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Occupational therapists, like many health practitioners, are in a unique relationship of trust with their clients. In occupational therapy practice, a conflict of interest arises when the occupational therapist has a relationship or interest, which could be seen by a reasonable person as improperly influencing their professional judgement or ability to act in the best interest of the client. An actual conflict of interest means an action has already occurred. A potential conflict of interest occurs where a neutral and informed person, would reasonably conclude that an occupational therapist may fail to fulfil their professional obligation to act in the best interest of the client. A perceived conflict of interest is where a neutral and informed person would reasonably conclude that the occupational therapist has been improperly influenced even if that is not actually the case. Therefore, a perceived or potential conflict of interest is as significant as an actual conflict of interest. A conflict of interest, whether it is actual, potential or perceived, needs to be addressed.

The Regulated Health Professions Act, 1991 (RHPA), as amended, acknowledges occupational therapists as autonomous practitioners. The regulation of the profession requires occupational therapists to practice according to established standards and principles of practice, and to apply these standards consistently in a responsible, intentional manner within the health care environment.

Occupational therapists have a legal and ethical duty to act in good faith and to deliver health care services in the best interest of their clients. A conflict of interest may compromise clients’ trust in the occupational therapist. The Standards for Prevention and Management of Conflict of Interest are meant to ensure that occupational therapists in Ontario are aware of the minimum expectations for recognition, prevention and management of conflict of interest.

A conflict of interest is often viewed in terms of monetary benefits. However, it may also be a result of a boundary-crossing or violation, such that the occupational therapist is meeting their own needs in the relationship to the detriment of the client in the immediate context or possibly in the future.

If not addressed, a conflict of interest may compromise the confidence, trust and respect the client has in the occupational therapist or the organization that is represented by the occupational therapist. This makes conflict of interest a significant issue of concern to Registrants and the College. In addition, the College receives many calls from Registrants seeking information or guidance on practice issues that revolve around conflicts of interest. The Ministry of Health and Long-Term Care is also concerned about this issue and has issued guidelines to assist health regulatory Colleges in developing conflict of interest regulations.

Occupational therapists are in a position of authority and thus have a duty to meet the best interest of their clients who rely on them. They have access to personal and sensitive information and often work with people who may be vulnerable in different ways. Because of this, occupational therapists have a professional responsibility to uphold fundamental values of respect and trust. When an occupational therapist is in a conflict of interest, these key fundamental values and confidence in the health care system may be compromised. Managing a conflict of interest is important because it encompasses the principles that support the values of honesty, fairness, accountability and transparency. Ensuring one’s practice is free from conflict of interest also maintains principles of good practice; client centeredness, recognition of the dignity and worth of each person and their diversity and individuality. It is considered professional misconduct for an occupational therapist to practise while in a conflict of interest. The standards for conflict of interest are intended not only to enable occupational therapists to comply with the standards and regulations, but also to maintain and promote trust and respect of the profession.

Occupational therapists are responsible for recognizing, as well as anticipating situations of conflict of interest. On an ongoing basis, occupational therapists will proactively prevent or avoid a conflict of interest and where that is not possible, take measures to effectively manage the conflict.

In the delivery of occupational therapy services, and in order to meet the best interests of the client, an occupational therapist will identify all the other stakeholders involved. Using professional judgement and knowledge, the occupational therapist is responsive to the expectations of each stakeholder separately. During the process of determining the parameters of his or her role, the occupational therapist identifies and manages competing interests of different stakeholders, as well as their own self-interest.

Given their professional knowledge, trust and position of authority, an occupational therapist should keep in mind that it is her/his responsibility to prevent conflict of interest from occurring through an abuse of their power or authority. The onus is on the occupational therapist to recognize issues of power and control; anticipate, be alert to, manage conflict of interest and practise in a manner that preserves the client’s trust and confidence. An occupational therapist should always bear in mind that the consent of a client is not a defence in a conflict of interest situation.

In circumstances where conflict of interest cannot be avoided or such action may not be in the best interest of the client, occupational therapists are expected to effectively manage the conflict while demonstrating care and professional integrity. The following standards and performance indicators outline the expectations of occupational therapists related to avoiding or managing actual, potential or perceived conflict of interest. The standards will enable Registrants to be more proactive and exercise sound professional judgement in recognizing, preventing or managing conflict of interest situations.

• The following standards describe the minimum expectations for occupational therapists.
• The performance indicators listed below each standard describe more specific behaviours that demonstrate the standard has been met.
• There may be some situations where the occupational therapist determines that a particular performance indicator has less relevance due to client factors and environmental factors (e.g., an occupational therapist practising in a remote area may not be able to avoid certain relationships). Such situations may call for the occupational therapist to seek further clarification.
• It is not expected that all performance indicators will be evident all the time, but could be demonstrated if requested.
• It is expected that occupational therapists will always use their clinical judgement to determine how to best meet the client needs in accordance with the standards of the profession.
• It is also expected that occupational therapists will be able to provide reasonable rationale for any variations from the standards.

Pursuant to the Regulated Health Professions Act, 1991 (RHPA), the College is authorized to make regulations in relation to professional practice. Ontario Regulation 95/07: Professional Misconduct, establishes that “contravening, by act or omission, a standard of practice of the profession or failing to maintain a standard of the profession,” constitutes grounds for professional misconduct.

College publications contain practice parameters and standards which should be considered by all Ontario occupational therapists in the care of their clients and in the practice of the profession. College publications are developed in consultation with occupational therapists and describe current professional expectations. It is important to note that these College publications may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained.

Part A

The first three standards are the guiding principles proposed for these Standards for Prevention and Management of Conflict of Interest:

Standard 1.		Recognition of Conflict of Interest
Standard 2.		Prevention of Conflict of Interest
Standard 3.		Management of Conflict of Interest

Part B

The following are more specific Prevention and Management of Conflict of Interest Standards:

Standard 4.		Personal Benefit
Standard 5.		Dual or Multiple Relationships
Standard 6.		Self-Referral
Standard 7.		Stakeholder Relationships
Standard 8.		Research or Quality Assurance and/or Improvement
Standard 9.		Council, Committee or Administrative Membership

Sometimes, a conflict of interest situation may not be obvious and even an experienced occupational therapist may not easily recognize it. A situation may potentially lead to a conflict of interest, or be seen by others as presenting a conflict of interest although the occupational therapist may not see it that way. Nevertheless, whether the conflict of interest is perceived, potential or actual, the occupational therapist will be expected to foresee and appropriately address such a situation.

Standard 1

The occupational therapist will proactively be alert to and recognize any actual, potential or perceived conflict of interest.

      Performance Indicators

While not every conflict of interest can be avoided, most can.

Standard 2

The occupational therapist will make deliberate efforts including communication with clients, to avoid or prevent an actual, potential or perceived conflict of interest from occurring.

      Performance Indicators

Not all conflicts of interest are the same. Some may be very serious and need to be prevented or avoided at all costs. However, other conflicts of interest may be less serious and could be judiciously managed. There are instances where a conflict of interest cannot be avoided. In those circumstances, the conflict of interest must be managed. For instance, in a small rural community an occupational therapist may provide services to a client who is also a friend he or she met through the church that they both attend.

Standard 3

The occupational therapist will be proactive in effectively managing and mitigating an unavoidable conflict of interest.

      Performance Indicators

Please refer to the first three standards before proceeding with the following specific prevention and management of conflict of interest standards.

Conflicts of interest may be described as involving the receipt of a benefit that conflicts with an occupational therapist’s responsibilities to a client, or that may improperly influence the occupational therapist’s ability to act in the best interest of the client. Such a benefit may lead to an occupational therapist or a closely related person or corporation gaining materially, financially, professionally or personally. Professional judgement and practices are expected to be rendered in an objective and transparent manner without consideration of personal, financial or material gain. One of the most common issues for occupational therapists is the presentation of gifts. Please refer to the practice examples in the Standards for Professional Boundaries for reflection on this topic.

Standard 4

The occupational therapist will not exploit the therapeutic relationship with a client for any form of personal gain, benefit or advantage, which may interfere with his/her exercise of sound professional judgement.

      Performance Indicators

A dual relationship exists when an occupational therapist serves in the capacity of both occupational therapist and at least one other relationship (multiple relationships if more than two) with the same client. The second (or more) relationship could be personal, social, financial or professional and may be concurrent or subsequent to the therapeutic relationship. It can also exist when an occupational therapist is in a professional role with a person and promises to enter into another relationship in the future with that person or somebody closely related to that person.

Standard 5

The occupational therapist will avoid dual or multiple relationships (e.g., personal, professional or financial relationships) that could compromise their professional judgement or increase the risk of a boundary violation leading to conflict of interest.

      Performance Indicators

Self-referral occurs when an occupational therapist working in one professional setting refers clients to him/herself in another professional setting in which the occupational therapist has any interest or gains any benefit. For instance, an occupational therapist working in a hospital refers a client to a clinic in which they have a financial interest, amounting to self-referral.

Standard 6

The occupational therapist will avoid self-referral when there is a potential, perceived or actual financial benefit, unless alternative options are not in the best interest of the client or the client is at risk of not receiving the services.

      Performance Indicators

Occupational therapists need to anticipate actual, perceived or potential conflict of interest in personal, professional, or business relationships with stakeholders. These stakeholder relationships can, depending on the circumstances, constitute a conflict of interest.

In this standard, stakeholders refer to vendors, companies and manufacturers. Some relationships or business ventures with stakeholders can be a source of conflict of interest. An occupational therapist may have a close relationship or rapport with an equipment vendor borne out of experience using the vendor’s equipment. The vendor may provide the occupational therapist with the latest model of the equipment to be trialed at the clinic where the occupational therapist works. Similarly, an occupational therapist may provide assessment and recommend equipment or prescription and also have a business association with the vendor selling the equipment (self-dealing).

Standard 7

The occupational therapist will reflect upon personal, financial and business relationships with stakeholders, and will avoid those that would constitute or be perceived to constitute a conflict of interest.

      Performance Indicators

Research, in this context, can be defined as the search for knowledge and new understandings or as any systematic investigation using scientific methods.

When research is conducted involving human subjects, it is expected that occupational therapists will ensure they obtain approval through a Research Ethics Board (the Board is responsible for ethical assessment and approval of all research involving human subjects to ensure that participants are not harmed, abused or exploited and to maintain commitment to the scientific methods rather than interest in results for personal gain or financial benefit for researchers or sponsors). When an occupational therapist engages a client in research, they will follow the expected procedures and cautions laid out by the approval process of the Research Ethics Board of their related organization or institution. These procedures will include a full explanation of all aspects of the research before requesting informed and ongoing consent from the client. Also, the procedures will ensure that clients are not subject to undue pressure to participate.

There may be times when an occupational therapist has decided to study or evaluate a certain aspect of their practice that does not qualify as research under the Research Ethics Board. The Interagency Advisory Panel on Research Ethics which brings together the three federal government research agencies has determined that these types of projects may be categorized as Quality Assurance and/or Improvement studies. The Panel defines Quality Assurance and/or Improvement studies as program evaluation activities, and performance reviews or testing used exclusively for assessment, management or improvement purposes. These are unlike research studies which are meant to answer a research question and invite critical appraisal of that conclusion by peers through presentation and debate in public forums.

While some of the performance indicators outlined below are usually covered by the Research Ethics Board, they are restated here to guide Registrants undertaking quality improvement or assurance projects that are not covered by such a Board. Whether it is a research or quality improvement project, clients need to be assured of confidentiality of the information they give and that their anonymity will be maintained.

An occupational therapist will avoid conflict of interest by ensuring that client’s best interests are the priority. That means clients should be assured that their interests are not subordinate to the occupational therapist’s interests.

Standard 8

The occupational therapist will ensure that the client’s interest and well being is prioritized when involving them in a research or quality assurance and/or improvement project.

      Performance Indicators

Some occupational therapists are members of committees, boards, councils or other similar bodies where they have access to privileged information and/or they influence decision-making. An occupational therapist compromises their role in such a committee if they stand to gain financially or by obtaining a privilege, an appointment or employment from a certain decision.

Standard 9

The occupational therapist will protect the integrity of any committee, board, council or other similar bodies where they are members. The occupational therapist will avoid and/or address (e.g. by full disclosure) any circumstance that may lead to an actual, potential or perceived conflict of interest.

      Performance Indicators

Examples of Practice Scenarios

Personal Benefit

A company that supplies wheelchairs has offered funding for an occupational therapy course. Would this be considered a conflict of interest?

When determining whether to accept this kind of gift, an occupational therapist should consider:

• The motives of the giver;
• Any constraints or conditions attached to the gift;
• The potential or perception of a conflict of interest; and/or
• Employer policy regarding gifts.

Performance Indicator 4.1 states an occupational therapist should refrain from exchanging gifts, hospitality and other benefits to avoid creating expectations for the type of care a client will receive, and prevent the perception that the occupational therapist’s integrity may be compromised. Gifts from commercial sources have the potential to create an obligation and a loss of objectivity. For instance, a gift such as this could influence the occupational therapist’s discussion with clients about their choice of vendor. Overall, such an offer needs to be declined (unless, perhaps, it was part of a project that was open to all occupational therapists and the selection was made by a neutral party).

An occupational therapist should identify these issues and discuss them with his/her supervisor to raise awareness of possible conflicts and assist in their decision making. The company may offer the funding with a motive of influencing the occupational therapist to recommend the company to his or her clients when they are purchasing equipment. It may also add conditions to the offer that would compromise the occupational therapist’s professional judgement. For instance, the offer may be on condition that the occupational therapist will be required to work in a certain area of practice, location or industry upon completion of the course.

Self-Referral

Alice is an occupational therapist operating her own private practice but has been employed at a rehabilitation centre. She is wondering if she could give out her private business cards to clients she sees at the rehabilitation centre.

An occupational therapist will avoid self-referral or soliciting clients for his/her private business, from clients seen at his/her place of employment. Where this is unavoidable, performance Indicators 6.1-6.3 states that the occupational therapist will disclose, give clients options and retain records to show that a disclosure was made. It is not appropriate for the occupational therapist to refer clients from their employment to their private practice. As the performance indicator states, the occupational therapist’s personal interests could interfere with his/her professional judgement or the client’s best interests. For instance, the OT may advocate for an earlier than usual discharge to enable private services to begin, or it may be perceived that this is the case. In addition, Ontario Regulation 226/96: General – Part V: Advertising, does not permit direct solicitation to individual clients. However, an occupational therapist who has a practice separate from hospital employment would be able to distribute their advertising materials to referral sources such as doctor’s offices or through other professionals.

Stakeholder Relationship

An occupational therapist has worked in a rehabilitation centre for a long time and is considered an expert in physical disability rehabilitation. She is well known and respected by the local community and is often invited to speak about physical disability at conferences. In one instance, she has been invited to speak at a conference and present a paper on effectiveness of assistive devices to persons with physical disabilities.

After accepting the invitation, she receives conference materials and learns that each session has a corporate sponsor. Her session is being sponsored by a company that develops wheelchairs among other products. Speakers are also provided with the company logo and are requested to use it in all their presentation slides and handouts. They are also requested to acknowledge and thank the sponsors for the generous sponsorship. Should the occupational therapist agree to present?

It is important to understand that clients seeking health care such as occupational therapy services are typically in a vulnerable position. They look to the occupational therapist for assistance and hold that individual in a position of trust. The public trust that the occupational therapist as a health care professional will act in the client’s best interest. As such, an occupational therapist is expected to practise in a highly ethical, transparent and client-centred manner. Performance indicator 7.1 states that an occupational therapist will recognize and ensure that the primary objective of interactions between the occupational therapist and companies, manufacturers or vendors are in the best interest of the client rather than the private interest of either party.

Further, Performance Indicator 7.2 states that an occupational therapist’s primary obligation is towards the client. Relationships with stakeholders will only be made if they do not affect the integrity, trust and confidence in the occupational therapist/client relationship. In this scenario, the dilemma is whether the occupational therapist is using her professional status to implicitly endorse the company. The occupational therapist might also be pressured to slant the presentation in a particular way to avoid upsetting the sponsor. Using the company logo on handouts and presentation sends the message that the company might have influenced the content of the presentation. This kind of relationship should be avoided unless there are enough safeguards to highlight the objectivity of the occupational therapist (e.g., a disclaimer in the written materials and handouts indicating that the occupational therapist had no connection with the sponsor).

Dual or Multiple Relationships

Paul Smith, an OT, works in a mental health clinic where he has gained a lot of expertise in psychotherapy. His best friend Kate talks a lot about issues with her husband, Andrew, and their intimacy problems. Over time, Kate convinces Andrew to seek therapy. She asks Paul, the OT for a referral, but Paul mentions that finding a therapist can be difficult so he would be willing to see Andrew.

When Paul starts to see his friend’s husband in therapy, Kate mentions at lunch with Paul that her husband has a chronic drug problem that she hopes he has mentioned in therapy. In addition, Andrew informs Paul during therapy that his wife is physically abusing their child. Andrew also wants to bring up issues about his sexual relationship with Kate in therapy, but he feels he can’t share certain things with Paul because he fears the influence of Paul’s friendship with Kate.

In this scenario, there are a number of role conflicts that complicate the situation. The occupational therapist must hold confidential information that he hears from Andrew but he cannot share with Kate. While Paul may have very good processes for protecting confidential information, it can still be easy to slip up and forget who has shared what when he hears stories about the same events and relationship from two different people.

Performance Indicator 5.1 states that the occupational therapist will identify when dual or multiple roles affect or could be reasonably perceived to affect one’s judgement, or ability to be impartial and neutral in the therapeutic relationship (e.g., business partner, friend, relative).

Further, Performance Indicator 5.4 states that the occupational therapist will avoid entering into a therapeutic relationship with family, colleagues, or friends unless no other option is available to provide the required service. When that happens, the occupational therapist will give full disclosure to the client and any third party payer of the potential boundary and conflict of interest issues involved. By agreeing to start a therapeutic relationship with a friend’s spouse, Paul has not only risked a boundary crossing, but may also compromise his judgement leading to a conflict of interest. Paul should have explored other options, such as another occupational therapist or health service professional to provide the required service to Andrew.

College References:
Ontario Regulation 226/96: General – Part V: Advertising
Ontario Regulation 95/07: Professional Misconduct
Standards for Consent (2008)
Standards for Prevention of Sexual Abuse (2007)
Standards for Professional Boundaries (2009)
Standards for Record Keeping (2008)
Code of Ethics (2011)

Legislative References:
The Occupational Therapy Act, 1991
The Regulated Health Professions Act, 1991

Ministry of Health and Long-Term Care References:
Policy Guidelines for Drafting Conflict of Interest Regulations by Health Regulatory Colleges (2005)

Other References:
Canadian Medical Association. (2007). Guidelines for Physicians in Interactions with Industry (CMA Publication Number PD08-01). Ottawa, ON. CMA Online.

College of Physiotherapists of Ontario (n.d.). Standards for Professional Practice – Conflict of Interest. Retrieved from: http://www.collegept.org/Physiotherapists/College%20Documents/Registrants%20Guide/Businesspractices

McMaster Research Ethics Board. (2007). Informed Consent. In MREB Research Ethics Tutorial. Retrieved from: http://www.mcmaster.ca/ors/ethics/tutorial/informedconsent.htm">http://www.mcmaster.ca/ors/ethics/tutorial/informedconsent.htm

Government of Canada, Panel on Research and Ethics, Tri-Council Policy Statement (TCP-2). Retrieved from: http://www.pre.ethics.gc.ca/pdf/eng/tcps2/TCPS_2_FINAL_Web.pdf