Ethical Issues in Private Practice Settings

Original Editor - Simisola Ajeyalemi

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

Introduction

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

Ethics in Physiotherapy

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

Ethical issues in physiotherapy can be:

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

• about how to manage the given power asymmetry; the patient comes to the physiotherapist in a vulnerable state and since imbalance in knowledge, power, and authority is a condition, the physiotherapist must constantly be aware of the inherent vulnerability of the patient, even when there is a need to engage in a process of mutual partnership.
• about how to communicate in a respectful manner with all clients regardless of age, level of education, ethnicity, or how to live up to the patients' right to self-determination and privacy during all aspects of the course
• about ethical dilemmas- relational situations, filled with doubt and ambivalence; where the physiotherapist has to choose between action alternatives that will have negative consequences for the patient
• There is a growing demand for rehabilitation services, but resources are often insufficient to meet this demand. This situation creates an ethical dilemma for physiotherapists who must manage wait-lists and prioritise access to services
• Physiotherapists in US and Britain main issue is scarce resources and time constraints affecting quality of treatment

Ethical Issues in Private Practice settings

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

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

Step 1		Step 2		Step 3			Step 4
Initial themes		Identifying units of meaning		Condensation of analysis: one main theme: The ideal of being beneficent towards the patient Main theme			The results of the analysis
				Ethical issues related to equality Feeling obligated to do one’s best for the patient	Being equal partners
					Patient advocacy
					Having an unreflected role
					It is my duty to do my best
					Further education is the road to achieveing and mainataining professional
				Transgressing boundaries	Feeling forced to circumvent the rukes
					Being respectful of patients autonomy
					Being beneficial by telling or not telling the truth
					Being in special situation- insurance claims
					To be or not be obliged to document the process
					The dilemma of being beneficent versus doing business
					Transgressing bodily boundaries

1) Ethical issues related to equality

Includes the interviewees' reflections on how the understanding of ethical issues was related to equality in the physiotherapist–patient relationship and on how the interviewees acted upon these from a perspective of beneficence. This code-group encompassed 3 appertaining subgroups including a) being equal partners in the relationship b) patient advocacy and c) relating unreflectedly toward one's role.

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

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

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

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

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

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

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

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

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

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

  Another ethical aspect of patient advocacy revealed itself; some private clinics offered home treatment to patients who were too sick to get to the clinic and, in this setting, these interviewees had several reflections on ethics. They felt that the power balance was altered when the therapy took place in the patient's private home where the patient defined the setting. They expressed difficulty coping with this. They further expressed the feeling of being alone, insecure, and in lack of tools when dealing with very sick and/or palliative patients:

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

2) Feeling Obligated to do one's best

This code-group has eight appertaining subgroups, which are presented below.

• It is my duty to do the best: All interviewees claimed to do their absolute best for their patients, and when asked “Why?” they referred to the professional obligation.

I see it as my duty to do my best for the patient. That's what I have learned. To remove pain and harm. Do my absolute best. … I don't really know why. Is it tradition? Culture? Morality? Christianity? I don't know – but I have to do my best.

Some favored systematic tools and mentioned McKenzie's examination manual as an applicable guide to do one's best and to minimize ethical issues from occurring. Some, who used the manual systematically, addressed the ethical issue a systematic tool could encompass; physiotherapy by habit without having the unique patient in focus:

Well, I can see one ethical issue in this; physiotherapy by habit … due to business. Maybe forgetting the patient as a person … Maybe primarily focus on diagnosis …

Some expressed a daily ethical dilemma not knowing how to do one's best for the patient and not really knowing how to cooperate with the patient due to lack of experience. They felt that they did not live up to their professional obligation. In these cases, they turned to more experienced colleagues but as the colleagues often were busy, they described it as an ethical dilemma and a personal frustration.

Of course, I often experience situations where I don't know what to do. Then I ask my colleague – he always knows … But often he hasn't the time … he is treating patients so then I have to wait. Sometimes until after the patient has left. The day ends … I don't know. I don't feel well. I don't know if I have benefitted the patient … it's frustrating.

They considered their lack of competence in coping with psychosocial issues as a major ethical dilemma, often resulting in handling the situation too rapidly as a means to reduce their own emotional stress. Some interviewees only considered their physiotherapy intervention to be successful when the physiotherapy had benefitted the patient, and therefore found it very stressing and frustrating when they were not able to live up to their own expectations about beneficence.

Physiotherapy is about all aspects of human life, but I have never realised the amount of psychosocial issues involved. I feel so unprepared. So many questions, feelings and knowledge I don't know what to do about and … not knowing if it is beneficial. Whether it is physiotherapy (I am providing)?

I find it an ethical issue not to be able to deliver successful treatment to all the patients that enter my clinic. I mean what is that? … I see it as my professional duty to provide beneficence to all.

• Postgraduate education: Some interviewees sought to become capable of acting out their obligation to beneficence through further education. They found it essential that physiotherapists were able to respond to patients' and society's demands for evidence-based treatments and beneficence:

I see it as a means towards beneficence. If I don't know about evidence, if I haven't attended some education courses, I mean in the broad sense; … how do I really know how to treat the patient right? I find lifelong education necessary for providing physiotherapy in the patients' best interests.

Some others reflected differently while a few told they did not bother about further education:

Of course we attend further education. But we don't make a big fuss about it. I have taken a few courses, but I do not really feel I have learned anything. So I haven't participated in any for the last several years.

Well, I have a lot of patients. They must feel satisfied otherwise they wouldn't return.

For some interviewees, it was important to express worries about ethical dilemmas related to the lack of scientific evidence in physiotherapy:

I regard it as a disaster that so many elements of physiotherapy aren't evidence-based. Without this we can never gain optimal acceptance (from society) because we can't explain what we are doing. We don't know why the interaction was successful, just that it was. How can we consider this to be in the patient's best interest? That's not professionalism… That's the professions ethical dilemma.

Obligatory participation in supervision groups was mentioned as a method by which personal or professional difficulties, successes, or new knowledge could be shared among the employees in a clinic in order to promote consciousness in a daily practice:

I tell my physiotherapists that if they want to work here they have to undergo supervision. We touch people and we are touched by people. That is very important to be aware of in order to truly benefit the patients.

• Feeling forced to circumvent the rules: Another ethical dilemma of enacting beneficence toward the patient revealed itself. Several interviewees explained how they circumvent rules of governmental subsidies in order to ensure beneficence toward the patient even though it was illegal:

Private practice is subjected to rules; very specific rules about how many times a person can receive treatment per week and so on. So, when we have patients that need more treatments than the rules allow, who are really in pain and agony, … then I kind of mingle dates and bills in order for them to seem correct … Yes, it's illegal. And why do I bother?…In the patients' best interest, of course.

• Being respectful of patient autonomy: Some interviewees described respect for patient autonomy as an essential part of beneficence. They stressed the importance of incorporating patient education strategies and insight into their efforts to provide beneficence toward the patient. They told of teaching patients how to perceive, interpret, respect and accept body signals and emotions, and explained how these abilities can become tools for the patient and increase patient autonomy. Others did not articulate reflections upon patient autonomy.
• Being beneficial by telling or not telling the truth: Some told that they were doing their best to tell the truth to all patients and found it ethically right and natural to express it when they felt uncertain or insecure. In these situations, they would try to find the right answers for the patient – or for themselves – before the next session. Some expressed considerations about how to keep a patient informed about his/her condition or progress of treatment or how to answer difficult questions truthfully, and they considered this an ethical dilemma:

Especially when I have eager patients I can feel trapped. They want so much to have all the answers, but sometimes there just are no answers to when this symptom will end or how the prognosis will turn out. I don't know what to say, and I feel inferior. I feel I am not being honest with the patient – I can't say that I don't know because it sounds unprofessional and I can't invent an answer. But since the patient expects an answer I sometimes make one up. To their benefit. But, … This, I assume, is an ethical dilemma?

• Being in special situations – insurance claims: Some interviewees identified ethical issues relating to one special situation (i.e., insurance claims). These situations were especially difficult to handle since they appeared so rarely and it would thus be difficult to obtain routine and hard to keep up with the latest knowledge in the area. The interviewees felt alone and under pressure while having important decisions

I reflect when a patient comes to me and says “my job is too hard, it makes me sick, please help me”. It is always a weighing between the person not getting sick from his job, and the fact that all jobs wear people out. We cannot manage the same at age 55 as at age 25. This I find is an ethical dilemma; when is it fair to put one's foot down, and when is it not? … Or how long is it acceptable to wait when the patient needs his pension today? How can we best support the patient?

They acted by cooperating with the referring physician and/or performing extensive, time-consuming examinations, and often it would take years to reach a final conclusion:

It can take years to reach a decision and this I believe is another ethical issue, because how long time is appropriate when the patient is in pain and distress?

• To be or not to be obliged to document the process: Some documented their interventions and argued on basis of beneficence toward the patient and professional duty. They primarily documented successful functional measures, treatments and/or process descriptions. One explained that, for the last 25 years, she had written journals on every patient. Others never documented their examinations or treatments, giving as reasons lack of time and lack of governmental subsidies for documentation. They further explained that they felt able to remember their treatments and successes. Only a few of these interviewees regarded their lack of documentation as entailing ethical aspects.
• The dilemma of being beneficent versus doing business: Some interviewees narrated about the interface between beneficence toward the patient versus doing good business, and were aware of their personal and professional honesty and role:

If I don't deliver real and honest therapy then I have no business

3) Transgression of boundaries

This code-group contains the following three sub-groups: 1) transgressing bodily boundaries; 2) transgressing cultural boundaries; and 3) transgressing privacy.

• Transgressing bodily boundaries: The interviewees had numerous reflections on the risk of humiliation and violation due to the necessity for patients to uncover parts of their body for the physiotherapy examination and treatment. Their main strategy was information; information about the setting. The need for examination and examination positions; treatment and treatment positions; the professional rationale for closeness to the skin, muscles, and joints to optimizing the therapy; offering the explanation to findings; and ensuring the patients' understanding of this.

I inform all the time about what I am doing and possibly also why I am doing what I do …We both need to know what is happening and why, especially since the patient is partly undressed …

• Transgressing cultural boundaries: The most difficult situations of protecting patients' boundaries were described as situations with patients from other cultures than Western, where the understandings of sickness, health, responsibility, and gender differed fundamentally.

Sometimes I feel I do more harm than good to the patient, because we don't seem to understand each other. I try to explain why she has to do this exercise or why this position is needed for the examination, but then she refuses to participate and then I try the second best. But it is not the best! In a way I am being caught between a rock and a hard place. This ethical issue is relentless

• Transgressing privacy: All interviewees reported that they occasionally accidentally had violated patients' privacy and were aware about the ethical issues and dilemmas this could entail. They described it as a feeling of unpleasantness more than an active conscious reflection. The violation was often caused by asking questions which the patients did not find relevant or by asking too much about personal matters without really wanting to know –just wanting to talk.

Sometimes I just find myself asking questions where I suddenly wondered: Why do I ask this? What relevance does it have? For instance: How do you plan to arrange your birthday? I mean this is really not relevant for my training and I feel ashamed because it gives no professional meaning for me to ask.