Ethics and Jurisprudence for the Physical Therapy Professional Licensed in Illinois (2026)

Learning Outcomes

After completing this course, participants will be able to:

• Define ethics and distinguish it from law and professional standards, and identify core ethical principles and theories relevant to physical therapy practice.
• Describe the nine Ethical Commitments, six foundational ethical principles, and enforceable Standards of Conduct outlined in the new APTA Code of Ethics for the Physical Therapy Profession (effective January 1, 2026).
• Identify 3–4 sources of rules and laws governing physical therapy practice in Illinois.
• Explain how to access the most recent Illinois Physical Therapy Practice Act and apply the clinical scope of practice in Illinois.
• List the key supervision requirements for physical therapist assistants and physical therapy aides.
• Examine the Illinois Practice Act to determine requirements for physical therapists and physical therapist assistants to maintain and renew their licenses, including continuing competence requirements.
• Recognize and describe both established and emerging ethical and legal issues in physical therapy practice, including HIPAA, malpractice, licensure, supervision, disciplinary action, fraud and abuse, social media, artificial intelligence, moral distress, and care of special populations.
• Apply the RIPS Model of Ethical Decision-Making to analyze clinical ethical dilemmas through case study examples.
• Identify proactive strategies and key resources to avoid ethical violations in practice.

Part 1:  Ethics Foundations

Defining Ethics and Morality

Ethics is the branch of philosophy concerned with questions of right and wrong, good and bad, and how we ought to act toward one another. At its core, ethics involves systematic reflection on moral beliefs — examining not just what we do, but why we do it and whether our actions can be justified. The term morality is closely related and is often used interchangeably with ethics in everyday conversation, though a useful distinction exists between the two. Morality generally refers to the values, norms, and beliefs that individuals and communities hold about right conduct — the lived experience of distinguishing right from wrong. Ethics, by contrast, is the disciplined study and analysis of those moral beliefs. In professional contexts, ethics asks us to move beyond intuition and custom to reason carefully about what we owe to the people we serve.

This distinction matters for healthcare professionals because acting morally is not simply a matter of following instinct or doing what feels right in the moment. As a licensed physical therapist (PT) or physical therapist assistant (PTA), you bring both your personal moral framework and a professional ethical identity to every clinical encounter. Understanding how those two layers interact and sometimes conflict is fundamental to ethical practice.

Ethics, Law, and Professional Standards: Related but Not the Same

One of the most important early lessons in professional ethics is recognizing that ethics, law, and professional standards are related but distinct systems of obligation. Many practitioners assume that behaving legally is the same as behaving ethically, or that following a professional standard automatically satisfies the demands of good moral practice. Neither assumption holds up under scrutiny.

Law represents the codified rules of society, enforceable by governmental authority. Laws set minimum thresholds for acceptable behavior and carry formal consequences such as fines, license revocation, criminal prosecution, when violated. Professional standards go beyond what the law requires and reflect the values a profession has collectively committed to upholding. In physical therapy, that standard is now articulated in the Code of Ethics for the Physical Therapy Profession, adopted by the APTA House of Delegates in 2025 and effective January 1, 2026. Importantly, this unified code applies to both PTs and PTAs; a significant development that reflects the profession's recognition that ethical responsibility is not divided by credential or role. Where the previous framework maintained separate documents for each credential, the profession now speaks with a single ethical voice.

Ethics operates at a still deeper level than either law or professional standards. An action can be entirely legal, fully compliant with professional standards, and yet remain ethically troubling. Consider a scenario in which a PT provides technically adequate care but does not take the time to ensure a patient with limited health literacy truly understands their diagnosis or home program. Nothing about this violates the law or triggers a formal complaint, yet ethically, the practitioner has failed to honor the patient's autonomy and right to informed participation in their own care. Conversely, ethical reflection sometimes demands that practitioners speak up or take action even when no rule explicitly requires it. Understanding these boundaries of where law ends, where professional standards begin, and where ethical responsibility extends beyond both is essential preparation for the complexity of clinical life.

Why Ethics Matters in Healthcare and Physical Therapy

Healthcare is a domain defined by vulnerability, trust, and power imbalance. Patients come to physical therapists and physical therapist assistants during some of the most difficult periods of their lives — recovering from injury or surgery, managing chronic pain, adapting to disability, or striving to regain independence. This vulnerability creates a profound ethical responsibility. Patients must trust that their care providers will prioritize their well-being, respect their dignity, tell them the truth, and protect their private information. That trust is not incidental to physical therapy practice — it is the very foundation upon which effective therapeutic relationships are built.

Ethics matters in healthcare not only because individual patients deserve protection, but because the integrity of the healthcare system depends on practitioners who are reflective, accountable, and committed to something larger than technical competence. A physically skilled practitioner who lacks ethical grounding can cause real harm — through dishonesty, disregard for patient preferences, exploitation of vulnerable individuals, or failure to advocate for equitable care. Conversely, practitioners who engage thoughtfully with ethical questions contribute to a culture of accountability that benefits patients, colleagues, and the profession as a whole.

The Scope of Ethical Responsibility in Physical Therapy

The ethical dimensions of physical therapy practice are not confined to the one-on-one relationship between clinician and patient. Ethical obligations operate simultaneously at individual, organizational, and societal levels. At the individual level, ethics shapes how you communicate with a patient, how you obtain informed consent, and how you respond when a patient's goals conflict with your clinical judgment. At the organizational level, ethical questions arise around workplace policies, resource allocation, documentation practices, and the pressures of productivity expectations. At the societal level, all physical therapy professionals bear responsibility for advocating on behalf of vulnerable populations, advancing health equity, and contributing to a healthcare system that serves the public good.

This multi-level view of ethics resists the temptation to reduce professional ethics to a checklist of individual behaviors. Ethical practice requires attention to context — to the systems within which care is delivered and to the broader social conditions that shape who receives care, under what circumstances, and with what quality. This framework is reflected in the structure of the Code of Ethics for the Physical Therapy Profession itself, which addresses individual, organizational, and societal dimensions of ethical conduct and applies equally to every member of the physical therapy team.

Foundational Ethical Principles

Introduction: Why Principles Matter

Ethical decision-making in clinical practice requires more than good intentions — it requires a shared moral language. Ethical principles provide that language. They are the conceptual building blocks that allow practitioners to identify what is at stake in a given situation, articulate competing obligations, and reason toward a defensible course of action. Six principles form the foundation of the Code of Ethics for the Physical Therapy Profession: autonomy, beneficence, nonmaleficence, justice, veracity, and fidelity.

Autonomy

Autonomy is the principle that recognizes every patient's right to make informed decisions about their own care. Derived from the Greek words for "self" and "law," autonomy reflects the moral conviction that individuals are the legitimate authors of their own lives and that healthcare providers have an obligation to support — not override — that authorship. In physical therapy practice, respecting autonomy means far more than obtaining a signature on a consent form at the outset of care. It encompasses a commitment to ongoing informed consent throughout treatment, ensuring that patients have the information they need to make meaningful choices at every stage of their care.

Autonomy also encompasses the related obligations of privacy and confidentiality. Patients share sensitive information about their bodies, their functional limitations, their home environments, and their personal circumstances because the therapeutic relationship requires it — not because they have forfeited their right to control that information.

In practice, autonomy can be challenging to uphold. Patients may make decisions that their therapist believes are not in their best interest — refusing a recommended intervention, declining to follow a home exercise program, or choosing to discontinue care prematurely. Respecting autonomy means accepting that a competent patient's right to decide for themselves takes precedence over the clinician's judgment, even when that is difficult. The therapist's role in such moments is not to override the patient's choice but to ensure it is genuinely informed — that it reflects the patient's own values and a real understanding of the available options and their likely consequences.

Beneficence

Beneficence is the obligation to act in the best interest of the patient and to actively promote good for the individual, for the profession, and for society. It is, in many ways, the animating principle of healthcare: the reason practitioners enter the field and the moral force behind the therapeutic relationship. In physical therapy, beneficence manifests as a commitment to providing care that is evidence-based, individualized, and genuinely oriented toward the patient's well-being rather than institutional convenience, financial incentives, or professional habit.

Beneficence extends beyond the individual clinical encounter. It calls on physical therapy professionals to advance the health and well-being of communities, to contribute to the development of the profession through education and scholarship, and to advocate for healthcare systems that serve all people equitably. A practitioner who provides excellent care to individual patients but remains indifferent to broader questions of access, equity, and professional integrity is fulfilling only a portion of their beneficent obligation.

Nonmaleficence

Nonmaleficence — the obligation to "do no harm" — is perhaps the most widely recognized principle in healthcare ethics, yet it is also among the most frequently misunderstood. It is sometimes interpreted as a simple prohibition against causing injury, but in clinical reality it demands much more nuanced application. Nearly every therapeutic intervention carries some degree of risk. The principle of nonmaleficence does not require that clinicians eliminate all risk — that would make practice impossible — but rather that they make deliberate, informed decisions that prevent or minimize harm and never expose patients to risks that are disproportionate to the potential benefits of treatment.

Nonmaleficence also applies to harms that are less visible than physical injury: emotional harm, harm to a patient's dignity, harm resulting from inadequate or incompetent care, and harm caused by failing to refer or escalate when a situation is beyond one's scope. For PTAs in particular, nonmaleficence is closely tied to the obligation to practice within the supervisory relationship and to communicate with the supervising PT when a patient's condition or response to treatment raises concerns.

Justice

Justice in healthcare ethics refers to the fair and equitable distribution of care and resources, grounded in a recognition of the mutual dignity of all human beings. At its most fundamental level, justice demands that patients receive care based on their clinical needs and not on the basis of race, ethnicity, gender, age, socioeconomic status, disability, sexual orientation, or any other characteristic unrelated to their healthcare needs.

Justice operates at multiple levels of practice. At the individual level, it shapes how a clinician allocates attention and effort across their caseload and how they respond to patients whose backgrounds, beliefs, or behaviors differ from their own. At the organizational level, justice informs decisions about scheduling, resource allocation, and the design of care delivery systems. At the societal level, justice calls on physical therapy professionals to advocate for policies and systems that expand access to care, reduce health disparities, and ensure that the benefits of physical therapy are available to all who need them.

Veracity

Veracity is the commitment to truthfulness and honest communication with patients, colleagues, payers, institutions, and the public. In clinical practice, veracity requires that physical therapy professionals provide patients with accurate information about their diagnoses, prognoses, and treatment options — even when the truth is difficult to deliver. It demands honest documentation that accurately reflects what occurred in a clinical encounter, without embellishment, omission, or fabrication. And it requires transparency about the limits of one's knowledge and competence, including the willingness to say "I don't know" or "this is outside my expertise" when that is the honest answer.

The obligation of veracity is not always comfortable. There are clinical situations in which the truth — about a poor prognosis, an uncertain outcome, or a recommendation that conflicts with a patient's hopes — is unwelcome. There are institutional pressures that can create incentives for less-than-fully-honest documentation. Veracity demands that practitioners resist these pressures. Trust in the therapeutic relationship, and in the profession as a whole, depends on it.

Fidelity

Fidelity is the principle of faithfulness — to promises, to professional obligations, and to the therapeutic relationship itself. It calls on physical therapy professionals to follow through on their commitments, to treat every patient with consistent respect and integrity, and to honor the trust that patients place in them when they enter into the therapeutic relationship. Fidelity is expressed in the reliability and consistency with which a clinician shows up for their patients — not only in scheduling and continuity of care, but also in the quality of attention, respect, and professional engagement they bring to every encounter.

Fidelity also encompasses the obligation to treat all individuals with fairness and integrity, regardless of whether they are easy or difficult to work with, their diagnosis or prognosis, or their social circumstances. The therapeutic relationship carries an implicit promise — that the clinician will remain faithful to the patient's interests throughout the course of care — and honoring that promise is a core ethical obligation.

Principles in Tension

It is important to recognize from the outset that these six principles, while individually clear, do not always point in the same direction when applied to real clinical situations. A patient's autonomous choice may conflict with the therapist's beneficent desire to act in their best interest. The demands of systemic justice may create resource constraints that make it difficult to provide optimal individual care. Veracity may require delivering information that, in the short term, causes distress. These tensions are not failures of the ethical framework — they are the very substance of ethical practice. Learning to recognize when principles are in tension, to reason carefully about how to weigh competing obligations, and to make defensible decisions under conditions of moral uncertainty is the central challenge of clinical ethics.

Ethical Theories: Frameworks for Moral Reasoning

Why Theory Matters in Practice

It is tempting to view ethical theory as abstract and remote from clinical reality. This view is mistaken. Every time a clinician reasons through an ethical challenge, they are drawing — whether consciously or not — on theoretical frameworks that shape how they define the problem, what they count as relevant, and what kind of answer they find satisfying. Making those frameworks explicit makes the reasoning more transparent, more rigorous, and ultimately more defensible.

Four major frameworks inform ethical reasoning in healthcare: deontological ethics, consequentialism, virtue ethics, and principlism. No single framework provides a complete account of moral life, and none should be applied mechanically to clinical situations. Rather, these theories function as lenses — each illuminating certain features of an ethical situation while potentially obscuring others. The skilled ethical practitioner learns to move among them fluidly, using each to sharpen their understanding of what is at stake.

Deontological Ethics: The Ethics of Duty

Deontological ethics holds that the moral quality of an action is determined not by its consequences but by whether it conforms to a rule, duty, or obligation. The term derives from the Greek word deon, meaning duty. For Kant, the most influential deontological theorist, an action is morally right if it is performed out of duty and conforms to a principle that could be consistently applied to all rational agents in similar circumstances.

In healthcare, deontological thinking underpins many of the obligations practitioners feel most strongly. The duty to obtain informed consent before initiating treatment, the obligation to maintain patient confidentiality, the commitment to tell the truth even when it is uncomfortable — these are experienced less as calculations about outcomes and more as duties that hold regardless of consequences. A deontological framework captures something important about why it feels wrong to lie to a patient even if the lie might produce a better short-term outcome.

The primary limitation of deontological ethics in clinical practice is its rigidity. A strict duty-based framework can struggle to accommodate situations where rules conflict — where, for example, the duty to respect autonomy pulls against the duty to prevent harm. Deontological ethics is most useful as a framework when it reminds practitioners that some obligations are not negotiable and that the ends do not always justify the means.

Consequentialism and Utilitarianism: The Ethics of Outcomes

Consequentialist theories evaluate the moral quality of an action entirely by reference to its outcomes. An action is right if it produces good consequences and wrong if it produces bad ones. Utilitarianism holds that the morally correct action is the one that produces the greatest good for the greatest number of people. In healthcare contexts, utilitarian reasoning often surfaces in discussions of resource allocation, public health policy, and triage.

Consequentialist thinking offers practitioners a valuable counterweight to purely rule-based reasoning. It demands that clinicians pay attention to real-world outcomes and encourages thinking beyond the individual patient to consider the broader impact of decisions on families, communities, and healthcare systems.

The limitations of consequentialism become apparent when its logic is followed to uncomfortable conclusions. A strict utilitarian calculus could, in principle, justify withholding resources from a patient whose prognosis is poor in order to redirect them to patients with better expected outcomes — a conclusion that most practitioners would find ethically unacceptable because it fails to honor the inherent dignity of the individual patient.

Virtue Ethics: The Ethics of Character

Virtue ethics shifts the central question of moral inquiry from "What should I do?" to "What kind of person should I be?" Rooted in the philosophical tradition of Aristotle, virtue ethics holds that ethical behavior flows naturally from a person of good character. Virtues are stable character traits — such as honesty, courage, compassion, practical wisdom, and integrity — that dispose a person to perceive situations clearly, feel the appropriate emotions, and act well consistently over time.

Virtue ethics resonates deeply with the culture of healthcare professions. Being the kind of physical therapy practitioner patients can trust is not primarily about knowing the rules, nor solely about calculating the best outcomes. It is about being honest, compassionate, and courageous enough to deliver difficult news or challenge an institutional policy that harms patients, and exercising the practical wisdom — what Aristotle called phronesis — to discern the right course of action in genuinely complex situations. The APTA's articulation of core values for the physical therapy profession — including accountability, altruism, compassion and caring, integrity, and excellence — reflects a distinctly virtue-oriented understanding of what it means to be a good practitioner.

Principlism: An Integrated Framework for Healthcare Ethics

Principlism is an integrated, middle-ground approach developed specifically for the challenges of healthcare ethics. First articulated by philosophers Tom Beauchamp and James Childress in Principles of Biomedical Ethics, principlism proposes that ethical reasoning in healthcare should be guided by four core principles: autonomy, beneficence, nonmaleficence, and justice. The physical therapy profession adds veracity and fidelity to reflect its specific ethical commitments.

The appeal of principlism lies in its practicality. Rather than committing to a single theoretical framework and applying it rigidly, principlism draws on the insights of multiple traditions while providing a common language that healthcare professionals from different backgrounds and disciplines can share. The four principles are presented not as an absolute hierarchy but as prima facie obligations — each is binding unless it conflicts with another principle of equal or greater weight in a specific situation.

Principlism has become the dominant framework in clinical and biomedical ethics education precisely because it maps onto the practical structure of healthcare decision-making and is reflected in the structure of the Code of Ethics for the Physical Therapy Profession itself.

Using Theories Together: Toward Integrated Ethical Reasoning

In practice, experienced ethical reasoners rarely restrict themselves to a single theoretical framework. Deontological thinking alerts them to duties and rights that must be respected regardless of outcomes. Consequentialist thinking keeps them focused on real-world impact and the well-being of all affected parties. Virtue ethics reminds them that how they act — the character they bring to a situation — is morally significant. And principlism provides the organizing structure that allows these insights to be brought together into a coherent analysis.

A useful way to think about these frameworks is as diagnostic tools. When you encounter an ethical challenge, asking which framework seems most relevant — and then asking what the other frameworks would add or complicate — is a reliable way to ensure that your reasoning is thorough and that you have not overlooked a morally significant dimension of the problem.

Part II: The 2026 APTA Code Of Ethics For The Physical Therapy Profession

Background and Purpose — A Landmark 2026 Update

A Unified Code for the Entire Profession

Professional ethics codes do not emerge fully formed — they evolve in response to changes in the profession, in healthcare delivery, in society, and in the collective moral understanding of what it means to practice with integrity. The most recent — and most significant — revision in the APTA's history took effect on January 1, 2026. On July 14, 2025, the APTA House of Delegates officially adopted the Code of Ethics for the Physical Therapy Profession, a landmark document that fundamentally restructures how the profession articulates its ethical obligations.

What makes this revision a landmark is not merely its updated content but its architecture: for the first time in the profession's history, a single, unified ethical code applies to physical therapists, physical therapist assistants, and students across all roles and practice settings. The former framework — which maintained a separate Code of Ethics for the Physical Therapist organized around eight principles, and a parallel Standards of Ethical Conduct for the Physical Therapist Assistant organized around seven standards — has been retired. In its place stands one document, one set of obligations, one moral community.

This unification carries both symbolic and practical significance. It reflects a professional consensus that ethical responsibility in physical therapy is not divided by credential or scope of practice. PTs and PTAs work together within a supervisory relationship, share accountability for patient outcomes, and together represent the profession to the public. A unified code expresses the understanding that the ethical commitments binding on one are, in their essential character, binding on all.

Scope and Application

The new Code applies broadly across the full range of roles in which physical therapy professionals work. It governs conduct in patient and client management, consultation, education, research, and administration. Whether a PT is treating a patient in an outpatient clinic, serving as a clinical instructor, conducting research, managing a department, or consulting for an organization, the Code applies. The same is true for PTAs operating within their defined scope and supervisory relationship, and for students in the context of their clinical and professional activities.

A Dual Purpose: Enforceable Standards and Aspirational Guidance

One of the most important structural features of the new Code is its explicit articulation of two distinct but complementary purposes. The first is to delineate enforceable Standards of Conduct — the minimum ethical requirements against which APTA's Ethics and Judicial Committee (EJC) will assess whether a member has engaged in unethical conduct. The second is to provide aspirational, illustrative examples that guide members toward best practices and the ideals of the profession, going beyond the minimally required toward what excellent, values-driven practice looks like in action.

This dual structure acknowledges a truth that any thoughtful ethics educator would affirm: the floor of ethical conduct and the ceiling of ethical aspiration are not the same place, and a profession committed to excellence should be clear about the difference. Knowing what can get you disciplined is important — but it is not the same as knowing what it means to practice with genuine integrity, compassion, and commitment to patients and society.

Key Changes from the Prior Code

From two documents to one. The consolidation of two separate documents into one unified code applicable to all physical therapy professionals is the most structurally significant change. This is not merely an administrative consolidation — it represents a deliberate professional statement that the ethical community of physical therapy is unified.

Explicit accountability for social media and artificial intelligence. The prior Code was written before these technologies were central to professional life. The new Code explicitly addresses accountability for the use of social media and artificial intelligence — each raising questions about accuracy, accountability, transparency, and the appropriate limits of delegation to non-human systems.

Mandatory reporting requirements. The new Code gives more prominent and explicit treatment to mandatory reporting obligations. Physical therapy professionals are now explicitly required by the Code — not only by state law — to comply with mandatory reporter requirements for abuse, neglect, and exploitation of children and vulnerable adults. This positions reporting not merely as a legal compliance matter but as an ethical obligation.

Ongoing informed consent. Where the prior Code addressed informed consent in general terms, the new Code emphasizes the ongoing nature of the informed consent requirement. Consent is not a one-time event completed at the first visit — it is a continuous process that must be revisited as treatment evolves, as new interventions are introduced, and as the patient's understanding, condition, and goals change over time.

Direction and supervision as a distinct ethical commitment. The new Code elevates direction and supervision to its own Ethical Commitment — Commitment 7 — recognizing that the supervisory relationship between PTs and PTAs is not merely a legal and regulatory matter but carries substantial ethical weight.

Transition Rules

Complaints regarding conduct occurring on or after January 1, 2026, are assessed under the new Code. Conduct occurring prior to that date may continue to be evaluated under the former Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant through December 31, 2027.

The Nine Ethical Commitments

The new Code is organized around nine Ethical Commitments, each representing a domain of professional obligation central to physical therapy practice. Together, these commitments provide a comprehensive map of the ethical landscape — from the treatment of individual patients to the management of professional relationships, from the integrity of business practices to the responsibilities practitioners carry toward society.

Commitment 1 — Respect

The first commitment establishes the moral bedrock of all that follows: physical therapy professionals shall respect the inherent dignity and rights of all individuals. The enforceable standards under this commitment prohibit discrimination against any person and require the protection of confidential patient and client information, permitting disclosure only as authorized or required by law.

The aspirational dimensions of this commitment reach further, calling on practitioners to acknowledge and actively respect individual identity and cultural context, and to recognize both explicit and implicit personal biases. Implicit bias — the unconscious associations and assumptions that influence perception and behavior without the practitioner's awareness — has been documented as a significant driver of health disparities and differential quality of care. The Code's explicit acknowledgment of implicit bias as an ethical concern signals that the profession expects its members to engage in honest self-examination.

Commitment 2 — Integrity

Commitment 2 addresses professional integrity and legal and ethical obligation. Among its enforceable standards, the PT is explicitly established as retaining full responsibility for all physical therapy services provided under their license, regardless of who delivers them. The ongoing informed consent requirement appears here. Practitioners are required to report colleagues they reasonably believe to be unfit to practice safely, to address known illegal or unethical acts, and to comply with mandatory reporter laws for abuse, neglect, and exploitation.

The aspirational character of this commitment envisions practitioners who actively discourage misconduct and harassment and who demonstrate integrity across all professional relationships — with patients, families, colleagues, students, payers, and the public.

Commitment 3 — Accountability

Accountability requires practitioners to make sound professional judgments within the scope of practice established by law and regulation. The enforceable standards are concrete: do not exceed scope of practice; communicate, collaborate, and refer when a patient's needs exceed one's competence or authority; and practice without impairment from substance misuse, cognitive deficiency, or mental illness.

The aspirational dimension of accountability extends explicitly into the technological present: practitioners are encouraged to be accountable for the accuracy of all information they disseminate, including information shared via social media and generated or assisted by artificial intelligence. A PT who shares inaccurate health information on social media, or who relies on AI-generated content without verifying its accuracy, has not merely made a technical error — they have failed an ethical obligation.

Commitment 4 — Maintaining Professional Relationships

This commitment addresses the boundaries of professional, therapeutic, organizational, and personal relationships. The enforceable standards are among the most unambiguous in the Code: no abusive exploitation of patients, students, supervisees, or employees; no sexual relationships with patients, clients, supervisees, or students; no verbal, physical, emotional, or sexual harassment of any kind.

Aspirationally, Commitment 4 calls on practitioners to empower patients in healthcare decision-making, cultivate inclusive and civil work environments, and encourage impaired colleagues to seek assistance.

Commitment 5 — Compassion and Trust

Commitment 5 focuses on the relational and communicative dimensions of trustworthy practice. Its enforceable standards require practitioners to provide patients with the information genuinely needed for informed decision-making, to author clinical documentation, patient education materials, publications, and presentations truthfully and accurately, and to address barriers to communication and comprehension.

The aspirational vision of this commitment pictures practitioners who demonstrate genuine care and compassion across all services and who maintain respectful, accurate, and truthful communication in every form — explicitly including social media.

Commitment 6 — Responsible Business and Organizational Practices

The sixth commitment addresses the ethical dimensions of business and organizational environments. Enforceable standards prohibit false, deceptive, or misleading billing and business practices; require accurate representation of qualifications and credentials; and prohibit the acceptance or offering of improper financial inducements.

Aspirationally, this commitment envisions practitioners as active advocates for ethical organizational practices — willing to report fraudulent billing and committed to promoting cultures of compliance within their organizations.

Commitment 7 — Direction and Supervision

Elevating direction and supervision to an ethical commitment of its own is one of the most significant structural innovations of the new Code. The enforceable standards establish that the PT maintains supervisory responsibility for all care provided under their license and that direction and supervision of PTAs and support personnel must comply with applicable laws and regulations. Delegation does not diminish accountability — the supervising PT remains ethically and professionally responsible for the quality and appropriateness of all care delivered within the supervisory relationship.

The aspirational dimension calls for clear communication and direction and for ensuring that delegated tasks fall within the supervisee's competence and skill level.

Commitment 8 — Professional Expertise

The eighth commitment addresses the obligation to engage in career-long learning and maintain professional competence. Its enforceable standards require practitioners to maintain and advance their professional knowledge and skills and to accurately represent their areas of competence and qualifications.

Aspirationally, Commitment 8 envisions practitioners who pursue lifelong learning with genuine engagement, who mentor students and colleagues, and who ground their practice in evidence. The mentorship expectation reflects an understanding that professional expertise is not merely a personal asset but a communal resource.

Commitment 9 — Societal Responsibility

The final commitment places physical therapy professionals within the broader social context of healthcare, calling on them to participate in efforts to meet the health needs of people locally, nationally, and globally. The enforceable standards require practitioners to address societal needs related to physical therapy access and health equity — a significant standard that positions health equity not as an optional advocacy priority but as an enforceable ethical obligation.

The aspirational dimension pictures the physical therapy professional as an engaged citizen of their community and of the profession — advocating for equitable access to care, engaging in public health initiatives and pro bono services, contributing to health policy efforts, and working toward an inclusive moral community.

APTA's Core Values

Running beneath all nine Ethical Commitments like a moral foundation are the APTA's core values for the physical therapy profession: accountability, altruism, collaboration, compassion and caring, duty, excellence, integrity, and social responsibility.

Accountability means accepting responsibility for one's decisions, actions, and their consequences. Altruism calls on practitioners to place the interests of patients and the public above personal gain. Collaboration recognizes that good care depends on effective teamwork. Compassion and caring are moral commitments to attending to the suffering, vulnerability, and dignity of the people practitioners serve.

Duty speaks to the binding character of professional obligation — the recognition that choosing a healthcare profession entails accepting responsibilities that are not optional. Excellence is both a personal commitment to continuous improvement and a professional obligation to the patients who deserve nothing less. Integrity requires consistency between values and conduct. And social responsibility positions every physical therapy professional as a stakeholder in a just and equitable healthcare system.

These core values apply across all professional roles and settings — not only in direct patient care but also in education, research, administration, and consultation. The values describe who practitioners should be. The principles articulate what they owe. The commitments specify how those obligations are expressed in professional life.

Enforceable Standards of Conduct: Summary Reference

The following table summarizes the enforceable Standards of Conduct for each of the nine Ethical Commitments in the Code of Ethics for the Physical Therapy Profession (effective January 1, 2026). These standards represent the minimum floor of ethical conduct against which the APTA Ethics and Judicial Committee will assess whether a member has engaged in unethical conduct. They are distinct from the aspirational Illustrative Examples that accompany each Commitment, which describe best practices and the ideals of excellent, values-driven practice. Conduct that violates an enforceable standard may result in formal disciplinary action; conduct that falls short of an aspirational example, while undesirable, does not itself constitute an ethical violation subject to EJC proceedings.

A Note on Interpreting This Table

Several features of this table deserve emphasis for practitioners and students.

The PT's retained responsibility under Commitment 2 is one of the most practically significant enforceable standards in the Code. A supervising PT who delegates care to a PTA, student, or aide does not transfer ethical or professional responsibility for that care to the supervisee. The obligation remains with the PT of record.

The ongoing informed consent standard under Commitment 2 marks a significant departure from how consent is often practiced. A signature obtained at the first visit does not satisfy this standard. Consent must be revisited as treatment evolves, as new interventions are introduced, and as the patient's understanding, condition, and goals change.

The mandatory reporting standard under Commitment 2 elevates what is also a legal obligation (see Illinois ANCRA and elder abuse reporting statutes, Part III) to an ethical obligation enforceable under the Code. A practitioner who fails to report reasonable suspicion of abuse or neglect has violated both state law and the Code's enforceable standards simultaneously.

The scope of practice standard under Commitment 3 applies to both PTs and PTAs. For PTAs, this includes the prohibition on performing evaluation, developing or making major modifications to a plan of care, or interpreting referrals — functions that fall exclusively within the PT's scope, regardless of the PTA's experience or the supervising PT's preferences.

The health equity standard under Commitment 9 is the most recently elevated enforceable obligation in the 2026 Code and represents a significant professional statement: advocating for equitable access to physical therapy is not aspirational for those who choose to engage in it. It is a binding commitment of every member of the profession.

Part III: Physical Therapy And The Law In Illinois

Sources of Law Governing Physical Therapy Practice

The rules governing physical therapy practice are embedded within the State Practice Act. Additionally, the legal landscape incorporates common law, also known as case law, originating from judicial decisions and encompassing aspects like malpractice cases. In Illinois, rules for the administration of the Illinois Practice Act are found in the administrative code: Title 68: Professions and Occupations Chapter VII: Department of Financial and Professional Regulation Subchapter b: Professions and Occupations Part 1340 Illinois Physical Therapy Act.

Establishing physical therapy practice guidelines in each state rests upon the State Practice Act, a legislative creation that reflects administrative insights from the state board. These boards, responsible for interpreting and upholding the State Practice Act, oversee physical therapy practice within their jurisdiction. Given the diversity of state regulations, all 50 states possess distinct practice acts shaping the scope of physical therapy within their borders.

Licensed professionals in Illinois are held accountable by the Department of Financial and Professional Regulation's Division of Professional Regulation. This regulatory agency has been granted the authority to safeguard the public's health, safety, and well-being within the state of Illinois.

Licensure is the primary regulatory mechanism within the domain of physical therapy. It mandates that individuals cannot identify as physical therapists or offer physical therapy services without a valid physical therapy license. For instance, in states like Illinois, acquiring a license typically necessitates completing a licensing examination. Although many states, including Illinois, opt for the licensing examination provided by the Federation of State Boards of Physical Therapy, this remains a discretionary decision. Reciprocity, whereby a license in one state permits practice in another, isn't guaranteed.

Federal Laws Relevant to Physical Therapy Practice

The realm of physical therapy practice is also influenced by federal laws that have jurisdictional impact across all states. Several prominent federal laws are of relevance within clinical practice.

Health Insurance Portability and Accountability Act (HIPAA)

HIPAA is a pivotal confidentiality law. It establishes guidelines for safeguarding patient medical information and personal data. Accompanying HITECH, it ensures the confidentiality of electronic health records. (HIPAA is addressed in depth in Part IV of this course.)

HITECH (Health Information Technology for Economic and Clinical Health Act)

This law complements HIPAA by addressing technology-related confidentiality concerns. It supports the secure exchange of electronic health information while upholding patient privacy.

Medicare Rules and Regulations

Guidelines established by the Centers for Medicare & Medicaid Services (CMS) dictate reimbursement policies, documentation requirements, and standards of care for physical therapy services provided to Medicare beneficiaries.

Medicare, originally comprised of Parts A and B (inpatient and outpatient categories), has expanded to encompass Parts C and D. Part C represents a version of Medicare that resembles an HMO or PPO, and Part D pertains to pharmaceutical coverage. Unlike Medicaid, which is managed at the state level, Medicare is federally funded and administered.

The American Physical Therapy Association (APTA) is a valuable resource for navigating Medicare rules and regulations. Medicare policies often set the precedent for other third-party payers. For example, the concept of direct access, which allows patients to seek physical therapy without a physician referral, has varying degrees of acceptance among third-party payers.

Americans with Disabilities Act (ADA)

The ADA ensures the protection of individuals with disabilities against discrimination in various spheres, including employment and access to public service, healthcare services, and facilities.

The impact of the ADA on clinical practice extends to ensuring accessibility for all individuals. Common considerations include:

Accommodations for Deaf Patients. Providing a sign language interpreter is a common accommodation for deaf individuals. While using a family member might not always be ideal, seeking a professional translator is preferable.

Service Animals in Clinics. Determining which service animals to permit can be challenging. Developing well-defined clinic policies is crucial. Generally, service animals should be accommodated with appropriate documentation from a medical professional.

Wheelchair Accessibility in Clinics. While promoting wheelchair accessibility aligns with the principles of physical therapy, the financial feasibility is also considered. While full accessibility is ideal, if implementing it poses a significant financial burden, complete wheelchair accessibility might not be mandated.

Viewing the ADA from the perspective of PTs and PTAs involves more than meeting legal requirements. It also serves as a tool for patient advocacy — ensuring legal compliance while championing patients' rights and inclusivity.

IDEA (Individuals with Disabilities Education Act)

IDEA governs how states and public agencies provide early intervention, special education, and related services to children with disabilities. IDEA covers early intervention services for infants and toddlers with developmental delays or disabilities and their families. Children with disabilities must be educated with non-disabled children to the maximum extent possible. Parents must be included in the IEP process, and older students are also involved in developing their educational plan. The main purposes of IDEA are to ensure all children with disabilities have access to a free and appropriate public education, protect their rights, and provide early intervention services.

Stark Law

The Stark Law prohibits physicians from referring Medicare patients to entities with which they have a financial relationship, which can impact physical therapists who have referral relationships with physicians.

Anti-Kickback Statute

The Anti-Kickback Statute prohibits the exchange of remuneration in exchange for referrals for services reimbursed by federal healthcare programs, which can affect relationships between physical therapists and other healthcare providers.

Illinois-Specific Laws and Regulations

Illinois Practice Act

The Illinois Practice Act governs the practice of physical therapy in Illinois.

Rules for the Administration of the Illinois Physical Therapy Act (Administrative Code)

The Administrative Code provides detailed regulatory guidance.

Medical Patients Rights Act

The Medical Patients' Rights Act outlines the rights of medical patients in Illinois.

Right to Care. Patients have the right to receive care consistent with sound nursing and medical practices. They must be informed of the physician coordinating their care, receive information about their condition and proposed treatment, refuse any treatment as permitted by law, and have privacy and confidentiality of their records except as otherwise provided by law.

Right to Billing Information. Patients have the right to examine and receive a reasonable explanation of their total bill for services, including itemized charges for specific services received.

Right to Privacy. Patients have the right to privacy and confidentiality in health care. Information can only be disclosed to the patient or their decision-maker for treatment, payment, or health care operations as required by law or with written patient consent.

Identification Badges. Healthcare facility employees and volunteers must wear badges disclosing their first name, licensure status, and staff position.

Patient Examination. Healthcare professionals must inform patients of their profession when providing treatment or care.

Child Abuse Mandatory Reporting

The Abused and Neglected Child Reporting Act (ANCRA) is an Illinois law that requires certain professionals, including PTs and PTAs, to report suspected cases of child abuse or neglect to the Illinois Department of Children and Family Services (DCFS). PTs and PTAs are mandated to make a report to DCFS if they have reasonable cause to believe that a child may be suffering from abuse or neglect.

Elder Abuse Mandatory Reporting

Physical therapists and physical therapist assistants are required to report suspected abuse of adults aged 60 or older, or people with disabilities aged 18–59 who are unable to report for themselves due to dysfunction. For more information on how to report, visit the Illinois Department of Aging page on reporting abuse.

Sexual Harassment

State and federal laws prohibit sexual harassment in the workplace.

Discrimination

State and federal laws prohibit discrimination based on race, gender, age, disability, religion, nationality, sexual orientation, gender, and marital status.

Disability Placards

Effective January 1, 2023, Public Act 102-1011 authorizes Physical Therapists to certify that a patient has a medical condition meeting the requirements for the state to issue a temporary or permanent disability placard.

Changing Your Name on Your License

If you have changed your name due to marriage, divorce, or any other reason, you must inform the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation. This update cannot be done through email or other electronic means. Instead, you must send a written notice to: Division of Professional Regulation - LAU 320 West Washington Street, 3rd Floor Springfield, IL 62786 Fax: (217) 557-8073

To access the required form, click here. Include documentation of your legal name change, such as a marriage license, court order, divorce decree, or naturalization document.

Please note that updating your name on your license does not automatically update your name in your APTA/IPTA membership records. To change your name with APTA/IPTA, contact APTA Membership Services at 800-999-2782. Notifying IPTA separately is unnecessary, as APTA and IPTA share information monthly.

Changing Your Address on Your License

Illinois law mandates that you keep the Division of Professional Regulation informed of your current address and email address. You can update your address, email address, and phone number on your license online. Failing to update your address after moving may result in not receiving your license renewal information promptly.

You must notify the Department of the new information within 14 days of the change.

APTA and IPTA members should note that updating your address on your license does not automatically update your APTA/IPTA membership records. Contact APTA Membership Services at 800-999-2782 to update your membership address.

Illinois State Practice Act and Administrative Code

The provision of physical therapy services in Illinois is guided by state laws governing the licensing of PTs and PTAs. The Department of Financial and Professional Regulation (IDFPR), specifically the Division of Professional Regulation (DPR), oversees license issuance and the discipline of licensees. It is important to note that the Practice Act and its associated Rules are subject to periodic changes. 

Definitions (Sec 1) — What We Can Do

Physical therapy encompasses the following:

Examination, Evaluation, and Testing. Examining, evaluating, and testing individuals who may have mechanical, physiological, or developmental impairments, functional limitations, disabilities, or other health and movement-related conditions. Classifying these disorders, determining a rehabilitation prognosis and plan of therapeutic intervention, and assessing the ongoing effects of the interventions.

Therapeutic Interventions. Alleviating impairments, functional limitations, or disabilities by designing, implementing, and modifying therapeutic interventions that may include evaluation or treatment through the use of the effective properties of physical measures and heat, cold, light, water, radiant energy, electricity, sound, and air; use of therapeutic massage, therapeutic exercise, mobilization, dry needling, and rehabilitative procedures, with or without assistive devices and equipment.

Injury and Disability Prevention. Reducing the risk of injury, impairment, functional limitation, or disability, including the promotion and maintenance of fitness, health, and wellness.

Administration, Consultation, Education, and Research. Engaging in administration, consultation, education, and research related to physical therapy.

Scope of Physical Therapy (Section 1)

Physical therapy includes:

• Performance of Specialized Tests and Measurements
• Administration of Specialized Treatment Procedures
• Interpretation of Referrals from physicians, dentists, advanced practice registered nurses, physician assistants, and podiatric physicians
• Establishment and Modification of Treatment Programs
• Administration of Topical Medication that is used in generally accepted physical therapy procedures when prescribed by the patient's physician, APRN, PA, podiatric physician, or dentist
• Supervision or Teaching of Physical Therapy
• Dry Needling procedures within the scope of physical therapy practice

Exclusions from Physical Therapy Scope (Section 1)

Physical therapy does not include practicing:

• Radiology
• Electrosurgery
• Acupuncture
• Chiropractic Technique

Physical therapy does not include providing a determination of a differential diagnosis. However, this limitation does not prevent a licensed physical therapist from performing an evaluation, establishing a physical therapy treatment plan and performing physical therapy interventions that the physical therapist is educated and licensed to perform.

Key Definitions

Physical Therapist. A person who practices physical therapy and has met all the requirements outlined in this Act.

Department. The Department of Financial and Professional Regulation.

Director. The Director of the Division of Professional Regulation of the Department of Financial and Professional Regulation.

Board. The Physical Therapy Licensing and Disciplinary Board approved by the Secretary.

Referral. A written or oral authorization for physical therapy services by a physician, dentist, advanced practice registered nurse, physician assistant, or podiatric physician. This professional must maintain medical supervision of the patient and make a diagnosis or verify that the patient's condition can be treated by a physical therapist.

State. Includes the states of the United States of America, the District of Columbia, and the Commonwealth of Puerto Rico.

Physical Therapist Assistant. A person licensed to assist a physical therapist who has met all requirements as provided in this Act. They work under the supervision of a licensed physical therapist to assist in implementing the physical therapy treatment program. Their activities do not include interpreting referrals, conducting evaluation procedures, planning, or making major modifications to patient programs.

Physical Therapy Aide. A person who has received on-the-job training specific to the facility where they are employed.

Health Care Professional. A physician, dentist, podiatric physician, advanced practice registered nurse, or physician assistant.

Address of Record. The official mailing address that the Department uses for you. It is your professional responsibility to ensure the address listed in your license file is always current.

Email Address of Record. The official email address the Department uses for all communication regarding your license. It is your professional responsibility to ensure the email listed in your file is accurate and up-to-date.

Secretary. The Secretary of the Illinois Department of Financial and Professional Regulation (IDFPR).

Physical Therapy Services, Direct Access, and Referral Requirements (Section 1.2 / Section 1340.85)

A physical therapist may provide physical therapy services to a patient with or without a referral from a health care professional.

If a physical therapist provides services without a referral, they must notify the patient's treating healthcare professional within five business days of their first visit. This requirement does not apply to physical therapy services related to fitness or wellness unless the patient presents with an ailment or injury. If no treating health care professional is assigned to a patient, the physical therapist should offer to notify a health care professional chosen by the patient.

When a physical therapist treats a patient with a diagnosed chronic disease, the therapist must communicate monthly with the patient's primary healthcare professional regarding progress updates — whether or not the patient has a referral.

This requirement does not apply to services delivered as part of the Illinois Early Intervention (EI) Program, an individualized education plan (IEP), or a federal 504 plan through a school system.

A physical therapist must refer a patient to their treating health care professional or to a health care professional of the patient's choice if:

• Lack of Improvement. The patient does not demonstrate measurable or functional improvement after 10 visits or 15 business days, whichever occurs first, and there is no subsequent improvement.
• Recurring Condition Without Chronic Disease Diagnosis. The patient returns for services for the same or a similar condition after 30 calendar days of discharge from physical therapy without a diagnosis of a chronic disease established by a healthcare professional.
• Condition Beyond the Scope of Practice. The patient's condition at the time of evaluation or services is determined to be beyond the physical therapist's scope of practice.

Wound debridement services may only be provided by a physical therapist with written authorization from a health care professional.

If a physical therapist suspects a patient's condition is related to temporomandibular disorder (TMD), they must promptly consult with the appropriate healthcare professional.

Telehealth Services (Section 1.3)

Purpose and Scope of Telehealth in Physical Therapy

The Illinois Physical Therapy Practice Act recognizes telehealth as a legitimate and valuable mode of service delivery for physical therapists. Rather than functioning as a wholesale replacement for in-person care, telehealth is intended to serve specific practical goals: improving patient access to care, enhancing the overall delivery of physical therapy services, and enabling physical therapists to observe and guide patients within their own environments. This contextual observation — watching a patient navigate their home, workplace, or community — can provide clinical insights that a traditional clinic setting cannot replicate. Understanding this purpose is essential for physical therapists, as it frames telehealth as a tool to extend quality care rather than a shortcut around established clinical standards.

Who May Provide Telehealth Services

The Act is explicit about who bears legal authority to deliver physical therapy via telehealth. Only a licensed physical therapist or a physical therapist assistant (PTA) operating under the general supervision of a physical therapist may provide these services. This supervisory requirement is not unique to telehealth — it mirrors the broader framework governing PTA practice in Illinois — but it carries particular significance in a remote context, where the supervising physical therapist must be deliberately available even when not physically present. Physical therapists must be mindful that delegating telehealth services to a PTA does not diminish their professional and legal responsibility for the care being provided.

Initial Evaluation Via Telehealth: Criteria and Clinical Judgment

One of the more nuanced provisions of Sec. 1.3 concerns the conditions under which a physical therapist may conduct an initial evaluation through telehealth. The Act identifies three qualifying criteria: the patient has a referral or diagnosis from a health care professional; the patient has a pre-existing relationship with the physical therapist; or the physical therapist has the capacity to arrange an in-person, hands-on examination at any point the clinical situation demands it. These criteria reflect the legislature's recognition that a purely remote first contact carries inherent limitations, and that some form of accountability — whether through a referring provider, an established patient relationship, or a standing ability to pivot to in-person care — must be in place. Physical therapists should treat these criteria not as bureaucratic checkboxes but as genuine clinical and ethical thresholds that protect patient safety.

Patient Rights and the In-Person Care Requirement

The Act establishes clear, affirmative rights for patients receiving telehealth-based physical therapy. A patient must be able to request and receive in-person care at any point during the course of their treatment. This right cannot be waived by the therapist or restricted by a care plan, and it places an ongoing obligation on the treating physical therapist to maintain a meaningful pathway to in-person services. Importantly, this obligation is geographically defined: the physical therapist must have the capacity to provide, or to facilitate a referral to, in-person care within the State of Illinois. Physical therapists practicing across state lines or through large telehealth platforms must carefully evaluate whether they can genuinely satisfy this requirement, not merely in theory, but in practical terms for each patient they serve.

Equally noteworthy is the Act's preservation of clinical authority: a physical therapist or PTA retains the right to require a patient to attend an in-person visit rather than continue via telehealth. This provision ensures that the therapist's professional judgment is not overridden by patient preference or platform convenience when the clinical picture demands direct, hands-on assessment or intervention.

Scope of Practice and Standards of Care

A foundational principle embedded in Sec. 1.3 is that telehealth does not alter the scope of practice for physical therapists or physical therapist assistants. Whatever a therapist is authorized or not authorized to do in an in-person setting remains the boundary in a telehealth setting. The Act further requires that telehealth services be delivered consistent with the standards of care applicable to in-person physical therapy. This means the delivery medium changes, but the clinical, ethical, and legal obligations do not. Physical therapists should resist any assumption that telehealth creates a more permissive environment; the law is explicit that it does not authorize the delivery of services in any manner not otherwise permitted.

Licensure Requirements for Telehealth Practice

Illinois law is unambiguous on the question of licensure: any physical therapist or physical therapist assistant who treats a patient located in Illinois through telehealth must be licensed or otherwise authorized to practice physical therapy in Illinois, regardless of where the provider is physically located at the time of the session. This has significant practical implications as telehealth platforms increasingly connect providers and patients across state lines. A physical therapist licensed only in another state who provides services to an Illinois patient via telehealth is operating outside the law. Physical therapists considering telehealth practice in multiple states must conduct careful licensure planning and remain attentive to interstate compacts and reciprocity agreements that may affect their authorization to practice.

Exemptions for Early Intervention and School-Based Services

The Act acknowledges that certain service environments present unique challenges that may not align neatly with its telehealth requirements. To address this, the Department, in consultation with the Department of Human Services and the Department of Early Childhood, is granted rulemaking authority to exempt physical therapists and PTAs who provide services through the Illinois Early Intervention Program, an individualized education program (IEP), or a federal Section 504 plan within a school system. This exemption authority exists specifically to prevent service delays for vulnerable pediatric populations. However, such exemptions must not be read as overriding federal law: the Act expressly states that nothing in Sec. 1.3 permits noncompliance with the Individuals with Disabilities Education Act (IDEA), the Early Intervention Services System Act, the Department of Early Childhood Act, or any other applicable state or federal law. Physical therapists working in early intervention or school-based settings must remain conversant with both state telehealth rules and the federal frameworks that govern those service systems.

Key Takeaways 

Physical therapists practicing in Illinois must approach telehealth not as an informal extension of their practice, but as a legally defined mode of service delivery with its own set of criteria, obligations, and boundaries. The law requires that they maintain licensure in Illinois, operate within their established scope of practice, preserve patient access to in-person care, and ensure appropriate supervision structures are in place. Failure to comply with any of these provisions does not merely represent a lapse in best practices — it constitutes a violation of Illinois law and may expose the physical therapist to disciplinary action by the Department of Financial and Professional Regulation. A thorough understanding of Sec. 1.3 is therefore not optional for the contemporary Illinois physical therapist; it is a core component of responsible, lawful professional practice.

Dry Needling (Section 1.5 / Section 1340.75)

Dry needling, also known as intramuscular manual therapy, is a technique used by licensed physical therapists and physical therapist assistants to treat myofascial pain. This method involves inserting a single-use, sterile filiform needle into the skin or underlying tissues to stimulate trigger points. It is based on Western medical concepts, requires an examination and diagnosis, and targets specific anatomical areas without using acupuncture techniques.

To perform dry needling, practitioners must meet rigorous training requirements:

1. Successful completion of a total of 50 hours of college-level instruction from an accredited program covering the musculoskeletal and neuromuscular system; the anatomical basis of pain mechanisms, chronic pain, and referred pain; myofascial trigger point theory; and universal precautions.
2. Completion of at least 30 hours of didactic coursework specific to intramuscular manual therapy (dry needling). This requirement can be fulfilled by the didactic pre-study required for the dry needling practicum course.
3. Successful completion of at least 54 practicum hours in dry needling coursework offered through an approved CE sponsor. These 54 hours must be completed in one or more modules, with the initial module being no fewer than 27 hours, and all 54 hours must be completed within no more than 24 months. Each course must specify the anatomical regions covered and whether the instruction is introductory or advanced. Required content includes: dry needling technique; indications and contraindications; documentation; management of adverse effects; practical psychomotor competency; and OSHA Bloodborne Pathogens standards.
4. Completion of at least 200 supervised patient treatment sessions. Physical therapists must complete these sessions under general supervision consistent with APTA guidelines. Physical therapist assistants must complete these sessions under the direct line of sight supervision of a licensed physical therapist who has met the requirements of this section.
5. Successful completion of a competency examination approved by the Division. The Division will accept competency examinations administered as part of the dry needling practicum coursework.

Physical therapists and assistants must ensure that dry needling is not misrepresented as acupuncture. A physical therapist or physical therapist assistant shall not advertise, describe to patients or the public, or otherwise represent that dry needling is acupuncture, nor shall they represent that they practice acupuncture unless separately licensed under the Illinois Acupuncture Practice Act. Each licensee is responsible for maintaining records of completed training requirements and shall be prepared to produce those records upon request by the Division. New licensees must wait at least one year after obtaining their license before they can practice dry needling unless they can demonstrate compliance with the requirements through prelicensure educational coursework.

Dry needling may only be delegated to a licensed physical therapist assistant who has met all of the requirements of this section. When a PTA performs dry needling, the supervising physical therapist must maintain direct line of sight observation and supervision of the physical therapist assistant at all times while the treatment is rendered.

Licensure Requirements and Supervision (Section 2)

As of August 31, 1965, it is mandatory for anyone practicing physical therapy in Illinois to hold a license. Since 1990, this also applies to those practicing as physical therapist assistants. Licensed physical therapists must use the initials "PT," and physical therapist assistants must use "PTA" alongside their names to indicate licensure.

Exceptions

• Other Licensed Professionals. Individuals licensed in Illinois for other professions are allowed to engage in activities specific to their licenses.
• Pre-Examination Practice. Individuals can practice physical therapy under the supervision of a licensed physical therapist if they have met all relevant qualifications until the next available examination.
• Temporary Practice. Non-residents may practice physical therapy in Illinois for up to six months during medical emergencies or for special projects, provided they are licensed in another state.
• Endorsement Applicants. Qualified individuals awaiting license endorsement may practice for up to one year or until their licensure is confirmed or denied, whichever is sooner.
• Professional Service Corporations. Licensed physical therapists are permitted to form a professional service corporation under the Professional Service Corporation Act.
• Physical Therapy Aides perform patient care activities under the direct supervision of a licensed physical therapist or assistant but are restricted from interpreting referrals, evaluating patients, or making major program modifications.
• Physical Therapist Assistants (PTAs). PTAs are authorized to carry out patient care activities under the general supervision of a licensed physical therapist. The supervising physical therapist must maintain ongoing contact with the assistant, including regular personal supervision and guidance.
• Physical Therapy Students. Physical therapy students and physical therapist assistant students can practice under the on-site supervision of a licensed physical therapist.
• Supervision Ratio. The practice act is silent on the supervision ratio (the number of aides and/or PTAs a licensed physical therapist can supervise).
• Educational Program Participants. Physical therapists licensed in another state or country may practice in Illinois for up to six months as part of an educational program.

Unlicensed Practice (Sec 2.5)

Penalties for Unlicensed Practice. Anyone who practices or claims to be able to practice as a physical therapist or assistant without a license can face a civil penalty as high as $10,000 for each violation, in addition to any other legal penalties. The Department will determine the specific penalty amount after conducting a formal hearing.

Investigation of Unlicensed Activities. The Department has the authority to investigate any suspected unlicensed activity in physical therapy.

Payment and Legal Actions. The civil penalty must be paid within 60 days from the date the penalty order is issued. The penalty order can be treated as a court judgment and enforced accordingly.

Powers and Duties of the Department of Professional Regulation (Sec 3)

The Department is responsible for overseeing the regulation and administration of physical therapy in Illinois. Key responsibilities include: defining curriculum standards; developing and publishing rules for the examination process; reviewing applications to verify qualifications; authorizing examinations to determine applicant qualifications; conducting hearings to decide whether to refuse license issuance or discipline licensed individuals; and creating rules necessary for the administration of this Act.

Duties and Functions of the Secretary and the Board (Sec 6)

The Secretary will establish a Physical Therapy Licensing and Disciplinary Board consisting of seven members: six physical therapists with at least five years of experience practicing in Illinois, and one public member who is not licensed under this or a similar act. Members serve four-year terms, and no member can serve on the Board for more than nine consecutive years. The Board provides expert knowledge and advice on disciplinary issues, professional performance, and ethical conduct.

Licensure (Sec 8)

To qualify for a license as either a physical therapist or a physical therapist assistant in Illinois:

Application Process. Submit a completed application using the department-provided forms and pay the required fees.

Age and Character. Physical therapists must be at least 21 years old; physical therapist assistants must be at least 18 years old. Applicants must demonstrate good moral character. The Department will consider felony convictions, which do not automatically disqualify an applicant.

Education. Physical therapists must graduate from a Department-approved physical therapy curriculum. Physical therapist assistants must graduate from an approved program and have attained at least an associate's degree. Graduates from non-U.S. programs must validate their degree as equivalent to one conferred by a regionally accredited U.S. college or university.

Examination. Applicants must pass an examination approved by the Department. Non-native English speakers from outside the U.S. must pass the Test of English as a Foreign Language (TOEFL) and the Test of Spoken English (TSE) before taking the licensure examination.

Endorsement (Section 11)

The Department may grant licensure by endorsement to physical therapists or physical therapist assistants who are already licensed in another jurisdiction. Requirements include:

• Submission of a completed application form and required fees.
• Meeting Department-specified requirements, which may include additional education or examination.
• Long-term Practice. Applicants who have practiced for at least 10 consecutive years in another jurisdiction can obtain licensure by endorsement by proving continuous licensure without any disciplinary actions.
• Time Limit. Applicants must have completed all requirements within three years of their application.

Examinations for Licensure (Section 12)

The Department conducts examinations at times and places it determines. At least two written examinations are scheduled annually.

Once notified of eligibility, an applicant must take the examination within 60 days of the notification or on the next available exam date. Failure to take the exam within this timeframe results in forfeiture of the examination fee and the right to practice until the examination is passed.

If an applicant fails the examination three times in any jurisdiction, they are barred from retaking it until they provide satisfactory evidence of completing appropriate remedial work.

Applicants must complete the examination and application process within 3 years of filing the application.

Renewal of Licenses (Section 14 / Section 1340.55)

License Expiration and Renewal Schedule.

• Licenses for physical therapists expire on September 30 of each even-numbered year.
• Licenses for physical therapist assistants expire on September 30 of each odd-numbered year.
• Licensees can renew their licenses during the month preceding the expiration date by paying the required fee and fulfilling any required continuing education.

Licensee Responsibilities. Each licensee must inform the Division of any changes in their address. Licensees should not rely on receiving a renewal form from the Division as an excuse for not renewing on time.

Consequences of Not Renewing. Practicing or offering to practice with an expired license is considered unlicensed and subject to disciplinary actions as outlined in Section 31 of the Act.

Continuing Education Requirements (Section 14.1 / Section 1340.61)

CE Requirements:

• Physical Therapists. Must complete 40 hours of CE relevant to physical therapy every renewal period. At least 3 hours must focus on ethical practice, including jurisprudence.
• Physical Therapist Assistants. Required to complete 20 hours of CE every renewal period. At least 3 hours should cover ethical practice, including jurisprudence.

Mandatory CE Topics:

• Implicit Bias. All healthcare professionals subject to continuing education requirements must now take at least a one-hour course on implicit bias awareness each renewal period.
• Sexual Harassment Prevention Training. All employees are required to complete annual sexual harassment prevention training. Licensed professionals, including PTs and PTAs, must provide proof of completing one hour of sexual harassment prevention training as part of their CE requirements each renewal cycle.
• Dementia Training. All licensed healthcare professionals who directly interact with adult patients aged 26 and above must complete a one-hour dementia training course each renewal period.
• Cultural Competence. Effective January 1, 2025, Illinois-licensed healthcare professionals (including PTs and PTAs) must complete a one-hour cultural competency training course before renewing a license. This training must be repeated once every six years and may be delivered in person, via webinar, or online.

Renewal Period. The renewal period is defined as the 24 months before September 30 in the license renewal year.

CE Credit. One CE hour equals 50 minutes. After the first hour, credits can be awarded in half-hour increments. University or college courses are credited at 15 CE hours per semester hour or 10 CE hours per quarter hour. Licensees are exempt from CE requirements for the first renewal following original license issuance.

Out-of-State Compliance. Illinois licensees practicing in other states must meet Illinois CE requirements. CE credits from other states may count if they meet Illinois' requirements.

Approved CE Activities

Relevant Activities. Activities must advance and enhance patient management skills, including physical therapy examination, evaluation, intervention, prevention, and service provision. Credits will not be awarded for courses conducted in Illinois if offered by non-approved sponsors.

Ineligible Activities. Courses unrelated to professional functions — such as personal estate planning, financial planning, investments, and health (for personal benefit) — do not qualify. Entry-level coursework, employee orientation, work experience, or general meetings that do not involve approved sponsors' educational programming are also ineligible.

Specific Activities for CE Credits. The following activities may earn CE credit:

• Correspondence and Web-Based Courses. Up to 75% of required CE credits through correspondence or web-based courses from approved CE sponsors, including recorded professional presentations or webinars; must pass an included test.
• Publication-Based Tests/Quizzes. Up to 50% of total CE credits through tests or quizzes based on APTA publications.
• Virtual Attendance at Live Events. CE credits through virtual attendance at live professional presentations where real-time communication with the speaker is possible.
• Teaching CE Courses. Teaching may fulfill up to 50% of total CE requirements. Instructors earn 2 hours of CE credit for each hour awarded to attendees when teaching a course for the first time; 1 hour per attendee hour when teaching a second time; no credit for teaching the same course three or more times.
• ABPTS Clinical Specialist Certification. 40 hours of CE credit for the renewal period in which the initial ABPTS Clinical Specialist Certification is received.
• APTA-Approved Clinical Residencies or Fellowships. 1 CE hour for every 2 hours spent in an APTA-approved post-professional clinical residency or fellowship, with a maximum of 20 hours per renewal period.
• Professional Research, Writing, and Editing. 15 hours per peer-reviewed article published; 3 hours per non-refereed article, abstract, or book review; 5 hours per published textbook chapter; 5 hours per poster or platform presentation; 5 hours per editor of professional books or journals; 5 hours per primary or co-author of professional grants.
• Departmental In-Services. Up to 5 hours of CE credit for attending in-service educational sessions at healthcare facilities.
• Skills Certification Courses. Up to 5 CE hours, including a maximum of 2 hours for CPR and 3 hours for BLS/ACLS/PALS certification.
• Clinical Instructor. PTs can earn up to 10 hours; PTAs can earn up to 5 hours. Credit is calculated at 1 CE hour for every 120 student hours.
• Journal Clubs. Up to 5 hours of CE credit, based on actual participation hours.
• Board Service. Up to 8 hours of CE credit for serving on the Board of Directors for IPTA or APTA, calculated at 1 credit hour per 3 months of board service.
• Committee or Sub-committee Service. Up to 8 hours of CE credit for serving on a committee or sub-committee of a chartered professional organization, calculated at 1 credit hour per 3 months of service.
• Educational Programs at IPTA Meetings. Up to 5 hours of CE credit for participating in programs at IPTA district meetings.

CE Sponsorship

Approved sponsors include: the APTA and its components, along with programs approved by the IPTA; the Federation of State Boards of Physical Therapy (FSBPT); educational institutions with CAPTE-accredited PT or PTA programs (for post-professional academic coursework, all accredited colleges and universities are approved sponsors); and any person, firm, association, corporation, or group approved by the Division following the recommendation of the Board.

CE Credits from Other Jurisdictions

If a licensee has completed CE hours from a sponsor not approved by Illinois standards, they must submit an application to the Division or Board for pre-approval, accompanied by a $20 processing fee, at least 90 days before the license expiration date. Late submission requires the initial $20 processing fee plus a $10 per CE hour late fee, not to exceed $150 total.

Compliance and Certification

Applicants must certify compliance with CE requirements on their renewal application and retain proof for five years. When non-compliance appears, the licensee will be notified, given the opportunity to request an interview with the Board, and potentially subject to formal disciplinary proceedings.

Waivers. Waivers for CE requirements can be granted due to hardships like military service or severe illness. "Good cause" circumstances include full-time active military duty during a substantial portion of the prerenewal period, or extreme hardship such as temporary incapacitating illness (documented by a licensed physician, applicable only for one renewal period) or temporary undue hardship such as prolonged hospitalization.

Restoration of Expired Licenses (Section 15 / Section 1340.60)

Licenses Expired or on Inactive Status for More Than Five Years. Individuals must submit: a completed and signed application; the required fee; and proof of CE requirements completed within the 24 months before applying for restoration. Additionally, applicants must provide one of the following: certification of current licensure from another state; an affidavit confirming military service; proof of having passed the licensure examination; or evidence of recent participation in educational programs or related work experience, including 160 contact hours of clinical training for licenses lapsed 5–10 years, or 320 contact hours for licenses lapsed over 10 years.

Licenses Expired for Five Years or Less. Submit a completed application, required fees, and proof of required CE hours earned within two years before license restoration.

Inactive Licenses for Less Than Five Years. Can be restored by paying the current renewal fee and providing proof of required CE hours earned within two years before applying.

Inactive License (Section 16)

Physical therapists and physical therapist assistants can place their licenses on inactive status by notifying the Department using prescribed forms. Once inactive, they are exempt from paying license renewal fees until they decide to reactivate. To return to active status, they must notify the Department in writing, pay the current renewal fee, and follow the procedures for license restoration. While inactive, the holder is prohibited from practicing physical therapy in Illinois. Practicing while on inactive status is considered unlicensed practice.

Fees; Returned Checks (Section 16.1)

The Department will establish by rule all nonrefundable fees related to this Act. If a check or other payment submitted to the Department is returned unpaid, a $50 fine will be added to the original amount owed. The individual must pay all outstanding fees and fines by certified check or money order within 30 calendar days of the notification date. Failure to pay within this period will result in the automatic termination of a license or denial of an application, without a hearing.

Advertising Services (Section 16.5 / Section 1340.66)

Licensed physical therapists in Illinois may advertise services through any media in a manner that is truthful, direct, dignified, and easily understandable by the public. All advertisements must include the licensee's title as it appears on their license.

Television and Radio 

Advertisements broadcast via television or radio must be prerecorded and approved by the licensee. A recording of the actual transmission must be retained for three years.

Permissible Content

Advertisements may include: licensee's name, address, office hours, and telephone number; educational background; announcements about professional staff changes; professional memberships; credit and payment information; languages spoken; typical fees with disclaimers; and office features.

Prohibited Content

It is unlawful to include content that is untruthful, fraudulent, deceptive, or misleading, such as misrepresentations; guarantees of favorable outcomes; exploitation of client fears; exaggerations about the quality of care; claims of superior quality to entice the public; comparisons of fees with other professionals; or advertising services the licensee is not authorized to provide.

Licensing Actions and Unprofessional Conduct (Section 17 / Section 1340.65)

The Department may take various disciplinary actions against licenses, including for:

• Providing false or misleading information to the Department
• Breaching this Act or associated rules
• Criminal convictions related to dishonesty or professional practice
• Falsely obtaining a license or violating advertising rules
• Showing a pattern of practice indicating incapacity to practice
• Failing to provide the requested information to the Department within 60 days
• Engaging in unethical or unprofessional conduct
• Illegal handling or use of drugs; habitual or excessive substance use
• Having a license revoked or suspended in another jurisdiction
• Improper financial interactions concerning professional services
• Patient abandonment
• Willfully failing to report suspected child abuse or neglect
• Willfully failing to report suspected elder abuse or neglect
• Suffering from physical illness or deterioration resulting in the inability to practice with reasonable judgment, skill, or safety
• Using PT/PTA titles without a valid license
• Practicing with a communicable, infectious, or contagious disease
• Scope of practice violations
• Interpretation of referrals, performance of evaluation procedures, planning, or making major modifications of patient programs by a physical therapist assistant
• Failure by a physical therapist assistant and supervising physical therapist to maintain continued contact to ensure the safety and welfare of patients
• Violation of the Health Care Worker Self-Referral Act

Automatic Suspension. A licensee's involuntary admission to a mental health facility results in automatic suspension, which ends only upon a court's determination of the licensee's capability to resume practice.

Tax Compliance. The Department may refuse to issue a license or suspend a license for failure to meet state tax obligations.

Definitions of Unprofessional Conduct. Unprofessional conduct includes, but is not limited to: exploitative promotion; improper referrals; breach of confidentiality; scope-of-practice violations; improper delegation; supervisory failures; service overutilization; misrepresentation; overcharging or billing for undelivered services; poor record-keeping; and misleading advertising.

Additional Enforcement Provisions

License Suspension for Non-Payment of Restitution (Section 17.5)

If a court determines that a licensed individual has not paid legally ordered restitution, the Department will immediately suspend their license. The individual cannot practice until they have fully paid the restitution.

Injunctions and Cease and Desist Orders (Section 18)

If anyone breaches this Act, the Secretary can seek a court order to stop the violation. If someone practices or claims to be a physical therapist or assistant without a proper license, any licensed physical therapist, interested party, or injured person can seek court intervention.

Procedures for Investigations, Notices, and Hearings (Section 19)

Before refusing to issue, renew, or take disciplinary action against a license, the Department must notify the individual in writing at least 30 days prior to a hearing. The individual must submit a written response under oath within 20 days of receiving the notice.

Confidentiality of Investigation Information (Section 19.5)

All information gathered by the Department during an investigation is confidential, for the Department's use only, with exceptions for law enforcement, other regulatory agencies with regulatory need, and parties with lawful subpoenas.

Board Findings (Section 22)

At the end of a disciplinary hearing, the Board submits a detailed written report of findings and recommendations to the Secretary.

Restoration of Suspended or Revoked License (Section 27)

Based on the Board's written recommendation, the Department can restore a suspended or revoked license unless such restoration would not be in the public interest.

Surrender of License (Section 28)

Upon revocation or suspension, the licensee must immediately surrender their license to the Department.

Temporary Suspension (Section 29)

The Secretary may immediately suspend a license without prior notice if evidence indicates that continued practice would pose an imminent danger to the public. A hearing must be held within 30 days of the suspension.

Administrative Review (Section 30)

All final decisions made by the Department regarding disciplinary actions are subject to review in court under the Administrative Review Law.

Violations and Penalties (Section 31)

Any person or company found violating any provision of this Act will face criminal charges. The first offense is classified as a Class A misdemeanor, and any subsequent offense is a Class 4 felony. It is illegal to use the titles "PT," "DPT," "MPT," "RPT," "LPT," or "PTA" to misrepresent oneself as a licensed physical therapist.

Additional Civil Penalty Provisions (Section 32.2)

 In addition to the $10,000 civil penalty available under Section 2.5 for unlicensed practice, Section 32.2 provides that any person who practices, offers to practice, attempts to practice, or holds oneself out to practice physical therapy without a license, or who violates the advertising provisions of Section 16.5 or the misrepresentation provisions of Section 31(b) or (c), shall pay a civil penalty to the Department in an amount not to exceed $5,000 for each offense, as determined by the Department following a hearing. The civil penalty must be paid within 60 days after the effective date of the order and constitutes a judgment enforceable in the same manner as any court judgment.

Emergency Care; Civil Liability (Section 35)

Exemption from civil liability for emergency care provided by a licensed physical therapist is governed by the Illinois Good Samaritan Act. Physical therapists who provide emergency care in good faith are afforded the protections established under that Act.

Part IV: Common Ethical And Legal Issues In Practice

HIPAA and Patient Privacy

Overview

The Health Insurance Portability and Accountability Act, enacted by Congress in 1996, establishes the federal legal framework governing the privacy and security of patient health information. For physical therapy practitioners, HIPAA governs decisions made dozens of times each day about how patient information is accessed, stored, shared, and discussed. The Privacy Rule establishes patients' rights to their health information and sets limits on how covered entities may use and disclose it. The Security Rule applies specifically to electronically protected health information.

Understanding HIPAA is a prerequisite for ethical practice, but it is important to situate the law within its proper relationship to ethics. HIPAA defines the legal floor of privacy protection — the minimum standard below which no covered practitioner may fall without incurring legal consequences. The ethical obligation to protect patient privacy extends beyond what the law requires and is rooted in the profession's foundational commitments.

Protected Health Information

Protected Health Information (PHI) is defined as individually identifiable health information that is created, received, maintained, or transmitted by a covered entity. Information becomes PHI when it contains any of 18 categories of identifiers that could be used to identify the patient, including:

• Name; Address; All elements (except years) of dates related to an individual; Telephone numbers; Fax number; Email address; Social Security Number; Medical record number; Health plan beneficiary number; Account number; Certificate or license number; Any vehicle or device serial number; Web URL; IP Address; Finger or voice print; Photographic images; and any other characteristic that could uniquely identify the individual.

PHI in physical therapy practice extends far beyond formal medical records. A therapy note, a scheduling message, a photograph used for posture assessment, a voicemail about an upcoming appointment, and a conversation overheard in a clinic waiting room can all involve PHI.

Permissible Uses of PHI: The TPO Framework

We can use and share PHI for treatment, payment, or operations (TPO). For patient care and treatment, HIPAA does not restrict healthcare providers' use and disclosure of PHI (exceptions: psychotherapy information, HIV test results, and substance abuse information). For everything else, HIPAA requires the minimum necessary amount of information — users may access only what is necessary to perform their duties and disclose it only to those who have a need to know.

For purposes other than TPO, written authorization from the patient is required. Even positive stories about patient outcomes or new equipment require authorization to be shared publicly. Well-intentioned aggregated data could still indirectly identify individuals.

Patient Rights Under HIPAA

Patients have the right of access to their PHI generally within 30 days of a request. They have the right to request amendment of their PHI if they believe it is inaccurate or incomplete. And they have the right to an accounting of certain disclosures of their PHI made during the preceding six years.

Keeping Health Information Secure

This includes: secure faxing; safe emailing; no texting of PHI via unsecured SMS; safe internet use; password protection; private conversations; social media awareness; secure discarding of papers; computer security; knowing where paperwork is at all times; storing records in secure locations not available for public viewing; not removing records from facilities unless required; verifying identity before releasing records; and not allowing building access to unknown individuals.

Best practices for communication:

• Email PHI only to a known party (e.g., patient, health care provider). Do not email PHI to a group distribution list unless individuals have consented.
• Do not give PHI over the phone unless you confirm the listener's identity and authority to receive PHI. Be aware of your surroundings and who is around.
• Refrain from discussing PHI in public areas such as coffee shops, airports, elevators, restrooms, and reception areas.
• Do not leave detailed voicemails. Instead, say something like: "This is [name] from therapy. I need to speak with you. Please call me at your earliest convenience."

Common HIPAA Violations in Physical Therapy Practice

HIPAA violations in physical therapy settings are more common than many practitioners realize, and the most frequent sources of violation are often mundane rather than dramatic.

• Verbal discussions of patient information in settings where they can be overheard — at the nurses' station, in the hallway, in the gym area of an outpatient clinic — are among the most persistent sources of inadvertent PHI disclosure.
• Electronic records pose a growing compliance risk. Leaving a workstation unlocked and unattended when a patient record is open on the screen, sharing login credentials with colleagues, or accessing records from unsecured networks are all common sources of electronic PHI breaches.
• Texting via standard SMS to communicate about patients is generally not HIPAA-compliant because SMS messages are not encrypted. Practitioners who wish to communicate about patients via mobile messaging must use platforms that offer end-to-end encryption and have a business associate agreement in place.
• Social media warrants special attention. Posting about patients — even without using their name — can constitute a PHI violation if the post contains sufficient detail to allow the patient to be identified. The combination of HIPAA's broad definition of PHI and the permanent, searchable nature of social media content means consequences can be both legally serious and professionally damaging.

Consequences of HIPAA Violations

Civil penalties are tiered according to whether the violation was unknown, the result of reasonable cause, the result of willful neglect that was corrected, or willful neglect that was not corrected — with minimum per-violation penalties ranging from $100 to $50,000, and annual caps on penalties for repeated violations. Criminal penalties can result in fines and imprisonment, with enhanced penalties for violations committed for personal gain. State licensing boards may treat HIPAA violations as grounds for professional discipline.

The Ethical Obligation to Privacy Beyond Legal Minimums

The ethical obligation to protect patient privacy extends beyond what HIPAA legally requires. Commitment 1 of the Code of Ethics for the Physical Therapy Profession establishes the obligation to protect confidential patient and client information. Commitment 5 requires practitioners to address barriers to communication and maintain truthful, respectful communication in all forms. Together, these commitments establish privacy not merely as a regulatory obligation but as an expression of the fundamental respect and trust that define the therapeutic relationship.

What does it mean to honor privacy beyond HIPAA's legal minimum? It means treating patients' personal information with the same discretion and respect that one would want shown to one's own most sensitive information. It means resisting the temptation to share interesting clinical details when sharing serves no clinical purpose. HIPAA tells practitioners what they must do. The profession's ethical commitments tell practitioners what kind of practitioners they should be — and the two standards, while related, are not the same.

Malpractice and Standard of Care

Defining Malpractice and Negligence

Malpractice is a form of professional negligence — a civil wrong that occurs when a licensed professional fails to meet the standard of care applicable to their profession, causing harm to a patient or client. In the context of professional practice, negligence is judged not against the standard of a reasonable layperson but against that of a reasonably competent physical therapist with similar training and experience, practicing under similar conditions.

Malpractice claims in physical therapy are civil, not criminal, matters pursued under tort law. The consequences of a successful malpractice claim can include significant financial damages, increased professional liability insurance premiums, and referral to the state licensing board for disciplinary proceedings.

The Four Elements of Malpractice

For a malpractice claim to succeed, the plaintiff must establish four elements by a preponderance of the evidence:

Duty. The existence of a professional relationship that gave rise to a legal obligation to provide care. In physical therapy, duty is typically established at the moment the PT-patient relationship is formed — when the patient presents for an evaluation, and the therapist begins to provide services.

Breach. A departure from the applicable standard of care, usually established through expert testimony from another physical therapy professional who can speak to what a competent practitioner would have done under the same circumstances.

Causation. A direct causal link between the breach of the standard of care and the harm suffered by the patient. It is not enough that the practitioner departed from the standard and that the patient was harmed; the departure must be shown to have caused the harm.

Damages. Actual, quantifiable harm suffered by the patient as a result of the breach, including physical injury, additional medical expenses, lost wages, and pain and suffering.

Common Malpractice Scenarios in Physical Therapy

Falls during treatment are among the most common malpractice claims. Improper use of therapeutic modalities represents another recurring category. Failure to refer or escalate — a practitioner who treats a patient without recognizing a condition requiring medical evaluation, or who continues treatment when a patient's presentation suggests deterioration — is a particularly serious category. Inadequate documentation can both contribute to and compound malpractice risk.

Standard of Care

The standard of care refers to the degree of care, skill, and treatment that a reasonably competent physical therapist in the same or similar specialty would provide under the same or similar circumstances. The standard is not one of perfection — it does not require that every clinical decision be optimal in hindsight or that no adverse outcome ever occur. It requires that the practitioner exercise the degree of knowledge, skill, and judgment that a competent professional in their position would exercise.

Ethical vs. Legal Responsibility

The relationship between malpractice law and ethics in physical therapy parallels the broader relationship between law and ethics: they overlap substantially but are not identical. The legal standard asks whether the practitioner met the minimum required by a reasonably competent peer. The ethical standard — rooted in Commitment 3 of the new Code, which requires practitioners to make sound professional judgments within their scope of practice — asks whether the practitioner brought their best judgment, their current knowledge, and their genuine commitment to the patient's welfare to every clinical encounter.

Licensure

State Licensure and the Role of Practice Acts

Physical therapy practice in the United States is regulated at the state level, with each state maintaining its own licensing authority and its own physical therapy practice act. State practice acts serve a critical public protection function. Licensure is society's mechanism for ensuring that only those who meet established standards of education, examination, and competence are permitted to practice physical therapy. For this reason, the obligation to maintain licensure and to practice within its boundaries is not merely a legal formality — it is a fundamental component of the social contract between the profession and the communities it serves.

Scope of Practice and Practicing Within One's Competence

The scope of practice in physical therapy has two dimensions practitioners must navigate simultaneously: the legal scope of practice defined by the applicable state practice act, and the practitioner's individual scope of competence — the range of activities for which a specific practitioner has the education, training, experience, and demonstrated proficiency to perform safely and effectively. These two dimensions do not always coincide. The legal scope of practice may permit activities for which a given practitioner has not received adequate preparation, and the ethical obligation to practice within one's competence applies regardless of what the law technically permits.

Ethical Obligations Around Maintaining Licensure

Maintaining licensure requires ongoing action, not merely the absence of disciplinary violations. Every state requires licensed physical therapy professionals to complete a specified number of continuing education units within each renewal cycle, to submit timely renewal applications, and in many states to attest to compliance with requirements and report certain events — such as disciplinary action in another jurisdiction or criminal convictions — to the licensing board.

The ethical dimensions of CE compliance go beyond simply accumulating required hours. Commitment 8 calls on practitioners to pursue lifelong learning through genuine engagement with advances in clinical knowledge — not merely to check a compliance box.

Practicing Without a License or on a Lapsed License

Practicing physical therapy without a valid license is both a serious legal violation and a significant ethical failure. In Illinois, practicing on a lapsed license subjects a practitioner to disciplinary action. License lapses most commonly occur through inadvertent failure to complete renewal requirements on time. Practitioners who discover a license lapse should immediately cease practice, contact their licensing board promptly, and follow the applicable reinstatement procedures before resuming clinical activities.

Reciprocity, Endorsement, and the PT Compact

Physical therapy professionals who wish to practice in a state other than the one in which they were originally licensed have historically needed to apply for licensure by endorsement. The Physical Therapy Compact (PT Compact) was developed to streamline this process. The PT Compact is an interstate agreement among participating states that allows licensed PTs and PTAs who meet the Compact's eligibility criteria to obtain a Compact privilege to practice in other member states without undergoing the full endorsement process in each state. Practitioners interested in the Compact should consult the PT Compact website at ptcompact.org for current membership status, eligibility requirements, and application procedures.

The existence of the PT Compact does not alter the fundamental obligation to hold a valid license — or compact privilege — in each state where one practices.

Supervision of Physical Therapist Assistants and Support Personnel

The Ethical Foundation of Supervision

The supervisory relationship between physical therapists and physical therapist assistants carries substantial ethical weight — enough that the new Code of Ethics for the Physical Therapy Profession dedicates an entire Ethical Commitment, Commitment 7, to Direction and Supervision. The ethical foundation of supervision extends beyond the legal and regulatory requirements that define its minimum parameters. A supervising PT who fulfills the letter of state supervision requirements while failing to provide meaningful clinical guidance, genuine availability, and attentive oversight has met a legal standard but may still fall short of the ethical one.

Illinois Supervision Requirements

In Illinois, the practice act distinguishes among the following:

General Supervision of PTAs. PTAs carry out patient care activities under the general supervision of a licensed physical therapist. The supervising physical therapist must maintain ongoing contact with the assistant, including regular personal supervision and guidance, to ensure the patient's safety and well-being.

Direct Supervision of Physical Therapy Aides. Physical therapy aides perform patient care activities under the direct supervision of a licensed physical therapist or assistant. Aides are restricted from interpreting referrals, evaluating patients, or making major program modifications.

On-Site Supervision of Physical Therapy Students. Physical therapist students and physical therapist assistant students practice under the on-site supervision of a licensed physical therapist, who must be readily available to provide direct supervision and instruction.

Supervision Ratio. The practice act is silent on the supervision ratio (the number of aides and/or PTAs a licensed physical therapist can supervise).

Delegating Tasks Appropriately

PTAs are educated and licensed to provide physical therapy interventions under the supervision of a PT, within the limits established by their state practice act and the supervising PT's plan of care. Certain aspects of practice, such as evaluation, diagnosis, prognosis, development of the plan of care, and certain reassessment functions, are within the exclusive domain of the PT and cannot be delegated to a PTA regardless of the PTA's experience or competence.

Physical therapy aides may perform only non-skilled tasks and support functions that do not require the clinical judgment of a licensed professional. Delegating skilled physical therapy interventions to aides is both a legal violation and an ethical failure with direct implications for patient safety.

Consequences of Improper Supervision

The consequences of inadequate or inappropriate supervision can be severe and fall simultaneously on multiple parties. For patients, improper supervision creates risk of harm. For the supervising PT, improper supervision can result in malpractice liability, disciplinary action by the state licensing board, and professional censure. For the PTA or other supervisee involved, practicing beyond the bounds of appropriate supervision may constitute unlicensed practice with its own legal and regulatory consequences.

Disciplinary Action

Grounds for Disciplinary Action

State licensing boards are empowered to investigate and act on complaints against licensed physical therapy practitioners. The specific grounds for disciplinary action in Illinois are detailed in Section 17 of the Practice Act (summarized in Part III of this course) and typically include: incompetence or gross negligence; unprofessional conduct including fraud and misrepresentation; violation of the practice act or its implementing regulations; criminal convictions substantially related to professional practice; substance abuse or impairment; violation of a prior disciplinary order; practicing beyond scope of licensure; and failure to comply with mandatory reporting requirements.

Types of Disciplinary Actions

Available disciplinary actions include: reprimand (formal written censure, becomes part of licensure record but does not restrict practice); probation (continued practice under specified conditions); suspension (removal of authorization to practice for a specified period); and revocation (permanent removal of the license to practice, with reinstatement rarely granted in the most serious cases). Boards may also impose license restrictions less severe than full suspension.

The Disciplinary Process

Upon receipt of a complaint, the board conducts an initial screening. Complaints that survive proceed to investigation. If the investigation yields sufficient evidence, the matter may proceed to a formal hearing at which the practitioner has the right to present their defense, be represented by counsel, call witnesses, and cross-examine adverse witnesses. The Department must notify the individual in writing at least 30 days prior to a hearing, and the individual must provide a written response under oath within 20 days of receiving notice. Boards may also resolve matters through consent agreements.

Mandatory Reporting Obligations

Commitment 2 of the Code of Ethics for the Physical Therapy Profession establishes as an enforceable standard the obligation to report colleagues who are reasonably believed to be unfit to practice safely. Many states have parallel mandatory reporting requirements. The discomfort practitioners feel about reporting a colleague is understandable — but the obligation to protect patients from harm, rooted in nonmaleficence and in Commitment 2's enforceable standards, takes precedence over that discomfort, provided the reporting practitioner has a reasonable good-faith basis for their concern. The standard is not certainty, it is a reasonable belief.

The Ethical Duty to Self-Report

Alongside the obligation to report concerns about others, practitioners carry an ethical duty to self-report certain events — criminal convictions, disciplinary actions by other licensing jurisdictions, and findings of professional misconduct — to their licensing board within specified timeframes. Self-reporting is an expression of the accountability and integrity that the Code demands. Practitioners who fail to self-report required events, when discovered, typically face more serious disciplinary consequences than they would have faced had they reported promptly.

Fraud and Abuse

Definitions and the Distinction Between Fraud and Abuse

Fraud is intentional misrepresentation — the knowing submission of false information to obtain payment or benefits to which the submitting party is not entitled. The element of intent is what distinguishes fraud from other billing errors.

Abuse does not require proof of intent. Abuse refers to practices that are inconsistent with sound fiscal, business, or medical practices and that result in unnecessary costs or improper payments — practices that may reflect carelessness, poor systems, or misunderstanding of applicable rules rather than deliberate misrepresentation.

Both fraud and abuse undermine the integrity of the healthcare payment system and represent a fundamental betrayal of the trust that patients and the public place in healthcare professionals.

Common Fraud and Abuse Scenarios in Physical Therapy

Billing for services not rendered. Submitting claims for treatment sessions that did not occur, or for units of service not actually provided, is the most straightforward form of billing fraud.

Upcoding. Billing at a higher service level than was actually documented and provided. If you provide therapeutic exercise, that's what you bill and document.

Unbundling. Billing separately for services that should be billed together under a single bundled code.

Billing non-covered services. Billing for services that are not covered by the relevant payer.

Billing for services provided by unlicensed personnel. Billing for therapy services not provided by a licensed provider, such as when a therapy aide works with a patient but the claim is submitted as if a licensed professional provided the service.

Billing for a one-to-one visit when a group or concurrent visit was provided. This arises with particular frequency in the Medicare context involving students.

Kickbacks and self-referral arrangements. Offering, paying, soliciting, or receiving anything of value to induce referrals, or participating in prohibited financial arrangements between referral sources, violates both the Anti-Kickback Statute and the Stark Law.

Falsifying documentation. Documentation that misrepresents what occurred in a clinical encounter — fabricating treatment, recording findings not assessed, or documenting progress not achieved — violates every relevant ethical commitment simultaneously.

Providing medically unnecessary services. Treating patients beyond the point of clinical benefit in order to maintain billable visits.

Abuse in the Medicare context occurs when Medicare pays for services that should not be covered, or anytime a provider bills Medicare for services that are not medically necessary. Denials citing "not medically necessary" exemplify abuse.

Consequences of Fraud and Abuse

The consequences are severe and multidimensional. Exclusion from participation in Medicare and Medicaid can effectively end a practitioner's career. Civil monetary penalties under the False Claims Act can reach tens of thousands of dollars per false claim, and the government is entitled to treble damages — three times the amount of the fraudulent claims — in addition to per-claim penalties. Criminal prosecution for healthcare fraud can result in substantial fines and imprisonment. State licensing boards routinely treat findings of fraud and abuse as grounds for suspending or revoking a license.

Mandatory Reporting of Fraud

If you are aware of fraudulent or abusive activities, you must report them. Failure to do so violates codes of ethics and practice acts and may result in criminal charges for conspiracy. Commitment 6 of the new Code aspirationally calls on practitioners to report fraudulent billing and advocate for ethical organizational practices.

Establishing a Culture of Compliance

The most effective protection against fraud and abuse is not fear of consequences. It is the cultivation of an organizational culture in which ethical billing practices are understood as a shared professional value. A culture of compliance is one in which billing and documentation policies are clearly articulated and consistently applied, staff receive regular training, questions and concerns about billing can be raised without fear of retaliation, and leadership models the integrity it expects of its staff.

Residents' Rights and Elder Abuse

Resident Rights

The 1987 Nursing Home Reform Law established critical protections for long-term care residents, though these rights broadly apply across settings. Providers participating in Medicare/Medicaid must uphold resident dignity, self-determination, and well-being. Key rights include:

The Right to Be Fully Informed

Individuals have the right to full disclosure regarding services, associated charges, governing rules and regulations, and a written copy of their rights.

Right to Complain

Individuals have a right to present grievances without fear of reprisal and a prompt effort to resolve those grievances.

Right to Participate in One's Own Care

This includes receiving adequate and appropriate care, being informed of any change in medical condition, participating in care planning and treatment, refusing medication and treatment, reviewing medical records, and being free from charges for covered services.

Right to Privacy and Confidentiality.

Includes private and unrestricted communication with anyone of their choice.

Rights During Transfers and Discharges

Individuals must receive a thirty-day notice that includes the reason, effective date, and location of any transfer or discharge.

Right to Be Treated with Dignity, Respect, Freedom, and Self-Determination

Individuals have a right to be treated with consideration, respect, and dignity, and to be free from abuse.

Right to Visits

Individuals have a right to visits from family members, friends, their physician, state surveyors, the ombudsman, or organizations providing social or legal services.

Right to Make Independent Choices

This includes the right to choose their own physician, manage their own financial affairs, and participate in community activities.

Your Role

Know your patients' rights wherever you're working. Respect their dignity and privacy at all times. Knock on the door before entering and ask for permission. Speak respectfully. Allow them to make choices about their care. Respect their right to refuse therapy, care, medications, or specific activities. Listen to them and their family members and refer individuals with questions to the appropriate person.

Elder Abuse

Elder abuse is a growing concern in geriatric practice. Key definitions:

• Elder: 65 years or older.
• Elder abuse: An act or omission by someone in a trusted relationship that harms or threatens an older adult's health or welfare.
• Caregiver: Anyone with custody or control over an elder.

Estimates suggest 10–15% of elders experience abuse. While there is no single victim profile, 90% of perpetrators are known to the victim. Physical therapists are well-positioned to detect and report abuse.

Forms of abuse: Physical abuse; sexual abuse; emotional abuse; neglect; abandonment; financial exploitation; and self-neglect.

Elder Abuse Indicators:

• Physical Abuse: Sprains, fractures, broken bones, burns, internal injuries, bruising; injuries that are unexplained or have implausible explanations.
• Sexual Abuse: Fear of being touched or inappropriate modesty on evaluation; inner thigh or breast bruising or tenderness.
• Emotional Abuse: Depression, sleep and appetite disturbances, decreased social contact, loss of interest in self, apathy, suicidal ideation, evasiveness, anxiety, and hostility.
• Neglect and Self-Neglect: Inadequate, dirty, or inappropriate clothing; malnutrition; dehydration; odor and poor hygiene; pressure sores; misuse or absence of medicines or medical assistive devices.
• Financial Abuse: Fear, vague answers, and anxiety when asked about personal finances; disparity between assets and appearance; failure to purchase medicines or seek medical care.

Elder Justice Act. You have a duty to report any suspected acts involving resident mistreatment, neglect, abuse, crimes, misappropriation of resident property, or injuries of unknown source. Specific timeframes apply:

• Events causing suspicion of a crime resulting in serious bodily injury: report to HHS and law enforcement authorities immediately, but not later than two hours after forming the suspicion.
• Events that do not result in serious bodily injury: report no later than 24 hours after forming the suspicion.

Serious bodily injury involves extreme physical pain or substantial risk of death; protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.

Part V: Emerging Ethical Issues In Physical Therapy Practice

Moral Distress in Physical Therapy

Defining Moral Distress

Among the most significant emerging areas of inquiry in healthcare ethics is the phenomenon of moral distress — a concept that captures an experience many physical therapy practitioners will recognize immediately, even if they have not previously had precise language for it. First described by philosopher Andrew Jameton in the context of nursing practice in 1984, moral distress is defined as the psychological suffering that results from knowing the ethically right course of action but being constrained by institutional, systemic, or interpersonal forces from carrying it out.

This definition draws a crucial distinction worth careful examination: it sets moral distress apart from ethical dilemmas. An ethical dilemma arises when a practitioner faces genuine uncertainty about the right course of action — when competing principles pull in different directions, and no clearly correct answer is apparent. Moral distress is a fundamentally different experience. In moral distress, the practitioner does not lack clarity about what ethics requires. They know what the right thing to do is. The problem is that they cannot do it, or believe they cannot, because of constraints imposed by their environment that lie largely outside their individual control. The suffering of moral distress is not the suffering of uncertainty; it is the suffering of perceived moral powerlessness.

This distinction carries important practical implications. Ethical dilemmas call primarily for better reasoning. Moral distress calls for recognition of the systemic and relational forces that constrain ethical action, for organizational structures that support practitioners in acting on their values, and for the professional courage and advocacy skills to push back against constraints that should not be accepted as immovable.

The Prevalence and Sources of Moral Distress in Physical Therapy

Research confirms that moral distress is a prevalent feature of clinical professional life, particularly in healthcare environments characterized by productivity pressure, resource limitation, and staffing constraints. The finding that moral distress is tied particularly to productivity pressures and resource limitations is significant because it locates the problem not primarily in individual practitioner deficiencies but in the structural conditions of contemporary healthcare delivery.

The sources of moral distress in physical therapy practice cluster around a recognizable set of recurring situations:

Premature discharge due to insurance limitations. A practitioner's clinical judgment clearly indicates that the patient would benefit from continued care, but authorization has been denied, and the institutional response is to discharge rather than advocate. Knowing a patient needs more while being told that more is not available is a paradigmatic moral distress scenario.

Productivity quotas at the expense of care quality. When productivity standards require patient loads that make genuinely individualized, attentive care practically impossible, the experience of being compelled to participate in a system that falls short of one's professional standards generates the characteristic suffering of moral distress.

Witnessing unethical colleague behavior without feeling empowered to report it. A practitioner who observes a colleague behaving in ways that raise serious ethical concerns but fears professional retaliation experiences a form of moral distress rooted in the gap between what integrity requires and what the social and organizational environment appears to permit.

Conflict between institutional policies and patient-centered care. Being required to follow organizational protocols that the practitioner believes do not serve the patient's best interests, with no effective mechanism for challenging those policies.

Recognizing Moral Distress in Yourself and Others

Moral distress does not always announce itself clearly. Symptoms can include: persistent feelings of guilt or shame about clinical decisions made under constraint; a growing sense that one's professional values and daily work have become disconnected; emotional numbness or detachment in patient interactions that previously felt meaningful; and a preoccupying sense of helplessness in the face of systemic conditions that feel immovable.

Moral distress is not a sign of weakness or inadequate professional resilience — it is a sign that a practitioner cares enough about their work to suffer when they cannot do it as well as they believe they should.

Strategies for Addressing Moral Distress

Peer consultation and interdisciplinary support. Creating opportunities to discuss ethical challenges with trusted colleagues can significantly reduce the isolation that compounds the suffering of moral distress. When a practitioner discovers that their experience is shared by colleagues, the individual burden becomes a collective one that can more effectively be addressed through collective action.

Institutional ethics committees. Where they exist, ethics committees provide a formal mechanism for addressing ethically complex situations that individual practitioners cannot resolve on their own.

Reflective practice and mentorship. Structured opportunities to process ethical experiences, examine one's responses, and develop professional identity and resilience are essential tools for managing moral distress sustainably.

Advocacy through the Code. Commitment 9 calls on practitioners to participate in efforts to meet the health needs of people locally, nationally, and globally, and to advocate for equitable access to care and ethical organizational practices. Commitment 6 calls for advocacy for ethical organizational practices. When practitioners advocate for better reimbursement policies, evidence-based staffing standards, and regulatory protections that support patient-centered care, they are fulfilling the societal responsibility the Code calls them to accept. Moral distress, understood in this light, is not only a personal burden to be managed — it is a signal about the gap between what ethical practice requires and what current systems support.

Social Media and Ethical Responsibilities

The Ethical Landscape of Social Media in Physical Therapy Practice

Social media has transformed the way healthcare professionals communicate, market their services, educate the public, and engage with colleagues and patients. The same technologies that offer genuine opportunities for patient education, professional community building, and public health communication also introduce a distinct and evolving category of ethical risk. The Code of Ethics for the Physical Therapy Profession, effective January 1, 2026, directly addresses this challenge by explicitly naming social media as a domain of ethical accountability.

Common Social Media Ethical Violations

Sharing patient information or photographs without proper authorization. This category of violation is broader than many practitioners initially appreciate — it is not limited to posts that explicitly identify a patient by name. A photograph taken in a clinical setting that captures a patient in the background may constitute a PHI disclosure if the patient is identifiable. A description of a clinical case that is sufficiently detailed to allow identification violates privacy, even without a name. Before any image, video, or clinical narrative is shared, the practitioner must confirm that no identifiable patient information is present or that appropriate written authorization has been obtained.

Posting clinical content that compromises patient dignity. Exercise demonstration videos, photographs documenting clinical progress, and case presentations shared for educational purposes can all cross ethical lines if the patient's dignity is not carefully protected. Practitioners should also consider how clinical content might appear to viewers who lack the clinical context to interpret it accurately.

Blurring professional and personal boundaries online. The norms of personal social media use — casual, informal, emotionally expressive, occasionally impulsive — are at odds with the standards of professional conduct that apply to licensed healthcare practitioners in all public-facing activities. Posts made in a personal capacity can still carry professional implications when the practitioner is identifiable as a physical therapist.

Providing clinical advice to individuals outside a formal therapeutic relationship. When a practitioner responds to a comment or message with what amounts to clinical advice, they may be establishing a duty of care without the safeguards of a formal clinical relationship.

Misleading marketing and credential misrepresentation. Claims of specialized expertise without the requisite training or certification, testimonials structured to misrepresent typical outcomes, and marketing content that overpromises clinical results all constitute professional misrepresentation with direct ethical and regulatory consequences.

What the New Code Requires

Aspiration 3.D (under Commitment 3 — Accountability) calls on practitioners to be accountable for the accuracy of all information disseminated, explicitly including information shared via social media and artificial intelligence. A practitioner who shares inaccurate health information on a social media platform has failed an ethical obligation explicitly recognized by the Code.

Aspiration 5. B (under Commitment 5 — Compassion and Trust) calls on practitioners to use respectful, accurate, and truthful communication in all forms, again explicitly including social media.

Best Practices for Ethical Social Media Use

Never share identifiable patient information in any format on any platform without proper written authorization — this applies to names, photographs, videos, and written descriptions alike.

Maintain clear professional boundaries between personal and professional online presence. Regularly consider how your overall social media presence would appear to a patient, a colleague, a licensing board investigator, or a member of the public.

Apply the same standards of truthfulness and accuracy online as in clinical documentation. If the same content would be inappropriate in a clinical note or a formal professional communication, it is almost certainly inappropriate on social media.

Consider whether a post could be misused, misinterpreted, or harm the profession's reputation before publishing it. Cultivate the habit of a brief reflective pause — asking whether a post could be taken out of context, whether it could be used to cause harm, and whether it reflects the values you wish to embody professionally.

Artificial Intelligence and Digital Ethics in Physical Therapy

The Integration of AI into Physical Therapy Practice

Artificial intelligence is an increasingly present feature of the clinical environments in which physical therapy is practiced. Machine learning algorithms, natural language processing systems, computer vision tools, and predictive analytics platforms are being integrated into physical therapy practice across a widening range of applications: automated documentation systems, movement analysis software, predictive outcome models, and robotic rehabilitation platforms. For physical therapy practitioners, this technological transformation introduces both a genuine clinical opportunity and a set of ethical obligations that are still being defined.

Accountability: When AI-Assisted Decisions Cause Harm

The question of accountability in AI-assisted clinical practice is one of the most practically urgent ethical issues introduced by these technologies. When a clinical decision supported by an AI tool leads to patient harm, who bears responsibility?

The answer is unambiguous: the licensed physical therapy professional who used the tool and made the clinical decision bears responsibility. The existence of an AI system in the clinical workflow does not transfer professional accountability to a software developer, a technology vendor, or an algorithm. Commitment 3 requires practitioners to make sound professional judgments within their scope of practice — a standard that applies with full force to decisions made with AI assistance.

This accountability principle has immediate practical implications. A PT who implements a treatment plan based primarily on an AI-generated recommendation without applying their own clinical reasoning has not delegated a clinical task — they have abandoned a professional obligation. The appropriate role of AI in clinical decision-making is to inform and support the practitioner's judgment, not to replace it.

Transparency: Informing Patients About AI Use

The principle of autonomy requires that patients have the information they need to make meaningful decisions about their care. When AI tools are used in a patient's evaluation, treatment planning, or ongoing care management, patients generally have a reasonable interest in — and ethical right to — that knowledge. Transparency about AI use operates at two levels: organizational and systemic disclosure (making clear that AI tools are used in clinical operations), and specific clinical communication (informing individual patients when AI-assisted analysis is used in their particular care, in a way that is meaningful rather than merely formal).

Commitment 5 calls on practitioners to provide patients with the information genuinely needed for informed decision-making and to address barriers to communication and comprehension. Applied to AI use, this commitment requires practitioners to think carefully about how to explain AI tools to patients in accessible, non-technical language.

Bias: The Equity Problem in AI-Assisted Care

Among the most serious ethical concerns introduced by AI in healthcare is the problem of algorithmic bias — the tendency of AI systems trained on non-representative or historically skewed data to produce outputs that are systematically less accurate, less equitable, or less beneficial for underrepresented populations. In physical therapy, an outcome prediction model trained predominantly on data from one demographic population may generate inaccurate prognoses for patients from other groups. A movement analysis system developed and validated on a population that does not reflect the diversity of the patients a practitioner serves may produce unreliable assessments.

The ethical obligation to recognize and respond to algorithmic bias flows directly from the principle of justice and from Commitment 1's requirement to respect the inherent dignity and rights of all individuals without discrimination. A practitioner who uses an AI tool without considering whether it has been validated for the population they serve risks allowing a technological system to introduce or amplify inequities that their own clinical judgment would otherwise resist.

Data Privacy

AI platforms may transmit patient data to external servers, use patient data for ongoing model training, share data with third-party partners, or retain data in ways that create long-term privacy risks that standard clinical data retention policies were not designed to address. Practitioners should understand, to the extent possible, how AI platforms used in their practice handle patient data. At the organizational level, institutions that adopt AI platforms bear responsibility for ensuring HIPAA compliance and appropriate business associate agreements.

Competence: The Obligation to Understand the Tools You Use

The ethical obligation of professional competence extends to the tools and technologies practitioners incorporate into their clinical work. Commitment 8 calls on practitioners to pursue career-long acquisition and refinement of knowledge, skills, and abilities — a standard that, in the current technological environment, necessarily includes developing the capacity to engage critically and competently with AI tools. This competence obligation does not require that physical therapy practitioners develop the technical expertise of AI engineers. It does require a functional understanding sufficient to use AI tools safely and to recognize their limitations.

What the New Code Requires

Aspiration 3.D under Commitment 3 explicitly calls on practitioners to be accountable for the accuracy of all information disseminated, including information generated or assisted by artificial intelligence. The practitioner who publishes AI-generated content without verifying its accuracy — who allows an algorithm to speak on their behalf without applying their own professional judgment — has failed the accountability standard the Code establishes.

Guidance for Ethical AI Use

Maintain clinical judgment as the primary driver. AI tools are aids to clinical reasoning, not substitutes for it. The practitioner's direct assessment, including observation, examination findings, knowledge of the patient's history and goals, and clinical experience, must remain the primary basis for care decisions.

Obtain informed consent when AI tools are used in patient evaluation or treatment. The form and extent of disclosure should be proportionate to the significance of the tool's role in the patient's care.

Stay current on AI developments through continuing education. The profession is increasingly offering resources specifically focused on AI in physical therapy. Practitioners who engage with these resources are better equipped to use AI tools responsibly.

Advocate for equitable, transparent AI implementation. Practitioners who understand the ethical dimensions of AI adoption and who can ask informed questions about bias, validation, data privacy, and transparency when their organizations consider new tools are fulfilling both their competence obligations under Commitment 8 and their advocacy obligations under Commitments 6 and 9.

Part VI: Ethical Issues In Caring For Aging Populations

The Ethical Complexity of Geriatric Physical Therapy Practice

Physical therapy with older adults is among the most ethically rich domains of clinical practice — not because older patients present more ethical problems than younger ones, but because the constellation of clinical, relational, and systemic factors that characterize geriatric care creates conditions in which ethical challenges arise with particular frequency, complexity, and consequence. Cognitive changes that affect decision-making capacity, family dynamics that complicate the therapeutic relationship, functional trajectories that require honest and sometimes difficult conversations about realistic goals, and the heightened vulnerability of older adults to neglect, abuse, and exploitation — each of these factors introduces ethical dimensions that practitioners in geriatric settings must be prepared to navigate with both clinical skill and ethical sophistication.

The aging of the population makes these competencies increasingly essential across practice settings. Practitioners who work primarily in settings not traditionally associated with geriatric care will nonetheless encounter older patients with complex ethical presentations.

Determining Decision-Making Capacity for Informed Consent

Among the most practically consequential ethical challenges in geriatric physical therapy is the question of whether a patient retains the decision-making capacity necessary to provide valid informed consent. Decision-making capacity refers to a patient's ability to understand the information relevant to a healthcare decision, appreciate how that information applies to their situation, reason about the options available to them, and communicate a consistent choice.

Cognitive impairment in older adults exists on a continuum, and the presence of a dementia diagnosis does not automatically establish that a patient lacks decision-making capacity for a specific clinical decision. Capacity is decision-specific — a patient may have the capacity to consent to a straightforward exercise program while lacking the capacity to make informed decisions about a complex surgical intervention. It fluctuates with time of day, medication effects, delirium, pain, and other reversible factors. And it should be presumed present unless there is specific clinical evidence to the contrary.

For physical therapy practitioners, the practical implications of this framework are significant. Before concluding that a patient cannot provide valid informed consent, the practitioner should consider whether the apparent capacity impairment is reversible — whether consent could be obtained at a different time of day, after pain has been addressed, or with communication modifications. Excluding a patient with partial or fluctuating capacity from participation in decisions about their own care is itself an ethical failure that violates the respect for persons that Commitment 1 demands.

Surrogate Decision-Making and the Balancing of Competing Interests

When a patient's decision-making capacity is genuinely impaired, clinical decisions require a surrogate. The ethical complexity of surrogate decision-making arises from several sources.

The preferred ethical standard for surrogate decision-making is substituted judgment—the surrogate should make the decision the patient would make if they retained capacity, based on the patient's previously expressed values and goals of care. When the patient's prior wishes are unknown or unclear, the best interests standard applies.

A frequent source of complexity is the misalignment between what a surrogate wishes for a patient and what the patient — to the extent their preferences can be known — appears to want. A family member who insists on aggressive rehabilitation for a patient who consistently expresses a desire to rest, who cries during treatment sessions, or who actively resists therapy presents the practitioner with a genuine ethical tension. Commitment 1's requirement to respect the inherent dignity and rights of all individuals, and Commitment 5's call for compassionate and trustworthy, patient-centered care, both support the practitioner's obligation to advocate for the patient's observable preferences.

Navigating Goals of Care When Functional Improvement Is Limited

Physical therapy's professional identity is strongly associated with restoration of function. In geriatric practice, this identity faces its most significant challenge in caring for patients for whom meaningful functional improvement is limited or unlikely. For these patients, the question is not whether physical therapy can restore function but what it can offer in service of the patient's goals and quality of life, given realistic limits.

This reframing — from restoration to optimization of quality of life within realistic limits — is both clinically and ethically important. It requires the kind of honest, compassionate communication about prognosis and realistic goals that Commitment 5 demands — including conversations that may be difficult for patients, families, and practitioners alike.

Providing false hope — allowing patients and families to believe that intensive rehabilitation will produce functional outcomes that clinical judgment does not support — is a violation of the veracity obligation. It is also a disservice to patients, whose ability to make meaningful decisions about how they spend their time and energy depends on accurate information. The courage to have honest conversations about goals of care, framed with genuine compassion and with consistent attention to what the patient values most, is one of the most important ethical competencies in geriatric physical therapy practice.

Recognizing and Reporting Elder Abuse, Neglect, and Exploitation

Physical therapy practitioners who work with older adults are in a clinically privileged position with respect to the detection of elder abuse, neglect, and exploitation. The hands-on nature of physical therapy assessment provides observational access that many other members of the care team may not have. Unexplained bruising, patterns of injury inconsistent with reported mechanisms, signs of malnutrition or poor hygiene, a patient who appears fearful in the presence of family members or caregivers, financial exploitation disclosed in the context of a therapeutic relationship — these are among the signs that may indicate abuse, neglect, or exploitation.

The obligation to recognize and act on these signs is explicitly established by the new Code. Commitment 2, Standard 2.5, requires physical therapy professionals to comply with mandatory reporter laws for abuse, neglect, and exploitation of children and vulnerable adults. In Illinois, PTs and PTAs are mandatory reporters under state law (see Part III). The appropriate standard for reporting is not certainty — it is reasonable suspicion. The investigation and determination of what actually occurred is the responsibility of the protective services system; the practitioner's responsibility is to ensure that the system has the information it needs to protect a vulnerable person.

Resource Allocation and Equitable Access to Rehabilitation for Older Adults

The principle of justice and Commitment 9's call for equitable access to care are tested with particular acuity in the context of rehabilitation services for older adults. Resource allocation decisions affecting older adults occur at multiple levels: systemic (Medicare coverage policies), organizational (staffing decisions and productivity standards), and individual clinical (how a practitioner allocates time and attention).

Implicit biases about the value of rehabilitation for older adults — the assumption that functional decline is inevitable, that rehabilitation investment will not produce meaningful returns, or that older patients are less deserving of clinical attention than younger ones — can produce discriminatory allocation of rehabilitation resources that violates both the principle of justice and the Code's explicit prohibition on discrimination.

Physical therapy practitioners who work with aging populations have an obligation to examine their own assumptions, to advocate within their organizations for resource allocation policies that are equitable and evidence-based, and to bring to every older patient the same quality of clinical attention and professional commitment that they would bring to any other member of their caseload.

Part VII: Ethical Issues In Caring For Pediatric Populations

The Ethical Complexity of Pediatric Physical Therapy Practice

Physical therapy with children occupies a uniquely complex ethical terrain within the profession. The clinical, relational, and systemic factors that characterize pediatric care are distinctive in ways that have no direct parallel in adult practice — not because children present more ethical problems than adult patients, but because the fundamental structure of the therapeutic relationship is different from the outset. In pediatric practice, the practitioner does not work with one autonomous individual but with a triad: the child, the parent or guardian, and the therapeutic relationship that must somehow serve both. Managing that triadic relationship with integrity — honoring the child's emerging autonomy while recognizing the legitimate authority of parents and the legal framework governing the care of minors — is one of the defining ethical challenges of pediatric physical therapy practice.

The breadth of pediatric practice settings adds a further layer of complexity. Physical therapists and physical therapist assistants working with children may practice in outpatient clinics, early intervention programs, school-based settings operating under federal IDEA mandates, acute care hospitals, specialty pediatric facilities, and home health environments. Each setting carries its own institutional norms, legal frameworks, and ethical pressures. A school-based PT navigating the IEP process operates within a fundamentally different ethical landscape than an outpatient PT treating a child with a sports injury, even though both are practicing physical therapy with pediatric patients. Understanding the ethical dimensions of pediatric practice requires attention to the specific context in which care is delivered, not only to the general principles that apply across contexts.

The growing recognition that children are not simply small adults — that their developmental stage, cognitive capacity, emotional vulnerability, and dependence on caregivers give rise to ethical obligations that are qualitatively distinct from those owed to adult patients — has reshaped pediatric healthcare ethics over the past several decades. Physical therapy practitioners working with children carry a responsibility to bring that same developmental and relational sophistication to their ethical reasoning, recognizing that what serves a child's best interests may not always align neatly with what their parents want, what their institution requires, or what is most convenient for the therapeutic schedule.

Informed Consent, Parental Permission, and the Child's Assent

The Legal Framework of Parental Permission

Informed consent for the physical therapy evaluation and treatment of a minor patient is legally the prerogative of the child's parent or legal guardian, not the child. This legal framework recognizes that minor children, particularly young children, may lack the cognitive and emotional maturity to understand and weigh the information needed for truly autonomous healthcare decision-making. Parents and legal guardians are presumed to act in their child's best interests, and the law accordingly vests them with the authority to make healthcare decisions on the child's behalf until the child reaches the age of majority.

For physical therapy practitioners, this framework creates clear baseline obligations. Before initiating evaluation or treatment with a minor patient, the practitioner must ensure that informed consent has been obtained from a parent or legal guardian with legal authority to provide it. This requires attention to situations where parental authority may be divided or contested — including divorce or separation, cases involving foster care or state guardianship, situations in which a non-custodial parent presents for a child's care, and cases in which the child's legal guardian is someone other than a biological parent. Proceeding with care based on the authorization of someone who lacks legal authority to provide it is both a legal vulnerability and an ethical failure, and practitioners should establish clear intake procedures that identify the appropriate authorizing adult before care begins.

Practitioners in Illinois should be aware that the state's legal framework governing minor consent and parental authority has specific provisions that can affect clinical practice. While parents and legal guardians retain general authority over their minor children's healthcare decisions, Illinois law recognizes certain circumstances in which minors may consent to specific categories of care without parental involvement — provisions that are most relevant in contexts involving reproductive health, substance abuse treatment, and mental health services. Physical therapists working in settings where these provisions may be relevant should familiarize themselves with the applicable Illinois statutes and consult legal or compliance resources when questions arise about the appropriate consent framework for a specific patient.

The Ethical Obligation of Assent

While parental permission is legally required for the treatment of minor patients, the ethical obligations of physical therapy practitioners extend beyond the legal minimum. The principles of autonomy and respect for persons do not simply disappear when the patient is a child; they are applied in a developmentally appropriate way that honors the child's emerging capacity for self-determination and includes the child as a participant in decisions about their own care to the fullest extent permitted by their developmental stage. This ethical practice is captured in the concept of assent — the child's affirmative agreement to participate in evaluation and treatment, obtained separately from and in addition to parental permission.

Assent is not a legal requirement in the same sense as parental permission, and the appropriate form and weight of assent vary considerably with the child's age, developmental stage, and cognitive capacity. A four-year-old cannot be expected to engage with the same depth of informed participation as a fourteen-year-old, and the practitioner's obligations are calibrated accordingly. For younger children, assent may take the form of the practitioner's attentiveness to the child's comfort, willingness to engage, and behavioral cues of distress — a recognition that the child's experience of the therapeutic encounter matters and deserves respect even when formal consent is beyond the child's developmental reach. For older children and adolescents approaching the age of majority, assent approaches the character of genuine informed consent, with a corresponding obligation to ensure that the young person has received age-appropriate information about their condition, the proposed treatment, and what they can expect.

The ethical significance of assent in physical therapy practice is grounded in Commitment 1 of the Code of Ethics for the Physical Therapy Profession, which requires practitioners to respect the inherent dignity and rights of all individuals. Children are individuals. They have interests, preferences, and experiences of their own, not simply extensions of their parents'. A practitioner who proceeds with a treatment technique that visibly distresses a child, even with the parent's consent, without taking any steps to explain the technique to the child, modify the approach, or attend to the child's experience, has complied with the legal requirement of consent while failing the ethical obligation of respect. Conversely, a practitioner who takes the time to explain a procedure to a ten-year-old in age-appropriate language, answer the child's questions, and incorporate the child's feedback into the therapeutic approach is honoring the child's emerging autonomy, thereby strengthening the therapeutic relationship and supporting better clinical outcomes.

Ongoing Informed Consent and Assent

The 2026 Code of Ethics for the Physical Therapy Profession emphasizes the ongoing nature of the informed consent requirement. The obligation to revisit and renew consent as treatment evolves, as new interventions are introduced, and as the patient's understanding, condition, and goals change over time. In pediatric practice, this ongoing obligation has a distinctive character. Children grow and develop over the course of a treatment episode, and a child who was too young to participate meaningfully in consent discussions at the outset of care may have developed sufficient capacity to be meaningfully involved in decisions about continuing or modifying treatment by the time those decisions need to be made. Practitioners should periodically reassess the child's capacity for assent and adjust their communication and involvement practices accordingly, recognizing that honoring the child's growing autonomy is itself a goal of ethical pediatric practice.

Confidentiality and Its Limits in Pediatric Practice

The Complexity of Confidentiality with Minor Patients

Confidentiality in adult physical therapy practice, while subject to specific exceptions, follows a relatively straightforward framework: the patient's health information belongs to the patient, is shared with other providers as necessary for treatment, and is protected from disclosure to third parties without the patient's authorization. In pediatric practice, this framework is complicated by the fact that the patient is a minor and that the legal authority over the child's healthcare (including the authority to authorize disclosure of health information) rests primarily with the parent or legal guardian rather than with the child.

Under HIPAA and Illinois law, parents and legal guardians of minor children generally have the right to access their child's protected health information and to make decisions about its disclosure. This means that a parent who requests information about their child's physical therapy evaluation or progress notes is ordinarily entitled to receive it — the practitioner cannot withhold the child's health information from the authorizing parent on the grounds that the child would prefer it not to be shared. For most pediatric physical therapy encounters, this framework presents no particular ethical difficulty. Parents are appropriately involved in their children's care, and open communication of clinical information among the child, family, and care team serves the child's best interests.

The ethical complexity arises in situations that fall outside this ordinary framework. As children approach adolescence, they may share information with their physical therapist, such as their home environment, their emotional state, concerns about their family, or experiences that may be relevant to their physical presentation, that they have not shared with their parents and do not wish their parents to know. The practitioner who receives this information faces a genuine ethical tension: the legal authority to authorize disclosure generally rests with the parent, but disclosing the information over the child's expressed objection may damage the therapeutic relationship, undermine the child's trust, and discourage the open communication that effective pediatric care depends upon.

Navigating this tension requires careful clinical and ethical judgment. Practitioners who work with older children and adolescents would do well to address expectations about confidentiality explicitly — in age-appropriate language — at the outset of the therapeutic relationship, explaining both what information will be shared with parents and caregivers as a routine matter of care coordination, and the circumstances under which information shared in confidence might need to be disclosed. This transparent, proactive communication about the limits and purposes of confidentiality is itself an expression of the veracity and respect for the child's developing autonomy that ethical pediatric practice requires.

Confidentiality, Non-Legal Guardians, and Information Requests

A practical confidentiality challenge that arises with particular frequency in pediatric physical therapy involves requests for information from individuals who are not the child's legal guardian. Extended family members, stepparents who are not legal guardians, coaches, teachers, and family friends may all have genuine care and concern for a child patient, and may present what seem like reasonable requests for information about the child's condition and progress. Practitioners must respond to these requests with clarity and consistency: protected health information about a minor patient may not be disclosed to individuals who lack legal authority to receive it, regardless of their relationship to the child, their apparent care and concern, or the benign nature of their intentions.

This principle requires particular vigilance in cases where parents are separated or divorced, and custodial arrangements are contested. A non-custodial parent who lacks legal authority over the child's healthcare decisions may nonetheless seek information about the child's physical therapy, sometimes as part of a larger family conflict in which the child's medical care has become a point of contention. Practitioners should ensure that their intake and records management procedures clearly identify who holds legal authority to access and authorize disclosure of the child's health information, and should consult their organization's legal or compliance resources when questions about parental authority arise in the context of family conflict.

Navigating the Parent-Child-Therapist Triad

When Parental Goals and the Child's Best Interests Diverge

The most ethically complex situations in pediatric physical therapy arise not from straightforward violations of legal standards but from the more ambiguous territory where parental authority intersects with and sometimes conflicts with the child's best interests. Parents are presumed to act in their children's best interests, and in the vast majority of cases, that presumption holds. But practitioners who work with children long enough will encounter situations in which parental goals for a child's rehabilitation diverge in meaningful ways from what the practitioner's clinical judgment identifies as the child's best interest or from the child's own expressed preferences.

These divergences can take several forms. Parents may push for more intensive rehabilitation than the child's clinical presentation supports, driven by anxiety about their child's prognosis, competitive pressure in athletic or academic contexts, or unrealistic expectations about what physical therapy can achieve. Parents may resist or discontinue treatment that the practitioner believes is clinically necessary, citing inconvenience, cost, distrust of the healthcare system, or philosophical preferences about medical intervention. Parents may prioritize goals for their child's rehabilitation — maximizing competitive athletic performance, for example — that the practitioner believes conflict with the child's long-term physical well-being. And in some cases, parents may make decisions about their child's care that raise concerns not merely about clinical judgment but about the child's safety and welfare.

Commitment 2 of the Code of Ethics for the Physical Therapy Profession establishes the obligation of the physical therapist to remain the practitioner of record responsible for all physical therapy services delivered under their license. Commitment 5 calls for compassionate, patient-centered communication and care. Commitment 8 requires practitioners to maintain and advance their professional knowledge and skills. Together, these commitments establish that the practitioner who provides what a parent requests, over their own clinical judgment about what the child needs, has not merely deferred to parental authority — they have failed their professional obligation to the child who is their patient. Navigating this tension requires the kind of honest, respectful communication about clinical reasoning and realistic goals that ethical pediatric practice consistently demands: explaining clearly what the evidence supports, what the practitioner's clinical assessment indicates, and what the consequences of different approaches are likely to be, while genuinely respecting the parent's ultimate legal authority to make decisions about their child's care.

Adherence, Engagement, and the Limits of Parental Authority

A persistent practical challenge in pediatric physical therapy is families' nonadherence to home exercise programs, attendance expectations, and the ongoing care requirements that effective rehabilitation depends on. When families fail to attend scheduled appointments, do not follow through with home programs, or discontinue care prematurely, practitioners face both clinical and ethical questions: What are the consequences of this non-adherence for the child's outcomes? What obligations does the practitioner have when a family's choices appear to compromise the child's rehabilitation progress? And at what point does a pattern of care neglect rise to the level of a concern that warrants more formal intervention?

These questions require careful, non-judgmental clinical and ethical analysis. Non-adherence to physical therapy recommendations can reflect a wide range of circumstances — financial constraints, transportation barriers, competing family demands, parental skepticism about the treatment's value, the child's own resistance to therapy, or cultural differences in how rehabilitation and recovery are understood. Before interpreting non-adherence as a failure of parental concern or responsibility, practitioners should make genuine efforts to understand its underlying causes and address them through flexible scheduling, simplified home programs, motivational strategies that engage the child directly, and clear communication about the clinical significance of the recommended care.

When non-adherence is persistent, and the practitioner has genuine concerns about the impact on the child's health and well-being, the ethical obligation is to document those concerns clearly, communicate them honestly and compassionately to the family, and involve other members of the care team — including the referring physician, a social worker, or other relevant professionals — as appropriate. Illinois practitioners should be aware that severe or persistent medical neglect of a child — including consistent failure to obtain medically necessary treatment — may meet the threshold for mandatory reporting under the Abused and Neglected Child Reporting Act. Determining whether a particular pattern of care non-adherence constitutes medical neglect requires careful clinical judgment and, when uncertain, consultation with supervisors, legal counsel, or the relevant child protective services authority.

Paternalism and the Child's Voice

A specific form of paternalism warrants particular attention in pediatric practice: the tendency to treat the child's own voice as irrelevant to clinical decision-making, given that legal authority rests with the parent. The ethical and clinical literature on pediatric practice consistently affirms that children's expressed preferences about their care, including their preferences about specific therapeutic activities, their communication about pain and discomfort, and their goals for what they hope to achieve through rehabilitation, are clinically and ethically significant and should be incorporated into the treatment approach to the fullest extent their developmental stage permits.

A practitioner who consistently ignores a child's expressed distress, pushes through resistance without explanation or modification, or makes clinical decisions entirely on the basis of parental preferences without any reference to the child's own experience is practicing a form of age-based paternalism that violates the commitment to respect the inherent dignity and rights of all individuals that Commitment 1 requires. Children who feel that their experience and preferences are genuinely respected by their therapist, who are treated as active participants in their own rehabilitation rather than passive subjects of parental authority and clinical intervention, are more engaged, more motivated, and more likely to achieve the rehabilitation goals for which they were referred. The ethical and the clinical case for attending to the child's voice point in precisely the same direction.

Mandatory Reporting: Child Abuse and Neglect

The Physical Therapist as Mandatory Reporter in Illinois

Physical therapists and physical therapist assistants in Illinois are mandatory reporters under the Abused and Neglected Child Reporting Act (ANCRA); a legal obligation that is also an ethical commitment explicitly recognized in Commitment 2, Standard 2.5 of the 2026 Code of Ethics for the Physical Therapy Profession. The obligation to report reasonable suspicion of child abuse or neglect to the Illinois Department of Children and Family Services (DCFS) is not discretionary. It does not require proof that abuse or neglect has occurred — it requires only that the practitioner has reasonable cause to believe that a child may be suffering from abuse or neglect. Once that threshold is met, the obligation to report is mandatory and immediate.

This mandatory reporting obligation reflects the profession's recognition that physical therapy practitioners are uniquely positioned to observe signs of child abuse and neglect. The hands-on, body-focused nature of physical therapy assessment means that practitioners frequently observe children's bodies directly, including examining range of motion, assessing skin integrity, observing movement patterns, and palpating soft tissue in ways that may reveal physical evidence of abuse that is not visible through clothing or routine observation. The sustained therapeutic relationship that develops over the course of a treatment episode gives practitioners the relational access to observe behavioral indicators of abuse such as fearfulness, withdrawal, regression, unexplained changes in behavior or affect that may not be apparent to providers who see the child only briefly.

Recognizing Signs of Child Abuse and Neglect

Physical therapy practitioners should be familiar with the clinical presentation of child abuse and neglect across the forms in which it may present.

Physical abuse may present as bruising, burns, fractures, or other injuries that are inconsistent with the child's developmental stage, inconsistent with the reported mechanism of injury, or located in anatomical regions not typically injured in accidental falls or play. Patterned injuries — bruising or burns in the shape of an object, for example — are particularly significant indicators. Injuries in various stages of healing, suggesting repeated trauma, and delays between the reported time of injury and the seeking of medical care are also clinically significant.

Neglect — the most prevalent form of child maltreatment — may present as failure to thrive, persistent poor hygiene, inadequate clothing or nutrition, untreated medical or dental conditions, or evidence that a child's basic developmental and healthcare needs are not being met. In the physical therapy context, neglect may present as a child whose assistive device has been allowed to fall into disrepair, whose home exercise program is persistently not followed despite adequate parental instruction and capacity, or whose medical needs identified in the therapy evaluation are not being addressed by the family.

Emotional abuse and sexual abuse may present with behavioral rather than physical indicators — withdrawal, regression, excessive fearfulness, age-inappropriate sexual behavior or knowledge, reluctance to be touched in specific anatomical regions, or unexplained changes in behavior, mood, or school performance. Physical therapists who work with children regularly should be familiar with the behavioral indicators of child maltreatment and should take unexplained behavioral changes seriously as clinical and ethical signals that warrant attention.

The Reporting Process in Illinois

In Illinois, mandatory reports of suspected child abuse or neglect are made to the Illinois DCFS by calling the DCFS Child Abuse Hotline at 1-800-25-ABUSE (1-800-252-2873). Reports may be made by phone, and DCFS is available twenty-four hours a day, seven days a week. The practitioner making the report is not required to have proof that abuse or neglect has occurred — only reasonable cause to believe that a child may be an abused or neglected child as defined by ANCRA. The investigation of that suspicion is DCFS's responsibility; the practitioner's responsibility is to report it promptly.

Many physical therapy organizations have established internal policies requiring practitioners to notify a supervisor or compliance officer when making a mandatory report to DCFS. Practitioners should be familiar with their organization's reporting procedures — but they should also understand that compliance with organizational procedures does not supersede or replace the individual practitioner's mandatory reporting obligation. If a supervisor advises against making a report that the practitioner has reasonable cause to believe is warranted, the practitioner's obligation to report to DCFS remains intact regardless of that advice. Failure to report is itself a violation of both Illinois law and the enforceable standards of the 2026 Code.

Navigating the Emotional and Relational Dimensions of Mandatory Reporting

Practitioners who encounter suspected child abuse or neglect for the first time often find the experience emotionally and professionally challenging in ways that ethics training does not fully prepare them for. The decision to make a mandatory report, particularly when the family is engaged, the parents appear caring, or the evidence of abuse is ambiguous, can feel uncertain, frightening, and potentially destructive of a therapeutic relationship that has been carefully built. These emotional realities are understandable and deserve acknowledgment. They, however, do not alter the practitioner's obligation.

Several principles can help practitioners navigate the emotional and relational dimensions of mandatory reporting with integrity. First, the standard for reporting is reasonable suspicion, not certainty — practitioners who wait for proof before reporting have already delayed beyond the point at which the law requires action. Second, the practitioner's role is to report suspicion and provide the clinical observations that gave rise to it; the determination of whether abuse has actually occurred belongs to the investigative authority, not the practitioner. Third, a good-faith report made on the basis of reasonable clinical concern does not constitute a breach of confidentiality or a violation of the therapeutic relationship — it is an expression of the fundamental obligation to protect a vulnerable patient from harm. And fourth, practitioners who are uncertain whether their observations meet the threshold for reporting should consult with their supervisor, their organization's legal or compliance resources, or DCFS directly — the Hotline can provide guidance on whether a particular set of observations warrants a formal report.

Ethical Issues in School-Based and Early Intervention Practice

The IEP and 504 Process: Ethics at the Intersection of Education and Healthcare

A significant proportion of pediatric physical therapy in the United States is delivered in school-based settings under the Individuals with Disabilities Education Act (IDEA) or Section 504 of the Rehabilitation Act. Physical therapists practicing in these settings operate within an institutional and legal framework that is fundamentally different from the clinical healthcare framework that governs most physical therapy practice — one in which the primary goal of intervention is not health restoration or rehabilitation in the clinical sense but the student's access to educational benefit in the least restrictive environment. Understanding this distinction and its ethical implications is essential for practitioners working in school-based settings.

In school-based practice, the PT's role is defined by the student's Individualized Education Program (IEP) or 504 plan, which is developed through a collaborative process involving the student's parents, educational professionals, and relevant service providers. The ethical obligations of school-based physical therapists include meaningful participation in this collaborative process, contributing clinical expertise and functional assessment data that genuinely inform the student's educational goals, and honest communication about the relationship between physical therapy services and educational outcomes. A practitioner who recommends physical therapy services that exceed what is necessary for the student's educational access, or who allows the IEP process to result in a service plan that is inadequate to meet the student's identified needs, has failed the ethical obligations of honest communication and advocacy that school-based practice requires.

Parents who participate in the IEP process bring their own expectations, concerns, and goals, which may not always align with the educational team's assessment. Practitioners who work in school-based settings regularly navigate the tension between parental advocacy for more intensive or specialized services beyond what the educational framework may provide and the institution's obligation to offer services appropriate to educational needs rather than optimal from a clinical perspective. Honest, compassionate communication about this distinction, explaining clearly what school-based physical therapy can and cannot provide, and how the educational framework shapes the services available through the IEP, is both ethically required and practically important for maintaining trust with families who may be frustrated by the limits of what the educational system offers.

Early Intervention and the Ethical Obligations of Family-Centered Practice

Physical therapy services delivered through the Illinois Early Intervention (EI) Program operate within a framework that emphasizes family-centered practice—an approach that recognizes the family, not the individual child, as the primary unit of intervention in the earliest years of life. The EI framework reflects the research evidence that intervention outcomes for very young children with developmental delays or disabilities are powerfully shaped by the quality of family interactions and the family's capacity to support the child's development in everyday routines and environments.

The ethical implications of family-centered EI practice are significant. When the family is the unit of intervention, the practitioner's obligations extend beyond the child to encompass the family's capacity, needs, and well-being—a scope of responsibility that requires careful ethical navigation. Practitioners must respect the family's cultural values, parenting beliefs, and personal priorities as central features of the intervention context, not as obstacles to be overcome in the service of clinical goals. At the same time, the child's developmental needs and best interests remain the ultimate purpose of the intervention, and practitioners have a responsibility to advocate for those needs even when they may conflict with family preferences.

Honest communication with families in EI practice requires a particular kind of compassion and sensitivity. Parents of very young children with developmental delays or disabilities are often navigating profound emotional experiences — grief, fear, uncertainty about their child's future — that shape their capacity to receive and process clinical information. The veracity obligation that Commitment 5 requires does not mean delivering difficult information about a child's developmental status without regard for the emotional context in which it will be received. It means finding ways to communicate honestly and accurately that honor both the truth of the clinical findings and the emotional reality of the family's experience — a balance that is at the heart of ethical family-centered practice.

Resource Allocation and Advocacy for Pediatric Patients

Insurance Limitations and the Ethics of Pediatric Rehabilitation Access

Physical therapy practitioners working with children regularly encounter resource allocation challenges that raise significant ethical questions. Insurance coverage for pediatric rehabilitation services varies enormously across payers, and the gaps between what children clinically need and what their insurance will authorize are often stark. Visit limits, medical-necessity criteria that do not adequately reflect the nature of pediatric rehabilitation, and authorization processes that create barriers to timely access to care are features of the payer landscape that pediatric physical therapy practitioners must navigate on behalf of their patients.

The ethical dimensions of these resource allocation challenges are grounded in the principle of justice and in Commitment 9 of the 2026 Code, which calls on practitioners to participate in efforts to meet the health needs of people locally, nationally, and globally and to address societal needs related to physical therapy access and health equity. Children who lack adequate access to physical therapy services because of insurance limitations, geographic barriers, or socioeconomic constraints are experiencing an inequity that the profession has an obligation to take seriously — not merely as a background condition to be accepted, but as a problem that practitioners, through their individual advocacy and their collective professional voice, can and should work to address.

At the individual practice level, advocacy for pediatric patients with inadequate insurance coverage may take the form of thorough, evidence-based documentation of medical necessity; active participation in the appeals process when services are denied; communication with referring physicians and other members of the care team to ensure that insurance authorization efforts are coordinated and well-supported; and honest communication with families about their options when insurance coverage is insufficient. At the organizational and systemic level, advocacy may involve contributing to professional association efforts to improve payer policies for pediatric rehabilitation, participating in public comment processes on regulatory and coverage policy, and supporting legislative initiatives that expand access to early intervention and rehabilitation services for children with disabilities.

The Ethics of Advocacy in Pediatric Practice

Advocacy for pediatric patients — speaking up on behalf of children who cannot fully advocate for themselves within complex healthcare and educational systems is not merely an optional expression of professional commitment. It is an ethical obligation grounded in the foundational principle of beneficence, in Commitment 9's call for societal responsibility, and in the particular vulnerability of children as a patient population. Children who come to physical therapy with developmental disabilities, chronic conditions, or injuries that require ongoing rehabilitation are, by definition, among the most vulnerable members of the community's physical therapy services. They depend on the adults in their lives, including their physical therapists, to understand the systems that affect their access to care and to speak up when those systems are failing them.

Advocacy in pediatric practice takes many forms: communicating clinical findings clearly and compellingly in documentation that supports insurance authorization; participating actively in IEP and 504 processes to ensure that a student's physical therapy needs are accurately represented; educating families about their rights and the resources available to them; and contributing to the profession's collective advocacy efforts on behalf of the children and families that pediatric physical therapy serves. Each of these forms of advocacy is an expression of the values (beneficence, justice, compassion, and social responsibility) that the 2026 Code of Ethics for the Physical Therapy Profession calls all physical therapy professionals to embody throughout their careers.

The Code's Commitments in Pediatric Practice

The ethical challenges of pediatric physical therapy practice engage multiple commitments of the new Code simultaneously, and the intersection of those commitments in this practice context illustrates how the Code functions as an integrated ethical framework rather than a collection of independent obligations.

Commitment 1 — Respect establishes the foundational obligation to honor the dignity and rights of all individuals — including children whose developmental stage may limit their capacity for self-advocacy but does not diminish their inherent worth or the validity of their own experience, preferences, and voice. The explicit acknowledgment of implicit bias in Commitment 1's aspirational provisions is particularly relevant in pediatric practice, where biases about children's capacity for meaningful participation in their own care can subtly undermine the quality and equity of the services they receive.

Commitment 2 — Integrity establishes both the mandatory reporting obligations that protect children from abuse and neglect — anchored in ANCRA for Illinois practitioners — and the broader obligation to address known illegal or unethical acts encountered in the clinical environment. The explicit elevation of mandatory reporting to an enforceable standard of the Code positions child protection not merely as a legal compliance matter but as a core expression of professional integrity.

Commitment 5 — Compassion and Trust calls practitioners to provide the kind of genuinely patient-centered — and in pediatric practice, family-centered — communication and care that the therapeutic triad of child, parent, and therapist requires. This means honest communication about clinical findings and realistic goals; compassionate attention to the emotional experience of families navigating their child's rehabilitation; and consistent attentiveness to the child's own voice, experience, and emerging capacity for self-determination.

Commitment 9 — Societal Responsibility frames the advocacy obligations that inequities in pediatric rehabilitation access create: the obligation not merely to provide good individual care within the constraints of the current system but to work, through the collective voice and individual advocacy of the profession, toward a system that serves children and families more equitably and more fully. Every child who needs physical therapy and cannot access it because of system failures represents an unmet obligation of justice that the profession, through its members, has an ongoing responsibility to address.

Together, these commitments describe a vision of pediatric physical therapy practice that is developmentally informed, relationally attentive, ethically grounded, and socially engaged — a vision that honors the full humanity of every child patient and takes seriously the obligations the profession has accepted in their service.

Part VIII: Analyzing Ethical Dilemmas — The RIPS Model

Introduction to the RIPS Model

Why Structured Ethical Decision-Making Matters

Throughout this course, we have examined the principles, commitments, theories, and emerging issues that define the ethical landscape of physical therapy practice. What we have not yet addressed directly is the question of process — how a practitioner actually moves from recognizing an ethical challenge to making a defensible decision about how to respond.

This is the function of a structured ethical decision-making model, and it is the function that the Realm-Individual Process-Situation (RIPS) Model of Ethical Decision-Making was specifically designed to serve in the context of physical therapy and health professions practice. Developed by Swisher, Arslanian, and Davis (2005), the RIPS Model provides a systematic framework that guides practitioners through the analysis of ethical situations in a way that is both comprehensive and practically applicable — one that organizes the complexity of real clinical ethical challenges without reducing that complexity to a false simplicity.

The value of a structured model lies not in the provision of predetermined answers, but in the discipline it imposes on the reasoning process. Unstructured ethical reasoning is vulnerable to a range of cognitive and emotional distortions — the tendency to focus on the most emotionally salient features of a situation, the pull toward the first defensible option rather than the most defensible one, and the risk of allowing personal discomfort, institutional pressure, or interpersonal loyalty to substitute for genuine ethical analysis.

Alignment with the New APTA Code

The RIPS Model aligns naturally with the ethical framework established by the Code of Ethics for the Physical Therapy Profession. The Code's recognition that ethical obligations operate simultaneously at the individual, organizational, and societal levels maps directly onto the RIPS Model's Realm component. The Code's consistent emphasis on ethical judgment rather than prescribed responses reflects the same orientation that structured ethical decision-making models are designed to support.

The Four Components of the RIPS Model

Component One: Realm — Identifying the Domain of the Ethical Situation

The first step in the RIPS framework is to identify the realm — the domain or level at which the ethical situation is primarily occurring. This step shapes the kinds of responses available, who the relevant stakeholders are, and which ethical principles apply with the greatest force.

The Individual Realm encompasses the personal and relational dimensions of practice — the patient or client, the physical therapist, the PTA, the patient's family members, and the direct therapeutic relationship. Ethical situations in the individual realm typically involve questions of informed consent, patient autonomy, privacy, communication, and the management of the therapeutic relationship.

The Organizational or Institutional Realm encompasses the policies, structures, and practices of the healthcare organizations and practice settings within which physical therapy is delivered. Ethical situations here involve questions of billing practices, productivity standards, supervision policies, resource allocation, and the alignment — or misalignment — between organizational norms and professional ethical standards.

The Societal Realm encompasses the broader social, political, and systemic dimensions of healthcare delivery — health policy, equitable access to care, the social determinants of health, and the profession's collective obligations to the public it serves. The practitioner's obligations in this realm are captured most explicitly in Commitment 9 of the new Code and in the foundational principle of justice.

Most complex ethical situations in physical therapy involve multiple realms simultaneously. Identifying all relevant realms, rather than defaulting to the most immediately obvious one, ensures a more complete analysis of what is at stake.

Component Two: Individual Process — Moral Development and Ethical Readiness

The second component directs attention to the practitioner themselves — specifically to where they are in their moral development and what capacities they bring to the ethical situation. This component draws on the moral development framework articulated by James Rest, which identifies four psychological processes that must occur in sequence for ethical action to result.

Moral Sensitivity is the perceptual capacity to recognize that an ethical issue exists — to notice the morally relevant features of a clinical or professional encounter. A practitioner who lacks moral sensitivity may encounter ethical challenges without recognizing them as such.

Moral Judgment is the reasoning capacity to determine what the right course of action is — to apply ethical principles, professional standards, and contextual understanding to the specific features of the situation and arrive at a defensible conclusion.

Moral Motivation is the capacity to prioritize ethical values over competing personal, institutional, or relational interests. Even a practitioner who has recognized an ethical issue and determined the right course of action may be pulled away from ethical action by fear of professional consequences, loyalty to a colleague, or economic self-interest.

Moral Courage is the capacity to implement ethical action despite the risks — to speak up, report a concern, advocate for a patient, or refuse to participate in unethical conduct even when doing so carries real professional or personal costs.

Component Three: Situation — Classifying the Type of Ethical Challenge

The third component involves classifying the specific type of ethical situation the practitioner is facing. The RIPS Model identifies four primary situation types.

Ethical Distress occurs when a practitioner knows the right course of action but is constrained from taking it by institutional, systemic, or interpersonal barriers. The challenge is not reasoning toward the right answer — the practitioner already knows what that is — but finding the means and the courage to act on it, or to address the constraints that prevent action.

Ethical Dilemmas arise when two or more courses of action are each ethically justifiable — when genuine competing obligations point in different directions and no clearly superior option is apparent. Dilemmas require careful analytical reasoning — the application of ethical frameworks, the weighing of principles, the consideration of all stakeholders and consequences.

Ethical Temptation occurs when a practitioner faces a situation in which an unethical course of action offers personal benefit — financial gain, convenience, the avoidance of an uncomfortable conversation — and is tempted to pursue it despite knowing it is wrong.

Ethical Silence occurs when a practitioner is aware of an ethical issue — whether in their own practice or in the conduct of a colleague, supervisor, or organization — and fails to speak up or take action. Ethical silence is not merely the absence of action; it is itself a form of ethical conduct with real consequences for patients, for colleagues, and for the integrity of the profession.

Resolving Ethical Dilemmas: Kidder's Three Approaches

Once the type of ethical situation has been classified in Component Three, the next analytical task — before moving to Component Four's action steps — is determining how to resolve a genuine ethical dilemma. This analysis applies specifically to "right versus right" situations and is not needed when the situation is one of right versus wrong, where the correct course of action is already clear and the challenge is implementation rather than decision. For true dilemmas, Swisher and colleagues draw on the work of ethicist Rushworth Kidder, who identifies three basic approaches to resolving competing obligations. The rule-based approach focuses on following established rules, duties, obligations, and ethical principles regardless of outcome — consistent with deontological reasoning. The ends-based approach focuses on consequences, asking which course of action produces the greatest good for the greatest number of stakeholders — consistent with consequentialist reasoning. The care-based approach resolves dilemmas through the lens of relationships and concern for others, captured simply in the Golden Rule: doing unto others as you would have them do unto you. No single approach is universally superior, and skilled ethical reasoners consider the insights and limitations of each. Importantly, if any of the following tests confirms that a situation is actually right versus wrong rather than a true dilemma — the legal test, the "stench" test, the front-page test, the "mom" test, or the professional ethics test — the practitioner should bypass Step 3 entirely and proceed directly to implementation.

Component Four: Action — Steps Toward Resolution

The fourth component involves a structured process of moving from analysis to decision and from decision to implementation, through six sequential steps:

1. Gathering relevant facts — ensuring that the practitioner's understanding of the situation is as complete and accurate as possible before proceeding to analysis and decision.
2. Identifying stakeholders — all individuals, groups, and institutions with a legitimate interest in the outcome, including those whose interests may not be immediately apparent.
3. Applying ethical principles and the Code of Ethics — bringing the analytical frameworks and professional standards to bear on the specific features of the situation.
4. Considering options and consequences — identifying the full range of available responses and reasoning through the likely consequences of each, including consequences for all identified stakeholders and across all relevant realms.
5. Choosing and implementing a course of action — making a decision and taking the concrete steps necessary to carry it out; this step requires moral motivation and moral courage.
6. Reflecting and evaluating outcomes — examining the results of the chosen course of action and incorporating the learning from this specific situation into the practitioner's ongoing ethical development.

Applying the RIPS Model: Step-by-Step Walkthrough

Sample Scenario: A PTA working in an outpatient orthopedic clinic is treating a post-surgical knee patient. During a session, the patient discloses that she has been taking considerably more of her prescribed pain medication than directed because her pain is not well controlled and she has not been able to reach her surgeon. She asks the PTA not to tell anyone because she is embarrassed and fears being judged.

Realm: The situation has its most immediate dimensions in the individual realm — it involves a specific patient, a specific PTA, and a direct therapeutic relationship. However, it also has organizational dimensions, insofar as the clinic's communication systems and referral protocols will shape the options available to the PTA.

Individual Process: The PTA has demonstrated moral sensitivity — she has recognized that this disclosure raises ethical concerns. Her uncertainty suggests she is in the process of forming moral judgment. The patient's explicit request for confidentiality creates a moral motivation challenge — the PTA must prioritize patient safety over the desire to honor a request that conflicts with the patient's best interests and the PTA's professional obligations.

Situation: This situation is best classified as an ethical dilemma. There are genuine competing obligations at play: the obligation to respect the patient's autonomy and privacy on one hand, and the obligation of beneficence and nonmaleficence on the other.

Action: Gathering relevant facts involves clarifying the nature of the patient's medication use. Identifying stakeholders includes the patient, the PTA, the supervising PT, and the prescribing surgeon. Applying ethical principles reveals that while autonomy supports honoring the patient's request, nonmaleficence, beneficence, and the PTA's professional obligation to communicate patient status changes to the supervising PT all support disclosure to the supervising PT — which is itself a professional requirement rather than a discretionary choice. Considering options makes it clear that complete confidentiality is not available to a PTA who is aware of a clinically significant patient safety concern. Choosing and implementing a course of action means the PTA promptly communicates the patient's disclosure to the supervising PT, explains to the patient why this communication is necessary and how it will be handled, and documents the disclosure and action taken. Reflecting and evaluating includes considering how the conversation with the patient was handled and what this situation reveals about the importance of establishing clear communication expectations early in the therapeutic relationship.

Case Studies Using the RIPS Model

Case Study 1: Supervision and Delegation

The Scenario. A physical therapist working in an outpatient neurological rehabilitation clinic assigns a PTA to treat a patient with a complex neurological condition involving significant spasticity, cognitive impairment, and a recent history of falls. The PTA, who has primarily worked in orthopedic settings and has limited experience with neurological patients, privately believes that the patient's needs exceed her current skill level. When she expresses this concern to the clinic director — who is not a physical therapist — she is told that the schedule is full, the PT is unavailable, and she should proceed with the patient.

Identifying the Ethical Issues, Realm, and Situation Type. The ethical issues are multiple: a question of clinical competence and patient safety; a question of appropriate supervision (is the supervising PT fulfilling their Commitment 7 obligation?); and a question of moral courage when institutional pressure conflicts with professional judgment.

The realm analysis reveals that this situation spans the individual and organizational realms. The situation type is primarily ethical distress — the PTA does not appear uncertain about what the right course of action is. She has correctly recognized that proceeding with a patient whose needs exceed her competence creates patient safety risk. The problem is that she has been pressured by institutional authority to ignore that judgment.

Applicable Ethical Commitments. Commitment 3 — Accountability requires practitioners to practice within their scope and competence. Commitment 7 — Direction and Supervision establishes that the supervising PT retains responsibility for ensuring delegated care falls within the PTA's competence, and that a non-PT clinic director has inappropriately intervened in a clinical staffing decision. Commitment 2 — Integrity applies through the obligation to address known ethical violations.

Applying the RIPS Model. Gathering relevant facts requires the PTA to assess and articulate specifically the nature of her competence concerns — and to confirm whether the supervising PT has actually been informed of her concerns, or only the clinic director. The most defensible option is direct communication with the supervising PT before the scheduled treatment session. Implementing this course requires the moral courage to assert professional judgment in the face of institutional pressure and to contact the supervising PT directly rather than accepting the clinic director's representation as the final word. Reflecting on outcomes includes examining the systemic question of whether the clinic's supervision arrangements are adequate — which may warrant follow-up documentation or reporting to the relevant licensing authority if the pattern persists.

Case Study 2: Billing Fraud

The Scenario. A physical therapist at an outpatient practice begins to notice that multiple patients scheduled for individual physical therapy sessions are consistently treated simultaneously in groups of four or five, but billing submitted to insurance consistently uses individual therapy codes rather than group therapy codes. The PT raises the issue informally with her supervisor, who dismisses her concern.

Ethical and Legal Obligations. This scenario involves systematic billing fraud — one of the most clear-cut categories of healthcare fraud. This is not an ambiguous billing question. It is a systematic misrepresentation to payers — including Medicare and Medicaid — that constitutes fraud under both civil and criminal healthcare fraud statutes. Commitment 2's enforceable standards require practitioners to address known illegal or unethical acts. Commitment 6's enforceable standards prohibit participation in false, deceptive, or misleading billing practices. The fact that the PT is not the person submitting the fraudulent claims does not extinguish her ethical obligation.

Applying the RIPS Model. The realm analysis identifies this as primarily an organizational realm situation with significant societal dimensions. The situation type is best classified as ethical distress combined with ethical silence: the PT likely knows what the right course of action is, but interpersonal loyalty and fear of consequences have combined to prevent her from acting.

Gathering relevant facts involves the PT documenting specific observations — dates, treatment configurations, billing codes submitted — factually and completely. Considering options reveals several available paths: escalating internally in writing to the practice owner or through any compliance reporting mechanism; consulting with a healthcare attorney about obligations and protections under the False Claims Act; filing a report with the relevant payer, the OIG, or the state licensing board. The option of continuing to do nothing is no longer ethically available, given the pattern of observations. The moral courage required is substantial, and the PT should seek legal counsel and peer support as she navigates it.

Case Study 3: HIPAA and Social Media

The Scenario. A physical therapist posts a photograph on Instagram showing the clinic gym following a busy treatment day. Upon closer review, a colleague notices that a patient is visible in the background and identifiable—the patient's face is clearly visible, and the patient has a distinctive assistive device. The PT did not obtain written authorization, and the post has been publicly visible for three days.

HIPAA and Ethical Principles Implicated. The photograph contains PHI — the patient's image in a healthcare setting, combined with visual information about their use of an assistive device, constitutes individually identifiable health information. The absence of written authorization is determinative. HIPAA does not distinguish between deliberate and inadvertent disclosure of PHI. Aspiration 5. B of the new Code explicitly calls on practitioners to maintain respectful, accurate, and truthful communication on social media.

Corrective Actions. The RIPS Model's action phase begins with immediate steps to limit ongoing harm. The photograph should be removed from Instagram immediately. The PT should notify her organization's privacy officer or HIPAA compliance officer promptly, as the organization has legal obligations under HIPAA's Breach Notification Rule. The PT should also make direct contact with the patient — ideally through the organization's established process for handling privacy incidents — to acknowledge the error, apologize sincerely, and explain what steps are being taken.

Going forward, the PT should establish a personal protocol for reviewing any clinic-related social media content before posting to ensure that no PHI, including incidental patient images, is present. Reflecting on this case reveals a broader lesson about the gap between intention and consequence in social media use. Cultivating the habit of careful review before posting and treating social media content with the same deliberate attention to privacy that one would bring to a clinical note is the practical expression of the values Commitment 1 and Commitment 5 require.

Case Study 4: Impaired Colleague

The Scenario. A physical therapist working in an inpatient rehabilitation hospital has observed, on four separate occasions over the past six weeks, that a colleague appears to be impaired at work — exhibiting slurred speech, unsteady gait, and an odor of alcohol on one occasion. On two of the occasions, the colleague was scheduled to treat patients. The observing PT has not yet raised the concern with anyone, partly because she is uncertain whether she is interpreting the signs correctly, partly because of their collegial relationship, and partly because she fears the professional and personal consequences of making an accusation.

Ethical Principles and Code Commitments. Commitment 2 — Integrity contains an enforceable standard requiring practitioners to report colleagues whom they reasonably believe to be unfit to practice safely. The standard is reasonable belief, not certainty. The PT has observed consistent signs of impairment on multiple occasions over the past six weeks — she has more than adequate grounds for a reasonable belief. Commitment 1 and the foundational principle of nonmaleficence establish the patient safety obligation: patients who are treated by an impaired practitioner are exposed to risks they have not consented to and that they are depending on the healthcare system to protect them from.

The PT's concerns about accuracy and consequences are understandable and reflect genuine moral seriousness. But they do not alter the ethical calculus in a situation where the pattern of observed signs is consistent, the potential harm is serious, and the standard for reporting is reasonable belief rather than proof. Many states have mandatory reporting requirements in their practice acts that legally require practitioners to report colleagues they have reasonable grounds to believe are practicing unsafely due to impairment. Most states also provide immunity from civil liability for practitioners who report in good faith.

Applying the RIPS Model. The realm analysis identifies this as primarily an individual realm situation with organizational dimensions. The situation type is most accurately classified as ethical distress combined with ethical silence: the PT likely knows what the right course of action is, but interpersonal loyalty, uncertainty, and fear of consequences have combined to produce six weeks of inaction. Gathering relevant facts involves the PT documenting specific observations — dates, behaviors observed, any direct patient safety concerns — factually and clearly. Implementing the chosen course of action requires the moral courage to accept that protecting patients from potential harm is more important than protecting a collegial relationship from discomfort.

Case Study 5: Moral Distress and Productivity Pressure

The Scenario. A physical therapist working in a skilled nursing facility is required by her employer to maintain a daily productivity quota. In practice, meeting this quota consistently leaves her with insufficient time for thorough patient evaluations, meaningful family communication, and complete, accurate documentation. She has observed that patient care quality is being compromised — she is spending less time on clinical reasoning, skipping important elements of patient education, and documenting sessions with less precision than she believes is clinically appropriate.

Moral Distress vs. Ethical Dilemma. This scenario is an example of moral distress rather than an ethical dilemma. The PT is not experiencing uncertainty about what ethical practice requires. She knows that thorough evaluation, meaningful family communication, and accurate documentation are components of competent, ethical care.  She also knows that the current productivity standard is compromising her ability to provide them. The problem is not insufficient ethical reasoning; it is the characteristic moral suffering of ethical distress: knowing what right looks like and being prevented from achieving it by institutional constraints.

Applicable Code Commitments. Commitment 3 establishes the obligation to make sound professional judgments. Commitment 2 requires practitioners to address known ethical concerns. Commitment 6 aspirationally calls on practitioners to advocate for ethical organizational practices. Commitment 9 connects the PT's individual experience of moral distress to the broader professional obligation to advocate for healthcare systems that genuinely serve patients.

Applying the RIPS Model. The realm analysis identifies this as spanning the individual and organizational realms. Gathering relevant facts means the PT should document specific instances in which the productivity requirement has compromised patient care, including specific clinical tasks not performed, documentation elements omitted factually and clinically, rather than emotionally. Considering options reveals available pathways: raising concerns in writing with her direct supervisor, documenting the specific clinical impacts; consulting APTA resources on productivity and ethical practice; seeking peer consultation with colleagues who may share her concerns; consulting with a healthcare attorney about whistleblower protections if billing irregularities are also involved; or, as a longer-term consideration, assessing whether this organization's culture can be changed through advocacy. Implementing a course of action begins with the written communication to her supervisor — a step that requires moral courage but fulfills her Commitment 2 obligation to address known ethical concerns through available channels before escalating.

Case Study 6: Adolescent Autonomy and Parental Authority — A True Ethical Dilemma

Why This Case Study Is Different. Before examining the scenario, a brief orientation is warranted. The five preceding case studies were classified primarily as instances of ethical distress or ethical silence — situations in which the practitioner generally knew the right course of action but faced institutional, relational, or personal barriers to taking it. This case study is deliberately structured to illustrate a genuine ethical dilemma: a situation in which two or more courses of action are each ethically defensible, competing obligations point in different directions with roughly equal weight, and no clearly superior option is immediately apparent. Ethical dilemmas require a different kind of reasoning than ethical distress — not the courage to act on a known answer, but the analytical rigor to work carefully through competing obligations toward the most defensible conclusion available. Recognizing the difference between these situation types is itself an essential ethical skill.

The Scenario. A physical therapist in an outpatient orthopedic clinic has been treating a 16-year-old competitive swimmer, Maya, for eight weeks following surgical repair of a partial rotator cuff tear. Maya's parents initiated care, provided written consent, attended most sessions, and are deeply invested in her return to competitive swimming. Clinically, the PT believes Maya has made good progress but estimates that four to six additional weeks of therapy are indicated before she can safely return to competitive sport. The parents have expressed a strong desire for Maya to be cleared for the upcoming regional qualifying meet in seven weeks.

During a session when her parents are briefly out of the room, Maya tells the PT that she does not want to continue physical therapy. She explains that she has been feeling depressed and overwhelmed for several months, is burned out from competitive swimming, and is seriously considering quitting the sport. She says she has not told her parents how she feels because they have sacrificed significantly for her athletic career, and she fears their reaction. She asks the PT to tell her parents either that she has completed her rehabilitation goals or that further therapy is not medically necessary — so that she can end treatment without having the conversation with her parents herself.

Maya is articulate, consistent in her account, and shows no signs of cognitive impairment. She is four months from her 17th birthday. She is not expressing any intent to harm herself, though she does describe a persistent low mood and loss of enjoyment in activities she previously valued. She tells the PT, "You're the only person I've told any of this to. I just need you to help me get out of this."

Why This Is a Genuine Dilemma. This scenario does not present a practitioner who knows the right answer and lacks the courage to act on it. It presents a practitioner facing multiple competing obligations, each ethically grounded and none of which can be satisfied simultaneously. The competing obligations include:

Respecting Maya's autonomy and emerging self-determination. Maya is 16, cognitively intact, and capable of forming and expressing her own healthcare preferences. Commitment 1 requires practitioners to respect the inherent dignity and rights of all individuals, and the ethical concept of assent — the minor patient's affirmative agreement to participate in care — carries genuine moral weight. A 16-year-old's expressed preference about her own treatment is not ethically irrelevant simply because she has not yet reached the legal age of majority. Honoring that preference supports the therapeutic relationship and takes seriously the reality that therapy performed against a patient's genuine wishes may produce limited benefit.

Honoring parental authority and the legal framework governing minor consent. Maya's parents hold legal authority to make healthcare decisions on her behalf. They have provided informed consent, are paying for treatment, and are engaged in Maya's care. The legal and ethical frameworks governing the treatment of minors exist because adolescents — even capable, articulate ones — do not always have the developmental maturity to fully weigh the long-term consequences of healthcare decisions. Deferring entirely to Maya's preferences in the absence of parental knowledge arguably fails the parents' legitimate role in her care.

Upholding veracity. Maya has asked the PT to tell her parents something that is not true — either that she has met her rehabilitation goals or that continued therapy is unnecessary. The PT's clinical judgment clearly indicates that neither statement is accurate. Commitment 5's enforceable standard requires truthful and accurate communication in all professional contexts, and the foundational principle of veracity is unambiguous: fabricating or misrepresenting clinical findings to a patient's legal guardian is not ethically available regardless of the compassion that motivates it.

Attending to Maya's emotional health and well-being. Maya has disclosed a pattern of symptoms — persistent low mood, loss of enjoyment, burnout, social withdrawal from a significant source of identity — that warrant clinical attention beyond the orthopedic context. Commitment 5 calls for genuine compassion and trust in the therapeutic relationship, and beneficence extends beyond the shoulder to encompass the whole patient. The PT who focuses exclusively on rotator cuff rehabilitation while treating Maya's disclosure of depression as a scheduling issue has not fully honored their obligation to the patient in front of them.

Protecting the confidentiality of what Maya shared. Maya disclosed sensitive personal information in the context of a therapeutic relationship, with an explicit request for privacy. Commitment 1 requires the protection of confidential patient information. Disclosing Maya's emotional state, her depression symptoms, and her desire to quit swimming to her parents without her consent — even with the most benevolent intentions — would breach the trust she placed in the PT and potentially cause the very family confrontation she is trying to avoid.

Identifying the Realm and Situation Type

Realm: This situation primarily falls within the individual realm; it involves the direct therapeutic relationship among the PT, Maya, and her parents. It also touches on the organizational realm, insofar as the clinic's policies on confidentiality, communication with minors, and mental health referrals will shape the resources and procedures available.

Situation Type: This is an ethical dilemma. The PT is not experiencing uncertainty about whether something is wrong. There is no ethical distress in the sense of knowing the right answer and being blocked from it. Rather, the PT faces genuinely competing obligations — autonomy, veracity, beneficence, parental authority, and confidentiality — none of which can be fully honored without placing some constraint on another. The key signal that this is a dilemma rather than distress is that a thoughtful, well-informed practitioner could construct a defensible ethical argument for more than one course of action.

Applicable Ethical Principles and Code Commitments. Autonomy establishes that individuals have the right to make informed decisions about their own care. Applied to Maya, this principle does not grant her the same legal authority as an adult patient — but it does establish that her expressed preferences carry moral weight and deserve genuine consideration rather than dismissal.

Beneficence and Nonmaleficence pull in two directions simultaneously in this case. Completing rehabilitation supports Maya's long-term physical well-being and reduces the risk of reinjury. Ending therapy or redirecting the therapeutic encounter toward Maya's emotional health may serve her psychological well-being. Neither direction is obviously superior without deeper engagement with Maya's actual situation and values.

Veracity is not in tension here — it functions as a constraint that closes off one option entirely. The PT cannot lie to Maya's parents. This is not a matter of weighing competing goods; it is an enforceable ethical and professional standard. Recognizing that veracity forecloses the specific action Maya has requested is an important early step in analyzing this dilemma.

Commitment 1 — Respect establishes both the obligation to respect Maya's dignity and emerging autonomy and the obligation to protect the confidential information she has shared.

Commitment 2 — Integrity includes the ongoing informed consent obligation, which, in this case, raises the question of whether Maya's parents can provide meaningful, ongoing informed consent for treatment that their daughter has actively expressed she does not want to continue.

Commitment 5 — Compassion and Trust calls for genuine patient-centered communication that provides patients with the information they need for informed decision-making — and in this case, for compassionate attention to the full person, not only the orthopedic presentation.

Commitment 8 — Professional Expertise includes recognizing when a patient's presentation warrants referral. Maya's self-reported symptoms — persistent low mood, anhedonia, social withdrawal, and significant functional distress — are consistent with a clinical presentation that warrants mental health evaluation.

Applying Kidder's Three Approaches to the Dilemma. Because this case is classified as a genuine ethical dilemma — a "right versus right" situation in which competing obligations each have defensible ethical grounding — it is appropriate to apply Kidder's three approaches before moving to the action steps of the RIPS model.

The rule-based approach focuses on duties and obligations that hold regardless of the outcome. Applied here, it highlights that veracity is non-negotiable: the PT has a professional and ethical duty not to misrepresent clinical findings to Maya's parents, and that duty does not yield to compassion or convenience. It also highlights the duty to respect a minor's parents' legal authority over the minor's care.

The ends-based approach asks which course of action produces the best outcomes for all stakeholders. Complying with Maya's request provides short-term relief but exposes her to reinjury risk, deceives her parents, and compromises the PT's professional integrity. Immediate full disclosure to her parents without Maya's consent may produce family conflict, damage the therapeutic relationship, and remove the PT as a source of support at a clinically significant moment. A middle path — honest, compassionate engagement with Maya that declines to fabricate findings while also protecting the confidentiality of her emotional disclosure and opening a dialogue about realistic options — produces the most favorable outcomes across the full range of stakeholders.

The care-based approach asks what doing unto others as you would have them do unto you looks like in this situation. Applied to Maya, it calls for treating her the way any person navigating a difficult and emotionally loaded situation would want to be treated — with honesty, genuine concern, and respect for her dignity and emerging autonomy — rather than either dismissing her concerns or simply complying with a request that places the PT in an ethically untenable position. Applied to her parents, it recognizes that they, too, deserve honest communication from the clinician responsible for their daughter's care. Taken together, all three approaches converge on the same conclusion: the PT cannot lie to Maya's parents, cannot immediately disclose her full emotional disclosure without her consent, and must engage Maya honestly and compassionately while opening pathways that serve her whole person. This convergence across all three approaches strengthens the defensibility of the course of action identified in the action steps that follow.

Applying the RIPS Model. Gathering relevant facts requires the PT to be clear about what is and is not known. The PT is aware of Maya's clinical progress and remaining rehabilitation needs. The PT knows what Maya has disclosed about her emotional state and her request. What the PT does not yet know — and what matters enormously — is how serious Maya's depressive symptoms are, whether she has any other sources of support, and whether her desire to discontinue therapy is a stable, considered preference or an expression of acute distress that may shift with appropriate support. This uncertainty should shape how the PT responds initially: listening carefully, asking thoughtful open-ended questions, and resisting the urge to act prematurely while Maya's disclosure is still unfolding.

Identifying stakeholders includes Maya, her parents, the supervising PT or clinic director (if the treating PT has any supervisory relationship or consultation resource available), and potentially a mental health professional to whom referral might be appropriate.

Applying ethical principles reveals the key structure of the dilemma: veracity closes off Maya's specific request entirely; confidentiality counsels against immediately disclosing her emotional disclosure to her parents without her consent; beneficence and nonmaleficence are genuinely in tension between her physical and psychological needs; and autonomy argues for taking her expressed preference seriously even while acknowledging that the legal framework places final authority with her parents.

Considering options and consequences surfaces several possible courses of action, none of which is without cost:

Option A — Comply with Maya's request. Tell her parents that therapy goals have been met or that continued therapy is unnecessary. This option is not ethically available. It requires the PT to make false statements to Maya's legal guardians. Veracity and Commitment 5's enforceable standards foreclose this option, regardless of the compassion that motivates it.

Option B — Immediately disclose Maya's full disclosure to her parents without her consent. This option respects parental authority and ensures that her parents are aware of her emotional state. However, it breaches the confidentiality of what Maya shared in a therapeutic context, almost certainly damages the therapeutic relationship irreparably, and may trigger the very confrontation Maya fears in a way that leaves her without the PT as a support. It does not serve Maya's interests in a manner consistent with Commitment 1 or Commitment 5.

Option C — Decline to lie, while also declining to immediately disclose, and instead engage Maya in a direct, compassionate conversation about the situation. The PT acknowledges that telling her parents she has completed therapy is not something the PT can do honestly, explains why that is, and invites Maya into a genuine conversation about what options exist. This conversation includes: acknowledging what she has shared about her emotional state with genuine concern; expressing that these symptoms deserve real attention and support; discussing what an honest conversation with her parents about wanting a break from competitive swimming might look like and how the PT might support that conversation; and exploring whether a referral to a counselor or mental health professional might be appropriate and helpful. This option preserves the relationship, honors veracity, treats Maya as a developing, autonomous person, and opens pathways that neither option A nor B provides.

Option D — Consult with a colleague or supervisor before responding further. Given the complexity of what has just been disclosed and recognizing that Maya is not in immediate danger, the PT may consult with a supervisor, the clinic's mental health referral resources, or a trusted peer before the next session, while carefully protecting Maya's confidentiality in any consultation.

Choosing and implementing a course of action. The most defensible course available to this PT combines elements of Options C and D. In the immediate moment, the PT engages Maya honestly and compassionately — declining to make false statements to her parents, taking her emotional disclosure seriously as a clinical concern, and beginning a conversation about what honest, supportive options are available. Before the next session, the PT consults with a supervisor and explores the clinic's mental health referral pathway. The PT should also document the encounter carefully, noting that Maya expressed a preference to discontinue treatment and that the PT has begun exploring appropriate next steps consistent with both her clinical needs and her expressed concerns.

Critically, the PT should resist the urge to reach a quick resolution. This scenario does not have a single clearly correct answer that can be identified and implemented in the ten minutes before Maya's parents return to the waiting room. The most ethically defensible response is one that acknowledges the complexity, preserves the therapeutic relationship, keeps honest communication open, and creates space for a more deliberate process — including the possibility of a facilitated family conversation, a mental health referral, and a genuine renegotiation of Maya's rehabilitation goals that takes her whole situation into account.

Reflecting and evaluating outcomes invites the PT to consider several questions: Did this encounter make it more or less likely that Maya will get the support she needs? How were Maya's competing interests (physical recovery, psychological well-being, emerging autonomy, and her relationship with her family) honored in the resolution? What does this case reveal about the clinic's preparedness to address the emotional and relational dimensions of adolescent rehabilitation? And what would the PT do differently to structure communication and confidentiality expectations at the outset of care for adolescent patients going forward?

Key Takeaways

This case illustrates several principles central to ethical dilemma analysis.

Recognizing what is not ethically available is the first step in a dilemma, not the last. Identifying that Option A — lying to the parents — is foreclosed by veracity does not resolve the dilemma; it clarifies its structure by eliminating one branch from the decision tree. The genuine ethical work begins after the obviously unavailable options have been identified.

A dilemma does not require equal treatment of all competing obligations. Although genuine dilemmas present defensible arguments for more than one course of action, careful analysis typically reveals that some options better balance the full constellation of relevant principles than others. The PT's goal is not to treat all options as equally good — it is to reason carefully toward the most defensible option available, acknowledging what is sacrificed in choosing it.

Timing matters in dilemma resolution. Not every ethical dilemma requires an immediate decision. A practitioner who recognizes that a situation is complex, pauses to think carefully, consults appropriate resources, and returns to the patient with a more deliberate response has often served the patient better than one who acts quickly on insufficient analysis.

Adolescent patients occupy a distinct ethical category. Maya is neither a young child whose preferences can be subordinated entirely to parental authority nor an adult whose autonomous choice is determinative. Ethical reasoning in this case requires genuine engagement with what it means to respect the developing autonomy of a person who is approaching — but has not yet reached — the legal threshold of independent decision-making. The Code's commitment to respecting the inherent dignity and rights of all individuals applies to her in full.

PART IX: PROACTIVE STRATEGIES AND RESOURCES

Proactive Strategies for Ethical Practice

Ethics as a Preventive Discipline

Proactive ethics is not a passive state — it is not simply the absence of violations or the avoidance of trouble. It is an active, ongoing commitment to developing and maintaining the knowledge, skills, relationships, and habits that enable ethical practice across the full range of circumstances a practitioner will encounter throughout their career. The strategies that follow are practices to be cultivated continuously, integrated into the daily rhythms of professional life, and revisited as circumstances, technology, and professional standards evolve.

Develop and Maintain Personal Ethical Awareness and Moral Sensitivity

The foundation of proactive ethical practice is the cultivated capacity to notice ethical dimensions in clinical and professional situations before they escalate into crises. Moral sensitivity is a prerequisite for all ethical action, and it is a skill that develops through deliberate attention rather than passive experience. Practitioners who invest in their ethical awareness — who read the ethics literature, who reflect on the ethical dimensions of their clinical encounters, who engage in conversations with colleagues about the moral texture of their work — develop a finer-grained perception of the ethical landscape.

Maintaining personal ethical awareness also means attending honestly to one's own values, biases, and vulnerabilities. Every practitioner brings a personal moral history to their professional practice. Some of those personal commitments align well with professional ethical standards; others may create blind spots that require conscious attention. The practitioner who has honestly reflected on their own biases — including implicit biases about patient populations, colleagues from different backgrounds, and the organizational contexts in which they work — is better positioned to ensure that those biases do not distort their clinical judgment or ethical reasoning.

Know Your State Practice Act and Scope of Practice

One of the most practically effective proactive strategies available to physical therapy practitioners is thorough, current knowledge of the state practice act and regulations that govern their practice. Practitioners who know the Illinois Practice Act well are far less likely to inadvertently violate its terms. Knowledge of the scope of practice is particularly important because scope violations are among the most common sources of patient harm and disciplinary action in physical therapy.

When questions arise about allowable practices or scope, ask the licensing board directly — and get interpretations in writing. Do not rely on employers alone to convey licensure details. If your practice act is unclear on a point, proactively seek clarification and document the response.

Maintain Current Licensure and Competency Through Continuing Education

The obligation of career-long professional development is simultaneously a legal requirement and a foundational ethical commitment. Practitioners should establish systems for tracking renewal requirements — calendar reminders, organized records of completed continuing education, regular review of licensure status — to reduce the risk of inadvertent lapse.

Beyond minimum requirements, Commitment 8 calls on practitioners to pursue continuing education that genuinely advances clinical knowledge and professional capability rather than merely accumulating required hours. In an era of rapidly evolving technology, expanding evidence bases, and increasing clinical complexity, the practitioner who treats continuing education as a genuine investment in their ability to serve patients well fulfills both the letter and the spirit of Commitment 8's professional expertise requirements.

Document Thoroughly, Accurately, and Promptly — Including AI-Generated Content

Clinical documentation is simultaneously a legal record, a communication tool for the care team, a basis for reimbursement claims, and an expression of professional integrity. Proactive ethical practice requires completing documentation promptly, reviewing documentation before signing to ensure it accurately reflects what occurred, and applying the same standard of truthfulness to documentation that the principles of veracity and the enforceable standards of Commitment 5 require in all professional communication.

The specific obligation to review AI-generated documentation before signing, highlighted in Commitment 3's Aspiration 3.D, warrants particular emphasis. As AI documentation tools become more prevalent, the temptation to treat AI-generated content as inherently reliable will grow. The proactive practitioner establishes a consistent personal practice of careful review that resists pressure to prioritize efficiency. A signed clinical note carries the practitioner's professional and legal certification of its accuracy; that certification is meaningful only if the practitioner has actually verified the content they are certifying.

Establish Clear Communication with Patients, Families, and Colleagues

Many ethical challenges in physical therapy practice have their roots in communication failures — misunderstandings about the nature and goals of treatment, unaddressed concerns about a patient's progress, and ambiguities in the supervisory relationship. Proactive ethical practice means investing in the quality and clarity of professional communication as a preventive measure.

With patients and families, clear communication means ensuring that informed consent is genuinely ongoing — that patients receive honest, accessible information about their diagnosis, prognosis, and treatment options at each stage of care, and that their questions and concerns are invited and addressed. With colleagues, clear communication means establishing explicit understandings about supervisory expectations, clinical responsibilities, and the channels through which concerns should be raised — creating conditions in which ethical issues can be surfaced and addressed early.

Create a Culture of Compliance Within Your Practice Setting

Individual ethical practice occurs within organizational contexts that either support or undermine it. A culture of compliance is one in which ethical practice is understood as a shared professional value, in which concerns can be raised without fear of retaliation, in which policies and practices are transparent and consistently applied, and in which the gap between stated values and actual conduct is treated as a problem worth addressing.

Contributing to a culture of compliance means modeling the ethical practices one wishes to see in colleagues, creating opportunities for colleagues and supervisees to discuss ethical challenges in a supportive environment, and being willing to speak up when organizational practices depart from ethical standards.

Seek Supervision, Mentorship, and Peer Consultation When Uncertain

One of the most important and most consistently underutilized proactive strategies in ethical practice is the willingness to seek consultation when facing uncertainty. Peer consultation provides the perspective of someone who shares the practitioner's professional framework but is not embedded in the specific relational and institutional dynamics of the situation. Mentorship by experienced practitioners who have navigated similar challenges offers the additional benefit of accumulated practical wisdom. Practitioners should treat consultation as a routine professional resource rather than an admission of inadequacy.

Recognize and Address Moral Distress Proactively

Proactive recognition of moral distress means developing the self-awareness to notice when persistent feelings of powerlessness, frustration, or ethical dissatisfaction are accumulating in response to workplace conditions — and treating those feelings as clinically significant signals that warrant attention rather than as personal weaknesses to be managed in silence. Creating the relational conditions within peer groups, supervisory relationships, and professional communities in which moral distress can be named and discussed — rather than isolated and suppressed — is itself a form of ethical practice.

Recognizing Warning Signs

When the Environment Itself Is the Risk

Proactive ethical practice requires not only self-monitoring but environmental monitoring — the capacity to recognize when the practice setting itself is generating conditions that place practitioners and patients at ethical risk. Warning signs frequently manifest as the gradual normalization of practices that, upon careful examination, depart from ethical and legal standards; a process sometimes called ethical drift.

Pressure from employers or payers to alter documentation or exceed the scope of practice is among the most serious warning signs a practitioner can encounter. Requests to document services differently than they occurred — to record a one-on-one session when group treatment was provided, or to document interventions that were not performed — are requests to participate in fraud. These requests should never be complied with, regardless of how they are framed, who makes them, or the stated justification.

Vague or absent policies for billing, supervision, and patient care signal that the conditions for ethical drift are present. A practitioner who discovers that their organization lacks clear policies in these areas should raise this gap with appropriate leadership as a patient safety and compliance concern.

Retaliation for raising ethical concerns is both a warning sign and an ethical wrong in its own right. When a practitioner who raises a legitimate concern is met with negative performance evaluations, schedule changes, or explicit threats rather than genuine engagement with the substance of the concern, the organizational environment has signaled that ethical compliance is less valued than silence.

Persistent feelings of powerlessness, frustration, or exhaustion related to workplace ethical conflicts warrant recognition as a warning sign in their own right — the internal signal that moral distress has reached a level that requires active response.

Key Resources

Illinois New Licensing Portal-CORE system (2026)

The Comprehensive Online Regulatory Environment (CORE) is the new, paperless licensing platform launched by the Illinois Department of Financial and Professional Regulation (IDFPR). It replaces the old "Online Services Portal" and is designed to streamline how you apply for, renew, and manage your professional license. You will need to create an account to use this system when you renew your license.   

• Mandatory Digital Account: You can no longer renew via paper or legacy systems. All PTs and PTAs must create a new account through the state’s ILogin portal to access CORE.
• Real-Time Status Tracking: Unlike the old system, CORE provides a "360-degree view" of your license. You can see exactly when your renewal is processed and whether there are "deficiencies" (missing information) in your application.
• Digital Credentials: The IDFPR has moved toward digital-only pocket cards. Once your renewal is approved in CORE, you will download and print your own license; the state will no longer mail physical copies.
• Pro-Tip for Practice Owners: Because the system is linked to individual ILogin credentials, employers can no longer "bulk renew" for their staff. Every PT and PTA must personally manage their own CORE portal account to ensure ethical and legal compliance.

APTA Code of Ethics for the Physical Therapy Profession (2026)

The primary professional ethical standard governing all physical therapy practitioners and students. The full text of the Code, including its enforceable Standards of Conduct and aspirational Illustrative Examples organized around the nine Ethical Commitments, is available at apta.org.

APTA Ethics and Judicial Committee (EJC)

The body within APTA responsible for interpreting and enforcing the Code of Ethics for APTA members. Practitioners with ethical questions or concerns — including uncertainty about how the Code applies to a specific situation — can contact the EJC directly at [email protected]. Access to this resource should be considered a standard part of professional practice.

APTA Practice Advisories and Guidance Documents

Address a range of specific clinical, regulatory, and ethical issues in physical therapy practice — including guidance on documentation, supervision, billing compliance, telehealth, and the use of emerging technologies. These documents are regularly updated to reflect changes in regulation, technology, and professional standards.

Illinois State Licensing Board (IDFPR)

The Illinois Department of Financial and Professional Regulation is the regulatory authority with primary jurisdiction over physical therapy licensure and professional conduct in Illinois. The IDFPR publishes the practice acts, regulations, and interpretive guidance that define the legal framework of physical therapy practice in Illinois. Practitioners with questions about the Illinois-specific scope of practice, supervision requirements, mandatory reporting obligations, or disciplinary processes should consult the IDFPR directly. The link to the Physical Therapy page on IDFPR is here.

Illinois Practice Act and Administrative Code

• Illinois Physical Therapy Act
• Rules for Administration of the Illinois Physical Therapy Act

HHS Office for Civil Rights (OCR)

The federal agency responsible for enforcing HIPAA's Privacy and Security Rules and for receiving and investigating HIPAA complaints. Guidance and complaint-filing resources are available at the OCR website and helpline.

OIG Compliance Resources

Available at oig.hhs.gov, this collection includes comprehensive guidance, model compliance program documents, advisory opinions, and enforcement information relevant to healthcare fraud and abuse prevention. The OIG's annual Work Plan identifies the fraud and abuse issues the agency intends to prioritize for investigation in the coming year and is an important reference for practitioners and organizations seeking to understand where enforcement attention is focused.

PT Compact

Accessible at ptcompact.org, which provides information about the Interstate Physical Therapy Licensure Compact, including current member state status, eligibility requirements, and application processes for practitioners seeking to obtain compact privilege to practice in member states.  Illinois is currently not a PT compact member, but legislation has been introduced.  

Risk Management Consultation

Available through professional liability insurance carriers, including advice on documentation practices, supervision arrangements, scope of practice questions, and HIPAA compliance. Practitioners should know how to access these services through their carrier and treat them as a routine professional resource rather than a last resort.

Employee Assistance Programs (EAPs)

Employer-sponsored programs that provide confidential support services to employees facing personal and professional challenges. For practitioners experiencing moral distress, navigating a whistleblower situation, or struggling with the emotional consequences of workplace ethical conflicts, EAP services (which typically include counseling and legal consultation) can provide important support.

Institutional Ethics Committees

Where they exist in hospital and health system settings, ethics committees provide case consultation, policy guidance, and educational support on ethical issues arising in clinical care. Practitioners should investigate whether their institution has an ethics committee proactively, before a situation arises that requires one.

A Final Word: Ethics as a Career-Long Commitment

Ethics is not peripheral to physical therapy practice; it is foundational to it. Every patient who seeks care from a physical therapist or physical therapist assistant extends trust that the practitioner will act with integrity, honesty, and genuine commitment to their well-being. Honoring that trust requires more than technical competence; it requires ethical knowledge, judgment, and courage.

The landmark Code of Ethics for the Physical Therapy Profession, effective January 1, 2026, establishes a single unified ethical standard for all PTs, PTAs, and students through nine Ethical Commitments, each carrying enforceable standards that define the floor of acceptable conduct and aspirational guidance that describes the ceiling of excellent practice. That Code directly addresses the full range of ethical obligations examined in this course: the legal foundations of privacy, malpractice, licensure, supervision, and fraud; the emerging challenges of moral distress, social media, artificial intelligence, and geriatric care; and the profession's collective responsibility to advocate for equitable, patient-centered care at every level of the healthcare system.

In Illinois, those professional ethical obligations intersect with a specific body of state law—a practice act, an administrative code, and a constellation of related statutes—that defines the legal boundaries of practice and imposes additional obligations unique to this jurisdiction. Understanding both dimensions of professional responsibility — the ethical and the legal — is not a compliance exercise to be discharged once per renewal cycle. It is the ongoing work of a professional life lived with integrity, compassion, and genuine commitment to the patients and communities we serve.

References

Aguilar-Rodríguez, M., Kulju, K., Hernández-Guillén, D., Mármol-López, M. I., Querol-Giner, F., & Marques-Sule, E. (2021). Physiotherapy students' experiences about ethical situations encountered in clinical practices. International Journal of Environmental Research and Public Health, 18(16), 8489.

American Physical Therapy Association. (2026). Code of ethics for the physical therapy profession. https://www.apta.org/apta-and-you/leadership-and-governance/policies/code-of-ethics

Beauchamp, T. L., & Childress, J. F. (n.d.). Principles of biomedical ethics (8th ed.). Oxford University Press.

Bertoni, G., Manzati, S. P., Pagani, F., Testa, M., & Battista, S. (2026). Ethical and bioethical issues in physical therapy: A systematic scoping review. Physical Therapy, pzag011.

Delany, C., Edwards, I., & Fryer, C. (2019). How physiotherapists perceive, interpret, and respond to the ethical dimensions of practice: A qualitative study. Physiotherapy Theory and Practice, 35(7), 663–676.

Illinois Department of Financial and Professional Regulation. (2024). Illinois Physical Therapy Act, Title 68: Professions and Occupations, Chapter VII, Subchapter b, Part 1340. https://www.ilga.gov/commission/jcar/admincode/068/06801340sections.html

Illinois General Assembly. (2024). Illinois Physical Therapy Act. https://ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1319&ChapAct=225 ILCS 90/&ChapterID=24&ChapterName=PROFESSIONS+AND+OCCUPATIONS&ActName=Illinois+Physical+Therapy+Act.

Inbar, N., Doron, I. I., & Laufer, Y. (2024). Physiotherapists' moral distress: Mixed-method study reveals new insights. Nursing Ethics, 31(8), 1537–1550.

Lemersre, P., Gervais-Hupé, J., Carrier, A., Bourges, N., Mathieu-Fritz, A., & Hudon, A. (2025). Physical therapy and social media: Protocol for a critical interpretive synthesis of ethical and social issues. JOSPT Methods, 1(3), 96–101.

Mohapatra, A., Mohanty, P., Pattnaik, M., & Padhan, S. (2024). Physiotherapy in the digital age: A narrative review of the paradigm shift driven by the integration of artificial intelligence and machine learning. Physiotherapy—The Journal of Indian Association of Physiotherapists, 18(2), 63–71.

Olsen, N. J., Swisher, L. L., & Mueller, R. P. (2021). Ethical issues in clinical physical therapy education: Cases and commentary. Journal of Physical Therapy Education, 35(2), 134–142.

Orgambídez, A., Borrego, Y., Alcalde, F. J., & Durán, A. (2025). Moral distress and emotional exhaustion in healthcare professionals: A systematic review and meta-analysis. Healthcare, 13(4), 393.

Richardson, R. W. (2015). Ethical issues in physical therapy. Current Reviews in Musculoskeletal Medicine, 8(2), 118–121.

Sousa, J. L., Gonçalves-Lopes, S., & Abreu, V. (2021). Ageing and ethical challenges in physiotherapy: Application of the RIPS model in ethical decision-making. Annals of Medicine, 53(1), 188–192.

Swisher, L. L. D., Arslanian, L. E., & Davis, C. M. (2005). The realm-individual process-situation (RIPS) model of ethical decision-making. Technology, 305, 284–4535.