As new theories emerge and new exercises, movements and techniques are taken up by the hands and mind of a physiotherapist, our profession is continuously developing. This paper discusses the development of ethical concerns within the profession, specifically in relation to autonomy and welfare of the patients.
Physiotherapy is a new science. As new theories emerge and new exercises, movements and techniques are taken up by the hands and mind of a physiotherapist, our profession is continuously developing. Since a physiotherapist is able to use new tools to answer old problems like disability, restriction of movement, and the consequences of aging, physiotherapy’s borders are not solidly defined but continuously and variously expanding towards new territories. But if this expansion is to prove a lasting achievement, it will only be by embracing theories and techniques that have proved to be effective and safe for the patient.
One of the quality standards for this ever developing profession is evidence based practice. We need evidence-based information because by systematically appraising, teaching, and applying clinical research findings, we can give optimum clinical care to patients (Rosenberg and Donald 1995). As physiotherapy has tried to shore up its scientific profile through evidence-based practice with increasingly rigorous studies and research protocols, a genuine shift has resulted in our profession. Physiotherapists have started to identify and confront ethical problems in clinical settings. Dilemmas of an ethical rather than of a solely clinical nature have multiplied. Inevitably, physiotherapy has started trying to develop a distinct awareness and possible solutions for these new problems. It was natural, in an era where the notion of autonomy is widely accepted and encouraged, to expect as a direct consequence a ‘turn’ towards the patient’s views on what he needs. To do that, physiotherapists had to adopt an inductive process of clinical reasoning that enables them to take into account the understanding and premises of each particular patient. It is thus nowadays widely accepted that clinical reasoning must be a collaborative process where the patient’s views must be respected and taken into account (Edwards and Delany 2008).
To reciprocate this turn towards the patient, new paths for investigation are ordained based on different grounds. A physiotherapist used to be considered successful if she objectively and effectively addressed the disability of her patient as defined almost exclusively by the consulting doctor. Over time, however, the patient’s own estimate of the rehabilitative process and goals has grown considerably in importance. And with it the potential conflicts between patient and therapist, as well as the therapist’s own dilemmas regarding the options offered to the patient.
Autonomy in physiotherapy ethics
Autonomy in physiotherapy has the meaning that all the other health care professions attribute to it, namely, that of the respect of the patient’s wishes. Beauchamp and Childress (2001) in their ‘Principles of Biomedical Ethics’ gave an account of an autonomous person. They analyse autonomous actions in terms of normal choosers who act intentionally with understanding and without controlling influences (Beauchamp and Childress 2001). Personal autonomy is defined as, ‘personal rule of the self, free from both controlling inferences by others and from personal limitations that prevent meaningful choice’ (Beauchamp and Childress 2001). As Harris notes, the ability to choose itself has a special importance that autonomy is valuable per se, because this is what makes a life worth living, the very choices that we make about our life (Harris 1985). The notion of autonomy has understandably been invoked as central to the integration of bioethics in physiotherapy.
Physiotherapy itself has sought a measure of autonomy for itself after labouring under the supervision of medicine and has thus endeavored to obtain a greater clinical decision making role for their patients (Rose 1989). The increased autonomy consequently conveys increased responsibility for the physiotherapist.
Moreover, there is the special meaning that autonomy has in physiotherapy. Disability, physiotherapy’s main target, is by definition a restriction of the patient’s choices. This restriction is a physical one but the patient has to come to terms with her inability to fulfill his choices, making autonomy a key part of his agenda. The patient (not all but most of the times) is actively doing his exercises, and therefore he is able to assess the results during the rehabilitation period and not after, making him more responsible for his treatment, giving him a bigger role in the decision making process. Usually physiotherapy requires prolonged treatment and involves an evolving process of care prescribed and jointly agreed upon by the lead physician and by therapist; the extent of consultation with the patient can vary greatly however. In some cases, a close relationship may develop between the therapist and the patient due in part to the frequency of treatment as well as direct physical contact when doing assisted movements or manipulation-mobilisation. No less important to the formation of a distinct form of intimacy between patient and doctor can be the unavoidable discussion of the effects and necessary adjustments to the patient’s way of life, which may include a range of functions and capabilities, from his ability to continue working, fulfilling former duties or roles in family life. It is not surprising that major western physiotherapeutic associations and confederations explicitly report it as part of the ethical duties of their members (Swisher 2010). All the above create an environment for the physiotherapist that has a constant challenge since the notion of autonomy with a meaning is continuously altered and magnified.
Welfare as a key issue in physiotherapy
Another reason for the steady integration of bioethics in our profession is the challenging notion of welfare. In ethics welfare is commonly defined as the condition of doing or faring well. Synonyms include ‘‘wellbeing’’ and ‘‘best interests.’’ As a socially defined concept welfare exceeds the physical wellbeing of the patient. Welfare includes not only physical integrity but also psychological integrity, completeness of aims, etc.
When a patient visits a physiotherapist the first question she asks is ‘Do you know when I will be healthy or fully fit again?’ In physiotherapy practice, notions like welfare, health and disability are routinely employed by both patients and therapists, but seldom with significant disparities in meaning which are not immediately, or ever, reconciled. Upon these notions serious decisions affecting the rest of the lives of the patients are taken. When is the patient healthy and when can she cease to receive physiotherapeutic treatment? When is she disabled? What, in fact, are the thresholds for entering and exiting physical therapy? The physiotherapist, the patient, or increasingly in some parts of the world, an insurance company, must decide, according to their expertise, expectation, or financial interests, which course of treatment meets the combination of criteria being considered. As a rule, easier to assent to in spirit than to apply in letter, whenever a conflict appears in a clinical setting among the various contributing criteria, the patient’s ‘welfare’ is invoked as the over-riding principle to resolve this conflict, since welfare is often broadly understood to be the patient’s aim in seeking rehabilitation treatment. The provisional clarification of such an indeterminate notion is indispensable in almost every ethical conflict in a physiotherapy setting.
It seems that the notion of welfare is defined according to the opinion of persons with different aims, aspects, and different socio-cultural backgrounds. Some people may begin to formulate, in highly impressionistic terms, what welfare is for the first time after an accident; others, like health care professionals, decide and form an opinion in a dynamic continuous way during the years spent in on the job, adjusting their values in light of myriad experiences. Disability for a physiotherapist is a term defined according to a variety of factors, including age and wide experience of the natural diversity of ‘normal’ functioning among human beings born with uneven or distinct capacities for movement. Still, a physiotherapist cannot help but share commonly defined disability, such as a broken leg or a torn muscle or a swollen joint. But disability is a variable and fluid concept. Professional dancers or athletes, for example, may be in great pain as a result of a serious injury, but will nevertheless perform well. Is disability then a medical, scientifically-defined state, or a subjective or individually determined one, or perhaps a varying mix of both? Is a healthy person someone who is pain-free, someone who is able to do the things that he wants or someone who is both pain free and may perform well in his everyday life activities? These parameters compose a fluid notion difficult to define.
The exact scope of a rehabilitation program is formed upon the patient’s conception of this key notion, based not only on what the physiotherapist has decided but also on what each patient believes. This is not simple. Firstly and most importantly there is no agreement on the definition of this notion. There are subjective and objective theories of welfare. Usually an objective theory would include reference to certain objective states of ill health. It is most commonly related to health, to species normal functioning or the absence of disease. Subjective theories of well being make our well being dependent on our attitudes of favour or disfavour whilst objective theories deny this dependency.
If a decision based on the individual was possible things would have been easy. Purtilo predicted a model in physiotherapy ethics that evolved from self-identity to patient-focused identity, with increasing representation of societal identity (Purtilo 2000). Welfare is not only what we believe; it is a combination of the patient’s views and the views and needs that society has on health and disease. The notion of the patient’s welfare is a dynamic notion affected my many factors and must always inform practice. The patient must explicitly contribute to the discussion concerning the scope of treatment and must actively participate in the definition of the notion of welfare in collaboration with the physiotherapist.
Until now many physiotherapists have worked on the ethics of our profession. In future the integration of bioethics in our profession will be more intense and more complicated; if we want to respect the patient, ourselves and society we have to work harder with these notions.
Beauchamp TL and Childress JF (2001) Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press; p.123.
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