Editor’s Note:
For
some, the topic of ethics for some conjures up images of staunch, bearded, pipe
smoking professors. For others it means trying to figure out how to apply the
rhetoric of their college philosophy professor to the clinical setting. This
article demystifies ethics for the clinician practicing in the realm of aquatic
rehabilitation.
Discussion
centers around an overview of biomedical principles. Ethics and the resolution
of ethical dilemmas starts with an appreciation for ones personal moral
convictions, and analysis of the situation at hand using the four biomedical
principles of autonomy, beneficence, nonmaleficence, and justice. These
principles are discussed in Ethical
Theory in Aquatic Rehabilitation, by Dr. Frampton, published in the
February, 2006 issue of the Aquatic
Therapy Journal (available from info@aeawave.com). To aid in application of these biomedical
principles, following is a discussion of sample cases modified from real
situations.
During the discussion of ethics readers should
reflect on their own moral stance, in an effort to understand the complexity of
issues surrounding seemingly simple decisions made on a daily basis in the
rehabilitation of patients. Each of us is drawn to the field of rehabilitation
for various reasons. For some it is a spiritual calling, for others a way of
life, and still for others it is a way to give unselfishly of ourselves in the
service of our fellow human. What ever the reason is, we are guided in our
service by an intrinsic set of values. When our intrinsic values conflict with
our patients, co-workers, or administrators we are faced with an ethical
decision. This article began with a discussion of the key concepts of
biomedical ethics. These concepts are here discussed as they relate to several
sample cases taken from the area of aquatic therapy. It should be noted that to
this day no formal legal action has resulted from any of these cases.
Case Analysis
Julie is an entrepreneur who has done exceptionally well for
herself considering that she has had no formal professional or college
education. Julie decides to open a physical therapy clinic specializing in
aquatic rehabilitation and hires therapists to work with the patients while she
manages the clinic. This clinic is in a very populated region, and has a very
upscale patient/client mix. Within six months Julie is at full complement. She
has employed three physical therapists, three physical therapy assistants, and
three technicians.
Problems begin when Julie decides to
put herself in the clinic and begin treating patients She feels this will
improve the clinics’ viability within the community. At first she treats in the
capacity of a technician. However, Julie is not satisfied with that role, and
quickly assumes additional treatment roles when there are staff shortages. She
also begins to inform the patients she is their therapist. As the clinic
continues to grow in volume Julie demands therapists and assistants work from
7:30 am to 7:30 pm, four days a week and 7:30 am to 5:00 pm on Fridays. The
staff notices Julie is spending more one-on-one time with patients and is
subsequently more active in treatment. Patients are beginning to become dissatisfied
with their level of care and report discomfort and pain with the techniques she
performs.
There are several issues here.
·
Julie is treating
without a license.
·
As such, Julie may be
providing not only inappropriate treatment, but harmful care.
·
She may also be
violating a labor law for the number of hours her employees work.
·
Julie is not happy
with her current social status.
·
Therefore, she has
schemed to create a new identity for herself, and in doing so, to improve the outlook of her clinic
To
begin, the violation of practice without a license is an issue having ethical
implications, but realistically this is a state or license board issue.
Ethically, she has set out to intentionally deceive the community in which she
resides. Julie's lack of regard for the welfare of the people of the community
also violates the principle(s) beneficence,
nonmaleficence, and autonomy.
Extending this line of though, providing harmful care definitely violates the
same principles.
The
principle of beneficence is violated
because Julie has the intention of secondary monetary gain in mind. She is
purposefully seeking to increase the clinic’s general revenue base, and, in
effect, create a larger income for herself. This is done at the expense of the
general public in that community. Not only do individuals pay for a level of
services they cannot receive because Julie is not a licensed practitioner, but also she is causing grave
discomfort in applying the techniques. It should be obvious at this time Julie
has placed herself in a situation of compromise on two levels. First the clinic
is at risk for closure if the State License Board is notified of the violation.
Secondly, the repport that is beginning to be established with the clientele
has changed. This directly affects
the following of patients and number
of subsequent referrals for treatment.
The
obvious violation to the principle of nonmaleficence
is the flagrant disregard for inflicting pain to the patients Julie treats
because of her lack of skill and training. The not so obvious violation
involves the professional staff employed by Julie in the clinic. By now the
questions of concern include what the staff responsibility is, and, perhaps,
why no one has attempted to do anything about this situation. Most of these
individuals may believe their jobs would be placed in jeopardy should they say
anything directly to Julie. As was pointed out already, not to say anything will more than likely result in a
patient-filled complaint, which could lead to an investigation, and possibly closure of the clinic
for a license violation. The end result for the professional staff remains the
same -- they stand the chance of
losing their jobs. The dilemma faced by the individuals is to risk their job
for the purpose of saving the clinic, and the jobs of their coworkers, or allow
the state to take action.
“Do no harm.” Is it wrong to extend this belief to ones’ family?
Certainly the family of the professional that approaches Julie may be placed in
desperate straits if their income is cut as a result of the professional being
fired. For the professional in this situation this may be a very real
possibility, and the position they choose to take may depend, primarily, on
where they place the greatest priority in their life. Remember, there is a
possibility, remote at best, Julie will stop this behavior, and the problem
will go away. There is also the possibility patients who have been hurt will
speak to Julie, and reach some resolution, without feeling the need to file a
formal complaint.
On
the issue of autonomy, the patient
has the right to self determine. The question, however, is whether or not the patient can request a new therapist. The
answer is yes. They can, and should, request a new therapist, after all there
is no information presented in the above case that leads one to believe that
Julie conducted or completed an evaluation. One solution may be for the evaluating physical therapist to re-evaluate any
patients in question, and determine it is for the patient’s benefit care be
transferred back to the original therapist. The problem then becomes one of
scheduling. If the therapists, who are already expected to see an increased
caseload, assume treatment for more patients, what becomes of those currently under their care? Certainly, the therapists are
overworked, and find it difficult to
keep up the appropriate standard of care,
which is why they allowed Julie
to serve as a technician in the pool in the first place. So, the resolution of
one problem creates a second. The patients will suffer yet again by being
transferred to Julie, or by failing to get the care they deserve and have come
to expect.
Hopefully,
the review of this case has placed more questions in the readers’ mind. For
example, principles of veracity, justice,
and informed consent have not yet
been discussed in relationship to this case, but it should be obvious full
informed consent would have included the right to refuse treatment and request
a change in treatment approaches and/or therapists. The principle of veracity would
also allow for truthful disclosure
of credentials of all support staff, and the need for or utilization of such
non-licensed individuals in the clinical setting. In regards to justice, the
real violation occurs if patients are
denied the level of care and treatment they have become accustomed too. It
would be a great disservice to alter one patient’s treatment to sacrifice
another’s.
As demonstrated by review of the above case, principles are not prescriptive. There is no easy answer to rectify ethical dimensions of this case. These principles have served to guide exploration of the case issues, and point out some potential problems. The patients, therapists, and Julie must be able to agree that although there may not be a perfect way to resolve the above case, there is a best way, which it leads to the least offensive ethical and legal violations.
A female patient, Virginia, is
receiving physical therapy at a local clinic that also offers aquatic
rehabilitation programs. Virginia is evaluated by a physical therapist for the
diagnosis of frozen shoulder. The therapist believes benefits of aquatic
rehabilitation will be of value to Virginia, and result in a decreased length
in course of treatment. Virginia agrees with the therapist’s recommendations,
and grants consent, knowing fully the risks, benefits, alternatives and
possibility of recovery with no treatment.
Then the therapist suggests PTA Brian
continue the aquatic therapy. Brian receives high praise from the therapist,
and is touted as being very knowledgeable and professional. Virginia again
agrees to participate. On her first visit with Brian he performs some land
based joint mobilizations of the shoulder, and introduces Virginia to exercises
she should continue at home. On a subsequent follow-up session, prior to moving
into a massage procedure, Brian begins with the aquatic therapy treatments. He
recommends beginning with a technique offering some additional distraction at
the shoulder. The execution of the technique is as follows: Brian places
Virginia’s right arm in abduction and distraction by the wrist with his left
hand, while placing his right into the axillary region to increase distractive
force on the right upper extremity. From there treatment proceeds as Brian had
indicated, with a massage technique. Treatment for the day ends, and Virginia
thanks Brian for his assistance, remarking her shoulder feels better.
Two days later Virginia and her
husband Sam arrive at the clinic, and ask to speak to the owner, a physical
therapist but not the evaluating therapist. The purpose of this visit is to
file a complaint against Brian, stating he grabbed Virginia’s breast during the
distraction technique. They also inform the owner they have filed a complaint
with the State License and Ethics Board and with the local police department.
The owner responds by telling the couple “Brian has never had a complaint
lodged against him” and says the videotaped session from the other day would be
reviewed and findings reported to the local authorities. Virginia was unaware
the sessions were being taped, and becomes outraged. She asks “Just what other
areas and treatments are taped?” to which the owner responds “The gym,
poolroom, treatment rooms, lobby, and parking lot.” The owner continues, “This is
done in an effort to ensure the safety of our clients.”
This
issues raised in this case are quite alarming, to say the least. Virginia has
proven to be a very compliant and considerate patient. She doesn’t appear to be
someone with a hidden agenda or an axe to grind. The entire treatment program
has been explained to her, informed
consent was given. She agreed with all the treatment options
and suggestions presented to her. What is the purpose of the alleged action,
and what could possibly be gained by such an accusation? While Virginia may not have an axe to grind,
she is however very conscious of her
self, and feels very strongly about unwelcome touching. She believes Brian
placed her in a compromising position because of her looks and physical build
to pursue intimate touching that otherwise would never have occurred.
In
the area of aquatic rehabilitation it should be realized patients are in a state of minimal dress, and
are in close physical contact with their therapists. It may be difficult, at
times, to maintain a professional demeanor.
But, the professional’s career depends on it. It would be advisable at the
onset to discuss with the patient necessity of maintaining a professional
relationship. It is also advisable to discuss the appearance of both
individuals in the pool (e.g. bathing suits, minimal clothing, etc.) and the
affect that might have on a trusting and professional relationship. Certainly,
the patient entering a physician’s office for an annual check-up understands
they are to disrobe, and expects to
be touched in ways that under another circumstance would be considered
unwelcome touching. The area of aquatic rehabilitation is no different, except
patients must be informed.
Now, having advocated for full disclosure in an effort to establish a fiduciary relationship with the patient, let’s take that one step further and say unwelcome and unwarranted touching is an ethical and legal violation. Many professions involved in the delivery of aquatic interventions have a Code of Ethics and would find such behavior unacceptable.
The
issue of video tapping treatment sessions is of grave concern, especially if
patients are not being advised of the taping. This is a separate issue of
consent. The informed consent granted by the patient in the initial treatment
session is not a carte blanche approval to do whatever the therapists, owner, or administrator feels necessary. That
consent is for the proposed treatment plan as it is discussed with the patient.
Any additions, deletions, or adjustments to that plan ought to be discussed
with the patient prior to execution.
The
courts have dealt with this issue on several occasions and in different
context. For whatever reason the
clinic feels the need to tape the patient, the patient must be informed and
grant consent to participate. The issue of confidentiality should be of concern
to the reader. Confidentiality is of the utmost concern when dealing with
patients. This is consistent with the fiduciary
responsibility owed to the patient. Patients discuss topics with their
therapist they would not mention to another individual, and perhaps not even
their referring physician, not to mention the touch of a massage or the need to
disrobe in the treatment room for the purpose of exposing a sensitive area for
treatment. Who views these tapes, and what purposes do they serve?
If tapes are used for educational purposes without the consent of the patient it would be unethical, and if the patient sought legal action such taping could deemed illegal. If the tapes are used to educate staff and professionals in the clinic from which they are obtained, the confidence and trust of the patient-professional relationship is broken. The patient must consent to their use for any reason.
On
the other hand, in public swimming pools, having a video camera running as part
of the security system is fairly common practice. A pool surveillance system
called Poisiden, uses cameras for
underwater monitoring of swimmers. To inform patrons, signage must be in place
in all areas where cameras are running, informing patrons of the surveillance.
The patron, then, has a choice whether or not to use that facility under this
form of surveillance.
Where
is the line between inappropriate and appropriate video taping/camera
surveillance? This is a matter for each
facility to determine, based on patron/client base, purpose of surveillance,
and eventual use of same. In any event, all clients must be informed.
Summary
Ethics and the resolution of ethical dilemmas start
with an appreciation for ones personal moral convictions, and the analysis of
the situation at hand using the four biomedical principles of autonomy, beneficence, nonmaleficence, and
justice. The practice of appropriate ethical behavior is often clouded by
the conflicting views of right and wrong behavior. Professionals are no better
and certainly no worse at arriving at a solution. Understanding the four
biomedical principles and examining the specifics of any dilemma can assist the
players in arriving at a plausible solution.