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Ethical Rehabilitation Clinical Guidelines and AI Integration

Original Editor - Stacy Schiurring

Top Contributors - Stacy Schiurring and Jess Bell  

Introduction

Rehabilitation professionals worldwide encounter complex and recurring ethical challenges: resource scarcity, inequitable access, competing professional allegiances, financial pressures, and the rapid integration of digital technologies into clinical practice.[1][2] These circumstances are common in the environments in which rehabilitation professionals work every day.

This Physiopedia page serves as a practical reference for navigating these challenges within professional and ethical obligations. It is organised into two sections. The first covers clinical practice guidelines and ethical frameworks across physiotherapy, occupational therapy, speech-language pathology (SLP, also known as speech-language therapy SLT), and orthotics and prosthetics (O&P), with particular attention to delegation. The second section focuses on the ethical implications of artificial intelligence (AI) in rehabilitation practice. The term 'ethical code' is used throughout to encompass codes of ethics, codes of conduct, and professional standards documents, all of which share the purpose of guiding professional behaviour and protecting the public.

Clinical Practice Guidelines and Ethical Frameworks

The ethical codes of rehabilitation professions share a common foundation in beneficence, non-maleficence, autonomy, justice, fidelity, and veracity. These principles are not merely aspirational; ethical practice also requires moral agency. Moral agency is the capacity not only to recognise an ethical issue, but to act on it, encompassing the cognitive capacities, feelings, skills, and actions required to make and implement ethical decisions in specific situations.[3] Research demonstrates that rehabilitation professionals frequently recognise ethically problematic situations but struggle to act when organisational systems fail to support them. This gap between recognition and action underscores the importance of education, mentorship, and systemic advocacy as practical tools.[2]

The major ethical codes across all rehabilitation disciplines share consistent commitments to patient welfare, informed consent, competence, confidentiality, and honest communication. The tables below list the applicable codes by region for each profession, alongside key ethical considerations. Regardless of region, when employer or financial pressures conflict with the best interests of the patient, the codes are unambiguous: patient welfare takes precedence.

Physiotherapy.

Table 1.0. Physiotherapy Ethical Codes and Guidelines.
Region Applicable Codes Key Ethical Note
United States APTA Code of Ethics (2025) Includes a social responsibility principle calling physiotherapists to advocate for equitable access not just for individual patients but at a systemic level.[4]
United Kingdom The 2024 HCPC revision strengthened provisions on equality, duty of candour, and digital practice. Both codes apply in the UK, but the HCPC carries statutory force.[5] The CSP Code additionally emphasises General Data Protection Regulation (GDPR) compliance and the supervisory responsibilities of qualified physiotherapists toward support workers.[6]
Canada Emphasises practitioner wellbeing, which is linked in research to moral distress and attrition.[7][8]
South Africa HPCSA Ethical Rules, including Ethical Rule 7 (2022) The most common transgression lodged with the HPCSA between 2010 and 2020 was charging for services not personally rendered. Ethical Rule 7 explicitly prohibits this.[9]
International World Physiotherapy Policy Statement on Ethical Principles (2022) Provides a globally applicable framework. Explicitly states that physiotherapists shall not delegate any activity requiring their unique skill, knowledge, and judgement.[10]


Occupational Therapy. Research identified competing allegiances as a defining ethical tension in occupational therapy practice internationally: between client autonomy, employer directives, colleague loyalty, and regulatory mandates. These tensions are not unique to any one country or health system; they can arise wherever occupational therapists work across institutional and community settings.[11]

Table 1.1. Occupational Therapy Ethical Codes and Guidelines.
Region Applicable Codes Key Ethical Note
United States AOTA Code of Ethics (2020) Centres occupational justice (e.g., equitable access to meaningful occupation) as a core ethical concern.[12]
United Kingdom Both apply, but the HCPC carries statutory weight.[5] RCOT Standards address duty of care, informed consent, confidentiality, and duty of candour.[13]
Canada CAOT (2022) Frames shared decision-making as an ethical obligation, not a clinical preference.[14]
South Africa OTASA Guidelines and Principles for Ethical and Professional Conduct (2024) The OTASA Guidelines explicitly state that the occupational therapist bears vicarious liability for the actions or omissions of junior or auxiliary staff under their supervision.[15]


Speech-Language Pathology (Therapy). Across all regions, the supervising SLP retains full professional and ethical responsibility for all care delivered by speech-language pathology assistants (SLPAs), regardless of productivity or billing pressures. This principle is consistent across every code listed below.

Table 1.2. Speech Language Pathology (Therapy) Ethical Codes and Guidelines
Region Applicable Codes Key Ethical Note
United States ASHA Code of Ethics (2023) Addresses business integrity, including misrepresentation of credentials to attract funded clients. Pressures arising from government-funded disability and paediatric services administered through private providers are not geographically unique and arise wherever such funding structures exist.[16]
United Kingdom Both apply, but the HCPC carries statutory weight.[5][17]


Orthotics and Prosthetics. Patients are routinely excluded from prosthetic decision-making despite evidence that involvement improves outcomes. Shared decision-making is an ethical obligation stated across O&P codes internationally; when reimbursement structures undermine it, clinicians have both the right and the responsibility to advocate through insurance appeals and professional association channels.[18]

Table 1.3. Orthotics and Prosthetics Ethical Codes and Guidelines.
Region Applicable Codes Key Ethical Note
United States Duty to act in the patient's best clinical interest, not in the interest of cost containment or insurer preference.[19]
United Kingdom Both apply, but the HCPC carries statutory weight.[5][20]

Delegation: Ethical Principles and Responsibilities

The American Nurses Association (ANA) and National Council of State Boards of Nursing (NCSBN) define delegation as the process of directing another person to perform a specific activity, skill, or procedure that is beyond their traditional role, with the delegating professional retaining accountability for the outcome. This is distinct from routine task assignment, which involves activities already within the delegatee's standard scope.[21][22] Notably, the APTA uses the paired term 'direction and supervision' rather than delegation. This reflects the profession's emphasis on the ongoing supervisory relationship rather than a discrete transfer of a task.[23] Across all rehabilitation professions, however, the core principle is consistent: responsibility for the outcome of delegated or directed care remains with the qualified therapist.

The supervising therapist retains professional and legal accountability for all care delivered under their direction, regardless of who carries it out. Certain functions are universally non-delegable: initial and discharge evaluations, clinical diagnosis, modifications to the plan of care, and any element requiring the unique knowledge and professional judgement of the qualified therapist. What may be delegated are well-defined tasks that do not require ongoing clinical reassessment, that fall within the assistant's documented scope, and that are performed under adequate supervision by someone whose competence has been actively assessed, not assumed from job title or prior training.[23]

Delegation becomes ethically problematic in three recurring situations. First, when it is driven by financial rather than clinical reasoning.[2][24] No code endorses delegation as a cost-saving measure at the expense of patient welfare. Second, when caseload pressures make genuine supervisory oversight impossible, the ethical obligation is to raise that concern formally rather than accept unsafe supervision as normal practice. Third, when organisational culture discourages assistants from raising concerns.[25] When used well, delegation supports good patient care; used poorly, it becomes a risk the supervising therapist bears professionally, legally, and morally.

Ethical Considerations of Artificial Intelligence (AI) in Rehabilitation

AI integration does not create new ethical principles, but it does intensify and complicate the application of existing ones. The WHO's Ethics and Governance of Artificial Intelligence for Health (2021) established six consensus principles: protecting human autonomy; promoting wellbeing; ensuring transparency; fostering accountability; ensuring equitable and inclusive access; and promoting responsible and sustainable AI. A 2025 update extended these to large multi-modal and generative AI models. These are ethical obligations that clinicians carry when choosing to use, recommend, or defer to AI-assisted tools in practice, not aspirational targets for AI developers.[26]

AI-Assisted Clinical Decision Support. AI tools for clinical decision support are increasingly available in rehabilitation: outcome prediction algorithms, risk stratification tools, movement analysis from wearables, and prosthetic fitting aids. A systematic review found promising applications across motor rehabilitation, functional assessment, and remote monitoring.[27] The WHO (2021) is unambiguous: AI must function as an assistive tool within a human-in-the-loop architecture.[28]

The clinician remains responsible for clinical decisions. Accountability does not transfer to an algorithm.

A significant concern is algorithmic bias. AI systems carry the biases embedded in their training data, and rehabilitation research has historically under-represented older adults, women, and patients from low- and middle-income countries. Tools trained on existing datasets may perpetuate rather than correct these gaps.[27]

Before incorporating any AI tool into clinical reasoning, professionals should ask: what population was this validated on; is that population representative of my patients; and what are its known limitations? This is an extension of the obligation to practise within one's competence; competence in an AI-integrated environment increasingly includes AI literacy. Surveys indicate that general awareness of AI among rehabilitation professionals is high, but knowledge of specific applications and their ethical implications remains substantially lower.[29] Uncritical deference to AI outputs is not consistent with the obligation of autonomous professional judgement.

Patient Data Privacy. Health apps, wearable devices, and remote monitoring platforms generate substantial personal health data: gait patterns, sleep quality, movement trajectories, and adherence to home programmes. The ethical obligation to protect patient confidentiality does not end when the consultation ends. Research and guidelines state that rehabilitation professionals have a responsibility to evaluate the ethical implications of digital tools before using them with clients, rather than assuming compliance on the basis of commercial availability.[30]

Data protection legislation provides minimum legal standards: Health Insurance Portability and Accountability Act (HIPAA) in the United States, the General Data Protection Regulation (GDPR) in the EU and UK, the Privacy Act in Australia, and the Protection of Personal Information Act (POPIA) in South Africa. The ethical obligation to protect confidentiality exists independently of the legal minimum and in many cases exceeds it. A patient who taps 'agree' on a tablet before a session may not have understood the data implications; the clinician's duty of care encompasses the patient's digital experience of their own health data.[31]

AI and Clinical Documentation. Where AI tools assist with session notes, assessment reports, or correspondence, the professional retains full responsibility for the accuracy, appropriateness, and confidentiality of those documents. Submitting AI-generated content without verification is inconsistent with the professional standards of every body referenced in this reading. Specific guidance on AI in documentation is actively developing; practitioners are encouraged to monitor their own professional body and regulatory authority.[27]

Resources

International Ethical Codes

Physiotherapy:


Occupational Therapy:


Speech Language Pathology (Therapy):


Orthotics and Prosthetics:

References

  1. ↑ Fryer C, Sturm A, Roth R, Edwards I. Scarcity of resources and inequity in access are frequently reported ethical issues for physiotherapists internationally: an observational study. BMC medical ethics. 2021 Jul 20;22(1):97
  2. ↑ 2.0 2.1 2.2 Sturm A, Edwards I, Fryer CE, Roth R. (Almost) 50 shades of an ethical situation—international physiotherapists’ experiences of everyday ethics: a qualitative analysis. Physiotherapy Theory and Practice. 2023 Feb 1;39(2):351-68.
  3. ↑ Edwards I, Delany CM, Townsend AF, Swisher LL. Moral agency as enacted justice: a clinical and ethical decision-making framework for responding to health inequities and social injustice. Physical Therapy. 2011 Nov 1;91(11):1653-63.
  4. ↑ American Physical Therapy Association. Code of Ethics for the Physical Therapist. Available from: https://www.apta.org/apta-and-you/leadership-and-governance/policies/code-of-ethics-for-the-physical-therapist (accessed 24/February/2026).
  5. ↑ 5.0 5.1 5.2 5.3 Health & Care Professions Council. Revised standards of conduct, performance and ethics. Available from: https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics/revised-standards/ (accessed 24/February/2026).
  6. ↑ Chartered Society of Physiotherapy. Code of Members' Professional Values and Behaviour. Available from: https://www.csp.org.uk/publications/code-members-professional-values-behaviour (accessed 24/February/2026).
  7. ↑ Canadian Physiotherapy Association. Code of Ethical Conduct. Available from: https://alliancept.org/wp-content/uploads/2024/06/Code-of-Ethical-Conduct.pdf (accessed 24/February/2026).
  8. ↑ College of Health and Care Professionals of British Columbia. Available from: https://chcpbc.org/wp-content/uploads/2024/08/RPT_-Code-of-Ethical-Conduct-2024-03-04.pdf (accessed 24/February/2026).
  9. ↑ Health Professions Council of South Africa. Available from: https://www.hpcsa-blogs.co.za/new-and-updated-ethical-guidelines/ (accessed 24/February/2026).
  10. ↑ World Physiotherapy. Available from: https://world.physio/sites/default/files/2022-03/PS-2022-Ethical_responsibilities_principles_Eng.pdf (accessed 24/February/2026).
  11. ↑ Durocher E, Kinsella EA. Ethical tensions in occupational therapy practice: Conflicts and competing allegiances. Canadian Journal of Occupational Therapy. 2021 Oct;88(3):244-53.
  12. ↑ American Occupational Therapy Association. Available from: https://research.aota.org/ajot/article/74/Supplement_3/7413410005p1/6691/AOTA-2020-Occupational-Therapy-Code-of-Ethics (accessed 24/February/2026).
  13. ↑ Royal College of Occupational Therapists. Professional standards for practice, conduct and ethics. Available from: https://www.rcot.co.uk/explore-resources/standards-guidelines/professional-standards-conduct-ethics (accessed 24/February/2026).
  14. ↑ Canadian Association of Occupational Therapists. Academic Accreditation Standards and Self-Study Guide (2022). https://caot.in1touch.org/uploaded/web/Accreditation/Academic%20Accreditation%20Standards%20and%20Self-Study%20Guide%20(2022)%20EN.pdf (accessed 24/February/2026).
  15. ↑ Occupational Therapy Association of South Africa. OTASA GUIDELINES AND PRINCIPLES FOR ETHICAL AND PROFESSIONAL CONDUCT (2024). https://www.otasa.org.za/wp-content/uploads/2024/09/GUIDELINES-AND-PRINCIPLES-FOR-ETHICAL-AND-PROFESSIONAL-CONDUCT.pdf (accessed 24/February/2026).
  16. ↑ American Speech-Leanguage-Hearing Association. Code of Ethics. Available from: https://www.asha.org/siteassets/publications/code-of-ethics-2023.pdf?srsltid=AfmBOooIjOtYkYmg50FIeSnXcn2zdE1DeQl00ZPC8rcTum0QPWYN95OT (accessed 24/February/2026).
  17. ↑ Royal College of Speech and Language Therapists. RCSLT guidance to meet HCPC standards. Available from: https://www.rcslt.org/speech-and-language-therapy/rcslt-guidance-to-meet-hcpc-standards/ (accessed 24/February/2026).
  18. ↑ Baumann MF, Frank D, Kulla LC, Stieglitz T. Obstacles to prosthetic care—legal and ethical aspects of access to upper and lower limb prosthetics in Germany and the improvement of prosthetic care from a social perspective. Societies. 2020 Jan 16;10(1):10.
  19. ↑ American Board of Certifications. What Standards Apply to Me?. Available from: https://www.abcop.org/facility-accreditation/abc-standards (accessed 24/February/2026).
  20. ↑ The British Association of Prosthetics and Orthotics. BAPO’s Standards, Policies, and Guides. Available from: https://www.bapo.com/resources/bapos-standards-policies-and-guides/ (accessed 24/February/2026).
  21. ↑ American Nursing Association. ANA’s Principles for Delegation. Available from: https://www.nursingworld.org/globalassets/docs/ana/ethics/principlesofdelegation.pdf (accessed 24/February/2026).
  22. ↑ National Council of State Boards of Nursing. National Guidelines for Nursing Delegation. Available from: https://www.ncsbn.org/public-files/NGND-PosPaper_06.pdf (accessed 24/February/2026).
  23. ↑ 23.0 23.1 American Physical Therapy Association. Direction And Supervision Of The Physical Therapist Assistant. Available from: https://www.apta.org/apta-and-you/leadership-and-governance/policies/direction-supervision-pta (accessed 24/February/2026).
  24. ↑ Howard BS, Govern M, Haney M, Ottinger HJ, Earls A, Retter A, Rippe T. Encounters with ethical problems during the first 5 years of practice in OT. The American Journal of Occupational Therapy. 2022 Jul 1;76(Supplement_1):7610510158p1-.
  25. ↑ Crevacore C, Jacob E, Coventry LL, Duffield C. Integrative review: Factors impacting effective delegation practices by registered nurses to assistants in nursing. Journal of advanced nursing. 2023 Mar;79(3):885-95.
  26. ↑ Who Health Organization. Ethics and governance of artificial intelligence for health: Guidance on large multi-modal models. Available from: https://www.who.int/publications/i/item/9789240084759 (accessed 24/February/2026).
  27. ↑ 27.0 27.1 27.2 Sumner J, Lim HW, Chong LS, Bundele A, Mukhopadhyay A, Kayambu G. Artificial intelligence in physical rehabilitation: A systematic review. Artificial Intelligence in Medicine. 2023 Dec 1;146:102693.
  28. ↑ Who Health Organization. Ethics and governance of artificial intelligence for health. Available from: https://www.who.int/publications/i/item/9789240029200 (accessed 24/February/2026).
  29. ↑ Alsobhi M, Khan F, Chevidikunnan MF, Basuodan R, Shawli L, Neamatallah Z. Physical therapists’ knowledge and attitudes regarding artificial intelligence applications in health care and rehabilitation: cross-sectional study. Journal of medical Internet research. 2022 Oct 20;24(10):e39565.
  30. ↑ Kaelin VC, Nilsson I, Lindgren H. Occupational therapy in the space of artificial intelligence: Ethical considerations and human-centered efforts. Scandinavian Journal of occupational therapy. 2024 Dec 31;31(1):2421355.
  31. ↑ Bulan PM, Kuizon DA, Casaña RS, Fuentes CG, Pestaño NY, Suerte JR. A Scoping Review on Artificial Intelligence in Occupational Therapy. OTJR: Occupational Therapy Journal of Research. 2025 Oct 21:15394492251379332.
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