Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 112 The History of Ethics and Professionalism within Optometry in the United States of America 1898- 2015, Part 4 R. Norman Bailey, MA, OD, MBA, MPH Clinical Professor, Retired University of Houston College of Optometry nbailey@uh.edu Continued from Volume 47, Number 3 A NEW CENTURY DAWNS s the decade of the 1990s was coming to a close, the Ethics and Values Committee developed a proposal in 1997 to produce a textbook addressing the ethical issues that a doctor of optometry may face in clinical practice. As the result of obtaining subsequent funding to write and print the text, An Optometrist’s Guide to Clinical Ethics was published in 2000.107 The text was edited by committee chair, R. Norman Bailey, OD, and bioethicist, Elizabeth Heitman, PhD. There were sixteen contributing authors.108 This text was one of a planned series of projects for the Ethics Education Program for Optometric Practitioners. Funds allowed every doctor of optometry member of the AOA, as well as every third year and graduating optometry student in 2000 to receive a free copy of this text. Complimentary copies were sent to the libraries and to the ethics educators of the schools and colleges of optometry throughout the world. Distribution of the text was also made available to attendees of a presentation by the text’s optometrist editor to the 13th Asia-Pacific Optometric Congress held in Coolum Beach, Australia in 2001. It is worthy to note that during this period of time, committee members encouraged state and regional continuing education administrators to place ethics courses/lectures into their programs.103, 107, 109-112 In December 2000, an Ethics Workshop with David Ozar, PhD, Department of Philosophy and Center for Ethics, Loyola University of Chicago was held in Chicago for the purpose of assessing the ethical values that influence contemporary optometric practice. The Committee was expanding discussions on how the profession could more fully express to the public and to the membership those principles that guide professional behavior as individual primary eye care providers.111, 112 During the January 2001 AOA Mid-year Planning Conference, the Committee recommended that the Standards of Conduct be continued as written until such time as the document could be incorporated into a more comprehensive statement by the House of Delegates regarding the ethical obligations of doctors of optometry.111 The Committee had begun discussions on the need to develop new versions of the Code of Ethics and Standards of Conduct. A new Ethics and Values Committee determined in 2002 that many of the standards in the 1976 Standards of Conduct were considered dated and not consistent with current thinking in biomedical ethics. The Committee recommended that the Board A mailto:nbailey@uh.edu Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 113 of Trustees retire the 1976 Standards of Conduct to the Historical Archives, which the Board did.113 It is noted that the Board of Trustees could take this action with subsequent approval of the House of Delegates as this document had been approved as a Board Policy Statement. The Code of Ethics was minimally modified in June 2005 to make the language more inclusive in three of its stated principles. This historical event occurred during the American Optometric Association’s Annual Congress held in Grapevine, Texas. For the first time in 61 years, the House of Delegates voted to make changes to the Code of Ethics as recommended by the Ethics and Values Committee under the leadership of Chair N. Scott Gorman. While some may not consider the few modification of language of much significance, others would see the wording changes as timely. (See Appendix I) Subsequently, in 2006, with the AOA Board of Trustees encouragement; the Ethics and Values Committee reviewed all AOA related documents and concluded the Code of Ethics needed to be updated to (1) address patient autonomy, (2) to expand the vision- only language to include both general and eye health language, and (3) to recognize the limited exceptions to confidentiality resulting from legislation. The Ethics and Values Committee also concluded that a new supporting document should be created to address a broad range of ethical issues in support of the Code of Ethics. This would be a working document that could also replace many of the resolutions and board policy statements and be more easily modified over time. A goal would be that periodic modifications of this document could embrace changing circumstances in the profession or society.114 The Ethics and Values Committee set out to complete the monumental task of drafting new and updated documents to replace the 1944/2005 Code of Ethics and the now archived 1976 Standards of Conduct. In 2007, the House of Delegates in Boston, Massachusetts adopted the current Code of Ethics115 that incorporated the three changes identified in 2006. This new document was drafted by the Ethics and Values Committee under the leadership of Chair N. Scott Gorman.116 The adopting resolution resolved that the Code of Ethics adopted as Substantive Motion 1 in 1944 and modified in 2005 be repealed and the following be adopted:115 Code of Ethics of the American Optometric Association (adopted 2007) It shall be the ideal, resolve, and duty of all optometrists: TO KEEP their patients' eye, vision, and general health paramount at all times; TO RESPECT the rights and dignity of patients regarding their health care decisions; TO ADVISE their patients whenever consultation with, or referral to another optometrist or other health professional is appropriate; TO ENSURE confidentiality and privacy of patients' protected health and other personal information; TO STRIVE to ensure that all persons have access to eye, vision, and general health care; TO ADVANCE their professional knowledge and proficiency to maintain and expand competence to benefit their patients; Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 114 TO MAINTAIN their practices in accordance with professional health care standards; TO PROMOTE ethical and cordial relationships with all members of the health care community; TO RECOGNIZE their obligation to protect the health and welfare of society; and TO CONDUCT themselves as exemplary citizens and professionals with honesty, integrity, fairness, kindness and compassion. An online course, Ethical Issues in Contact Lens Practice, was developed and produced in 2007. The course was authored by Elizabeth Heitman, PhD, a bioethicist at Vanderbilt University and R. Norman Bailey, OD, past-chair of the Ethics and Values Committee and a clinical professor at the University of Houston College of Optometry. The course, sponsored by the Ethics and Values Committee under the leadership of Chair N. Scott Gorman, was posted on the American Optometric Association’s website in 2008 for the benefit of the membership. Nova Southeastern University in Florida provided media production facilities and education technology staff for the production of the course.116-120 Between 2007 and 2009, the Ethics and Values Committee developed a working draft of the Standards of Professional Conduct document.118, 120-123 Modifications were made to the first draft based on numerous comments and suggestions received from the profession. The final draft of the Standards of Professional Conduct from the Ethics and Values Committee under the leadership of Chair James E. Paramore was adopted as Motion 2011-M-2 by the House of Delegates in June 2011, in Salt Lake City, Utah.124 While the Code of Ethics refers to the ethical principles that guide the profession as it serves the public, the Standards of Professional Conduct spell out in more detail how these principles may be applied in practice from day to day. The 2011 Standards of Professional Conduct read as follows:124 Standards of Professional Conduct (adopted 2011) Background: The profession of optometry is privileged to serve the eye care needs of the public and is entrusted by society to do so in a professional and ethical manner. The placement of the patient’s interests above self-interest is referred to as fiduciary duty and is the primary ethical responsibility of all health care professionals. Specifically, optometrists have the duty to look after the best interests of their patients with regard to the patient’s eye, vision and general health. Additionally, the ethical optometrist strives to protect and enhance the health and welfare of the public in general. The American Optometric Association (AOA) has adopted a Code of Ethics and Standards of Professional Conduct to guide optometrists in their professional and ethical duties. These documents are supplemented by The Optometric Oath, and certain AOA House of Delegates’ resolutions and Board of Trustees’ policy statements. The content of these ethical documents and pronouncements is the result of a continually evolving relationship between the profession of optometry Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 115 and the society it serves. While the Code of Ethics of the American Optometric Association sets forth the basic tenets of ethical behavior for optometrists, the Standards of Professional Conduct is a more evolving document that amplifies the Code of Ethics and describes appropriate ethical and professional behaviors in greater detail. It is the intent of the American Optometric Association that the Code of Ethics and the Standards of Professional Conduct be written expressions of and a continuing commitment to professional and ethical behavior for all optometrists. Discussions of biomedical ethics traditionally identify four categories or fundamental principles of ethical behavior: patient autonomy, non-maleficence, beneficence, and justice. These principles provide the underlying support for specific ethical behaviors within the health care professions. Each of the topic areas within the AOA Standards of Professional Conduct is arranged under one of these principles. While each topic area can be identified and justified under several if not all of the principles, they are arranged here under what could be considered the most compelling principle for each. A fifth category, Non-patient Professional Relationships, is added to complete the content of the AOA Standards of Professional Conduct. It should be noted that these ethical documents and pronouncements are expressions of many but not all of the ethical ideals of the profession and are not necessarily expressions of legal obligations. Ethics and the law are two different entities, although many times these may overlap. The law sets minimum standards for societal behavior that all persons must comply with. Ethics generally sets higher than minimum standards for behavior that people should strive for as the ideal. Standards of Professional Conduct A – Patient Autonomy (“self-determination”) The optometrist has the duty to involve the patient in care and treatment decisions in a meaningful way, with due consideration of the patient’s needs, desires, abilities and understanding, while safeguarding the patient’s privacy. 1. Patient Participation: Optometrists have a duty to respect the right of their patients to be active participants in decisions affecting their health care. This duty should be reinforced and supported through patient education and effective communication. 2. Confidentiality: Optometrists and their staff should hold in confidence all protected health and other personal information. This is an essential element of the doctor-patient relationship that is necessary to build and maintain trust. The optometrist may reveal protected health and other personal information only with the written consent of the patient as defined under the Health Insurance Portability and Accountability Act (HIPAA). However, exceptions to confidentiality do exist that are ethically justified. These exceptions occur either when it is necessary to protect the welfare of the patient or others when faced with a significant threat, or Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 116 when the release of information is required by law. It should be noted that an ethical imperative of an optometrist to release information to protect the welfare of the patient or others without the patient’s consent may have legal considerations. 3. Truthfulness: Telling the truth is a necessary component of a trusting optometrist-patient relationship. From an ethical standpoint, there are two levels of truthfulness, veracity and candor. Simply put, veracity is “telling the truth” and candor is “telling the whole truth.” Optometrists should always practice veracity and strive to tell the truth. While candor is usually required from an ethical standpoint, exceptions are only justifiable out of kindness to the patient or to protect the overall best interests of the patient. Since breaching candor would be a violation of the basic principle of patient autonomy, it should only be considered after careful reflection and weighing the alternatives. 4. Informed Consent: Optometrists have a duty to inform patients or their legal guardian about the patient’s health care and health care options. The process of informed consent requires the optometrist to make a reasonable determination of the patient’s ability to reason and make informed decisions free of external coercion. Additionally, optometrists should explain to the patient or their legal guardian the patient’s health care status, what appropriate procedures are available, and the risks and benefits of each procedure. Finally, optometrists should make the effort to ensure that the patient or guardian has a reasonable understanding of the information presented. 5. Patient Records: The optometrist is responsible for maintaining appropriate and accurate records on every patient encounter. Upon written request and in accordance with applicable federal and state laws, patients or their legal guardian have a right to obtain or have sent copies or summaries of their medical records. B – Nonmaleficence (“do no harm”) The optometrist has the duty to avoid acts of omission or commission that would harm the patient. 1. Standards of Care: Optometrists should strive to provide care that is consistent with established clinical practice guidelines such as those adopted by the American Optometric Association that are based on the latest scientific knowledge and procedures and utilize the opinions of authoritative experts and is in accordance with existing laws. 2. Professional Competence: Optometrists have an obligation to strive to stay current with the prevailing scope of practice and standards of care to benefit their patients. Additionally, optometrists should employ only those clinical procedures and treatment regimens for which they are educated and competent to perform. 3. Delegation of Services: Optometrists may delegate services to office staff as permitted by law. For any services performed on patients by office staff, the optometrist must ensure that they are adequately trained and/or certified. Additionally, the staff member’s level of training or designation Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 117 (technician, assistant, etc.) must be clearly communicated to the patient receiving care. 4. Conflict of Interest: The care of a patient should never be influenced by the self-interests of the provider. Optometrists should avoid and/or remove themselves from any situation that presents the potential for a conflict of interest where the optometrist‘s self-interests are in conflict with the best interests of the patient. Disclosure of all existing or potential conflicts of interest is the responsibility of the optometrist and should be appropriately communicated to the patient. 5. Referral: An optometrist should refer a patient whenever the optometrist believes this may benefit the patient. The provider and/or facility to which the patient is referred should be based primarily on what is in the best interest of the patient. When a patient is referred to another health care provider, the referring optometrist should remain involved in co- managing the patient’s overall care. An optometrist should not offer or accept payment of any kind, in any form, from any source, for referring a patient. Payment between health providers, or from a health service industry, solely for the referral of a patient, is considered fee splitting and is unethical. 6. Relationships with Patients: Optometrists should avoid intimate relationships with patients as such relationships could compromise professional judgment or exploit the confidence and trust placed in the optometrist by the patient. If such a relationship does inadvertently develop, the professional care of this patient should be transferred to another optometrist. 7. Impaired Optometrist: Optometrists who are impaired because of the use of controlled substances, alcohol, or other chemical agents must remove themselves from patient care activity. In an effort to protect patients and encourage help for impaired providers, optometrists should assist impaired colleagues in seeking professional help and/or identify impaired colleagues to appropriate state agencies or licensing boards. Optometrists who have physical or cognitive limitations should not provide professional care if the condition limits their ability to provide the highest level of care to their patients. C. - Beneficence (“do good”) The optometrist has the duty to proactively serve the needs of the patient and the public at large regarding eye, vision and general health. 1. Character: Optometrists should conduct themselves with good character in all of their actions to build trust and respect with patients, the public, and colleagues. Good character includes but is not limited to honesty, integrity, fairness, kindness, and compassion. 2. Respect for the Law: Optometrists should comply with all applicable state and federal laws and should remove themselves from any situation which prevents them from fulfilling their legal and professional responsibilities. It should also be noted that ethical duties may sometimes exceed legal obligations. Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 118 3. Protected Populations: Optometrists have the responsibility to identify signs of abuse and neglect in children, dependent adults and elders and to report suspected cases to the appropriate agencies, consistent with state law. 4. Public Health: Optometrists have an ethical obligation primarily to their patients but also to society in general. As primary health care providers, optometrists should participate actively in professional organizations and other efforts that enhance the eye, vision, and general health of their patients and the public. Optometrists should also strive to ensure that all persons have access to eye, vision, and general health care. 5. Clinical Research and Trials: It is the ethical responsibility of an optometrist to maintain integrity and independent judgment in all research endeavors to advance the best interests of patients, the public welfare, and the profession. Optometrists who conduct research should adhere to accepted scientific conduct guidelines and respect all ethical tenets that protect patients’ rights. When collaborating with industry, optometrists should encourage and support the timely and accurate publication of all scientifically relevant findings. Optometrists who present scientific information shall fully disclose any financial and/or other relationship that exists with a company when its product or services are discussed in the presentation. D – Justice (“fairness”) The optometrist has the duty to treat patients, colleagues, and society fairly and without prejudice. 1. Patient Selection: Optometrists, in serving the public, may exercise reasonable discretion in selecting patients for their practices. However, services should not be denied to patients presenting with emergent conditions. Optometrists must not refuse to accept patients into their practice or deny services to patients because of the patient’s race, religion, ethnicity, gender, sexual orientation, disability, socioeconomic status, or health status. 2. Patient Abandonment: Once the optometrist has undertaken a course of treatment, the optometrist should not discontinue treatment without giving the patient adequate notice and the opportunity to obtain the services of another eye care provider. Optometrists are responsible for ensuring appropriate follow-up care when not available to render such care. 3. Advertising: Advertising by optometrists should be truthful and in accordance with prevailing federal and state laws and regulations. Optometrists who advertise should identify their professional degree and/or their profession in all forms of advertising and should never mislead the public regarding their expertise or competency. Optometrists should not hold themselves as having superior knowledge or credentials other than their earned degrees, certifications or license types. 4. Economic Interests: Fees for optometric services must be reasonable and accurately reflect the care delivered to the patient. Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 119 E – Non - patient Professional Relationships Optometrists have an obligation to conduct themselves with integrity and without conflicts of interest in all of their professional relationships. 1. Relationships with Industry: In their interactions with industry, optometrists are expected to maintain the highest level of ethical conduct in order to retain their professional autonomy and clinical integrity. Optometrists have a responsibility to provide the best care possible for their patients and to continuously advance their clinical and scientific knowledge. Industry can be a valuable resource in these endeavors. However, optometrists must avoid situations and activities that would not be in the best interest of their patients. Any financial and/or material incentive offered by industry that has the appearance of, or could be an inappropriate influence on an optometrist’s clinical judgment should be avoided. 2. Employer-Employee Relationships: Optometrists should avoid or terminate any employment situation where the employer interferes with or attempts to control the independent professional judgment of the employed optometrist within the scope of optometric practice. Relations between optometrists, and between optometrists and staff, must be conducted in a manner that advances the best interests of patients, including the sharing of relevant information. An optometrist’s clinical judgment and practice should not be compromised by economic interest in, commitment to, or benefit from professionally-related commercial enterprises. 3. Harassment and Relationships with Subordinates: An optometrist should not engage in any acts of emotional abuse, physical abuse, or sexual misconduct/ exploitation related to the optometrist’s position as a health care professional. Intimate relationships, even when consensual, between an optometric supervisor and a colleague, student, office trainee, or staff member raise concerns because of inherent inequalities in the status and power of the individuals and are therefore inappropriate. 4. Expert Testimony: When optometrists provide expert testimony within a judicial or administrative action, the testimony should be balanced, fair, and truthful based on scientific and clinical knowledge. A reasonable fee, which is not contingent upon the outcome, may be accepted. Article V. Section 2. F. of the AOA Bylaws125 provides that: “The Judicial Council shall also, in appropriate cases, render advisory opinions interpreting the Code of Ethics of the Association, The Optometric Oath, and the AOA Standards of Professional Conduct.” In 2012 Carolyn Carman and Douglas Totten, a subcommittee of the Ethics and Values Committee, reviewed the potential ethical considerations of optometrists using social media. An article by Carman and Totten, Social Media Recommendations was published in November 2012. In that article, James E. Paramore, immediate past-chair, stated that, “Optometrists need to be aware of how to uphold the same professional and ethical standards in their social media participation as they do in the rest of their practice.”126, 127 Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 120 In 2014, 128 the Ethics and Values Committee developed plans for an online forum to present a monthly case study with an ethical challenge. The Ethics Forum was launched in April 2015 on the AOA website under the Ethics and Values link to “foster ethical practices for the optometric community by providing a vehicle for education and discussion.”129 The forum is setup to solicit opinions from practitioners on how they would handle each ethical challenge. This concludes a description of the history of ethics and professionalism within optometry in the USA as revealed through the history of the American Optometric Association during its first 117 years (1898-2015). More detail of this history can be obtained by carefully reviewing the references and appendices. Acknowledgements The author would like to thank the following persons for their advice and assistance on the manuscripts and supporting references during the development of this paper or the original paper to which this paper is an update: Larry L. Creasey, OD; Linda J. Draper; James R. Gregg, OD; Kirsten Hébert; James E. Paramore, OD; Danette Miller, and Jerald W. Strickland, OD, PhD. My greatest gratitude and thanks go to Sherry L. Cooper and Thomas E. Eichhorst, JD, both longtime AOA staff and now retired. Both contributed much time and advice to the successful completion of this paper. I am especially grateful for Mr. Eichhorst’s efforts in providing research for and editing of the final drafts of the text. Ms. Cooper was the AOA Associate Director of State Government Relations from 1990 until her retirement in 2013. She also has served as staff for the AOA Resolutions Committee from 1998 to the present time. Mr. Eichhorst was the AOA Counsel from 1965 through 2002, when he retired. He has served as a legal consultant to the AOA since 2008. Special thanks and acknowledgement is given to Elizabeth Heitman, PhD of the Center for Biomedical Ethics and Society at Vanderbilt University Medical Center and David T. Ozar, PhD of the Graduate Program in Health Care Ethics and Department of Philosophy at Loyola University of Chicago. Their consultations, writings, and other assistance during the development of projects of the Ethics Education Program for Optometric Practitioners were invaluable. Special gratitude is extended to the former CIBA Vision Corporation and Richard E. Weisbarth, OD, then CIBA’s Executive Director of Professional Services for North America, for the unrestricted grant support essential during the development and distribution phases of the Recommended Curriculum For The Teaching of Professionalism and Ethics in Optometry, An Optometrists Guide to Clinical Ethics, and Ethical Issues in Contact Lens Practice. These Ethics Education Program for Optometric Practitioner projects could not have been successful without this generous support. Dr. Weisbarth, a past president of the American Academy of Optometry, is currently the Vice President of Professional Affairs at Alcon, Inc., which subsequently merged together with CIBA Vision Corporation in 2011. References 107. Annual report to the house of delegates of the AOA ethics and values committee. 1997-1998. Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 121 108. Bailey, RN, Heitman, E., eds. An Optometrist’s Guide to Clinical Ethics. St. Louis: American Optometric Association, 2000. Ethics and Values section of the American Optometric Association website: http://www.aoa.org/documents/optometrists/book.pdf. Accessed November 19, 2015. 109. Annual report to the house of delegates of the AOA ethics and values committee. 1998-1999. 110. Annual report to the house of delegates of the AOA ethics and values committee. 1999-2000. 111. Midyear planning conference agenda and minutes of the ethics and values committee. 2001. 112. Annual report to the house of delegates of the AOA ethics and values committee. 2000-2001. 113. Midyear planning conference agenda and minutes of the ethics and values committee. 2002. 114. Paramore J, Berman M, Eichhorst T. Development of the AOA Code of Ethics and Standards of Professional Conduct. Guest Editorial. Optometry: J Am Optom Assoc 2012:83(4);6-7. 115. Resolution #1969 (4 0f 2007). Code of Ethics. St. Louis: America Optometric Association. Also: Ethics and Values section of the American Optometric Association website: http://www.aoa.org/about-the-aoa/ethics-and-values/code-of-ethics?sso=y. Accessed November 19, 2015. 116. Annual report to the house of delegates of the AOA ethics and values committee. 2006-2007. 117. Annual report to the house of delegates of the AOA ethics and values committee. 2005-2006. 118. Annual report to the house of delegates of the AOA ethics and values committee. 2007-2008. 119. Online course in ethical behavior on way. AOA News. St. Louis: American Optometric Association, 2006:April:24. 120. Annual report to the house of delegates of the AOA ethics and values committee. 2008-2009. 121. Annual report to the house of delegates of the AOA ethics and values committee. 2009-2010. 122. Annual report to the house of delegates of the AOA ethics and values committee. 2010-2011. 123. Annual report to the house of delegates of the AOA ethics and values committee. 2011-2012. 124. Standards of Professional Conduct. St. Louis: American Optometric Association, 2011. Ethics and Values section of the American Optometric Association website: http://www.aoa.org/documents/about/Standards-of-Professional-Conduct_Adopted- June-2011.pdf. Accessed November 19, 2015. 125. Article V. Section 2. F. of the AOA Bylaws. St. Louis: American Optometric Association. 126. Annual report to the house of delegates of the AOA ethics and values committee. 2012-2013. 127. Carman C, Totten D. Social Media Recommendations. St. Louis: American Optometric Association, 2012. Ethics and Values section of the American Optometric http://www.aoa.org/documents/optometrists/book.pdf http://www.aoa.org/about-the-aoa/ethics-and-values/code-of-ethics?sso=y http://www.aoa.org/documents/about/Standards-of-Professional-Conduct_Adopted-June-2011.pdf http://www.aoa.org/documents/about/Standards-of-Professional-Conduct_Adopted-June-2011.pdf Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 122 Association website: http://www.aoa.org/about-the-aoa/ethics-and-values/social- media-recommendations?sso=y. Accessed November 19, 2015. 128. Annual report to the house of delegates of the AOA ethics and values committee. 2013-2014. The Ethics Forum was placed online at the Ethics and Values section of the AOA website: http://www.aoa.org/about-the-aoa/ethics-and-values/ethics- forum?sso=y as of April 2015. Accessed November 19, 2015. 129. Annual report to the house of delegates of the AOA ethics and values committee. 2014-2015. Additional Readings: (to further appreciate the setting in which the discussed history occurs) Koetting RA. The American Optometric Association’s first century. St. Louis: American Optometric Association. 1997. Past issues of HINDSIGHT: Journal of Optometry History, Official Publication of the Optometric Historical Society Author’s Notes I have been interested in the professional practice of optometry since my days in optometry school at Indiana University in the 1960s. I had the privilege of serving my profession both as a private practitioner in Charlotte, North Carolina for ten years during the 1970s and as an educator and member of the faculty at the University of Houston College of Optometry for almost thirty years. I was particularly honored to be asked to serve on the AOA Ethics and Values Committee for ten years beginning in 1991. I am currently serving a third term on the Judicial Council of the AOA. As you may recall from the paper, the AOA launched the Professional Advancement Program in 1942. The Professional Advancement Program was part of the continuing effort by the AOA to particularly address the challenges highlighted by the Reader’s Digest articles in 1937 and the lack of respect by the military for the profession during World War II. At that time, James A. Palmer of Charlotte, North Carolina was appointed National Director of the Office of Ethics and Economics. In 1970, upon my entering practice in Charlotte, I had the opportunity to meet Dr. Palmer at one of our local professional society meetings; however, I was unaware at the time of the impact he had made on the professional practice of optometry in North Carolina and nationally. For me, this point highlights the importance of today’s optometry student and practitioner alike knowing and appreciating the history of our profession, in all its aspects. Organized optometry in North Carolina (N.C.) was quite progressive during my practice in that state in the 1970s, which led to the state becoming the second state to pass legislation allowing for the prescribing of therapeutic pharmaceuticals by optometrists. I was a member of the initial therapeutics licensed group in N.C. This was also a period when there were many rules of practice required by the regulations of the optometry practice act of N.C., largely reflecting those promoted by the AOA. While it may be difficult to believe in today’s environment, one N.C. regulation in my practice years did not allow for eyewear frames to be visible from the reception area of the office. In addition, I also followed the recommended guidelines for charging professional service fees plus material http://www.aoa.org/about-the-aoa/ethics-and-values/social-media-recommendations?sso=y http://www.aoa.org/about-the-aoa/ethics-and-values/social-media-recommendations?sso=y http://www.aoa.org/about-the-aoa/ethics-and-values/ethics-forum?sso=y http://www.aoa.org/about-the-aoa/ethics-and-values/ethics-forum?sso=y Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 123 costs for eyewear rather than using a “mark-up of materials” system, which was a common practice in most commercial optical businesses and some optometric practices. I followed this system throughout my ten years in private practice, attempting constantly to promote a professional image rather than a merchant image. It was not always easy. While one can appreciate the arguments that it should be easier for members of the public to make purchasing decisions if they have all of the information regarding optometrists’ professional services and fees, the practitioner needs to realize that promotion of optical goods may make it more difficult, as a professional, to manage the more commercial/product aspects of an optometric practice that both prescribes and dispenses. The nature of product promotions has the potential to lead the public to view some optometrists more as merchants than as professionals. Some would say that the U. S. Supreme Court’s decision, allowing for the professions to advertise in ways that were historically considered unprofessional and illegal in most states, places an additional challenge on today’s Doctors of Optometry and other professionals to maintain a professional image. The optometric practitioner should be ever mindful of the potential for conflicts of interest in all areas of practice, especially when dispensing materials or any professional services that the optometrist prescribes. This requires one to take additional care in order to maintain the highest professional behavior. As noted in the paper, professional ethics demands more than just adhering to the letter of the law, but sets obligations that are greater than the law. Following ethical principles and standards has become increasingly complex as optometry has expanded its scope of practice into medical eye care. The 2007 Code of Ethics and 2011 Standards of Professional Conduct clearly guide the optometrist in the obligations that should enable the practitioner to serve as the patient’s fiduciary. It is very difficult to include all the nuances reflecting the profession’s efforts to establish its ethical basis and to advance the public’s image of the profession through legal and association endeavors. The author encourages the reader to review the references, read the appendices carefully, and to complete additional readings where an expanded understanding of events, and the times in which they occurred, is desired. I especially want to acknowledge the monumental task of my colleague and professional friend, John G. Classé, in researching and authoring his text, Legal Aspects of Optometry. I personally refer the reader to its contents for greater detail of the discussed subject matter, including his three chapters devoted to the topic of ethics. The views expressed in these Author’s Notes and throughout this paper to which it is attached, The History of Ethics and Professionalism within Optometry in the United States of America 1898-2015, are those of the author and do not necessarily reflect the views of the American Optometric Association. I hope this paper on the history of ethics and professionalism within optometry in the USA has been of interest to the practitioner and student alike, and that it will serve as a useful reference in the future. R. Norman Bailey, MA, OD, MBA, MPH, FAAO Emeritus Clinical Professor, Retired University of Houston College of Optometry Member, Judicial Council Past-chair, Ethics and Values Committee American Optometric Association Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 124 Past-chair, Vision Care Section American Public Health Association Dedication: I would like to dedicate this paper to all who helped me to become the Doctor of Optometry I became; regrettably knowing I will miss some important individuals in the list below. Parents and Siblings: Clyde H. and Ruby Dell Bailey and my four siblings, Betty, Larry, William, and Margaret Public Schools and Community: Chattanooga, Tennessee Faculty at the University of Chattanooga (University of Tennessee at Chattanooga): (1959) BA, Comb. Science Faculty at Peabody College of Vanderbilt University: (1960) MA, Psychology* Faculty and Graduate Students at Indiana University: (1969) O.D., Optometry Especially, Faculty (alphabetical): Graduate students: Merrill J. Allen Anthony J. Adams Irvin M. Borish T. David Williams Gordon G. Heath George C.S. Woo Henry W. Hofstetter, Dean John R. Pierce Jerald W. Strickland Distinguished Staff at the Gesell Institute of Child Development: (1969-70) Optometric Fellowship** Many others after beginning optometric practice in Charlotte, North Carolina in 1970. *This degree led to my subsequent employment as a masters-level school psychologist for the Chattanooga, Tennessee Public Schools where I examined children with learning problems. While there are many reasons why children do not succeed in school, it was during this time I became acutely aware that vision difficulties (not just refractive) could contribute to the learning difficulties of some children. In 1964, while in this position, I had the opportunity to attend a School Readiness Workshop at the Gesell Institute of Child Development in New Haven, Connecticut where I met Richard J. Apell, OD and John W. Streff, OD and began investigating optometry as a calling for a way to assist others to a better life. **Upon graduation from Indiana University, I was awarded the Gesell Institute’s Optometric Fellowship and benefited from the instruction and experience of Drs. Apell and Streff. The co-founders of the Gesell Institute of Child Development, Francis L. Ilg, MD, and Louise Bates Ames, PhD, taught me the relationship between visual development and the other areas of child development. Appendix H: Currently Active (Extant) Ethics Resolutions and Substantive Motions as of July 2015 (not shown in the order they were adopted) Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 125 Ethics Code of Ethics #1969 The Optometric Oath #1847 Standards of Professional Conduct #M-2011- 2 VISION USA #1865 Standing Committee Dealing with Ethics and Values of Optometric Care and Services #1883 HIV and AIDS Research #1852 Ethics Committee #1913 Study of Ethics Integral Part of Optometric Education #1904 State Board Credit for Continuing Education Courses in Ethics #1938 Practice with Other Health Care Professions and Disciplines #1534 Abuse against Individuals Unable to Protect Themselves #1916 Doctor/Patient Communications in Managed Health Care Plans #1920 Protecting Against Potential Bias in Patient Care #1939 Patients Benefit from Optometric Professionalism #1960 Billing to Third Party Insurance Plans #1844 Restrictions on Certain Activities of Trustees, Officers and Volunteers of the American Optometric Association #392 Disclosure of Conflicts of Interest #1910 #1969(4 of 2007) CODE OF ETHICS RESOLVED, that the Code of Ethics adopted as Substantive Motion 1 in 1944 and modified in 2005 be repealed and the following be adopted. CODE OF ETHICS (see the body of the paper for the text of the 2007 Code of Ethics) #1847 (4 of 1986) THE OPTOMETRIC OATH WHEREAS, over the years numerous optometric organizations and the schools and colleges of optometry have developed and utilized an optometric oath; and WHEREAS, the American Optometric Association has always supported and endorsed the highest standards, ethics and ideals for the profession of optometry; now therefore be it RESOLVED, that the following statement be adopted as the oath of the optometric profession, to wit: THE OPTOMETRIC OATH (see the body of the paper for the text of The Optometric Oath) and be it further RESOLVED, that the American Optometric Association encourages all state and local optometric associations and the schools and colleges of optometry to endorse and to employ the Optometric Oath whenever appropriate. #M-2011-2 (2011) Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 126 STANDARDS OF PROFESSIONAL CONDUCT (see the body of the paper for the text of the 2011 Standards of Professional Conduct) 1865 (8 of 1989)(Mod. 2005) VISION USA WHEREAS, most Americans recognize the importance of good vision; and WHEREAS, some people are unable to obtain needed eye care services due to their lack of financial ability, or their inability to secure private health insurance, or their inability to qualify for government health care programs; and WHEREAS, the Code of Ethics of the American Optometric Association states that "it shall be the ideal, the resolve and the duty of its members to see that no person shall lack for visual care regardless of his financial status"; and WHEREAS, the American Optometric Association has developed a national optometric charity entitled VISION USA which provides needed vision care services to the working poor throughout this nation; now therefore be it RESOLVED, that all members of the American Optometric Association be urged to participate in the VISION USA National Optometric Charity Project and to donate at least 8 hours of their services each year to individuals who are unable to obtain needed eye care services due to their lack of financial ability, their inability to secure private health insurance, or their inability to qualify for government health care programs. #1883 (2 of 1991)(Mod. 2010) STANDING COMMITTEE DEALING WITH ETHICS AND VALUES OF OPTOMETRIC CARE AND SERVICES (see the body of the paper for the full text of the original resolution as adopted in 1991) RESOLVED, that the American Optometric Association Board of Trustees establish a standing committee dealing with ethics and values of optometric care and services with a broad mission and focus to address a variety of circumstances and problems which now exist in the health care arena that affect the practices and services of Doctors of Optometry; and be it further RESOLVED, that the standing committee dealing with ethics and values of optometric care and services make an annual report to the American Optometric Association House of Delegates. #1852 (5 of 1987) (Combined in 2015 with 1890 (9 of 1991) and continued as 1852) HIV AND AIDS RESEARCH WHEREAS, it is incumbent upon optometrists, as primary health care providers, to be knowledgeable and to counsel patients about Acquired Immune Deficiency Syndrome (AIDS), since the disease has ocular manifestations and the Human Immunodeficiency Virus (HIV) antibody has been isolated in tears but not found to be transmissible; and WHEREAS, it is important to educate the public to take precautionary measures to prevent AIDS transmission; now therefore be it Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 127 RESOLVED, that the American Optometric Association strongly recommends that it be the responsibility of all practicing optometrists to acquire background and knowledge, through continuing professional education of HIV infections, appropriate infection control and related public health and patient care issues; and be it further RESOLVED, that the American Optometric Association supports private and government funding of educational programs to inform the general public accurately with scientific facts, to reduce unfounded fear of infection in the general population, and to prevent further infection in populations at risk of contracting AIDS; supports confidentiality in voluntary testing for the HIV antibody; supports increased private and federal funding for AIDS research; and supports continual efforts to assess potential improvement of treatment in order to provide the most efficacious cost-effective care. #1913 (3 of 1995) (Mod. 2015) ETHICS COMMITTEE RESOLVED, that the affiliated associations of the American Optometric Association be encouraged to make efforts to raise the level of consciousness about issues of ethical behavior; to identify and address ethical concerns that relate to clinical practice; and to identify and address ethical concerns that relate to organizations' behavior; and be it further RESOLVED, that the affiliated associations of the American Optometric Association be encouraged, with advice and guidance from their legal counsel, to activate committees on ethics and values which would address concerns as they may arise related to issues of ethical behavior in accordance with applicable federal and state laws. #1904 (1 of 1994)(Mod. 2000) EDUCATION IN ETHICS WHEREAS, a comprehensive understanding of ethics is essential for the humanitarian delivery of health care; and WHEREAS, the practice of optometry must be firmly based on professional and moral ethics; and WHEREAS, ethics education should be included within the formal optometric curricula of the schools and colleges of optometry; and WHEREAS, optometric educators have formulated a curriculum model on ethics; now therefore be it RESOLVED, that the American Optometric Association endorses the study of ethics as an integral part of optometric education; and be it further RESOLVED, that the American Optometric Association urges the schools and college of optometry, as well as its affiliate associations providing continuing education, to adopt structured curricula and programs in ethics. #1938 (3 of 2001) STATE BOARD CREDIT FOR CONTINUING EDUCATION COURSES IN ETHICS WHEREAS, the present complexity of health care practice has created a variety of new ethical issues, concerns, and dilemmas; now therefore be it Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 128 RESOLVED, that the American Optometric Association supports the inclusion of presentations on ethics in national, regional, and state continuing education programs; and be it further RESOLVED, that the American Optometric Association encourages all State Boards of Optometry to accept courses in ethics toward fulfillment of continuing education requirements for license renewal. #1534 (7 of 1964)(Mod. 1995) PRACTICE WITH OTHER HEALTH CARE PROFESSIONS AND DISCIPLINES WHEREAS, optometrists and state associations have sought guidance from the American Optometric Association concerning the ethical relationship of optometrists with other health care professions and disciplines in the joint practice of their professions; and WHEREAS, it is against the public interest if the public cannot readily identify and distinguish the profession or discipline practiced by each individual in a joint practice; now therefore be it RESOLVED, that the American Optometric Association declares that it is ethical for optometrists, as permitted by law, to be associated with, to be partners with, to employ or be employed by other health care professions and disciplines, so long as each practitioner is clearly identified by designation and title of the profession or discipline for which he or she is licensed. #1916 (1 of 1996) ABUSE AGAINST INDIVIDUALS UNABLE TO PROTECT THEMSELVES WHEREAS, the awareness of abuse against individuals unable to protect themselves has been elevated to a level where society has taken increased steps to curtail the exploitation of these persons; and WHEREAS, the profession of optometry has an ethical and societal responsibility to be advocates for those suffering abuse; now therefore be it RESOLVED, that the American Optometric Association and affiliated state associations be encouraged to provide members with educational resources to aid in the recognition of abuse against individuals unable to protect themselves; and be it further RESOLVED, that the American Optometric Association encourages the National Board of Examiners in Optometry to include questions on the subject of abuse against individuals unable to protect themselves as a portion of their examination, making future practitioners more aware of these problems; and be it further RESOLVED, that individual doctors of optometry be encouraged to report cases of suspected abuse to the appropriate authorities in accordance with current laws; and be it further RESOLVED, that the American Optometric Association encourage all affiliated state associations to adopt a similar resolution. #1920 (5 of 1996) (Mod. 2015) DOCTOR/PATIENT COMMUNICATIONS IN MANAGED HEALTH CARE PLANS WHEREAS, there is concern that some managed health care contracts may limit doctors' ability to communicate with patients; and Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 129 WHEREAS, it is the ethical duty of doctors of optometry, as a fundamental element of the doctor-patient relationship, to act as advocates on behalf of the patient; and WHEREAS, it is a doctor's obligation to discuss necessary and appropriate treatment alternatives and in good faith to fully inform the patient of all treatment options; and WHEREAS, the failure to communicate specific information may limit the patient's access to timely, relevant and quality health care services; now therefore be it RESOLVED, that the American Optometric Association strongly encourages the adoption of federal legislation prohibiting managed health care organizations from using restrictive contract clauses that may serve to limit a doctor's ability to communicate openly and freely with patients about their care options; and be it further RESOLVED, that the American Optometric Association strongly encourages the affiliated state associations to seek the adoption of similar state legislation. #1939 (4 of 2001) (Mod. 2015) PROTECTING AGAINST POTENTIAL BIAS IN PATIENT CARE RESOLVED, that the American Optometric Association reiterates its time-honored principle of appropriate professional care for all patients; and be it further RESOLVED, that the American Optometric Association, as a matter of ethical concern, strongly encourages all practicing optometrists to be cognizant of the potential for bias in patient care based upon health, gender, age, ethnicity, race, financial status or any other patient characteristic. #1960 (7 of 2004) PATIENTS BENEFIT FROM OPTOMETRIC PROFESSIONALISM WHEREAS, the American Academy of Ophthalmology has adopted a policy excluding optometrists from all educational courses offered at American Academy of Ophthalmology meetings; and WHEREAS, the new exclusionary policy of the American Academy of Ophthalmology is offensive to the principles of scientific professionalism, the free exchange of medical knowledge for the benefit of the public, and the ethics of collegiality among all health care professionals that helps to ensure the best care for patients; now therefore be it RESOLVED, that the American Optometric Association shall continue unchanged its long-standing policy of opening all educational courses offered at American Optometric Association meetings to ophthalmologists to attend; and be it further RESOLVED, that, in all educational relationships with ophthalmologists, the American Optometric Association shall, for the benefit of patients, adhere to the principles of scientific professionalism, the free exchange of medical knowledge, and the ethics of collegiality among health care professionals. #1844 (1 of 1986)(Mod. 1990)(Mod. 1995)(Mod. 2000) BILLING TO THIRD PARTY INSURANCE PLANS Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 130 RESOLVED, that the American Optometric Association considers the excess billing of benefit plans, whether in the public or private sector, to be unethical and to be contrary to the behavior of a professional practitioner of a learned health care profession. #392 (4 of 1938)(Mod. 1990)(Mod. 1995)(Mod. 1997)(Mod. 2005)(Mod. 2012) RESTRICTIONS ON CERTAIN ACTIVITIES OF TRUSTEES, OFFICERS AND VOLUNTEERS OF THE AMERICAN OPTOMETRIC ASSOCIATION WHEREAS, the American Optometric Association, with an established code of ethics, is a membership organization of optometrists and others devoted to improving the visual welfare of the public; and WHEREAS, the participation of trustees, officers and volunteers of the American Optometric Association on boards, advisory boards, councils, or committees of other entities may be beneficial to the advancement of the objectives of the Association; and WHEREAS, the individuals serving as trustees and officers of the American Optometric Association, a non-profit corporation organized and governed by the laws of the State of Ohio, are obligated, both legally and ethically, to maintain faithfully their duty of loyalty to the American Optometric Association and to protect the integrity of their positions as fiduciaries of the Association by promptly disclosing any actual or potential conflicts of interest, and in appropriate circumstances, recusing themselves from participating in deliberations and/or voting on any matter involving a conflict of interest that may come before the Board of Trustees in the course of their duties; and WHEREAS, all individuals serving as volunteers and elected officials of the American Optometric Association, including members of the Board of Trustees, as recognized leaders of the optometric profession and representatives of the AOA and its membership must, as a condition of service, comply with and adhere to the Association's established policy and procedures requiring the disclosure of all personal professional and financial interests and activities which may cause a conflict of interest; and WHEREAS, any meaningful and effective policy intended to guard against the potential for conflicts of interest, whether actual or perceived, must necessarily be an evolving policy, adaptable and flexible enough to address unforeseeable situations in which potential conflicts may arise; and WHEREAS, under such a policy, questions regarding the interpretation and application of the policy can be expected to arise; and WHEREAS, it is in the best interest of the Association, its members, and its elected leaders on the Board of Trustees, to maintain fair and effective procedures to protect against potential conflicts of interest, whether actual or perceived; now therefore be it RESOLVED, that the current AOA board policy, that imposes a duty on a board member of the American Optometric Association to recuse himself or herself from discussion and voting on any matter in which they may have a conflict of interest, is hereby affirmed; and that the Board of Trustees, consistent with governing law, is empowered to temporarily suspend from any discussion or vote a Board member whom they determine to have a conflict of interest and who refuses to recuse himself or herself from discussion and voting on the matter in which he or she has a conflict of interest; and that the Board of Trustees shall develop and implement policies to carry out the principles of this Resolution, including the reporting of matters by the Board of Trustees to the Judicial Council for its review when necessary; and be it further RESOLVED, that the policy expressed in Resolution 1910, requiring each member of the Board of Trustees and each volunteer of the American Optometric Association to properly disclose any potential conflict of interest, along with a description of any personal business interests, affiliations, or activities with any entity active in the health care field, is hereby affirmed; and be it further Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 131 RESOLVED, that a member of the Board of Trustees of the American Optometric Association may not serve as a member of a board, advisory board, or as a principal, agent, or employee of, or have any other active personal affiliation with, any other entity, if such affiliation would conflict with the objectives and policies of the American Optometric Association; and be it further RESOLVED, that, prior to election, a candidate for the American Optometric Association Board of Trustees shall publicly disclose any potential conflict of interest and provide to the House of Delegates a description of any personal business interest, affiliation or activity with any entity that, whether or not active in the health care field, may have the potential to give rise to a conflict of interest with the Association or its objectives and policies; and be it further RESOLVED, that in no case shall the House of Delegates elect a candidate who has, nor shall a candidate or member of the Board of Trustees develop, a personal interest of such a nature that it would compromise that individual's ability to perform his or her responsibilities as a member of the American Optometric Association Board of Trustees; and be it further RESOLVED, that all members of the American Optometric Association Board of Trustees shall, on an annual basis, disclose any potential conflict of interest by providing to the House of Delegates a description of any personal business interest, affiliation or activity with any entity that, whether or not active in the health care field, may have the potential to give rise to a conflict of interest with the Association or its objectives and policies; and be it further RESOLVED, that elected officials of the American Optometric Association shall not allow their names, photographs, titles and/or positions with the Association to be used improperly by any other entity-to advance that entity's business interests, and/or for the official's own personal financial gain; and be it further RESOLVED, that the American Optometric Association Counsel shall be responsible for ensuring: that the information provided in accordance with the Association's conflict of interest and disclosure policies is properly collected, reviewed, and maintained at the Association's main office; that, upon request, such information is provided to any delegates, officers, and trustees at the House of Delegates each year at the annual congress; that any interim disclosures of information submitted in accordance with these policies in between annual congresses is promptly redistributed to all members of the Board of Trustees and to all members of the Judicial Council for their review; and that such information be made available for inspection, upon the written request of any member, by appointment with the Association Counsel, during regular business hours; and be it further RESOLVED, that the Judicial Council shall be responsible for overseeing the administration of the Association's conflict of interest and disclosure policies, and shall make recommendations, where appropriate, to the House of Delegates as to the sufficiency and appropriateness of these policies and the procedures established to implement them; and be it further RESOLVED, that the Judicial Council shall be responsible for rendering final decisions on any questions arising under the Association's conflict of interest and disclosure policies. Complaints against any member elected or appointed to a position in the Association related to conflicts of interest or failure to disclose any conflict of interest shall be made in writing to the Judicial Council setting forth the details of the complaint with specificity. The Judicial Council shall initially screen such complaint, with assistance from Counsel, and determine if it merits further review. If further review is determined to be warranted, the Judicial Council shall conduct a hearing at which the party making the complaint and the party against whom the complaint is being made shall have the right to be heard, be represented by an attorney, give evidence, and present and cross-examine witnesses. The Judicial Council, by majority vote, shall then render a written decision on the complaint, including any recommendations thereon. Such decision shall be forwarded to the Board of Trustees for final action on any recommendations. Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 132 #1910 (Combination in 1995 of 1903 (8 of 1993) and 1905 (2 of 1994) into new 1910) (Mod. 2015) DISCLOSURE OF CONFLICTS OF INTEREST WHEREAS, the American Optometric Association continues to recognize the necessity that individuals holding elected or appointed positions within the American Optometric Association embrace the principles of integrity and trust; and WHEREAS, the American Optometric Association continues to recognize that officers, trustees and other volunteers of the American Optometric Association and of its affiliated associations bear a special responsibility to avoid conflicts of interest or the appearance thereof between their association responsibilities and their private business interests; and WHEREAS, the American Optometric Association has adopted a process to identify potential conflicts of interest for volunteers and staff; now therefore be it RESOLVED, that all elected officials of the American Optometric Association, including the American Optometric Association Board of Trustees and Section Officers, all appointed volunteers and staff of the American Optometric Association should disclose any conflict of interest when engaged or about to engage in activities on behalf of the American Optometric Association, provided that an American Optometric Association entity may adopt stricter guidelines; and be it further RESOLVED, that all elected and appointed volunteers and staff of the American Optometric Association shall annually execute a statement that they will reveal personal business interests relating to any activities in which the American Optometric Association is engaged; and be it further RESOLVED, that no person shall hold an elected or appointed position within the American Optometric Association volunteer structure, without having executed the disclosure statement within 30 days of appointment or election to the volunteer structure and then annually thereafter; and be it further RESOLVED, that the affiliated associations are urged to develop conflict of interest disclosure requirements comparable to those of the American Optometric Association. Appendix I: 2005 Modification of the 1944 Code of Ethics (M-1-1944) showing the modifications adopted in 2005; NOTE: deleted wording is indicated by strikethrough; added language is indicated by underscore (a new Code of Ethics replacing M-1-1944 was later adopted as Resolution #1969 in 2007): It Shall Be the Ideal, the Resolve, and the Duty of the Members of the American Optometric Association: TO KEEP the visual welfare of the patient uppermost at all times; TO PROMOTE in every possible way, in collaboration with this Association, better care of the visual needs of mankind humankind; TO ENHANCE continuously their educational and technical proficiency to the end that their patients shall receive the benefits of all acknowledged improvements in visual care; TO STRIVE TO SEE THAT no person shall lack for visual care, regardless of his financial status; TO ADVISE the patent whenever consultation with an optometric colleague or reference for other professional care seems advisable; Hindsight: Journal of Optometry History, Volume 47, Number 4 Bailey: History of Ethics, Part 4 2016| Page 133 TO HOLD in professional confidence all information concerning a patient and to use such data only for the benefit of the patient; TO CONDUCT themselves as exemplary citizens; TO MAINTAIN their offices and their practices in keeping with professional standards; TO PROMOTE and maintain cordial and unselfish relationships with members of their own profession and of other professions for the exchange of information to the advantage of mankind humankind.