Autonomy The third client care ethical principle states that physical therapy personnel shall respect the right of the individual to self-determination. Often autonomy is referred to as the self- determination principle. However, respect for autonomy goes beyond acknowledging individuals as mere agents and also acknowledges, according to Beauchamp and Childress (2013), “the right to hold views, to make choices and take action based on their values and beliefs” (p.106). Autonomy has become a prominent principle in healthcare ethics; the right to make a determination regarding care decisions that directly affect the life of the service recipient should reside with that individual. The APTA Code of Ethics for the Physical Therapist (2010b) addresses physical therapists’ responsibilities regarding the rights of others to information, communication, and independent decision making: ● “Physical therapists shall provide the information necessary to allow the patients or their surrogates to make informed decisions about physical therapy care or participation in clinical research” (APTA, 2010b, Principle 2C). ● “Physical therapists shall collaborate with patients/clients to empower them in decisions about their health care” (APTA, 2010b, Principle 2D). ● “Physical therapists shall protect confidential patient/client information and may disclose confidential information to appropriate authorities only when allowed or as required by law” (APTA, 2010b, Principle 2E). In health care, two important examples of the principle of autonomy are informed consent and confidentiality . Informed consent As indicated in Principle 2C, clients have a fundamental right to direct what happens to their bodies, and as such, healthcare professionals have an ethical (and in many cases a legal) obligation to involve clients in the process of shared decision making and seek clients’ informed consent for evaluations and treatment. Elements of informed consent are to inform a client of the relevant risks, benefits, and uncertainties of a treatment and each alternative procedure; the consequences of nontreatment; goals of treatment; and the prognosis for achieving the goals (Beauchamp & Childress, 2013). It is important to appreciate that informed consent is more than a simple checklist but a process in which the practitioner, client, and/or client’s family or surrogate (if the client is a minor or lack’s the capacity to make an informed decision) to engage in a dialogue that fosters shared understanding. Shared understanding suggests that each stakeholder understands and respects the values, goals, and aims of the other, thus leading to a respectful process of shared decision making for informed consent (Moore & Kaplan, 2018). Some practitioners are challenged about how much information is necessary and adequate to allow a client or family to make an informed decision. On the basis of case law, the prudent person test has provided a guideline to help practitioners. According to this test, the information given to a client must be sufficient to satisfy and fully inform a prudent and reasonable person so that he or she can decide whether to undergo a treatment (Kegley, 2004). In some clinics, healthcare professionals ask clients to sign routine or blanket consent. A blanket consent asks clients to agree to all procedures deemed necessary on the basis of the client’s diagnosis and judgment of the physical therapist. However, blanket consent is insufficient consent for individual treatments that may pose risk and potential harm. For informed consent, a person must have the ability (physical and cognitive), opportunity (context, environment, situation, or circumstance), and freedom to make an autonomous choice or decision. But determining whether a person has the cognizance and emotional ability to understand and make choices is sometimes difficult for healthcare professionals to ascertain.
The question in each case is whether individuals have the capacity to make a healthcare decision or, in essence, to be treated autonomously. In addition to performing a mental status examination, Tunzi (2001) suggests that four specific abilities should be assessed: ● The ability to understand information about treatment. ● The ability to appreciate how that information applies to treatment. For physical therapy practitioners, these assessments can be done through a clinical interview or through a formal, validated questionnaire. Confidentiality The obligation of ensuring client confidentiality is rooted in the ethical obligation of autonomy and is described in Principle 2E in the APTA Code of Ethics for the Physical Therapist (2010b) . The principle of confidentiality applies to students in an education program, to participants in research studies, and to the public who seek information about physical therapy services (APTA, 2010b, Principle 7). According to Beauchamp and Childress (2013), confidentiality is present when “one person discloses information to another, whether through words or examination, and the person to whom information is disclosed pledges not to divulge that information to a third party, without the confider’s permission” (p. 318). The limits and scope of confidentiality can be a contested ethical and legal concept. To understand the limits of confidentiality, it is important to understand the difference between privacy and confidentiality. It is generally accepted in the United States that everyone has a right to privacy – the control over the extent, timing, and circumstances of sharing oneself (physically, behaviorally, or intellectually) with others (Andrews, Mehlman, & Rothstein, 2006). In health care, health information of individuals is protected by the Health Insurance Portability and Accountability Act (HIPAA) from disclosure of personnel information (U.S. Department of Health & Human Services, n.d.a.). The Privacy Rule protects all individually identifiable health information held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. Protection of inadvertent disclosure of private health information is particularly challenging and important with ● The ability to reason with that information. ● The ability to make a choice and express it. the ubiquity of access to electronic medical records. Although some use the terms privacy and confidentiality interchangeably, they are not the same. Privacy is information that an individual keeps to himself or herself and chooses not to share with others. Confidentiality is viewed as an extension of privacy, in that an individual has voluntarily disclosed, in a relationship of trust, private information about himself or herself with the expectation that it will not be divulged without permission (Andrews et al., 2006). Although the expectation is that privacy is a constitutional right that under most conditions is absolute, that is not the case with confidentiality. Are there circumstances when a physical therapist or physical therapy assistant is ethically and legally allowed to disclose confidential information without the consent of his or her client? Take, for example, a case in which a client confides in her physical therapist that she is planning to physically harm another or herself. Most would agree that the physical therapist has an obligation to protect the public welfare and safety and can disclose this information to the proper authorities. But what about the case vignette about Jay that was described earlier? If you recall, Jay is HIV positive and to be discharged home where his sister will provide wound care. He asks his physical therapist not to reveal to his sister that he is HIV positive. Is this an instance in which his therapist should break confidentiality and disclose to Jay’s sister about his HIV status? Perhaps Jay’s therapist can honor his request for confidentiality while at the same time protecting the welfare and safety of his sister by instructing her in meticulous wound care protocol.
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