Ethics in Hearing Healthcare - The Basics

Editor’s Note: This text course is an edited transcript of a live seminar.  Download supplemental course materials here.

My name is Suzanne Lindsey-Henderson, and I am an audiologist and Senior Educational Specialist with Beltone Hearing Care.   I have been around the industry for over 30 years.  For the last 7 or 8 years, my job has been to create seminars and then teach them.  Welcome to Ethics in Hearing Healthcare.  We are going to talk about the basics of ethics. 

I want to introduce the sections we will be covering today.  We will define the terms related to ethics, talk about ethical principles, and discuss ethical strategies and how they relate to fitting hearing instruments. 

Defining the Terms

The first thing I want to do is define the terms.  We are going to talk about each of these terms:  ethics, morality, the law, bioethics and ethical dilemmas.  In the ethical dilemma section, we will first address what that is and then talk about some different strategies and theories about solving ethical dilemmas.  Different cultures have different moral codes.  Thus, there are no universal truths in ethics.  It is difficult to say that customs are either correct or incorrect. 

Morality is what people believe to be right or wrong, while ethics is a critical reflection about morality.  Some authors really believe that morality and ethics are the same.  You will be hearing me use the terms somewhat interchangeably. 

Ethics is a system of moral principles.  They are rules of conduct recognized in respect to a particular class of human actions or a particular group or culture.  There are subcategories to ethics.  For example, there are medical ethics or Christian ethics.  Law is brought about by tension, agitation and conflict.  Law can also be enacted due to dramatic situations.  Laws are societal rules or regulations that are obligatory to observe.  Today, federal and state governments have constitutional authority to create and enforce laws.  Can anyone name a law brought about by tension, agitation, or conflict?  One answer is the Geneva convention.  Another says civil rights.  Both of those are true.  They were brought about by agitation and conflict.  Another one that you all know is the Amber Alert.  That was brought about by a horrible situation.  A child was abducted and murdered, and there was not a coordinated system to look for the child.  Law enforcement knows that best results in finding a child are going to be within those first 24 to 48 hours.  So now we have Amber Alerts. 

Some laws protect society by protecting the welfare and safety of society and resolving conflicts, and those laws are constantly evolving.  Some examples of law that protect society are driving-under-the-influence (DUI) laws, safety belts, child car seats and bicycle helmet laws.  We are all very familiar with a law that governs the practice of medicine.  Laws have governed the practice of medicine for over 100 years, and they govern the practice of hearing aids and audiology.  You have to obtain a license.  Some of you had to go through a long apprenticeship.  Some of you had to be supervised 100% of the time.  Then once you obtained that license and took your exam, you had to maintain it by getting continuing education units (CEUs).  The Hippocratic Oath is an example of the intersection of ethics and the law, and says first, “Do no harm.” 

I want to play a little scenario game with you: Is it Legal, Moral or Ethical?  Type in the box your response when I give you a question.  Scenario #1.  I want to talk about a competitive user.  A woman wearing a set of digital hearing aids comes into your office and she is complaining that the hearing aids do not work very well.  When you talk to her, you discover the following: 

• Her hearing aids are less than 1 year old;
• They are entry-level, three-channel, digital hearing instruments;
• They have very basic noise reduction, anti-feedback, and omnidirectional microphones;
• They are full shell in-the-ear (ITEs); 
• Her binaural aided discrimination is 72%;
• The woman is telling you that she is very disappointed, revealing that the dispenser said that this was top technology, and she paid what amounted to her life savings to get these. 

Was what the other dispenser did legal?  Many of you are saying yes.  Was what the other dispenser did moral?  Many say no.  Was what the other dispenser did ethical?  The answers are pouring in, with most of you saying no. 

Here are some things to think about with this scenario that might change your opinion a little bit.  Do we know what the person who fit the hearing aids really said?  I do not know if any of you watch the show House.  It is now off the air, but Dr. House said that all patients lie.  I am not going to go that far, but I will say that patients certainly hear what they want to hear, and sometimes they exaggerate to their benefit.  Do we know if she went for her follow-up appointments?  Next, what is not working about her hearing aids?  Why is she unhappy?  In what situations would she like to hear and understand better?  Moving on, what does “life savings” mean, and was she shown other choices in technology when she bought the instruments? 

The hearing aids are under warranty, so I would like you to tell me what you do with this patient.  I am getting quite a few answers.  One says sound-field verification.  Another says that the patient may not be objective.  Several people have said to test her hearing.  Some of you said to counsel her to return to her provider for additional adjustments. 

If she insists and you had the software, would you take care of this customer?  Everyone is saying absolutely.  I think the important thing here is that we get the patients taken care of whether you do it or someone else does it. 

Let’s look at another scenario, a poorly-fit user.  A man and his wife return from their winter extended stay.  A lot of our folks go South for the winter.  They come to your office with their new hearing aids and they are having a little trouble with them.  You discover the following:

• They have worn them only one month;
• They are budget completely-in-the-canals (CICs);
• They paid $6,500 for them;
• They were told to come to you for further adjustments;
• They were told that you would make any adjustments they needed at no charge;
• This dispenser has not contacted you;
• They were sold an extended three-year warranty that they believe is good at any location that sells this brand; 
• When you call customer service, you discover they only have a one-year factory warranty; 
• Their loss is normal through 1,000 Hz and mild to severe steeply sloping sensorineural hearing loss, and their chief complaint is hollow sounds and whistling; 
• Additionally, you sold them advanced-level receiver in the ears (RITEs) one year ago. 

Was what the other dispenser did legal? Some of you say no, some say yes; some are saying probably.    One of you said no because they did not honor the three-year warranty.  Was it moral?  No, no, no, no, are your answers.  Last but not least, was this ethical?  Again, you are all saying no, some with multiple no’s in the same answer. 

Let’s think about this one a little bit more.  Did you do your job?  Did you do adequate follow-up?  Did you fit them immediately before they left for their winter home?  The biggest question, I think, is why did they go looking for new hearing aids, and do you really know what the other dispenser said to them?  I have done this class previously, and a lot of people were outraged that the hearing aids were budget CICs and they were $6,500.  Do you think charging $6,500 for a budget product is legal?  Yes.  Do you think it is moral and ethical?  That depends on the market and whose definition of budget we are going by, but generally, no.  What is your next step with this patient?  Perhaps you will call the dispenser.  Does the patient still have the hearing aids you sold them one year ago? Ask more questions and ask why they are not wearing the RITE aids that you sold them.  What was the problem with their other hearing aids?  We need a lot more information. 

Bioethics

Bioethics is a bit of a different category.  It refers to the moral issues and problems that have arisen as a result of modern medicine and medical research.  Issues in bioethics are usually life and death issues.  They can be personal.  They can be organizational, institutional, or world-wide.  Medicine and technology are changing so rapidly that they are offering many choices to individuals.  Although challenging and even exciting, the choices can be difficult for each of us. 

For example, should medications known to be effective be withheld from homeless or incompetent people because they do not have the means to store them?  What if they cannot manage their medication properly?  In our world of hearing aids, should we fit cochlear implants to a deaf child who has deaf parents?  We would probably say yes, but the Deaf culture would say that you are destroying their way of life. 

When you compare the law and ethics, they are different but related.  Moreover, law, ethics, and bioethics are different, but related concepts.  Laws are mandatory.  All citizens must adhere or risk civil or criminal liability.  Ethics relate to morals and help us organize complex information, competing values and interests to formulate consistent and coherent decisions.  There are penalties for failing to follow the law, and this includes our professional practices acts.  Though there are no penalties for not following the principle of ethics, there are consequences to you, to your organization, and to the community at large.  One of those consequences of not being ethical can actually worsen your sales because word spreads so quickly, especially these days with the Internet, and you could end up with no business at all if you are unethical. 

Ethical Dilemma

Ethical dilemmas are value conflicts.  There is no clear consensus as to the right thing to do.  They are a conflict between moral obligations that are difficult to reconcile and require moral reasoning.  It is a situation necessitating a choice between two equal, usually undesirable, alternatives.  Sometimes we think of this as the “lesser of two evils” scenario, or the “no win” scenario.  For those of you who are Star Trek fans, you know about the Kobayashi Maru scenario. 

Here are some ethical questions, and I want to ask what you think about each of them. Should a parent have the right to refuse immunizations for his or her child?  The answers I am seeing are yes, yes, absolutely yes.  Looking at the other side of the coin, if you decide not to immunize your child, does the school have a right to not admit your child?  The answers are mixed, yes and no.  One person says, “What if it jeopardizes the health of other children?”  You can see the ethical question here. 

Here are some others.  Does public safety supersede an individual’s rights?  Should children with serious birth defects be kept alive?  Should a patient be prescribed drugs that are addictive if they are terminally ill?  Should terrorists be tortured to gain information that can possibly save hundreds of lives?  You all saw the hoopla with waterboarding not too long ago.  Should healthcare workers be required to receive the H1N1 (swine flu) vaccination?  Who should get the finite number of organs for transplantation? 

Can any of you think of another ethical question that has been in news lately?  The responses I am seeing are, “Should minors be able to receive birth control without informing their parents?  Is it right to mandate one child if your country is overpopulated?  Should weapons be provided to Syria ?”  These are good examples. 

Ethical Theories

There are several ethical theories that are employed to serve as framework to respond to a myriad of ethical questions.  We are going to look at those in the next several minutes. 

The first ethical action strategy is called Deontology.  The second is consequentialism.  Third is virtue ethics or intuition.  There are also beliefs like rights ethics, which is individuality in the American culture.  Let’s talk about deontology first. 

Deontology/Nonconsequentialism

Deontology is derived from the Greek word deon meaning duty.  It considers that some acts are right or wrong, independent of their consequences.  It looks to your obligation to determine what is ethical and answers the question, “What should I do, and why should I do it?”  If you think it is the right thing to do, you are going to do it regardless of the consequences.  One example of deontology we are going to look at is about Zelda; she is a nurse practitioner.  She believes that she has the duty to give cardiac clients detailed information on the pathology involved in their condition even though the client has indicated that they are not ready or may be terrified to hear the information causing the client distress.  So even though this client has said, “I’m going to be terrified,” Zelda is going to give them all the information that she thinks is necessary. 

Consequentialism

Consequentialism, a bit on the opposite side, is also called teleological theory from the Greek word telos, meaning consequences or end.  The actions are determined and justified by the consequence of the act.  So consequentialists consider all the consequences of what they are going to do prior to deciding a right action.  All of these ethical theories answer the question, “What should I do, and why should I do it?”  In this case, a consequentialist knows what is ethical, but considers all the different possible results before taking action. 

Let’s look at Zelda again.  Zelda now respects the wishes of her patients.  She gives them only the information which would have been a benefit to them and does not cause them undue stress.  She would have been motivated by her desire to do good, which is beneficence, rather than her sense of duty.  Zelda, in this case, studied the information.  She decided what she would give to the patient that would not upset them, and she believes that that is the right thing to do.  This is a betrayal on the deontological side, because they do not look at the consequences at all. 

Utilitarian Ethics

Utilitarian ethics considers the greatest good for the largest number of people.  I think the problem with employing utilitarian ethics is determining who decides the definition of greatest and good. 

Intuitionism

Intuitionism resolves ethical dilemmas by appealing to one’s intuition, a moral faculty of a person which directly knows what is right or wrong.  You can call this a “gut” feeling or “gut instinct” of knowing what is right.  The difficulty with intuitionism is deciding whose moral position is more valid.  For example, even though abortion is legal, considered ethical by some and upholds the principles of autonomy and privacy, in most states people still have moral ambivalence in their gut about the law and are actively working towards overturning the law. 

Rights

This is an American theory, and it is very popular.  It resolves ethical dilemmas by first determining what rights or moral claims are involved and which right or moral claim takes precedence.  If you look at the abortion debate again, the personal side of this is mom versus fetus or child and the societal version would be a woman’s choice versus murder. 

Virtue Ethics

Virtue ethics is contrary to other ethical theories.  It tells us what kind of person one ought to be, rather than what they do.  The focus is on the character or the goodness of the person.  Who decides what kind of person you ought to be?  I think we should consider the values of some of the world’s leaders and see if you agree with their actions or their values.  There are always names of world leaders that come to mind immediately.  We have Adolf Hitler, Saddam Hussein, Kim Jong Il, but we can even look at American heroes like Charles Lindbergh, who, for several years, actively espoused the practice of eugenics, and he thought that that was perfectly moral and ethical.  When you are faced with an ethical dilemma, no matter what ethical theory you agree with, there are always two questions involved in resolving it:  what should I do, and why should I do it?

Besides ethical theories, there are other issues that are involved with deciding what is moral and ethical.  We have the identity argument.  Premise 1 – What is understood to be morally right depends at least in part on one’s identity as a moral person.  Premise 2 – One’s race, ethnicity, and culture is central to one’s identity as a moral person.  So what is understood to be morally right by an individual depends, at least in part, on that person’s race, ethnicity and culture.  Can you give me some examples in different cultures of what is morally right and ethically right in one culture, but would be considered reprehensible in another culture?  I am getting answers like cannibalism and consanguinity.  Other examples could be piercing children’s ears so they look like big disks.  I think for some of our teens that is a fashion statement.  In some cultures it is legal for a man to kill his wife, or commit honor killings.  What about cultures that say women do not have the same rights as men?  There are a lot of different ones about the roles of women.  Others to think about are cultures that define the roles of women, dietary rules in different cultures, the age at which young people are considered adults.  There are lots of different identity arguments. 

What do we mean by race, ethnicity, and culture?  Genetically, there is only one race and that is the human race, but society does make judgments about the varieties of biological characteristics.  So biological characteristics eventually are seen as socially constructed which often leads to stereotyping.  An example of stereotyping is saying that all Irish people are alcoholics, that all New Yorkers are crass and loud, that all Northerners are prejudiced, or that all Sicilians are members of the mafia.   That is stereotyping. 

Ethnicity is an individual’s identification with a particular cultural group to which they are biologically related.  Ethnicity can be misleading.  For example, all Latinos do not necessarily share the same cultural values, as they come from different countries.  There might be a difference in the culture in South America versus Mexico.  Even though one may identify with a certain cultural group, they may not share its values. 

Culture is a set of beliefs, values, and traditions that are transmitted socially from one generation to another.  It defines a group’s norms or community identity.  Cultural differences might include valuing the family over the individual, engaging and expecting the family support in their self-care, or valuing the institutions that are sensitive to their cultural needs.  One example of cultural differences would be in the way that elderly are viewed.  I see adult children, all the time in our practices, who treat their parents like children.  In other cultures, the elderly are revered for their wisdom.  In some cultures it is very common for three and four generations to live in the same home.  With cultural differences, again, comes the danger of stereotyping. 

Stereotyping and its dangers are oversimplifications to conceptions or images of what a particular group or person should look like or how they should act, totally disregarding each person’s uniqueness.  I think my example for you today is about redheads, because I am redhead, and that is that redheads have a temper.  Some people expect certain behaviors from me because of my red hair.  They think I am going to be quick on the trigger. They think I am temperamental.  That is one danger of stereotyping.  Stereotypes represent the end point of one’s understanding that all members of a particular group fit the same mold, but it does not encourage further exploration of the individual or assimilation into a majority group. 

Generalizations

We do generalize.  We make statements that represent common trends in a group with the understanding that further information needs to be gathered to verify its application to a particular person.  It represents a starting point and has been used by anthropologists whenever they see a broad pattern of similarities among groups of people.  If we generalize, we can find a lot of inaccuracies.  One inaccuracy for us could be that all seniors are on a fixed income and, therefore, they have no money.  However, if you look at a fixed income on someone who is from a very fancy resort style community, like Palm Springs, a fixed income could be $10,000 a month.  If you generalize with your patients, it could lead to inaccuracies in their application to that specific patient.  You could be doing the wrong thing for that patient if you generalize. 

How do we generalize with patients?  The third party is always an advocate for hearing instruments.  I think that we all know that most of the time having a third party, a party of influence, is a good influence on the person that you need to convince that they need hearing aids.  It always amazes me when a third party just blows you out of the water.  The second one is that sensorineural hearing loss means terrible word discrimination. Sometimes it does, and sometimes it does not.  Next is that our patients with a fixed income need to be fit with low-end product.  I think it is sometimes even unethical of us to assume that what they earn is low income.  We have to give them a choice.  Last but not least, and I think that this has come up in the last couple of years particularly, is not showing our older patients wireless accessories because they are technology challenged.  I think that the joke in the industry is that our senior patients cannot program a VCR or DVR.  I have to tell you that my parents are in their 80s and they have all the current wonders of technology and electronics.  They have a big-screen TV, a DVR, and they have a computer.  Did they set them up?  No; their grandson did.  But they can work them without difficulty.  I think we are doing a disservice sometimes when think of our seniors as always being technologically challenged. 

There are some other organizational ideas and actions.  We have group think, cultural relativism which is “everybody does it”, cheating, taking home office supplies, and conducting personal business at work.  If the group does something a little wrong, is it less dangerous?  Are little white lies okay?  As some Catholics might say, it does not send you to hell, but it keeps you in purgatory a little bit longer.  One recent example of this would be companies that totally ran out of bandwidth because their employees were watching the Olympics online.  Do you think it is okay to watch the Olympics online while you are at work?  Do you think that is ethical?   The answers I see are no, if my boss says I can, depends on what my workload is.  Do you think that it is okay to take home pens or paper clips from work because everyone does it?  I see lots of no’s on that one.  Do you think that doing personal business at work should be considered theft?  This one is taking you longer to respond; everyone is thinking about it.  Some of you are saying that it depends, some say probably.  Some people are saying it really is a gray area and other people saying that it really makes them feel guilty if they do it. 

Ethical Principles

What are ethical principles and how do they help us with decision-making?  Ethical principles exist because conflict is inevitable.  Ethical principles provide the framework or tools which may facilitate individuals in society to resolve conflict in a fair, just and moral manner.  Those principals are autonomy or freedom, voracity, privacy or confidentiality, beneficence or non-maleficence, fidelity and justice.  Decisions are based on these principles, but if we follow these principles in our practice, there will never be a worry about being ethical. 

The first one is autonomy, which is the right to participate in and decide on a course of action without undue influence or self-determination.  It is the freedom to act independently.   Individual actions are directed toward goals that are exclusively one’s own.  Voracity is easy.  It is the duty to tell the truth or honesty.  Privacy and confidentiality is respecting privileged knowledge, following our HIPAA rules, respecting self or others.  Beneficence or non-maleficence  is the principle and obligation of doing good and avoiding harm.  This is your Hippocratic oath.  First, do no harm.  It counsels a provider to relate to clients in a way that will always be in the best interest of the client, not the provider.  Fidelity is strict observance of promises or duties.  This principle, as well as other principles, should be honored by both the provider and the client.  Last is justice.  This is the principle that deals with fairness, equity, and equality and provides for an individual to claim that to which they are entitled.  Two categories of justice are comparative justice and noncomparative justice.  Comparative justice is making a decision based on criteria and outcomes.  How to determine who qualifies for one available kidney– a 55-year-old male with three children versus a 13-year-old girl– is an example of comparative justice.  In a noncomparative system of justice, a method of distributing needed kidneys uses a lottery. 

I want to talk through some ethical dilemmas.

Ethical dilemma #1 – A freak accident occurs at a chemical factory.  That factory had a previously exemplary safety record.  A man dies in the accident.  An investigation into the causes of the accident recommends measures to prevent similar accidents happening in the future.  These changes would be prohibitably expensive to implement.  The chief executive officer (CEO) of this company faces the choice of closing down the plant with the loss of hundreds of jobs or allowing the plant to continue with changes in procedure which reduce the risk, but do not eliminate the risk.  Let’s say all of you are the CEO.  Are you going to close the plant?  The answers I see are no, no, no, I wouldn’t be able to sleep with all those lost jobs, no. 

This case is an example of incommensurable outcomes.  We are asked to determine the value of eliminating a small but significant risk of injury or death versus the value of continuing to provide employment.  A dogmatic response would be to say that no value, however great, can be put on a man’s life.  However, if that principle were to be put literally into practice, daily life would grind to a halt.  If only one person a year died in a car accident, all private transportation and cars would be banned.  While we pay lip service to the belief that a human life is beyond measure, in practice decisions are made which are inconsistent with that belief. 

Ethical dilemma #2– An investigative reporter gets whiff of a story about corruption in a blue chip corporation.  It concerns a board member who accepted a free vacation from a company negotiating a multimillion dollar land deal.  The chairman has already spoken to the board member concerned who offered his resignation.  Luckily the deal has not been finalized, and no harm has been done.  On the telephone, a reporter asks the chairman if there is any truth in the rumor.  An admission will send share prices tumbling.  The chairman can admit the truth about the board member or he can give an innocuous explanation designed to throw the reporter off the scent, basically telling a white lie.  Does the chairman tell a white lie or does he tell the truth?  Answers you are giving me are that the reporter is not ethical, white lie, white lie, white lie, absolutely tell the truth.  There are lots of different opinions out there.

Case #2 is an example of a clash between principles and consequences.  As a matter or moral principle it is always wrong to tell a lie.  However in real life, there comes a point where the price of telling the truth is one we are not prepared to pay.  I think a classic but horrible example is the one of the ax-carrying murderer who asked you, “Which way did he go?”  Any response other than the literal truth really is a lie.  Now Kant, who was a philosopher, in an essay talked about ethics and benevolent motives, and he argued for the dogmatic view that even in this extreme case, one’s moral duty is to tell the truth irrespective of the consequences.  So Kant would have showed the ax-carrying man where his prey was, but few of us would embrace that extreme conclusion. 

Ethical dilemma #3–A customer comes into the office and they want you to do an audiogram and impression so that they can buy a hearing aid on the Internet.  Your ad says “free hearing test.”  Is it ethical for you to deny this patient a hearing test?  Everyone is saying yes, it is ethical.  Some of you are saying, audiogram no, impression yes.  Some of you are saying that you have fees set up so that someone can take the audiogram and impression with them.  My next question is if this customer comes in and says, “I am going to buy this online.  Would you take an impression and an audiogram for me that I can take with me?”  Would you do that?  Answers are no, never, no.  Next question– if a person came in with a hearing aid that they had bought online, would you service them?  Would you take care of them?  Answers are yes, yes, with a fee.  Most of you are saying you would, but with a fee. 

Making this Work

We have talked about ethical dilemmas.  We have talked about principles.  We have talked about theories.  How do we actually make this work in our business?  There is an example of a decision-making model called ADPIE (Assessment, Diagnosis, Plan, Implementation, and Evaluation).  If you use a counselor-dispensing presentation with your patients, the steps of the presentation will work with the ADPIE decision-making model. 

Assessment means you are gathering the facts.  You are collecting information from a variety of sources.  Diagnosis is identifying the problem or the issue.  When we first meet our patients and when we engage, we are gathering facts.  We are meeting and greeting the patient.  We are starting to form that relationship, and we are starting to explain procedures to our patients.  Diagnosis for us is a lot more complicated because we are doing otoscopy, air and bone testing, speech testing, and in some cases tympanometry, and we are also doing a case history.  We are identifying the problem or the issue through all of these diagnostic tests and also performing a case history on the patient.  Ideally, the case history should include lifestyle, medical history, hearing history, and all kinds of things that will help us make the right recommendation for the client. 

Next in the model is plan, which is exploring alternatives and options, identifying the consequences of action or nonaction, analyzing the values and professional issues at stake, selecting a course of action and making a decision.  I would be carrying out the plan and then later on evaluating how you did.  Determine how the problem could possibly have been prevented and assess your outcomes.  In the plan, we are counseling the patient about the right alternative, identifying the consequences of action or non-action.  Certainly, non-action can lead to a lot of things with these patients.  The most recent thing that I read said that patients are waiting up to 15 years sometimes before taking action.  There is some very compelling research out there on depression, auditory deprivation, and on dementia which means that those patients who do not treat their losses are at risk for any number of consequences. 

We are also taking all the little jigsaw puzzle pieces that we have learned about this patient through our diagnostic testing and case history and we are recommending what we think is best for the patient.  We are narrowing it down for them.  We are not making the decision for them, but we are assisting them as experts in making that decision.  Carrying out the plan would certainly be delivery and follow-up.  You want to make sure you have a satisfactory result.  You may need to have them keep a journal so that you can make the appropriate recommendations.  Then during the follow-up you can see how they did with this.  Each time we see a patient do well or do poorly, we learn something about treating the next patient and the next patient.  We learn how well a hearing aid works with a certain type of loss or if the features really do what the manufacturer claims.   All of those things involved, ADPIE is very similar.  If we have a routine in our office of counselor selling, it follows this decision-making model. 

Summary

In summary, we defined the terms related to ethics.  We discussed ethical principles.  We talked about ethical strategies.  As you have seen, there is not anything black and white about ethics.  Sometimes there is no right or wrong, but I think in ending this today, I have to say that the most important points of all for us are to tell the truth, to keep our promises, and to do absolutely what is best for our patient, and we will always be within the realm of ethics.  I want to thank you all for participating.