Adv in Health Sci Educ (2014) 19:611–623

DOI 10.1007/s10459-013-9484-2

REFLECTIONS

Utilizing codes of ethics in health professions education

Michael D. Dahnke

Received: 7 March 2013 / Accepted: 26 November 2013 / Published online: 22 January 2014
 Springer Science+Business Media Dordrecht 2014

Abstract Codes of ethics abound in health care, the aims and purposes of which are
multiple and varied, from operating as a decision making tool to acting as a standard of
practice that can be operational in a legal context to providing a sense of elevated seri-
ousness and professionalism within a field of practice. There is some doubt and contro-
versy, however, regarding the value and use of these codes both in professional practice
and in the education of healthcare professionals. I intend to review and analyze the various
aims and purposes of ethics codes particularly within the study and practice of healthcare
in light of various criticisms of codes of ethics. After weighing the strength and import of
these criticisms, I plan to explore effective means for utilizing such codes as part of the
ethics education of healthcare professionals. While noting significant limitations of this
tool, both in practice and in education, I plan to demonstrate its potential usefulness as
well, in both generating critical thinking within the study of ethics and as a guide for
practice for the professional.

Keywords Ethics
Codes of ethics
Professional ethics
Education

Healthcare education

Introduction

Several years ago I was tasked, along with a nurse ethicist colleague, with developing an
ethics course for a Master of Science in Nursing program. My nurse ethicist colleague
insisted that the ANA Code of Ethics be included in the content of the course. I was at first
reticent. My training as a philosopher, I felt, put me at odds with this approach to ethics and

M. D. Dahnke (&)
Division of Graduate Nursing, Department of Health Services Administration, College of Nursing and
Health Professions, Drexel University, 1501 Cherry Street, Room 111, Friends Center, Philadelphia,
PA 19102, USA
e-mail: mdd23@drexel.edu

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to education. As a philosopher, I’ve read Plato’s Euthyphro. As a college level instructor in

philosophy I’ve taught that text innumerable times. And one of the primary lessons I’ve
tried to instill in my students from this classic, canonical work is to be suspect (or at least
critical) of textual authority; to instead, employ individual, critical thought. To teach ethics
as something that can be contained within a fixed and written code runs counter to such a
lesson. Even the word ‘code’ felt problematic to me. It seemed to entail dogmatism,
inflexibility and rule-fetishizing (Dahnke 2009; Hadjistavropoulos et al. 2002; Haws 2004).
The conception of ‘ethics’ as a doctrinaire set of rules is contrary and antithetical to the
philosophical view of ethics to which I have been socialized in my academic training. That
gets to the heart of my initial concerns regarding the inclusion of codes of ethics within an
ethics class. Rather than instilling in a learner the philosophical attitude of sustained and
in-depth inquiry, conceptualizing ethics as a ‘code,’ I feared, would suggest a more
legalistic view of ethics (Dahnke 2009; Eriksson et al. 2008). That is, students and pro-
fessionals would see the principles of the code simply as rules to be applied and not to be
questioned or to spur deeper inquiry. An alternative, though equally concerning, danger I
considered was that teaching ethics from the position of a code of ethics might suggest the
polar opposite approach that ethics is wholly relativist, thus reinforcing the subjectivist and
relativistic views learners often bring to the learning environment (Dahnke 2009). That is,
the rules of the code would be perceived by the learners merely as the whims of some
unseen, unknown person or group of persons who arbitrarily decide for them the rules of
the game. After some time working with codes of ethics as teaching tools, however, I have
found they can in fact help to instill critical thinking and in-depth analysis of ethical issues
and problems when properly conceived and utilized. Within the context of multiple crit-
icisms of codes of ethics, I plan here to explore the challenges and possible advantages of
utilizing codes of ethics in teaching ethics within health professions education and propose
a strategy or rubric for effectively doing so.

Teaching health care ethics: styles and methodologies

There are a wide variety of approaches to teaching health care ethics. The approach taken
by any particular instructor will depend on many factors. As with any teaching, style and
methodology will depend in part on preferences of individual instructors and social mores
of education. In addition, instructors of ethics in health care come from a variety of
backgrounds, including philosophy, law, theology, medicine and other clinical work,
which will affect their approaches to teaching ethics. Attorneys are likely to focus on those
areas where law and ethics intersect. Philosophers and theologians are likely to focus on
more theoretical issues, whereas clinicians are likely to be more concrete and casuist.
Whether the educational environment will be classroom or clinical or a mixture will also
affect educational choices. Clinical settings are more naturally conducive to case
approaches, and classroom settings are more conducive to lectures. The level of the learner
will also be an influence: whether undergraduate students, graduate students, or practicing
professionals of various levels. Needs and backgrounds of these types of learners will
influence the style and methodology of teaching. There is also the variability of teaching
professionals of a single profession or taking a more interdisciplinary approach. Some may
argue that particular approaches are best suited for particular health professions (Jaeger
2001), while others call for more interdisciplinary approaches (Browne et al. 1995; Hanson
2005).

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Many of the approaches to teaching health care ethics can be understood as fitting into
either a top-down or bottom-up method (Beauchamp and Childress 2008). Beauchamp and
Childress (2008) of course present these as methods of justification, but methods of
teaching largely reflect these nonetheless. A top-down method is one that begins with
broad principle and theory. The primary theories addressed in the study of health care
ethics include Kantian deontology, utilitarianism, rights theory, virtue ethics, the prin-
ciplism of Beauchamp and Childress (2008), and some forms of feminist ethics such as the
ethics of care (Noddings 2003). Once an understanding of theory has been established, that
theory can then work its way down to the level of concrete, specific issues and cases. A
bottom-up method, such as casuistry or narrative ethics, begins with specific, concrete
information such as actual cases and works up to general ethical principles that can be
applied in future cases with the studied case as precedent. Each of these approaches has its
advantages and disadvantages. The top-down method is more formally academic, fol-
lowing the more traditional views and approaches of philosophical ethics, introducing
general moral norms and their justification at the beginning, thus allowing for a broad
application from the start. However, the top-down method of teaching ethics can be taken
by learners in a strict, regulative manner that may not allow for the complexity and
uncertainty that so often characterize difficult ethical issues and cases. The bottom-up
method allows more room for complexity and nuance. However, norms are left assumed
and unexplored at the beginning, leading to a possible over-emphasis on factual details and
unquestioned norms. Whichever approach is used by any particular instructor, what I am
proposing here can fit in. A top-down approach will appreciate the theory that stands
behind a code of ethics. A bottom-up approach will be enhanced by the application of
particular codes to cases studied.

Purposes of codes of ethics

First, it is important to understand the various purposes that codes of ethics in general have
been recognized in the literature as serving. These purposes range from the noble to the
mundane and even cynical. Here, I divide these purposes into three general categories:
Personal, Organizational, and Professional. The commonly cited personal purposes are
• To aid in ethical decision making (Dahnke 2009)
• to ‘‘prompt, guide, and inform’’ ethical consideration (Pope and Vasquez 2007, p. 75)
• to translate philosophical ethics ‘‘into a set of guidelines that can be applied to…day to
day decision making…’’ (Dean 1992, p. 285)
• to delineate professionals’ responsibilities (Morrison 2011).
The organizational purposes include
• providing guidelines for ‘‘deportment as a professional within an organizational
setting’’ (Morrison 2011, p. 294)
• ‘‘send[ing] powerful messages about [an] organization’s expectations’’ (Adams et al.
2001, p. 201).
And the professional purposes include
• being an expression of professionalism (Dahnke 2009)
• providing (sometimes legally actionable or defensible) practice standards (Morrison
2011)

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• ‘‘describ[ing] the necessary characteristics for membership in a professional group’’

(Morrison p. 294, 2011)
• setting boundaries for acceptable behaviors (Morrison 2011)
• development of a group identity (Dahnke 2009; Peterson and Potter 2004)
• expressing a ‘professional image’ (Morrison 2011; Johnson 2009).
The final purpose in this third category, expressing a ‘‘professional image,’’ is distinct
from the first in the list, being an expression of professionalism. The first suggests a
recognition of the position, power, and responsibility of a profession, that is, as an im-
pactful activity beyond a mere job or occupation with social value and social responsi-
bility. The final purpose listed suggests a more cynical view of codes of ethics as mere
public relations, a superficial expression to the public world that the profession takes ethics
seriously, but in reality nothing more than lip service in the form of this code is paid to the
profession’s responsibilities. Even if a particular code is created with sincere purpose,
neglect and cynicism can lead a profession to lose that purpose. The existence of a code of
ethics may then provide the patina of ethics and professionalism, even if the code has no
substantive effect on the practice or advancement of the profession. Surely it is possible
that particular codes of ethics are employed in this cynical manner, but it is the respon-
sibility of members of the professions and ethics educators to do what they can to ensure
this is not the case.
A critical review of such purposes will alert learners to the motivations and goals behind
the construction of these codes. This will increase professionals’ and future professionals’
understanding of the codes as meaningful documents and not simply as arbitrary rules that
can either be followed or violated. Understanding the personal purposes, which focus on
codes as aids in ethical reasoning and in delineating professional responsibilities, places the
learner within a professional practice and professional socialization. It provides a mean-
ingful context for the more abstract study of ethical theory and reasoning that comes with
the study of ethics. It communicates to the learner the importance that the profession places
on ethics and ethical decision making. It creates a relationship based on value and ethics
between the learner, the profession as an abstract entity, and the code of ethics itself.
The organizational purposes, providing guidelines for ‘‘deportment as a professional
within an organizational setting’’ (Morrison 2011, p. 294) and ‘‘send[ing] powerful mes-
sages about [an] organization’s expectations’’ (Adams et al. 2001, p. 201), provide a
context of meaning for the code within the working of an institution such as a hospital or
clinic. Understanding that codes of ethics are meant to fulfill these goals demonstrates the
effect and utility of the code in the effective and ethical operation of an institution. It
reinforces the idea of team work and collective goals from within an ethical context.
The majority of the professional purposes refer to a code expressing and reinforcing a
practice as profession, demonstrating the social value, integrity, and even elevated status
inherent in a practice such as nursing, medicine, physical therapy, or healthcare admin-
istration. Understanding such purposes of a code of ethics helps to cultivate students’
professionalization. They learn the social importance of the practice they are studying and
the skills they are attaining as well as the responsibilities that attend this importance and
elevated status. Healthcare students and professionals learn that in studying this practice
and attaining these skills that they are not just skilled individuals but members of a unified
social group with common interests, goals, and responsibilities. As noted above, however,
the cynically identified purpose of expressing a ‘professional image’ (Morrison 2011;
Johnson 2009) interprets codes of ethics superficially as merely providing a façade or
patina of respectability. According to this view, codes of ethics do not provide substantive

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guidance or meaning but only fulfill superficial social expectations for a profession.
Studying this view has its value as well. An open discussion on the legitimacy of this view
will bring more meaning to a code of ethics for students and allow them to make the
decision to allow a code of ethics to develop more meaning for them than this view
implies. They develop their own meaningful relationship to the code and understanding of
a code’s true purposes.

Criticisms and limitations of codes of ethics

A review of the literature concerning codes of ethics uncovers several key criticisms of
codes of ethics, including the problems of interpretation, multiplicity, legalization, and
futility. These common criticisms should be addressed in order for learners to understand
the limits of codes of ethics, to understand that they do not express absolute truth about
morality but the reasoned, educated views of experienced, thoughtful, sincere members of
the profession—and that the power and authority of the code resides in both the extent and
the limits of this reasoning, not in the authority of the architects of the code. Also, it is
important to address these criticisms to demonstrate how education on a code can minimize
or even eliminate the problems that these criticisms raise.

The interpretation problem

According to the interpretation problem (Eriksson et al. 2008), because a simple set of
rules is not enough for a code of ethics to be helpful and effective, professionals will have
to interpret the ethics and will need a foundation of theory for this. And further, interpretive
and analytic skills will be necessary to work out inevitable conflicts that will arise even
within the strictures of a code. For example, according to the International Council of
Nurses Code of Ethics for Nurses,
The nurse holds in confidence personal information and uses judgement in sharing
this information.
The nurse shares with society the responsibility for initiating and supporting action to
meet the health and social needs of the public, in particular those of vulnerable
populations. (ICN 2012)
Given that the health of the public may sometimes be aided by public disclosure of health
problems, it is possible that the private information of a particular patient could benefit
someone other than the patient in question. The case of Prosenjit Poddar is a classic
example of this type of conflict (Tarasoff v. Regents of the University of California, 1976).
Poddar, a student at the University of California at Berkeley in 1969, confided in a
psychologist his plan to kill Tatiana Tarasoff, a female student with whom he had become
obsessed. An order to commit Poddar was not carried out and later rescinded. Poddar later
did kill the young woman. Tarasoff’s family then sued the university for failing to warn
Tatiana by divulging information related in confidence by Poddar to his psychologist.
Eriksson et al. (2008) identify three aspects of the interpretation problem. (1) Because of
an inevitable gap between rules and practice, agents have to interpret the rules or principles
of a code of ethics to apply them in particular, concrete situations. (2) In order to interpret
and effectively apply the rules of a code of ethics, a foundation of theory is needed. (3) The
inevitability of ethical conflict, involving conflicting values and incompatible imperatives,
demands interpretation. The perception of the interpretability problem as a ‘‘problem’’

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implies that health professionals as a rule will not have the requisite conceptual tools and
skills to properly and intelligently interpret the general principles and provisions contained
within a code of ethics, which is in itself a debatable point. It is true that no code of ethics
could reasonably foresee every possible ethical situation and problem that may arise and
thus some degree of interpretation will inevitably be needed by any professional who may
appeal to such a code. However, if it were even possible for such a fully comprehensive
code of ethics to be constructed, such a detailed set of rules would in fact contravene the
proper philosophical understanding of ethics and erode any sense of professional autonomy
and accountability as it will be the code, in a sense, making decisions not the trained
professional.
Morrison (2011) and Johnson (2009) each identify a similar criticism they refer to as the
vagueness problem. The charge is that the rules, principles, and provisions of codes of
ethics tend to be too vague to provide clear guidance in concrete situations. For example,
‘‘the Canadian Physiotherapy Association’s Code of Ethics and Rules of Conduct directs
physiotherapists to respect the client’s rights, dignity, needs, wishes and values’’ (Canadian
Physiotherapist Association 1989). These are clearly important directives, but what
‘‘rights, dignity, needs, wishes and values’’ are in any particular situation require clarifi-
cation and concretization to be truly meaningful. Indeed, even what it means to respect
each of these is in need of clarification to be put into practice.

The multiplicity problem

The multiplicity problem (Eriksson et al. 2008; Morrison 2011) involves the fact that for
any professional there may be various relevant codes of ethics. For example, for my
healthcare administration students I recently listed these possibly relevant ethical codes:
the ACHE (American College of Healthcare Executives) Code of Ethics, AAMA (American
Academy of Medical Administrators) Code of Ethics, the Code of Ethics for Long Term
Health Care Administrators, the PAHCOM (Professional Association of Health Care
Office Management) Code of Ethics, The Institute of Healthcare Management Code of
Conduct for Healthcare. And I’m not sure I’ve exhausted the possibilities for this list. Such
a multiplicity of codes can be confusing to a learner, particularly if codes are conceived
merely as regulative sets of rules. The learner is left wondering which of these is relevant
and authoritative for him or her.
Another aspect of this problem is the ‘‘bicodal’’ nature of some health professionals
(Morrison 2011), meaning that some health professionals’ training and position place them
within two distinct professions and thus subject to more than one code of ethics—or groups
of codes of ethics. For example, a physician who is also an administrator may be subject to
the AMA Code of Medical Ethics as well as the ACHE Code of Ethics or any of the other
various administrative codes I just noted. If provisions or directives among these codes
conflict, a physician-administrator may be left in a confusing position. The AMA Code of
Medical Ethics states an obligation for physicians ‘‘to place patients’ welfare above their
own self-interest and above obligations to other groups’’ (American Medical Association
2001). The ACHE Code of Ethics directs administrators to ‘‘[p]rovide healthcare services
consistent with available resources, and when there are limited resources, work to ensure
the existence of a resource allocation process that considers ethical ramifications’’
(American College of Healthcare Executives 2008). For a physician who is also an
administrator, these obligations could appear in conflict as both physicians and adminis-
trators may have duties to various individual and groups of individuals, including patients.
A foundation of theory and critical thinking is necessary to resolve such apparent conflict.

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Just as with the third aspect of the interpretation problem, the multiplicity problem is
especially troublesome with the possibility that imperatives among these various codes
might conflict.

The legalization problem

The legalization problem (Eriksson et al. 2008) is the criticism that understanding ethics
through codes leads to a conceptualizing of ethics in terms of mere legality, which may
lead to a number of ethically problematic consequences. Actions may be formulated in
order to minimally meet the perceived requirements of the code rather than toward
developing a coherent, comprehensive, and reflective ethical life. Health professionals may
lose a sense of accountability if they believe the answers to difficult ethical questions are
readily obtainable from a pre-existing document rather than being found through a process
employing their own reasoning, conscience, and character. And any ability of health
professionals to educate new and entering professionals inclusive of the ethical aspects of
practice would likely be lessened.
Related to this problem is the conceptualization of codes of ethics in terms of Fou-
cauldian governmentality (Foucault 1980, 2001). Foucault uses this term to refer to the
means by which modern governments utilize various forms of power to regulate society
and the behavior of citizens. In a similar manner, a code of ethics can be seen as a means of
regulating the behavior of individual practitioners. And thus, instead of practitioners for-
mulating their ethical behavior themselves, within critical consultation of the code, they
may be said to conform to a pre-existing morality established by the profession.

The futility problem

The futility problem (Morrison 2011) consists of the double presumption that an appro-
priately ethical professional will not need a code of ethics, and an unethical professional
will, as a matter of her/his character, ignore a code of ethics. Thus, for one a code would be
unnecessary and for the other a code would be neglected. This criticism, however, over-
simplifies both the state of many ethical problems and the character of most persons. Even
the most virtuous of professionals may need guidance when faced with difficult situations.
Virtue in itself may not guarantee right action. Strong character and moral virtue may
motivate one toward right action, but if the complexity and the nuance of a particular
situation overwhelm mere common sense, virtue may need to be accompanied by theo-
retical understanding and critical thinking skills. And the character of most persons,
including most health professionals, cannot be simply gauged on a dichotomous scale of
ethical or unethical. Most characters fall in a complex area in the middle where a code of
ethics can provide helpful guidance to direct them toward the ethical end of the scale.
A final common criticism is that it is difficult to enforce the provisions of codes of ethics
and what is needed instead are established ‘‘systems for reporting problems, investigating
charges, and reaching conclusions’’ (Johnson 2009, p. 285). Rather than being a code of
ethics, such a system would be a system for control or regulation of professional action.
While such a system may have its value, it does not encourage truly ethical decision
making and activity. It would direct or control behavior rather than guiding professionals to
make ethical decisions of their own. Also, such a system may not be able to take into
account the complexity of the potential problems to be faced by health professionals and
may restrict their actions and decisions beyond what the nuance and complexity of some
situations demand.

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From codes of ethics to a code of ethics

In addition to an analysis of ethics codes in general, an analysis of a relevant ethics code in

particular is needed. It is not enough to simply and cursorily read through the various
provisions. A close analysis of the content of the code in addition to an analysis of the
construction of the code can lead to deeper understanding of and more thoughtful appli-
cation of the code. This analysis can take many forms. Here I present one possible, quasi-
Aristotelian rubric: the What, Where, Why, and When of the code. This content and
context analysis can also mitigate or eliminate many of the problems with codes noted by
critics.

The What of a code

The What of a particular code includes what specifically the code says. What types of
behaviors does it permit, prohibit, and require? What are the ethical imperatives for
practice? What does it identify as the central values of the profession? And in concrete
terms what does it mean to follow and to violate specific provisions of the code? Here, I
typically have students take a specific principle or provision of the code and not just read it
but attempt a close analysis and interpretation in terms of these questions. Here, for
example, is an interpretation by a Master of Science in Nursing student of Provision 3 of
the ANA Code of Ethics for Nurses: ‘‘The nurse promotes, advocates for, and strives to
protect the health, safety, and rights of the patient’’ (ANA 2001, p. 12):
Provision three states that the nurse’s ‘ultimate moral duty’ is focused on caring for
those who are in need of nursing care…Provision three identifies and discusses the
key word ‘protect’ as a central part of nursing…The role of the nurse is to respect,
maintain, and protect patient autonomy. Nurses are able to protect patients in mul-
tiple ways. Protecting patient information involves respecting their privacy, main-
taining confidentiality, and keeping patients informed. Additionally, protecting
research participants by maintaining informed consent and communication between
researcher and patient is highlighted by provision three. Provision three describes yet
another way to protect patients with ensuring that nurses meet educational and
clinical standards and continue ongoing education to be highly prepared. Nurses
should decrease hindrances to patient care, recognize poor and harmful patient care,
and act as change agents to address poor practice and encourage safe care.
You see the student here reading beyond the broad directives to that which the provision
impels for actual practice, recognizing the plurality and complexity of application, so that
the provision is no longer a sterile collection of words but a meaningful statement of the
values of the profession. Studying this question may mitigate or eliminate the interpreta-
tion and vagueness problems, providing a basis for critical thinking and critical inquiry in
order to bring concrete and justifiable meaning to general principles and directives. Sim-
ilarly, the futility and legalization problems could be mitigated with the provision of a
background of critical interpretation.

The Where of a code

The Where question is a two-part question the purpose of which is to lead learners to the
understanding of the principles or provisions of the code as something more, something
deeper than a simple set of rules, but as a statement of value, as imperatives with rational,

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logical support, not directives that arbitrarily spring from some anonymous authority. So
the anonymity of the authors (from where, practically, the code comes) of the code should
be lifted. Identifying the authors of the code removes the sense of the code as disembodied
scripture to be followed blindly without thought or question. Learners should recognize
these authors as not morally superior but as flawed but presumably well-intentioned,
educated, thoughtful professionals with the goal of improving the profession and its place
in society. The details of this information are not always easily obtainable, but when they
are, it is valuable information that can be imparted and contextualized quickly.
For example, the American College of Healthcare Executive Code of Ethics was originally
written by an ACHE committee chaired by G. Harvey Agnew, both a physician and Fellow of
the ACHE (Squazzo 2008). This code was approved by both the ACHE and the American
Hospital Association and published by the AHA (Squazzo 2008). The ACHE later published
its own separate code, and both these joint and the individual codes were revised several times
by committees composed of members of the ACHE. But what is important for the learner to
realize is that the moral authority of the code lies not with these committees and their members
but the reasoning and the theory backed up by centuries of philosophical study that go into
these codes, which leads us to the second part of the Where question.
With the code no longer perceived as authoritarian but as a thoughtful document which the
student and professional can engage with on an intellectual level, I typically ask students to
provide a theoretical interpretation of one of the provisions of the code in question (from
where in terms of theory and justification the code and its provisions and principles comes) in
order to deepen the understanding of the code as well as communicate the true moral authority
of the code. For example, here is an undergraduate health administration student’s theoretical
analysis of provision I.E. of the ACHE Code of Ethics: ‘‘Avoid the improper exploitation of
professional relationships for personal gain’’ (ACHE 2008):
Exploitation suggests a violation of Kant’s categorical imperative to treat others as
ends in themselves and not as means only. In exploiting a professional relationship
you’re not only exploiting the relationship but also the person who you have the
relationship with or your own organization. Also, from a utilitarian point of view, if
you are exploiting a relationship and making decisions for your own gain and not the
good of your organization, you are likely not making the decision that will benefit the
most people the most.
We see this student coming to terms with the meaning of the provision and excavating an
ethical justification, so that this provision becomes more than a rule. It becomes a
meaningful imperative that the student can see as ethical in itself rather than just as a
directive from an anonymous authority. The student recognizes the authority lying not in a
sterile document but in the reasoning behind the document and, even more important, in
the student’s own understanding of this reasoning. A deeper theoretical understanding of
the code may also provide a basis for critique of the code, for professionals to ‘‘reflect their
ideas when they deal with the shortcomings of the codes in their practice’’ (Zahedi 2013,
p. 3). Such critique is necessary for future updates and revisions but also for a true ethical
relation to the code, that is in the sense of the professional owning their own actions and
choices, rather than acceding to a given morality, thus allowing for resistance to the code
as a species of Foucauldian governmentality, which allows for a Foucauldian development
of ethics as opposed to simple obedience to morality (Foucault 1978). Exploring the Where
question may help alleviate the interpretation and vagueness problems and the legalization
problem. Understanding the theoretical foundation of a code of ethics brings intellectual
meaning to the code. The student or professional comes to understand the code as more

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than a list of rules or directives, but as an eminently comprehensible and justifiable

statement of ethics that each person can bring into their own character, judgment, and
professional autonomy rather than following in a rote, mechanical manner. Specific and
concrete meaning can be brought to general principles and directives.

The Why of a code

The ‘Why’ question returns us to the purposes of codes of ethics—but now in a more
specific, particularized sense. Why did the profession construct this code? Why did pre-
sumably intelligent, educated, well-intentioned leaders in the profession find the creation
of a code important and valuable? You can look to the code in question itself and often a
preamble or commentary on the code will point to purposes identified by the architects of
the code. For example, the Code of Ethics for the Physical Therapist from the American
Physical Therapist Association explicitly defines five purposes for this code:
1. Define the ethical principles that form the foundation of physical therapist practice in
patient/client management, consultation, education, research, and administration.
2. Provide standards of behavior and performance that form the basis of professional
accountability to the public.
3. Provide guidance for physical therapists facing ethical challenges, regardless of their
professional roles and responsibilities.
4. Educate physical therapists, students, other health care professionals, regulators, and
the public regarding the core values, ethical principles, and standards that guide the
professional conduct of the physical therapist.
5. Establish the standards by which the American Physical Therapy Association can
determine if a physical therapist has engaged in unethical conduct (Code of ethics for
the physical therapist 2013).
The purposes identified for this particular code can be fit into the rubric for general
purposes of codes provided earlier. The first purpose fits within the organizational purposes
of guidelines for ‘‘deportment as a professional within an organizational setting’’ (Morrison
2011, p. 294). The second, fourth, and fifth purposes refer more to individual actions and so
fit within the personal purposes that focus on aid in ethical decision making (Dahnke 2009)
and informing ethical consideration (Pope and Vasquez 2007). And the third stated purpose
falls within the professional purposes of being an expression of professionalism (Dahnke
2009) or setting boundaries for acceptable behaviors (Morrison 2011).
These self-defined purposes can then be studied to enhance understanding of how the
architects of the code foresaw its implementation and contribution to the profession. This
study then can enhance a learner’s understanding of their profession, as a serious, autonomous
practice with social and cultural value, and valuable ends at stake. Understanding the
underlying purpose(s) of a particular code leads healthcare students and professionals to
understand its importance and function as a guide and statement of a profession’s ethical
views and responsibilities. The difficulty of enforcement and legalization problems can be
addressed in this way. Bad behavior will not be eliminated in this way, but neither would it
with a ‘‘system for reporting problems, investigating charges, and reaching conclusions’’
(Johnson 2009, p. 285). However, understanding the dignity of their profession and the value
given to ethics may provide professionals with the spirit, virtue, and inspiration to employ the
code in the critical, thoughtful manner intended. In support of this, Adams et al. (2001)
conclude in part from their study that ‘‘ethics codes may influence behavior more by generally
legitimizing and communicating the importance of appropriate behavior than by educating

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employees about what specifically constitutes ethical behavior’’ (p. 208), demonstrating the
capacity for a code of ethics to encourage and inspire ethical action dissociated from a
punitive system intended to regulate behavior.

The When of a code

Knowing When a code was first designed provides a deeper appreciation of the devel-
opment and maturation of a learner’s practice as a profession. Looking at the practice both
pre and post code development further highlights the purposes of the code, particularly
those regarding being a profession and recognizing the social value of that which the
learner is studying. As a learner conceptualizes her practice as a profession, the centrality
of ethical behavior, the social good offered by the practice, and the risk of harmful and
unethical behavior become more apparent. Qualities of a profession include ‘‘high social
prestige’’ and ‘‘an esoteric and complex body of knowledge’’ (Dahnke and Dreher 2011,
p. 13). Aspects such as these clearly imply responsibilities. Whether or not a profession or
professional deserves social prestige, if it is going to be bestowed, the profession and all
professionals have a responsibility to act and work as if it is deserved. Esoteric and
complex knowledge brings with it power and capacity for good and for evil. To ensure the
profession develops in a direction toward good, attention to ethics through the development
of codes of ethics, among other strategies, is important.
In addition, knowing both that and when a code has been revised helps learners con-
ceptualize the fallibility of the code. It helps to foster what I call a proper relationship with
the code. This proper relationship is not one of simple rule following but of active
engagement in order to autonomously handle not only simple ethical issues but difficult
dilemmas. Recognizing that a code of ethics has been—and may yet still be—revised
teaches healthcare professionals and students that any code is not scripture from on high
but a fallible document constructed by intelligent, well-intentioned but ultimately fallible
professionals. There are numerous motivations for revising a code, including the devel-
opment of new technology or changes in the environment or economics of health care, the
incidence of high profile immoral or unprofessional behavior, the inherent fallibility of the
code as a human document, and simply a profession’s commitment to high ethical stan-
dards and ethical excellence. This recognition of real-world fallibility communicates the
complexity of ethics, of problems that are not solved by simply applying a rule to a
situation and also communicates the need for continuing critique and reappraisal of our
moral beliefs and principles. This is a lesson itself in how seriously their profession takes
ethical conduct. In discussing Iran’s newly developed National Code of Ethics for Nurses,
Zahedi et al. (2013) describe the development of a code of ethics as ‘‘an ongoing pro-
cess…an overall responsibility to keep the codes current, updated with the new progresses
of science and emerging challenges’’ (p. 3). Recognizing that no one code is perfect in
itself can help healthcare students and professionals to understand why different relevant
codes may exist and how to handle that seeming inconsistency in practice standards, thus
bringing some mitigation to the multiplicity problem—and also, by extension, the inter-
pretation problem, the legalization problem, and the difficulty with enforcement problem.

Conclusion

In summary, codes of ethics, while not without faults, can be a valuable part of ethics
education if properly taught to help foster an appropriate relationship with the code.

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In more detail, this education can help deepen understanding of principle and theory and
help demonstrate how principle and theory can be put into practice. In addition, studies
have shown that decision making in organizational settings is not purely individual but
highly influenced by organizational context (Adams et al. 2001; Fraedrich and Ferrell
1992; Jones and Hiltebeitel 1995; Weber 1990). In the area of ethical decision making, this
means that having a sound code of ethics can provide substantive guidance and motivation
for making ethical decisions. And finally, as many professions include ethical codes as
constitutive of standards of practice that can have legal implications, it’s important from a
merely practical perspective for learners to have a clear understanding of the codes of
ethics of their professions.

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