COURSE PRICE: $20.00
CONTACT HOURS: 2
This course has been approved by the Texas Board of Physical Therapy Examiners, course approval #46944EA.
The planners and authors of this CE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity.
This course meets the two-hour ethics and professional responsibility continuing education requirement for license renewal purposes for Texas PTs and PTAs.
Persis Mary Hamilton has a rich background in nursing, nursing education, and writing. She has written fourteen nursing textbooks for two major publishers. Her doctoral dissertation investigated the relationship of learning to behavioral objectives and visual design in a textbook. Persis Hamilton works with Wild Iris Medical Education to ensure compliance with American Nurses Credentialing Center accreditation guidelines. She is involved with assessing needs, planning, implementing, and evaluating all nursing continuing education activities offered by the company. Over the years Hamilton has worked in most areas of nursing. She taught for more than 40 years in vocational, associate degree, baccalaureate degree, and graduate nursing programs, served as item writer for the League for Nursing, and was the principle speaker at numerous continuing education workshops. In addition, she has conducted research in Micronesia as well as Guam. Currently, Persis maintains a private practice in psychotherapy. Recently she completed a historical novel about the care of psychiatric patients in the 1930's, entitled Deportation Train.
Copyright © 2010 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to provide physical therapists and physical therapist assistants with a theoretical basis for ethical decision-making and knowledge in the Code of Ethics and Guide for Professional Conduct of the American Physical Therapy Association (APTA), legal standards of behavior, and application of ethical and legal standards to real-life situations.
Upon completion of this course, you will be able to:
Many people roll their eyes and change the subject when they hear the word ethics, viewing it as too controversial or too complex to discuss freely. Nonetheless, ethics is a significant concern of thinking, caring persons, especially healthcare providers such as physical therapists (PTs) and physical therapist assistants (PTAs).
Ethics is a branch of philosophy concerned with the rightness or wrongness of human behavior and the goodness or badness of its effects. Because ethics assumes that people have the ability to make choices about their behavior it has been the subject of philosophical discussion for centuries, generating an enormous body of literature. Students of ethics divide these writings into three general categories: descriptive, analytical, and prescriptive.
Descriptive ethics reports and describes the moral choices people make.
Analytical ethics scrutinize the language people use to discuss issues of right and wrong.
Prescriptive ethics offers advice about the way people decide what is good or bad behavior, doing so from two different perspectives: teleological and deontological.
Bioethics is the application of ethics to matters of human life. As scientific knowledge expands and healthcare providers have greater control over life and death, it is necessary to address issues of right and wrong behavior. Although some authors use the term morals to refer to human behavior and ethics to refer to formalized codes of conduct, both words mean the same thing. Ethics comes from the Greek word ethos and morals from the Latin word mores. In recent years, some politicians have substituted the word values for morality, however the word values has a much broader meaning.
Values are treasured ideals and attributes, such as creativity, achievement, power, beliefs, and ethical principles. Understanding what one values brings purpose and clarity to life. Seeking such clarity was recognized by Socrates, who is credited with saying, "An unexamined life is not worth living." In its Code of Ethics and Standard of Ethical Conduct, the American Physical Therapy Association (APTA) identifies seven core values: altruism, accountability, compassion/caring, excellence, integrity, professional duty, and social responsibility.
Belief systems are organized patterns of thought regarding the origin, purpose, and place of humans in the universe. These systems seek to explain the mysteries of life and death, good and evil, health and illness. Typically, belief systems include an ethical code of conduct about how people should relate to the world and its inhabitants.
Religions are schemes of thought and action that usually include belief systems, faith in a mystical power, devotional rituals, and organizational structures. Though some religions are centuries old, with myriad adherents, others are relatively new, with only a handful of followers. The U.S. Constitution specifically denies Congress the right to make laws regarding religious thought and practice.
Ethical principles are fundamental concepts by which people judge behavior. These principles help individuals make decisions and serve as criteria against which people gauge the rightness or wrongness of behavior. Laws are rules made by an authority with the power to enforce them. Although laws flow from ethical principles, they are limited to specific situations and codified by detailed language. Ethical principles, on the other hand, are guiding ideals of conduct that speak to the spirit of a law rather than its letter.
Throughout recorded history, leaders of world religions have taught an overarching ethical principle commonly called the Golden Rule: "Do unto others as you would they do unto you." Some philosophers emphasize certain principles over others. For example, Kant held that duty was the central issue; Mills, the interest of all; Fletcher, love; Thiroux, human dignity; Gilligan, care and justice; and Nodding, care (Thiroux, 2003). A single, global principle for exemplary behavior is an attractive approach, but when people face real-life situations, they seek more precise guidance.
Over the years, five ethical principles have emerged as especially applicable to healthcare providers. They are: respect for human life and dignity, beneficence, autonomy, honesty, and justice. The Code of Ethics of the American Physical Therapy Association, described below, applies all five principles to practice.
Respect for human life and dignity is one of the most basic of ethical principles. It requires that "individuals be treated as unique and equal to every other individual and that special justification is required for interference with an individual's own purposes, privacy, and behavior" (Rawls, 1971). This ethical principle elevates respect for the life, freedom, and privacy of all humans. Thiroux says this principle is necessary for any moral system because "there can be no human being, moral or immoral, if there is no human life" (1990). When applied to practice, respect for human life and dignity means that physical therapists (PTs) and physical therapist assistants (PTAs):
Beneficence means doing good to benefit others. Although some writers separate beneficence (doing good) from nonmalfeasance (not doing harm), Franken (1973) suggested the ethical principle of beneficence is a continuum, from a neutral not harming to a positive doing good—that is, from not inflicting harm to preventing harm and promoting good. At a minimum, beneficence means maintaining professional competence. However, it also means acting in ways that demonstrate care and nurturance. When applied to practice, beneficence means that PTs and PTAs:
Autonomy is the right of self-determination, independence, and freedom. It is the personal right of individuals to absorb information, comprehend it, make a choice, and carry out that choice. Physical therapists carry out the principle of autonomy by providing accurate, scientific information to clients, assisting them to understand the information and make decisions based on it. When applied to practice, autonomy means that PTs and PTAs:
Honesty means truthfulness in word and deed. Even when conveying unwelcome information to clients about their illness or treatment options, a physical therapist does so truthfully and with compassion, only withholding information from clients when they are minor children or adults with legal guardians. Dishonesty and deceit are especially grievous when they involve theft of pain-relieving drugs or devices. Honesty means absolute truthfulness regarding professional credentials and financial matters, never charging for unearned services or accepting commissions, discounts, or gratuities for covert gain. It means obeying both the spirit and the letter of the law. When applied to practice, honesty means that PTs and PTAs:
Justice implies fairness and equality. It requires impartial treatment of clients. Like other ethical principles, justice is based on respect for human life and dignity. The historic image of justice is a blindfolded woman with a scale, weighing an issue on the basis of objective evidence and judicial precepts. Justice means that scarce resources will be distributed equally, using the same criteria for everyone. When applied to practice, justice means that PTs and PTAs:
A dilemma is a perplexing problem that requires a choice between conflicting alternatives. An ethical dilemma is a moral problem that requires a choice between two or more opposite actions, each of which is based on an ethical principle. For example, a physical therapist may need to decide whether to honor the ethical principle of honesty and disclose the unlikely value of a treatment to cure an illness or to honor the principle of beneficence and withhold the information in order to give the client hope.
Resolution of ethical dilemmas requires careful evaluation of all the facts of a case, including applicable laws, consultation with all concerned parties, and appraisal of the decision-makers' ethical stance (honoring end results or obeying fixed laws).
Nowadays, ethical dilemmas in healthcare facilities arise more frequently because modern medicine can keep hearts and lungs functioning much longer than thinking brains. To help resolve these perplexing issues, many institutions appoint ethics committees made up of healthcare professionals, ethicists, lawyers, and clergy. The task of ethics committees is to help decision-makers resolve ethical dilemmas. Often these committees use an ethical decision-making process such as the following:
To reduce the number and complexity of ethical dilemmas, and in support of the ethical principle of autonomy, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recommends that all adults discuss their wishes regarding extraordinary treatment measures with their families, sign a legal document called an advance healthcare directive, and appoint someone to make healthcare decisions in their stead if they should become incapacitated (JCAHO, 2009).
Codes of ethics are formal statements setting forth standards of ethical behavior for members of a group. In fact, one of the hallmarks of a profession is that its members subscribe to a code of ethics. In order to make explicit the values and standards of professional physical therapists and their assistants, the American Physical Therapy Association revised the Code of Ethics and Guide for Professional Conduct for Physical Therapists and the Standards of Conduct and Guide for Conduct of the Physical Therapist Assistant in July 2009, effective July 1, 2010. The Texas State Board of Physical Therapy Examiners (TSBPTE) endorsed these standards of behavior.
Every member of a profession is expected to read, understand, and abide by the ethical standards of its occupation. The Preamble and Principles/Standards and their applications are reproduced below. The complete Guide for Professional Conduct and Guide for Conduct of the Physical Therapist Assistant can be accessed at http://www.apta.org/ethics.
CODE OF ETHICS FOR PHYSICAL THERAPISTS
Preamble
The Code of Ethics for the Physical Therapist delineates the ethical obligations of all physical therapists as determined by the House of Delegates of the American Physical Therapy Association. The purposes of this Code of Ethics are to:
No code of ethics is exhaustive nor can it address every situation. Physical therapists are encouraged to seek additional advice or consultation in instances where the guidance of the Code of Ethics may not be definitive.
This Code of Ethics is built upon the five roles of the physical therapist (management of patients/clients, consultation, education, research, and administration), the core values of the profession, and the multiple realms of ethical action (individual, organizational, and societal). Physical therapist practice is guided by a set of seven core values: accountability, altruism, compassion/caring, excellence, integrity, professional duty, and social responsibility. Throughout the document the primary core values that support specific principles are indicated in parentheses. Unless a specific role is indicated in the principle, the duties and obligations being delineated pertain to the five roles of the physical therapist. Fundamental to the Code of Ethics is the special obligation of physical therapists to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness, and enhanced quality of life.
Principles
Source: APTA, 2009. Reprinted from APTA Code of Ethics, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.
STANDARDS OF ETHICAL CONDUCT FOR THE PHYSICAL
THERAPIST ASSISTANT
Preamble
The Standards of Ethical Conduct for the Physical Therapist Assistant delineate the ethical obligations of all physical therapist assistants as determined by the House of Delegates of the American Physical Therapy Association. The Standards of Ethical Conduct provide a foundation for conduct to which all physical therapist assistants shall adhere. Fundamental to the Standards of Ethical Conduct is the special obligation of physical therapist assistants to enable patients/clients to achieve greater independence, health, and wellness, and enhance quality of life.
No document that delineates ethical standards can address every situation. Physical therapist assistants are encouraged to seek additional advice or consultation in instances where the guidance of the Standards of Ethical Conduct may not be definitive.
Standards
Source: APTA, 2009. Reprinted from APTA Standards of Ethical Conduct for the Physical Therapist Assistant, with permission of the American Physical Therapy Association. This material is copyrighted, and any further reproduction or distribution is prohibited.
Although physical therapists and physical therapist assistants gain professional certification from their national organization, they must be licensed to practice in their own state. For that reason, both PTs and PTAs need to understand the relationship of ethics to law, the basis of United States law, sources and types of laws, some salient legal concepts, standards and guides for professional conduct, and application of ethics and law to the practice of physical therapy.
Laws flow from ethical principles and are limited to specific situations and codified by detailed language. These rules of conduct are formulated by an authority with power to enforce them. As such, laws change with time and circumstances. In the United States, law is based on the old English system wherein the monarch held supreme power over the land and its people, acting according to "divine right." The ruler's decisions became the law of the land and eventually known as common, or case, law. These case-by-case decisions set precedent and shaped future laws.
In the United States, the U.S. Constitution is the supreme law of the land, filling the role once held by the monarch. The first ten amendments to the Constitution, the Bill of Rights, place restrictions on the power of government and establish specific individual freedoms, such as the right to free speech and assembly. When residents of the nation believe they have been denied any of these rights, they can seek redress in the courts.
The U.S. Constitution established three separate branches of government within the federal system—executive, legislative, and judicial—and granted specific powers to the federal government that are called express powers. Under the Tenth Amendment, all other powers are retained by the states, including licensure of healthcare professionals such as physical therapists and physical therapist assistants. As a result, both the federal government and the state governments create and enforce laws.
In the states, the division of power mirrors that of the federal government:
| Source: Adapted from Hamilton, 1996. | |
| CONSTITUTIONAL LAW | |
|---|---|
| Source | U.S. Constitution, the supreme law of the nation |
| Functions | Establishes executive, legislative, judicial branches of government |
| Examples |
|
| STATUTORY LAW | |
| Source | Laws passed by legislative bodies of federal, state, and local governments |
| Functions | Protects and provides for the general welfare of society |
| Examples | Controlled Substances Act of 1970 created a schedule of controlled substances, ranking them according to their potential for abuse from high (I) to low (V). |
| ADMINISTRATIVE LAW | |
| Source | Executive power of federal, state, and local government, delegated by the legislative branch |
| Functions | Carries out special duties of various agencies |
| Examples |
|
| COMMON (CASE) LAW | |
| Source | Precedent, custom, tradition, court-made |
| Functions | Avoids duplication and unnecessary expense of litigating issues many times |
| Examples | Amendment 14 grants "equal protection of the law," but because of Plessy v. Fergson, an 1896 decision of the Supreme Court, several states continued to segregate children by race in public schools. In 1954, the Brown v. Board of Education decision said, "Separation of children in public schools solely on the basis of race deprives children of a minority group equal educational opportunities, even though physical facilities and other tangible factors may be equal." |
There are two major divisions of law: civil and criminal. The purpose of civil law is to make restitution for injury suffered by one or more individuals. Civil law is further divided into contract law and tort law. Contract law is concerned with legally binding agreements between two or more parties. Tort law is concerned with civil wrongs other than contracts, such as assault, battery, and professional negligence.
The purpose of criminal law is to protect society from actions that directly threaten the order of society. Because some crimes are more serious than others and children are considered less responsible than adults, there are three categories of criminal offenses: misdemeanor, felony, and juvenile (see table).
| Source: Adapted from Hamilton, 1996. | |
| CIVIL LAW | |
|---|---|
| Function | To redress wrongs and injuries suffered by individuals |
| Categories |
|
| Proof | By a preponderance of the evidence; adjudicated by a judge or jury; a jury decision need not be unanimous |
| CRIMINAL LAW | |
| Function | To protect society from actions which directly threaten its orderly existence. Criminal acts, while aimed at individuals, are offenses against the state, thus perpetrators are punished by the state (imprisoned, fined, required to perform hours of work); victims usually are not compensated but may initiate civil action against perpetrators to make up for injury or loss. |
| Categories |
|
| Proof | Beyond a reasonable doubt; jury decision must be unanimous |
Historically, healthcare regulation has been the province of the states, but in recent years the federal government has become increasingly involved. Of particular interest to the practice of physical therapy are three acts of Congress, namely, the Social Security Act, the Americans with Disabilities Act, and the Health Insurance Portability and Accountability Act.
Medicare is a social insurance program administered by the United States government providing health insurance coverage to people 65 years of age or older and those who are disabled and meet other criteria. Medicare has two parts:
Medicaid is a joint federal and state program that helps pay medical costs for people with low incomes and limited resources. State participation is voluntary, but since 1982 all states have taken part, though benefits vary from state to state. Each administers its own program and may use its own unique name. Providers of health services, including physical therapy, must be authorized by the designated state government agency.
The Americans with Disabilities Act (ADA) of 1990 is a broad-reaching civil rights statute. Amended in 2008 to broaden protections for disabled workers, it protects the rights of people with a variety of ailments, including persons infected with human immunodeficiency virus (HIV) and those with respiratory and musculoskeletal disorders. Its provisions include measures of special interest to physical therapists, such as access to public buildings, equal protection of disabled persons, and nondiscrimination in employment (USDJ, 2008).
The Health Insurance Portability and Accountability Act (HIPAA) of 1996 limits the extent to which health insurance plans may exclude care for pre-existing conditions and creates special programs to control fraud and abuse within the healthcare system. The most well-know provision of the Act is its standards regarding the electronic exchange of sensitive, private health information. Known as privacy standards, these rules (1) require the consent of clients to use and disclose protected health information, (2) grant clients the right to inspect and copy their medical records, and (3) give clients the right to amend or correct errors. Privacy standards require all hospitals and healthcare agencies to have specific policies and procedures in place to ensure compliance with the rules (USDHHS, 2009c).
All fifty states and jurisdictions of the United States have physical therapy practice acts. Typically, these acts create an administrative body within the state to define the scope and regulate the practice of physical therapy. The administrative body, called a board, writes rules and regulations that give detailed requirements for educational institutions and practitioners regarding the scope of practice, licensure, competency, disciplinary sanctions, and supervision of physical therapist assistants and aides. The goal of these acts is to protect the public by setting standards for education and practice.
Although PTPAs vary from state to state, they contain similar grounds for complaints, including obtaining a license by fraud, practicing in a grossly incompetent or negligent manner, diverting controlled substances for personal use, and being convicted of a felony. It is the responsibility of license holders to know, understand, and obey the rules and regulations of the state in which they are licensed to practice.
The Texas State Board of Physical Therapy Examiners administers and enforces the Texas Physical Therapy Practice Act and is responsible to the citizens of Texas to maintain the standards set forth in the Act. Information is available at the website of The Executive Council of [Texas] Physical Therapy and Occupational Therapy Examiners.
CASE 1
The neighbor of Molly Soft, PTA, repeatedly complains about her painful neck and asks Molly to treat her. At first Molly refuses, but eventually she gives in and performs four manual therapy treatments on the neighbor's cervical spine. At first the treatments help, but after the fourth one the neighbor complains of increased neck pain.
Molly has violated a specific standard of professional conduct, the one that requires a PTA to work under the direct supervision of a PT (Standards of Ethical Conduct, 3E).
Discussion
What action should Molly take?
Suggested Answer
Molly should refer her neighbor to a physician for examination and treatment. She needs to tell the neighbor that Molly, as PTA, should not be treating her without supervision. Molly has put both her neighbor and herself in jeopardy.
CASE 2
Joe Peters, PT, feels a strong sexual attraction for one of his clients. He is considering asking his client for a date, and he shares his thoughts and feelings with a colleague.
If Joe pursues his sexual interest, he will violate principle 4E of the Code of Ethics, which prohibits a PT from engaging in any sexual relationship with any client.
Discussion
If you were Joe's colleague, what would you advise him to do?
Suggested Answer
Joe should terminate his relationship with the client before he pursues a personal relationship. He should ask his supervisor to assign someone else to the client.
CASE 3
Paul Krug, PTA, is employed by a home-health agency. He is assigned the ongoing care of a 75-year-old woman of Middle Eastern descent who is recovering from hip-replacement surgery. When he returns to the office each day, he has another story to tell about the "crazy old woman who insists on wearing a scarf on her head," whose culture he scorns.
Clearly, Paul disrespects his patient and has no sympathy for her sense of propriety in the presence of a man. This is a violation of standard 1A of the Standards of Ethical Conduct. Furthermore, Paul may not recognize his own personal biases relative to ethnicity, disability, religion, age, or the like. This is a violation of standard 1B of the Standards of Ethical Conduct.
Discussion
If you were a colleague of Paul, what action should you take?
Suggested Answer
Colleagues should tell Paul that he is showing disrespect for his patient and is demonstrating his own biases. The PT who supervises Paul should consider providing in-service education about respecting the inherent dignity and rights of all individuals.
CASE 4
A 33-year-old client is admitted with severe, systemic cellulitis, with weeping sores covering her legs and lower torso. Lisa Newsom, a new PT graduate, is asked to administer wound care. Although Lisa received wound care instruction during her education, she has not done it since graduation and does not feel she has the experience or competence to treat the client.
Principle 6B of the Code of Ethics requires that PTs "take responsibility for their professional development based on critical self-assessment." Principle 3C states that PTs "shall make judgments within their scope of practice and level of expertise."
Discussion
What should Lisa do?
Suggested Answer
Lisa should discuss the problem with her supervisor at once, preferably asking to observe a demonstration of wound care by a competent colleague; after which, she should give a satisfactory return demonstration.
CASE 5
Diana Learner, PTA, has just taken a position with a healthcare agency in town. On her fourth day at work, a client phones to say she must cancel her mid-morning appointment. Diana's immediate supervisor tells her to document the treatment as if it had taken place, because "we reserved the time and that counts as an appointment." Diana does not feel right about recording something that is not true.
Indeed, Diana should feel uncomfortable about such deceit. To do so would be a clear violation of Standards of Ethical Conduct, namely 7D, requiring that "documentation for their interventions accurately reflect the nature and extent of the services provided."
Discussion
What should Diana do?
Suggested Answer
Diana is a new employee and especially vulnerable. Pleasantly but honestly, she should explain to her supervisor that such an act violates ethical standards and that she does not want to taint the reputation of the agency. If the supervisor insists on false documentation, Diana should consult with the local APTA branch, follow their advice, and seek other employment.
American Physical Therapy Association (APTA). (2009). Code of Ethics. Retrieved October 15, 2009, from http://www.apta.org.
American Physical Therapy Association (APTA). (2009). Standards of Ethical Conduct for the Physical Therapist Assistant. Retrieved October 15, 2009, from http://www.apta.org.
Franken WK. (1973). Ethics. Paramus, NJ: Prentice-Hall.
Hamilton PM. (1996). Realities of Contemporary Nursing (2nd ed.). Menlo Park, CA: Addison-Wesley Nursing.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2009). Hospital Accreditation Standards. Oakbrook Terrace, IL: JCAHO.
Raths LE, Harmin M, Simons SB. (1979). Values and Teaching (2nd ed.). Columbus, OH: Merrill.
Rawls JA. (1971). A Theory of Justice. Cambridge, MA: Harvard University Press.
Thiroux JP. (2003). Ethics, Theory and Practice (8th ed.). New York: Macmillan.
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2009a). Medicare Program: General Information. Retrieved October 20, 2009, from http://www.cms.hhs.gov/MedicareGenInfo.
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2009b). Medicaid Program: General Information. Retrieved October 20, 2009, from http://www.cms.hhs.gov/MedicaidGenInfo.
U.S. Department of Health and Human Services, Health Information Privacy. (2009c). HIPPA Administrative Simplification Statue and Rules. Retrieved October 21, 2009, from http://www.hhs.gov/ocr/privacy/hipaa/administrative/index.html.
U.S. Department of Justice. (2009). Americans with Disabilities Act of 1990, as amended. Retrieved October 21, 2009, from http://www.ada.gov.
