Tennessee Ethics: Ethics in Physical Therapy: Bioethics and Our Code of Ethics

Tennessee Ethics: Ethics in Physical Therapy: Bioethics and Our Code of Ethics
July 24, 2018

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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 healthcare 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 are 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.

Professionalism in the News

North Carolina law.  This isn't going to get political at all, and I'm not going to give my opinions, although I have them. I want to bring up professionalism in the news because I think it's a perfect example, and we don't always get a lot of examples of how a professional could get stuck in an ethical situation.  For those of you that don't watch TV or the news, just a few months ago, there was a big issue in North Carolina. The North Carolina bathroom law is a gender issue, and it primarily affects people that are transgendered or in the process thereof. What the law says is that you must go with the sex that matches your birth certificate. That does not work for people that identify with a different gender or transgendered. This was seen as an attack on that community.  In May of 2016, a legal battle between the state of North Carolina and the federal government. What does this have to do with professionalism? Interestingly, it has a lot to do with professionalism because the professional in question is the attorney general in North Carolina.  His name is Roy Cooper and he is an attorney. That's his profession. He has a license and he has taken an oath.

As the attorney general, his job is to be the chief legal officer of the state, meaning if the state of North Carolina faces any lawsuits or legal issues, he is to defend them. He also has to follow the rules of professional conduct because he's a professional like all of us. Of course, the rules of professional conduct do ask him to do a good job, but they also ask him not to do anything that's unconstitutional. As an attorney, one of the professional commitments he has made is to have a duty to the constitution. Interestingly, he has a conflict. On one hand, he said, "I'm going to defend North Carolina in all lawsuits." On the other hand, when he got his attorney's license, he said, "I have a duty to uphold the constitution of the United States and I think this law is discriminatory."

Tennessee example. Around the same time, and on some of the same news feeds, Tennessee also decided to have a law that some people say is directed towards the LGBT community.  The TN bill says that as a professional marriage counselor, a therapist, or a licensed social worker that's acting as a counselor or a therapist has a right to refuse treatment to a client if you think that their beliefs are in direct conflict with your religious beliefs.

Some people say this law is discriminatory and that professionals must treat everyone the same.  Other people say no and that we are trying to protect the religious rights of these therapists and these counselors. My analysis of this as an attorney is a slippery slope problem.  My concern is if you decide not to treat one group of people, for whatever reason, where does that stop? Who's the next group of people that we don't treat? What happens to treat everyone with dignity? Which is our first principle, regardless of their beliefs.  Again, I'm not trying to share my beliefs with you. I am sharing current examples of ethical conflicts that involve professionals and that relate to the issue of professionalism.

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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. This course is open captioned.

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