Ethical Issues in Private Practice Settings

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Top Contributors - Simisola Ajeyalemi, Kim Jackson, Jess Bell and Robin Tacchetti  

Description

Ethics is a systematic reflection on morality. Systematic because it is a discipline that uses special methods and approaches to examine moral situations and reflection because it consciously calls into question assumptions about existing components of moralities that fall into the category of habits, customs, or traditions. The term moral refers to a group of notions about what is right or wrong in connection with one's own or others' action. Physiotherapy in private practice must be considered both within an organizational frame and a frame of meaning. The nature of the physiotherapy process includes examination, diagnostic assessment, evaluation, prognosis, plan of treatment, and re-examination in close interaction with the patient. From this follows that physiotherapy is relational.

Ethics in Physiotherapy

Within the last four decades, the physiotherapy profession has experienced an increase in professional autonomy. An important aspect of professional autonomy is to have a prominent ethical dimension both collectively and for the individual members of the profession. The growing autonomy thereby increases the need for formal ethical considerations for physiotherapists and serves to focus more clearly on the individual physiotherapist's ethical competence: the ability to identify; to examine; to assess; and to decide in relation to the ethical issues in daily practice. The increased interest in ethical issues and dilemmas facing physiotherapists is, on one hand, reflected in the recent years of formal codifications of and guidelines for professional morality: The World Confederation of Physical Therapy has had a Code of Ethics since 1995 (WCPT, 2007); on the other hand, it is reflected in the increased amount of articles on the subject.

Ethical issues in physiotherapy can be :

• about how to maintain a professional proximity in the close and, mostly, continued relationship between physiotherapist and patient where both physiotherapist and patient are being touched by one another, bodily, mentally, and emotionally without entering the personal sphere in which friendships occur.

• about how to manage the given power asymmetry; the patient comes to the physiotherapist in a vulnerable state and since imbalance in knowledge, power, and authority is a condition, the physiotherapist must constantly be aware of the inherent vulnerability of the patient, even when there is a need to engage in a process of mutual partnership.
• about how to communicate in a respectful manner with all clients regardless of age, level of education, ethnicity, or how to live up to the patients' right to self-determination and privacy during all aspects of the course
• about ethical dilemmas- relational situations, filled with doubt and ambivalence; where the physiotherapist has to choose between action alternatives that will have negative consequences for the patient

Ethical Issues in Private Practice settings

Results from a Danish study revealed a great overall interest in ethics and a great diversity in the understanding of what constitutes ethical issues in physiotherapy private practice. The results of the analysis revolved around the theme 'the ideal of being beneficent toward the patient.' This main theme expressed how looking out for the best interests of the patient was the central focus of ethical care in private practice. The ethical issues discovered in the interviews were embedded in 3 code-groups and their appertaining subgroups:

• ethical issues related to equality;
• feeling obligated to do one's best; and
• transgression of boundaries,

Ethical issues related to equality

Includes the interviewees' reflections on how the understanding of ethical issues was related to equality in the physiotherapist–patient relationship and on how the interviewees acted upon these from a perspective of beneficence. This code-group encompassed three appertaining subgroups including a) being equal partners in the relationship b) patient advocacy and c) relating unreflectedly toward one's role.

Being equal partners in the relationship: Some interviewees argued for an interactive role in professional practice from an ethical perspective. They considered themselves and their patients as morally equal partners. They took pride in identifying the needs of the patient through dialogue and had many examples of how they struggled to ask the right questions in order to improve patient resources and autonomy.

I see the patient as an equal partner; he knows about his symptoms and life and I know about physiotherapy. If I don't have the patient bring forward his resources, thoughts and expectations, how can I succeed? Physiotherapy must be interactive – otherwise it is expert pressure (paternalism).

Some further argued in favor of an interactive role in consequence of the professional status given by society. They felt obligated to care for the patient as an equal human being and considered their conscious professional role as equal partners as a means of avoiding or minimizing some ethical dilemmas:

We have to be aware that as professionals we have to meet the demands and expectations of society. That's an obligation we have. Otherwise society has every right to withdraw its acceptance of our professional autonomy. … Patients want to be involved, … we have to involve them, and also because research shows that the patients' understanding, insight and activity contribute to the healing process. In my experience this also helps to avoid basic ethical conflicts.

Patient advocacy: It was an important part of ethically sound professionalism for most interviewees. Advocating implied recognizing that for some patients it was difficult to obtain a fair and equitable healthcare on their own and in these cases the interviewees told that they felt ethically obligated to take action. They related using their professional power to push the way for the patient:

Sometimes I act on behalf of the patient (e.g. I phone the physician for a quicker service for the patient).

Some considered themselves as experts who had to take special care of their (vulnerable) patients and they found it crucial to do so despite other demands on their time.

I see it is as a professional duty to reflect holistically on the child's situation; attending meetings, being active when the family has to choose institutions or assistive technologies, when there needs to be taken action on grant application for lost earnings, … I act as an advocate for the individual patient – no matter how much time it requires.

Their actions varied: making contact with the physician; ensuring referral to medical specialists; or writing letters to insurance companies. Some further told about doing personal favors like shopping or visiting former patients to ensure their well-being. A particular ethical call to advocate for patients with learning disabilities or cognitive deficits was expressed:

I cannot live with myself if I don't act upon the troublesome and tiresome issues these patients and their families are subjected to. I have to act. It is a personal moral drive. I sometimes act even before the family becomes aware of the issues. In this way, I try to prevent them from more pain and distress than absolutely necessary.

Another ethical aspect of patient advocacy revealed itself; some private clinics offered home treatment to patients who were too sick to get to the clinic and, in this setting, these interviewees had several reflections on ethics. They felt that the power balance was

altered when the therapy took place in the patient's private home where the patient defined the setting. They expressed difficulty coping with this. They further expressed the feeling of being alone, insecure, and in lack of tools when dealing with very sick and/or palliative patients:

Then it turns out that the patient has a severe cancer. And three weeks later I take her as a terminal patient, and treat her in her home. She specifically asks for me. It turns out she has only weeks to live – it can only go in one direction, and here I must transgress myself into some of her territory of death and sickness, … and this disregarding the fact that I usually help patients. Now I cannot do this. I can't heal her. And the patient clings to me as a hope, as the miracle. It is so difficult. I find it very difficult. I lack the tools for handling such a process. … How to do the best for the patient?