Phys Ther 1980 Guccione 1264 72

1980; 60:1264-1272.PHYS THER. Andrew A GuccioneSurvey of Physical Therapists in New EnglandEthical Issues in Physical Therapy Practice: A

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Ethical Issues in Physical Therapy Practice

A Survey of Physical Therapists in New England

ANDREW A. GUCCIONE, MS

This survey was an attempt to identify which ethical decisions are most fre-quently encountered and are most difficult to make for practicing physical therapists. A questionnaire that described 30 situations with an ethical dimen-sion was sent to 450 American Physical Therapy Association members practicing in New England. A total of 187 (41.5%) usable questionnaires was returned. Issues raised by items were designated as primary, secondary, or nonpriority. Seven primary and 11 secondary ethical issues were identified. In brief, these issues involve the decision about which patients should be treated, what obli-gations are entailed by that decision, who should pay for treatment, and what duties derive from the physical therapist's relationship with other health profes-sionals, including physicians. Some of these decisions are more frequent in certain types of employment facilities than in others. Sources of ethical conflict and the role of the professional organization in defining moral values for the profession are discussed in this paper, and implications for education are presented.

Key Words: Ethics, medical; Ethics, professional; Physical therapy.

The need to identify and clarify ethical issues within a health profession increases as the profession assumes responsibility for those areas of direct patient care in its domain. A brief comparison of the 1935 American Physiotherapy Association CODE OF ETH-ICS with its 1977 American Physical Therapy Asso-ciation (APTA) counterpart reflects the development of physical therapy as a profession in its own right.1

The physical therapist today, in defining the limits of his legal and professional autonomy, must examine the practice of his profession from an ethical point of view. By doing so, he carefully guards the rights of patients, maintains his integrity as a professional, and promotes the ideals of physical therapy as a profes-sion.

Thompson has suggested that there are three sources of conflict for health professionals making ethical decisions.2 First, conflicts may arise between an individual's private convictions and his conception of the requirements of his professional role. Second, ethical dilemmas may be encountered when the atti-tudes, values, and goals of one profession conflict with those of another. Finally, the ethos (ideology) of a profession and that of the society in which it func-tions may be in conflict.

Professional ethics has developed in response to these sources of conflict, and the APTA CODE OF ETHICS and the guidelines for its interpretation emerge historically and sociologically with that de-velopment.1 The C O D E may be regarded as an attempt to counsel physical therapists making ethical judg-ments by asserting the ideals of the profession and by defining some of the limits of professionally and morally acceptable behavior. Continuing documen-tation of the ethical concerns of practicing physical therapists is essential to maintain timely counsel.

The twofold purpose of this study was to identify which ethical problems were perceived by physical therapists to be the most frequently encountered and

Mr. Guccione was a candidate for the degree of Master of Science in Physical Therapy at Sargent College of Allied Health Professions, Boston University, when this study was conducted. He is currently Staff Physical Therapist, Physical Therapy Department, Massachu-setts Rehabilitation Hospital, 125 Nashua St, Boston, MA 02114 (USA).

Adapted from a paper presented at the Fourth Annual Convention of the Massachusetts Chapter, American Physical Therapy Associa-tion, Hyannis, MA, April 1978.

This article was submitted April 2, 1979, and accepted January 4, 1980.

1 2 6 4 PHYSICAL THERAPY

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the most difficult to solve in their daily professional practice.

Simply stated, ethics, or moral philosophy, is criti-cal, analytical thinking about the behavioral expres-sions of human interdependence and what is the morally right thing to do. Currently, the complexities of medical practice have given rise to ethical questions that demand the participation of both medical per-sonnel and academic ethicists in discussing the issues involved. These discussions have served, at least, to define what some of the problems are, but continuing dialogue is needed to determine more adequately the range of morally sound solutions.

Topics that have received attention include abor-tion, euthanasia, the right to health care, the patient's rights while receiving health care, and the limits of experimentation with human subjects. Although the physical therapist is concerned with these issues as an informed member of the health care team, his involve-ment in the decisions they require is sometimes not directly evident. All moral dilemmas occur within a context of proposed action.2-4 Some ethical problems are specific to physical therapists because what they do is different from what physicians, nurses, and other health professionals do. Other ethical problems involve physical therapists in only limited or periph-eral ways. Because of the context of certain ethical problems, the ethics of health care professionals has been recognized as an area of study akin to, but distinct from, medical ethics.

In order to select a defensible choice, a decision-maker first adopts a point of view from which to interpret the facts. Any point of view adopted will emphasize one kind of fact over another, perhaps equally important, kind. The moral point of view is distinguished from others by the kind of justification given in support of a particular choice. For example, the decision to perform passive range of motion be-cause it will achieve certain treatment goals is reason-ing from the therapeutic point of view. If a therapist cites a legitimate physician referral as his reason for performing passive range of motion, then he has justified his choice from the legal point of view. If his choice of passive range of motion is defended on the grounds that it is the only procedure that would avoid unnecessary harm to the patient, the decision has been made according to the moral point of view. Purtilo's discussion of the physical therapist as ethicist is a significant contribution toward defining the moral point of view for a health professional.3 Generally, no clinical decision is made without analyzing the situ-ation from several points of view, but each point of view is unique in the kind of questions it asks about a proposed action. When an alternative is compatible with one point of view and incompatible with an-

other, the uniqueness of different viewpoints is more obvious. In these instances, the multiple dimensions of judgments made by physical therapists are appar-ent. When the choice is easily compatible with several viewpoints, however, there is a tendency to collapse distinctions and regard the decision as a therapeutic judgment only, ignoring ethical and other dimensions of the situation.

Ethical Issues in Physical Therapy

The ethical dimension of actual clinical practice is not well documented in the literature. Ethical devel-opment has been cited as a basic objective of physical therapy education,5 and several authors have noted an ethical dimension in the routine functions of the physical therapist.3,6-11 Behavior guided by an ethical code has been described as identifying physical ther-apy as a profession rather than a technology and as contributing to professional stature.1,10,11 Often, phys-ical therapists have been encouraged to exhibit par-ticular behaviors. Exact recommendations have been made, for example, on selection of topics for discus-sion with patients,8"10 the uses of proper vocal tone when speaking with patients,9,10 presentation of a modest appearance,9 cooperation with and ultimate deference to the physician's judgment concerning patient treatment,8-11 and maintenance of a patient's dignity and his confidence in his physician.8"11 There has been little discussion of the moral principles behind these expectations, and the ways in which they pose problems for the therapist have not always been identified. If the underlying principles are not made explicit, recommendations for particular behav-iors are no more compelling than remarks on profes-sional etiquette. Physical therapy education that does not cover ethical theory, as well as application, may inadvertently trivialize the importance of ethical be-havior.

Discussions of professional ethics can seem over-whelmingly complex, and the question of where to begin is posed as often as the question of what to do. A guiding assumption of this study is that, while all ethical problems are important, attention should be directed first to those ethical issues that affect and perplex the majority. The results of this survey pro-vide a focus for that attention.

METHOD

Subjects

Four hundred fifty members of the APTA were selected at random from the total APTA membership in the six New England states (N = 2,017) as of

Volume 60 / Number 10, October 1980 1 2 6 5


December 1977. The sole criterion for inclusion in the study was that a therapist be employed in some aspect of therapy excluding education. A major as-sumption of this study is that problems of professional ethics originate within the specific context of clinical practice. Therapists whose primary employment is in academic education do not experience that context on a daily basis. Also, educators and graduate stu-dents were not included because they might be more sensitive to the complexities of some ethical issues and thus skew the results.

Instrument

Thirty items that described situations suggestive of ethical problems were presented to the sample in a questionnaire format. Inasmuch as demographic dif-ferences are often a source of variations in response, data were collected on age, sex, total years of physical therapy work experience, and highest educational level obtained, as well as the respondent's present type of employment facility, level of his position, setting of employment, and state. Information on sources of contact with issues of professional ethics and the number of physical therapists available to discuss actual ethical problems was also collected.

Procedure Respondents were asked to score items according

to the frequency with which they had encountered a situation of the type described in their own profes-sional practice and the difficulty they experienced in reaching a decision in those instances. The frequency measure had five levels: high, moderate, minimal, none, and not applicable. The difficulty measure had four levels: extreme, moderate, minimal, and none.

Assuming that ethical problems arise out of a par-ticular context, accurate measurement of the difficulty of an item requires at least minimal experience with it. In cases in which a respondent reported having no experience with the situation described by an item, or thought it inapplicable to him, the difficulty rating was excluded from the results.

Data Analysis

The Kolmogorov-Smirnov One-Sample Test was employed to determine the significance of the distri-bution of responses on both the frequency and the difficulty scales.12 This test measures the agreement between a theoretical cumulative distribution of re-sponses and an observed cumulative distribution. If responses are divided almost equally among the levels of a scale, there will be no significant difference between the theoretical and the observed distribu-tions. In order to consider a level on a scale to be a significant preference of the respondents, it must be demonstrated that the dissimilarity between a theo-

retical array of data values and the actual or observed array could not have happened by chance. The ab-solute value of the maximum deviation (Dm a x) be-tween the theoretical and the observed arrays deter-mines whether a significant preference exists for one of the possible response choices. The rigor of this test is great for small groups, and, thus, in some of the breakdowns of responses reported below, only the . 1 level of confidence was reached.

In order to determine which issues warrant atten-tion according to the frequency and the difficulty criteria, an arbitrary lower limit was imposed. The issues raised by items that were not perceived as at least moderately frequent or at least moderately dif-ficult by a minimum of 35 percent of the respondents were rejected as priority issues (Figure). The issues covered in those items that met both the frequency and the difficulty criteria levels were designated pri-mary issues of professional ethics for physical thera-pists. The items that met either the frequency or the difficulty criterion level, but not both, were desig-nated secondary issues of professional ethics.

1. Deciding criteria for allowing a pa-tient/family to refuse treatment.

2. Accepting gratuities or gifts from pa-tients/families.

3 . Deciding what to do when my values and beliefs are at odds with a patient 's/family's values and beliefs.

4. Setting the limits necessary to main-tain professional relationships with pa-tients/families.

5. Controlling access to privileged or confidential information about a pa-tient/family.

6. Choosing a form of dress that assures professional respect and maintains identity a s a physical therapist.

7. Deciding when I do not have adequate therapeutic knowledge to treat a pa-tient.

8. Setting financially sound fees that maintain a patient 's ability to receive treatment.

9. Providing accurate information to con-sumers about the cos ts of treatment.

10. Determining methods for making the particulars of physical therapy ser-vices known to health care consumers.

11 . Deciding the limits for standing by my own ethical principles.

Figure. Issues that did not meet either criterion.



TABLE 1 Characteristics Profile of Respondents

a. b. c.

d. e.

f. g.

h.

Under 3 0 years old Female 6 years or l ess total physical ther-apy work experience Baccalaureate degree Employed in acute general facili-ties Employed in an urban area Learned about professional ethics in P.T. course only had 3 or more therapists available to d i scuss actual ethical problems

% 6 1 . 3 8 5 . 4 58.1

72 .7 4 2 . 8

4 3 . 5 5 9 . 9

6 9 . 0

N

1 8 6 1 8 5 1 8 4

187 187

1 8 4 181

187

RESULTS AND DISCUSSION

Two hundred seven questionnaires were returned, representing a 46 percent response. Of these, 187 (41.5%) were usable. Major demographic character-istics are presented in the respondents' profile (Tab. 1). Primary and secondary issues were grouped on the basis of the kind of concern each expressed. Four groups of concerns were identifiied: decisions regard-ing the choice to treat, obligations deriving from the patient-therapist contract, moral obligation and eco-nomic issues, and a physical therapist's relationship with other health professionals. A single item that examined conflicts between values also merited dis-cussion.

TABLE 2 Decisions Regarding the Choice to Treat

1.

2.

3.

4.

Establishing priorities for patient treatment when time or resources are limited.

Discontinuing treatment for patients who habitually disregard instructions such as for home programs, treatment regimens, and safety instructions.

Continuing treatment with a terminally ill patient.

High Mod Min None

High Mod Min None

High Mod Min None

Nursing Homes and Chronic Care Facilities

Continuing treatment to provide psychological sup-port after physical therapy treatment goals have been reached.

High Mod Min None

High Mod Min None

Nursing Homes and Chronic Care Facilities High Mod Min None

Frequency n 67 70 46

3 N = 186

% 36.0 37.6 24.7

1.6 100.0

D m a x = .237a

13 61 88 11

N = 173

7.5 35.3 50.9

6.4 100.0

Dmax= .186a 25 63 80

6 N = 174

14.4 36.2 46.0

3.4 100.0

Dmax= .216a

1 12

3 0

N = 16

6.2 75.0 18.8

0.0 100.0

Dmax = .312C 30 69 72 11

N = 182

16.5 37.9 39.6

6.0 100.0

Dmax= -19a

7 6 3

_0 N = 16

43.8 37.5 18.8

0.0 100.0

Dmax= .313c

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Difficulty n

9 74 89

10 N = 182

% 4.9

40.7 48.9 5.5 100.0

Dmax= .201a 23 62 65 11

N = 161

14.3 38.5 40.4

6.8 100.0

Dmax= .181a 22 72 52 21

N = 167

13.2 43.1 31.1 12.6

100.0 Dmax= .124b

34 60 64 12

N = 170

20.0 35.3 37.6

7.1 100.0

Dmax= .179a

a p < .01. b p < .05. c p < .1.

Volume 60 / Number 10, October 1980 1267


Decision to Treat

The first group of concerns to be considered con-sisted of four related primary issues regarding who should be treated (Tab. 2). More than 70 percent of the respondents perceived the basic question of estab-lishing priorities for patient treatment when time or resources are limited as moderately or highly fre-quent. This questionnaire item was also rated at least moderately difficult by slightly more than 45 percent of all those who had experienced the problem. Using the frequency and the difficulty criteria, responding therapists also regarded discontinuation of treatment on the grounds of habitual noncompliance as a second primary issue of professional ethics. Third, contin-uation of treatment with the terminally ill is a priority issue, especially for therapists in nursing homes and chronic care facilities, for whom the frequency of this situation is greater than for other therapists. Fourth, continuation of treatment to provide psychological support after physical therapy treatment goals have been reached is a primary issue for over half of the responding therapists, again more frequent for ther-apists working in nursing homes and chronic care facilities.

When deciding whom to treat, a therapist is re-quired, in part, to consider two important aspects of this type of professional judgment. First, it is becom-ing apparent that the increase in the number of patients needing physical therapy knowledge and skills could become overwhelming. The expansion of physical therapy into new areas, in which the profes-sion offers a unique viewpoint, forces the choice of which patients shall be treated and which shall not.

Even when research into the efficacy of treatment for certain types of patients sheds some light on this matter, the therapist is still confronted with a second, and perhaps more important, considerationper-sonal beliefs and values. Underlying all therapists' ethical decisions are the values that help to direct their choices.13 The extent to which a person values psychological support for patients beyond the usual physical therapy intervention, as well as what he thinks is an appropriate response to the needs of a dying patient, bear heavily on what he will choose to do. Conflict between personal values and professional values, or between the profession's values and soci-ety's attitudes, may easily arise. The professional organization's declaration of its values sometimes is helpful in these instances. However, beyond this dec-laration, each physical therapist must decide what he values as a health professional. Educators may need to provide the student with the opportunity to ex-amine his own values as he is formally and informally socialized into the profession.

Patient-Therapist Contract

The therapist's professional relationship to a pa-tient is a major source of moral obligation. Basic questions concerning the often-unspoken contract be-tween patient and therapist were apparently not a problem to the respondents. The primary issue in patient-therapist interaction emerged from a conflict concerning professional adjudication between a patient's needs or goals and a family's needs or goals (Tab. 3). The respondents identified this dilem-ma as the primary issue of the second group of con-cerns.

The nature of the patient-therapist contract has changed as physical therapy has increased its function and scope within the health care system. The first of six secondary issues in this group of concerns stems directly from this change, which augmented the ed-ucation component of clinical practice. A problem in defining the physical therapist's role in the initial education of a patient or family regarding diagnosis or prognosis was encountered often enough to war-rant attention. This situation was experienced with high frequency by 45 percent of all therapists whose primary employment was in pediatric facilities or school-system settings. Students pursuing careers in the treatment of developmental disabilities should be urged to consider the ethical aspects of this problem in clinical judgment. Two other secondary issues whose frequency merit discussion are questions about informing a patient or family about the limitations of treatment and assuring that the patient or family have input into treatment and discharge planning.

The three remaining secondary issues in this group of concerns emanate from the patient's expectations of the therapist. First, the knowledge that a therapist might be expected to bring to the treatment situation was examined in an item that questioned the assump-tion of personal responsibility for continuing educa-tion. Over 84 percent of the respondents noted that decisions allowing them to keep up with new treat-ment ideas had to be made with either moderate or high frequency. The limits of the clinician's obligation to update his practice are unclear. Continuing edu-cation is well-recognized as an essential of providing quality health care. However, the growth of physical therapy knowledge and the increasing cost of contin-uing education courses also demand consideration.

The final two secondary issues pertaining to pa-tient's expectations are encountered in actual treat-ment: weighing the effects of treatment against the discomfort created by the procedure and maintaining a patient's sense of personal space and dignity during treatment. Both of these issues are usually addressed in the classroom and the clinical education of the



student, and this survey's results suggest that this practice should continue. Each of these items was rated only minimally difficult by more than half of the respondents. This may be attributable to the attention these issues have received in the respon-dent's education.

Moral Obligation and Economic Issues

Some economic issues have a moral component, and the respondents identified both a primary and a secondary issue of professional ethics relating to eco-nomics (Tab. 4). Decisions about whether to represent

TABLE 3 Obligations Deriving from the Patient-Therapist Contract

1.

2.

3 .

4 .

5.

6.

7.

Determining professional responsibilities when a pat i ents n e e d s or goals conflict with the family's n e e d s or goals .

Defining the limits of the physical therapist's role in the initial education of a patient/family regarding diagnosis or prognosis.

High Mod Min None

High Mod Min None

Frequency n

8 6 4 9 7 12

N = 181

% 4 .4

3 5 . 4 5 3 . 6

6.6 1 0 0 . 0

Dmax = . 2 0 5 a 3 2 7 0 7 0

7 N = 1 7 9

17 .9 39.1 39.1

3 .9 1 0 0 . 0

Dmax = . 2 8 9 a

Pediatric Facilities and School System Settings

Informing a patient/family about the limitations of treatment.

Assuring that the patient/family has input into treatment and discharge planning.

Assuming personal responsibility for continuing education to keep up with new treatment ideas in order to maintain quality of care.

Weighing the effects of treatment against the dis-comfort created by the procedure.

Maintaining a patient's s e n s e of personal s p a c e and dignity when treatment requires arrangements such a s c lo se proximity and group settings.

High Mod Min None

High Mod Min None

High Mod Min None

High Mod Min None

High Mod Min None

High Mod Min None

9 6 5 0

N = 2 0

4 5 . 0 3 0 . 0 2 5 . 0

0 .0 1 0 0 . 0

Dmax = . 4 5 a

5 2 8 3 4 9

2 N = 1 8 6

2 8 . 0 4 4 . 6 2 6 . 3

1.1 1 0 0 . 0

D m a x = .239a

6 2 8 3 3 2

1 N = 1 7 8

3 4 . 8 4 6 . 6 1 8 . 0

0 .6 1 0 0 . 0

Dmax = . 3 1 5 a

7 3 8 3 2 6

3 N = 1 8 5

3 9 . 5 4 4 . 9 14.1

1.6 1 0 0 . 0

Dmax = . 3 4 3 a

3 6 81 6 4

4 N = 1 8 5

19 .5 4 3 . 8 3 4 . 6

2 .2 1 0 0 . 0

Dmax = . 2 2 8 a

51 6 5 5 0 10

N = 1 7 6

2 9 . 0 3 6 . 9 2 8 . 4

5.7 1 0 0 . 0

D m a x = . 1 9 3 a

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Difficulty n

16 71 6 5 17

N = 1 6 9

% 9.5

4 2 . 0 3 8 . 5 10.1

1 0 0 . 0 Dmax = .155 a

8 5 3 9 0 2 0

N = 171

5 51

1 0 2 2 6

N = 1 8 4

8 2 9

1 0 3 3 7

N = 177

14 61 7 3 3 4

N = 1 8 2

8 6 2 9 4 17

N = 181

2 17

1 0 8 3 9

N = 1 6 6

4 .7 3 1 . 0 5 2 . 6 11 .7

1 0 0 . 0

2.7 2 7 . 7 5 5 . 4 14.1

1 0 0 . 0

4 . 5 16 .4 5 8 . 2 2 0 . 9

1 0 0 . 0

7.7 3 3 . 5 40.1 18 .7

1 0 0 . 0

4 .4 3 4 . 3 5 1 . 9

9 .4 1 0 0 . 0

1.2 1 0 . 2 65.1 2 3 . 5

1 0 0 . 0

a p < .01.



TABLE 4 Moral Obligation and Economic Issues

1.

2.

Deciding whether to represent certain necessary patient services in a way that would meet third-party-payer limitations.

High Mod Min None

Nursing Home or Chronic Care Facilities

Withholding or limiting physical therapy services in order to improve work conditions, salaries, staff/ patient ratios, etc .

High Mod Min None

High Mod Min None

Frequency n

3 6 51 4 2 15

N = 1 4 4

% 2 5 . 0 3 5 . 4 2 9 . 2 1 0 . 4

1 0 0 . 0 D m a x = . 1 4 6 a

9 2 1 1

N = 1 3

6 9 . 2 1 5 . 4

7.7 7.7

1 0 0 . 0 Dmax = . 4 4 9 a

12 14 2 9 61

N = 1 1 6

1 0 . 3 12.1 2 5 . 0 5 2 . 6

1 0 0 . 0

Ext Mod Min None

Ext Mod Min None

Difficulty n

2 3 4 9 4 7 1 0

N = 1 2 9

% 1 7 . 8 3 8 . 0 3 6 . 4

7 .8 1 0 0 . 0

Dmax = . 1 7 2 a

21 16 13

5 N = 5 5

3 8 . 2 29.1 2 3 . 6

9.1 1 0 0 . 0

Dmax = . 1 7 3 b

a p < .01. b p < .1.

TABLE 5 Physical Therapist's Relationship to Other Health Professionals

1.

2.

3 .

4 .

5.

Maintaining a patient's/family's confidence in other health professionals regardless of personal opinions.

Determining criteria for delegating duties to sup-portive personnel.

Reporting questionable practices of another phys-ical therapist to the appropriate person.

Reporting questionable practices of a physician to the appropriate person.

Reporting questionable practices of another health professional who is not a physical therapist or a physician to the appropriate person.

High Mod Min None

High Mod Min None

High Mod Min None

High Mod Min None

High Mod Min None

Frequency n 2 3 77 6 8 1 3

N = 181

% 12 .7 4 2 . 5 3 7 . 6

7 .2 1 0 0 . 0

D m a x = . 1 7 8 a

5 8 6 3 3 7 11

N = 1 6 9

3 4 . 3 3 7 . 3 2 1 . 9

6 .5 1 0 0 . 0

Dmax = . 2 1 6 a

6 5

7 5 7 3

N = 1 5 9

5 2 8 8 8 5 2

N = 1 7 3

7 2 2 9 0 4 8

N = 1 6 7

3 .8 3.1

4 7 . 2 4 5 . 9

1 0 0 . 0

2 .9 1 6 . 2 5 0 . 9 30.1

1 0 0 . 0

4 .2 1 3 . 2 5 3 . 9 2 8 . 7

1 0 0 . 0

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Ext Mod Min None

Difficulty

8 6 2 7 5 2 3

N = 1 6 8

% 4 .8

3 6 . 9 4 4 . 6 13 .7

1 0 0 . 0 Dmax = . 2 0 2 a

5 4 2 8 8 2 3

N = 1 5 8

3 7 2 8 17

4 N = 8 6

3 .2 2 6 . 6 5 5 . 7 1 4 . 6

1 0 0 . 0

4 3 . 0 3 2 . 6 1 9 . 8

4 .7 1 0 0 . 0

D m a x = . 2 5 6 a

5 2 2 6 31 12

N = 121

4 3 . 0 2 1 . 5 2 5 . 6

9 .9 1 0 0 . 0

Dmax = . 18 a

3 5 4 2 31 12

N = 1 2 0

2 9 . 2 3 5 . 0 2 5 . 8 1 0 . 0

1 0 0 . 0 Dmax = . 1 5 a

a p < .01.

1270 PHYSICAL THERAPY


certain necessary patient services in a way that would meet the present limitations imposed by third-party payers are not uncommon or easy to make. Almost 70 percent of those therapists working primarily with patients in nursing home and chronic care facilities perceived a high frequency of the need to make this decision. The source of conflict is the difference be-tween what a physical therapist may value as neces-sary for patients and what society regards as essential to the health of those who are dependent upon it.

respect to peers and superiors. That place has changed considerably with the development of the profession and will continue to do so.15 ,16

Four secondary issues were examined in this group of concerns. Determinations of the criteria for dele-gating duties to supportive personnel occur frequently enough to constitute a secondary issue of professional ethics. Respondents did not frequently make deci-sions to report the questionable practices of another physical therapist, physician, or other health profes-

TABLE 6 Conflicts Between Two Ethical Principles

1. Deciding what to do when two of my ethical prin-ciples or values are in conflict.

High Mod Min None

Frequency n

2 25

100 49

N = 176

% 1.1

14.2 56.8 27.8

100.0

Ext Mod Min None

Difficulty n 26 50 44

5 N = 125

% 20.8 40.0 35.2

4.0 100.0

Dmax = .21 a

a p < .01.

There is, at present, no simple resolution to this conflict. Those physical therapists concerned with this issue should participate forcefully in changing societal concepts of adequate and essential health care.

In light of developments in other health profes-sions, which have included strikes by physicians and nurses,14 one question examined the issue of curtail-ment or limitation of physical therapy services in order to improve work conditions, salaries, staff/pa-tient ratios, and the like. Most of the respondents perceived this item as inapplicable to their present situations. Of those therapists who regarded this event as a possibility, most had no personal experience of it. However, slightly over 38 percent of those who had experience with this problem reported that it was an extremely difficult decision to make. Further exami-nation of this issue may become necessary.

Relationship to Other Health Professionals

The last group of issues considered the physical therapist's relationship to other health professionals (Tab. 5). Maintaining a patient's or family's confi-dence in other health professionals regardless of per-sonal opinions has traditionally been an issue of professional ethics,8-11 and the data collected show that it was perceived to be the primary issue of this group. The response that a therapist makes in situa-tions of this type is derived, in part, from the place the profession holds within the health care team with

sional. However, such a decision clearly poses mod-erate difficulty in the case of another health profes-sional and extreme difficulty in the cases of another physical therapist or a physician, when it needs to be made.

Identification of Ethical Decisions

Ethical dilemmas arise when two or more ethical principles or values conflict with each other in a given situation. Despite the fact that respondents perceived seven primary issues and they recognized the diffi-culty of making decisions when principles conflict, they did not perceive themselves as making a choice between conflicting principles or values with any great frequency (Tab. 6). Although respondents rec-ognized that a difficult decision had to be made in some instances, they probably had not identified it as a decision of ethical choice. The moral point of view requires that some unique aspects of a situation be explored. Failure to recognize that a moral point of view is required is a first step toward unethical be-havior. The educational implication of this data is inescapable: in order to meet all the challenges of clinical practice, physical therapy students must be taught how to make ethical as well as clinical judg-ments. To prepare future clinicians less adequately could jeopardize the integrity and the autonomy that physical therapy as a health profession has so ar-duously worked to achieve.



CONCLUSION

Complex ethical issues have emerged with the de-velopment of the profession. These issues pose an important challenge to the clinician and require that he develop skill in making ethical judgments in professional practice. This study was undertaken to achieve several objectives. First, to establish priorities of concern so that the APTA can respond to the more pressing ethical questions of its members. Second, to identify the issues of professional ethics so as to encourage discussion among physical therapists and

to promote application of the ideals expressed in the APTA CODE OF ETHICS to actual situations. Third, to summon the attention of academic ethicists so they can offer their counsel on the issues raised. Fourth, to alert educators to the needs of their students in order to meet the challenges of ethical professional practice. Fifth, to provide an opportunity for physical thera-pists to learn about and reflect upon the issues of professional ethics as they have experienced them.

Acknowledgment. Grateful appreciation is ex-pressed to Jane Coryell, PhD, Sargent College of Allied Health Professions, Boston University, for her assistance.

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Phys Ther 54:588-591, 1974



1980; 60:1264-1272.PHYS THER. Andrew A GuccioneSurvey of Physical Therapists in New EnglandEthical Issues in Physical Therapy Practice: A

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