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Ethics in Physical Therapy: Bioethics and Our Code of Ethics

Ethics in Physical Therapy: Bioethics and Our Code of Ethics
Brigette Cuffia, PT, JD
October 17, 2016


Why Ethics?

A lot of people think that ethics is about right and wrong, and ethics did start that way. Ethics has been around since we first had philosophers. Aristotle was the first person to actually put it in writing. Before the term ethics came about, he talks about virtue. These great philosophers believed that we can learn to be good through practice.

Interestingly, hundreds of years later in the field today, a lot of people are talking about moral competency. Can we teach people to be good? How do we establish what good is? Sometimes good can be something very simple like manners. For example, our society functions a lot better in my opinion when people are using their manners. I'm not the only person to feel that way. When I was preparing and researching for my ethics courses, I found out that George Washington was a big fan of ethics, manners, and societal rules. He created this 100 rules document that has increased in popularity lately because it was published.  It's very odd but true that if you go back to the beginning of the United States, what constituted good manners is probably still true today.

Why Us?

There's always been this longstanding question, "What makes people good?" and the corresponding question, "Why do people choose to do the wrong thing?" For a health care provider, this is an interesting conversation. It's interesting that ethics is a required course, and I think that there are definitely multiple ways to look at this. Is the glass half full or the glass half empty? I think that there are facts and research to back it up both ways. In my experience and in teaching ethics, I really like to look at it as half full. I don't like to think about all the fraud and abuse that exists. I don't like to think about the people that are not giving the greatest patient care. I like to think that we all want to do right by our patients and the purpose of having an ethics course is just to get better at what we're already doing.

Poulis in the Journal of Medical Ethics brings up some great points. The question she asks is, "Why do PTs," (or PTAs can be interchanged here as well) "face serious ethical dilemmas?" She articulates I think what we all know but maybe haven't actually written or printed, is one area that is rife for an ethical problem is that we do have a very close physical relationship with our patients, and sometimes it may be a closer relationship than they have with most people in their lives.  The example I give here, and of course it's a joke and I mean it to be funny but it's not funny, is how often do you go into the bathroom and help one of your friends or somebody in your family? Not necessarily all that often, but it wouldn't be unreasonable at all for us to go into the bathroom and help one of our patients. We're in a very close physical relationship with them.

Also, physical therapy is a time intensive intervention. This isn't a 7-minute physician appointment. We're with that person and we're interacting with them for a period of time, often over a period of weeks. Hopefully, we're in constant communication with them and we're engaging them. It's always a dialogue such as what is your need, what can I help you work on, what are your goals? We collaborate with them. We have ideas, they have ideas, and we work together to achieve common goals. Although all these things are positive, when you have this intense, serious relationship, you're going to have intense ethical issues arise as well.

Ethics and Professionalism

Ethics is important as PTs, PTAs, or any other health care professional as well because we are professionals.  As an individual we are concerned with our morals and ethics.  We practice with an adopted code of ethics we will discuss later and as a medical professional we practice with an adopted code based on bioethics. 

What is a profession?

I was using the Curtis textbook that is in your reference list with some physical therapy students here at Newman.  I think it fits in really well to describe to people why does it matter that we are a profession.  A profession is distinct from other occupations in the sense that we have autonomy. I'm not talking about direct access. I'm talking about the ability to and the responsibility to make our own decisions. When you're a PT, the only person making PT decisions should be you, and that is autonomy.  We also have a prolonged and specialized training and our unique body of knowledge.  We are oriented toward service to society.  All this leads to licensure. Most professionals are licensed, although sometimes it's called something slightly different. For example, in PA, I believe PTs are actually certified rather than licensed. The idea is that there is this governing body made up of people in that profession that are giving them the okay to practice, and along with the okay to practice comes laws and codes that govern the profession.

When people think of professionals, they often think of doctors, lawyers, and teachers. It isn't always something strictly academic. For example, in most states, your beautician is a professional and will have a license and in the same way that you do. Another interesting example I think is of someone that does (HVAC) heating, venting, and air conditioning. They often have specialized training that leads to a certificate or a license and they're oriented toward society. It doesn't have to be those big, academic careers. It sometimes is something else that's geared to serve society.

Fiduciary Duty

The most important thing about the concept of professionalism is that professionalism creates what is a fiduciary duty. This is my main take home message of this course. We have a duty to our patient that they don't have to us. A fiduciary relationship is a relationship where one person has power over the other person. There's an imbalance of power. That power is due to the other aspects of professionalism. We have specific education. We have those rules and codes. We have the license. With the power, knowledge, and the evidence behind us, we have a greater responsibility.

I want you also to remember that this fiduciary duty is always to the patient. I'm not saying that we don't need to act ethically in all of our interactions. We certainly do. We have a responsibility to the insurer. We have a responsibility to our employer. We have other responsibilities, but our duty falls to the patient and to the patient alone. Our duty is based on the Code of Ethics and on what we know as far as our professional body of knowledge.  It's not limited to general ethics because we're health care providers which stresses and is specific to bioethics.

Interestingly, back to this power differential, the patient has no duty to us beyond their personal code of conduct. I joke this is not a car accident because in a car accident, there's no professionals. Everybody's on the same level ground. No one has a different level of responsibility to the other person, so it's going to end up being somebody's fault. The insurance company is going to determine that it's someone's fault, but there's no duty in that situation. When there's a "car accident" in a medical setting, if there's a problem in a physical therapy setting, we always have had that extra responsibility, that extra duty, because we are the professionals.

brigette cuffia

Brigette Cuffia, PT, JD

Brigette Cuffia is an Assistant Professor at Neumann University and teaches in the Physical Therapy Program. She is also one of the Academic Coordinators of Clinical Education responsible for student clinical placements. She received her Bachelor’s Degree in Physical Therapy and her Master’s Degree in Physical Therapy from Thomas Jefferson University and her Juris Doctorate Degree from Temple University. She is both a licensed PT in Pennsylvania as well as a licensed attorney admitted to the Pennsylvania Bar.

Brigette has taught live ethics and jurisprudence courses for licensed therapists since 2009. She is currently teaching courses on ethical technology usage, pediatric ethics and legal issues. She is also an on-line instructor for Care Resources, LLC and Elite Rehabilitation Solutions teaching ethics and legal issues for healthcare providers.

 Clinically, Brigette has worked for Moss Rehab Hospital for over 15 years in some capacity- currently she is an outpatient per-diem. While at Moss as the neurology team lead she was integral in developing a CARF accredited spinal cord injury program, bariatric program and also reviving the sexuality and disability education committee. Brigette was awarded a grant to develop Moss Muscle Builders, a maintenance group for persons with disabilities, which is still active today.

 At Neumann Brigette developed and implements the service-learning curriculum which allows students the opportunity to participate in public health initiatives throughout the community Brigette also chairs the Philadelphia Area Clinical Education Consortium a nonprofit group providing continuing education in the region:

Related Courses

Ethics in Practice: Examining Medical Errors: An Ounce of Prevention is Worth a Pound of Cure
Presented by Brigette Cuffia, PT, JD
Recorded Webinar
Course: #4830Level: Introductory2 Hours
This course examines the role of physical therapists and physical therapists assistants in the prevention of medical errors. Topics discussed include APTA Code of Ethics Analysis, creating a culture of safety and the economic impact of medical errors. This course is directly related to the practice of physical therapy and is therefore appropriate for the PT/PTA.

Tennessee Ethics in Physical Therapy: Bioethics and Our Code of Ethics
Presented by Brigette Cuffia, PT, JD
Course: #4590Level: Intermediate3 Hours
This course is specifically designed for PTs and PTAs licensed in the state of Tennessee. Physical therapists make ethical decisions on a daily basis. In routine clinical practice PTs and PTAs are also faced with tough situations known as ethical dilemmas. Understanding bioethics and the APTA Code of Ethics can help therapists make decisions regarding ethical issues in an informed way. Models of ethical decision making will be presented and clinical examples analyzed. Upon taking this course therapists will more readily recognize the ethical makeup of their clinical practice and feel more confident in their ethical decision making. This course is directly related to the practice of physical therapy and is appropriate for the PT and PTA.

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

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

Alzheimer's and Other Dementias: Overview for Healthcare Professionals
Presented by Megan L. Malone, MA, CCC-SLP
Recorded Webinar
Course: #4864Level: Introductory1 Hour
An overview for healthcare professionals about Alzheimer’s disease and related disorders is provided in this course. Characteristics of the dementias, such as symptoms, progression, and how they are diagnosed, are described. Care planning strategies for improving communication with patients and families, understanding and managing behavioral challenges, and promoting independence are also discussed.

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