What Can We Learn from Maine? A Case Study in the Shifting Ethics of Occupational Therapy

In my previous post, I raised concerns about the increasing use of politicized language in the AOTA Code of Ethics. I argued that terms like equity and justice—however well-intentioned—have taken on broad, contested meanings, and that their uncritical adoption into our profession’s foundational documents risks substituting moral clarity for ideological fashion.

In further research, I’ve come across something worth examining in more detail: how the state of Maine handled two different versions of AOTA’s Code of Ethics—first in 2010, and then again in 2023. The difference between these two adoption events reveals a great deal about how professional ethics are evolving—not necessarily for the better.

Maine in 2010: Ethical Caution

In 2010, the Maine Board of Occupational Therapy adopted AOTA’s then-current Code of Ethics with exclusions. Specifically, they removed Principle 4: Social Justice, signaling that parts of the document were seen as extending beyond enforceable professional conduct and veering into advocacy or ideology. That act of exclusion demonstrated philosophical restraint and a commitment to enforceable, consensus-based ethics.

Maine in 2023: Full Adoption, No Questions Asked

By 2023, Maine adopted the full 2020 AOTA Code of Ethics with no exclusions. This version introduces terms like equity, inclusion, and marginalization—language not only absent in 2010 but likely considered too ideologically charged at the time for enforceable standards.

What changed?

The Overton Window and the Ethics of Cultural Alignment

The ethics of occupational therapy should be stable, universal, and grounded in professional principles—not swayed by cultural trends. Yet between 2010 and 2023, the institutional culture around DEI shifted dramatically. What was once excluded for vagueness became embedded without question.

This reflects the shift of the "Overton window"—the range of ideas seen as socially acceptable. In 2010, social justice was outside that window in an enforceable code. In 2023, it had moved well inside.

And this shift wasn’t isolated to Maine. How many other boards, universities, and institutions adopted these changes without critical examination—simply because they aligned with prevailing trends?

Why This Matters

Professional ethics are not about aligning with the language of the moment. They are about setting clear, enforceable boundaries for professional behavior that protect both patients and practitioners. A profession cannot simply substitute one morally charged term for another without consequences. A clear example of this is the shift from “equality” to “equity.”

Equality refers to consistent treatment under a shared standard—an essential foundation for fairness, due process, and enforceability. Equity, by contrast, calls for differentiated treatment based on group identity or historical context. While equity may be a worthwhile goal in some settings, it is highly interpretive, politically contested, and difficult to measure.

Embedding “equity” into enforceable standards introduces ambiguity. How is equity defined? Who determines when it has been achieved? What evidence is sufficient to prove noncompliance? Without operational clarity, equity becomes not a legal or ethical standard—but a rhetorical device subject to bias and selective enforcement.

A growing concern is that many advancing these revisions do not view their values as ideological. Concepts like “equity” and “inclusion” are treated as moral truths—above critique. But embedding such broad terms into enforceable rules invites ideological conformity and institutional dogma.

This isn’t about resisting change—it’s about protecting the integrity of ethical oversight. When enforceable ethics rely on vague or subjective interpretation, they become arbitrary. That undermines trust in both the profession and its regulators.

Enforceability Under Pressure

The 2025 draft embeds aspirational, ideologically driven language directly into enforceable standards. This introduces significant problems:

  • Terms like “challenge inequitable power dynamics” or “demonstrate cultural humility” lack operational clarity.

  • They shift the focus from conduct to alignment with worldview.

  • They create enforcement standards that vary by interpretation, not by evidence.

This opens the door to selective accountability. Practitioners risk sanction not for what they do—but for how well they reflect dominant ideologies. That’s not ethical clarity. That’s coercive consensus.

Illustrative Scenarios

To understand how this plays out, consider the following cases:

1. Cultural Humility as a Requirement
An OT questions the framing of a required DEI training. A colleague files an ethics complaint, alleging a lack of “cultural humility.”
Concern: What is the standard for “demonstrating” cultural humility? Is dissent unethical?

2. Challenging Power Dynamics in Schools
A school-based OT supports a student but does not confront school administration. A parent alleges the therapist failed to “challenge inequitable power dynamics.”
Concern: Are therapists now expected to act as activists in institutional settings? To what extent?

3. Language Sensitivity Violations
A therapist refers to a patient as “elderly.” A supervisor claims this violates expectations for inclusive language.
Concern: Who defines acceptable terminology, and on what authority? Is outdated language unethical?

4. Existential Harm Allegations
A patient denied a non-covered service later claims the interaction caused “existential harm.”
Concern: How does a board assess a subjective emotional claim? Can ethical complaints be based on feelings alone?

5. Occupational Justice Expectations
A private-practice OT is reported for not engaging in “advancing occupational justice.”
Concern: Has clinical care become contingent on political or advocacy work beyond scope?

What Makes a Standard Enforceable?

These examples raise a larger question: what counts as enforceable?

Can boards objectively determine when a practitioner has failed to uphold terms like “equity” or “justice”? Can someone be disciplined for not using the right language, even if their behavior is clinically and ethically sound?

In 2010, Maine drew a line. In 2023, that line vanished. If ethics enforcement is based on ideology instead of clarity, trust in regulation will erode.

A Call for Re-examination

Maine’s shift from caution to full adoption isn’t just bureaucratic. It’s symbolic of how quickly foundational standards can change—without rigorous debate.

It’s time to ask:

  • What do we mean by ethics?

  • What frameworks are we using?

  • What makes a principle enforceable?

  • Are we grounded in enduring standards—or chasing ideological trends?

Let’s return to clarity over fashion, principle over posturing, and ethics that can withstand cultural winds.

References

2010 Code of Ethics (Maine adoption with exclusions): https://www.maine.gov/sos/cec/rules/02/477/477c007.doc
2020 Code of Ethics (adopted in Maine 2023): https://www.maine.gov/pfr/professionallicensing/sites/maine.gov.pfr.professionallicensing/files/inline-files/ADOPTED_CH_7_CODE_OF_ETHICS_2023.pdf

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