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.
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:
- Rationale for ethics courses: Why are these courses mandated?
- APTA documents on ethics
- Code of Ethics (and Core Values) for Physical Therapists: https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/CodeofEthics.pdf
- Standards of Practice for Physical Therapist Assistants: http://www.ptot.texas.gov/idl/6AE93EF1-F21C-EDE1-9C69-5DB686260B5E
- REASON: A six-step model for resolving ethical dilemmas
- Ten case studies
- Additional resources
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)