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This survey was an attempt to identify which ethical decisions are most frequently encountered and are most difficult to make for practicing physical
therapists. A questionnaire that described 3 0 situations with an ethical dimension was sent to 4 5 0 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 a s 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 obligations are entailed by that decision, who should pay for treatment, and what
duties derive from the physical therapist's relationship with other health professionals, 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
ICS with its 1977 American Physical Therapy Association (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 profession.
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, Massachusetts 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 Association, Hyannis, MA, April 1978.
This article was submitted April 2, 1979, and accepted January 4,
1980.
1264
therapy.
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
1265
TABLE 1
Characteristics Profile of
61.3
85.4
58.1
186
185
184
72.7
42.8
187
187
43.5
59.9
184
181
69.0
187
TABLE 2
Decisions Regarding the Choice to Treat
High
Mod
Min
None
Frequency
n
%
67
36.0
70
37.6
24.7
46
1.6
3
N = 186 100.0
Ext
Mod
Min
None
D m a x = .237a
High
Mod
Min
None
High
Mod
Min
None
4. Continuing treatment to provide psychological support after physical therapy treatment goals have
been reached.
High
Mod
Min
None
a
b
c
13
7.5
61
35.3
88
50.9
11
6.4
N = 173 100.0
D max = .186 a
14.4
25
63
36.2
46.0
80
3.4
6
N = 174 100.0
D max = .216 a
1
6.2
12
75.0
3
18.8
0
0.0
N = 16 100.0
Dmax = .312 C
16.5
30
69
37.9
72
39.6
6.0
11
N = 182 100.0
D max = -19 a
Ext
Mod
Min
None
Ext
Mod
Min
None
Ext
Mod
Min
None
Difficulty
n
9
74
89
10
%
4.9
40.7
48.9
5.5
N = 182 100.0
D max = .201 a
23
14.3
62
38.5
65
40.4
11
6.8
100.0
N = 161
D max = .181 a
22
13.2
72
43.1
52
31.1
21
12.6
N = 167 100.0
D max = .124 b
34
60
64
20.0
35.3
37.6
7.1
12
N = 170 100.0
D max = .179 a
7
43.8
37.5
6
3
18.8
_0
0.0
N = 16 100.0
D max = .313 c
p < .01.
p < .05.
p < .1.
1267
Decision to Treat
Patient-Therapist Contract
The first group of concerns to be considered consisted of four related primary issues regarding who
should be treated (Tab. 2). More than 70 percent of
the respondents perceived the basic question of establishing priorities for patient treatment when time or
resources are limited as moderately or highly frequent. 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, continuation 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 therapists working in nursing homes and chronic care
facilities.
The therapist's professional relationship to a patient is a major source of moral obligation. Basic
questions concerning the often-unspoken contract between 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 dilemma as the primary issue of the second group of concerns.
When deciding whom to treat, a therapist is required, in part, to consider two important aspects of
this type of professional judgment. First, it is becoming 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 profession 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, considerationpersonal 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 society's attitudes, may easily arise. The professional
organization's declaration of its values sometimes is
helpful in these instances. However, beyond this declaration, each physical therapist must decide what he
values as a health professional. Educators may need
to provide the student with the opportunity to examine his own values as he is formally and informally
socialized into the profession.
1268
PHYSICAL THERAPY
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TABLE 3
Obligations Deriving from the Patient-Therapist Contract
Frequency
n
1. Determining professional responsibilities when a
p a t i e n t s n e e d s or g o a l s conflict with the family's
n e e d s or g o a l s .
High
Mod
Min
None
High
Mod
Min
None
8
64
97
12
Difficulty
n
%
4.4
35.4
53.6
6.6
N = 181
100.0
D max = . 2 0 5 a
32
17.9
70
39.1
70
39.1
7
3.9
N = 169
Dmax
Ext
Mod
Min
None
N = 179
100.0
D max = . 2 8 9 a
Pediatric Facilities and School System Settings
High
9
45.0
Mod
6
30.0
Min
5
25.0
None
0
0.0
High
Mod
Min
None
N = 20
100.0
D max = . 4 5 a
52
28.0
83
44.6
49
26.3
2
1.1
N = 186
Dmax =
6. Weighing the effects of treatment against the discomfort created by the procedure.
High
Mod
Min
None
62
83
32
1
Ext
Mod
Min
None
100.0
%
9.5
42.0
38.5
10.1
100.0
.155 a
8
53
90
20
4.7
31.0
52.6
11.7
N = 171
100.0
5
51
102
26
2.7
27.7
55.4
14.1
N = 184
100.0
8
29
103
37
4.5
16.4
58.2
20.9
N = 177
100.0
14
61
73
34
7.7
33.5
40.1
18.7
N = 182
100.0
8
62
94
17
4.4
34.3
51.9
9.4
N = 181
100.0
2
17
108
39
1.2
10.2
65.1
23.5
N = 166
100.0
.239a
34.8
46.6
18.0
0.6
High
Mod
Min
None
N = 178
100.0
D max = . 3 1 5 a
39.5
73
44.9
83
14.1
26
3
1.6
High
Mod
Min
None
N = 185
100.0
D max = . 3 4 3 a
36
19.5
43.8
81
64
34.6
4
2.2
High
Mod
Min
None
N = 185
100.0
D max = . 2 2 8 a
51
29.0
65
36.9
28.4
50
5.7
10
Ext
Mod
Min
None
Ext
Mod
Min
None
Ext
Mod
Min
None
Ext
Mod
Min
None
N = 176
100.0
Dmax= .193a
a
16
71
65
17
Ext
Mod
Min
None
p < .01.
1269
TABLE 4
Moral Obligation and Economic Issues
Frequency
n
1. Deciding whether to represent certain n e c e s s a r y
patient s e r v i c e s in a way that would meet thirdparty-payer limitations.
High
Mod
Min
None
36
51
42
15
%
25.0
35.4
29.2
10.4
High
Mod
Min
None
17.8
38.0
36.4
7.8
N = 129
100.0
Dmax = . 1 7 2 a
69.2
15.4
7.7
7.7
9
2
1
1
N = 13
100.0
D max = . 4 4 9 a
12
10.3
14
12.1
29
25.0
52.6
61
N = 116
23
49
47
10
Ext
Mod
Min
None
N = 144
100.0
Dmax= .146a
Nursing Home or Chronic Care Facilities
High
Mod
Min
None
Difficulty
n
21
16
13
5
Ext
Mod
Min
None
100.0
38.2
29.1
23.6
9.1
N = 55
100.0
Dmax = . 1 7 3 b
p < .01.
p < .1.
TABLE 5
Physical Therapist's Relationship to Other Health Professionals
Frequency
n
1. Maintaining a patient's/family's c o n f i d e n c e in
other health professionals regardless of personal
opinions.
High
Mod
Min
None
12.7
42.5
37.6
7.2
23
77
68
13
N = 181
Dmax =
High
Mod
Min
None
High
Mod
Min
None
58
63
37
11
Difficulty
178a
34.3
37.3
21.9
6.5
8
62
75
23
Ext
Mod
Min
None
100.0
.
N = 169
100.0
Dmax = . 2 1 6 a
3.8
6
5
3.1
47.2
75
73
45.9
N = 159
Ext
Mod
Min
None
100.0
N = 168
Dmax = . 2 0 2 a
3.2
5
42
26.6
55.7
88
14.6
23
N = 158
100.0
37
28
17
4
43.0
32.6
19.8
4.7
Ext
Mod
Min
None
N = 86
100.0
Dmax =
High
Mod
Min
None
High
Mod
Min
None
5
28
88
52
2.9
16.2
50.9
30.1
N = 173
100.0
7
22
90
48
4.2
13.2
53.9
28.7
N = 167
100.0
43.0
21.5
25.6
9.9
100.0
N = 121
Dmax = . 1 8 a
29.2
35
42
35.0
25.8
31
12
10.0
N = 120
Dmax
100.0
.256a
52
26
31
12
Ext
Mod
Min
None
Ext
Mod
Min
None
4.8
36.9
44.6
13.7
100.0
.15a
p < .01.
1270
PHYSICAL THERAPY
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TABLE 6
Conflicts Between Two Ethical Principles
High
Mod
Min
None
Frequency
n
%
2
1.1
14.2
25
100
56.8
49
27.8
N = 176 100.0
Ext
Mod
Min
None
Difficulty
n
26
50
44
5
N = 125
Dmax
%
20.8
40.0
35.2
4.0
100.0
.21 a
p < .01.
sional. However, such a decision clearly poses moderate difficulty in the case of another health professional and extreme difficulty in the cases of another
physical therapist or a physician, when it needs to be
made.
1271
CONCLUSION
Complex ethical issues have emerged with the development 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
REFERENCES
1. Purtilo RB: The American Physical Therapy Association's
code of ethics. Phys Ther 57:1001 - 1 0 0 6 , 1977
2. Thompson IE: The implications of medical ethics. J Med
Ethics 2:74-82, 1976
3. Purtilo RB: Understanding ethical issues. Phys Ther 54:239243, 1974
4. Jameton A: The nurse: When roles and rules conflict. Hastings Cent Rep 7(4):22-23, 1977
5. Callahan ME, Addoms EC, Schulz BF: Objectives of basic
physical therapy education. Phys Ther Rev 41:795-797,
1961
6. Addoms EC, Callahan ME, Schulz BF: Functions of the
physical therapist. Phys Ther Rev 41.793-794, 1961
7. Marton T: Ethics. Phys Ther Rev 30:178, 1950
8. Huppert CR: Organization of an inservice training program in
a physical therapy department. Phys Ther Rev 30:174-178,
1950
1272
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