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1980; 60:1264-1272.PHYS THER. Andrew A GuccioneSurvey of
Physical Therapists in New EnglandEthical Issues in Physical
Therapy Practice: A
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Ethical Issues in Physical Therapy Practice
A Survey of Physical Therapists in New England
ANDREW A. GUCCIONE, MS
This survey was an attempt to identify which ethical decisions
are most fre-quently encountered and are most difficult to make for
practicing physical therapists. A questionnaire that described 30
situations with an ethical dimen-sion was sent to 450 American
Physical Therapy Association members practicing in New England. A
total of 187 (41.5%) usable questionnaires was returned. Issues
raised by items were designated as primary, secondary, or
nonpriority. Seven primary and 11 secondary ethical issues were
identified. In brief, these issues involve the decision about which
patients should be treated, what obli-gations are entailed by that
decision, who should pay for treatment, and what duties derive from
the physical therapist's relationship with other health
profes-sionals, including physicians. Some of these decisions are
more frequent in certain types of employment facilities than in
others. Sources of ethical conflict and the role of the
professional organization in defining moral values for the
profession are discussed in this paper, and implications for
education are presented.
Key Words: Ethics, medical; Ethics, professional; Physical
therapy.
The need to identify and clarify ethical issues within a health
profession increases as the profession assumes responsibility for
those areas of direct patient care in its domain. A brief
comparison of the 1935 American Physiotherapy Association CODE OF
ETH-ICS with its 1977 American Physical Therapy Asso-ciation (APTA)
counterpart reflects the development of physical therapy as a
profession in its own right.1
The physical therapist today, in defining the limits of his
legal and professional autonomy, must examine the practice of his
profession from an ethical point of view. By doing so, he carefully
guards the rights of patients, maintains his integrity as a
professional, and promotes the ideals of physical therapy as a
profes-sion.
Thompson has suggested that there are three sources of conflict
for health professionals making ethical decisions.2 First,
conflicts may arise between an individual's private convictions and
his conception of the requirements of his professional role.
Second, ethical dilemmas may be encountered when the atti-tudes,
values, and goals of one profession conflict with those of another.
Finally, the ethos (ideology) of a profession and that of the
society in which it func-tions may be in conflict.
Professional ethics has developed in response to these sources
of conflict, and the APTA CODE OF ETHICS and the guidelines for its
interpretation emerge historically and sociologically with that
de-velopment.1 The C O D E may be regarded as an attempt to counsel
physical therapists making ethical judg-ments by asserting the
ideals of the profession and by defining some of the limits of
professionally and morally acceptable behavior. Continuing
documen-tation of the ethical concerns of practicing physical
therapists is essential to maintain timely counsel.
The twofold purpose of this study was to identify which ethical
problems were perceived by physical therapists to be the most
frequently encountered and
Mr. Guccione was a candidate for the degree of Master of Science
in Physical Therapy at Sargent College of Allied Health
Professions, Boston University, when this study was conducted. He
is currently Staff Physical Therapist, Physical Therapy Department,
Massachu-setts Rehabilitation Hospital, 125 Nashua St, Boston, MA
02114 (USA).
Adapted from a paper presented at the Fourth Annual Convention
of the Massachusetts Chapter, American Physical Therapy
Associa-tion, Hyannis, MA, April 1978.
This article was submitted April 2, 1979, and accepted January
4, 1980.
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the most difficult to solve in their daily professional
practice.
Simply stated, ethics, or moral philosophy, is criti-cal,
analytical thinking about the behavioral expres-sions of human
interdependence and what is the morally right thing to do.
Currently, the complexities of medical practice have given rise to
ethical questions that demand the participation of both medical
per-sonnel and academic ethicists in discussing the issues
involved. These discussions have served, at least, to define what
some of the problems are, but continuing dialogue is needed to
determine more adequately the range of morally sound solutions.
Topics that have received attention include abor-tion,
euthanasia, the right to health care, the patient's rights while
receiving health care, and the limits of experimentation with human
subjects. Although the physical therapist is concerned with these
issues as an informed member of the health care team, his
involve-ment in the decisions they require is sometimes not
directly evident. All moral dilemmas occur within a context of
proposed action.2-4 Some ethical problems are specific to physical
therapists because what they do is different from what physicians,
nurses, and other health professionals do. Other ethical problems
involve physical therapists in only limited or periph-eral ways.
Because of the context of certain ethical problems, the ethics of
health care professionals has been recognized as an area of study
akin to, but distinct from, medical ethics.
In order to select a defensible choice, a decision-maker first
adopts a point of view from which to interpret the facts. Any point
of view adopted will emphasize one kind of fact over another,
perhaps equally important, kind. The moral point of view is
distinguished from others by the kind of justification given in
support of a particular choice. For example, the decision to
perform passive range of motion be-cause it will achieve certain
treatment goals is reason-ing from the therapeutic point of view.
If a therapist cites a legitimate physician referral as his reason
for performing passive range of motion, then he has justified his
choice from the legal point of view. If his choice of passive range
of motion is defended on the grounds that it is the only procedure
that would avoid unnecessary harm to the patient, the decision has
been made according to the moral point of view. Purtilo's
discussion of the physical therapist as ethicist is a significant
contribution toward defining the moral point of view for a health
professional.3 Generally, no clinical decision is made without
analyzing the situ-ation from several points of view, but each
point of view is unique in the kind of questions it asks about a
proposed action. When an alternative is compatible with one point
of view and incompatible with an-
other, the uniqueness of different viewpoints is more obvious.
In these instances, the multiple dimensions of judgments made by
physical therapists are appar-ent. When the choice is easily
compatible with several viewpoints, however, there is a tendency to
collapse distinctions and regard the decision as a therapeutic
judgment only, ignoring ethical and other dimensions of the
situation.
Ethical Issues in Physical Therapy
The ethical dimension of actual clinical practice is not well
documented in the literature. Ethical devel-opment has been cited
as a basic objective of physical therapy education,5 and several
authors have noted an ethical dimension in the routine functions of
the physical therapist.3,6-11 Behavior guided by an ethical code
has been described as identifying physical ther-apy as a profession
rather than a technology and as contributing to professional
stature.1,10,11 Often, phys-ical therapists have been encouraged to
exhibit par-ticular behaviors. Exact recommendations have been
made, for example, on selection of topics for discus-sion with
patients,8"10 the uses of proper vocal tone when speaking with
patients,9,10 presentation of a modest appearance,9 cooperation
with and ultimate deference to the physician's judgment concerning
patient treatment,8-11 and maintenance of a patient's dignity and
his confidence in his physician.8"11 There has been little
discussion of the moral principles behind these expectations, and
the ways in which they pose problems for the therapist have not
always been identified. If the underlying principles are not made
explicit, recommendations for particular behav-iors are no more
compelling than remarks on profes-sional etiquette. Physical
therapy education that does not cover ethical theory, as well as
application, may inadvertently trivialize the importance of ethical
be-havior.
Discussions of professional ethics can seem over-whelmingly
complex, and the question of where to begin is posed as often as
the question of what to do. A guiding assumption of this study is
that, while all ethical problems are important, attention should be
directed first to those ethical issues that affect and perplex the
majority. The results of this survey pro-vide a focus for that
attention.
METHOD
Subjects
Four hundred fifty members of the APTA were selected at random
from the total APTA membership in the six New England states (N =
2,017) as of
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December 1977. The sole criterion for inclusion in the study was
that a therapist be employed in some aspect of therapy excluding
education. A major as-sumption of this study is that problems of
professional ethics originate within the specific context of
clinical practice. Therapists whose primary employment is in
academic education do not experience that context on a daily basis.
Also, educators and graduate stu-dents were not included because
they might be more sensitive to the complexities of some ethical
issues and thus skew the results.
Instrument
Thirty items that described situations suggestive of ethical
problems were presented to the sample in a questionnaire format.
Inasmuch as demographic dif-ferences are often a source of
variations in response, data were collected on age, sex, total
years of physical therapy work experience, and highest educational
level obtained, as well as the respondent's present type of
employment facility, level of his position, setting of employment,
and state. Information on sources of contact with issues of
professional ethics and the number of physical therapists available
to discuss actual ethical problems was also collected.
Procedure Respondents were asked to score items according
to the frequency with which they had encountered a situation of
the type described in their own profes-sional practice and the
difficulty they experienced in reaching a decision in those
instances. The frequency measure had five levels: high, moderate,
minimal, none, and not applicable. The difficulty measure had four
levels: extreme, moderate, minimal, and none.
Assuming that ethical problems arise out of a par-ticular
context, accurate measurement of the difficulty of an item requires
at least minimal experience with it. In cases in which a respondent
reported having no experience with the situation described by an
item, or thought it inapplicable to him, the difficulty rating was
excluded from the results.
Data Analysis
The Kolmogorov-Smirnov One-Sample Test was employed to determine
the significance of the distri-bution of responses on both the
frequency and the difficulty scales.12 This test measures the
agreement between a theoretical cumulative distribution of
re-sponses and an observed cumulative distribution. If responses
are divided almost equally among the levels of a scale, there will
be no significant difference between the theoretical and the
observed distribu-tions. In order to consider a level on a scale to
be a significant preference of the respondents, it must be
demonstrated that the dissimilarity between a theo-
retical array of data values and the actual or observed array
could not have happened by chance. The ab-solute value of the
maximum deviation (Dm a x) be-tween the theoretical and the
observed arrays deter-mines whether a significant preference exists
for one of the possible response choices. The rigor of this test is
great for small groups, and, thus, in some of the breakdowns of
responses reported below, only the . 1 level of confidence was
reached.
In order to determine which issues warrant atten-tion according
to the frequency and the difficulty criteria, an arbitrary lower
limit was imposed. The issues raised by items that were not
perceived as at least moderately frequent or at least moderately
dif-ficult by a minimum of 35 percent of the respondents were
rejected as priority issues (Figure). The issues covered in those
items that met both the frequency and the difficulty criteria
levels were designated pri-mary issues of professional ethics for
physical thera-pists. The items that met either the frequency or
the difficulty criterion level, but not both, were desig-nated
secondary issues of professional ethics.
1. Deciding criteria for allowing a pa-tient/family to refuse
treatment.
2. Accepting gratuities or gifts from pa-tients/families.
3 . Deciding what to do when my values and beliefs are at odds
with a patient 's/family's values and beliefs.
4. Setting the limits necessary to main-tain professional
relationships with pa-tients/families.
5. Controlling access to privileged or confidential information
about a pa-tient/family.
6. Choosing a form of dress that assures professional respect
and maintains identity a s a physical therapist.
7. Deciding when I do not have adequate therapeutic knowledge to
treat a pa-tient.
8. Setting financially sound fees that maintain a patient 's
ability to receive treatment.
9. Providing accurate information to con-sumers about the cos ts
of treatment.
10. Determining methods for making the particulars of physical
therapy ser-vices known to health care consumers.
11 . Deciding the limits for standing by my own ethical
principles.
Figure. Issues that did not meet either criterion.
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TABLE 1 Characteristics Profile of Respondents
a. b. c.
d. e.
f. g.
h.
Under 3 0 years old Female 6 years or l ess total physical
ther-apy work experience Baccalaureate degree Employed in acute
general facili-ties Employed in an urban area Learned about
professional ethics in P.T. course only had 3 or more therapists
available to d i scuss actual ethical problems
% 6 1 . 3 8 5 . 4 58.1
72 .7 4 2 . 8
4 3 . 5 5 9 . 9
6 9 . 0
N
1 8 6 1 8 5 1 8 4
187 187
1 8 4 181
187
RESULTS AND DISCUSSION
Two hundred seven questionnaires were returned, representing a
46 percent response. Of these, 187 (41.5%) were usable. Major
demographic character-istics are presented in the respondents'
profile (Tab. 1). Primary and secondary issues were grouped on the
basis of the kind of concern each expressed. Four groups of
concerns were identifiied: decisions regard-ing the choice to
treat, obligations deriving from the patient-therapist contract,
moral obligation and eco-nomic issues, and a physical therapist's
relationship with other health professionals. A single item that
examined conflicts between values also merited dis-cussion.
TABLE 2 Decisions Regarding the Choice to Treat
1.
2.
3.
4.
Establishing priorities for patient treatment when time or
resources are limited.
Discontinuing treatment for patients who habitually disregard
instructions such as for home programs, treatment regimens, and
safety instructions.
Continuing treatment with a terminally ill patient.
High Mod Min None
High Mod Min None
High Mod Min None
Nursing Homes and Chronic Care Facilities
Continuing treatment to provide psychological sup-port after
physical therapy treatment goals have been reached.
High Mod Min None
High Mod Min None
Nursing Homes and Chronic Care Facilities High Mod Min None
Frequency n 67 70 46
3 N = 186
% 36.0 37.6 24.7
1.6 100.0
D m a x = .237a
13 61 88 11
N = 173
7.5 35.3 50.9
6.4 100.0
Dmax= .186a 25 63 80
6 N = 174
14.4 36.2 46.0
3.4 100.0
Dmax= .216a
1 12
3 0
N = 16
6.2 75.0 18.8
0.0 100.0
Dmax = .312C 30 69 72 11
N = 182
16.5 37.9 39.6
6.0 100.0
Dmax= -19a
7 6 3
_0 N = 16
43.8 37.5 18.8
0.0 100.0
Dmax= .313c
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Difficulty n
9 74 89
10 N = 182
% 4.9
40.7 48.9 5.5 100.0
Dmax= .201a 23 62 65 11
N = 161
14.3 38.5 40.4
6.8 100.0
Dmax= .181a 22 72 52 21
N = 167
13.2 43.1 31.1 12.6
100.0 Dmax= .124b
34 60 64 12
N = 170
20.0 35.3 37.6
7.1 100.0
Dmax= .179a
a p < .01. b p < .05. c p < .1.
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Decision to Treat
The first group of concerns to be considered con-sisted of four
related primary issues regarding who should be treated (Tab. 2).
More than 70 percent of the respondents perceived the basic
question of estab-lishing priorities for patient treatment when
time or resources are limited as moderately or highly fre-quent.
This questionnaire item was also rated at least moderately
difficult by slightly more than 45 percent of all those who had
experienced the problem. Using the frequency and the difficulty
criteria, responding therapists also regarded discontinuation of
treatment on the grounds of habitual noncompliance as a second
primary issue of professional ethics. Third, contin-uation of
treatment with the terminally ill is a priority issue, especially
for therapists in nursing homes and chronic care facilities, for
whom the frequency of this situation is greater than for other
therapists. Fourth, continuation of treatment to provide
psychological support after physical therapy treatment goals have
been reached is a primary issue for over half of the responding
therapists, again more frequent for ther-apists working in nursing
homes and chronic care facilities.
When deciding whom to treat, a therapist is re-quired, in part,
to consider two important aspects of this type of professional
judgment. First, it is becom-ing apparent that the increase in the
number of patients needing physical therapy knowledge and skills
could become overwhelming. The expansion of physical therapy into
new areas, in which the profes-sion offers a unique viewpoint,
forces the choice of which patients shall be treated and which
shall not.
Even when research into the efficacy of treatment for certain
types of patients sheds some light on this matter, the therapist is
still confronted with a second, and perhaps more important,
considerationper-sonal beliefs and values. Underlying all
therapists' ethical decisions are the values that help to direct
their choices.13 The extent to which a person values psychological
support for patients beyond the usual physical therapy
intervention, as well as what he thinks is an appropriate response
to the needs of a dying patient, bear heavily on what he will
choose to do. Conflict between personal values and professional
values, or between the profession's values and soci-ety's
attitudes, may easily arise. The professional organization's
declaration of its values sometimes is helpful in these instances.
However, beyond this dec-laration, each physical therapist must
decide what he values as a health professional. Educators may need
to provide the student with the opportunity to ex-amine his own
values as he is formally and informally socialized into the
profession.
Patient-Therapist Contract
The therapist's professional relationship to a pa-tient is a
major source of moral obligation. Basic questions concerning the
often-unspoken contract be-tween patient and therapist were
apparently not a problem to the respondents. The primary issue in
patient-therapist interaction emerged from a conflict concerning
professional adjudication between a patient's needs or goals and a
family's needs or goals (Tab. 3). The respondents identified this
dilem-ma as the primary issue of the second group of con-cerns.
The nature of the patient-therapist contract has changed as
physical therapy has increased its function and scope within the
health care system. The first of six secondary issues in this group
of concerns stems directly from this change, which augmented the
ed-ucation component of clinical practice. A problem in defining
the physical therapist's role in the initial education of a patient
or family regarding diagnosis or prognosis was encountered often
enough to war-rant attention. This situation was experienced with
high frequency by 45 percent of all therapists whose primary
employment was in pediatric facilities or school-system settings.
Students pursuing careers in the treatment of developmental
disabilities should be urged to consider the ethical aspects of
this problem in clinical judgment. Two other secondary issues whose
frequency merit discussion are questions about informing a patient
or family about the limitations of treatment and assuring that the
patient or family have input into treatment and discharge
planning.
The three remaining secondary issues in this group of concerns
emanate from the patient's expectations of the therapist. First,
the knowledge that a therapist might be expected to bring to the
treatment situation was examined in an item that questioned the
assump-tion of personal responsibility for continuing educa-tion.
Over 84 percent of the respondents noted that decisions allowing
them to keep up with new treat-ment ideas had to be made with
either moderate or high frequency. The limits of the clinician's
obligation to update his practice are unclear. Continuing
edu-cation is well-recognized as an essential of providing quality
health care. However, the growth of physical therapy knowledge and
the increasing cost of contin-uing education courses also demand
consideration.
The final two secondary issues pertaining to pa-tient's
expectations are encountered in actual treat-ment: weighing the
effects of treatment against the discomfort created by the
procedure and maintaining a patient's sense of personal space and
dignity during treatment. Both of these issues are usually
addressed in the classroom and the clinical education of the
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student, and this survey's results suggest that this practice
should continue. Each of these items was rated only minimally
difficult by more than half of the respondents. This may be
attributable to the attention these issues have received in the
respon-dent's education.
Moral Obligation and Economic Issues
Some economic issues have a moral component, and the respondents
identified both a primary and a secondary issue of professional
ethics relating to eco-nomics (Tab. 4). Decisions about whether to
represent
TABLE 3 Obligations Deriving from the Patient-Therapist
Contract
1.
2.
3 .
4 .
5.
6.
7.
Determining professional responsibilities when a pat i ents n e
e d s or goals conflict with the family's n e e d s or goals .
Defining the limits of the physical therapist's role in the
initial education of a patient/family regarding diagnosis or
prognosis.
High Mod Min None
High Mod Min None
Frequency n
8 6 4 9 7 12
N = 181
% 4 .4
3 5 . 4 5 3 . 6
6.6 1 0 0 . 0
Dmax = . 2 0 5 a 3 2 7 0 7 0
7 N = 1 7 9
17 .9 39.1 39.1
3 .9 1 0 0 . 0
Dmax = . 2 8 9 a
Pediatric Facilities and School System Settings
Informing a patient/family about the limitations of
treatment.
Assuring that the patient/family has input into treatment and
discharge planning.
Assuming personal responsibility for continuing education to
keep up with new treatment ideas in order to maintain quality of
care.
Weighing the effects of treatment against the dis-comfort
created by the procedure.
Maintaining a patient's s e n s e of personal s p a c e and
dignity when treatment requires arrangements such a s c lo se
proximity and group settings.
High Mod Min None
High Mod Min None
High Mod Min None
High Mod Min None
High Mod Min None
High Mod Min None
9 6 5 0
N = 2 0
4 5 . 0 3 0 . 0 2 5 . 0
0 .0 1 0 0 . 0
Dmax = . 4 5 a
5 2 8 3 4 9
2 N = 1 8 6
2 8 . 0 4 4 . 6 2 6 . 3
1.1 1 0 0 . 0
D m a x = .239a
6 2 8 3 3 2
1 N = 1 7 8
3 4 . 8 4 6 . 6 1 8 . 0
0 .6 1 0 0 . 0
Dmax = . 3 1 5 a
7 3 8 3 2 6
3 N = 1 8 5
3 9 . 5 4 4 . 9 14.1
1.6 1 0 0 . 0
Dmax = . 3 4 3 a
3 6 81 6 4
4 N = 1 8 5
19 .5 4 3 . 8 3 4 . 6
2 .2 1 0 0 . 0
Dmax = . 2 2 8 a
51 6 5 5 0 10
N = 1 7 6
2 9 . 0 3 6 . 9 2 8 . 4
5.7 1 0 0 . 0
D m a x = . 1 9 3 a
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Difficulty n
16 71 6 5 17
N = 1 6 9
% 9.5
4 2 . 0 3 8 . 5 10.1
1 0 0 . 0 Dmax = .155 a
8 5 3 9 0 2 0
N = 171
5 51
1 0 2 2 6
N = 1 8 4
8 2 9
1 0 3 3 7
N = 177
14 61 7 3 3 4
N = 1 8 2
8 6 2 9 4 17
N = 181
2 17
1 0 8 3 9
N = 1 6 6
4 .7 3 1 . 0 5 2 . 6 11 .7
1 0 0 . 0
2.7 2 7 . 7 5 5 . 4 14.1
1 0 0 . 0
4 . 5 16 .4 5 8 . 2 2 0 . 9
1 0 0 . 0
7.7 3 3 . 5 40.1 18 .7
1 0 0 . 0
4 .4 3 4 . 3 5 1 . 9
9 .4 1 0 0 . 0
1.2 1 0 . 2 65.1 2 3 . 5
1 0 0 . 0
a p < .01.
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TABLE 4 Moral Obligation and Economic Issues
1.
2.
Deciding whether to represent certain necessary patient services
in a way that would meet third-party-payer limitations.
High Mod Min None
Nursing Home or Chronic Care Facilities
Withholding or limiting physical therapy services in order to
improve work conditions, salaries, staff/ patient ratios, etc .
High Mod Min None
High Mod Min None
Frequency n
3 6 51 4 2 15
N = 1 4 4
% 2 5 . 0 3 5 . 4 2 9 . 2 1 0 . 4
1 0 0 . 0 D m a x = . 1 4 6 a
9 2 1 1
N = 1 3
6 9 . 2 1 5 . 4
7.7 7.7
1 0 0 . 0 Dmax = . 4 4 9 a
12 14 2 9 61
N = 1 1 6
1 0 . 3 12.1 2 5 . 0 5 2 . 6
1 0 0 . 0
Ext Mod Min None
Ext Mod Min None
Difficulty n
2 3 4 9 4 7 1 0
N = 1 2 9
% 1 7 . 8 3 8 . 0 3 6 . 4
7 .8 1 0 0 . 0
Dmax = . 1 7 2 a
21 16 13
5 N = 5 5
3 8 . 2 29.1 2 3 . 6
9.1 1 0 0 . 0
Dmax = . 1 7 3 b
a p < .01. b p < .1.
TABLE 5 Physical Therapist's Relationship to Other Health
Professionals
1.
2.
3 .
4 .
5.
Maintaining a patient's/family's confidence in other health
professionals regardless of personal opinions.
Determining criteria for delegating duties to sup-portive
personnel.
Reporting questionable practices of another phys-ical therapist
to the appropriate person.
Reporting questionable practices of a physician to the
appropriate person.
Reporting questionable practices of another health professional
who is not a physical therapist or a physician to the appropriate
person.
High Mod Min None
High Mod Min None
High Mod Min None
High Mod Min None
High Mod Min None
Frequency n 2 3 77 6 8 1 3
N = 181
% 12 .7 4 2 . 5 3 7 . 6
7 .2 1 0 0 . 0
D m a x = . 1 7 8 a
5 8 6 3 3 7 11
N = 1 6 9
3 4 . 3 3 7 . 3 2 1 . 9
6 .5 1 0 0 . 0
Dmax = . 2 1 6 a
6 5
7 5 7 3
N = 1 5 9
5 2 8 8 8 5 2
N = 1 7 3
7 2 2 9 0 4 8
N = 1 6 7
3 .8 3.1
4 7 . 2 4 5 . 9
1 0 0 . 0
2 .9 1 6 . 2 5 0 . 9 30.1
1 0 0 . 0
4 .2 1 3 . 2 5 3 . 9 2 8 . 7
1 0 0 . 0
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Ext Mod Min None
Difficulty
8 6 2 7 5 2 3
N = 1 6 8
% 4 .8
3 6 . 9 4 4 . 6 13 .7
1 0 0 . 0 Dmax = . 2 0 2 a
5 4 2 8 8 2 3
N = 1 5 8
3 7 2 8 17
4 N = 8 6
3 .2 2 6 . 6 5 5 . 7 1 4 . 6
1 0 0 . 0
4 3 . 0 3 2 . 6 1 9 . 8
4 .7 1 0 0 . 0
D m a x = . 2 5 6 a
5 2 2 6 31 12
N = 121
4 3 . 0 2 1 . 5 2 5 . 6
9 .9 1 0 0 . 0
Dmax = . 18 a
3 5 4 2 31 12
N = 1 2 0
2 9 . 2 3 5 . 0 2 5 . 8 1 0 . 0
1 0 0 . 0 Dmax = . 1 5 a
a p < .01.
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certain necessary patient services in a way that would meet the
present limitations imposed by third-party payers are not uncommon
or easy to make. Almost 70 percent of those therapists working
primarily with patients in nursing home and chronic care facilities
perceived a high frequency of the need to make this decision. The
source of conflict is the difference be-tween what a physical
therapist may value as neces-sary for patients and what society
regards as essential to the health of those who are dependent upon
it.
respect to peers and superiors. That place has changed
considerably with the development of the profession and will
continue to do so.15 ,16
Four secondary issues were examined in this group of concerns.
Determinations of the criteria for dele-gating duties to supportive
personnel occur frequently enough to constitute a secondary issue
of professional ethics. Respondents did not frequently make
deci-sions to report the questionable practices of another physical
therapist, physician, or other health profes-
TABLE 6 Conflicts Between Two Ethical Principles
1. Deciding what to do when two of my ethical prin-ciples or
values are in conflict.
High Mod Min None
Frequency n
2 25
100 49
N = 176
% 1.1
14.2 56.8 27.8
100.0
Ext Mod Min None
Difficulty n 26 50 44
5 N = 125
% 20.8 40.0 35.2
4.0 100.0
Dmax = .21 a
a p < .01.
There is, at present, no simple resolution to this conflict.
Those physical therapists concerned with this issue should
participate forcefully in changing societal concepts of adequate
and essential health care.
In light of developments in other health profes-sions, which
have included strikes by physicians and nurses,14 one question
examined the issue of curtail-ment or limitation of physical
therapy services in order to improve work conditions, salaries,
staff/pa-tient ratios, and the like. Most of the respondents
perceived this item as inapplicable to their present situations. Of
those therapists who regarded this event as a possibility, most had
no personal experience of it. However, slightly over 38 percent of
those who had experience with this problem reported that it was an
extremely difficult decision to make. Further exami-nation of this
issue may become necessary.
Relationship to Other Health Professionals
The last group of issues considered the physical therapist's
relationship to other health professionals (Tab. 5). Maintaining a
patient's or family's confi-dence in other health professionals
regardless of per-sonal opinions has traditionally been an issue of
professional ethics,8-11 and the data collected show that it was
perceived to be the primary issue of this group. The response that
a therapist makes in situa-tions of this type is derived, in part,
from the place the profession holds within the health care team
with
sional. However, such a decision clearly poses mod-erate
difficulty in the case of another health profes-sional and extreme
difficulty in the cases of another physical therapist or a
physician, when it needs to be made.
Identification of Ethical Decisions
Ethical dilemmas arise when two or more ethical principles or
values conflict with each other in a given situation. Despite the
fact that respondents perceived seven primary issues and they
recognized the diffi-culty of making decisions when principles
conflict, they did not perceive themselves as making a choice
between conflicting principles or values with any great frequency
(Tab. 6). Although respondents rec-ognized that a difficult
decision had to be made in some instances, they probably had not
identified it as a decision of ethical choice. The moral point of
view requires that some unique aspects of a situation be explored.
Failure to recognize that a moral point of view is required is a
first step toward unethical be-havior. The educational implication
of this data is inescapable: in order to meet all the challenges of
clinical practice, physical therapy students must be taught how to
make ethical as well as clinical judg-ments. To prepare future
clinicians less adequately could jeopardize the integrity and the
autonomy that physical therapy as a health profession has so
ar-duously worked to achieve.
Volume 60 / Number 10, October 1980 1271
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CONCLUSION
Complex ethical issues have emerged with the de-velopment of the
profession. These issues pose an important challenge to the
clinician and require that he develop skill in making ethical
judgments in professional practice. This study was undertaken to
achieve several objectives. First, to establish priorities of
concern so that the APTA can respond to the more pressing ethical
questions of its members. Second, to identify the issues of
professional ethics so as to encourage discussion among physical
therapists and
to promote application of the ideals expressed in the APTA CODE
OF ETHICS to actual situations. Third, to summon the attention of
academic ethicists so they can offer their counsel on the issues
raised. Fourth, to alert educators to the needs of their students
in order to meet the challenges of ethical professional practice.
Fifth, to provide an opportunity for physical thera-pists to learn
about and reflect upon the issues of professional ethics as they
have experienced them.
Acknowledgment. Grateful appreciation is ex-pressed to Jane
Coryell, PhD, Sargent College of Allied Health Professions, Boston
University, for her assistance.
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1 2 7 2 PHYSICAL THERAPY
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1980; 60:1264-1272.PHYS THER. Andrew A GuccioneSurvey of
Physical Therapists in New EnglandEthical Issues in Physical
Therapy Practice: A
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