Common ethical issues in physical therapy practice What are the common issues faced by physical therapy personnel in contemporary practice? In a recent article, Richardson (2015) describes how the current healthcare system often challenges physical therapists to compromise what is best for the client because of fiscally driven rules. In a seminal research article, Herman Triezenberg (1996) used a series of focus group interviews to identify three categories of ethical issues common in physical therapy practices: issues related to client rights and welfare, issues associated with professional responsibilities and role, and issues involving business relationships and economic considerations. The following case vignette illustrates an important issue related to clients’ rights and welfare – the limits of client confidentiality: Jay is about to be discharged home from the hospital as he recovers from a gunshot wound to the shoulder. He will need PT as well as wound care. Beth is a physical therapist who will be seeing him for PT after his discharge, and she learns that Jay’s sister, Marie, will do most of his wound care. Beth also learns that Jay is HIV positive and that he begs the staff to keep his HIV status confidential, especially from his family. He is afraid his father will evict him. Beth faces an ethical dilemma: Should she maintain confidentiality in keeping Jay’s HIV condition secret? Or should she break confidentiality because she has an obligation to protect the welfare of Marie? Of course, in grappling with this issue, it is likely that Beth is also experiencing moral distress because she is not certain what is the right or best course of action. The following case vignette illustrates moral distress based on an issue relating to professional roles and responsibilities and the concomitant duty of physical therapy personnel to report misconduct: Angela and Rod were classmates in school, and both now work as physical therapists at the local hospital. Rod is aware from socializing outside of class that Angela likes to go drinking. Nine months after accepting the job, Rod notices that Angela is consistently late to work, seems sluggish in the morning, and makes numerous documentation errors. Rod walks into the break room at 10 a.m. and sees Angela placing a flask into her locker. Rod is ethically and legally obligated to report Angela’s behaviors to the state board of physical therapy if indeed he suspects she is abusing alcohol while caring for clients (APTA, 2010b). Yet it is not clear to Rod whether Angela is indeed
drinking because he does not know with certainty what is in the flask. He is also distressed about potentially reporting a classmate and friend. This case raises the question of what Rod’s obligations are to Angela, the local hospital, and society. Is this an ethical or legal case, or both? What does the APTA Code of Ethics for the Physical Therapist say? What about state practice acts? In a situation like this, the therapist who suspects inappropriate behavior must have evidence. Protocols need to be followed – not only the institution protocols and Code of Ethics for the Physical Therapist, but most state practice acts have an “Impaired Practitioner” clause and define steps to report substance abuse. Finally, an important issue involves business relationships and economic factors. The involvement of physical therapists in business relationships that have the potential for exploitation is illustrated in the following case vignette: Mary is a physical therapist who recently took a position with a home health agency. The agency has negotiated a value-based payment (VBP) model with Medicare that incentivizes cost- effective care. The VBP provides incentives for a few specific elements of a single disease or condition that may neglect the complexity of care for the whole patient. Mary is treating an elderly woman recovering from a hip fracture to restore function. Although the patient’s Medicare reimbursement has an established cost-containment model that rewards outcomes based on cost, Mary’s patient presents with multiple morbidities that contribute to a slow recovery. Mary is faced with moral distress and a moral dilemma in that her company wants to discharge the patient within the standard parameters and time constraints established by the VBP for patients with hip fractures. Mary believes that the complexity of conditions presented by this patient does not fit the VBP for her primary condition and requires additional physical therapy. These three case vignettes raise some of the following questions. What are the issues? What are the obligations of the physical therapists and their justifications? What would be the most practical action to take and why? Physical therapy personnel should reflect on these questions as they continue to the next section, which explores theories and approaches as tools to help make ethical decisions. These tools will be applied to an ethical decision-making model to address the questions raised by these case vignettes.
ETHICAL APPROACHES, THEORIES, AND PRINCIPLES: TOOLS FOR ETHICAL DECISION MAKING
Making ethical decisions can be quite daunting in clinical practice when ethical issues unexpectedly arise and physical therapy practitioners are unable to clarify the issue or issues to make a fair and justifiable ethical decision. Doherty and Purtilo (2016) suggest that the focus of an ethical decision is a caring response that is directed toward the best interest, goals, and values of the client. Conceptual tools that help physical therapy practitioners make a caring response include the use of ethical Ethical approaches Several approaches have been identified to help physical therapy practitioners make ethical decisions. An ethical approach is a step (and a component) in an overall framework of ethical decision making. Depending on the ethical case and the type of information practitioners may need, they may choose to use one or more of these approaches in their ethical decision-making framework (Doherty & Purtilo, 2016). Narrative approach In the presence of an ethical issue, physical therapy practitioners often have limited information to make a caring response. An
approaches and theories. According to Doherty and Purtilo (2016), an ethical theory is well developed and expansive and provides physical therapy practitioners with assumptions about right or wrong or good and bad actions. In contrast, an approach is not a complete system or model but an aid to existing theories. The following section reviews basic but important approaches and theories that provide physical therapy personnel guidance in making ethical decisions. important step in making an ethical decision is to “get the story straight.” That means expanding the narrative of a case to fill in gaps in the story. The narrative approach to ethics is based on the observation that humans are storytelling creatures by nature and pass on information by sharing stories to make sense of experiences. As often is the case, many situations involving moral issues are presented or recalled in fragments in which only one perspective (the narrator) is favored and the perspectives of other stakeholders are not readily apparent. A stakeholder is “a person, group, or other entity that has a deep and compelling interest in a situation that it wants to protect” (Doherty & Purtilo,
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