All clinicians be they in health care, social services and psychology and similar, function in the real world.  It is accepted and realized that professionals are human with lives in and outside of the professional context and as such, might be tempted to veer away from the optimal behavior. This is one of the reasons that these professions have in depth codes of ethics to guide professional conduct.  The code of ethics helps us cope with our own human weaknesses and enables us to interact with our clients in unique relationships.

Clinician/ client relationships, including the breastfeeding professional/ client relationship, differ from other relationships in many ways. Some unique aspects of  functioning clinical relationships include well defined boundaries and roles as well as an unequal division of power. The main reason for forming and maintaining the relationship is to enrich client well being and not the opposite. While clinicians may in fact benefit from these relationships, this is a chance by product but not the main function of the relationship. 
 
The  unique function of the professional relationship, entitles the clinician to interact with the client in a manner that would not be accepted outside of the relationship and vice versa.  For example, lactation consultants often view as well  touch women's breasts and infants' bodies. Clients in clinical relationships enable clinician behavior through their trust in our talents and knowledge and their belief that we are acting in their best interest. 
 
Codes of ethics reflect these underlying relational principles. Again, the codes of ethics is there to assist us with our human weaknesses and to ensure that we continue to hold the client as central.  The issue of client interests and conflict of interest is one item that is discussed and appropriate conduct in this regard is implicitly detailed in most clinical code of ethics that I am aware of.  I am highlighting this point because of the relevance of this particular issue to our discussion lately on lactnet. 

Can or should we emulate ethical behavior in our practice. Of course we must regardless of the obstacles that are placed before us.  Is this realistic? Of course it is. The very nature of client/clinician relationships requires this of us. Is it difficult and does it cause anguish and perhaps punitive measures for some professional? Yes, in fact this might also be true, but our personal distress does not excuse us from optimal professional performance in any area of practice.  
 
I say all of this with confidence after practicing for two decades in the real world. The conception of the "Ginger Bread House Theory" came to me as I tried to analyze my last experience in a very unethical environment. I came to the difficult realization that no matter how wonderful and fulfilling it is to change environments (and we did make some unbelievable progress), some contexts will only evolve to a certain point.  I learned that it is important to differentiate between well meaning, health focused but ignorant staff or administrators and those interests are  not congruent with the provision of optimal health care. While work with the first group can be most frustrating, the change process is genuine and thus, justifies our hard work. Work the later group is a facade and it would be better if we re-directed our efforts.

I acknowledged that some institutions, who portray themselves as client centered might are in fact, holding  goals that have greater meaning and benefits for them and thus, will only take advantage of our talents until it interferes with their real aims. This hinders the principle of ensuring  that client interests always remain central to the clinical relationship and thus, negates the very basics of ethical practice. 
 
Now let's look at the argument that practitioner financial welfare sometimes justify taking jobs in environments that displace client welfare with other goals. It is important to note that for centuries families have sacrificed morals to put food on the table for their children, so relinquishing  values for financial gain is not a new idea. However, it is important to remember the very essence of clinical work is the formation and maintenance of the client/clinician relationship. Again, this relationship is defined by ensuring that client welfare is central. How do you think the lapse in one area of care will  affect other contingent areas of practice?   Furthermore, how would that make you feel if you were the client in this situation?
 
Indeed, let's look outside of the context of breastfeeding to understand this point in greater detail. Let's look for example, at the geriatric population. This population is also targeted by various marketing professionals. How would most of you feel if your elderly parents were tended to by a practitioner, who  not only cared deeply for your parents' needs, but also worked for an institution that was funded, sponsored and influenced by a company that sold gadgets to this target population. As we all know employees who do not meet the aims of companies, do not stay on board for long. So how would you feel if you knew that your elderly mother was cared for by a practitioner with long standing employment in this institution?  How would this effect your interactions with the practitioner at all levels? 
    
Hence, this topic that we have discussed in great depth really boils down to an understanding of the principles that form professional ethics. Breastfeeding professionals are still be tested at great lengths by clients and professionals alike. Thus, it is vital that we demonstrate that we are true clinicians and as such, we must show that we value the very basics of clinical practice, the client/clinician relationship.

Keren Epstein-Gilboa MEd BScN RN FACCE LCCE IBCLC 
PhD (Candidate)  

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