these scenarios are meant to help build knowledge, competence and confidence in handling these types of ethical or conduct situations in your practice. The scenarios described do not represent specific conduct or ethical challenges of regulated members; however, they are situations that could occur. 

Upon reviewing each scenario, consider this question: what would you do to handle the situation?


Scenario – Personal Accountability

A patient who was involved in a motor vehicle collision has been coming to see you over the past month. Their symptoms included back pain, neck pain and left arm pain.

After two-three treatments, you feel like you have built a good rapport with the patient. At the end of a treatment, you call them “kiddo” and tap them on the nose before leaving the room.

You are surprised to hear from the College a week later informing you that the patient has submitted a complaint against you for unprofessional conduct. The Complaints Director has asked you to provide a response in writing.

In your letter of response, you (a regulated member) state:

“… a clinical visit need not be a stale or socially vacant experience. The optimal atmosphere is generally a balance of clinical professionalism blended with a courteous and friendly tone. The gesture of an innocuous light tap is not uncommonly used by individuals to denote the end of a session. This might occur on the arm, shoulder, back or as in this instance, a light tap on the forehead or nose. This was such an innocent gesture and was certainly not intended to create discomfort. Likewise, the use of the term “kiddo” is a term of endearment like “friend” or other similar reference. I would never expect a patient to find objection to the use of such innocuous expressions that have wide-spread use in a variety of circumstances. I’m sorry they perceived my communication as inappropriate or unprofessional. I will exercise heightened vigilance in monitoring my exchanges with all patients but particularly with those who may be of a more sensitive disposition.”

The Conduct in Question

The conduct in question will focus on the behaviours and decisions of the chiropractor before and after the “nose tap” and “kiddo” comment. There are three primary issues in this regulated member conduct: personal accountability, professional boundaries and informed consent. Personal accountability has the most impact; without it, the regulated member will struggle to maintain professional boundaries and practice appropriate informed consent.

Personal Accountability

In their written response, the regulated member adopts a victim mindset to avoid taking personal accountability for their behaviour. The regulated member writes several examples of why their behaviour is acceptable, completing dismissing the patient’s concerns while stating the patient’s “sensitive disposition” is the issue.

A regulated member is accountable for their actions and choices and must adhere to the Standards of Practice, Code of Ethics and CCOA Directives.

Other Issues

In this scenario, there are issues regarding professional boundaries and informed consent. However, the focus of this scenario is personal accountability.

Advice to the Profession – Ethical Decision Making

Personal Accountability

Personal accountability is an individual taking responsibility for the consequences of their actions and choices. It is essential to a regulated member’s professional conduct performance.

Stephen R. Covey in his book ‘The 7 Habits of Highly Effective People’ describes responsibility as follows:

“Look at the word responsibility— “response-ability”—the ability to choose your response. Highly proactive people recognize that responsibility. They do not blame circumstances, conditions, or conditioning for their behaviour.”

Stephen R. Covey further clarifies that when we make a mistake, the responsible way to address this mistake is very simple:

“The proactive approach to a mistake is to acknowledge it instantly, correct and learn from it.”

Personal Accountability Consideration for Regulated Members of the CCOA

Personal accountability requires contemplation and awareness of our actions and behaviours. These are essential personal and professional skills that help us identify the congruency of our actions to the outcomes and requirements that are established in the Standards of Practice, Code of Ethics and CCOA Directives.

The CCOA does not expect that regulated members are flawless or perfect in all aspects of their professional conduct. The CCOA recognizes that regulated members may, occasionally, or in isolation, make a poor decision or behave poorly. Occasional or isolated errors are not the same as patterns of poor decisions or poor behaviour.

Personal Accountability and Trust

James Clear, in his book "Atomic Habits," emphasizes the importance of accountability in building trust. He states, "When we judge ourselves, we are more likely to follow through on commitments because our brains are wired to avoid the pain of being wrong." This means that when we hold ourselves accountable, we are more likely to stick to our commitments, and as a result, build trust with others.

The combined effort of regulated members to be personally accountable to the Standards of Practice, Code of Ethics and CCOA Directives, establishes, maintains and builds trust with patients, government, stakeholders, other healthcare providers and our peers.

Professional Expectations and Personal Accountability

There is an expectation that regulated members must consistently consider the Standards of Practice, Code of Ethics and CCOA Directives and self-evaluate themselves based on these.

When an error is made, the regulated member needs to personally acknowledge the mistake instantly, correct the mistake and learn from it.

Part of owning our mistakes means that we communicate with all individuals impacted by our decision or behaviour and the resulting error. Disclosure should include what we have learned and our action plan to avoid errors in the future.

The Standards of Practice and Code of Ethics do contain some absolute reporting rules that a regulated member must follow. At times, personal accountability will require self-reporting or reporting of a colleague to the College.

Complaints and Personal Accountability

When the College is addressing poor behaviour and decisions, the focus is to investigate patterns of actions. These patterns are identified with evidence gathered through investigation and inspections. They may be summative or cumulative.  A summative pattern occurs when the evidence identifies multiple behaviours and judgements errors that culminated in an event. A cumulative pattern occurs when there is a repetition of one or more behaviours and judgements over time.

The chance of a regulated member interacting with the Complaints Director under Part IV of the Act increases when a regulated member is not consistent with their personal accountability. The failure of the regulated member to self-reflect, identify and address conduct when it was isolated or occasional, leads to the regulated member normalizing poor decision making and behaviour. This leads to a progressive departure from following the Standards of Practice, Code of Ethics and CCOA Directives. 

The Complaints process may uncover unprofessional conduct when evidence demonstrates a lack of personal accountability Part IV of the Health Professions Act is the tool that the College uses to impose accountability for a regulated member’s failure to be personally accountability.

When a regulated member’s fails to be personally accountable, there are often enhanced accountability measures to remediate behaviour associated with findings of unprofessional conduct, including financial fines or other conditions. The primary outcomes the College pursues are public protection and professional competence.

What Standards and Ethics apply to this scenario

In this scenario, there are multiple Standards of Practice and Codes of Ethics that may apply. The CCOA Guidelines on Professional Boundaries is also available to all regulated members to provide guidance in managing the chiropractor-patient relationship.

CCOA Code of Ethics

2. Nonmaleficence (do no harm)

Chiropractic treatment, in all circumstances and situations, must be expressly intended not to leave the patient in a worse state than if no treatment had been performed.

Article A14: Doctor-patient Boundaries

Due to the inherent inequality of power in the doctor-patient relationship, chiropractors must maintain the clear separation between professional and inappropriate personal relationships.

Standards of Practice

6.1 Professional Boundaries with Patients

Regulated members must always maintain professional boundaries with patients.

Professional boundaries in patient care are physical and emotional limits of the therapeutic relationship between the patient and the regulated member. The regulated member’s responsibility is always to act in the patient’s best interest and to manage the boundaries within the doctor-patient relationship. Additionally, regulated members must recognize that each patient’s boundaries will be unique to their own experiences, including their culture, age, values or experiences of trauma.

Scenario Specific Advice

In this situation, the regulated member could have demonstrated personal accountability with the following response:

“Thank you for bringing this patient experience to my attention. I have reflected on the situation raised in your letter. This situation is difficult for me to consider and recognize that I have made errors in actions and choices.

I tapped the patient on the nose while calling them “kiddo.”

At the time, it seemed so innocuous to me as I have practiced with a preference of maintaining a casual and friendly tone.

I have considered the Standards of Practice, Code of Ethics, CCOA Directives and Communications. My actions are out of touch with the current expectations for the profession.

I am disappointed in my actions and recognize that they had, and may still have, a negative impact on the patient.

I acknowledge that I need to take immediate action to adjust my personal filters relative to the chiropractor-patient relationship. I will enhance my knowledge and skills to align with the current expectations for chiropractor-patient relationships. I think that expanding my knowledge and skills will provide for better decisions and behaviour in my professional relationships as I reset my filters.

If you have other recommendations on how I can improve, please let me know."

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