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The Dynamic Nature of Professional Codes of Ethics

Original Editor - Wanda van Niekerk based on the course by Andrea Sturm

Top Contributors - Wanda van Niekerk and Jess Bell  

Introduction

Healthcare professionals today face expanding workloads, resource constraints and increasingly diverse patient populations. These circumstances create frequent ethical dilemmas for healthcare professionals. Thus, healthcare professionals must understand ethical principles and theories, professional obligations and their scope of practice to effectively navigate these complex situations.[1][2]

The Merriam-Webster dictionary defines a code of ethics as “a set of rules about good and bad behaviour.”[3] In healthcare, a code of ethics is an important document “that defines the key values and behaviours expected of healthcare professionals.”[4] These codes are created by international, national or regional healthcare professionals or regulatory bodies.[4]

Purpose and Function of a Code of Ethics

“Ethical codes or ethical principles describe a moral vision of the self-image of a profession. They express shared ideals with the aim of providing guidance and orientation.”[5]

Codes of ethics serve several important functions in healthcare.

They are intended as guidelines to help healthcare professionals identify and solve ethical issues.[6] They guide professional behaviour or provide broad standards for professional conduct.[4][6] Codes of ethics create opportunities for self-regulation where the profession determines the ethical standards expected of members of the same profession. They establish professional status, identity and loyalty among colleagues while building public trust by demonstrating the commitment of the profession to ethical practice.[6]

Codes of ethics provide frameworks to educate new students or early career professionals on the expected behaviour and values of a professional. More experienced professionals can use these codes to determine if their values align with the collective values of the profession.[6] In addition, the development of a code of ethics is integral to the professionalisation of an occupation.[6]

Ethical codes and other regulatory documents, such as codes of conduct, strengthen the public’s trust in a profession and discourage unethical behaviour.[6] This helps ensure that both the profession's and patients' interests are protected.

The content of codes of ethics can vary from providing set rules and guidance to establishing more aspirational goals for healthcare professionals.[7] Other codes, such as codes of conduct or codes of practice, may also include ethical information and guidance.[7] Please click here if you would like to read more about other regulatory documents.

The Need for Codes of Ethics and Ethical Competence

Ethical issues frequently arise in healthcare and professionals must be able to determine the "right thing to do" in challenging situations.[8] [9]Although the specific ethical issues may differ across healthcare professions, providing ethical care is fundamental across all fields.[6]

Research has shown that ethical competence is strongly associated with understanding the ethical concepts and principles incorporated in codes of ethics.[10]

To effectively respond to ethical challenges, healthcare professionals must be aware of their:

  • personal moral values and standing[11]
  • thoughts and perceptions[8]
  • legal obligations as a healthcare professional[11]
  • ethical obligations/responsibilities when confronted with an ethical dilemma[11]

They must also consider if they are "doing right by the patient's best interests".[12] In cases where a clinician's personal values supersede professional values, care may be compromised. Understanding the ethical expectations and values of the profession, as outlined in the code of ethics, helps prevent this conflict.[11]

Thus, “sound ethical behaviour is intrinsically linked to and shaped by knowledge of relevant professional codes.”[11]  

Awareness of Codes of Ethics

A recent scoping review on professional codes of conduct reported that most healthcare professionals (doctors and nurses in this study) have read their respective codes of ethics or are at least aware of them. While study participants reported low levels of self-evaluated awareness of the content, in studies that used objective measures to evaluate participants' knowledge of their ethical code, 75% of doctors had good knowledge and 77.5% of nurses could distinguish between true and false statements from their code. This suggests that healthcare professionals may underestimate their knowledge of their ethical codes, but this needs to be investigated further.[6]

Another study by Namaanka et al.[1] found that ethical knowledge is an important factor in physiotherapists' ethical competence. Physiotherapists with more ethical knowledge rated themselves as more ethically competent.[1] Additionally, Fryer et al.[13] note that physiotherapists with knowledge of their code of ethics and who received formal ethics training during entry-level education face fewer ethical challenges in the workplace.

The Value of Codes of Ethics

Healthcare professionals have varied perspectives on professional codes of ethics. On the whole, they highly regard these codes because they support professionalism and reflect the profession's commitment to uphold their core values. Professionals who value professional codes tend to have good knowledge of them.[6]

However, healthcare professionals' views on practical relevance can differ significantly. Some believe that professional codes play a significant role in clinical practice while others find them too theoretical or idealistic. Yet even professionals who question their clinical relevance feel that they are important to the public as an indication of the profession's values.[6]

How healthcare professionals perceive these codes also influences attitudes. Those who view professional codes as decision-making guides or tools to consult in ethical dilemmas hold more positive views. Conversely, healthcare professionals who regard codes as regulatory or disciplinary-driven are more likely to have negative views.[6]

The purpose of a code of ethics must be clear for it to be effective. It should not be written as a set of rules that need to be followed. Instead, it should be presented in such a way that leads to improved and quality patient care. There is a greater likelihood of clinicians implementing professional codes in their clinical practice when they fully understand the intentions of a code.[6]

Application of the Code of Ethics

Despite clinicians indicating a high regard for professional codes, they don't seem to be used on a regular basis in clinical practice.[6] Barriers to their use in clinical practice include[6]:

  • understaffing
  • conflicting work practices and policies
  • lack of knowledge about the content of the code
  • conflict with other healthcare professionals
  • belief that codes are too abstract, vague or idealistic
  • scarcity of resources[13]
  • inequity in access to resources[13]

In physiotherapy, research has shown that clinicians do not usually consult ethical principles or guidelines when making ethical decisions.[1][14] However, they remain important as they set expectations for a profession and define normative expectations, aims or aspirations.[4]

"At their very core, professional codes [i.e. codes of ethics] are intended to guide decision-making and direct professional behaviour"[6]

Historical Development of Codes of Ethics in Physiotherapy

Codes of ethics are reviewed and revised over time.[4] Table 1 shows a timeline of the development of codes of ethics in physiotherapy and illustrates how historical, cultural, political and social factors have shaped the physiotherapy profession and its ethical frameworks globally.

Table 1. Timeline of the historical development of the code of ethics in physiotherapy
Time Period Event Context
Early foundations (19th century)
Early 1800s Modern physiotherapy began in Sweden[15] The roots of modern physiotherapy trace back to Sweden in the early 1800s. The profession was initially dominated by men from the upper class. By the 1880s, Swedish medical gymnasts and masseurs had brought their practices to Great Britain, which led to significant developments. The 1894 "massage scandal" in Britain prompted the formation of the Society of Trained Masseuses.[16] Early ethical concerns focused on professional reputation and conduct. Initial ethical guidelines emphasised propriety and professional boundaries.
1864 Women were first admitted to learn the profession of Director of Gymnastics in Sweden[15]
1880s Swedish medical gymnasts and masseurs migrate to Great Britain[16]
1894 British Medical Journal publishes editorial sparking “massage scandal”[16]
1894 Society of Trained Masseuses was founded in response to the scandal[16]
1895 First training centre for gymnastic masseuses/masseurs opened in Argentina[17]
Early 20th Century Development - Professional recognition and early ethics
1910s - 1950s The worldwide polio epidemic began, and peaked in the 1950s[17][18] World War I proved transformative for physiotherapy, as women from massage professions treated wounded soldiers across various countries. The American Physical Therapy Association published the first formal Code of Ethics and Conduct in 1935. Early ethical codes primarily addressed the relationship between physiotherapists and physicians. Professional autonomy was limited, with diagnosis and treatment prescription remaining the physician's domain.
World War I period Birth of worldwide recognition for physical therapy as women treat wounded soldiers[19][20]
1921 Certified Masseurs Association was formed in South Africa to help soldiers and people with polio[21]
1924 Formation of the South African Society of Massage and Medical Gymnastics[21]
Post World War I Foundation of the Women’s Physical Therapeutic Association in the USA (later American Physical Therapy Association)[18]
1935 First Code of Ethics and Conduct published by the American Physical Therapy Association[18]
1937 Academic bachelor’s programme in physiotherapy introduced in Argentina[17]
1940s Physiotherapy introduced at all locations in South Africa[21]
1940s British physiotherapists introduced physical therapy to Nigeria[22]
1948 Universal Declaration of Human Rights by the United Nations[23]
Global Organisation and Growth
1951 World Confederation for Physiotherapy (WCPT) was formed by 11 member countries[24] The mid-20th century saw significant advancement in professional organisations. The World Confederation for Physiotherapy (now World Physiotherapy) was formed in 1951 with 11 member countries. The first WCPT code of ethics was published in 1959. Professional ethics began evolving from hierarchical structures toward patient-centred approaches.
1952 Polio epidemic in Mumbai helped establish physiotherapy in India[25]
1953 First physiotherapy school was founded in Mumbai, India[25]
1950s Introduction of informed consent in medicine the USA
1959 First code of ethics published by the World Confederation for Physiotherapy[24]
Bioethics Era
1967 Argentine military coup curtails physiotherapist autonomy[17] The bioethics movement of the 1970s influenced healthcare ethics broadly. Professional autonomy increased in many countries, requiring ethical code revisions.
1970 The term “bioethics” was coined by Potter van Rensselaer[26]
1970s WCPT expands to include many more countries (42 members by 1978)[24]
Early 1980s Physiotherapy was introduced to Afghanistan[27]
Early 1980s First physiotherapy training began in Saudi Arabia[28]
Late 1970s Physiotherapists in Australia became independent of medical referrals in the treatment of patients[24]
1982 Amendment to the Code of Ethics of the WCPT[24]
Modern Developments
1984 Coloured physiotherapy students were able to attend the University of Western Cape during apartheid[29] By 2020, World Physiotherapy had grown to include 128 member countries across five regions. Modern codes of ethics increasingly recognise sociocultural dimensions and local contexts.
1996 Further development of professional ethical principles of the WCPT[24]
2020 World Confederation for Physiotherapy was renamed as World Physiotherapy[30]
Present There are 128 member countries of World Physiotherapy across five World Physiotherapy Regions[30]

"Historical, cultural, political and social factors have determined the development of the profession since the beginning and impacted its versions of the ethical principles or codes of conduct."[5]

Contemporary Application of the Code of Ethics

As mentioned earlier, knowledge of ethical codes correlates with ethical competence.[13]

"Being knowledgeable about codes of ethics is a predictor of experiencing ethical challenges less frequently."[5]

Variations in Professional Ethical Codes

A scoping review by Essex et al.[4] investigated variations in both the form (i.e. the structure of a code, the content of a code, principles or rules used in the code) and function (what the code says it does) of ethical codes. This review provides insight into differences in codes across healthcare professions, countries and time periods. Differences included changes in terminology over time, inconsistencies in definitions of key concepts and variability in terms of detail—some codes are more detailed and specific, whereas others act as a more "flexible" guideline. From this scoping review, it is evident that some inconsistency is normal and reflects legitimate cultural and contextual differences and that codes of ethics remain valuable and important for setting guidelines and professional goals.[4]

Frameworks for Ethical Decision-Making

Modern approaches to ethical practice and decision-making recognise that a code of ethics alone is insufficient for navigating complex healthcare environments. Contemporary frameworks for ethical decision-making incorporate cognitive processes, relational aspects, emotional dimensions and contextual factors. Examples of these frameworks are:

These frameworks provide practical tools for applying ethical principles in everyday clinical practice.

Ethics in a Changing Landscape

Every healthcare professional can be part of the solution in responding to the ethical challenges in healthcare in the 21st century. Active engagement is needed with these evolving changes to sustain and improve ethical practice.[5] Challenges and goals that we can address include[5]:

Resources

References

  1. ↑ 1.0 1.1 1.2 1.3 Naamanka K, Suhonen R, Tolvanen A, Leino-Kilpi H. Ethical competence-exploring situations in physiotherapy practice. Physiotherapy Theory and Practice. 2023 Jun 3;39(6):1237-48.
  2. ↑ Sturm A, Ager AL, Roth R. Western ideals and global realities–physiotherapists’ views on factors that play a role in ethical decision-making: an international qualitative analysis. European Journal of Physiotherapy. 2024 Jan 2;26(1):12-24.
  3. ↑ Merriam Webster. Code of Ethics. Available from https://www.merriam-webster.com/dictionary/code%20of%20ethics (last accessed 20 May 2025)
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 Essex R, Mainey L, Gonzales‐Walters F, Gurnett P, Weldon SM. A scoping review of comparative healthcare codes of ethics studies. Journal of Advanced Nursing. 2025 Mar 3.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 Sturm, A. The Dynamic Nature of Professional Codes of Ethics Course. Plus. 2025.
  6. ↑ 6.00 6.01 6.02 6.03 6.04 6.05 6.06 6.07 6.08 6.09 6.10 6.11 6.12 6.13 6.14 Collings-Hughes D, Townsend R, Williams B. Professional codes of conduct: A scoping review. Nursing ethics. 2022 Feb;29(1):19-34.
  7. ↑ 7.0 7.1 Chiappinotto S, Igoumenidis M, Galazzi A, Kokic A, Palese A. Between mandatory and aspirational ethics in nursing codes: a case study of the Italian nursing code of conduct. BMC nursing. 2024 Jan 10;23(1):30.
  8. ↑ 8.0 8.1 Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC medical ethics. 2022 Mar 19;23(1):29.
  9. ↑ Vinckers F, Landeweer E. Moral distress among healthcare professionals in long-term care settings: a scoping review. Philosophy, Ethics, and Humanities in Medicine. 2025 Dec;20(1):1-1.
  10. ↑ Kangasniemi M, Pakkanen P, Korhonen A. Professional ethics in nursing: an integrative review. Journal of advanced nursing. 2015 Aug;71(8):1744-57.
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Commons L, Baldwin S. Ethical policy guidelines development for general hospital nurses. International journal of nursing studies. 1997 Feb 1;34(1):1-8. as cited in Collings-Hughes D, Townsend R, Williams B. Professional codes of conduct: A scoping review. Nursing ethics. 2022 Feb;29(1):19-34.
  12. ↑ Andersson H, Svensson A, Frank C, Rantala A, Holmberg M, Bremer A. Ethics education to support ethical competence learning in healthcare: an integrative systematic review. BMC medical ethics. 2022 Mar 19;23(1):29.
  13. ↑ 13.0 13.1 13.2 13.3 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 Dec;22:1-6.
  14. ↑ Delany C, Edwards I, Fryer C. How physiotherapists perceive, interpret, and respond to the ethical dimensions of practice: A qualitative study. Physiotherapy Theory and Practice. 2019 Jul 3;35(7):663-76.
  15. ↑ 15.0 15.1 Ottosson A. Als Orthopäden noch Physiotherapeuten waren, oder warum es Physiotherapeuten an Geschichtsbewusstsein mangelt–Verhältnis von Orthopädie und Physiotherapie in Schweden im 19. Jahrhundert. manuelletherapie. 2010 May;14(02):76-84.
  16. ↑ 16.0 16.1 16.2 16.3 Nicholls DA, Cheek J. Physiotherapy and the shadow of prostitution: The Society of Trained Masseuses and the massage scandals of 1894. Social Science & Medicine. 2006 May 1;62(9):2336-48.
  17. ↑ 17.0 17.1 17.2 17.3 Giraldo-Pedroza A, Robayo-Torres AL, Guerrero AV, Nicholls DA. Narrative histories of physiotherapy in Colombia, Ecuador, and Argentina. Physiotherapy Theory and Practice. 2021 Mar 4;37(3):447-59.
  18. ↑ 18.0 18.1 18.2 Purtilo RB. A time to harvest, a time to sow: ethics for a shifting landscape. Physical Therapy. 2000 Nov 1;80(11):1112-9.
  19. ↑ American Physical Therapy Association. Remembering the Reconstruction Aides [Internet]. APTA. 2018
  20. ↑ Australian Physiotherapy Association. Our history. We’ve been a profession for over 115 years. 2025. Available from: https://australian.physio/aboutus/our-history
  21. ↑ 21.0 21.1 21.2 Fourie M. The Development of Physiotherapy in South Africa. HISTORY.PHYSIO. 2020. Available from https://history.physio/the-development-of-physiotherapy-in-south-africa/
  22. ↑ University of Lagos Association of Physiotherapy Students. History of Physiotherapy in Nigeria. Available from: https://www.ulaps.org/history-of-physiotherapy-in-nigeria
  23. ↑ United Nations. Universal Declaration of Human Rights. 2015. Available from: https://www.un.org/en/about-us/universal-declaration-of-human-rights
  24. ↑ 24.0 24.1 24.2 24.3 24.4 24.5 World Physiotherapy. WCPT: The first 50 years. World Physiotherapy. 2001. Available from: https://world.physio/sites/default/files/2020-06/50th-anniversary-2001.pdf
  25. ↑ 25.0 25.1 Shimpi A, Writer H, Shyam A, Dabadghav R. Role of physiotherapy in India–A cross-sectional survey to study the awareness and perspective among referring doctors. Journal of Medical Thesis. 2014 May;2(2):18-22.
  26. ↑ Valera L. The bioethics of Potter: A search for wisdom in the origins of bioethics and environmental ethics. Medicina y Ética: Revista internacional de bioética, deontología y ética médica. 2017;28(2):413-30.
  27. ↑ Edwards I, Wickford J, Adel AA, Thoren J. Living a moral professional life amidst uncertainty: ethics for an afghan physical therapy curriculum. Advances in Physiotherapy. 2011 Mar 1;13(1):26-33.
  28. ↑ Alghadir A, Zafar H, Iqbal ZA, Anwer S. Physical therapy education in Saudi Arabia. Journal of physical therapy science. 2015;27(5):1621-3.
  29. ↑ Fourie M. Black Physiotherapy Education continued: The first coloured Students allowed University of the Western Cape. HISTORY.PHYSIO. 2020. Available from: https://history.physio/black-physiotherapy-education-continue-the-first-coloured-students-allowed-university-of-the-western-cape/
  30. ↑ 30.0 30.1 World Physiotherapy. Our members | World Physiotherapy. 2025. Available from: https://world.physio/our-members
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