How to Use This Book

There are two parts to this book. Part One provides more didactic, foundational material while Part Two strives to apply ethical decision making tools to relevant cases in physical therapy practice. The two parts are meant to be used together but they also can stand alone providing basic conceptual material about ethics, and ethical decision-making in physical therapy practice, with the second section focusing on case analysis.

This text begins with foundational material that serves as a good introduction for students and a light review for practicing clinicians. Each chapter in the first section of the text concludes with Ideas to Consider. Chapter One introduces the reader to healthcare ethics with a brief overview of how ethical decision making has evolved. It is not the intention of the book to make the reader a bioethicist. Rather the chapter introduces the terms utilized in the field of Bioethics with the clinical relevance highlighted with references to the Code of Ethics to provide a practical application of the term. The chapter also gives us insight into the responsibility we have to take action, exercise moral potency, not to be passive in the relationship that benefits those who have entrusted their care to us. The chapter concludes with a brief discussion of the relationship between ethics and law. Chapter Two explores the evolution of the Code of Ethics for the Physical Therapists and the Standards of Ethical Conduct for the Physical Therapist Assistant. It focuses on how these core documents and our core values have evolved as the profession of physical therapy has evolved. It is meant to provide a strong framework for clinicians to rely on to empower them to work collaboratively but to accept the challenge and the imperative to take personal responsibility for sound professional judgments. Chapter Three establishes the framework of professionalism and sets the foundation for ethical decision making firmly on the patient/therapist relationship, the importance of trust and the dynamic involved in that trust are developed in this chapter. Chapter Four, ethical guidance can stand alone, independent of any other aspect of the text but it is also a foundation to understanding how we as physical therapists and physical therapist assistants are expected to behave. It delves into each of the principles and standards of the Code of Ethics for the physical therapist and the Standards of Ethical Conduct of the physical therapist assistant. Regardless of role, to work together effectively, the PT and the PTA must understand their ethical obligations as well as the ethical obligations of their colleagues. Chapter Five, ethical risk factors, addresses the “unthinkable” the fact that any one of us can easily engage in an ethical breach, because just like our patients we are human and not infallible. This chapter lends itself to an opportunity for introspection, how many of the risk factors identified have I had in the past, or currently have or may have in the future, suggestions are offered for how to recognize potential risks, and how to mitigate those risks if possible. A new section has been added to this chapter addressing the concept of moral injury, and how a clinician suffering from moral injury is more likely to have a negative impact on a patient.

Chapter Six is the heart of the ethical decision-making portion of the text and if you are planning to use just the cases, you would benefit from first reviewing Chapter Six to provide the context for efficient ways in which to utilize the suggested decision-making model. Two cases are presented and developed fully to model an extensive ethical decision-making framework. When using the cases in Part Two it is often helpful to return to this chapter to review application of the decision-making frameworks. Ethical decision-making is what is expected of professionals by the public we are privileged to work with. The complications in ethical decision-making arise not just from the individual relationships we have with patients but on the confounding factors that develop because of the influences of the institutions and organizations and the societal pressures that impact our practice. With each passing day, and each technological advance, the questions become more complex impacted by resource allocation, access to PT services, and technological advances. This chapter poses the question that we are consistently faced with … “just because we can, doesn’t mean we should.” Chapter Seven is new to the second edition, reflecting dramatic practice changes that evolved over the past few years in telehealth and digital physical therapy practice. The first edition addresses telehealth in the ethical challenges of the future chapter but the future is now, and telehealth and digital health both have notable advantages for patient care but at the same time raise interesting ethical questions. Chapter Eight is also new to the second edition and is a result of that all-important clinical dialogue. Clinicians began to notice a significant uptick in questions from patients and clinicians and students about verbal, nonverbal, and even physical behaviors that appeared to cross the line between appropriate and less than appropriate behavior. What does the PT clinician, educator, researcher, administrator need to be aware of when practicing a hands-on profession in a hands-off world? The final chapter in Part One, Chapter Nine looks to the future, that which challenges us today will always be just a part of what will challenge us tomorrow and as professionals we have an obligation not just to keep up with new advances clinically but also with the new ethical challenges that arise from the technological changes.

Part Two of the text is designed to be integrated with Part One or it can stand alone for clinical or class discussions. The cases are divided into the major areas in which ethical decisions fall in clinical practice. Each section now has four cases with a new case added for each section related to updated material presented in section one on this second edition. When used in a clinical setting, cases can be used independently to encourage discussion or to stimulate thought as background for a clinically relevant case in the setting in which you are practicing. In the classroom setting the four cases per section allow you many options about how to use the cases either in a dedicated ethics or professional issues class or to integrate the cases into clinical courses as they may be applicable to that course content. You can use one case to introduce the process in the classroom and then use subsequent cases for either individual work to be discussed in class or group work. Chapter Ten provides an introduction to case analysis guiding the reader through a case with suggestions on how the case analysis process could be applied. Chapter Eleven deals with cases having to do with professional accountability, particularly when the PT is navigating the many entities to whom they are accountable to. Chapter Twelve navigates the always tricky area of boundary issues. In a profession that gets so close to their patients physically and emotionally boundary awareness is critical and boundary breeches always a concern. Chapter Thirteen covers the broad spectrum of practice issues. PT’s treat across the lifespan, in a myriad of practice settings and each situation is unique but the basic responsibilities of the physical therapist remain constant regardless of setting or patient presentation. This chapter is focused on helping the PT drill down to the core parameters of ethical practice. Chapter Fourteen traverses the complex but critical area of professional relationships both intra professional and inter professional both critical to maintaining a productive working environment. The cases speak to the carefully traversed path between the necessity to be autonomous in our decision-making but at the same time be collaborative and not isolated in our practice. Chapter Fifteen addresses professional responsibility. This complex relationship that we have with all the institutions that impact our practice is most important to understand in the context of our responsibility to our colleagues, profession, and most important our patients. The cases in this chapter explore professional responsibility from various perspectives. Chapter Sixteen addresses self-regulation, every professional has the responsibility to regulate themselves as well as the responsibility to be accountable for the regulation of physical therapy practice. The public grants professionals the right to regulate their own practice and with that comes the responsibility of professionals to be deliberate and thoughtful about what that privilege/responsibility requires. Chapter Seventeen traverses the complex world of supervision and being supervised. It is built on the premise that delegation does not mean abdication. These cases look at the responsibility of the supervisor as well as the responsibility of the person being supervised. The ultimate responsibility whether supervisor or supervisee lies with the individual licensee, often leading to some very complicated ethical situations. Chapter Eighteen, the final chapter in the book navigates the very special relationship between the novice, the student physical therapist, and their future profession. There is a uniqueness to healthcare education that requires a considerable amount of on-the-job training as part of the formal education. This training, while highly beneficial, places unique and complex responsibilities on both the student and the licensed clinician. Many of the issues discussed in previous chapters impact the student, clinical instructor relationship but there are some situations that are unique to this very special student, teacher, mentor, future colleague relationship.

The challenge of this text is to constantly keep it relevant and current providing new cases via on line resources that reflect new professional challenges, but the text itself with its foundation in principle and application should endure and provide continued meaning and relevance to inform clinical practice and encourage practitioners to consistently to strive to do what is right recognizing that there is never a “right way” to do the “wrong thing.”