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Bioethics for Physical Therapists and Physical Therapist Assistants: A Case Study Approach

Bioethics for Physical Therapists and Physical Therapist Assistants: A Case Study Approach
Janice Bruckner, PT, PhD, CLT-LANA
May 31, 2018

Editor’s note: This text-based course is a transcript of the webinar, Bioethics for Physical Therapists and Physical Therapist Assistants: A Case Study Approach, presented by Jan Bruckner, PT, PhD, CLT-LANA.

Learning Objectives

As a result of this course, learners will be able to:

  • Define and discuss the 7 core values and 8 principles that the American Physical Therapy Association established to guide physical therapy practice
  • Apply a decision-making model to a given case study as a strategy for resolving ethical issues
  • Identify resources available to assist in addressing ethical questions and concerns
  • Appreciate rationale for mandated courses in professional ethics

Introduction and Overview

To begin, I'd like to share a personal story that relates to today's topic of bioethics. I'm legally blind. I can't see, I can't drive, I can't work. As a matter of fact, I can't even read my own slides that you're going to see because the glare is too great. I have cataracts. My cataract surgeon guaranteed 100% recovery if I had my cataracts removed. To have this surgery to restore my vision, I need medical clearances. I have tears in both of my retinae and these tears had to be repaired before I could be cleared for cataract surgery. On my first visit to the retinal practice to get these tears fixed, my patient rights were violated twice. My HIPAA privacy rights and my informed consent rights were both violated.

To have the laser treatment on my right eye, the staff required me to scribble my signature on a keypad. I received no copy of what I signed, I received no written or verbal explanation of what was wrong with my retinae, what they planned to do, and how they planned to correct the problem. Since I wanted my clearance, I signed the form, but this was coercion. This is not informed consent. Today, we're going to be talking about what real informed consent is.

At the checkout, I had a HIPAA violation. I checked out and I asked for a copy of the report that would be sent to my cataract surgeon. The receptionist printed something out, she put it in an envelope, handed it to me, and I went home. At home, I opened the envelope and I realized that I had been given the report of a different patient. At my second visit, I received the results of my first eye and was to receive treatment for the second eye. I went back to the checkout desk and returned the report from the other patient and I asked for my own report, which she gave to me. I asked to speak with the ethics compliance officer of this practice and they said they didn't have one. I said, "This is a problem. I need to speak to someone."

After a considerable amount of time, they introduced me to the office manager. I explained to the office manager that I had been given someone else's report instead of mine, and that this was a HIPAA violation. I said that I had not received a copy of my signed informed consent statement, nor had I been given either verbal or written information about my diagnosis, treatment, or side effects. This is not informed consent: this is coercion. He asked me what I wanted. I said I want five things. I want an investigation of what went wrong, I want him to develop a strategy to address the problem, I want him to implement the strategy, I want him to evaluate the effectiveness of the implementation, and then I want him to report back to me on the results of this whole process. The manager agreed.

The manager sent me a letter outlining all the steps that he had taken to address the HIPAA violation and asked to meet with me on my third visit (a checkup of both of my eyes and a clearance for cataract surgery). When I showed up for my third visit, he asked to meet with me and he also asked if their billing officer could sit in. I told him that I was satisfied that they were taking steps to comply with the HIPAA requirements and address the violations that I had experienced. I mentioned that I wanted a copy of my signed informed consent for the left eye, the second eye. Unfortunately, no one had a clue how to print this out. After they called multiple people, they finally gave me a copy. Next, when I sat down with the retinal surgeon, he did not explain to me in words that I could understand what the problem was with my retina, how the laser corrects the problem, or what side effects I should look for. Again, I had no real informed consent. I told the office manager and the billing manager that I was not satisfied that they met the requirements for informed consent. This was still coercion. They said that they would try and do something. This remains a work in progress.

I tell you this story because ethical violations are very real, and they happen every day. We are physical therapists and physical therapist assistants, but we must earn this status. We earn it by being advocates for ourselves and for the people who we serve. How do we do this? We do this by becoming aware of the problems and seeking strategies to resolve these issues. I want you to keep this in mind as we spend the next few hours discussing bioethics.


The agenda for this course is as follows:

Why Do License Boards Require Courses on Bioethics?

Why do licensing boards require courses on bioethics? As physical therapy professionals, we're required to take all kinds of courses. For example, we are required to take courses on CPR, and in some institutions, we're required to take courses on how to use fire extinguishers. As much as we would like to take courses on how to improve our clinical skills, we have to be aware that there are a lot of things that we have to do, even though we may not want to. We need to take courses on bioethics for many reasons, some of which include avoiding negative consequences (such as malpractice), as well as those with positive intent (with an emphasis on healing).  

HPSO 2011 Claim Survey

Some of you may have practice insurance through the company Healthcare Providers Service Organization (HPSO). HPSO insures 50% of all physical therapists and physical therapist assistants in the United States. In 2011, HPSO conducted a claim survey. They found out that they paid 44 million dollars in malpractice claims. They also concluded that accidents happen, and some accidents cannot be prevented. However, not all accidents constitute malpractice. They also determined that education and experience are inversely related to malpractice claims. It seems that people with less experience tend to do more risky things. As a result, they have accidents that they don't know how to handle. They end up with malpractice claims, some of which are large enough to result in disciplinary action from the licensing boards. The next thing you know, they're out of physical therapy. Think about how much time, effort, and money you put into getting your education in physical therapy. You don't want to waste it. You want to remain in the practice and in the good graces of everyone, patients and licensing boards included. Most of all, you certainly want to avoid a malpractice suit. 

Who are the practitioners most vulnerable to malpractice claims? The first group includes individuals in solo practice. Second, individuals who lack training in risk management are also vulnerable. The third group is comprised of individuals who lack training in quality assurance and have no system for peer review. These are some of the questions that are going to be asked when you're facing a malpractice trial. HPSO concluded that education is important, specifically education in risk management and quality assurance. In addition, physical therapists should have some sort of peer review in place. That's the best way to minimize the risk of malpractice.

Federation of State Boards of PT

A second reason why you're taking this course comes from the Federation of State Boards of Physical Therapy. These are the organizations that manage professional licensing. They are also the organizations that discipline PTs and PTAs who do something wrong. They are challenged and charged to protect patients, clients, and the public from professionals who engage in illegal and unethical behaviors. They also conducted research and concluded that the best way of preventing problems of professional misconduct is through continuing education in bioethics. They also have research literature to support this. Since they have the ability to do that, they are the ones that mandated courses like this. 

Dr. Edmund Pelligrino

On the positive side, Dr. Edmund Pelligrino is considered the father of modern bioethics. Dr. Pelligrino was a cardiologist with a Ph.D. in philosophy. I had the privilege of studying with him one summer when I had a national endowment for the humanities grant to study Allied Health Ethics. He taught us that the word profession comes from two Latin words: "Pro" (meaning "before") and "fateri" (meaning "promise" or "vow"). Dr. Pelligrino was interested in the relationship between professional healers and people in need of healing (i.e., our patients and clients). The professional promises to act in accordance with the definition of the profession as described in the State Practice Act. We must understand that the person in need of healing is in a vulnerable state. They don't just have an injury to their shoulder, or their knee, or whatever the presenting diagnosis is. Because of this injury, they're not able to do what they want to do. They can't carry out their lives in the way that they want. They are less than whole. Dr. Pelligrino considered this to be an affront to their very personhood and their very identity. He called this a state of wounded humanity. Dr. Pelligrino believed that the professional healer promises two things. First, we have the authentic knowledge and skills of our profession. This speaks to our clinical competency. Second, we must have compassion. We have to understand that our patients are in this vulnerable state. We have to share some of their experience of being less than whole. We have to go along with them on this journey of recovery.

Guidance from APTA

We receive guidance for ethical practice from the American Physical Therapy Association (APTA) in the form of:

  • Codes of Ethics for PTs and PTAs
  • Guides for Professional Conduct
  • Statements of Resolving Disputes and Complaints
  • Clarification on Principles and Standards
  • Additional Documents (available on the APTA website)

janice bruckner

Janice Bruckner, PT, PhD, CLT-LANA

Jan Bruckner, PT, PhD, CLT-LANA, has been a physical therapist for forty years with an academic background in anthropology, philosophy, physical therapy, and lymphology. While working for United Cerebral Palsy, she learned about the horrific abuses that occurred at Willowbrook State School. Her reaction led her to a six-week National Endowment for the Humanities summer symposium on allied health ethics and doctoral studies where she wrote a theory of physical therapy ethics for her PhD minor. She taught in academic physical therapy programs, did research and worked as a clinician. She served as a physical therapist in the US Peace Corps and consulted to both the US Indian Health Service and the Canadian First Nations Health Service. She provided pro bono services to the US Army in Indianapolis, IN during Desert Storm, to people in Les Cayes, Haiti after the 2010 earthquake, and in a shelter for men who are homeless in Philadelphia, PA.  The case studies in her ethics seminar draw on her experiences in these varied settings.

Related Courses

Lymphedema Management of the Orthopedic Patient
Presented by Janice Bruckner, PT, PhD, CLT-LANA
Recorded Webinar
Course: #2957Level: Intermediate3 Hours
This three-hour course examines ways to use lymphatic therapy techniques to manage patients with orthopedic problems, such as joints replacements, fractures, sprains, and strains. Topics include: anatomy and physiology of the human lymphatic system, techniques, such as manual lymphatic drainage, compression, elevation, diaphragmatic breathing, therapeutic exercise, kinesiotaping, and skin care, program planning, including problems, short term goals, long term goals, and treatment plan, and case studies to illustrate the application of the material presented. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

Editor's Note: Regarding Pennsylvania credits, this course is approved by the PA State Board of Physical Therapy for 2 hours of general and 1 hour of Direct Access CE credit.

Supervising Assistants, Students, and Aides: Upholding Your Ethics in a Challenging Health Care Environment
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP
Recorded Webinar
Course: #4377Level: Intermediate2 Hours
This presentation reviews the definitions of supervision as well as APTA guidance related to supervising assistants, students, and aides in various healthcare environments. Documentation guidelines for Medicare are reviewed as these relate to what an assistant can complete versus a therapist. The use of students and rehab aides in long-term care is reviewed in accordance with Medicare guidelines. Real examples of common supervisory ethical dilemmas from the field, including the appropriate action steps to take in each one, are highlighted. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA

Ethics in Practice: Examining Medical Errors: An Ounce of Prevention is Worth a Pound of Cure
Presented by Brigette Cuffia, PT, JD
Recorded Webinar
Course: #4160Level: Introductory2 Hours
This course examines the role of physical therapists and physical therapists assistants in the prevention of medical errors. Topics discussed include APTA Code of Ethics Analysis, creating a culture of safety and the economic impact of medical errors. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Supporting the LGBTQ Senior in Healthcare
Presented by Kathleen D. Weissberg, OTD, OTR/L, CMDCP, CDP, OTR/L
Recorded Webinar
Course: #4096Level: Intermediate2 Hours
This training describes the required elements for responding to the emerging needs of long term care communities to provide sensitive and respectful services to LGBT elders. The training reviews definitions related to sexual orientation and gender identity challenges experienced by LGBT older adults, and strategies for communication and policies that honor residents' rights. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT and PTA.

OASIS E: New Items
Presented by Cindy Krafft, PT, MS, HCS-O
Recorded Webinar
Course: #4612Level: Intermediate2 Hours
The course will focus on the items that are unique to the OASIS E data collection process. Official guidance sources will be explored to ensure the accuracy of the information.

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