GOALS
Course
Description
“Ohio Occupational Therapy Ethics” is a home study continuing education
program for OH licensed occupational therapists and occupational therapist
assistants. The course focuses on
defining moral, ethical, and legal behavior of
Course
Rationale
This course was developed to educate, promote and facilitate ethical and
legal behavior by
Course Goals & Objectives
At the end of this course, the participants will be able to:
1.
Define the meaning
of ethics and recognize the various theories that promote ethical behavior.
2.
Apply a systematic
approach to ethical decision-making.
3.
Recognize the
principles of ethical conduct as defined in the Ohio Occupational Therapy Code
of Ethics
4.
Assess their
current professional practices to ensure ethical conduct
5.
Apply the concepts
of ethical practice to clinical situations to determine appropriate
professional ethical behavior.
Course Instructor
Michael
Niss PT
Target Audience
Occupational
Therapists, occupational therapist assistants, physical therapists, physical
therapist assistants
Course Educational Level
This course
is applicable for introductory learners.
Course Prerequisites
None
Criteria for issuance of Continuing Education Credits
A
documented score of 70% or greater on the written post-test.
Continuing Education Credits
One (1)
hour of continuing education credit (1 NBCOT PDUs/1 contact hour)
AOTA - .1 AOTA CEU, Category 3: Contemporary Issues & Trends
Determination
of Continuing Education Credit Hours
“Ohio Occupational Therapy Ethics” will require at least 1 hour to complete. This estimate is based on the accepted
standard for home study courses of approximately 12 pages of written text (12
pt font) per hour. The complete text of
this course is 14 pages (excluding Bibliography and Post Test)
OUTLINE
page
Goals and
Objectives 1
Outline 2
Ethics
Overview 3
Why Ethics are Important 3
Ethics vs. Morals 3
Ethical Questions 3
Ethics
Theories 3-5
Utilitarianism 4
Social Contract Theory 4
Deontological Theory 4
Ethical Intuitionism 4
Ethical Egoism 4
Natural Law Theory 4
Virtue Ethics 4-5
How to Make
Right Decisions 5-6
4755.10 of
the Revised Code 9
Case Studies 10-14
Case Study #1 – Confidentiality 10
Case study #2 – Qualifications of
Practice 10-11
Case Study #3 – Informed Consent 11-12
Case Study #4 – Medical Necessity 12
Case Study #5 – Conflict of Interest 12-13
Case Study #6 – Relationships / Referral
Sources 13-14
References 15
Post-Test 16-17
.
ETHICS OVERVIEW
The word “ethics” is derived
from the Greek word ethos (character), and from the Latin word mores
(customs). Together, they combine to define how individuals choose to interact
with one another. In philosophy, ethics defines what is good for the individual
and for society and establishes the nature of duties that people owe themselves
and one another. Ethics is also a field of
human inquiry (“science” according to some definitions) that examines the bases
of human goals and the foundations of “right” and “wrong” human actions that
further or hinder these goals.
Ethics
are important on several levels.
Ethics vs. Morals
Although the terms “ethics” and “morals” are often
used interchangeably, they are not identical. Morals usually refer to
practices; ethics refers to the rationale that may or may not support such
practices. Morals refer to actions, ethics to the reasoning behind such
actions. Ethics is an examined and carefully considered structure that includes
both practice and theory. Morals include ethically examined practices, but may
also include practices that have not been ethically analyzed, such as social
customs, emotional responses to breaches of socially accepted practices and
social prejudices. Ethics is usually at a higher intellectual level, more
universal, and more dispassionate than morals. Some philosophers, however, use
the term “morals” to describe a publicly agreed-upon set of rules for
responding to ethical problems.
Ethical Questions
Ethical questions involve 1) responsibilities to the
welfare of others or to the human community; or 2) conflicts among loyalties to
different persons or groups, among responsibilities associated with one’s role
(e.g. as consumer or provider), or among principles. Ethical questions include
(or imply) the words “ought” or “should”.
Throughout history, mankind
has attempted to determine the philosophical basis from which to define right
and wrong. Here are some of the more
commonly accepted theories that have been proposed.
Utilitarianism
This philosophical theory
develops from the work of Jeremy Bentham and John Stewart Mill. Simply put,
utilitarianism is the theory that right and wrong is determined by the
consequences. The basic tool of measurement is pleasure (Bentham) or happiness
(Mill). A morally correct rule was the
one that provided the greatest good to the greatest number of people.
Social Contract Theory
Social
contract theory is attributed to Thomas Hobbes, John Locke, and from the twentieth century, John Rawls. Social contract theories believe that the moral
code is created by the people who form societies. These people come together to
create society for the purpose of protection and gaining other benefits of
social cooperation. These persons agree to regulate and restrict their conduct
to achieve this end.
Under this theory you
determine if an act or rule is morally right or wrong if it meets a moral
standard. The morally important thing is not consequences but the way choosers
think while they make choices. One famous philosopher who
developed such a theory was Immanuel Kant (1724-1804).
Under this view an act or
rule is determined to be right or wrong by appeal to the common intuition of a
person. This intuition is sometimes referred to as your conscience. Anyone with
a normal conscience will know that it is wrong to kill an innocent person.
This view is based on the
theory that each person should do whatever promotes their own best interests;
this becomes the basis for moral choices.
Natural Law Theory
This is a moral theory which
claims that just as there are physical laws of nature, there are moral laws of
nature that are discoverable. This theory is largely associated with Aristotle
and Thomas Aquinas, who advocated that each thing has its own inherent nature,
i.e. characteristic ways of behavior that belong to all members of its species
and are appropriate to it. This nature determines what is good or bad for that
thing. In the case of human beings, the moral laws of nature stem from our
unique capacity for reason. When we act against our own reason, we are
violating our nature, and therefore acting immorally.
This ethics theory proposes
that ethical behavior is a result of developed or inherent character traits or
virtues. A person will do what is
morally right because they are a virtuous person. Aristotle (384-322 B.C.) was
a famous exponent of this view. Aristotle felt that virtue ethics was the way
to attain true happiness. These are some of the commonly accepted virtues.
Autonomy: the duty to maximize the individual’s right to make
his or her own decisions.
Beneficence: the duty to do good.
Confidentiality: the duty to respect privacy of information.
Finality: the duty to take action that may override the
demands of law, religion, and social customs.
Justice: the duty to treat all fairly, distributing the risks
and benefits equally.
Nonmaleficence: the duty to cause no harm.
Understanding/Tolerance: the duty to understand and to accept other
viewpoints if reason dictates.
Respect for persons: the duty to honor others, their rights, and their
responsibilities.
Universality: the duty to take actions that hold for everyone,
regardless of time, place, or people involved.
Veracity: the duty to tell the truth.
The foundation for making proper ethical decisions is
rooted in an individual’s ability to answer several fundamental questions
concerning their actions.
Weighing
the legality of one’s actions is a prudent way to begin the decision-making
process. The laws of a geographic region are a written code of that region’s
accepted rules of conduct. This code of
conduct usually defines clearly which actions are considered acceptable and
which actions are unacceptable. However,
a legitimate argument can be made that sometimes what is legal is not always
moral, and that sometimes what is moral is not always legal. This idea is easily demonstrated by the
following situation.
It is illegal for a
pedestrian to cross a busy street anywhere other than at the designated
crosswalk (jaywalking). A man is walking
down a street and sees someone fall and injure themselves on the other side of
the street. He immediately crosses the
street outside of the crosswalk to attend to the injured person. Are his actions legal? Are they moral? What if by stepping into the street he causes
a car to swerve and to strike another vehicle?
Admittedly,
with the exception of policemen and attorneys, most people do not know all of
the specific laws that govern their lives.
However, it is assumed that most people are familiar with the
fundamental virtues from which these laws are based, and that they will live
their lives in accordance with these virtues.
(To read all of the laws and rules governing the practice of
Occupational Therapy in
Professional
ethical behavior as it is defined in this context relates to actions that are
consistent with the normative standards established or practiced by others in
the same profession. For
(An abridged copy of Chapter 4755-7-08, The Ohio
Occupational Therapy Code of Ethics, is included in this text)
I
think most people would agree that the concept of fairness is often highly
subjective. However, for these purposes, we will define fairness as meaning
deserved, equitable and unbiased.
Fairness requires the decision-maker to have a complete understanding of
benefits and liabilities to all parties affected by the decision. Decisions that result in capricious harm or
arbitrary benefit cannot be considered fair.
The goal of every decision should be an outcome of relative equity that
reflects insightful thought and soundness of intent.
This
question presents as a true reflection of the other three. Legal, ethical, and fair are defined quite
differently by most people when judged in the comfort of anonymity versus when
it is examined before the forum of public opinion. Most often it is the incorrect assumption
that “no one will ever find out about this” that leads people to commit acts of
impropriety. How would your decisions
change, if prior to taking any actions, you assumed just the opposite; “other
people will definitely know what I have done”.
One sure sign of a poor decision is debating the possible exposure of an
action instead of examining the appropriateness of it.
4755-7-08 Code of Ethics.
(A) Pursuant to section
4755.05(E) of the Revised Code, the standard of ethical conduct in the practice
of occupational therapy will be as follows:
(1)
Occupational therapy practitioner shall demonstrate a concern for the
well-being of the recipients of their services.
(a) Occupational therapy practitioners shall provide
services in a fair and equitable manner. They shall recognize and appreciate
the cultural components of economics, geography, race, ethnicity, religious and
political factors, marital status, sexual orientation, and disability of all
recipients of their services. Occupational therapy practitioners should strive
to understand culture and its impact on human performance and context while
recognizing the strengths that exist in all cultures.
(b) Occupational therapy practitioners shall strive
to ensure that fees are fair, reasonable, and commensurate with services
performed.
(c) Occupational therapy practitioners shall make
every effort to advocate for recipients to obtain needed services through
available means.
(2) Occupational therapy practitioners shall take
reasonable precautions to avoid imposing or inflicting harm upon the recipient
of services or to his or her property.
(a) Occupational therapy
practitioners shall maintain relationships that do not exploit the recipient of
services sexually, physically, emotionally financially, socially, or in any
other manner. In the case of minors, the practitioner/client relationship extends
to the minor’s parent or guardian. (b) Occupational therapy practitioners shall
not engage in any sexual relationship or activity, whether consensual or
nonconsensual, with any recipient while a practitioner/client relationship
exists and for six months immediately following the termination of therapy. In
the case of minors, the practitioner/client relationship extends to the minor’s
parent/guardian.
(c) Occupational therapy
practitioners shall not provide occupational therapy services to a service
recipient while under the influence of a substance that impairs his or her
ability to do so safely.
(d) Occupational therapy
practitioners shall protect the public by reporting any conduct that they
consider unethical, illegal or incompetent relating to the practice of
occupational therapy to the occupational therapy section of the
(3)
Occupational therapy practitioners shall respect the recipient and/or their
surrogate(s) as well as the recipient’s rights.
(a) Occupational therapy practitioners shall
collaborate with service recipients or their surrogate(s) in setting goals and
priorities throughout the intervention process.
(b) Occupational therapy practitioners shall fully
inform the service recipients of the nature, risks, and potential outcomes of
all interventions.
(c) Occupational therapy practitioners shall obtain
informed consent from participants involved in research activities and indicate
that they have fully informed and advised the participants of potential risks
and outcomes. Occupational therapy practitioners shall endeavor to ensure that
the participant(s) comprehend these risks and outcomes.
(d) Occupational therapy practitioners shall respect
the individual’s right to refuse professional services or involvement in
research or educational activities.
(e) Occupational therapy practitioners shall protect
all privileged confidential forms of written, verbal, and electronic
communication gained from educational, practice, research, and investigational
activities unless otherwise mandated by local, state or federal regulations.
(4)
Occupational therapy practitioners shall achieve and continually maintain high
standards of competence.
(a) Occupational therapy practitioners shall take
responsibility for maintaining and documenting competence by participating in
professional development and educational activities.
(b) Occupational therapy practitioners shall
critically examine and keep current with emerging knowledge relevant to their
practice so they may perform their duties on the basis of accurate information.
(c) Occupational therapy practitioners shall protect
service recipients by ensuring that duties assumed by or assigned to other
occupational therapy practitioners match credentials, qualifications,
experience, and scope of practice.
(d) Occupational therapy practitioners shall provide
appropriate supervision to individual for whom the practitioners have
supervisory responsibility.
(e) Occupational therapy practitioners shall refer to
or consult with other service providers whenever such a referral or
consultation would be helpful to the care of the recipient of service. The
referral or consultation process should be done in collaboration with the recipient
of service.
(5)
Occupational therapy practitioners shall comply with the laws and rules
governing the practice of occupational therapy.
(a) Occupational therapy practitioners shall
familiarize themselves with and seek to understand and abide by the
(b) Occupational therapy practitioners shall remain
abreast of revisions in those laws and rules that apply to the profession of
occupational therapy and shall inform employers, employees, and colleagues of
those changes.
(c) Occupational therapy practitioners shall maintain
accurate and timely documentation of occupational therapy services.
(6)
Occupational therapy practitioners shall provide accurate information about
occupational therapy services
(a) Occupational therapy
practitioners shall accurately represent their credentials, qualifications,
education experience, training, and competence for those to whom the
practitioners provide their services or with whom the practitioners have a
professional relationship.
(b) Occupational therapy
practitioners shall refrain from using or participating in the use of any form
of communication that contains false, fraudulent, deceptive, or unfair
statements or claims.
(c) Occupational therapy practitioners shall disclose
any professional, personal, financial, business, or volunteer affiliations that
may pose a conflict of interest to those with whom they may establish a
professional. contractual, or other working relationship.
(7) Occupational
therapy practitioners shall treat colleagues and other professionals with
fairness, discretion, and integrity.
(a) Occupational therapy practitioners shall
preserve, respect, and safeguard confidential information about colleagues, and
staff, unless otherwise mandated by national, state or local laws.
(b) Occupational therapy practitioners shall
accurately represent the qualifications, views, contributions, and findings of
colleagues.
(c) Occupational therapy practitioners must not
initiate, participate in, or encourage the filing of ethics complaints that are
unwarranted or intended to harm another practitioner. The intent of complaints
is to protect the public.
(B) Anyone found guilty of
violating any provision of this rule may be the subject of disciplinary action
pursuant to section 4755.10 of the Revised Code.
Sec. 4755.10. (A) In accordance with Chapter 119. of the Revised
Code, the occupational therapy section of the Ohio occupational therapy,
physical therapy, and athletic trainers board may suspend, revoke, or refuse to
issue or renew an occupational therapist or occupational therapy assistant
license, or reprimand, fine, or place a license holder on probation, for any of
the following:
(1) Conviction of an offense involving moral turpitude or
a felony reasonably related to the practice of occupational therapy, regardless
of the state or country in which the conviction occurred;
(2) Violation of any provision of sections 4755.01 to
4755.12 of the Revised Code;
(3) Violation of any lawful order or rule of the
occupational therapy section;
(4) Obtaining a license or any order, ruling, or
authorization by means of fraud, misrepresentation, or concealment of material
facts;
(5) Negligence or gross misconduct in the pursuit of the
profession of occupational therapy;
(6) Accepting commissions or rebates or other forms of
remuneration for referring persons to other professionals;
(7) Communicating, willfully and without authorization,
information received in professional confidence;
(8) Using any narcotic or alcohol to an extent that it
impairs the ability to perform the work of an occupational therapist or
occupational therapy assistant with safety to the public;
(9) Practicing in an area of occupational therapy for
which the individual is clearly untrained or incompetent;
(10) Failing the licensing examination;
(11) Aiding or abetting the unlicensed practice of
occupational therapy
John Johnson OT, Sue White (therapy receptionist),
and Mary Olson (therapy managed care contracting), are in a private OT office
discussing the fact that they are treating Biff Simpson, a star NFL
quarterback. John says, “I can’t believe
that I’m actually treating Biff Simpson.”
Mary asks, “How bad do you think his injury is?” John replies, “I saw his MRI report, it looks
like he is going to need surgery.”
Is this a breach in
confidentiality?
The information contained in each patient’s medical record must be
safeguarded against disclosure or exposure to nonproprietary individuals. The right to know any medical information
about another is always predicated on a sound demonstration of need. Frequently, many individuals require access
to information contained in a patient’s medical record. Their right to access
this information is limited to only that information which is deemed necessary
for them perform their job in a safe, effective, and responsible manner.
The first questions we must
ask are “What information is being disclosed and do the three individuals engaged
in the conversation have a need to know this information?”
John’s first statement
discloses the name of person receiving care, and his second statement reveals
private patient medical information.
Certainly, as the primary therapist, John would need to know the
patient’s name and therapy related diagnosis in order to provide care. Sue, the receptionist, may also need this
information to schedule appointments and perform other essential clerical
tasks. Mary, whose job it is to contract with managed care organizations, most
likely has no compelling reason to know either the patient’s identity or any of
his medical information. Therefore, the disclosure to Mary of the patient’s
identity and medical information is a breach of patient confidentiality. (4755-7-08
(3)(e) O.A.C.)
Case Study #2 –
Qualifications of Practice
You work in very busy outpatient rehab clinic. One of your coworkers is an occupational therapy aide who has worked in rehabilitation
for more than 20 years. Frequently, she
is called upon to perform treatments that should be done by an OT or COTA. The patients always give her compliments, and
frequently request her to treat them.
She demonstrates exceptional skills and achieves outstanding outcomes.
Is the clinic providing ethical care to its patients?
The practice of occupational therapy is regulated in
the state of
In this situation, the
aide’s abilities and outcomes are considered irrelevant. The key sentence in the paragraph is:
“perform treatments that should be done by an OT or COTA”. The “should” in this case must not be
interpreted as merely a casual suggestion but rather a legal definition
regulated by the state’s Occupational Therapy Practice Act. Any treatment or procedure that should
be performed by a licensed professional, must be performed by a licensed
professional. (4755-7-08 (4)(c) O.A.C.)
Case Study #3 – Informed Consent
Sam is an OT who has just received orders to begin ADL training with a
75-year-old woman who is s/p right humeral ORIF. He goes to her hospital room to evaluate her
and begin therapy. She says she does not
want therapy today because she is in too much pain. Sam explains to her that the doctor has left
orders for her to begin using her right arm.
The patient refuses. Sam leaves
and returns the next day to try again.
Again, she declines treatment and he leaves.
Under the guidelines of informed consent, were the therapist’s actions
adequate?
Informed consent is the
process by which a fully informed patient can participate in choices about
their health care. It originates from the legal and ethical right the patient
has to direct what happens to their body and from the ethical duty of the
therapist to involve the patient in her health care.
The most important goal of
informed consent is that the patient has an opportunity to be an informed
participant in their health care decisions. It is generally accepted that
complete informed consent includes a discussion of the following elements:
·
the nature of
the decision/procedure
·
reasonable
alternatives to the proposed intervention
·
the relevant
risks, benefits, and uncertainties related to each alternative
·
the consequences
on non-treatment
·
the goals of
treatment
·
the prognosis
for achieving the goals
·
assessment of
patient understanding
·
the acceptance
of the intervention by the patient
In order for the patient’s consent to be
valid, they must be considered competent to make the decision at hand and their
consent must be voluntary. It is easy for coercive situations to arise in
medicine. Patients often feel powerless and vulnerable. The therapist should
make clear to the patient that they are participating in a decision, not merely
signing a form. With this understanding, the informed consent process should be
seen as an invitation for them to participate in their health care decisions.
The therapist is also generally obligated to provide a recommendation and share
their reasoning process with the patient. Comprehension on the part of the
patient is equally as important as the information provided. Consequently, the
discussion should be carried on in layperson’s terms and the patient’s
understanding should be assessed along the way.
In this case study, the
therapist’s actions were not sufficient.
None of the required information was offered to the patient. The most
important thing the therapist failed to explain to the patient was the
consequences of non-treatment. The
patient cannot make an informed decision regarding therapy without this information. It could be argued that her decision to
refuse therapy may have changed had she known that one of the consequences of
this decision could be the development of secondary complications. (i.e.
increased risk of morbidity or mortality). (4755-7-08 (3)(b) O.A.C.)
Case Study #4- Medical Necessity
Mary Brown is an occupational therapist who owns her own therapy
clinic. She recently signed a contract
with an HMO to provide occupational therapy services. The contract stipulates that Mary will be
compensated on a case rate basis. (A
fixed amount of money per patient, based on diagnosis) Mary has performed a thorough cost analysis
on this contract and has determined that the financial “breakeven” point
(revenue equals expenses) on each of these patients is 5 visits. She informs her staff that all patients
covered by this insurance must be discharged by their fourth visit.
Is limiting care in this manner ethical?
Therapists are obligated to propose and provide care that is based on
sound medical rationale, patient medical necessity, and treatment efficacy and
efficiency. It is unethical to either
alter or withhold care based on other extraneous factors without the patient’s
knowledge and consent.
In this instance, the decision to limit care is not ethical. The quantity of care is not being determined
by the medical necessity of the patient.
A therapist must be able to justify all of their professional decisions
(such as the discharging of a patient from clinical care) based on sound clinical
rationale and practices. (4755-7-08 (1)
(c) O.A.C.)
Case Study #5 – Conflicts of Interest
Debi Smith OT works in an acute care hospital. She is meeting with a vendor whose company is
introducing a new brace onto the market.
He offers her 3 free braces to “try out” on patients. The vendor states that if Debi continues to
order more braces, she will qualify to receive compensation from his company by
automatically becoming a member of its National Clinical Assessment Panel.
Does this represent a conflict of interest?
Yes, there exists a conflict of interest in this situation. Debi has two primary obligations to
fulfill. The first is to her patient. It
is her professional duty to recommend to her patient a brace that, in her judgment,
will benefit them the most. The second
obligation is to her employer, the hospital.
As an employee of the hospital it is her responsibility to manage
expenses by thoroughly and objectively seeking effective products that also
demonstrate economic efficiency. The
conflict of interest occurs when she begins to accept compensation from the
vendor in direct or indirect response for her brace orders. Even if she truly believes it is the best
brace for her patient, and it is the most cost effective brace the hospital
could purchase, by accepting the money she has established at least an apparent
conflict of interest. Under this
situation she is obligated to disclose to all parties her financial interest in
ordering the braces. This disclosure is necessitated because the potential for
personal gain would make others rightfully question whether her objectivity was
being influenced.
A conflict of interest is a situation in which a person has a private or
personal interest that influences the objective exercise of his or her
professional duties. As a professional you take on certain responsibilities and
obligations to patients, employers, and others. These obligations must take
precedence over a therapist’s private or personal interests.
In addition to avoiding all real instances of conflict of interest,
therapists must also avoid any apparent or potential conflicts as well.
An apparent conflict of interest is one in which a reasonable person
would think that the professional’s judgment is likely to be compromised, and a
potential conflict of interest involves a situation that may develop into an
actual conflict of interest.
How do you determine if you
are in a conflict of interest, whether actual, apparent, or potential? The key
is to determine whether the situation you are in interferes or is likely to
interfere with your independent judgment. A good test is the ‘trust test’:
Would relevant others (my employer, my patients, professional colleagues, or
the general public) trust my judgment if they knew I was in this situation.
Trust is at the ethical heart or core of this issue. Conflicts of interest
involve the abuse, actual or potential, of the trust people have placed in
professionals. This is why conflicts of interest not only injure particular
patients and employers, but they also damage the whole profession by reducing
the trust people generally have in therapists. (4755-7-08 (6) (c) O.A.C.)
Case Study #6 – Relationships with Referral Sources
Larry Jones OT owns a private practice.
Business has been poor. He decides to sublease half of his space to an
orthopedic surgeon. Larry’s current
lease is at $20/sq ft. The doctor wants to pay $15/sq ft. They come to a
compromise of $17/sq ft. Larry also agrees that if the doctor is his top
referral source after 3 months, he’ll make him the Medical Director of the
facility and pay him a salary of $500/month.
Is this an ethical arrangement?
No, this agreement is not ethical.
The most notable infraction involves offering to designate the physician
as Medical Director contingent upon the number of referrals he sends. This is undeniably a direct offer of cash for
patients. Another area of concern is the
rent. At first glance, the rent amount
of $17/sq ft seems fair because it was a compromise between the two parties. However, closer scrutiny reveals this to be
unethical. The fair market value for
rent has been established as $20/ft.
(Larry’s current rental agreement with his landlord) By discounting the doctor $3/sq ft on his
rent, Larry is giving a referral source something of value.
It is unethical for an
occupational therapist to offer anything of value to physicians or any
other referral source in direct response for the referral of patients or
services. This includes cash,
rebates, gifts, discounts, reduced rent, services, equipment, employees, or
marketing. Many mistakenly believe that
it is a normal acceptable business practice to offer these things to referral
sources. It is not. In most states, the practice is not only
unethical, but it is also illegal.
Exchanges of valued items or services between therapists and referral
sources must never have any relationship to the referral of patients. Goodwill gifts of nominal value are
acceptable provided that no correlation can be made between the magnitude or
frequency of the gift giving and referral patterns. All business agreements and transactions
should always be well documented and most importantly, reflect fair market
value. (4755-7-08 (6) (c) O.A.C.)
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POST-TEST