This is an edited transcript of a live webinar presented on April 26, 2019. Review the course handouts for essential details required for a thorough understanding of course material.
After this course, participants will be able to:
- Identify at least three principles of ethics and their application to rehabilitation and physical therapy.
- Identify at least three codes of ethics that govern discipline-specific therapy practice.
- Discuss procedures for analyzing ethical dilemmas in healthcare.
- Correctly apply Code of Ethics to real-world issues through case scenarios.
- Identify common ethical issues experienced in healthcare settings.
Principles of Ethics
Simply stated, ethics guide the determination of right and wrong in moral life in everything that we do, not just healthcare. One's moral life extends into one's professional life and choices are dependent upon contextual situation and consideration.
Let's review the basic principles of ethics as they relate to healthcare and specifically, to physical therapy.
Autonomy refers to one's moral right to make choices and decisions about one's own course of action. In other words, it is the right to self-determination. Respect for autonomy dictates that we refrain from interfering with an individual's own choices. In a health and rehabilitation context, respect for autonomy means allowing and enabling patients and clients to make their own choices. This includes choices that we may not agree with, as clinicians. The desire of health and rehab professionals to help people sometimes result in diminished respect for their autonomy. Choosing not to participate in rehab, for example, is one way that patients may exercise their autonomy. They may refuse efforts to convince them otherwise. Sometimes, we as therapists cross that line and cajole a patient to participate without realizing we are taking away the patient's autonomy.
One question that comes up is, Does providing information without an attempt to influence a decision violate the principle of autonomy? This goes back to that question about refusals or what that person chooses to do or not to do. In those scenarios, patient education is important. You can provide education in a way that is not influencing or pressuring that person. Ultimately, if we provide the risks and benefits of participating or not participating in physical therapy, and the person refuses, then you take no for an answer.
This concept is extrapolated from the Hippocratic Oath, Do No Harm. This ethical principle is one of the oldest. It reminds us that if we can't help our patients, at the very least we have a duty not to harm them or make them worse off than they were before they sought our help. The harm here encompasses a wide range of harms, extending beyond the mere physical or psychological harm. It includes, for example, harm to one's reputation, their liberty or even their property. The questions of whose harm or which harm is open to a lot of different interpretations, especially when we're dealing with patients who might be unable to make their own decisions. Health and rehab professionals' opinions as to what constitutes harm may significantly differ from patients' opinions of what they consider as harm.
Beneficence stands for the duty to prevent harm to others. To remove harm from others and to promote good - isn't that why most of us therapists entered the profession in the first place? One's obligation to this moral duty ends where action can bring harm to oneself. In the health and rehab context, beneficence means looking out for our patients' wellbeing. However, health and rehab providers can have very differing views on what is good for the patient. You may think that it's good for the patient to walk and to do their strengthening exercises, for example, but the patient may not want to do that. They may not want to walk, or transfer, or do their exercises because they have fear of pain or fear of falling (or another reason). While we may consider something to be in their best interest, they may not consider it in their own best interest. When this happens, we are at a discord.
Justice looks at ways of fairly distributing burdens and benefits in society and giving individuals their fair share. Fairness is a key element of justice. As more and more people compete for limited healthcare resources, the principle of justice takes a front seat in healthcare decision making. Principles of justice focus on the question of, who should get the resources? This includes an examination of whether some people deserve those resources more than others. It also looks at who is actually making those decisions. Justice and fairness in ethical decision making depend on a lot of contextual factors. These factors include religious beliefs, professional issues, legal issues, institutional policies, procedures or standard operating procedures, and others. These factors can influence clinical decisions and choices.
Informed Consent and Veracity
This principle obligates all healthcare providers, not just therapists, to provide our patients with the benefits, the risks, and the potential risks of all proposed intervention strategies as well as non-participation. By providing these details, patients can make a willing and informed choice in their care. On the bottom of your evaluation form, there is likely a statement that says, "patient was educated to risks and benefits" or something indicating that a patient has provided consent. The vast majority of the time, we probably just check it and move along. This is important and we have to take it very seriously to ensure we truly are educating our patients. The patients will base their consent on the specific information that we give them about that proposed intervention. Obtaining informed consent relies heavily on veracity or having truth to what we deliver. Veracity is our obligation to speak and act truthfully and that impacts all communication with our patients. Truthful communication doesn't need to be harsh or condescending. Our communication needs to take into account cultural considerations as well as health literacy considerations of our patients.
Confidentiality is rooted in the Hippocratic Oath, part of which can be translated as, "Anything I say or hear of the life of men whether in a professional capacity or otherwise which should not be passed on to others, I will hold as professional secrets and not divulge them." All healthcare providers have a duty or an obligation to limit their access to information gathered in the course of treatment and keep that information strictly between the healthcare professional and the patient. There are some other ethical principles we'll discuss later that dictate some exceptions to this duty to keep patient information confidential. Based upon justice and beneficence there are certain laws that mandate breach of confidentiality to protect citizens, such as child abuse laws, mandatory reporting laws, and elder abuse laws. These laws are designed to protect individuals who may be mortally threatened.
Fidelity is closely related to confidentiality but refers to the moral duty to keep your promises and commitments. Patients expect all healthcare providers and therapists to keep their explicit and implicit promises, including the promise to keep shared information confidential and to provide services ordered by a physician. There is a saying in customer service that if you promise it, you better deliver it, and I think that is important for therapists as well. If we promise confidentiality, let's make sure that we're going to deliver it. If we've promised an intervention or a treatment or a follow-up, we must follow through on those obligations.
Duty refers to obligations that we have to others within our society. Sometimes those duties exist because of the nature of the relationship between the parties. For example, in therapy, when we start a patient-therapist relationship, we owe certain duties to that patient including the duty to provide a certain quality of care, a duty to provide confidentiality, etc.
Rights refer to the ability to take advantage of moral entitlement to do something or not to do something. Health care reform has ushered in an updated Patient's Bill of Rights. The Patient's Bill of Rights includes very specific rights such as the right to health insurance without regard to pre-existing conditions. There are other federal statutes that provide patients with very specific rights. For example, we are all familiar with HIPAA, the Health Insurance Portability and Accountability Act, which states that patients have the right to receive a privacy notice. States and even hospitals or other settings that have their own Patient Bill of Rights that grant the patient-specific rights or access. The best way to approach patient rights or resident rights is to follow that which is most strict. Follow whichever patient bill of rights is the most strict to ensure that at all times, you are protecting your patients.
Paternalism occurs when we fail to respect autonomy. When we act in a paternalistic manner, we act with disregard to an individual's right and substitute our own beliefs, opinions, and judgments for the patient's judgment. We may act without informed consent. We may act against the patient's wishes or under the guise of a desire to benefit the patient when that's not really what the patient wanted. People will justify paternalistic actions by claiming that they acted in the patient's best interest or they know best because they are the professional. In healthcare, oftentimes this happens when the patient's wishes and the family's wishes differ from the healthcare provider's wishes. To take it down to a basic level, you can even look at your evaluation and goals. Whose goals are those that you established? Maybe you established a goal for walking, strength, balance or pain. Is that the patient's goal or is that your goal as a therapist? We always want to respect the patient's autonomy, dignity and wishes, regardless of our work setting.
Codes of Ethics
Before we get into the APTA Code of Ethics for Physical Therapists, I will first review the background and intent of ethics and codes of ethics.
Professional ethics incorporate those values, principles, and morals that go into professional decision making. If professionals don't have guidance, values, or morals we can fall into trouble not just for us but for our patients, and for society in general. No one in a profession wants to see their colleagues making headlines because of unethical behavior.
I recently taught a class where the participants had to go out and find an article where therapy was considered unethical. Participants found articles related to fraud, abuse, and other unethical behavior involving therapy. I was surprised that all of the articles were very recent, and as mentioned, no one wants to see members of their profession in these situations. We want to avoid ethical and legal problems. To do that, we instill our values to avoid and prevent unwanted behaviors that are unprofessional and unethical. As therapists, we're dedicated to a common purpose and we have common training. We draw from that training and from our professional obligation as a source of our ethical values.
Codes of Ethics
Professional codes of ethics have been designed and promulgated by the professional associations, to help guide behavior in circumscribed professional situations. Professional codes of ethics incorporate sets of rules or principles to express the values of the profession as a whole. If you are a member of the professional association, your membership extends to you an obligation, responsibility, and commitment to that profession to abide by its code of ethics.
A profession's code of ethics doesn't just apply if you're a member of the professional association; it applies to everyone covered by that professional association. Licensing boards and other credentialing agencies incorporate professional codes of ethics into licensure regulations or credentialing rules. If you have specialty certification they may embrace or promulgate their own code of ethics for those that they certify.
Codes of ethics will help to promote the basic tenets of the profession. They codify the fundamental beliefs of the profession and the common moral values the profession chooses to protect patients and clients from harm. Codes of ethics give meaning to the uniqueness of what health and rehab professionals do. They also create a bond between professionals to practice according to common a standard. The goal is to protect the patients we serve, and society as a whole. Codes of ethics provide the basis, for the meaning of what it means to be a member of that particular health and rehab profession, in this case, physical therapy. It's a set of values that you need to incorporate into your moral and behavioral repertoire, in the same way, that you would incorporate social, cultural or religious values into your repertoire.
Courts will all often refer to the code of ethics as a measure of proper professional behavior as an element of the standard of care that a professional is supposed to render. Remember, a professional code of ethics applies to all members of the profession, even those who choose not to join their professional associations. It's interesting to me that many people don't know what their code of ethics states, what their licensure law states, what their practice acts state. Rarely does a code of ethics provide you with an absolute guide to your behavior or to your decision-making. What a code of ethics gives you is a starting place or a point of reference. From that reference point, you can begin interpretation.
Unethical practice refers to practice that does not conform to established professional standards. It also includes practices that range from those that are unreasonable, unjustified, ineffective, immoral, questionable, knowingly harmful, and knowingly wrong. All healthcare professionals can identify practices that we ourselves consider unethical. However, since we all arrive at our ethical analysis from different perspectives (e.g. social, religious, and cultural perspectives), not everyone is going to agree with our analysis. Unethical practices affect the patient, the health and rehab professions such as physical therapy, employers (because therapists are always a representation of the profession and of their employer), insurance providers, society, and more. Unethical practice can cause serious individual consequences and has potentially far-reaching social ramifications. In professional journals and online at licensing boards, there are lists of individuals who have lost their license to practice because of immoral or unethical practice or were fined because they billed an insurance company inappropriately.