Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 14 The History of Ethics and Professionalism within Optometry in the United States of America 1898- 2015, Part 1 R. Norman Bailey, MA, OD, MBA, MPH Clinical Professor, Retired University of Houston College of Optometry nbailey@uh.edu ABSTRACT Background: The history surrounding the development of codes of ethics and other official statements of desired professional conduct adopted by the American Optometric Association (AOA) reveals the struggle optometry faced in the United States of America (USA) in establishing itself as a leading primary health care profession. Methods: Information regarding the events and documents reported in this paper were obtained through research of the historical literature and archival material held in The Archives & Museum of Optometry at the American Optometric Association's headquarters at 243 N. Lindbergh Boulevard, St. Louis, MO; through current Association documents; and from discussions with those participating in the drafting of the more recent updates to the Association’s ethical statements; codes, oaths, standards, and resolutions. This writing is an update to an earlier paper by the author, The history of ethics in the American Optometric Association 1898-1994. J Am Optom Assoc 1994; 65:427-444, which was written to celebrate the 50th anniversary of the then current Code of Ethics of the AOA. An additional purpose of this present writing is to help the reader understand, from a historical perspective, some of the driving forces and imperatives for the advancement of optometry’s professional stature. Results: Forces outside as well as within the profession were found to have influenced the drafting and redrafting of the official ethical and professional conduct statements meant to guide the professional behavior of the membership of the AOA. Conclusions: Ethical codes and other statements of desired conduct have been essential to the establishment of the profession of optometry. As optometry has grown and matured as a provider of primary eye and vision care services, so have its ethical emphases. To further understand the ethical and legal challenges for optometry as it worked to establish itself as a reputable profession, it is suggested the reader investigate in more detail the information provided in the references. Any views expressed in this paper are those of the author and do not necessarily reflect the views of the American Optometric Association. Key Words: history, ethics, professionalism, Code of Ethics, The Optometric Oath, Standards of Professional Conduct, Ethics and Values Committee, American Optometric Association mailto:nbailey@uh.edu Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 15 o understand the history of the ethics movement within optometry in the USA requires an understanding of the history of the American Optometric Association itself. Much of the history of the ethics movement surrounds the Association's efforts to establish the professional status of optometry apart from the commercial practices of its roots in the ophthalmic goods industry. These early efforts attempted to control, if not eliminate, the advertising of ophthalmic goods and professional services. Those who practiced in a commercial manner were considered to be practicing unprofessionally and, therefore, unethically. Over the years, however, legislation and court decisions subsequently changed the profession's ability to control these behaviors. These actions, along with other considerations, made a Committee on Ethics, functioning within this somewhat old narrow view of ethics in optometry, no longer an appropriate element within the AOA organizational structure. However, as optometry expanded its scope of practice and assumed a more prominent role in the health care of the nation, there was an interest in bringing a new broader application of ethical principles to the attention of the profession and its practitioners. In 1991 the AOA House of Delegates meeting in Dallas moved to establish a Committee on the Ethics and Values of Optometric Care and Services to address some of these concerns. The committee eventually became known as the Ethics and Values Committee. This committee has been active in updating optometry’s ethical documents and pronouncements, and in promoting these ethical values within the profession. Before launching into more of the history of optometry in the USA and the impact of that history on the development of optometry’s ethical standards and professionalism, let’s consider the professional obligations of any health care profession for insights into optometry’s professional development. Looking at the writing of ethicist, David T. Ozar, PhD in “Professional Obligations and Optometry,” the Foreword of the 2000 AOA publication, An Optometrist’s Guide to Clinical Ethics, we should gain much insight into the background driving optometry to seek recognition as a profession: To begin, it is useful to identify some of the characteristics of professions and professionals that make optometry a profession and an individual optometrist a professional. Among the most important characteristics of professions and professionals are these four: First, each profession possesses a distinctive expertise that consists of both theoretical knowledge and the skills necessary to apply that knowledge in practice. To be accepted as a member of a profession, an individual must master the profession’s expertise to a sufficient degree that he or she can be depended on to routinely apply it correctly without direct supervision. Second, this combination of theoretical knowledge and the skills for applying it is a necessary means to the achievement of some class of important benefits for members of the larger community, in their individual lives or collectively. Third, the acquisition of such expertise ordinarily depends upon extensive theoretical study and training under the direction of persons already a part of the profession. The expertise of a profession is typically exclusive to the T Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 16 members of the profession. Those who are not members are typically unable to make timely and dependable judgments in matters pertaining to the profession’s expertise. And fourth, because members of a profession are recognized by the larger community as possessing expertise and because such expertise is ordinarily exclusive to the members, judgments pertaining to the profession’s expertise are usually made by its members. This fact grants a great amount of autonomy to the professions, as decisions made by their members are ordinarily accepted as authoritative within the larger community. Nonetheless, a community does not automatically accept the authority of an individual’s or group’s judgments about something simply because the person or group had undergone intensive training or is considered expert. Instead, a community might actually be very cautious if it fears that the expert group might use its exclusive expertise solely for the benefit of its members, or even hold the community hostage to their expertise. This risk would be the greatest when, as in the case of most professions, those outside the expert group simply do not have enough understanding of what is at stake to make dependable judgments about it, or to do so quickly enough to take appropriate action. So it is worth asking under what circumstances a society would be acting reasonably to routinely accept the judgments of persons with important, specialized expertise as authoritative. What would justify such a measure of trust of an expert group whose judgments cannot practically be tested because they depend on expertise that others do not have? What sort of social structure could effectively safeguard a community from the potential harms of an expert group’s misuse of its expertise? The answer to this question in the case of the professions is the complex social structure that we call professional obligation or, when it is a characteristic of a profession or an individual professional, professionalism. That is to say, there is a fifth core characteristic of professions and professionals that is, for present purposes, the most important: Professions and professionals have special obligations precisely because they are professionals. Becoming a member of a profession implies acceptance of a set of standards of professional conduct by that person, both in personal commitment and in actual practice. Some people take the view that practicing a profession is no different in principle from selling one’s wares in the marketplace. According to this view, a professional has a product to sell and makes agreements with interested purchasers, and that is all there is to it. Beyond some fundamental obligation not to coerce, cheat, or defraud others, which are the ethics of the marketplace, this view holds that a professional has no other obligations to anyone except those undertaken in voluntary agreements with specific individuals or groups. Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 17 According to this picture, in other words, there is nothing to which a person is obligated precisely because he or she is a professional. But most people in our society and most professionals themselves hold that when a group becomes a profession, or when an individual becomes a member of a profession, they undertake obligations to act and refrain from acting in certain ways. Otherwise, the community and its members would have no good reason to trust the profession and its members to use their exclusive expertise appropriately. Fortunately, our society has extensive positive experience with professional obligation and professionalism. The social structure of the professions has effectively shaped the behavior of professionals so that appropriate conduct is typical and aberrations are relatively rare. Thus the relationship of trust upon which the mutual flourishing of both the professions and the larger community genuinely depends has been maintained. Each profession has expertise that addresses specific aspects of human well-being, either individual or collective; and each profession has distinctive relationships with those whom it serves. In one sense, the content of a professional’s ethical life – what aspects of life the professional takes to be ethically important, and the standards of conduct by which the professional determines how to act, especially when actually engaged in professional practice – is distinctive for each profession.1 HISTORICAL BACKGROUND Throughout its history, the optometric profession in the USA has described its norms of conduct, or professional obligations, by a number of documents, including primarily codes of ethics, standards of conduct, resolutions, and an optometric oath. The need for these documents and for their revisions over time arose as optometry tried to meet its historical challenges, both externally and internally, to fulfill its role as a developing health care profession. Optometry sought to be recognized as a profession by both the public and the other health care professions. It had taken thousands of years from the discovery of glass at about 3000 B.C. for the art and science of optometry to reach a level where the public demand for optometric services in the USA could begin to support individuals in a separate profession. In 1898 these services were provided by opticians. This group of opticians, who prescribed spectacles following an adequate measurement of the ‘power of the eyes,’ was more frequently known as refracting opticians. The term ‘optometry’ was used rather extensively during the 1890s to refer to what the refracting opticians did in practice; however, it was not until 1904 that the term ‘optometrist’ was approved by the American Association of Opticians to refer to those opticians practicing optometry.2 As the following story is read, the “time line” in Figure 1 will assist the reader in following the history of ethics and the development of professionalism in the American Optometric Association. The Need to Organize In order to protect the public from poorly educated and unscrupulous opticians, reputable practitioners in the late 1800s became interested in organizing for the purpose Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 18 of gaining recognition as a profession through legislative regulation and other means. The science and technology of the profession had advanced to the point where, for the protection of the public, only the technically educated should be licensed to practice. Prior to 1901 anyone could practice optometry since there were no state legislative acts regulating this activity. About this time, organized medicine began to see the value of optometric care and the provision of lenses to improve eyesight.3 Even though nonmedical individuals developed the science of optometry, organized medicine began efforts to limit to medical practitioners the right to provide this service. The most dramatic early conflict with medicine came in New York between the refracting optician Charles F. Prentice and oculist H. D. Noyes, who wrote Prentice criticizing him for charging a separate fee for an optometric examination. Subsequently, another New York physician, D. B. St. John Roosa, vowed he would have the Medical Practice Act amended to prevent "men of Prentice's cult from meddling with ophthalmology." This challenge gave additional energy to the movement that led to the organization of the American Association of Opticians. The underlying purpose of this movement was to organize the various states to seek legislation to protect the public from the uneducated and the unscrupulous.3 The first attempt by this fledgling profession to gain control came in a bill introduced in New York in 1896 entitled, "An Act to Regulate the Practice of Optometry." This effort, however, was unsuccessful at the time largely because it also attempted to regulate the practice of optometry by physicians.4 The first state optometry regulatory act was passed in Minnesota in 1901. This legislative action started the process which would see all states and the District of Columbia obtain optometry sponsored regulatory acts by 1924.5 Early Organizational Efforts To assist the movement to establish optometry as a legally recognized profession, the American Association of Opticians was formally organized on October 10, 1898 in New York City. This organization would change its name twice over time and would finally become known as the American Optometric Association. Only six states had independently organized societies prior to the formation of this national organization. The constitution and bylaws of the new organization stated its purpose to be the "advancement of the optical trade in all its branches." This document extended membership to "any person engaged in the manufacture or sale of optical goods . . ."6 The association's charter membership represented 31 states and Canada and included refracting and dispensing opticians as well as manufacturers and suppliers of optical goods.6 The different interests of these membership groups led to many of the early internal struggles out of which a strong profession was to emerge. Dispensing opticians were forced by medicine to take sides against the refracting opticians in the battle for the New York law.6 By the time of the second American Association of Opticians' convention in 1899 in Rochester, New York, it appeared more and more like this was not to be an organization to meet the needs of the dispensing opticians and manufacturers. Disputes between the various factions persisted until membership was limited to the refracting opticians at the 1900 convention in Detroit.7 Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 19 1898-The American Association of Opticians is founded. 1901- Minnesota enacts the first state law defining the practice of optometry. 1904- The Association approves the term ‘optometrist’ for those opticians performing refractions and related services. The national association encourages the organization of state associations, which work to pass optometric legislation. 1908- The first Code of Ethics for the American Association of Opticians is adopted. Thirteen states have passed optometry laws and the national association has grown to 42 states. 1910- The national organization is renamed the American Optical Association. 1919-The national organization is renamed the American Optometric Association (AOA). 1923- A major revision of the Code of Ethics is considered but never adopted. 1935- The AOA adopts a new Code of Ethics. 1937- Reader’s Digest articles, Optometry On Trial, and the AOA response. 1942- Inauguration of the Professional Advancement Program by the Office of Ethics and Economics. 1944- A new version of the Code of Ethics is adopted. 1946- Supplements to the Code of Ethics are adopted. 1950- Rules of Practice are adopted. 1968- Supplements to the Code of Ethics and Rules of Practice are revised. 1970- Supplements to the Code of Ethics are revised. 1976- The Supplements to the Code of Ethics and Rules of Practice are replaced by the Standards of Conduct. 1986- The Optometric Oath is adopted. 1994- The AOA celebrates 50th Anniversary of the adoption of the 1944 Code of Ethics. 1994- The History of Ethics in the American Optometric Association 1898-1994 is published in the June issue of the AOA Journal. 1996- Recommended Curriculum for the Teaching of Professionalism and Ethics in Optometry is distributed. 1999- Standards of Conduct modified. 2000- An Optometrist’s Guide To Clinical Ethics is published by the AOA. 2002- The 1999 Standards of Conduct retired to the Historical Archives. 2005- The 1944 Code of Ethics was minimally modified. 2007- The AOA adopts a new Code of Ethics. 2008- The Ethical Issues in Contact Lens Practice online course was posted to the AOA website. 2011- The Standards of Professional Conduct was adopted by the AOA. 2014-2015- The online Ethics Forum was developed and placed on the AOA website. In 1900 the constitution read in part, Any person engaged in the practice of optometry shall be eligible for active membership . . . Any person of good repute who is a graduate of any reputable optical college or institute, or who has for at least two years practiced as a refracting optician and is recognized as such, shall be eligible to membership in this society. No person shall be deemed or considered a refracting optician who merely deals in spectacles and sells them as any other article of merchandise.8 These constitutional changes were made in spite of the reminder by association President Charles Lembke at the convention's opening speech that the association “has been organized for the purpose of joining together or blending all parties in the optical calling, Figure 1: A Time Line for the History of Ethics and Professionalism in the American Optometric Association Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 20 be they refracting or dispensing opticians, dealers, manufacturers or jobbers. . .”9 Lembke, a dispensing optician, was a strong force during the early years of organizational effort. It was also evident that these diverse membership groups would differ in their commercial and professional interests. A Sense of the Need for Ethical Standards Were there any indications that ethical standards stated in the form of a code of behavior should be a part of this developing association? Obviously, the early concerns for protecting the public from the poorly educated and unscrupulous practitioner indicated a concern for professional and ethical values. In a paper read at the June 1899 New York State Optical Society meeting titled "A Code of Ethics For Opticians," F. L. Swart called for an ethical code to govern the opticians and stated this could best be accomplished through a national body. He was calling for specific ethical rules to govern behaviors related to . . . , advertising, scope of practice, and for controlling the peddler optician.10 The diversity of the membership of the American Association of Opticians would make it difficult to be specific about ethical behavior. However, in an open letter to the membership in 1901, President Andrew Jay Cross stated, "a practical, not too exacting, code of ethics could be adopted.”11 In the March 12, 1902 issue of The Jewelers' Circular- Weekly, George A. Rogers made the keen observation that, . . . the most potent laws governing the conduct of men have never found a place among the statutes. Of this class are the various codes of ethics controlling the practice and the representations of professional men. It is perfectly natural and certainly very important that such codes be generally accepted and adopted. They are laws that are self-made and adopted without a vote, but stronger than statutory enactment. There must soon come to be understood among professional opticians such a code . . . 12 The adoption of a code of ethics would not happen, however, for another seven years. It is worth noting that some state affiliate associations would take official actions regarding educational requirements and codes of ethics before the national organization would formulate official positions.13 THE ADOPTION OF A CODE OF ETHICS In 1908, ten years after the American Association of Opticians was organized, the Committee on Code of Ethics which included A. Jay Cross as chair, John C. Eberhardt, and William E. Huston presented a report in the form of a code of ethics that was unanimously passed at the national convention in Philadelphia.13, 14 It was not apparent in 1908 that the adoption of this first code of ethics for the AOA, and its subsequent revisions over the years, would present an ongoing challenge as the profession worked to define its core values and to refine the standards to which members would be held accountable.15 The 1908 Code of Ethics read as follows, Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 21 Code of Ethics of the American Association of Opticians (adopted 1908) Each member should fully appreciate the responsibilities assumed by him, and endeavor by unceasing study to qualify in the important work of ministering to the visual needs of his fellow men. He should at all times emphasize the fact that optometry is a purely technical profession based on a comprehensive knowledge of the mechanism of the human eye, the skillful manipulation of instruments for its adequate examination, and a knowledge of the properties of light and the relative effect thereon of lenses. He should discourage the use of titles calculated to mislead or cause confusion in the public mind. He should cultivate those sensitivities which permit the formation of standards for the generous appreciation of the work of others and the criticism of his own. His methods of publicity should rigidly adhere to a dignified and modest statement of facts. He should value his services commensurate with his ability, special preparation and skill, always welcoming the opportunity to be generous with his knowledge where the opportunity is needed, thereby realizing in the fullest measure the true success, which lies in the consciousness that the world has profited by his work. 13,14 THE ASSOCIATION UNDERGOES A NAME CHANGE In 1910 the name of the American Association of Opticians was changed to the American Optical Association. Even though many members were now referring to themselves as optometrists, there was still concern for offending those using the optician title by adopting "optometric" in the organizational name. Finally, at the 1919 annual Congress of the American Optical Association in Rochester, Minnesota, the organization's name was changed to the American Optometric Association.16 A FAILED ATTEMPT TO ADOPT A CODE OF ETHICS In 1923 a new Code of Ethics was proposed by the Committee on Code of Ethics chaired by William V. Nicum who had been secretary of the Association between 1918 and 1922. Also serving on this committee were Fay McFadden and Glenn Winslow. The proposed Code contained thirty-six items that spelled out what was considered appropriate ethical behavior by optometric practitioners. The delegates decided to refer the Code to the affiliate associations for study and to be considered for approval by the national body the following year. This code was never adopted by the AOA.17-19 (See Appendix A for this proposed code of ethics) During the development of this unsuccessful Code, William V. Nicum sought input from others. A number of articles appeared in the literature responding to this attempt to formulate a new and timelier Code. An editorial on A National Code of Optometric Ethics published in The Optical Journal and Review of Optometry proposed that a Code of Ethics would encourage membership in the national organization. The individual optometrist would want to be recognized by the public as belonging to a professional organization with high ethical standards. "The enforcement of a stringent code of ethics Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 22 will be the greatest advertisement that the profession can have."20 L. J. Anderson, in a letter to the members of the North Dakota Optometric Association, wrote about the need for a national code of ethics, "As a body of professional men, we are divided. We do not all have the same general views and purposes in mind. There is certainly room for difference of opinion in methods of refraction and individual treatment of cases; but in the big things, vital to the welfare of optometry, we must agree if we are to gain recognition and favor.”21 G. L. Schneider, on the one hand, called for a very simple Code; one which would “. . . be sufficiently acceptable to appear on every piece of association stationery and literature, just as the Golden Rule. . . .”22 On the other hand, others called for specific rules to govern behavior. Bernard Meyer wrote, "An organized profession is a trade organized genuinely for the performance of function, according to rules enforcing certain standards for the better protection of the members of the profession and the better service of the public."23 A 1923 editorial in The Optical Journal and Review of Optometry stated, A code of optometric ethics should not be made up of a repetition of principles of conduct that are equally applicable to the optometrist, the lawyer, the grocer and the bricklayer. The characteristic of a proper optometric code should be that it carries the general principles of ethical conduct into the optometrist's own offices and there applies them to the special kind of activities and service in which he is engaged . . . there is little use in any of our associations adopting a code of ethics, unless they are prepared to purge their membership of violators of such code. 24 Fay McFadden, a member of the 1923 Committee on Code of Ethics, provided to The Optical Journal and Review of Optometry the following comments from a writer, Optometry has two things to offer in its field of service to humanity; the self, the knowledge, the skill, the understanding, upon one side; and the mere merchandise upon the other. It is true that the latter may embrace the dual duty of the optician and the merchandiser; but the former embodies his knowledge, his skill, tact, patience, perseverance, his reverence for himself and his fellow man, his honesty, his very purpose of existence; and all this must be backed by his facilities, by every device which his art, or that of others, have devised for his use in optometric work, always provided that it is a useful device, that it is employed for a useful purpose, and not to parade a knowledge or skill he does not possess; that he shall not make a mere bluffer of himself in order to deceive an unsuspecting patron—which, alas! is too often true. 25 The above statements represent the difficulties this profession has always had in relating to its roots in the dispensing optician business. Historically, there was often tension between those who advocated for a greater focus on professionalism vs. those who focused on the merchandiser role. The development of codes of ethics and other supplementary documents relating to ‘professional’ behavior has in the past faced difficulties because of this tension. Gregg, discussing optometric history, stated, No other profession has ever faced a comparable situation—starting with almost total emphasis on materials and little on service, then trying to gain Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 23 professional stature without complete divorcement from materials; and certainly the materials, lenses and frames are the most tangible commodity with which any health profession deals. . . . The crux of the matter was how to charge the patient. He was accustomed to paying a high price for precious items like gems, gold, glassware, fashionware—and glasses resembled such commodities. He was not used to paying high fees for services alone, or for some numbers written on a piece of paper, or for advice he might not even follow. So glasses were sold, since it was an easy way to charge and in many respects absolutely fair. The public got used to this method, as did the optometrist. . . . So the problems of commercialism, of being labeled a businessman, of ethics, and of proper fee structure in large measure were inherited by optometry because of its very nature.26 Codes of ethics were often seen as a way to control commercialism and to strengthen professionalism. The debate continued in the optometric publications27, 28 and elsewhere. During an address before the American Medical Association in 1928, a prominent ophthalmologist made the point that a major obstacle to consultations between physicians and optometrists was commercialism.29 A NEW DECADE AND A NEW CODE OF ETHICS The 1930s saw state and national organizations making efforts, through litigation and legislation, to limit commercial practice. State governments were increasingly using sales taxes as a source of revenue. Organized optometry argued that they used optical materials in the practice of their profession, were not merchants of eyewear and, therefore, should not be subject to this taxation. The various state governments took different actions on this argument.30 The association was having great difficulty establishing and maintaining its professional status. AOA General Counsel Harold Kohn had encouraged the association to adopt a more meaningful Code of Ethics since that adopted in 1908 by the American Association of Opticians had been all but forgotten.31 In his report to the 1935 AOA Congress, “Counsel Kohn upheld firmly the position that Optometry’s professional service begins when the patient appears in the office and continues all through the examination room and every part of the service until the patient leaves the office – professional all through the procedure.”32 The Resolutions Committee presented a somewhat extensive Code of Ethics to the 1935 AOA House of Delegates (HOD) in Coral Gables, Florida. Many felt this version was too detailed and could present problems for some members. Varied concerns of different factions of optometrists in 1923, when the last attempt had been made to adopt a new code of ethics, seemed to still be present in 1935. The proposed 1923 version that was never adopted had 36 duties and obligations listed, whereas the proposed 1935 version had only 10 listed duties and obligations. The controversy surrounded the attempt at detailed rule making by some in an effort to have all optometric offices look and behave more as professional practices than as shops providing optical goods. (See Appendix B for the 1935 proposed code of ethics) Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 24 A Committee on the Code of Ethics composed of four individuals was appointed by the 1935 House of Delegates to redraft the earlier presented Code of Ethics and to report to the House as soon as possible. Dr. John. J. O'Neil, Chair, of Springfield, Massachusetts, gave the report of the Committee on the redrafted Code of Ethics to the HOD the following day. Dr. O’Neil made the motion for adoption of this Code of Ethics, which was done by unanimous vote.34, 35 It is noted that the adopted version of the 1935 Code of Ethics had seven duties or obligations specified as compared to the ten proposed. Most of those adopted were among the originally proposed, though some skillful rewording no doubt made them more acceptable. The 1935 Code of Ethics read as follows, Code of Ethics (adopted 1935) 1. The optometrist shall keep inviolate all confidences committed to him in his professional relationship with his patient. 2. It shall be the duty of every optometrist to support organized optometry in its efforts to advance and promote the highest ideals of professional service. 3. It shall be an optometrist's duty to refrain from any exaggeration of a patient's condition. 4. It is the duty of every optometrist to keep himself informed as to every development in his profession and to contribute his share to the general knowledge and advancement of the profession by all means within his power. 5. It is the duty of every optometrist to refrain from all criticism reflecting upon the skill of a colleague. 6. All optometrists shall refrain from advertising, except that permitted by the Code of Ethics of his respective state association. 7. It shall be considered unethical for an optometrist to be employed except as an associate of a registered optometrist. 35 The association now had a Code of Ethics it could use to enhance its professional stature. It was offered to the state affiliate associations as a suggestion for their adoption.34,35 (See Appendix C for a listing of the chairmen and members of the AOA ethics committees from 1898-1935.) This same year, there was much unhappiness expressed by some delegates at the annual meeting over the way the officers had represented the AOA in the development of The Code of Fair Competition for the Retail Optical Trade, one of many similar codes developed as part of the National Recovery Act of 1933. They felt being represented in such a code was degrading to the professional image that optometry was working to develop. Yet, the officers had entered into the negotiations with the intent of being there to protect optometry. Many felt this discussion in the House of Delegates was unnecessary since the U.S. Supreme Court had earlier that year found the National Recovery Act of 1933 unconstitutional and this and all similar codes were nullified. While the resolution proposed to criticize the officers and their methods was defeated by the AOA House of Delegates, the impassioned discussion emphasized the need for optometry to increase its efforts to present a more professional image.29,36 Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 25 US SUPREME COURT DECISION HELPS IN STRUGGLE AGAINST COMMERCIALISM A decision of the U.S. Supreme Court in 1935 gave all states legal support in their attempts to control commercialism in the professions. The Court held that a state law prohibiting advertising by dentists was within state powers. This decision gave additional momentum to the state optometric associations' efforts to seek legislation to limit or remove commercialism in the practice of optometry. The opponents in these struggles were those against advertising and those for advertising. Efforts to restrict the advertising of ophthalmic goods would be successful in the majority of states.29 References 1. Ozar DT. Professional Obligations and Optometry. In: Bailey RN, Heitman E, eds. An Optometrist’s Guide to Clinical Ethics. St. Louis: American Optometric Association, 2000:xix-xxviii. Ethics and Values section of the American Optometric Association website: www.aoa.org/about-the-aoa/ethics-and-values/an-optometrists-guide-to- clinical-ethics?sso=y. Accessed November 19, 2015. 2. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:1-2, 26-27. 3. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:3-6. 4. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:7-9. 5. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972: 17,101. 6. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:9-10. 7. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:11-12. 8. Proceedings of the 1900 convention of the American Association of Opticians. Opt J 1900;7(9):803-804. 9. Proceedings of the 1900 convention of the American Association of Opticians. Opt J 1900;7(9):783-785. 10. Swart FL. A code of ethics for opticians. Opt J 1899;6(5):388-391. 11. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:14. 12. Rogers GA. Opticians' code of ethics. Jewelers' Circular-Weekly 1902;XLIV(6):65. 13. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:40. 14. Proceedings of the 1908 convention of the American Association of Opticians. Opt J 1908;22(7):378-379. 15. Gregg JR. The Story of Optometry. New York: The Ronald Press Company, 1965:206-207. 16. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:47,80. 17. Convention committees appointed by President Todd-Reports to be made in Chicago. Opt J Rev 1923;51(18):47. http://www.aoa.org/about-the-aoa/ethics-and-values/an-optometrists-guide-to-clinical-ethics?sso=y http://www.aoa.org/about-the-aoa/ethics-and-values/an-optometrists-guide-to-clinical-ethics?sso=y Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 26 18. Nicum WV. A.O.A.'s committee on code of ethics report submitted at the AOA Convention. Opt J Rev Optom 1923;52(l):64-65. 19. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:96. 20. A national code of optometric ethics. Opt J Rev Optom 1922;50(16):27-28. 21. National code of ethics a great need of the profession. Opt J Rev Optom 1922;50(22):48. 22. Schneider GL. Letter to W. V. Nicum. Opt J Rev Optom 1923;51(19):34. 23. Meyer B. The ethics of the profession. Opt J Rev Optom 1923;51(19):31-33. 24. The real issues in ethics. Opt J Rev Optom 1923;51(22):31-32. 25. McFadden F. Fundamentals in optometric ethics. Opt J Rev Optom 1923;51(22):46- 47. 26. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:116,149-150. 27. Haussmann OG. Ethics-where opinions differ. Opt J Rev Optom 1924;53(25):29-30. 28. Evenson HC. About a code of ethics. Optom Weekly 1927;18(25):889-891. 29. Classé JG. Legal aspects of optometry. Boston: Butterworths, 1989:15. 30. Classé JG. Legal aspects of optometry. Boston: Butterworths, 1989:187. 31. Gregg JR. American Optometric Association: A history. St. Louis: American Optometric Association, 1972:143. 32. Talk and action, Annual Congress of American Optometric Association and Boards of Optometry Examiners. Opt J Rev Optom 1935;72(14):17. 33. Report of the 38th Annual Congress of the American Optometric Association, June 23 to 28, 1935 House of Delegates. The Archives & Museum of Optometry, St. Louis: American Optometric Association, 1935:100-103. 34. Report of the 38th Annual Congress of the American Optometric Association, June 23 to 28, 1935 House of Delegates. The Archives & Museum of Optometry, St. Louis: American Optometric Association, 1935:121-124,139-141. 35. Talk and action, Annual Congress of American Optometric Association and Boards of Optometry Examiners. Opt J Rev Optom 1935;72(14):19,31 36. Report of the 38th Annual Congress of the American Optometric Association, June 23 to 28, 1935 House of Delegates. The Archives & Museum of Optometry, St. Louis: American Optometric Association, 1935:9,142-158. http://www.aoa.org/about-the-aoa/archives-and-museum/support-the-archives-and-museum-of-optometry?sso=y http://www.aoa.org/about-the-aoa/archives-and-museum/support-the-archives-and-museum-of-optometry?sso=y http://www.aoa.org/about-the-aoa/archives-and-museum/support-the-archives-and-museum-of-optometry?sso=y Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 27 Appendix A. Committee on Code of Ethics Report by W.V. Nicum to A.O.A. HOD, Chicago, June 26, 1923* Proposed 1923 Code of Ethics of Optometry (not adopted after one year of study by affiliates) We do agree to these things: 1. Render the public the best service within us and constantly strive to improve that service. 2. Conduct ourselves in a manner becoming to professional men. 3. Aid worthy civic movements, and be considerate of fellow practitioners. 4. To meet and study at frequent intervals with other optometrists to keep abreast of the best practices in optometry; and to aid and consult with fellow practitioners when requested. 5. To make examination of the eyes the paramount feature, not the sale of glasses. 6. To impress upon the public the importance of careful and correct ocular service. 7. To equip our offices with the latest and best instruments. 8. To discontinue the sale of merchandise which has no place in optometry. 9. To limit our publicity to (1) Conservation of vision. (2) Optometrical service. 10. To charge for, and to collect, a reasonable fee for eye examinations. 11. To charge a fee openly, both by verbal statement and upon the bill, not concealing said fee within the cost, thereby giving the patron reason to believe that service is rendered “free.” 12. We consider that optometry may be best presented to the public through organized effort, rather than individual. To this end we will endeavor, at proper times and in proper places, to preach the conservation of vision, and to teach methods whereby this may be obtained. 13. We believe that organized optometry can best be served by group publicity, as also by magazine and newspaper articles in which the author does not seek to present his own personality. 14. We believe that newspaper “card” is the correct way of presenting ourselves in the press in a direct advertising sense. 15. We agree to discontinue the use of handbills, billboard advertising, billposter advertising, large painted signs on buildings, all types of novelties, stickers of all kinds, except inside of cases; blotters, manufacturers’ literature, freely distributed; streetcar advertising, theater program, theater curtain, lantern slides, and signs reading, “Eyes Examined (or tested) Free.” 16. Not to advertise the prices of lenses, frames or supplies. 17. To discontinue window advertising, except in dignified and legitimate manner. 18. To discontinue and remove from refracting rooms, waiting rooms and other public rooms of our business places, signs of manufacturers relating to supplies. Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 28 To discontinue advertising articles of supplies as “better” or in any way superior in quality for the price asked, to that of other optometrists or refractionists. 19. To discontinue publicly advertising business ability as superior to that of others; reliability as superior to that of others; professional ability as superior to that of others. 20. To discontinue methods of practice which are manifestly “unfair” by those recognized practices of the public within which we dwell. 21. Where others who are doing refracting work are unethical and resort to unfair and unethical means, we are not to retaliate in kind until we have sought by all reasonable means to win them from errant methods, to interview them personally, or by letter, or by friends, or by judicious printed matter, publicly proclaimed, and in terms which will in no way lower our own dignity, seeking thereby to elevate their on standard of procedure and win them to our side by justice. 22. When others practice optometry and they are manifestly unqualified for the work, we are to seek them personally, by letter and by other just means, seeking to elevate their moral tone, their educational status, their equipment, or their other deficiencies, endeavoring to bring them to a higher and proper level. When other means have failed, we should bring them to the attention of higher authority. 23. When there is a difference of opinion with respect to ethical and non-ethical practices, customs or behavior, we should seek to bring about a meeting of all those engaged in optometry and have a dignified discussion, endeavoring to establish rules of practice. 24. It is unprofessional and prohibited to split fees, pay bonuses or offer, or to receive, any pecuniary benefits from others who may at various times refer patrons 25. It is unprofessional and prohibited to enter into mail-order advertising or eye- glass service. 26. It is unprofessional to seek out patrons by bribes, rebates, discounts or other profit-sharing means, through friends, relatives, or patrons. 27. It is unprofessional to seek patronage by solicitous means, personal or through others. 28. It is unprofessional and unethical to promise cures, relief or benefit from lenses, or from treatment, or by other means than that one will do as well as lies within his power to correct and neutralize the errors of refractions and muscular anomalies with the hope but not with the assurance of benefit or relief. 29. It is unprofessional and unethical to undertake practices under a name of a company or organization in which the principal member or members of the organization are not actively engaged in the actual practice of refraction. 30. It is unprofessional to conduct an optometric practice in which the name or names of the principal men are not named publicly in their printed matter upon door-plates, and other similar announcements. Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 29 31. It is unprofessional and unethical to travel from town to town, putting up in hotels and houses and doing refraction work without proper equipment and lighting facilities. 32. It is unprofessional and unethical to use low-grade lenses or lenses of a pattern which are not as properly designed and adapted to the correction of the errors of vision as are possible to obtain, basing the price of service and such supplies upon their cheapness, unless it is patent that the patron cannot afford to purchase the higher grade and perfected lenses, and in all such cases the factors should be carefully explained. 33. It is unprofessional for an optometrist who holds an office in any optometric association to use such position for advertising purposes. 34. It is unprofessional and unethical for an optometrist to make use of his diplomas and certificates in such a way as to be considered advertisements. 35. No member should advertise in a way which would lead to the supposition that he had a medical training unless he has such training. But it is not unethical to permit himself to be styled “doctor” by his patrons. 36. It is unethical and forbidden to keep open office or place of business on national holidays, State holidays, or Sundays. This refers to the regular manner of “keeping open” but not to responding to an emergency for a particular case. For the purpose of active membership in the American Optometric Association, having read the Code of Ethics and being agreeable to its provisions, I herewith subscribe to the same. Signed………………………. Date…………………………. *Nicum WV. A.O.A.'s committee on code of ethics report submitted at the AOA Convention. Opt J Rev Optom 1923;52(l):64-65. Appendix B. Initially Proposed Code of Ethics by the Resolutions Committee to the 1935 House of Delegates* (This proposed Code of Ethics was tabled and a redrafted version, by an appointed Committee on Code of Ethics, was presented to the House of Delegates (HOD) the following day and adopted. The initial version is provided here for comparison purposes to the version finally adopted by the 1935 HOD.) Resolution No. 1 “WHEREAS, the A.O.A. up to the present has not adopted an official Code of Ethics; and “WHEREAS, such a Code of Ethics is essentially necessary for public enlightenment regarding the ideals, aims and conduct of the individual Optometrist; NOW THEREFORE BE IT “RESOLVED, that said Code of Ethics be placed in the hands of each affiliated Association, urging its adoption as a part of the individual Association’s Constitution and By-Laws and Code of Ethics; and BE IT FURTHER Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 30 “RESOLVED, that this code of ethics shall be mandatory on such members as are admitted from territories in which there is no organization affiliated with the American Optometric Association. CODE OF ETHICS of the AMERICAN OPTOMETRIC ASSOCIATION “The Golden Rule Represents the vital principle of all ethical codes and the purpose of this Code of Optometric Ethics is to indicate and interpret the application of this rule to the practice of our profession. As such, we recommend it to all who are truly interested in the profession of Optometry: (1) It is the duty of every Optometrist to advance the interest of Optometry and to support the state association in all its work for the progress and recognition of the profession. (2) It is the duty of every Optometrist to keep himself informed with, and in touch with every modern development in his profession, to increase his knowledge and efficiency by the adoption of modern methods of proved worth, and to contribute his share to general knowledge and advancement of the profession by all means in his power. (3) It is the duty of every Optometrist to respect the confidence placed in him by a patient bringing his case to him, and all information received from him shall be treated as a “privileged communication”, and as such held sacred. (4) It is the duty of every Optometrist to refrain from an exaggeration of a patient’s visual defects. It is the duty of every Optometrist to properly advise his patient of any apparent or suspected pathologic condition coming to his notice that should have medical or other care outside the field of Optometry. (5) It is the duty of every Optometrist t to refrain from all forms of specific guarantees. (6) It is the duty of every Optometrist to refrain from all criticism that is calculated to, or would have the effect of reflecting upon the professional skill or integrity of a brother Optometrist. (7) It is the duty of every Optometrist to represent himself to the public in his legal capacity as that of an Optometrist. (8) It is the duty of every Optometrist to refrain from, and no Optometrist will, under any circumstances, canvas or solicit business from house to house, from town to town, from person to person, or solicit business in any street of public place, and no Optometrist shall transact business as such in a place other than in a regular place of business or permit any person to do so in his interest or his behalf. Nothing in this rule shall be construed or have the effect of preventing the establishment and maintenance of branch offices, properly equipped, by an Optometrist in his community. This rule shall not operate to prevent an Optometrist from making calls upon request. Hindsight: Journal of Optometry History, Volume 47, Number 1 Bailey: History of Ethics 2016| Page 31 (9) It is the duty of every Optometrist to refrain from the use of all printed and displayed advertising of whatever form, unless it shall be dignified and educational, expressed in good English and free from exageration [sic]. (10) It is the duty of every Optometrist to discontinue the use of all forms of the following types of advertising: Handbills; Road signs; all types of Novelties; “Eyes examined Free” signs, Street Car Signs, Bus Cards, Theatre Program or other program ads and lantern slides, or advertising fees or prices in the Press, Radio or other public manner or representing himself to be superior to other members of his Association. Every member of this Association shall refrain from any reference to the use of the words “free examinations”, “lowest prices”, “terms” and “installments”. (11) Optometrists employed by Corporations or laymen shall not be eligible for membership in this Association. (12) These standing rules of conduct may be amended by majority vote of Delegates present and voting in Annual Convention.” * Report of the 38th Annual Congress of the American Optometric Association, June 23 to 28, 1935 House of Delegates. The Archives & Museum of Optometry, St. Louis. Appendix C. Ethics Committees from 1898 – 1935 Committee on Code of Ethics Chairman Members 1907-08 A. Jay Cross John C. Eberhardt, William E. Huston 1922-23 W. V. Nicum Fay McFadden, Glenn Winslow 1935 John. J. O’Neil Thor A. Elmgren, Albert Fitch, Ernest A. Hutchison, J. Fred Andreae http://www.aoa.org/about-the-aoa/archives-and-museum/support-the-archives-and-museum-of-optometry?sso=y