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The Relationship Between Clinical Decision Making and Ethical Decision Making
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The Relationship Between Clinical Decision Making and Ethical Decision Making Ann L Clawson Key Words Ethics, ethical decision making, clinical decision making, ethical issues in physiotherapy. Summary Ethical issues involved in physiotherapy practice are examined in the context of clinical decision making. Similarities between one clinical decision making model and one ethical decision making model support the concept of incorporating ethical decision making into the daily practice of physiotherapy. The ethical issues of patient autonomy, informed consent, interprofessional relatlons, and resource distribution are analysed in relation to the practice of physiotherapy. A case example demonstrates how ethical decision making can be incorporated into a physiotherapy treatment decision.
Introduction The concept of clinical decision making has gained the attention of physical therapy practitioners in recent years. As the field of physical therapy has advanced in professional stature, development and improvement of clinical decision making skills have become essential components of professional growth. The role of ethical decision making as it relates to clinical decision making, however, is a topic of limited exposure in the physical therapy literature. The purpose of this paper is to examine ethical issues involved in treatment decisions in physical therapy practice, and to discuss the importance of ethical decision making within the clinical decision making paradigm. I will begin by comparing a clinical decision making model and an ethical decision making model. Next, I will offer support for ethical decision making in the treatment decisions of physical therapists. I will then provide examples of specific ethical issues encountered in everyday treatment decisions. I will conclude by demonstrating with a specific case study how ethical decision making can be incorporated into clinical decision making.
Decision Making Models: Clinical and Ethical Watts (1985) presents a decision analysis model originally developed at the Harvard Business School, and recently applied to health care decision making at the Harvard School of Public Health. The followingsteps are included in the Watts model establish a problem; narrow and delineate the focus of the problem; structure the decision process over time in a diagram to demonstrate all possible treatment choices available; estimate probabilities of the occurrence of each possible treatment consequence;and place value on strategies and outcomes.
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The diagram is a branching tree type, showing the success of treatment at each stage, and whether changes in treatment are required. The Hendrix model of ethical decision making (Barman and Hendrix, 1983)includes the following steps: identlfy a problem; express the problem as a conflict of values or ethical principles; list and rank values expressed in the problem; list and rank all alternative solutions (even those that do not agree with one’s values); take the highest ranked solution and list a t least ten values or principles that support the solution; take the lowest ranked solution and list at least eight values or principles that reject the solution; list and assign value to at least eight probable consequences of the highest ranked solution; determine whether any personally held ethical principles conflict with the highest ranked solution (if so, an opportunity to choose the next solution is given); list five reasons why others may not agree with the highest ranked solution; and assess the confidence level of the solution. Similarities in the decision making models include focusing a problem into a specific frameworkfor analysis, exploring all possible choices (of treatment or of solutions) available, determining possible outcomes, assessing consequencesof outcomes, and placing a value judgement on the selected outcome. In addition, both models allow alternative choices along the way. The similarities of the models allow conceptualisation of the possibility that ethical decision making in treatment decisions could take place in the daily practice of physical therapy.
Ethical Decision Making in Treatment Decisions Why worry about ethics in terms of treatment decisions? Are not clinical decision making models adequate for making treatment decisions? Ethical reasoning in physical therapy is usually associated with issues such as patient confidentiality, truth-telling, human experimentation, dealing with unpleasant patients, and whistle-blowing (Purtilo and Cassel, 1981). Davis (1988) discusses the critical role of values in patient care and in decision making. She states that personal values play a role in most of our decisions, but often at an automatic, unthinking level. ‘Most choices result from prioritising values. The more we know about our values, the more we learn and understand our science, and the more we know about the facts of the situation, the easier it is to make a decision that seems best’ (Davis, 1988, page 28). Purtilo (1989)makes the same point when she states that a physical therapist must ‘be mindful of which moral norms are governing his thinking because the course of action he chooses will reflect those norms’ (page 38). The Davis and Purtilo arguments are as applicable to
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treatment decisions by physical therapists as they are to any other ethical issues faced in clinical practice.
Ethical Issues Encountered in Treatment Decisions
Magistro (1989)briefly examines ethical implications of clinical decision making. He foresees ethical judgements playing an increasingly important role in the clinical decisions of physical therapists, as physical therapists continue to assume a more autonomous role in health care delivery. Magistro states: ‘Physical therapists must be on their guard to identify the numerous and sometimes serious ethical issues that can arise in practice and react to them in a responsible manner’ (page 532). He reports having seen physical therapists accused of making poor clinical judgements based on the manner in which ethical issues were handled.
Purtilo (1989) defines ethics as ‘the study of morals and moral judgements’ (page 37). Ethical theories allow individuals to resolve conflicts in duties, rights, or responsibilities. Purtilo writes: ‘Careful analysis can help to sort out the least harmful or most beneficial course of action from among the various alternatives’ (page 37). Guccione (1980) states that ethics, or moral philosophy, is critical, analytical thinking about what is the morally correct thing to do. An ethical issue is present when one can weigh alternative actions to a moral problem; an ethical dilemma occurs when acting on one moral conviction means breaking another (Purtilo and Cassel, 1981). Professional codes of ethics outline appropriate duties, rights and responsibilities of members as decided by the profession. Ethical codes, however, are written broadly, and list only general priciples that serve as boundaries of moral behaviour. They do not provide professionals with specific answers to all ethical situations (Davis, 1989).
Hansen (1985) analysed 74 ethical dilemmas identified in interviews with occupational therapists, and categorised the dilemmas into five types. All five categories dealt with treatment decisions: ‘1. The therapist had a conflict over the type of intervention method which is most appropriate. 2. The therapist had a difference with the referring professional on the appropriate method of intervention to be used. 3. There were conflicts because of the inherent constraints imposed due to the type of facility in which services were being delivered. 4. Disagreement occurred between members of the healthcare team upon the preferred method of intervention. 5. Disagreements occurred between the therapist and the client, or the therapist and the client’s family about the method of intervention to be used’ (Hansen, 1985, pages 4-5).
Physical therapists, however, do not seem to recognise the importance of values and ethics in everyday practice. Guccione (1980) surveyed New England physical therapists in an attempt to identify frequently encountered ethical dilemmas in physical therapy practice. An interesting finding of his study was a lack of perception of the surveyed therapists about making choices between conflicting principles or values. ‘Although respondents recognised that a difficult decision had to be made in some instances, they probably had not identified it as a decision of ethical choice . . . Failure to recognise that a moral point of view is required is a first step toward unethical behaviour’ (Guccione, 1980, page 127’1). Guccione states that clinical decisions are usually made by analysing situations from several points of view, and that various points of view are distinguished from others by the kind of justification given in support of a particular choice. For example: ‘When an alternative is compatible with one point of view and incompatible with another, the uniqueness of different viewpoints is more obvious. . . When the choice is easily compatible with several viewpoints, however, there is a tendency to collapse distinctions and regard the decision as a therapeutic judgement only, ignoring ethical and other dimensions of the situation’ (Guccione, 1980, page 1265).
A study of nurses (Lawrenceand Helm, 1987)found little consistency in their ethical decisions, and an ‘absence of any systematic difference in the justifications’ (page 171). The relative lack of emphasis on ethics in the physical therapy clinical decision making literature, along with the findings of the above two studies and the observations of Magistro (1989), leads to the conclusion that physical therapists must try harder to assimilate ethical theory into their daily decision making.
A number of ethical issues enter into treatment decisions by physical therapists. The issues of patient autonomy, informed consent, interprofessional relations, and resource distribution are major issues encountered daily by physical therapists. The relationship of these issues to treatment decisions by physical therapists will be examined.
Patient Autonomy Ethics of health care providedpatient relationships are historically rooted in the medical principles of beneficence - the duty to help, and. non-maleficence the duty to avoid harm. These principles allowed physicians t o make decisions about the best treatment for patients, because physicians had knowledge that patients did not. Physicians were not obliged to provide choices for patients (Caplan et al, 1987).This concept of ‘physicianknows best’ is known as medical paternaliatg A more recent model of health care represents a providedpatient relationship in which ‘physicians are morally responsible for providing care, but only such care as is desired or requested by patients’ (Caplan et al, 1987, page S9). Beneficence in patient care is limited by respect for the autonomy of individual patients. Purtilo (1984) refers to autonomy as the right to self-determination. Patients’ right to autonomy and autonomous choice is directly related to physical therapy care. Patients must be included in the decision making process by allowing them to make treatment choices based on accurate information from physical therapists about treatment benefits and risks. Physical therapists must be knowledgeable about benefits and risks of treatment alternatives presented to patients; physical therapists must rely on scientific documentation of treatment efficacy rather than using certain techniques ‘because they work.’ Patients must be allowed to refuse treatment that they do not desire. Treatment plans and treatment goals should be the product of joint decision making between therapists and informed patients. Although the autonomous patient model is widely accepted in the field of physical therapy, some physical therapists
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continue to operate under the paternalism model. Examples of paternalism in physical therapy include not providing patients with treatment alternatives, not explaining procedures to patients, and not allowing patients to participate in the goal setting process.
a patient referral. Any changes in ordered treatment must first be approved by the referring physician (APTA, 1991).This rule has a legal as well as an ethical basis.
Ethical dilemmas involving patient autonomy arise in many physical therapy situations concerning treatment decisions. One example is when patients do not seem to make wise decisions concerning their health (autonomy versus beneficence or non-maleficence).Another example is when a patient’s choice of treatment is not practical in terms of resources, ie the patient wants more than the therapist has time to provide or treatment that will not be reimbursed by the third party payer. Treatment decisions must be justified by the ethical principles personally held by the decision maker.
Two interprofessional relations issues were noted earlier in the Hansen categorisation of moral issues in occupational therapy (1985). For example, in a rehabilitation team setting, a physical therapist might disagree with the treatment approach and the rehabilitation goals selected by the team. Similarly, a physical therapist might disagree with the treatment approach chosen by an occupational therapist for a mutual patient. Both situations involve duty (or respect) for the health care professional versus patient beneficence. The decision to go along with the treatment approaches of other professionals or to follow personal convictions will be determined by ethical principles.
Informed Consent
Resource Distribution
The issue of informed consent is directly related t o the issue of patient autonomy, as stated by Caplan: ‘Thedoctrinethat h a s emerged as the guarantee of individual patient autonomy. . . is informed consent. Patients have an absolute right to make informed choices about the kind and degree of care they wish to receive’(Caplan eta/,1987, page 59).
The final ethical issue to be discussed is the problem of scarce resources. Two major limitations t o quality care are time and money. More than 70% of physical therapists surveyed by Guccione (1980) frequently established priorities for patient treatment when time or resources were limited. Thus, treatment decisions are often based on the availability of resources.
Purtilo (1984)states that health professionals initiate informed consent to ‘ensure that patients are aware of proposed treatment or evaluation plans and can thereby exercise their right to enter freely into treatment decisions’ (page 934). Informed consent has not always been an .issue in physical therapy care. When early physical therapists had more of a technician role in health care, physicians made treatment decisions and therapists carried out their orders. According to Purtilo (19841,the move towards more autonomous physical therapy practice and the increase of private practice emphasise the need to give serious attention to informed consent in physical therapy. Issues concerning informed consent in physical therapy are deciding whether consent should be obtained orally or in a formal written contract, determining the amount of information necessary to ensure full and informed consent, competence of a patient to decide rationally about treatment, and from whom to obtain consent if a patient is judged incompetent to decide (Purtilo, 1984). A physical therapist operating under the paternalism model might not value the importance of gaining informed consent. Again, any decisions regarding informed consent must be based on ethical analysis.
Interprofessional Relations Ethical issues concerning treatment decisions can pertain to interprofessional relations. The traditional referral relationship between physicians and physical therapists has the potential to create ethical dilemmas between physicians’ insistence on particular modes of treatment and therapists’ judgement about the best treatment for the patients (duty to physicians versus beneficence to patients). Even in US States where patients may legally receive physical therapy evaluation and treatment without physician referral, therapists are still bound by duty to the physician when they do receive
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Prioritisation of treatment is often necessary in situations of limited time. In the hectic day-to-day practice of physical therapy, time for lengthy treatment sessions is rare. Physical therapists not only prioritise treatments for individual patients, but also prioritise among several patients in need of services. Individual patients may not receive the ‘ideal’evaluation and treatment because of time constraints. Therapists must know precisely what to assess for each patient in order to conserve time. Watts (1985)discusses the physical therapy evaluation of a patient: ‘The danger is not so much that we will be too narrow, but that we may be wastefully broad . . . . I believe in many cases, a great deal of the evaluative data we collect are never actually used in designing treatment . . . . The cost of these unused evaluations is difficult to justify. . . . These are the.. . things we might have accomplished had we done something else with this time: the value of beginning treatment earlier, of treating the patient more often, of expanding our services to new patients . . . . The essential thing is that we use evaluation selectively’ (Watts, 1985, page 10). Others might argue that being ‘broad’ in evaluations is being thorough, and that because physical therapists are responsible for treatment decisions, steps must be taken to reduce the chances of missing important information in a scaled-down evaluation. The values of time and information are in conflict. On one hand is the possibility of wasting valuable time; on the other hand is the risk of missing valuable information. A personal decision must be made based on ethical analysis. Physical therapists must also prioritise treatments. When it might be best to provide a series of treatment procedures, it is often necessary to select the most important measures and discard others for the sake of time. The prioritisations of evaluation and treatment may be summarised as duty to an individual patient versus duty to all patients seeking services.
A similar ethical issue is prioritisation of patients for
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treatment. At times, the physical therapy clinic seems full of patients all waiting for the same therapist. The therapist must decide which to tre,at first. For example, four patients might arrive in the department at the same time. One might have severe back pain, one could be in a wheelchair awaiting an exercise session and need to use the lavatory, one might have come for an initial evaluation of a .knee injury during his lunch break, and the fourth might be accompanied by her family for instruction in a home exercise programme before discharge that day. Prioritisation should be accomplished through an ethical analysis of each patient’s situation. A human dignity concern of recognising basic human needs requires one to attend first to the patient who needs the toilet and the patient in severe pain. The other two patients are probably primarily concerned with time constraints of their own, imposed by work and family. The therapist’s ultimate decision should rest on a conscious weighing of the alternatives.
Case Example This paper has argued that clinical decisions made by physical therapists contain ethical components. Physical therapists must be aware of their moral views and values to provide ethical justification of their treatment decisions. The following case study will incorporate the Hendrix model of ethical decision making (Barman and Hendrix, 19831, applied to a physical therapy treatment decision. For reinforcement of the concept of introducing ethical decision making into clinical decision making, the case is extrapolated from the problem identified in Watts’ decision analysis model (1985). Mr Smith is a healthy adult who has just had a left total knee replacement. The physical therapy problems found in the evaluation include decreased range of motion, decreased strength, and pain in t h e left knee, and inability to bear full weight on the left leg. The goals of treatment are to secure pain-free functional range of motion, increased strength, and independence in functional activities within two weeks. The referring orthopaedic surgeon has ordered a treatment progression of a series of graded levels of exercise and functional training. The surgeon will manipulate Mr Smith’s left knee if 90° of pain-free motion has not been achieved within two weeks post-operatively.
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Financial limitations, normally imposed by third-party payers, also call for prioritisation in treatment decisions. Insurance companies control utilisation of health care services through restrictions on type, frequency, and length of treatment that will be reimbursed. Therapists must acknowledge these limitations imposed by outside agencies when making treatment decisions. Ethical issues confronted might include decisions to treat regardless of reimbursement potential, creativity in documentation to best serve the patient’s interests, and patient advocacy in the form of resubmission of denied charges. In all situations involving time and money constraints, the role of patient education in the treatment of physical therapy problems is of primary value. The more patients can rely on their own resources to accomplish their treatment goals, the less they will require one-on-one attention of a physical therapist for-an extended period of time.
consultation of the diagram suggests modification of treatment. Because specific treatment orders came from a physician referral, the therapist must contact the physician before any modification. The therapist does so, with results as stated in the case. At this point, neither model provides an explicit solution to the problem. However, to make an ethicu2 decision, one must follow an ethical decision making model. This is the point at which a therapist may not realise that an ethical decision is required. To repeat Guccione’s (1980) statement, ‘failure to recognise that a moral point of view is, required is a first step towards unethical behaviour’ (page 1271). The ethical dilemma can now be stated: What should I do when I must choose between two treatment alternatives (one that the physician ordered and one that I believe would benefit the patient more)? Because the therapist believes Mr Smith’s hamstring muscle pain is too severe to continue the exercise programme, this dilemma can be viewed as a conflict between duty to the physician and beneficence to Mr Smith. The therapist, following the Hendrix ethical decision making model, might arrive at this solution: Ask the physician t o observe Mr Smith during his second therapy session. The therapist believes that when the physician observesthe degree of Mr Smith’spain during attempts at the exercises, the physician will allow the alternative treatment requested by the therapist. This decision is based on a number of personal values, including empathy for the patient (freedom from pain), self-confidence in making assessments of patient problems, self-assertion, co-operation with the physician, and respect for the knowledge of the physician.
According t o the Hendrix model, the problem must be identified in terms of a conflict of at least two personal values or ethical principles. The case presented by Watts does not expressly state such a problem. However, many such problems are possible, even probable, in daily practice. For this example, let us embellish the case with the following information: M r Smith develops severe pain in his left hamstrings after his first therapy visit. The therapist contacts the physician with a request to discontinue the exercise progression until the pain is controlled, and meanwhile provides ice and massage to the left hamstrings to facilitate muscle relaxation and ,pain control. The physician replies in the negative, Another therapist might arrive at the same solution and states that he believes continuation of the exercise using a point of view other than a moral one, such as programme will eventually inhibit the pain. the clinical, or therapeutic, point of view. However, the In the Watts model, the therapist quickly ascertains decision would not be justified by ethical reasoning. that the patient is ‘Not OK’ after Level 1 therapy, Other therapists might arrive a t different solutions and evaluates the cause of the problem. When the using the ethical decision making model; yet they evaluation reveals pain from hamstring muscle spasm, would be able to justify their solutions ethically.
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Conclusion T h e message, as has been stated throughout t h e paper, i s that professional treatment decisions m u s t be based o n ethical analysis; ethical decision making m u s t take place as a component of clinical decision making. Development of the ability t o make ethical decisions i s an essential component of professional growth; w i t h o u t ethical decision making, t h e treatment decisions made by physical therapists have t h e potential t o jeopardise t h e advancement of t h e profession.
Author Ann L Clawson PT MS was assistant professor and academic coordinator of clinical education at the Krannert Graduate School of Physical Therapy, University of Indianapolis. She is now a physical therapist at West Side Home Health, Katy, Texas.
Address for Correspondence Ms A L Clawson, 2147 Crystal Greens Drive, Katy, Texas, USA.
Refemnces American Physical Therapy Association (1991).Code of Ethics and Guide for Professional Conduct, APTA, Alexandria, Virginia. Barman, C R, and Hendrix, J R (1983).‘Exploring ethical issues: An instructionalmodel’, The American Biology Teacher,45,23-31. Caplan, A L, Callahan, D, and Haas, J (1987).‘Ethical and policy issues in rehabilitation medicine’, Hastings Center Report, 17, Sl-S20.
Davis, C M (1988).‘Influence of values on patient care: Foundation for decision making’ in: O’Sullivan, S B, and Schmitz, T J (eds) Physical Rehabilitation: Assessment and Treatment (2nd edn), F A Davis, Philadelphia, Pennsylvania. Davis, C M (1989).Patient Practitioner Interaction: An Experiential Manual for Deve/opingthe Art of Health Care,Slack Inc, Thorofare, New Jersey. Guccione, A A (1980).‘Ethical issues in physical therapy practice: A survey of physical therapists in New England’, Physical Therapy, 60, 1264-72. Hansen, R A (1985).‘Moral reasoning and ethical decision-making in the practice of occupational therapy’, Paper presented at the Women Researcher Conference, November 8,1985, Kalamazoo, Michigan. Lawrence, J A, and Helm, A (1987). ‘Consistencies and inconsistencies in nurses’ ethical reasoning’, Journal of Moral Education, 16, 167-175. Magistro, C M (1989).‘Clinicaldecision making in physical therapy: A practitioner’s perspective’, Physical Therapy, 69, 525-534. Purtilo, R B (1984).‘Applying the principles of informed consent to patient care: Legal and ethical considerations for physical therapy’, Physical Therapy, 64, 934-937. Purtilo, R B (1989). ‘Ethical considerations in physical therapy’ in: Scully, R, and Barnes, M (eds) Physical Therapy,J B Lippincott, Philadelphia, Pennsylvania. Purtilo, R B, and Cassel, C K (1981). Ethical Dimensions in the Health Professions, W B Saunders, Philadelphia, Pennsylvania. Watts, N T (1985). ‘Decision analysis: A tool for improving physical therapy practice and education’ in: Wolf, S L (ed) Clinical Decision Making in Physical Therapy, F A Davis, Philadelphia, Pennsylvania.
ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN RESPIRATORY CARE
First Annual Conference
Respiratory Physiotherapy: From an Art to a Science June 3 - 4, 7994 Stoke Rochford, Hull, Nr Grantham, Lincolnshire
CALL FOR PAPERS This conference will look at the development of physiotherapy in respiratory care from its origins up to current research and new techniques. The Organising Committee invites research papers. Papers must be original and must include data. They must not have been published before in the form presented for consideration. Papers will be subjected to a critical review by panel. Please let the panel know whether you wish to make an oral or poster presentation. However, your paper may not be used in your preferred format. Oral presentations will be of 20 minutes duration. Papers featuring audit, qualitative or quantitative research are encouraged. Guide lines on writing and presenting abstracts and summaries are available and will be issued, free of charge, on request from the CSP Events Unit. Prospective presenters should submit a precis (no more than 200 words) to the Chairman, ACPRC Conference Committee, c/o The Events Unit, Chartered Society of Physiotherapy, 14 Bedford Row, London WC1 R 4ED, before February 1, 1994.
Physiotherapy, January 1994, voi80, no 1
The Relationship Between Clinical Decision Making and Ethical Decision Making Ann L Clawson Key Words Ethics, ethical decision making, clinical decision making, ethical issues in physiotherapy. Summary Ethical issues involved in physiotherapy practice are examined in the context of clinical decision making. Similarities between one clinical decision making model and one ethical decision making model support the concept of incorporating ethical decision making into the daily practice of physiotherapy. The ethical issues of patient autonomy, informed consent, interprofessional relatlons, and resource distribution are analysed in relation to the practice of physiotherapy. A case example demonstrates how ethical decision making can be incorporated into a physiotherapy treatment decision.
Introduction The concept of clinical decision making has gained the attention of physical therapy practitioners in recent years. As the field of physical therapy has advanced in professional stature, development and improvement of clinical decision making skills have become essential components of professional growth. The role of ethical decision making as it relates to clinical decision making, however, is a topic of limited exposure in the physical therapy literature. The purpose of this paper is to examine ethical issues involved in treatment decisions in physical therapy practice, and to discuss the importance of ethical decision making within the clinical decision making paradigm. I will begin by comparing a clinical decision making model and an ethical decision making model. Next, I will offer support for ethical decision making in the treatment decisions of physical therapists. I will then provide examples of specific ethical issues encountered in everyday treatment decisions. I will conclude by demonstrating with a specific case study how ethical decision making can be incorporated into clinical decision making.
Decision Making Models: Clinical and Ethical Watts (1985) presents a decision analysis model originally developed at the Harvard Business School, and recently applied to health care decision making at the Harvard School of Public Health. The followingsteps are included in the Watts model establish a problem; narrow and delineate the focus of the problem; structure the decision process over time in a diagram to demonstrate all possible treatment choices available; estimate probabilities of the occurrence of each possible treatment consequence;and place value on strategies and outcomes.
Physiotherapy,January 1994, vol80, no 1
SCHOLARLY PAPER
The diagram is a branching tree type, showing the success of treatment at each stage, and whether changes in treatment are required. The Hendrix model of ethical decision making (Barman and Hendrix, 1983)includes the following steps: identlfy a problem; express the problem as a conflict of values or ethical principles; list and rank values expressed in the problem; list and rank all alternative solutions (even those that do not agree with one’s values); take the highest ranked solution and list a t least ten values or principles that support the solution; take the lowest ranked solution and list at least eight values or principles that reject the solution; list and assign value to at least eight probable consequences of the highest ranked solution; determine whether any personally held ethical principles conflict with the highest ranked solution (if so, an opportunity to choose the next solution is given); list five reasons why others may not agree with the highest ranked solution; and assess the confidence level of the solution. Similarities in the decision making models include focusing a problem into a specific frameworkfor analysis, exploring all possible choices (of treatment or of solutions) available, determining possible outcomes, assessing consequencesof outcomes, and placing a value judgement on the selected outcome. In addition, both models allow alternative choices along the way. The similarities of the models allow conceptualisation of the possibility that ethical decision making in treatment decisions could take place in the daily practice of physical therapy.
Ethical Decision Making in Treatment Decisions Why worry about ethics in terms of treatment decisions? Are not clinical decision making models adequate for making treatment decisions? Ethical reasoning in physical therapy is usually associated with issues such as patient confidentiality, truth-telling, human experimentation, dealing with unpleasant patients, and whistle-blowing (Purtilo and Cassel, 1981). Davis (1988) discusses the critical role of values in patient care and in decision making. She states that personal values play a role in most of our decisions, but often at an automatic, unthinking level. ‘Most choices result from prioritising values. The more we know about our values, the more we learn and understand our science, and the more we know about the facts of the situation, the easier it is to make a decision that seems best’ (Davis, 1988, page 28). Purtilo (1989)makes the same point when she states that a physical therapist must ‘be mindful of which moral norms are governing his thinking because the course of action he chooses will reflect those norms’ (page 38). The Davis and Purtilo arguments are as applicable to
11
treatment decisions by physical therapists as they are to any other ethical issues faced in clinical practice.
Ethical Issues Encountered in Treatment Decisions
Magistro (1989)briefly examines ethical implications of clinical decision making. He foresees ethical judgements playing an increasingly important role in the clinical decisions of physical therapists, as physical therapists continue to assume a more autonomous role in health care delivery. Magistro states: ‘Physical therapists must be on their guard to identify the numerous and sometimes serious ethical issues that can arise in practice and react to them in a responsible manner’ (page 532). He reports having seen physical therapists accused of making poor clinical judgements based on the manner in which ethical issues were handled.
Purtilo (1989) defines ethics as ‘the study of morals and moral judgements’ (page 37). Ethical theories allow individuals to resolve conflicts in duties, rights, or responsibilities. Purtilo writes: ‘Careful analysis can help to sort out the least harmful or most beneficial course of action from among the various alternatives’ (page 37). Guccione (1980) states that ethics, or moral philosophy, is critical, analytical thinking about what is the morally correct thing to do. An ethical issue is present when one can weigh alternative actions to a moral problem; an ethical dilemma occurs when acting on one moral conviction means breaking another (Purtilo and Cassel, 1981). Professional codes of ethics outline appropriate duties, rights and responsibilities of members as decided by the profession. Ethical codes, however, are written broadly, and list only general priciples that serve as boundaries of moral behaviour. They do not provide professionals with specific answers to all ethical situations (Davis, 1989).
Hansen (1985) analysed 74 ethical dilemmas identified in interviews with occupational therapists, and categorised the dilemmas into five types. All five categories dealt with treatment decisions: ‘1. The therapist had a conflict over the type of intervention method which is most appropriate. 2. The therapist had a difference with the referring professional on the appropriate method of intervention to be used. 3. There were conflicts because of the inherent constraints imposed due to the type of facility in which services were being delivered. 4. Disagreement occurred between members of the healthcare team upon the preferred method of intervention. 5. Disagreements occurred between the therapist and the client, or the therapist and the client’s family about the method of intervention to be used’ (Hansen, 1985, pages 4-5).
Physical therapists, however, do not seem to recognise the importance of values and ethics in everyday practice. Guccione (1980) surveyed New England physical therapists in an attempt to identify frequently encountered ethical dilemmas in physical therapy practice. An interesting finding of his study was a lack of perception of the surveyed therapists about making choices between conflicting principles or values. ‘Although respondents recognised that a difficult decision had to be made in some instances, they probably had not identified it as a decision of ethical choice . . . Failure to recognise that a moral point of view is required is a first step toward unethical behaviour’ (Guccione, 1980, page 127’1). Guccione states that clinical decisions are usually made by analysing situations from several points of view, and that various points of view are distinguished from others by the kind of justification given in support of a particular choice. For example: ‘When an alternative is compatible with one point of view and incompatible with another, the uniqueness of different viewpoints is more obvious. . . When the choice is easily compatible with several viewpoints, however, there is a tendency to collapse distinctions and regard the decision as a therapeutic judgement only, ignoring ethical and other dimensions of the situation’ (Guccione, 1980, page 1265).
A study of nurses (Lawrenceand Helm, 1987)found little consistency in their ethical decisions, and an ‘absence of any systematic difference in the justifications’ (page 171). The relative lack of emphasis on ethics in the physical therapy clinical decision making literature, along with the findings of the above two studies and the observations of Magistro (1989), leads to the conclusion that physical therapists must try harder to assimilate ethical theory into their daily decision making.
A number of ethical issues enter into treatment decisions by physical therapists. The issues of patient autonomy, informed consent, interprofessional relations, and resource distribution are major issues encountered daily by physical therapists. The relationship of these issues to treatment decisions by physical therapists will be examined.
Patient Autonomy Ethics of health care providedpatient relationships are historically rooted in the medical principles of beneficence - the duty to help, and. non-maleficence the duty to avoid harm. These principles allowed physicians t o make decisions about the best treatment for patients, because physicians had knowledge that patients did not. Physicians were not obliged to provide choices for patients (Caplan et al, 1987).This concept of ‘physicianknows best’ is known as medical paternaliatg A more recent model of health care represents a providedpatient relationship in which ‘physicians are morally responsible for providing care, but only such care as is desired or requested by patients’ (Caplan et al, 1987, page S9). Beneficence in patient care is limited by respect for the autonomy of individual patients. Purtilo (1984) refers to autonomy as the right to self-determination. Patients’ right to autonomy and autonomous choice is directly related to physical therapy care. Patients must be included in the decision making process by allowing them to make treatment choices based on accurate information from physical therapists about treatment benefits and risks. Physical therapists must be knowledgeable about benefits and risks of treatment alternatives presented to patients; physical therapists must rely on scientific documentation of treatment efficacy rather than using certain techniques ‘because they work.’ Patients must be allowed to refuse treatment that they do not desire. Treatment plans and treatment goals should be the product of joint decision making between therapists and informed patients. Although the autonomous patient model is widely accepted in the field of physical therapy, some physical therapists
Physlotherapy, January 1994, vol80, no 1
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continue to operate under the paternalism model. Examples of paternalism in physical therapy include not providing patients with treatment alternatives, not explaining procedures to patients, and not allowing patients to participate in the goal setting process.
a patient referral. Any changes in ordered treatment must first be approved by the referring physician (APTA, 1991).This rule has a legal as well as an ethical basis.
Ethical dilemmas involving patient autonomy arise in many physical therapy situations concerning treatment decisions. One example is when patients do not seem to make wise decisions concerning their health (autonomy versus beneficence or non-maleficence).Another example is when a patient’s choice of treatment is not practical in terms of resources, ie the patient wants more than the therapist has time to provide or treatment that will not be reimbursed by the third party payer. Treatment decisions must be justified by the ethical principles personally held by the decision maker.
Two interprofessional relations issues were noted earlier in the Hansen categorisation of moral issues in occupational therapy (1985). For example, in a rehabilitation team setting, a physical therapist might disagree with the treatment approach and the rehabilitation goals selected by the team. Similarly, a physical therapist might disagree with the treatment approach chosen by an occupational therapist for a mutual patient. Both situations involve duty (or respect) for the health care professional versus patient beneficence. The decision to go along with the treatment approaches of other professionals or to follow personal convictions will be determined by ethical principles.
Informed Consent
Resource Distribution
The issue of informed consent is directly related t o the issue of patient autonomy, as stated by Caplan: ‘Thedoctrinethat h a s emerged as the guarantee of individual patient autonomy. . . is informed consent. Patients have an absolute right to make informed choices about the kind and degree of care they wish to receive’(Caplan eta/,1987, page 59).
The final ethical issue to be discussed is the problem of scarce resources. Two major limitations t o quality care are time and money. More than 70% of physical therapists surveyed by Guccione (1980) frequently established priorities for patient treatment when time or resources were limited. Thus, treatment decisions are often based on the availability of resources.
Purtilo (1984)states that health professionals initiate informed consent to ‘ensure that patients are aware of proposed treatment or evaluation plans and can thereby exercise their right to enter freely into treatment decisions’ (page 934). Informed consent has not always been an .issue in physical therapy care. When early physical therapists had more of a technician role in health care, physicians made treatment decisions and therapists carried out their orders. According to Purtilo (19841,the move towards more autonomous physical therapy practice and the increase of private practice emphasise the need to give serious attention to informed consent in physical therapy. Issues concerning informed consent in physical therapy are deciding whether consent should be obtained orally or in a formal written contract, determining the amount of information necessary to ensure full and informed consent, competence of a patient to decide rationally about treatment, and from whom to obtain consent if a patient is judged incompetent to decide (Purtilo, 1984). A physical therapist operating under the paternalism model might not value the importance of gaining informed consent. Again, any decisions regarding informed consent must be based on ethical analysis.
Interprofessional Relations Ethical issues concerning treatment decisions can pertain to interprofessional relations. The traditional referral relationship between physicians and physical therapists has the potential to create ethical dilemmas between physicians’ insistence on particular modes of treatment and therapists’ judgement about the best treatment for the patients (duty to physicians versus beneficence to patients). Even in US States where patients may legally receive physical therapy evaluation and treatment without physician referral, therapists are still bound by duty to the physician when they do receive
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Prioritisation of treatment is often necessary in situations of limited time. In the hectic day-to-day practice of physical therapy, time for lengthy treatment sessions is rare. Physical therapists not only prioritise treatments for individual patients, but also prioritise among several patients in need of services. Individual patients may not receive the ‘ideal’evaluation and treatment because of time constraints. Therapists must know precisely what to assess for each patient in order to conserve time. Watts (1985)discusses the physical therapy evaluation of a patient: ‘The danger is not so much that we will be too narrow, but that we may be wastefully broad . . . . I believe in many cases, a great deal of the evaluative data we collect are never actually used in designing treatment . . . . The cost of these unused evaluations is difficult to justify. . . . These are the.. . things we might have accomplished had we done something else with this time: the value of beginning treatment earlier, of treating the patient more often, of expanding our services to new patients . . . . The essential thing is that we use evaluation selectively’ (Watts, 1985, page 10). Others might argue that being ‘broad’ in evaluations is being thorough, and that because physical therapists are responsible for treatment decisions, steps must be taken to reduce the chances of missing important information in a scaled-down evaluation. The values of time and information are in conflict. On one hand is the possibility of wasting valuable time; on the other hand is the risk of missing valuable information. A personal decision must be made based on ethical analysis. Physical therapists must also prioritise treatments. When it might be best to provide a series of treatment procedures, it is often necessary to select the most important measures and discard others for the sake of time. The prioritisations of evaluation and treatment may be summarised as duty to an individual patient versus duty to all patients seeking services.
A similar ethical issue is prioritisation of patients for
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treatment. At times, the physical therapy clinic seems full of patients all waiting for the same therapist. The therapist must decide which to tre,at first. For example, four patients might arrive in the department at the same time. One might have severe back pain, one could be in a wheelchair awaiting an exercise session and need to use the lavatory, one might have come for an initial evaluation of a .knee injury during his lunch break, and the fourth might be accompanied by her family for instruction in a home exercise programme before discharge that day. Prioritisation should be accomplished through an ethical analysis of each patient’s situation. A human dignity concern of recognising basic human needs requires one to attend first to the patient who needs the toilet and the patient in severe pain. The other two patients are probably primarily concerned with time constraints of their own, imposed by work and family. The therapist’s ultimate decision should rest on a conscious weighing of the alternatives.
Case Example This paper has argued that clinical decisions made by physical therapists contain ethical components. Physical therapists must be aware of their moral views and values to provide ethical justification of their treatment decisions. The following case study will incorporate the Hendrix model of ethical decision making (Barman and Hendrix, 19831, applied to a physical therapy treatment decision. For reinforcement of the concept of introducing ethical decision making into clinical decision making, the case is extrapolated from the problem identified in Watts’ decision analysis model (1985). Mr Smith is a healthy adult who has just had a left total knee replacement. The physical therapy problems found in the evaluation include decreased range of motion, decreased strength, and pain in t h e left knee, and inability to bear full weight on the left leg. The goals of treatment are to secure pain-free functional range of motion, increased strength, and independence in functional activities within two weeks. The referring orthopaedic surgeon has ordered a treatment progression of a series of graded levels of exercise and functional training. The surgeon will manipulate Mr Smith’s left knee if 90° of pain-free motion has not been achieved within two weeks post-operatively.
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Financial limitations, normally imposed by third-party payers, also call for prioritisation in treatment decisions. Insurance companies control utilisation of health care services through restrictions on type, frequency, and length of treatment that will be reimbursed. Therapists must acknowledge these limitations imposed by outside agencies when making treatment decisions. Ethical issues confronted might include decisions to treat regardless of reimbursement potential, creativity in documentation to best serve the patient’s interests, and patient advocacy in the form of resubmission of denied charges. In all situations involving time and money constraints, the role of patient education in the treatment of physical therapy problems is of primary value. The more patients can rely on their own resources to accomplish their treatment goals, the less they will require one-on-one attention of a physical therapist for-an extended period of time.
consultation of the diagram suggests modification of treatment. Because specific treatment orders came from a physician referral, the therapist must contact the physician before any modification. The therapist does so, with results as stated in the case. At this point, neither model provides an explicit solution to the problem. However, to make an ethicu2 decision, one must follow an ethical decision making model. This is the point at which a therapist may not realise that an ethical decision is required. To repeat Guccione’s (1980) statement, ‘failure to recognise that a moral point of view is, required is a first step towards unethical behaviour’ (page 1271). The ethical dilemma can now be stated: What should I do when I must choose between two treatment alternatives (one that the physician ordered and one that I believe would benefit the patient more)? Because the therapist believes Mr Smith’s hamstring muscle pain is too severe to continue the exercise programme, this dilemma can be viewed as a conflict between duty to the physician and beneficence to Mr Smith. The therapist, following the Hendrix ethical decision making model, might arrive at this solution: Ask the physician t o observe Mr Smith during his second therapy session. The therapist believes that when the physician observesthe degree of Mr Smith’spain during attempts at the exercises, the physician will allow the alternative treatment requested by the therapist. This decision is based on a number of personal values, including empathy for the patient (freedom from pain), self-confidence in making assessments of patient problems, self-assertion, co-operation with the physician, and respect for the knowledge of the physician.
According t o the Hendrix model, the problem must be identified in terms of a conflict of at least two personal values or ethical principles. The case presented by Watts does not expressly state such a problem. However, many such problems are possible, even probable, in daily practice. For this example, let us embellish the case with the following information: M r Smith develops severe pain in his left hamstrings after his first therapy visit. The therapist contacts the physician with a request to discontinue the exercise progression until the pain is controlled, and meanwhile provides ice and massage to the left hamstrings to facilitate muscle relaxation and ,pain control. The physician replies in the negative, Another therapist might arrive at the same solution and states that he believes continuation of the exercise using a point of view other than a moral one, such as programme will eventually inhibit the pain. the clinical, or therapeutic, point of view. However, the In the Watts model, the therapist quickly ascertains decision would not be justified by ethical reasoning. that the patient is ‘Not OK’ after Level 1 therapy, Other therapists might arrive a t different solutions and evaluates the cause of the problem. When the using the ethical decision making model; yet they evaluation reveals pain from hamstring muscle spasm, would be able to justify their solutions ethically.
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Conclusion T h e message, as has been stated throughout t h e paper, i s that professional treatment decisions m u s t be based o n ethical analysis; ethical decision making m u s t take place as a component of clinical decision making. Development of the ability t o make ethical decisions i s an essential component of professional growth; w i t h o u t ethical decision making, t h e treatment decisions made by physical therapists have t h e potential t o jeopardise t h e advancement of t h e profession.
Author Ann L Clawson PT MS was assistant professor and academic coordinator of clinical education at the Krannert Graduate School of Physical Therapy, University of Indianapolis. She is now a physical therapist at West Side Home Health, Katy, Texas.
Address for Correspondence Ms A L Clawson, 2147 Crystal Greens Drive, Katy, Texas, USA.
Refemnces American Physical Therapy Association (1991).Code of Ethics and Guide for Professional Conduct, APTA, Alexandria, Virginia. Barman, C R, and Hendrix, J R (1983).‘Exploring ethical issues: An instructionalmodel’, The American Biology Teacher,45,23-31. Caplan, A L, Callahan, D, and Haas, J (1987).‘Ethical and policy issues in rehabilitation medicine’, Hastings Center Report, 17, Sl-S20.
Davis, C M (1988).‘Influence of values on patient care: Foundation for decision making’ in: O’Sullivan, S B, and Schmitz, T J (eds) Physical Rehabilitation: Assessment and Treatment (2nd edn), F A Davis, Philadelphia, Pennsylvania. Davis, C M (1989).Patient Practitioner Interaction: An Experiential Manual for Deve/opingthe Art of Health Care,Slack Inc, Thorofare, New Jersey. Guccione, A A (1980).‘Ethical issues in physical therapy practice: A survey of physical therapists in New England’, Physical Therapy, 60, 1264-72. Hansen, R A (1985).‘Moral reasoning and ethical decision-making in the practice of occupational therapy’, Paper presented at the Women Researcher Conference, November 8,1985, Kalamazoo, Michigan. Lawrence, J A, and Helm, A (1987). ‘Consistencies and inconsistencies in nurses’ ethical reasoning’, Journal of Moral Education, 16, 167-175. Magistro, C M (1989).‘Clinicaldecision making in physical therapy: A practitioner’s perspective’, Physical Therapy, 69, 525-534. Purtilo, R B (1984).‘Applying the principles of informed consent to patient care: Legal and ethical considerations for physical therapy’, Physical Therapy, 64, 934-937. Purtilo, R B (1989). ‘Ethical considerations in physical therapy’ in: Scully, R, and Barnes, M (eds) Physical Therapy,J B Lippincott, Philadelphia, Pennsylvania. Purtilo, R B, and Cassel, C K (1981). Ethical Dimensions in the Health Professions, W B Saunders, Philadelphia, Pennsylvania. Watts, N T (1985). ‘Decision analysis: A tool for improving physical therapy practice and education’ in: Wolf, S L (ed) Clinical Decision Making in Physical Therapy, F A Davis, Philadelphia, Pennsylvania.
ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN RESPIRATORY CARE
First Annual Conference
Respiratory Physiotherapy: From an Art to a Science June 3 - 4, 7994 Stoke Rochford, Hull, Nr Grantham, Lincolnshire
CALL FOR PAPERS This conference will look at the development of physiotherapy in respiratory care from its origins up to current research and new techniques. The Organising Committee invites research papers. Papers must be original and must include data. They must not have been published before in the form presented for consideration. Papers will be subjected to a critical review by panel. Please let the panel know whether you wish to make an oral or poster presentation. However, your paper may not be used in your preferred format. Oral presentations will be of 20 minutes duration. Papers featuring audit, qualitative or quantitative research are encouraged. Guide lines on writing and presenting abstracts and summaries are available and will be issued, free of charge, on request from the CSP Events Unit. Prospective presenters should submit a precis (no more than 200 words) to the Chairman, ACPRC Conference Committee, c/o The Events Unit, Chartered Society of Physiotherapy, 14 Bedford Row, London WC1 R 4ED, before February 1, 1994.
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