Chapter 2: Evolution of Physical Therapist Ethics (PDF)

Access Provided by: Professional Issues and Ethics in Physical Therapy: A Case­Based Approach, 2nd Edition Chapter 2: The Evolution of the Code of Ethics for Physical Therapists and the Standards of Ethical Conduct of the Physical Therapist Assistant There have been many attempts to provide a si...

Access Provided by: Professional Issues and Ethics in Physical Therapy: A Case­Based Approach, 2nd Edition Chapter 2: The Evolution of the Code of Ethics for Physical Therapists and the Standards of Ethical Conduct of the Physical Therapist Assistant There have been many attempts to provide a simple explanation or definition of the word profession and the individual who is a professional. The attempt always seems to center around an ethical foundation within an established expertise and established body of information. A profession has aptly been defined as a “disciplined group of individuals who adhere to ethical standards (Australian Council of Professions, 2022; Professional Standards Councils, 2022). A professional is an individual who identifies with a certain profession and adheres to the ethical standards of that group (Creuss et al., 2004). A profession must have at its foundation a Code of Ethics that reflects the activities of the profession and the behaviors expected of the members of that profession. The Code of Ethics of a health care profession demands a higher standard of behavior in respect to the services provided to the public and the responsibility the health care provider has to the public and to professional colleagues (Bernard 2016; Evetts, 2011). Having a distinct Code of Ethics is a mark of being a professional. Professionals bound by a Code of Ethics accept the right and obligations to accept the standards set, and to embrace the challenge of self­regulation of behavior and actions. Collectively the membership of an organization through its Code of Ethics upholds the profession’s image and reputation. The profession of physical therapy had its nascent beginnings in 1921 when a small group of women founded what would soon be called The American Physical Therapy Association, but it was not until 14 years later in 1935 that the first Code of Ethics and Discipline was adopted at the Physical Therapy Association’s annual meeting in Atlantic City, New Jersey. The initial Code explicitly defined the responsibilities of the PT, but also drew a clear picture of behaviors expected of physical therapists. The Code provided direction at that time that later evolved over the years as the profession grew and developed. In 1935 the following specific guidance was provided for the practicing PT. 1. The physician’s prescription has primacy in carrying out physical therapy treatments. 2. It is prohibited to procure patients through advertising. 3. Physical therapists cannot criticize physicians and colleagues in the presence of patients. The Code of Ethics reflected the early practice patterns of the profession, PT was provided by referral only. Physical therapists practiced only under the direction of a physician with no practice autonomy or independent decision­making. It was another 13 years before the next revision of the Code of Ethics in 1948. Physical therapy had proven its importance during and following World War II, and soon after the war found itself at the epicenter of care during the polio epidemic that began in the early 1950s and spanned the first part of the decade. The 1948 revision of the Code of Ethics reflected little growth in professional autonomy on the part of the PTs. While still far from independent in their practice the profession of physical therapy was becoming more familiar to the public. Significant components of the Code provided the following guidance to the PT practitioner. 1. The PT must have adequate medical supervision. 2. Diagnosis of disability and prescription of physical therapy is the responsibility of the physician only. 3. The PT is expected to give full support to the organization that the PT serves. 4. The PT is guided by the welfare of the patient. 5. The PT has the duty to disclose unethical activities of members and to testify in an investigation. While PT practice was still very much under the purview of physician direction, and the PT was not encouraged to think independently in terms of their Downloaded 2024­8­26 6:53 A Your IP is 132.174.253.211 organization Chapter relationship, 2: The Evolution of this therevision Code ofof Ethics the Code forof Ethics began Physical to address Therapists some and the of the expected Standards professional of Ethical Conduct ofresponsibility of the practicing the Physical Therapist Page 1 / 6 Assistant, ©2024 McGraw clinician, Hill. All for example, theRights Reserved. PT is guided by theTerms of of welfare Usethe patient, Privacy Policy Notice reinforcing Accessibility the importance of the physical therapist/patient relationship. In addition, the professional responsibility of the therapist to protect patients through the privilege of self­regulation is first mentioned in this Code revision making it clear that the PT has an obligation to self­monitor with a duty to disclose unethical actions. This demonstrated to the public that the 3. The PT is expected to give full support to the organization that the PT serves. 4. The PT is guided by the welfare of the patient. Access Provided by: 5. The PT has the duty to disclose unethical activities of members and to testify in an investigation. While PT practice was still very much under the purview of physician direction, and the PT was not encouraged to think independently in terms of their organization relationship, this revision of the Code of Ethics began to address some of the expected professional responsibility of the practicing clinician, for example, the PT is guided by the welfare of the patient, reinforcing the importance of the physical therapist/patient relationship. In addition, the professional responsibility of the therapist to protect patients through the privilege of self­regulation is first mentioned in this Code revision making it clear that the PT has an obligation to self­monitor with a duty to disclose unethical actions. This demonstrated to the public that the PT took their obligation to the public very seriously. The Code of Ethics remained essentially unchanged for the next thirty years. In 1978 the Code was revised again. Health care delivery particularly payment changed significantly during that time. Employment­based insurance and Government entitlement programs like Medicare and Medicaid changed the payment landscape. The Standards of Ethical Conduct for the Physical Therapist Assistant had also been developed. A Guide to Professional Conduct was added to the professional guidance documents for the PT to assist in interpreting the Code of Ethics. There were a few significant changes to the Code. 1. The Code encouraged sound judgment by the physical therapist. 2. PTs must conduct themselves as to not discredit the association and the profession. 3. Loyalty and support to the American Physical Therapy Association. 4. Reasonable and sound remuneration. 5. Written referral regardless of state law. There were some interesting juxtapositions in this revision. While PTs are encouraged to take professional responsibility for their own actions, both in exhibiting sound judgment and conducting themselves as professionals, at the time of this revision only one jurisdiction permitted direct access to physical therapy services. However, the concept of direct access was very much on the agenda for physical therapy as a practice community. The Association, through the Code of Ethics took a position that regardless of what is legislated for patient access, physical therapists practicing legally through direct access would be considered to be practicing unethically. The Association has of course taken a much different approach over time, as direct access became one of the tenets of Vision 2020. Over the next 30 years the Code of Ethics evolved, consistent with some of the changes in practice. In 2009 the Code of Ethics had 11 principles, the Standards of Ethical Conduct for the PTA which was adopted in the 1980’s had seven principles. The following principles/standards were the same for the PT and the PTA: 1. Respect the rights and dignity/provide competent care. 2. Be trustworthy. 3. Comply with laws and regulations. 4. Professional competence for the PT and competence for the PTA. 5. Protect the public from unethical, illegal, incompetent acts. The PT also had the following principles for guidance: 1. High standards: Practice/Research/Education. 2. Address the health needs of society. 3. Respect colleagues and other health care professionals. 4. Have sound professional judgment. 5. Reasonable remuneration. 6. Provide accurate and relevant information to the public. Downloaded 2024­8­26 6:53 A Your IP is 132.174.253.211 Page 2 / 6 Chapter 2: The Evolution of the Code of Ethics for Physical Therapists and the Standards of Ethical Conduct of the Physical Therapist Assistant, The PTAMcGraw ©2024 had the Hill. following standards All Rights for guidance: Reserved. Terms of Use Privacy Policy Notice Accessibility 1. Supervision and direction of the PT. 3. Respect colleagues and other health care professionals. 4. Have sound professional judgment. Access Provided by: 5. Reasonable remuneration. 6. Provide accurate and relevant information to the public. The PTA had the following standards for guidance: 1. Supervision and direction of the PT. 2. Judgement commensurate with education and legal qualifications. The APTA defined seven Core Values for the physical therapist. These were not incorporated in the Code of Ethics, however they were closely aligned with the expected behaviors of the PT and recently applied to the behaviors of the PTA as well: Accountability Altruism Compassion/caring Excellence Integrity Professional Duty Social Responsibility Collaboration was added later as it was recognized how important this value is to safe and effective patient care. The Ethics and Judicial Committee of the APTA became quite concerned in the early part of the 21st century that physical therapists were practicing with critically important core documents that were over three decades old. At that time, The Ethics and Judicial Committee (EJC) of the APTA was charged annually to review both the Code of Ethics and the Guide for Professional Conduct and make recommendations to the House of Delegates regarding changes to the documents as necessary. In their work to adjudicate ethical issues that came before the committee, members were finding that the Code of Ethics was not robust enough to provide guidance about the many contemporary ethical issues impacting professional behavior. Beginning in 2005 the Ethics and Judicial Committee began a process to thoroughly evaluate the Code of Ethics, and the Standards of Ethical Conduct for the PTA for their relevance and applicability to contemporary practice. The Ethics and Judicial Committee embarked on an extensive review of the Code of Ethics for similar health care associations to inform the committee of best practices for similar organizations. Following this review, it was determined that the Ethics and Judicial Committee would provide the evidence and rationale for APTA to embark on an extensive review of the current Code of Ethics and Standards with recommendations for revisions as indicated. The primary question as the profession embraced Vision 2020 and the future of PT practice was, “Do the APTA core documents guide the autonomous practice of physical therapy as a doctoring profession?” The ethics and judicial committee determined that the current document was inadequate, at a minimum, the current document failed to address the following. 1. The role of the physical therapist as an educator, critical inquirer, Consultant and administrator was not addressed. The Code of Ethics had the narrow focus on the responsibilities of the physical therapist as a patient client manager only. 2. The Code of Ethics did not provide guidance about how to manage the responsibilities and demands of the PT related to autonomous/independent practice. 3. The Code did not address the complexities within the contemporary health care environment. 4. In addition, the Code and the Standards did not focus on the nuances of the relationship between the PT and the PTA and the relationship of both to other health care providers. What was perhaps most disturbing was the Code of Ethics failed to articulate in any meaningful way the moral understanding that is unique to the profession of physical therapy. What is it about the patient­therapist relationship that requires an appreciation by the physical therapist and the physical therapist assistant of the privilege, and the inherent obligations associated with the PT patient therapeutic interaction? The APTA Board of Directors agreed to the extensive review of the Code of Ethics and appointed a task force to undertake this significant undertaking. It was determined Downloaded at the same 2024­8­26 6:53 Atime to look Your IP isat the Standards for Ethical Conduct for the PTA to see if better alignment could be achieved between the 132.174.253.211 Chapter 2: The Evolution of the Code of Ethics for Physical two documents reflecting the collaborative and integrated Therapists nature and the Standards of the practice of PT’s and of Ethical Conduct of the Physical Therapist Assistant, PTA’s. Page 3 / 6 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Revision of a document such as the Code of Ethics requires the input from multiple sources and extensive resources as it is the foundation of the moral fiber of the profession and all those who “profess” to be physical therapists. The revision of the Code of Ethics and the Standards of Ethical Conduct  to other health care providers. What was perhaps most disturbing was the Code of Ethics failed to articulate in any meaningful way the moral understanding that is unique to the profession of physical therapy. What is it about the patient­therapist relationship that requires an appreciation by the physical therapist and the Access Provided by: physical therapist assistant of the privilege, and the inherent obligations associated with the PT patient therapeutic interaction? The APTA Board of Directors agreed to the extensive review of the Code of Ethics and appointed a task force to undertake this significant undertaking. It was determined at the same time to look at the Standards for Ethical Conduct for the PTA to see if better alignment could be achieved between the two documents reflecting the collaborative and integrated nature of the practice of PT’s and PTA’s. Revision of a document such as the Code of Ethics requires the input from multiple sources and extensive resources as it is the foundation of the moral fiber of the profession and all those who “profess” to be physical therapists. The revision of the Code of Ethics and the Standards of Ethical Conduct were completed in parallel as it was critical that the documents were in concert with each other, and complemented one another. A task force consisting of thirteen physical therapists (including four EJC members), one physical therapist assistant, one student and one physical therapy regulator was appointed by the Board to formulate and initiate the process. The entire process took place over almost four years from inception to completion to enactment in 2010, The new documents reflected the current practice environment but also projected where practice was anticipated to go in the next few years. The new Code was consistent with the APTA vision statement at the time that envisioned a doctoring profession with patients having direct access to PT services. In 2022, the APTA Board of Directors appointed a new task force to review the Code and Standards and make recommendations to the Board regarding the currency and applicability of both to the current practice of physical therapy. A Code of Ethics has to be a dynamic document, based on universal principles and values that demonstrate professional duties and expectations. The Code must provide guidance that is meaningful and applied to the realities of physical therapy practice. The Code has to be assimilated into professional practice and recognized as the core foundational document for ethical behavior by those that will use it. Ethical decision making is a learned skill, and the application of the Code requires meaningful opportunities to apply the principles and concepts. The current Code of Ethics fundamentally has a very different design than the documents that preceded it. Addressing the limitations of the prior documents the current code of ethics begins with a preamble identifying the contemporary roles of the physical therapist and the “special obligation of the physical therapist to empower, educate, and enable those with impairments, activity limitations, participation restrictions, and disabilities to facilitate greater independence, health, wellness and enhanced quality of life.” The format is meant to be inclusive with the lettered principles expanding upon the numbered principles that clarify intent, meaning and application. All principles begin with the common phrase of “physical therapists shall” raising every principle to the level of an ethical obligation. The core values of the physical therapy profession are incorporated into the code and associated with each group of principles. The preamble further delineates the ethical obligation of all physical therapists as defined by the American Physical Therapy Association. The preamble also makes the purpose of the Code of Ethics clear to all physical therapists and physical therapy students who are bound by the code as well as patients and other stakeholders who interact with physical therapists. The purposes of the Code are the following: 1. Provide standards of behavior and performance that form the basis of professional accountability to the public. 2. Provide guidance for physical therapists facing ethical challenges. 3. Educate physical therapists, students, other health care professionals, regulators and the public regarding the ethical obligations of the physical therapist. 4. Establish the standards by which the American Physical Therapy Association can determine if a physical therapist has engaged in unethical conduct. The Code and Standards provided clarification for long­standing ethical obligations that were part of the original code and each subsequent revision. Ethical obligations toward patients and colleagues, the duty of respect the virtues of truthfulness, honesty, and integrity. The revised documents, recognizing the complexities of contemporary practice go beyond the original code, providing guidance in the individual, Organizational and societal realms. While elements of the original documents have carried over into the current code, there is new guidance that reflects what the physical therapy community identified as issues of ethical concern at the time the Code was being revised. This included the obligation to take personal responsibility for professional competence through lifelong engagement with the profession. The importance of encouraging, cultivating and developing best practices for service delivery and discouraging business practices that are not in the patient’s best interest and finally the critical need to address the social determinants of health in impact our society and help to make physical therapy services accessible. Principle/Standard Ethical Guidance Added in 2010 Downloaded 2024­8­26 6:53 A Your IP is 132.174.253.211 Chapter 1 2: The Evolution of the Code of Ethics forallPhysical Duty to individuals Page 4 / 6 Therapists and the Standards of Ethical Conduct of the Physical Therapist Assistant, ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility 2 Duty to patients/clients community identified as issues of ethical concern at the time the Code was being revised. This included the obligation to take personal responsibility for professional competence through lifelong engagement with the profession. The importance of encouraging, cultivating and developing best practices for service delivery and discouraging business practices that are not in the patient’s best interest and finally the critical need to address the Access Provided by: social determinants of health in impact our society and help to make physical therapy services accessible. Principle/Standard Ethical Guidance Added in 2010 1 Duty to all individuals 2 Duty to patients/clients 3 Accountability for sound judgment 4 Integrity in relationships 5 Fulfilling legal and professional obligations 6 Lifelong acquisition of knowledge, skills, abilities X 7 Organizational behavior and business practices X 8 Meeting the health needs of society X The last three principles are very important additions to the Code of Ethics and Standards, but they will not be the last. Some changes have been made to the Code of Ethics since first adopted in 2010, clarifying language and adding the important virtue of collaboration, as a core value, that speaks to our obligation to work with others within our discipline as well as other disciplines to provide the best care possible. Future issues that may need ethical guidance remain to be seen, but like any profession as we mature the complexities of our profession will continue to evolve new ethical issues. We already know that social inequity, respect for our environment and our natural resources, social media challenges, the impact of unethical behavior on patients and the profession are challenges that confront everyone in health care and how they are resolved will define much of how the profession of physical therapy grows in the future. We also recognize that as we continue to grow as a profession and become more comfortable in our professional evolution every clinician has to be empowered to own their professional behavior and take responsibility for individual and organizational professional growth. Ideas to Consider 1. What type of document is a professional Code of Ethics? a. Static. b. Dynamic. c. Transient. d. All of the above. 2. Which statement is true about health care professions? a. All have a guidance document like a Code of Ethics. b. Most have a guidance document like a Code of Ethics. c. Some have a guidance document like a Code of Ethics. d. Only hands­on health care fields have a Code of Ethics. 3. Which statement is true about the current Code of ethics and standards of ethical conduct? a. The Code Downloaded and Standards 2024­8­26 belong 6:53 A Your IP to the APTA. is 132.174.253.211 Page 5 / 6 Chapter 2: The Evolution of the Code of Ethics for Physical Therapists and the Standards of Ethical Conduct of the Physical Therapist Assistant, b. McGraw ©2024 The CodeHill. andAllStandards are bindingTerms Rights Reserved. on allof PTs and Use PTAs notPolicy Privacy just APTA members. Notice Accessibility c. The numbered and lettered principles and standards are equally important. behavior on patients and the profession are challenges that confront everyone in health care and how they are resolved will define much of how the profession of physical therapy grows in the future. We also recognize that as we continue to grow as a profession and become more comfortable in our professional evolution every clinician has to be empowered to own their professional behavior and take responsibility for individual and Access Provided by: organizational professional growth. Ideas to Consider 1. What type of document is a professional Code of Ethics? a. Static. b. Dynamic. c. Transient. d. All of the above. 2. Which statement is true about health care professions? a. All have a guidance document like a Code of Ethics. b. Most have a guidance document like a Code of Ethics. c. Some have a guidance document like a Code of Ethics. d. Only hands­on health care fields have a Code of Ethics. 3. Which statement is true about the current Code of ethics and standards of ethical conduct? a. The Code and Standards belong to the APTA. b. The Code and Standards are binding on all PTs and PTAs not just APTA members. c. The numbered and lettered principles and standards are equally important. d. All the above are true. Downloaded 2024­8­26 6:53 A Your IP is 132.174.253.211 Page 6 / 6 Chapter 2: The Evolution of the Code of Ethics for Physical Therapists and the Standards of Ethical Conduct of the Physical Therapist Assistant, ©2024 McGraw Hill. All Rights Reserved. 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