Responding to the moral dimensions of Physical Therapy practice

This special issue on ethics and professionalism in physical therapy is a wonderful collection of the work of many noteworthy authors from different parts of the globe. Each contribution in this issue demonstrates that ethical analysis and reflection continues to thrive in the physical therapy profession.

Taken as a whole, the special edition reflects a ‘movement’ in physical therapy ethics knowledge and practice, which draws from the needs of real patients and real challenges encountered by physical therapists in their everyday practice. This movement in the moral gaze of the profession was predicted earlier by Purtilo (2000),¹ when she suggested that the moral tasks for physical therapists will shift from a primary focus on the nature of ethical obligations in patient and collegial relationships, to one where the ‘moral foundations for a true professional partnering with the larger community of citizens and institutions’ will assume greater significance.

As the physical therapy profession advances, patient needs, and the scope and realms of clinical practice become more complex and the right clinical action becomes less prescribed, certain and defined. Such a practice landscape raises two key questions, both of which are addressed in the papers in this edition: What are the ethical issues facing physical therapists in 2012 and beyond?, and; How can the profession as a whole, and individual therapists best respond to them?

Sim and Dawson identify the growing role of physical therapy in the area of public health care and the consequent need to examine practice from a public health ethics perspective. These authors suggest physical therapists will increasingly need to weigh up priorities and use of resources for individuals, communities and patient populations. Using a public health ethics lens will also impact on the meaning of respect for a person’s autonomy. When individual autonomy is weighed against competing interests of others who would benefit from preventative health care, the role of the physical therapist is likely to change. Playing a role in public health ethics will also, according to Sim and Dawson raise questions for physical therapists about the extent of their involvement in the politics associated with delivery of health care. This paper provides important signposts for physical therapists to consider as their work extends beyond the sphere of the individual patient.

Three papers focus on ethics education as a way of equipping physical therapists to respond to the expanding moral dimensions of their practice. Jensen and Greenfield suggest ethics education is a crucial tool for increasing physical therapists’ capacity to respond to the diverse ethical challenges in clinical practice. A key purpose of ethics education, according to these authors is to develop in students, a capacity for critical self reflection, mindfulness and dispositions of life-long learning. While the evidence based practice movement has ensured physical therapists continually update their knowledge and skills, Jensen and Greenfield’s paper provides a curriculum framework for physical therapy educators to encourage in their students similar life-long learning ‘habits of mind’ for ethical practice.

Edwards et al and Swisher et al provide companion papers which use empirical methods to evaluate changes in physical therapy students’ moral reasoning and the organisation of their ethical knowledge following a short intensive undergraduate ethics course. For those who teach ethics to physical therapy students, these two papers provide some evidence that such teaching is effective in advancing students’ ethical knowledge and reasoning. The papers report on two different questions explored in research carried out with 37 students in the final year of their undergraduate physical therapy degree.

Swisher et al take a cognitive developmental approach using Rest’s defining issues test (DIT2)² to assess changes in students’ moral reasoning. The findings from this research indicate that a 6-week intensive ethics education module focussing on transformative learning, reflection and relationships between ethical and clinical knowledge can achieve gains in moral reasoning capacities of undergraduate physical therapy students. Importantly, this research suggests ethics education can facilitate ethical reflection by students.

In the Edwards et al paper, the authors focus on how the 6-week ethics course influenced students’ organisation of ethical reasoning knowledge. Using concept maps to record students’ ethical knowledge and understanding, Edwards et al demonstrate changes in ethical reasoning ability including a richer and more integrated organisation of underlying knowledge necessary for ethical decisionmaking.

Delany’s paper takes the idea of ethics education from the university setting to the clinical coalface. She suggests that participation in clinical ethics committees provides a potentially relevant vehicle for practising therapists to advance both moral agency and identity. As Delany describes, clinical ethics consultations provide a forum for a range of perspectives and values to be canvassed. There is often no one clear ‘right’ action and each person around the table has an opportunity to both present their views, but also to hear other interpretations and values. Participation in such dialogue provides an important experience to deepen therapists’ understanding of the moral dimensions of their practice and provides a means (post formal education) to develop dispositions of postconventional reasoning described in Swisher et al's paper.

Similarly Poulis highlights the importance of reasoning and analysis in developing awareness and understanding of the patient’s perspective. Poulis uses a case study about differences between the elite athlete’s priorities following injury and those of the physical therapist, to highlight the importance of broadening the moral gaze beyond the clinically based reference point. Poulis refers to philosophical conceptions of human flourishing to remind physical therapists of the importance of understanding and acknowledging a person’s individual choices as to what matters most in their life including decisions about their health and well being.

Anderson shifts attention to how the physical therapy profession as a whole might respond to the changing ethical landscape in clinical practice. Her approach is to examine the work of professional codes of ethics and how such documents can remain relevant to contemporary practice. Anderson presents five themes about what matters ethically, derived from an empirical examination of the experiences of working physical therapists in a range of practice settings. These themes are the influence of resources, relationships, scope of practice and professional integrity in physical therapy practice. In this paper, Anderson describes how these themes were derived and how they informed the review and development of the New Zealand Code of Ethics. The close connection between the work of a code of professional ethics and the everyday ethical realities of clinical practice provides a model of responsiveness between professions, their institutions and ethics documentation. It further advances the process of how the physical therapy profession can respond to ethical issues.

Finally, Purtilo provides an insightful look at the physical therapist as a member of a multidisciplinary team. She uses an ‘ethics of care framework’ to underpin her exposition of the moral practice landscape of physical therapists working with other health professionals in the interests of patients. In this paper, Purtilo expands the notion of professional integrity to go beyond each individual therapists’ reflections about their unidimensional perspective to recognise the shared goals amongst team members and the shared need for support for each other to achieve a caring response for the patient.

We hope you enjoy these papers and find the contributions to be helpful to further define the ethical issues facing physical therapists in 2012 and beyond, and how the profession as a whole, and individual therapists can best respond to them.

Clare Delany, Lynley Anderson