2016, p. 187). Stakeholders may have different priorities that can cause ethical conflicts. Kornblau and Burkhardt (2012) suggest that clients, family members, significant others, friends, neighbors, coworkers, students, colleagues, support staff, policy makers, and vendors all have roles in the healthcare delivery system; therefore, they are all potential stakeholders. Additional groups may be relatives, first responders such as police and firefighters, employees, visitors, and research participants. Caring approach and ethics of caring As indicated earlier, according to Doherty and Purtilo (2016), the goal of making an ethical decision is to make a caring response. The basis of a caring response is the fiduciary relationship that physical therapy personnel as healthcare professionals have toward their clients. A fiduciary relationship is a legal and ethical concept. In such a relationship, a “person [in] whom another person has placed a special trust or confidence is obligated to watch out for the best interests of the other party” (Doherty & Purtilo, 2016, p. 255). Physical therapy practitioners have a fiduciary obligation to clients and their families to care for them in a trustworthy manner with dignity, allowing the clients a “voice” in determining the nature and course of treatment, and Ethical theories Ethical theories, like ethical approaches, help physical therapy personnel make ethical decisions. As mentioned, ethical approaches are considered more limited in scope than an ethical theory. Beauchamp and Childress (2013) list several conditions that distinguish a theory from an approach. These include clarity, coherence, completeness, simplicity, explanatory power, justificatory power, output power, and practicability. For physical therapy practitioners, a theory helps clarify the ethical dimensions of a case and provides an option for making an ethical decision. As with ethical approaches, physical therapy practitioners often use elements of more than one theory to make an ethical decision. Deontology and teleology There are several traditional ethical theories, but the two most prevalent in the healthcare literature are deontology and teleology. Deontological theory is based on the concept of duties and rights (Doherty & Purtilo, 2016). Deontological theories hold that you are acting rightly when you act according to duties. Physical therapy personnel have a duty to protect and fulfill another person’s (client’s, student’s, or research subject’s) rights. To act rightly, however, a physical therapist or physical therapy assistant has to know what his or her duties are and how they apply in a particular situation. Deontological decision making based on principles and duties are made without regard for the consequences of actions. For example, a client has a right to autonomy, which the practitioner has a duty to respect. Under deontological theory, no other considerations are valid (e.g., whether the therapist likes the client, the client has good moral character, or the client is cognitively impaired). The duty to respect the client’s right to autonomy trumps these and all other considerations. Teleological theory, in contrast, is based on consequences or “ends” (Purtilo & Doherty, 2011). Actions are utilitarian and seek the best or least harmful consequences for the actions taken. For example, if two treatment techniques are equally effective according to research studies, the practitioner should consider the consequences: Which technique will bring the most benefit? That is, which will provide the best outcome to the client within his or her situation? Sometimes, these two theories may appear in conflict. For example, a client has a right to beneficial treatment, but suppose the best treatment is painful, such as stretching to prevent muscle shortening and joint contracture. Does the practitioner continue to stretch the limb (duty) despite the pain, or does the practitioner respect the client’s pain and quit stretching, thereby reducing the pain but also increasing the risk of contracture (consequence)? In this case, the physical therapist has conflicting
finally assuring the clients that competent care will be provided using sound professional judgment. Physical therapy practitioners that focus on providing a caring response to their clients use an ethics of caring approach. In this approach, ethical decision making is guided by the needs and goals of the client and family within a particular context (Doherty & Purtilo, 2016). Therapists who practice the ethics of care recognize that it is the relationships they develop with their clients that bring moral significance to clinical practice. Thus, ethical decisions focus on preserving that relationship or connection with the client for responsible decision making. To maintain a trustful relationship with their clients, practitioners who use an ethics of care approach tend to search for practical and creative solutions to moral problems that involve compromise. It is no surprise that experienced clinicians tend to use an ethics of care approach as part of their ethical decision making because they are very good at creative decision making and client-centered care (Greenfield, 2006). duties – not to cause pain and the duty to improve the client’s well-being by preventing contractures. As a result, the therapist is faced with a moral dilemma. One interesting solution to this dilemma is based on the “rule of double effect” (Beauchamp & Childress, 2013). The rule of double effect has been used to justify causing tolerable discomfort (or temporary harm). It is invoked to justify an intervention that has two foreseen effects, one good (preventing contractures) and one harmful (pain), which is not always morally prohibited. To involve the rule, four conditions must be satisfied: 1. The nature of the act must be good (prevent contractures). 2. The practitioner intends only the good effect (elongates tissue); the bad effect (pain from stretching a contracted limb) can be foreseen but is not intended. 3. A distinction is made between means and effects: The bad effect must not be a means to the good effect (increasing pain is not the primary means to elongating the contracted tissue). 4. There must be proportionality between the good effect and the bad effect. That is, in the example considered here, the practitioner violates Rule 4 if he or she accidentally fractures the client’s arm while stretching the contracture. The reason is that there is no proportionality between the harm and the good effect. A practitioner may be tempted to “split the difference” and stretch the limb until the client’s pain is no longer tolerable. The result may or may not be enough to reduce the risk of contracture. When the practitioner reflects on how to balance the correct ratio of benefit to harm, he or she is using ethical reasoning. Virtue ethics Virtue ethics has a long tradition in Judeo-Christian ethics and Western philosophy (Doherty & Purtilo, 2016). Virtue ethics teaches that one acts ethically when one acts according to certain virtues. The moral virtues include courage, temperance, liberality; the intellectual virtue of wisdom, according to Aristotle (trans. 1953), governs ethical behavior. As mentioned previously, the core values of the APTA represent the moral values (virtues) that the profession seeks to instill and guide ethical behavior. Doherty and Purtilo (2016) suggest that the easiest way to understand virtue ethics is through the basic idea of character traits and moral character. A character trait is a disposition to act in a certain way. Those who have character traits that are often praised by others are often referred to as having high moral character (Doherty & Purtilo, 2016). Certain character traits – honesty, compassion, courage – enable an individual to be the
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