Ethical Theory in Aquatic Rehabilitation: Case Study


Robert M. Frampton, PhD., DHCE


Editor’s Note:


The following material is supplementary to the article Ethical Theory in Aquatic Rehabilitation, by Robert M. Frampton, PhD., DHCE, published in the February, 2006 issue of the Aquatic Therapy Journal, 8(1), 11-15.


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  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


Vignette One

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.


Vignette Two

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. 



         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.