Ethical Dilemmas Encountered by Private Sector Rehabilitation Practitioners.

Rehabilitation practitioners are employed in a wide range of settings and provide a variety of services to individuals with differing disabilities. New financial incentives and growth for the rehabilitation profession are being created through rapid expansion of private sector employment in the health care and insurance industries (Habeck, Kress, Scully, & Kirchner, 1994; Shaw, McMahon, Chan, Taylor, & Wood, 1997). The case management industry, with its focus on cost containment, utilization review, and managed competition, has altered the traditional role of the rehabilitation practitioner. Consequently, new responsibilities can translate into ethical concerns for the private sector practitioner. In addition, it is unclear what specific issues are confronted by rehabilitation practitioners employed in private sector care and whether their training needs should be addressed regarding the unique conflicts encountered within the case management role.

Dilemmas associated with the eligibility and the allocation of health care have emerged with the concept and practice of managed care (Haldorn, 1992; Kopelman, 1996; Leahy, Chan, Shaw & Lui, 1997). Managed care becomes a focus of discussion when it is used to serve people with disabilities who often need specialized care, including equipment and services which do not necessarily fit in the fiscal plan of cost-efficient services (Haldorn, 1992; Huntt & Growick, 1997). Dilemmas also arise as individuals, whose conditions do not match applicable necessary-care guidelines for a desired service, fail to meet eligibility (Zola, 1989). Rehabilitation practitioners find themselves in the position of balancing patients' needs for services with the organization's need for cost control (Huntt & Growick, 1997).

In order to effectively deal with potential ethical dilemmas, the responses of rehabilitation practitioners should emerge from a reasoning process. This process includes identifying the available options to resolve dilemmas, recognizing the ethical principles associated with each option, analyzing the case information to determine the consequences associated with each option and making decisions based upon that analysis (Fischer, Rollins, Rubin, & McGinn, 1993; Patterson, 1988; 1989a; Rubin, Millard, Wong, & Wilson, 1991).

An ethical dilemma is a situation in which an individual must choose between two possible decisions, each decision being supported by ethical principles, and in which either choice will result in significant consequences (Rubin et al., 1991). The challenge to make decisions occurs when the decision of the rehabilitation professional for either choice of action may compromise his or her ethical principles and lead to the creation of an ethical dilemma.

Beauchamp and Childress (1983) identify five ethical principles: beneficence, nonmaleficence, autonomy, justice, and fidelity. Beneficence refers to promoting the welfare and interests of others. Nonmaleficence refers to avoiding intentional harm to others. Autonomy refers to respecting a consumer's choices and the right to self determination without controlling constraints. Justice refers to treating others fairly and the equitable allocation of goods and services. Fidelity or loyalty refers to keeping promises and honoring contracts.

A rehabilitation practitioner's failure to recognize ethical dilemmas or to seek appropriate guidance for resolution of dilemmas may suggest that his/her training was insufficient to develop the necessary skills for processing the moral issues involved and making decisions (Emener & Rasch, 1984; Pape, 1987). Frequently, practitioners are unequipped to identify and resolve ethical dilemmas (Fischer, 1992; Millard, 1990; Pape & Klein, 1986; Pelsma & Borgers, 1986; Pope & Vetter, 1992). Rehabilitation professionals will benefit from feeling more competent as they understand the processes that influence their decisions.

The purpose of this study was to: (a) identify ethical dilemmas faced by rehabilitation practitioners employed in private sector rehabilitation; (b) determine how frequently these practitioners are confronted with specific dilemmas; and (c) determine the importance private sector rehabilitation practitioners attach to the development of effective training materials to deal with ethical dilemmas.

Method

Participants

A stratified proportional random sample was selected from the 4,593 rehabilitation practitioners listed in the 1997 national registry of the Certified Disability Management Specialists (CDMS). A sample of 459 individuals was randomly selected, proportionate to the number of CDMS certificants listed for each state in the national registry. A total of 152 surveys were returned with respondents from 36 states. Thirty respondents were eliminated from the study for incomplete surveys or identified as "never employed" in the private sector. The returned useable surveys included 122 responses for an overall return rate of 26.5%.

The age of the respondents ranged from 29 to 66 years with a mean age of 47. The number of years employed in private sector rehabilitation ranged from 1 year to 27 years with an average of 12.7 years of employment. A majority of the sample had either a bachelor's degree 43.4% (n=53) or a master's degree 49.2% (n=60). The remaining respondents had completed a doctorate 4.1% (n=5) or less than a bachelor's 3.3% (n=4). The ethnicity of the sample were as follows: Caucasian 91.8% (n=112); African-Americans 4.92% (n=6); Hispanic 2.46% (n=3); and "other" [is less than] 1% (n=1). Females 69.7% (n=85) comprised the majority of the participants.

Respondents indicated employment in seven occupational settings as follows: the majority of respondents (48%) were employed in insurance/entitlement; 27% were employed as consultants; 7% were employed in facilities/hospitals; 3% were employed in employee assistance programs; and 15% indicated their occupational setting as "other." Eighty-one percent provided direct rehabilitation services. About 75% of the respondents indicated they had received some training in ethics.

Instrumentation

The Ethical Dilemma Survey for Private Sector Rehabilitation Professionals (EDSPS) was constructed for the purpose of measuring how often private sector dilemmas are encountered by practitioners in the work place, and how important it is to receive training in ethics to deal with each type of dilemma. A six-person content-validation panel consisting of CDMS Commissioners reviewed and modified dilemmas from Wong's (1990) study which identified dilemmas encountered in public sector and independent living rehabilitation services. Commissioners were asked to indicate if Wong's dilemmas were encountered in private sector practice. The panel eliminated seven dilemmas that did not relate to private sector practice and added two additional dilemmas, resulting in 33 ethical dilemmas specifically designed for private sector rehabilitation practitioners. The dilemmas were reviewed to ensure that they met the criteria of an ethical dilemma (e.g. contained competing ethical principles, two courses of action, or significant consequences). Respondents were asked to complete a demographic questionnaire and rate the dilemmas on two five-point rating scales (frequency and importance). The frequency scale was rated as follows: 1= Never; 2= Once a year; 3= Once every six months; 4= Once a month; or 5= Once a week. The importance scale was rated as follows: 1= Not important; 2= Somewhat important; 3= Moderately important; or 5= Very important.

Results

In order to determine ethical dilemmas that private sector rehabilitation practitioners encounter most often, the data analysis consisted of a distribution of the Frequency Scale and Importance Scale ratings for the 33 items (Table 1). Items are presented on the basis of the sum of the percent of all respondent ratings for that item that were encountered at least "once per year." In addition, the percent of practitioners that ranked each item as "very important" regarding training need are presented.

Table 1.

Private Sector Rehabilitation Practitioners' Ratings of Ethical Dilemmas Encountered and Importance of Training Need in Each Identified Ethical Dilemma.

                                                         Encountered
                                                             of
                                                         Frequency
                                                         Percent
                                                          (number)

1.  Rehabilitation of a SSDI client into competitive
    employment conflicts with maximizing                   61.67
    the client's financial security.                     (n = 74)
2.  Supporting a client's selection of a particular
    vocational objective conflicts with
    channeling a client toward a more realistic            86.67
    vocational objective.                                (n = 104)
3.  Providing support for a specific type of training
    requested by a client conflicts with supporting
    the type of training recommended in the                82.50
    client's evaluation report.                          (n = 99)
4.  Maximizing a client's placement success by
    withholding information from an employer
    conflicts with maximizing opportunities of             52.50
    other clients with that same employer.               (n = 63)
5.  Withholding information about a client's medical
    condition from other professionals at
    his/her request conflicts with making appropriate      55.00
    referrals for necessary medical services.            (n = 66)
6.  Coordinating a diagnostic service for an
    uncooperative client who appears psychotic
    conflicts with not coordinating that service           49.57
    for the client without his/her approval.             (n = 58)
7.  Maintaining client confidentiality regarding a
    poor work history to increase employment
    opportunities conflicts with providing an employer
    with the necessary information for                     68.97
    making an informed hiring decision.                  (n = 80)
8.  Providing an employer with all relevant requested
    client information conflicts with serving as
    an advocate for the client in the job                  72.17
    placement process.                                   (n = 83)
9.  Adhering with referral source case movement
    guidelines conflicts with providing an
    optimal package of rehabilitation services to          84.48
    a client.                                            (n = 98)
10. Completing required monthly activity summary
    reports conflicts with allotting sufficient time       67.24
    to provide direct services to clients.               (n = 78)
11. Informing an insurance carrier what a client can
    do vocationally knowing it will be used to             82.91
    suspend/cancel benefits the client is receiving.     (n = 97)
12. The clients desire to be trained and work
    conflicts with being asked by the client's
    attorney to testify to the worst vocational            53.91
    scenario.                                            (n = 23)
13. Maintaining a spinal cord injured client's family
    support system through placement in a small
    local community hospital with limited resources
    conflicts with sending the client to a highly          45.61
    specialized rehabilitation hospital far from home.   (n = 52)
14. Confronting a recently physically disabled
    individual concerning his/her life style
    conflicts with responding to the client in order
    to increase the likelihood that he/she
    will accept immediately necessary medical              62.16
    services.                                            (n = 69)
15. Intervening to meet the specific health care and
    safety needs of a client at his/her friend's
    request conflicts with adhering to a client's          47.41
    request to respect his/her privacy.                  (n = 55)
16. Encouraging a client to take responsibility for
    securing necessary medical services to
    prevent potentially dangerous health complications
    conflicts with your acting in accordance with
    an overly dependent client's request to obtain         77.97
    necessary medical services for him/her.              (n = 92)
17. Supporting a client's own choice of services
    conflicts with providing services that can             79.66
    increase the client's potential.                     (n = 94)
18. Concurring with the client's decision to continue
    residing with his/her aging parents conflicts
    with preparing the client to live independently
    outside a sheltered housing environment in the         31.30
    future.                                              (n = 36)
19. Persuading a client to enroll in a sheltered
    workshop to increase potential conflicts
    with respecting a client's wish to be                  31.03
    self-employed at home.                               (n = 36)
20. Trying to resolve problems between the client
    and his/her personal care assistant
    conflicts with respecting the integrity of their       35.04
    employer/employee relationship.                      (n = 41)
21. Providing clients with case file information they
    request conflicts with withholding                     59.83
    distressing information from clients.                (n = 70)
22. Agreeing to provide services for a client
    requested by your major funding source
    conflicts with responding to a client's needs          70.34
    in the most appropriate manner.                      (n = 83)
23. Returning a client to work at the insurance
    carrier's request conflicts with providing             70.69
    placement services when the client is job ready.     (n = 55)
24. Abiding by a supervisor's recommendation against
    providing a medical service conflicts with
    providing medical services you believe would be        54.70
    beneficial to the client.                            (n = 64)
25. Persuading a family to enroll the client in a
    beneficial sheltered workshop program
    conflicts with respecting the family's
    preference to keep the client at home for              31.30
    safety reasons.                                      (n = 36)
26. Telling a likely ineligible client what to say
    to meet eligibility requirements of a cooperating
    agency conflicts with respecting the integrity
    of the eligibility determination process of that       34.78
    cooperating agency.                                  (n = 40)
27. Providing vocational services to a client
    conflicts with adhering to the order                   32.17
    of selection criteria of the agency.                 (n = 37)
28. Keeping client records up to date to promote
    timely delivery of services conflicts
    with providing essential counseling services           51.72
     to clients which will reduce their anxiety.         (n = 60)
29. Informing a client about a terminal disease so
    he/she can plan for the future conflicts
    with not disclosing distressful medical
    information to a client whose physician                26.09
    has not explained the disease to him/her.            (n = 30)
30. Providing comprehensive services to the most
    severely disabled clients on your caseload
    conflicts with providing adequate and timely
    services to large numbers of less severely             52.99
    disabled clients.                                    (n = 62)
31. Providing a client with a needed service such as
    agency transportation conflicts with
    following agency policy that limits a service          26.96
    (vehicle use) for group activities.                  (n = 31)
32. Allocating sufficient time to serve the needs of
    several clients during a week conflicts
    with assisting a client to leave an abusive home       20.35
    situation during the same week.                      (n = 23)
33.  Avoiding educating the client too early to the
    reality of his/her situation conflicts
    with providing the client with requested               44.83
    information.                                         (n = 52)

                                                         Importance
                                                         of Training
                                                            Very
                                                          Important
                                                          Percent
                                                           (number)
1.  Rehabilitation of a SSDI client into competitive
    employment conflicts with maximizing                   27.87
    the client's financial security.                     (n = 34)
2.  Supporting a client's selection of a particular
    vocational objective conflicts with
    channeling a client toward a more realistic            44.26
    vocational objective.                                (n = 54)
3.  Providing support for a specific type of training
    requested by a client conflicts with supporting
    the type of training recommended in the                31.97
    client's evaluation report.                          (n = 39)
4.  Maximizing a client's placement success by
    withholding information from an employer
    conflicts with maximizing opportunities of             29.17
    other clients with that same employer.               (n = 35)
5.  Withholding information about a client's medical
    condition from other professionals at
    his/her request conflicts with making appropriate      34.43
    referrals for necessary medical services.            (n = 42)
6.  Coordinating a diagnostic service for an
    uncooperative client who appears psychotic
    conflicts with not coordinating that service           26.50
    for the client without his/her approval.             (n = 31)
7.  Maintaining client confidentiality regarding a
    poor work history to increase employment
    opportunities conflicts with providing an employer
    with the necessary information for                     29.06
    making an informed hiring decision.                  (n = 34)
8.  Providing an employer with all relevant requested
    client information conflicts with serving as
    an advocate for the client in the job                  29.91
    placement process.                                   (n = 35)
9.  Adhering with referral source case movement
    guidelines conflicts with providing an
    optimal package of rehabilitation services to          43.10
    a client.                                            (n = 50)
10. Completing required monthly activity summary
    reports conflicts with allotting sufficient time       25.00
    to provide direct services to clients.               (n = 29)
11. Informing an insurance carrier what a client can
    do vocationally knowing it will be used to             41.88
    suspend/cancel benefits the client is receiving.     (n = 49)
12. The clients desire to be trained and work
    conflicts with being asked by the client's
    attorney to testify to the worst vocational            43.10
    scenario.                                            (n = 50)
13. Maintaining a spinal cord injured client's family
    support system through placement in a small
    local community hospital with limited resources
    conflicts with sending the client to a highly          30.43
    specialized rehabilitation hospital far from home.   (n = 36)
14. Confronting a recently physically disabled
    individual concerning his/her life style
    conflicts with responding to the client in order
    to increase the likelihood that he/she
    will accept immediately necessary medical              24.32
    services.                                            (n = 27)
15. Intervening to meet the specific health care and
    safety needs of a client at his/her friend's
    request conflicts with adhering to a client's          21.74
    request to respect his/her privacy.                  (n = 25)
16. Encouraging a client to take responsibility for
    securing necessary medical services to
    prevent potentially dangerous health complications
    conflicts with your acting in accordance with
    an overly dependent client's request to obtain         23.14
    necessary medical services for him/her.              (n = 28)
17. Supporting a client's own choice of services
    conflicts with providing services that can             25.83
    increase the client's potential.                     (n = 31)
18. Concurring with the client's decision to continue
    residing with his/her aging parents conflicts
    with preparing the client to live independently
    outside a sheltered housing environment in the         20.34
    future.                                              (n = 24)
19. Persuading a client to enroll in a sheltered
    workshop to increase potential conflicts
    with respecting a client's wish to be                  12.61
    self-employed at home.                               (n = 15)
20. Trying to resolve problems between the client
    and his/her personal care assistant
    conflicts with respecting the integrity of their       11.67
    employer/employee relationship.                      (n = 14)
21. Providing clients with case file information they
    request conflicts with withholding                     21.85
    distressing information from clients.                (n = 26)
22. Agreeing to provide services for a client
    requested by your major funding source
    conflicts with responding to a client's needs          40.83
    in the most appropriate manner.                      (n = 49)
23. Returning a client to work at the insurance
    carrier's request conflicts with providing             34.45
    placement services when the client is job ready.     (n = 41)
24. Abiding by a supervisor's recommendation against
    providing a medical service conflicts with
    providing medical services you believe would be        33.61
    beneficial to the client.                            (n = 40)
25. Persuading a family to enroll the client in a
    beneficial sheltered workshop program
    conflicts with respecting the family's
    preference to keep the client at home for              17.24
    safety reasons.                                      (n = 20)
26. Telling a likely ineligible client what to say
    to meet eligibility requirements of a cooperating
    agency conflicts with respecting the integrity
    of the eligibility determination process of that       23.08
    cooperating agency.                                  (n = 27)
27. Providing vocational services to a client
    conflicts with adhering to the order                   12.82
    of selection criteria of the agency.                 (n = 15)
28. Keeping client records up to date to promote
    timely delivery of services conflicts
    with providing essential counseling services           23.53
    to clients which will reduce their anxiety.          (n = 28)
29. Informing a client about a terminal disease so
    he/she can plan for the future conflicts
    with not disclosing distressful medical
    information to a client whose physician                31.90
    has not explained the disease to him/her.            (n = 37)
30. Providing comprehensive services to the most
    severely disabled clients on your caseload
    conflicts with providing adequate and timely
    services to large numbers of less severely             26.05
    disabled clients.                                    (n = 31)
31. Providing a client with a needed service such as
    agency transportation conflicts with
    following agency policy that limits a service          11.97
    (vehicle use) for group activities.                  (n = 14)
32. Allocating sufficient time to serve the needs of
    several clients during a week conflicts
    with assisting a client to leave an abusive home       20.69
    situation during the same week.                      (n = 24)
33. Avoiding educating the client too early to the
    reality of his/her situation conflicts
    with providing the client with requested               23.73
    information.                                         (n = 28)

All 33 dilemmas were encountered, with six items rated by 75% or more of the respondents as occurring at least once a year. Those items listed in order of greatest frequency are as follow:

2. Supporting a client's selection of a particular vocational objective conflicts with channeling a client toward a more realistic vocational objective (86.7%). The competing principles for this dilemma are autonomy vs. beneficence.

9. Adhering to referral source case movement guidelines conflicts with providing an optimal package of rehabilitation services to a client (84.5%). The competing principles for this dilemma are fidelity vs. beneficence.

11. Informing an insurance carrier what a client can do vocationally knowing it will be used to suspend/cancel benefits the client is receiving (82.9%). The competing principles for this dilemma are fidelity vs. beneficence.

3. Providing support for a specific type of training requested by a client conflicts with supporting the type of training recommended in the client's evaluation report (82.5%). The competing principles for this dilemma are autonomy vs. beneficence.

17. Supporting a client's own choice of services conflicts with providing services that can increase the client's potential (79.7%). The competing principles for this dilemma are autonomy vs. beneficence.

16. Encouraging a client to take responsibility for securing necessary medical services to prevent potentially dangerous health complications conflicts with your acting in accordance with a client's request to obtain necessary medical services for him/her (78.0%). The competing principles for this dilemma are autonomy vs. beneficence.

In order to investigate private sector rehabilitation practitioners' views regarding the need for effective training to deal with each identified ethical dilemma, the items were rank ordered on the bases of the respondents who rated an item as "very important" on the Importance Scale. The five highest ranked items were as follow:

2. Supporting a client's selection of a particular vocational objective conflicts with channeling a client toward a more realistic vocational objective (44.3%). The competing principles for this dilemma are autonomy vs. beneficence.

9. Adhering to referral source case movement guidelines conflicts with providing an optimal package of rehabilitation services to a client (43.1%). The competing principles for this dilemma are fidelity vs. beneficence.

12. The client's desire for training conflicts with being asked by the client's attorney to testify to the worst vocational scenario (43.1%). The competing principles for this dilemma are nonmalifience vs. beneficence.

11. Informing an insurance carrier what a client can do vocationally while knowing the information will be used to suspend/cancel benefits the client is receiving (41.9%). The competing principles for this dilemma are fidelity vs. beneficence.

22. Agreeing to provide services for a client requested by the referring funding source conflicts with responding to a client's needs in the most appropriate manner (40.8%). The competing principles for this dilemma are fidelity vs. beneficence.

Discussion

Private sector rehabilitation is geared to assist individuals with disabilities become functional members of society, and at the same time meet the need of a prosperous industry to generate profits. The advent of private rehabilitation into specialty areas of service, such as managed care, insurance rehabilitation, and forensic testimony, has caused practitioners to encounter a variety of ethical issues not often experienced in public sector employment. These issues appear to be related to differences in funding sources, accountability, and litigation.

All 33 dilemmas contained in the EDSPS were encountered in this study. Six dilemmas (i.e., 2,9,11,3,17, and 16) were encountered by 75% or more of the respondents at least once a year. Ethical dilemmas 9 and 11 involved conflicts between the principles of beneficence and fidelity, in which a rehabilitation practitioner's adherence to agency case management guidelines (fidelity) conflicts with providing the optimal rehabilitation management services to a client (beneficence). Ethical dilemma 11 was developed by the CDMS Commissioners specifically for this study.

Ethical dilemmas number 2, 3, 16, and 17 involved a conflict between the ethical principles of autonomy and beneficence. Dilemmas 2 and 3 addressed meeting a client's vocational objective. However, some individuals may not possess vocational objectives that realistically relate to their abilities. The rehabilitation practitioner has an obligation to assist the client to attain their vocational choice (autonomy), while also successfully rehabilitating a client within the shortest amount of time to meet agency needs for closure (beneficence). Ethical dilemma number 3 involved supporting a client's vocational choice for a particular type of training which was not indicated by the vocational evaluation information.

Practitioners seek to support the vocational choice of their client while using the information available to them for the purpose of developing realistic vocational goals. A conflict arises when the vocational choice of a client is not a recommended area as indicated by the evaluation information. The rehabilitation practitioner is faced with a conflict in which supporting the vocational evaluation information may prevent the client from demonstrating skills in an area in which he/she is motivated to succeed. However, supporting the client's vocational choice despite evaluation results that predict vocational success may result in a waste of agency resources.

Pape and Klein (1986) indicated the existence of a similar dilemma where a practitioner is confronted with meeting both client expectations and demands of the rehabilitation agency. Practitioners must justify their rationale to their employer and the referring funding source for developing recommendations contrary to evaluation information. She/he must also satisfy the client with an explanation of why his/her vocational objective may not be realistic based on the evaluation report.

Although 75% of the respondents indicated they had some training in ethics, every dilemma was viewed by some of the respondents as "very important" to develop effective training materials. All 33 dilemmas were perceived by 80% of the respondents as "somewhat important, important, moderately important, or very important" in the development of effective training materials. Five dilemmas were viewed as "very important" by over 40% of respondents. The dilemmas viewed as "very important" by practitioners to develop effective training materials were dilemmas number 2, 9, 11, 12, and 22. Dilemmas 2, 9, and 11 were included in those dilemmas most frequently encountered. Dilemmas 2, 11, and 12 involved situations focused on the client's vocational choice and maximizing client benefits. In dilemma 12, the rehabilitation practitioner must choose between supporting the client's desires to be trained and work, or supporting the client's attorney's request to testify to the least desirable employment outcome. This situation provides a dilemma between autonomy and nonmaleficence. Specifically, the client's desire to be trained and to work (autonomy) is in conflict with protecting the client's welfare by presenting the worst case scenario, possibly insuring future benefits and financial well being (nonmaleficence).

Implications

The literature indicates there is a need to identify ethical dilemmas faced by private sector rehabilitation professionals (Patterson, 1989b). This study has contributed to the practice of rehabilitation by identifying specific ethical dilemmas encountered by practitioners employed in private sector rehabilitation. It has also identified the need to develop training materials specific to private sector occupations.

As managed care and social change, such as the Americans with Disabilities Act and the Rehabilitation Act Amendments, continue to influence new disability legislation, ethical dilemmas encountered will be altered o: may be eliminated. Additionally, new dilemmas may emerge and affect the type of training materials needed to prepare rehabilitation practitioners for these situations. Continued research will be needed to identify these ethical dilemmas.

A professional code of ethics is written to guide professional behavior and ensure that the interests of the profession and needs of the clients are adequately served. Various codes have been developed to assist rehabilitation professionals in addressing variations within their practice. Codes of ethics currently associated with rehabilitation practice include the American Board of Vocational Experts, Certification of Disability Management Specialist Commission, Commission of Rehabilitation Counselor Certification, and the National Association of Rehabilitation Professionals in the Private Sector. Although each code is applied to a specific area of rehabilitation, each requires a multifaceted and sophisticated ethical decision-making model (Havranek, 1997). The results of this study may provide guidance for expanding the utility of the codes of professional ethics for rehabilitation practitioners by recognizing and focusing on the dilemmas confronted in private sector rehabilitation.

Pape and Klein (1986) stated in a discussion of their national survey of rehabilitation practitioners, "... members have not found in their code of ethics or professional organizations the mechanism to resolve disputes, or to solve ethical dilemmas when encountered" (p. 12). The ability to understand the content of the code beyond the "I was told this is how a professional behaves" level is dependent on a clear understanding of the ethical principles (Howie, Gate-Robinson, & Rubin, 1992). In their daily work, rehabilitation practitioners face situations where decisions conflict between two or more ethical principles. Education is needed in order to understand the complex nature of the principles involved and will serve as a guide for making decisions when ethical dilemmas occur.

The results of this study should be used by instructors of rehabilitation education programs to address the training needs of both students on a private sector rehabilitation track and professionals currently employed in private sector rehabilitation. Educators who recognize the impact of managed care on service delivery should seek to develop instructional materials that deal with the ethical issues and dilemmas currently encountered in private sector rehabilitation. Using the dilemmas identified, case studies should be developed using those dilemmas indicated as having the highest importance.

Materials developed should be designed to address the current conflicts and dilemmas faced by case managers in managed care situations not addressed in other training. Instructional materials should be designed to assist students and rehabilitation professionals to: a) identify ethical dilemmas contained in case management situations; and b) develop resolutions utilizing the principles which influence each action.

The identification of ethical dilemmas encountered and attendant training to deal with them should serve to guide rehabilitation professionals and students toward greater competence as they understand the processes that influence their decisions. Administrators in private sector rehabilitation programs can rely on training as a basis to develop policy and guide staff in ways to deal with difficult situations.

Although the current study's findings contributed to the field of rehabilitation by identifying specific ethical dilemmas encountered by practitioners employed in private sector rehabilitation, it is unlikely that the survey instrument addressed all types of ethical dilemmas faced by rehabilitation practitioners. The data from this study is exploratory and has limited reliability; therefore, study replication utilizing a broader sample of practitioners is suggested. Additionally, future studies may address new dilemmas as a result of new legislation, social change, and the effects of managed care on rehabilitation practice.

The sample for this study was drawn from the 1997 National registry of CDMS certificants. This is the most current and active list of private rehabilitation practitioners in the nation. However, the target population -- private practitioners employed in private sector rehabilitation -- may not be representative of the entire population of practitioners who provide private sector rehabilitation services. In addition, the low return rate (26.5%) also may affect the generalizability of the study findings.

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Bonnie T. Vaughn

Southern Illinois Center for Independent Living

Darrell W. Taylor

W. Russell Wright

Southern Illinois University at Carbondale

Darrell W. Taylor, Rehabilitation Institute, Southern Illinois University at Carbondale, Carbondale, IL 62901-4609.