Dietitians – seasoned practitioners, new grads, and those that fall somewhere in between – face ethical dilemmas on a regular basis. Navigating the area of ethics can be difficult as the situations they face are not always black and white.

A clear-cut ethical dilemma, like whether to administer someone dialysis or provide important dietary recommendations are easily dealt with. But what happens when the scenario has more gray area?

Consider this scenario:

There are 2 dietitians covering a dialysis clinic, Gale and Devin.  Gale, who has been at the clinic for a year, covers most in-center hemodialysis patients. Devin on the other hand, has been at the clinic for 11 years and covers a smaller portion of in-center patients but sees all home dialysis patients.

Gale learns a patient’s granddaughter was recently certified as a nutritionist. Hoping to better help her grandfather manage his disease, she begins to include herbal supplements within the care packages she’s been sending to him on a regular basis. But Gale, who recently read an article about how “poisonous” and “unhelpful” supplements are, has an initial reaction to strongly discourage the patient from taking all supplements the granddaughter is sending.

The Dilemma:

  • This dilemma involves at least 2 of the standards from the 2018 Code of Ethics for the Nutrition and Dietetics Profession -> Non-Maleficence: Competence and professional development in practice; and Beneficence:
  • To maintain ethical practice, it’s important that Gale does her due diligence to respect the patient’s right to choose, but still provide evidence-based information while communicating professionally to the patient contributing to their overall well-being.

Instead of going with her knee-jerk reaction Gale obtains a list of supplements and researches each one. The patient reports the following supplements – cinnamon, nettle, turmeric, fish oil, and aloe vera juice.

After completing her research Gale sits down to educate the patient, carefully explaining her recommendations and answering the patient’s questions as they go through each supplement. After the discussion the patient decides to only take the turmeric and fish oil.

The next month Gale is on vacation, and Devin covers the patients. The same patient has new questions, so he mentions his supplements to Devin. Once Devin reviews the patient’s notes and does not see any documentation on supplements, Devin tells the patient to stop taking them since they are not safe. Devin then sets up a lunch and learn on herbal supplements for the clinic staff and uses the patient as an example of what not to do. Once Gale is back from vacation, she attends the lunch and learn to discover this was about her patient.

 The Dilemma:

  • The ethical dilemma now involves the same Non-Maleficence and Beneficence and expands to include Autonomy: Integrity in personal and organizational behaviors and practices; and Justice: Social responsibility for local, regional, national, global nutrition and well-being.
  • Gale missed an opportunity by not fully documenting the education she provided to the patient, making it difficult for Devin to provide consistent care.
  • Devin missed an opportunity by relying on outdated information instead of performing an evidence-based review, as well as using a patient example without discussing it with his dietitian to get the full picture on the patient care.
  • The patient receives mixed messages and loses trust in the dietitians’ advice thus rapport declines.
  • The staff also receives mixed messages making continuity of care difficult.

To resolve the dilemma, first the RD’s should ensure they provide more detailed documentation of patient assessment and education.

When it comes to nutrition knowledge, new evidence is constantly emerging, even for dietary supplements.  By using evidence-based research to guide their decisions, dietitians will be able to better resolve any mixed messages the patient has received and clarify recommendations.

To learn more about ethical practices for dietitians, check out the Academy of Nutrition and Dietetics page on ethics resources: