|Ethics Case Studies—Learning Application of the 2009 ADA/CDR Code of |[pic] |
|Ethics for the Profession of Dietetics | |

|Case Study #1: A registered dietitian (RD) is newly employed as part of a treatment team in an ambulatory care setting. After several |
|counseling sessions, one of the clients he is counseling for obesity discloses that she is being physically abused by her spouse and is |
|experiencing depression. The RD continues to have the client come in for nutrition counseling sessions in an attempt to better understand |
|the relationships among her current domestic situation, psychological state and weight issues. During a treatment team meeting, the RD |
|reports on the client and is questioned by one of the team members about why he did not refer the client to the mental health professional. |
|What should be done in this situation? |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to Clients. |
| |
|Indicate the Principle(s) of the Code of Ethics: Principle#8 - The dietetics practitioner recognizes and exercises professional judgment |
|within the limits of his/her qualifications and collaborates with others, seeks counsel, or makes referrals as appropriate. |
| |
|Explain how/why this relates to the Category and Principle: This principle relates to the ADA value of social responsibility and the |
|dietitian’s ability to recognize boundaries between nutrition treatment and medical nutrition therapy versus psychotherapy, and when it is |
|appropriate to refer clients to mental health professionals. |
|Key Points to Consider: |
|RDs must differentiate between client problems in their professional scope, such as issues related to food, eating patterns, and weight, |
|versus those that are beyond the scope of nutrition practice, such as suicidal tendencies, physical abuse, severe marital difficulties, |
|feelings of depression, past unresolved sexual abuse, and other severe problems. |
|RDs should understand the policies and procedures in the ambulatory practice setting regarding treatment of various types of clients and |
|especially those who need a team approach to treatment. |
|RDs should understand what it means to be part of a treatment team and the roles of other health care professionals. |
|Since the RD is new in this position, he could discuss the situation with a colleague who works in a similar setting, she could meet with |
|his direct supervisor, if available, or he could go directly to the treatment team for advice. |
|RDs need to engage in self-reflection and evaluation of professional roles, reassess interactions with clients, and recognize that each |
|client and each setting require their own scope of counseling theory and skill. |
|This scenario has important implications for academic programs and their role in educating students on scope of practice issues and state |
|licensure laws. |
|To prevent similar future ethical dilemmas, the dietitian could take graduate coursework in counseling, participate in continuing education |
|in the area of counseling, or complete a certification program in counseling. |

|Case Study #2: A Didactic Program in Dietetics (DPD) student, who is a student member of ADA, is in a computer lab at the university taking |
|an online examination for one of his courses. The course syllabus specifically states that the exam is to be taken without the use of the |
|textbook or class notes. One of the student’s classmates observes the student referring to the text and class notes while completing the |
|online exam. What should be done in this situation? |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles. |
| |
|Indicate the Principle(s) of the Code of Ethics: Principle#1 - The dietetics practitioner conducts himself/herself with honesty, integrity |
|and fairness. |
| |
|Explain how/why this relates to the Category and Principle: This principle relates to the ADA value of integrity and addresses attributes |
|that should characterize all professionals, including students who are preparing to become food and nutrtion professionals. |
|Key Points to Consider: |
|The student needs to recognize that he/she is being dishonest and is cheating. |
|The student may not view his behavior as violating ethical principles and the Code of Ethics. |
|This situation points out the important role of faculty who need to review acceptable ethical behaviors in all classes and discuss |
|consequences of professional misconduct, both during academic preparation and after graduation. |
|This scenario points out the importance of putting the institution’s academic honesty policy in all course syllabi, reviewing the policy and|
|consequences of violating the policy with students, and providing students with specific examples of dishonesty, such as cheating on online |
|exams. |
|The student should be disciplined based on academic honesty policies of the institution. |
|The student’s letters of recommendations /should/could disclose this infraction and the action could jeopardize his/her ability to obtain a |
|dietetic internship. |
|A student who is dishonest and cheats his/her way through the DPD and Dietetic Internship (DI) programs, may not pass the RD exam or could |
|become an incompetent dietetics practitioner, possibly causing potential harm to the public and clients. |

|Case Study #3: A registered dietitian (RD) is employed in a hospital-based outpatient clinic and her major role is to counsel clients with |
|diet-related chronic diseases with the goal of changing their dietary behaviors, successfully managing their chronic diseases, and improving|
|their health status. During counseling sessions, the RD routinely provides clients with the rationale for the prescribed medical nutrition |
|therapy, a written list of foods to include and exclude, and tips for menu planning, grocery shopping, and food preparation. After several |
|counseling sessions, one of the clients expresses her dissatisfaction with the progress she is making to institute dietary changes. The |
|client requests assistance in development of a different plan. However, the RD continues to provide the same types of information and |
|advice. After several more appointments with the RD, the client contacts the director of nutrition services to express her dissatisfaction |
|with the counseling sessions and her frustration with not being able to successfully change her dietary behaviors. What should be done in |
|this situation? |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue. But, this could be considered a |
|business dispute since there is no clarity on whether the client’s outcomes were established and agreed upon. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to the Profession |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and current information. |
|Principle #14 - The dietetics practitioner assumes a lifelong responsibility and accountability for personal competence in practice, |
|consistent with accepted professional standards, continually striving to increase professional knowledge and skills and to apply them in |
|practice. |
| |
|Explain how/why this relates to the Category and Principle: These principles relate to the ADA values of integrity and social |
|responsibility and the dietitian’s ability to engage in self-reflection and self-evaluation and to seek opportunities to improve |
|effectiveness by utilizing counseling theories and strategies that are current and evidence-based. |
|Key Points to Consider: |
|The RD needs to differentiate between nutrition education and nutrition counseling and be familiar with the literature that states that |
|providing information and advice alone do not lead to behavior change. Also, the RD needs to recognize that each client has unique needs |
|and ways of achieving success. |
|The RD has the responsibility to engage in self-reflection and evaluation and to recognize that he/she is not currently effective as a |
|nutrition practitioner within the current setting. |
|The RD should seek out opportunities to improve his/her skills in the area of counseling through continuing education, academic coursework |
|and/or certification programs. |
|If the RD does not believe he/she is making progress with the client after a period of time, it would be appropriate for him/her to refer |
|the client to another RD counselor, if available. |
|The director of nutrition services should have policies and procedures for the institution which include standards and expectations |
|regarding the use of appropriate counseling theories and strategies. |
|The director of nutrition services should adequately supervise and evaluate the RD staff to be sure they are using current practices based |
|on evidence-based information and, if not, make suggestions for improvement. |

|Case Study #4: A faculty member (PhD, RD) asks a graduate doctoral student (ADA RD member) to assist with a paper she is writing. She asks |
|the graduate student to update the paper’s literature review, add additional data to the analysis and do a draft revision to the results |
|section based on the additional data. The, the primary author prepares the discussion and methods section. The graduate student decides to|
|discuss this with a junior faculty person and with her encouragement, she asks to be listed on the paper as an author. The primary author |
|replies no, as student contributions to a paper do not merit an author byline. The PhD, RD agrees to an acknowledgement. The student feels|
|compromised as he/she cannot refuse to do the work and must accept the professor’s decision. The junior faculty member agreed with the |
|student and also felt she could not address her colleague on the issue. When the article is published in Journal of the American Dietetic |
|Association, the student is highly disappointed and reflects on this compromising situation as a very unpleasant professional encounter |
|early in her academic career. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue, not a business dispute. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles and Colleagues and other professionals. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity, and fairness. |
|Principle #19 - The dietetics practitioner demonstrates respect for the values, rights, knowledge and skills of colleagues and other |
|professionals. |
| |
|Explain how/why this relates to the Category and Principle: All RDs are accountable for adhering to the Code of Ethics including |
|professional writing in an area of dietetics practice. |
|Key Points to Consider: |
|Authorship guidelines are published by journals and need to be reviewed by all individuals involved in the process. |
|Collaboration on the dissemination of the research is necessary. |
|Issues of honesty and fairness are key components in collaborative authorship. |
|Addressing issues of authorship when collaborating with other RDs should be incorporated into the initial discussions of a research |
|publication. In this situation, the graduate doctoral student and senior faculty member should have discussed the issue of authorship |
|and/or acknowledgment of contribution at the time that the assignment was made. |
|To avoid similar situations in the future, there should be clear expectations and policies established for research authorship within an |
|institution. Merely updating the literature, adding data to analysis and drafting a simple revision may not constitue authorship. |
|It is critical to avoid any bias in student evaluations based on unrelated disagreement and hierarchy. |
|It is important that misleading and inappropriate educational/academic practices should be avoided. |
|Although difficult, it might be beneficial for the student to discuss this issue with the dean. |

|Case Study #5: A clinical registered dietitian (RD) is working with oncology patients in a large medical facility. A reputable |
|pharmaceutical company supplies nutrition-related products to the hospital, and has done so for over 20 years. In fact, the medical center |
|is the company’s largest account. A few years ago the company developed a product that can speed up the process of wound healing after |
|surgery and it is currently being used by the RD’s hospital. The product has recently been found to promote the building of muscle tissue, |
|and the company is interested in marketing it to cancer patients and their caregivers in a new and exciting way: an infomercial. The |
|company wants a RD to support the product in the infomercial and has asked the clinical nutrition/manager for his support. The clinical |
|nutrition manager agreed and asked the RD, as the only oncology RD, to represent the hospital and speak in favor of the product in the |
|infomercial. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is possibly both an ethical issue and business dispute. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to the Public. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #3 - The dietetic practitioner considers the health, safety and welfare of the public at all times. |
|Principle #6 - The dietetics practitioner does not engage in false or misleading practices or communications. |
| |
|Explain how/why this relates to the Category and Principle: |
|The situation involves mass media/communication as a means to endorse/promote a product to the public. This relates to the ADA value of |
|integrity. |
|Key Points to Consider: |
|The oncology RD may sense a threat that his relationship with the clinical nutrition manager is in jeopardy if he does not cooperate. |
|The clinical nutrition manager needs to determine if he has the authority to accept the offer presented by the pharmaceutical company on |
|behalf of the hospital and what policies and procedures should be reviewed. |
|Even though the clinical nutrition manager agreed on behalf of the hospital, it does not mean that the individual RD should feel pressured |
|to accept this role if he is uncomfortable doing so. |
|Does scientific evidence exists to support the use of this product in a new patient population (eg., oncology patients)? |
|If the RD is convinced that enough scientific evidence exists to support the use of this product in oncology patients, how much control will|
|he have over the delivery of the message (“script”) so that he can make sure the message is not delivered in a false or misleading manner? |

|Case Study #6: An RD colleague voiced his opinion on several occasions about organic versus conventional produce. During an outpatient |
|counseling session, you overhear this colleague strongly encouraging the use of organic produce despite the client protesting about the lack|
|of availability of organic produce in her nearby grocery store and the higher cost associated with these products. As the conversation |
|continues, the RD suggests to the client that purchasing smaller amounts of produce will ensure that the organic varieties can be obtained |
|within the family budget. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is appears to be a practice dispute on how to counsel |
|clients. However, there is an element of ethical behavior related to providing clients with information that will empower them to make a |
|decision. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to Clients and Responsibilities to the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration. |
|Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and current information. |
|Principle #13 - The dietetics practitioner presents reliable and substantiated information and interprets controversial information without |
|personal bias, recognizing that legitimate differences of opinion exist. |
| |
|Explain how/why this relates to the Category and Principle: This scenario represents both responsibilities to the client and to the |
|profession. RDs and DTRs must show respect and consideration for clients and allow them to make their own informed decisions. In addition,|
|the RD/DTR should present information to client that is based on evidence-based principles. |
|Key Points to Consider: |
|A RD/DTR has a right to his own opinion, such as the personal preference to select organic foods for use at home. |
|RDs/DTRs must allow clients to make their own informed decisions. The RD’s behavior is inconsiderate and disrespectful, especially when the|
|client voices legitimate concerns (eg, cost and availability). |
|Current scientific evidence supports increased consumption of fruits and vegetables to decrease chronic disease risk; it does not specify |
|that these foods must be organic. |

|Case Study #7: A 45-year old man was referred to the Lipid Disorders Clinic with a plasma triglyceride of 16,000 mg/dL. The physician |
|prescribed medical nutrition therapy (MNT) for a 10% fat diet. When the RD asked about his level of motivation for making changes in his |
|eating or exercise habits, he replied, “Exactly zero!” The RD responded, “Then we have nothing to talk about.” He replied, “What do you |
|mean?” The patient and the RD then had a 30-minute conversation. The patient set a goal to order Big Macs (29 grams fat) instead of the |
|Bacon Ultimate Cheeseburgers (77 grams fat). This goal was not in keeping with a 10% fat diet. At the end of the session, the RD gave the |
|patient an analysis of his eating habits, his goal sheet, practical information about the 10% fat diet, and a return appointment. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This situation could be an ethical issue. But, it may not be |
|an ethical issue as the RD assisted the patient to achieve some changes toward the desired MNT treatment. It could also be a business |
|dispute in reference to the patient and RD agreeing to change only one behavior. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to Clients. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration. |
|Principle #9 b - The dietetics practitioner respects the client’s right to make decisions regarding the recommended plan of care, including |
|consent, modification, or refusal. |
| |
|Explain how/why this relates to the Category and Principle: The principle relates to the ADA value of social responsibility. |
|Key Points to Consider: |
|This could be an ethical issue related to the RD accepting a goal not in keeping with the physician’s MNT prescription for a 10% fat diet. |
|However, regardless of the need for the patient to eat as little fat as possible in order to reduce his plasma triglycerides to a safer |
|level, it was essential for the dietitian to meet the patient “where he was.” |
|The fact that she respected and accepted the client’s goal which was not in keeping with his diet prescription may have encouraged him to |
|ultimately consider making goals more in keeping with a 10% fat diet. |
|It is highly likely the physician had already informed the patient about his high risk for developing acute pancreatitis. |
|The RD should communicate with the physician about the approach taken and document it appropriately. |

|Case Study #8: A registered dietitian (RD), who lived in a state with a voluntary licensure law (title act) with no scope of practice, |
|became licensed. The RD then failed to renew her license but continued to use the LD credential. This came to the attention of the |
|executive secretary of the licensure board who apprised the board members of this violation. The chair of the licensure board appointed a |
|committee to investigate. The committee determined that the RD had, in fact, filed a renewal application, but that it had been returned |
|because of missing information. The RD thought she had sent in the missing information but had not. The RD moved during this time and the |
|mailing disappeared. This all occurred within two to three months. The licensure board decided not to discipline the RD, but to provide |
|education about potential consequences related to this violation and reinstate the license after provision of the missing information. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue. It could be a business dispute, as |
|not all information may have been given about practices of the board for the renewal process and acceptance of funds for renewal. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibility to the Public. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #4 - The dietetics practitioner complies with all laws and regulations applicable or related to the profession or to the |
|practitioner’s ethical obligations as described in this Code. |
|Principle#4c - The dietetics practitioner must not commit an act of misfeasance of malfeasance that is directly related to the practice of |
|the profession as determined by a court of competent jurisdiction, a licensing board, or an agency of a governmental body. |
| |
|Explain how/why this relates to the Category and Principle: This principle relates to the responsibility of each licensed and credentialed |
|practitioner to maintain current licensure status with the state and national agencies responsible for ensuring the protection of the |
|public. |
|Key Points to Consider: |
|The licensure board could have disciplined the RD, which would then have been reported to the ADA Ethics Committee. Because the lapse in |
|licensure was determined to be unintentional and was of short duration, the licensure board decided to inform the RD of the potential legal |
|consequences that could occur if she referred to herself as an LD when she was not. |
|The RD put her facility in violation of Centers for Medicaid & Medicare (CMS) rules for which the facility could have been fined. CMS |
|facility rules specify that licensure or certification must be current for all employees. Therefore, all RDs working in facilities, whether|
|or not they provide Medicare MNT are affected. |
|Licensure is voluntary, but since the RD has applied and accepted the regulations for use of the credential, it is the RD’s responsibility |
|to ensure that her licensure/certification credential is current and active. |

|Case Study #9: An out-patient registered dietitian (RD) also consults part-time with worksite wellness programs. Weight management guidance|
|has become a major part of her practice. She recognizes that having the CDR Weight Management Certification would be usefull, but cannot |
|afford the cost and has no support from her employer. A friend who represents a company that makes and sells weight loss products suggests |
|that the firm would fund her enrollment fees and travel expenses to the course in exchange for her meeting with their team to learn more |
|about their products. Currently, she does not endorse any products and is generally against such products. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue: perceived or real. It is a potential|
|conflict of interest and potentially a violation of the Code for accepting a gift. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities of the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #18 - The dietetics practitioner does not invite, accept or offer gifts, monetary incentives, or other considerations that affect |
|or reasonably give an appearance of affecting his/her professional judgment. |
| |
|Explain how/why this relates to the Category and Principle: If one works for a company or is contracted as a consultant, a similar |
|arrangement would not be an ethics issue. However, the RD has placed herself in a position of appearing to endorse the company supporting |
|the trip. |
|Key Points to Consider: |
|Is this likely to affect the viewpoint of the RD toward the products? What are the companies’ reasons for providing this “gift”? |
|Serving as a consultant to the company implies you ascribe value to their product should be disclosed at appropriate times (eg, speaking |
|engagements, submitted articles). |
|Conducting an in-service to the company’s staff within the boundaries of science, licensure and business practice is acceptable and part of |
|the role of a consultant. |
|Evaluating the products before you accept funding for the trip is necessary. Also, it important that the RD discuss her perspective on |
|promotion of products with the company. |

|Case Study #10: A dietetics technician, registered (DTR) works for a supermarket chain. He is invited to attend a 2- day seminar offered by|
|a not-for-profit industry support group that represents a segment of major commodity (dairy, fruits, vegetables, meat, grains). Funding for|
|the support group is by growers and producers. The theme is “from farm to table,” and the program is approved for continuing education |
|units. The program includes visits to farms, producers and a food processing plant, presentations by researchers and marketing staff, and a|
|culinary demonstration. The plant visit is to the headquarters of a nationally known company that produces both a nationally known brand |
|and store brands. His transportation, lodging, meals, educational materials and presentations are being paid by the industry support group.|
|The location is a resort in a part of the country that is known for growing and producing the commodities being featured. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? Since the DTR is working for a supermarket, this is not an |
|ethical issue, provided his employer does not see it as a conflict of interest or as a gift that might be perceived as affecting his |
|professional judgment. However, it could become one if the DTR does not follow ethical lines when making decisions on the products that are|
|being showcased in this educational program. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles and Responsibilities of the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity, and fairness. |
| |
|Principle #18 - The dietetics practitioner does not invite, accept or offer gifts, monetary incentives, or other considerations that affect |
|or reasonably give an appearance of affecting his/her professional judgment. |
| |
|Explain how/why this relates to the Category and Principle: Depending on the employment status, this DTR may be expected to make |
|recommendations for products. |
|Key Points to Consider: |
|The DTR should discuss this with his employer to clarify business directives and any appearance of unethical behavior. |
|The DTR should research the commodity group, their mission, and their funding so he is aware of the funding for the opportunity. If the |
|reasons for the program, mission statements of the funders, or funding disclosure are unclear, it may be best to decline. |
|The DTR should discuss with the funder/planner any questions before accepting the invitation. |

|Case Study #11: A university professor who teaches clinical dietetics is provided with glucose testing supplies including meters, samples of|
|supplements for persons with diabetes, and computer programs by the local representative of a pharmaceutical company. Amounts provided are |
|sufficient for use in student demonstrations and for use at the school’s sponsored health fairs conducted for its employees and the |
|community. This is welcomed because of the lack of budget for these at the university. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It has the potential for being unethical. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities of the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #18 - The dietetics practitioner does not invite, accept or offer gifts, monetary incentives, or other considerations that affect |
|or reasonably give an appearance of affecting his/her professional judgment. |
| |
|Explain how/why this relates to the Category and Principle: Although such tools are welcomed, the perception of product endorsement comes |
|when only one product is featured. Knowing expectations that come with the “gift” and limitations that might come if competitors were |
|introduced is important. |
|Key Points to Consider: |
|The university’s policy should be reviewed and understood. |
|Support from more than one source, if acceptable to department policy, should be sought out. |
|Expectations should be discussed with the pharmaceutical representative. |

|Case Study #12: A client fails to pay for the final session of a private practice appointment ($150 outstanding). Three invoices are sent |
|and the registered dietitian (RD) leaves 3 voicemail messages. The client’s credit card number is on file. The RD does not have |
|authorization to use the credit card for this specific payment. The RD is considering the use of the credit care to charge for the |
|previously provided final session. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is both an ethical issue and a business dispute. Payment |
|practices for services must be made clear to clients prior to initiation of services to prevent disputes and should be provided in writing. |
|If provider RD charged the card for the service it would be both an ethical and legal issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity and fairness. |
| |
|Explain how/why this relates to the Category and Principle: |
|Although the RD has the credit card number, it is unclear if it’s fair to charge the card without approval. It is clear that the RD does not|
|have authorization to charge credit card for service. |
|Key Points to Consider: |
|The client owes $150 for service rendered, but did not sign any contract or authorization forms allowing the RD to charge for those |
|services. |
|In the future, the RD needs to obtain authorization for payment prior to rendering services. |
|Billing policies should be disclosed during initial appointment. |

|Case Study #13: A registered dietitian (RD) is reading blogs posted by colleagues in dietetics. He finds nutrition misinformation written |
|by an RD; her posting is not in agreement with a non-government organization’s recommendations and current scientific evidence. He is |
|familiar with the topic because he consults for a food company that relies on the information to support their brand messages. He knows |
|that the RD is incorrect and perpetuating myths, but he worries that it could also be considered a conflict of interest for him to correct |
|the RD on the site. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibility to the Public; and, Responsibility to the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #3 - The dietetics practitioner considers the health, safety and welfare of the public at all times. |
|Principle #6 - The dietetics practitioner does not engage in false or misleading practices or communications |
|Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and current information. |
|Principle #13 - The dietetics practitioner presents reliable and substantiated information and interprets controversial information without |
|personal bias, recognizing that legitimate differences of opinion exist. |
| |
|Explain how/why this relates to the Category and Principle: |
|The blogger is providing misinformation. The RD, on the other hand, may have a conflict of interest in that he benefits from the correct |
|message being posted. |
|Key Points to Consider: |
|Consider if the RD is expressing his opinion or professional advice/knowledge. |
|Consider if the research is conclusive. |
|What do the non-government organizations and professional health organizations (e.g., ADA) recommend? |
|Based on the scenario, discuss whether the RD should disclose his relationship with the food industry. And, if so, is the RD permitted to |
|speak on their behalf? |

|Case Study #14: At a regional dietetic educator’s meeting there is a discussion about how to meet some of the didactic program in dietetics|
|(DPD) and internship competencies. A DPD director has a disagreement with an internship director about how some of the competencies can be |
|met. That year the DPD director discourages all students who want to apply to that internship and tells them not to apply because it is of |
|poor quality. The internship director, who had previously talked to one of the potential applicants, runs into the applicant and asks the |
|student why he did not apply. He tells her he was advised against it because of the “dubious” quality of the program. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? An ethical issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles (Principle #1); Responsibilities to the Public (Principles #5 and #6);|
|and, Responsibilities to Colleagues and Other Professionals (Principle #19). |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #1 - Conducts himself/herself with honesty, integrity and fairness. |
|Principle #5 - The dietetics practitioner provides professional services with objectivity and with respect to the unique needs and values of|
|individuals. |
|Principle #6 - The dietetics practitioner does not engage in false or misleading practices or communications. |
|Principle #19 - The dietetics practitioner demonstrates respect for the values, rights, knowledge and skills of colleagues and other |
|professionals. |
| |
|Explain how/why this relates to the Category and Principle |
|Principle #1: The DPD director has not been fair to the student, the internship director and the program. |
|Principle #5: The DPD director has not provided the student professional services with objectivity and with respect to the unique needs and |
|values of the student. |
|Principle #6: The DPD director has provided unsupported and perhaps false information. |
|Principle #19: The DPD director has violated the rights of a colleague. |
|Key Points to Consider: |
|For Principle #1, consider the following questions related to the case. |
|Did the DPD director provide evidence or facts to support the statement of “dubious quality?” What evidence is needed to be provided to |
|support that statement? |
| |
|For Principle #5, consider the following points related to the case. |
|What should the DPD director consider when providing the student guidance about what internships would be most appropriate based on |
|individual needs, values, and desires? |
| |
|For Principle #6, consider the following questions related to the case. |
|What false or misleading communications did the DPD director provide and how did that impact the behavior of the students, their opinion of |
|the accused internship and its director? |
| |
|For Principle #19, consider the following questions and points related to the case. |
|Consider whether the behavior of the DPD director has been appropriate. Consider if the DPD director violated the internship director’s |
|personal rights (and that of the program’s). How could the DPD director have handled the disagreement and student desires to apply to the |
|internship? |

|Case Study #15: A registered dietitian (RD) in an ICU unit has been working with two very different clients. Mr. Jones is a client who is |
|very angry over an unexpected heart attack, the “unfairness of life” and the ensuing dietary restrictions. As a result, he telephones the |
|RD a couple of times a day with issues about the food or if he is not feeling well. Next door is Mr. Smith, who is very personable, |
|patient, and friendly. The RD has seen the telephone ring twice, noticed it was from Mr. Jones room, and ignored the call. The telephone |
|rings again and it is Mr. Smith. The RD answers the telephone, and agrees to go see Mr. Smith. The RD decides he’ll go see Mr. Jones after|
|talking with Mr. Smith. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? An ethical issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles (Principle #2); and, Responsibilities to Clients (Principle #9). |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #2 - The dietetics practitioner promotes and supports high standards of professional practice. |
|Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration. |
| |
|Explain how/why this relates to the Category and Principle |
|Principle #2: The RD did not use high standards of professional practice in working with the clients and providing equal and timely care in |
|the order or sequence required. |
|Principle #9: The RD did not treat all clients with respect and equal consideration. |
|Key Points to Consider: |
|For Principle #2, consider the following questions related to the case. |
|Does the failure to answer the telephone not support the provision of high standards for professional practice? |
|Does choosing to visit Mr. Smith before Mr. Jones violate the principle of high professional practice? |
| |
|For Principle #9, consider the following questions related to the case: |
|Does not answering Mr. Jones’ two telephone calls, constitute a failure to treat the client with respect and consideration? |
|What could the RD have done to respect Mr. Jones calls and minimize the annoyance that was felt by the client’s frequent demands? |

|Case Study #16: A registered dietitian (RD) has a follow-up appointment with a client who is on a weight loss diet. This client failed to |
|come to the last two meetings. The RD decides to call the client to remind her about the appointment. When the answering machine comes on,|
|the RD leaves a message for the client. The RD reminds the client about the appointment, states the importance of a weight check, and asks |
|the client to call back to confirm the meeting. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is both an ethical issue and a business (legal) issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles (Principle #2); and, Responsibilities to Clients (Principle #10). |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #2 - The dietetics practitioner promotes and supports high standards of professional practice. |
|Principle #10 - The dietetics practitioner protects confidential information and makes full disclosure about any limitations on his/her |
|ability to guarantee full confidentiality |
| |
|Explain how/why this relates to the Category and Principle |
|Principle #2: The RD has failed to practice in accordance with the standards of the profession. |
|Principle #10: The RD has not protected the patient’s information and treated it confidentially. |
|Key Points to Consider: |
|For Principle #2, consider the following points related to the case. |
|Consider the standards of practice related to confidentiality. |
|Consider some of the legal implications of this RD’s actions, both for the RD and the employing institution. |
|HIPAA laws prevent leaving confidential medical/nutrition information on a voicemail without prior authorization. It is appropriate for the|
|RD to do reminder calls. |
| |
|For Principle #10, consider the following points related to the case. |
|Discussing general business practices or operating procedures can be implemented to deal proactively with appointment compliance. |
|Consider options for how the RD deal with the appointment-keeping issues related to this client. These options should limit the purpose of |
|the call to avoid presenting confidential information. |

|Case Study #17: A registered dietitian (RD) who works in a clinical setting recently lost her significant other. Since the death, she has |
|had trouble concentrating, sleeping, decision making or putting focus into life. This is something that is evident when she is counseling |
|clients, reading records and charting. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This has the potential to be an ethical issue. The professional|
|is continuing to practice when he/she may have impaired judgment. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle#7 - The dietetics practitioner withdraws from professional practice when unable to fulfill his/her professional duties and |
|responsibilities to clients and others. |
| |
|Explain how/why this relates to the Category and Principle: Stress is an issue that can impair one’s judgment. Identification, treatment |
|and support are important but it is not known if this RD has sought any of these. If the role of this professional is making decisions that|
|affect the health and safety of others, and if there is no check and balance on decisions, the potential for the public to be harmed is |
|increased. |
|Key Points to Consider: |
|Important to know if the practitioner has identified there is a problem and sought help. |
|What types of decisions are being made by this professional? Nutrition support, recommendations for rehabilitation, serving as the |
|dietetics practitioner on a team can put additional stress on RDs. On a management side, employee negotiations and supervision, and budget |
|management are stresses where concentration and quick response are important. Regardless of the position, there is potential for clouded |
|judgment. |
|Removing oneself from a high-level decision position is difficult but is a part of ethical behavior. |
|Having support from coworkers and those who supervise the professional is important. |
|Although the protection of the public is the prime concern, the protection of the RD is also a point to consider. A compromised decision |
|can end up with loss of life and all the costs that come with liability lawsuits. Not withdrawing from the work environment could lead to |
|these actions. However, depending on the contract with the employer and the way the withdrawal from responsibility is handled, there is |
|also protection of the rights of the RD. |
|Possible disability requirements as it relates to the Americans with Disabilities Action should be discussed with the employee. |

|Case Study #18: A registered dietitian (RD) has constant back pain, something the doctors have been unable to treat. Biofeedback, physical |
|therapy, and pain medication are the current means to control. The current level of pain medication, although prescribed by his physician, |
|is at such a level that he has been advised not to drive after taking the medications for at least 4 hours. In addition, the side effects |
|include drowsiness, shortening of attention span and memory. His current job requires office hours in 3 different sites a week and involves|
|home visits to patients in critical need. The RD believes the situation is under control by limiting his appointments to control drive time|
|and home visits. In the past month, the dependence on the pain medication for relief has increased. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This is a potential ethical issue. Personal responsibility to |
|fulfill the needs of the employer and to provide service to the public. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibility to the Public. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle#7 - The dietetics practitioner withdraws from professional practice when unable to fulfill his/her professional duties and |
|responsibilities to clients and others. |
| |
|Explain how/why this relates to the Category and Principle: The RD has a condition that interferes with his ability to provide effective |
|service. In addition, the situation is escalating to be potential malpractice considering the side effects of the medication. |
|Key Points to Consider: |
|Need to consider if this is a “cover-up” by the RD to maintain a position that he is unable to fulfill. |
|Is there a back-up plan for covering patients who need nutrition care? |
|Where is the employer, including Human Resources, in this scenario? Do they know the issues and the potential liability they are assuming by|
|allowing the RD to perform duties that may not be safe for the patient or the individual? |
|What is the risk of misuse of the medication and the potential damage? |
|What can be done to “protect the public” depending on this professional providing service without the risks of a drug (even legal) |
|dependency? And, what can be done to protect the other players (the employer and the RD)? |
|Possible disability requirements as it relates to the Americans with Disabilities Action should be discussed with the employee. |

|Case Study #19: A registered dietitian (RD) works in an outpatient care center. Her patient discloses he is pursuing complementary and |
|alternative therapies. The client has a family history of diabetes and heart disease. He has been diagnosed with Type 2 diabetes and is |
|under control with one oral medication, diet and exercise. In addition he is on a low dose medication for hypertension. He asks the RD’s |
|opinion on several supplements and therapies she is already taking or thinking of using. The RD is not familiar with these supplements or |
|therapies and dismissed the comments. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical issue if the RD gives an opinion about the |
|supplements without adequate scientific knowledge of its benefits or side effects. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to Clients. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #8 - The dietetics practitioner recognizes and exercises professional judgment within the limits of his/her qualifications and |
|collaborates with others, seeks counsel, or makes referrals as appropriate. |
| |
|Explain how/why this relates to the Category and Principle: Supplements and their interaction with drugs is an issue that requires specific |
|knowledge. The fact that the client admits to already taking some is a trigger for more information. |
|Key Points to Consider: |
|By dismissing the request for an opinion without research or without providing an appropriate referral, the door is opened for harm to the |
|client. |
|Decisions of this type require assessment of the person’s family and health history (perhaps genetics), current meds and potential |
|interactions, diet and activity. Risks will vary. |
|Referral to an RD familiar with complementary and alternative medicine, or at least a referral to legitimate Web sites, may be appropriate. |

|Case Study #20: A consultant registered dietitian (RD) has a worksite wellness account. Her usual programming includes group classes on |
|basic nutrition, nutrition for those with diabetes, heart-healthy eating, and coping with food allergies. She also provides personal |
|coaching to the company’s employees. She is approached by one of an employee who is training for marathons and has specific interests in |
|sports nutrition, nutrition during training and pre-/post-event. Although the RD is comfortable with the role of exercise and nutrition in |
|basic health and general needs, competitive athletics is not an area of expertise. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? To decide on giving advice without adequate knowledge would be |
|an ethical issue if the client is accepting your advice believing you are an expert in sports nutrition. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to Clients. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #8 - The dietetics practitioner recognizes and exercises professional judgment within the limits of his/her qualifications and |
|collaborates with others, seeks counsel, or makes referrals as appropriate. |
| |
|Explain how/why this relates to the Category and Principle: Recommendations on fitness and activity for an elite athlete or someone seeking |
|that distinction is, by nature of the case study outside the limits” of this practitioner’s expertise. |
| |
|Key Points to Consider: |
|There is the potential to work with the client after disclosure of the RD’s limitations and willingness to research the necessary |
|information. |
|Sports nutrition for the “elite athlete” is an area that is best addressed by a RD with the appropriate certification/training. This is a |
|specialty certification. |
|How much time would it take to research the questions, seek counsel and from a business side, would it be a better decision for all to refer|
|to another practitioner? |

|Case Study #21: The Professional Development Portfolio (PDP) process has become a stumbling block to retaining a dietetic technician, |
|registration (DTR) who wishes to retain her registration status. She submitted the initial portfolio and is close to the end of the 5-year |
|period. Although she has attended meetings that offered continuing professional education (CPE), most of them were not specific to her |
|approved plan for continuing education. The reminder notices from Commission on Dietetic Registration (CDR) continue to come. Registration|
|is a requirement to remain licensed and employed. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical dilemma that was set up by the DTR not |
|putting emphasis on responsibilities to the profession. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #14 - The dietetics practitioner assumes a life-long responsibility and accountability for personal competence in practice, |
|consistent with accepted professional standards, continually striving to increase professional knowledge and skills and to apply them in |
|practice. |
| |
|Explain how/why this relates to the Category and Principle: The Portfolio Process is built on assessment and planning. It is a personal |
|responsibility. |
|Key Points to Consider: |
|Does the submitted plan meet the needs for the DTR to meet competencies of practice and reflect increasing professional knowledge and |
|skills? |
|Within the time frame, what opportunities are available within the submitted and approved plan (or amendments if possible)? |
|Attempting to make CPE “fit” the learning plan is taking a risk for the CPE not being accepted in the portfolio process, with loss of |
|registration and the reciprocity of licensure in this case. |
|Submitting CPE that “fits” but was not completed is fraudulent and is definitely unethical. Potentially, this places the dietetics |
|practitioner at risk in the case of an audit. |
|Review the reason for the portfolio process. CDR offers guidance and this should be sought. |
|What opportunities are available that meet needs (online, academic coursework, book or journal based articles, intensive seminars)? |

|Case Study #22: A group of registered dietetics practitioners, who are friends and co-workers have decided it will be easier (and less |
|expensive) to meet continuing professional education (CPE) requirements if as a group, they decide on a plan with minor variations for each |
|person to submit as their own. This, they rationalize will allow discussion and planning for helping those who are not sure of their plans.|
|Further, the attendance at the CPE events will be split among the group with designated members taking responsibility for attending, taking |
|detailed notes, taping speakers and duplicating any handouts, and CPE proof. This is rationalized as a form of “self-learning” with the |
|idea that group members not attending will be able to ask questions of those who did as well as study the handouts. While discussing this |
|as a group, several of the group members question if this is ethical. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? This is an ethical issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #14 - The dietetics practitioner assumes a life-long responsibility and accountability for personal competence in practice, |
|consistent with accepted professional standards, continually striving to increase professional knowledge and skills and to apply them in |
|practice. |
| |
|Explain how/why this relates to the Category and Principle: The Portfolio process is built on assessment and planning. It is a personal |
|responsibility. |
|Key Points to Consider: |
|Copying a group plan is clearly a breach of ethics. |
|Copying a group plan is not only unethical but also crosses the ethics line of personal competence in practice. Planning for continuing |
|education is a personal issue that takes into account skill and knowledge level, experience, interest and professional responsibilities; |
|both present and in the future. The goal of CPE is to meet competencies of practice and reflect increasing professional knowledge and |
|skills. This is unlikely and the submission of a single plan essentially “copied”, is another breach of ethics. |
|It is clearly unethical to record attendance at a CPE event that was not attended. Take the opportunity to review the purpose of the CDR |
|portfolio process. |
|There are programs that are preapproved for group sharing and discussion, but the intent of this group to “share” is fraudulent and is |
|definitely unethical. Potentially, this places each of the dietetics professional at risk in the case of an audit. |
|If practicality and convenience is the driver in this case study, think about the potential of one of the group deciding to report the |
|actions to CDR or ADA. What then? |

|Case Study #23: A skilled long-term facility patient with severe dementia tells a registered dietitian (RD) that she no longer wants to be |
|fed via her gastrostomy feeding tube. She has no advanced directive. The daughter wants the mother fed. What is the RD’s role in this |
|situation and what should be done? |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? It is an ethical and legal issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Responsibilities to Clients; Responsibilities to the Profession. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #8 - The dietetics practitioner recognizes and exercises professional judgment within the limits of his/her qualifications and |
|collaborates with others, seeks counsel, or makes referrals as appropriate. |
| |
|Principle #9 - The dietetics practitioner treats clients and patients with respect and consideration. |
| |
|Principle #12 - The dietetics practitioner practices dietetics based on evidence-based principles and current information. |
| |
|Explain how/why this relates to the Category and Principle: The RD must recognize and exercise their professional judgment when determining |
|what is best for the client. Client and patient preferences must be balanced with scientific judgment and legal considerations. |
|Key Points to Consider: |
|RDs are frequently called upon for their expertise regarding long-term and end-of-life nutrition issues. Is the RD knowledgeable about |
|these specific nutritional issues? If not, the ADA position paper on this topic could be of assistance. |
|If the RD has been working with the patient for a period of time, she may have had previous discussions about feeding. If the RD has this |
|knowledge, she has an ethical duty to report this information to the physician. |
|If there were no discussions and no advance directives, the daughter may be the person designated to make these decisions. State laws vary |
|widely and would need to be strictly followed to avoid liability to the institution or the individual health practitioners. |
|If there are additional family members, their input could also be sought. |
|If there is a bioethics committee, the RD needs to be an active participant, sharing her nutrition expertise. |
|A discussion with the daughter about the probable futility or lack of benefit of the tube feeding needs to be addressed. |
|If the decision is made to continue feeding the patient and the RD does not agree, she has a duty to get another RD to take over the care. |

|Case Study #24: A registered dietitian (RD) says that she had expenses paid by ADA to attend a conference. Her job also pays for the |
|expenses to attend the meeting. She decides to submit for reimbursement to each group. She explains that the ADA expenses can be |
|considered a honorarium for work done at the meeting. She shares this information with a colleague RD. |
|Questions for Discussion |
|Is the situation described an ethical issue? Or, is it a business dispute? The situation is an ethical issue. |
|What principle(s) of the Code of Ethics does it relate to and how/why? |
|Indicate the Category for the Code of Ethics: Fundamental Principles; Responsibilities to Colleagues and Other Professionals. |
| |
|Indicate the Principle(s) of the Code of Ethics: |
|Principle #1 - The dietetics practitioner conducts himself/herself with honesty, integrity and fairness. |
| |
|Principle: #19 - The dietetics practitioner demonstrates respect for the values, rights, knowledge and skills of colleagues and other |
|professionals. |
| |
|Explain how/why this relates to the Category and Principle: The fundamental actions of the practitioner are a personal responsibility to act|
|ethically with accountability. The RD colleague has a responsibility to act ethically. |
|Key Points to Consider: |
|It is a two-fold ethical issue. The ethical conduct of both individuals is called into question. |
|The practitioner who decides to double-dip is violating Principle #1. |
|The practitioner falsely claiming reimbursement for expenses, regardless of her rationale, is dishonest and double-dipping from the |
|professional association and employer. |
|While RDs cannot regulate the conduct of others, the colleague who hears about situation should confront the individual to discuss the |
|ethical issue. |
|The colleague could decide to ignore the breach of ethics or decide if the rationale is acceptable. How does the RD demonstrate respect for|
|the values, rights and knowledge of her colleague? |
|If the practitioner goes ahead with the submission, is it the responsibility of the RD colleague to report the issue to the ADA or the place|
|of employment or both? |