Ethical Issues in Physical Therapy Practice

A Survey of Physical Therapists in New England

ANDREW A. GUCCIONE, MS

This survey was an attempt to identify which ethical decisions are most fre-
quently encountered and are most difficult to make for practicing physical
therapists. A questionnaire that described 3 0 situations with an ethical dimen-
sion was sent to 4 5 0 American Physical Therapy Association members practicing
in New England. A total of 187 (41.5%) usable questionnaires was returned.
Issues raised by items were designated a s primary, secondary, or nonpriority.
Seven primary and 11 secondary ethical issues were identified. In brief, these
issues involve the decision about which patients should be treated, what obli-
gations are entailed by that decision, who should pay for treatment, and what
duties derive from the physical therapist's relationship with other health profes-
sionals, including physicians. Some of these decisions are more frequent in
certain types of employment facilities than in others. Sources of ethical conflict
and the role of the professional organization in defining moral values for the
profession are discussed in this paper, and implications for education are
presented.

Key Words: Ethics, medical; Ethics, professional; Physical therapy.

The need to identify and clarify ethical issues
within a health profession increases as the profession
assumes responsibility for those areas of direct patient
care in its domain. A brief comparison of the 1935
American Physiotherapy Association C O D E OF E T H -
ICS with its 1977 American Physical Therapy Asso-
ciation (APTA) counterpart reflects the development
of physical therapy as a profession in its own right.1
The physical therapist today, in defining the limits of
his legal and professional autonomy, must examine
the practice of his profession from an ethical point of
view. By doing so, he carefully guards the rights of
patients, maintains his integrity as a professional, and
promotes the ideals of physical therapy as a profes-
sion.
Mr. Guccione was a candidate for the degree of Master of Science
in Physical Therapy at Sargent College of Allied Health Professions,
Boston University, when this study was conducted. He is currently
Staff Physical Therapist, Physical Therapy Department, Massachu-
setts Rehabilitation Hospital, 125 Nashua St, Boston, MA 02114
(USA).
Adapted from a paper presented at the Fourth Annual Convention
of the Massachusetts Chapter, American Physical Therapy Associa-
tion, Hyannis, MA, April 1978.
This article was submitted April 2, 1979, and accepted January 4,
1980.
Thompson has suggested that there are three
sources of conflict for health professionals making
ethical decisions. 2 First, conflicts may arise between
an individual's private convictions and his conception
of the requirements of his professional role. Second,
ethical dilemmas may be encountered when the atti-
tudes, values, and goals of one profession conflict
with those of another. Finally, the ethos (ideology) of
a profession and that of the society in which it func-
tions may be in conflict.
Professional ethics has developed in response to
these sources of conflict, and the APTA CODE OF
ETHICS and the guidelines for its interpretation
emerge historically and sociologically with that de-
velopment. 1 The C O D E may be regarded as an attempt
to counsel physical therapists making ethical judg-
ments by asserting the ideals of the profession and by
defining some of the limits of professionally and
morally acceptable behavior. Continuing documen-
tation of the ethical concerns of practicing physical
therapists is essential to maintain timely counsel.
The twofold purpose of this study was to identify
which ethical problems were perceived by physical
therapists to be the most frequently encountered and

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 the most difficult to solve in their daily professional
practice.
Simply stated, ethics, or moral philosophy, is criti-
cal, analytical thinking about the behavioral expres-
sions of human interdependence and what is the
morally right thing to do. Currently, the complexities
of medical practice have given rise to ethical questions
that demand the participation of both medical per-
sonnel and academic ethicists in discussing the issues
involved. These discussions have served, at least, to
define what some of the problems are, but continuing
dialogue is needed to determine more adequately the
range of morally sound solutions.
Topics that have received attention include abor-
tion, euthanasia, the right to health care, the patient's
rights while receiving health care, and the limits of
experimentation with human subjects. Although the
physical therapist is concerned with these issues as an
informed member of the health care team, his involve-
ment in the decisions they require is sometimes not
directly evident. All moral dilemmas occur within a
context of proposed action. 2-4 Some ethical problems
are specific to physical therapists because what they
do is different from what physicians, nurses, and
other health professionals do. Other ethical problems
involve physical therapists in only limited or periph-
eral ways. Because of the context of certain ethical
problems, the ethics of health care professionals has
been recognized as an area of study akin to, but
distinct from, medical ethics.
In order to select a defensible choice, a decision-
maker first adopts a point of view from which to
interpret the facts. Any point of view adopted will
emphasize one kind of fact over another, perhaps
equally important, kind. The moral point of view is
distinguished from others by the kind of justification
given in support of a particular choice. For example,
the decision to perform passive range of motion be-
cause it will achieve certain treatment goals is reason-
ing from the therapeutic point of view. If a therapist
cites a legitimate physician referral as his reason for
performing passive range of motion, then he has
justified his choice from the legal point of view. If his
choice of passive range of motion is defended on the
grounds that it is the only procedure that would avoid
unnecessary harm to the patient, the decision has
been made according to the moral point of view.
Purtilo's discussion of the physical therapist as ethicist
is a significant contribution toward defining the moral
point of view for a health professional. 3 Generally, no
clinical decision is made without analyzing the situ-
ation from several points of view, but each point of
view is unique in the kind of questions it asks about
a proposed action. When an alternative is compatible
with one point of view and incompatible with an-
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other, the uniqueness of different viewpoints is more
obvious. In these instances, the multiple dimensions
of judgments made by physical therapists are appar-
ent. When the choice is easily compatible with several
viewpoints, however, there is a tendency to collapse
distinctions and regard the decision as a therapeutic
judgment only, ignoring ethical and other dimensions
of the situation.
Ethical Issues in Physical Therapy
The ethical dimension of actual clinical practice is
not well documented in the literature. Ethical devel-
opment has been cited as a basic objective of physical
therapy education, 5 and several authors have noted
an ethical dimension in the routine functions of the
physical therapist. 3,6-11 Behavior guided by an ethical
code has been described as identifying physical ther-
apy as a profession rather than a technology and as
contributing to professional stature. 1,10,11 Often, phys-
ical therapists have been encouraged to exhibit par-
ticular behaviors. Exact recommendations have been
made, for example, on selection of topics for discus-
sion with patients,8"10 the uses of proper vocal tone
when speaking with patients, 9,10 presentation of a
modest appearance, 9 cooperation with and ultimate
deference to the physician's judgment concerning
patient treatment, 8-11 and maintenance of a patient's
dignity and his confidence in his physician.8"11 There
has been little discussion of the moral principles
behind these expectations, and the ways in which
they pose problems for the therapist have not always
been identified. If the underlying principles are not
made explicit, recommendations for particular behav-
iors are no more compelling than remarks on profes-
sional etiquette. Physical therapy education that does
not cover ethical theory, as well as application, may
inadvertently trivialize the importance of ethical be-
havior.
Discussions of professional ethics can seem over-
whelmingly complex, and the question of where to
begin is posed as often as the question of what to do.
A guiding assumption of this study is that, while all
ethical problems are important, attention should be
directed first to those ethical issues that affect and
perplex the majority. The results of this survey pro-
vide a focus for that attention.
METHOD
Subjects
Four hundred fifty members of the APTA were
selected at random from the total APTA membership
in the six New England states (N = 2,017) as of
1265
 December 1977. The sole criterion for inclusion in
the study was that a therapist be employed in some
aspect of therapy excluding education. A major as-
sumption of this study is that problems of professional
ethics originate within the specific context of clinical
practice. Therapists whose primary employment is in
academic education do not experience that context
on a daily basis. Also, educators and graduate stu-
dents were not included because they might be more
sensitive to the complexities of some ethical issues
and thus skew the results.
Instrument
Thirty items that described situations suggestive of
ethical problems were presented to the sample in a
questionnaire format. Inasmuch as demographic dif-
ferences are often a source of variations in response,
data were collected on age, sex, total years of physical
therapy work experience, and highest educational
level obtained, as well as the respondent's present
type of employment facility, level of his position,
setting of employment, and state. Information on
sources of contact with issues of professional ethics
and the number of physical therapists available to
discuss actual ethical problems was also collected.
Procedure
Respondents were asked to score items according
to the frequency with which they had encountered a
situation of the type described in their own profes-
sional practice and the difficulty they experienced in
reaching a decision in those instances. The frequency
measure had five levels: high, moderate, minimal,
none, and not applicable. The difficulty measure had
four levels: extreme, moderate, minimal, and none.
Assuming that ethical problems arise out of a par-
ticular context, accurate measurement of the difficulty
of an item requires at least minimal experience with
it. In cases in which a respondent reported having no
experience with the situation described by an item, or
thought it inapplicable to him, the difficulty rating
was excluded from the results.
Data Analysis
The Kolmogorov-Smirnov One-Sample Test was
employed to determine the significance of the distri-
bution of responses on both the frequency and the
difficulty scales. 12 This test measures the agreement
between a theoretical cumulative distribution of re-
sponses and an observed cumulative distribution. If
responses are divided almost equally among the levels
of a scale, there will be no significant difference
between the theoretical and the observed distribu-
tions. In order to consider a level on a scale to be a
significant preference of the respondents, it must be
demonstrated that the dissimilarity between a theo-
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retical array of data values and the actual or observed
array could not have happened by chance. The ab-
solute value of the maximum deviation (D m a x ) be-
tween the theoretical and the observed arrays deter-
mines whether a significant preference exists for one
of the possible response choices. The rigor of this test
is great for small groups, and, thus, in some of the
breakdowns of responses reported below, only the . 1
level of confidence was reached.
In order to determine which issues warrant atten-
tion according to the frequency and the difficulty
criteria, an arbitrary lower limit was imposed. The
issues raised by items that were not perceived as at
least moderately frequent or at least moderately dif-
ficult by a minimum of 35 percent of the respondents
were rejected as priority issues (Figure). The issues
covered in those items that met both the frequency
and the difficulty criteria levels were designated pri-
mary issues of professional ethics for physical thera-
pists. The items that met either the frequency or the
difficulty criterion level, but not both, were desig-
nated secondary issues of professional ethics.
1. Deciding criteria for allowing a pa-
tient/family t o refuse treatment.
2. Accepting gratuities or gifts from pa-
tients/families.
3 . Deciding what to do when my values
and beliefs are at o d d s with a
patient's/family's values and beliefs.
4. Setting t h e limits n e c e s s a r y to main-
tain professional relationships with pa-
tients/families.
5. Controlling a c c e s s to privileged or
confidential information about a pa-
tient/family.
6. Choosing a form of d r e s s that a s s u r e s
professional respect and maintains
identity a s a physical therapist.
7. Deciding when I d o not have a d e q u a t e
therapeutic knowledge to treat a pa-
tient.
8. Setting financially sound fees that
maintain a patient's ability to receive
treatment.
9. Providing a c c u r a t e information to con-
s u m e r s about t h e c o s t s of treatment.
10. Determining methods for making the
particulars of physical therapy ser-
vices known t o health care consumers.
1 1 . Deciding t h e limits for standing by my
own ethical principles.
Figure. Issues that did not meet either criterion.
PHYSICAL THERAPY
 TABLE 1 RESULTS AND DISCUSSION
Characteristics Profile of Respondents
Two hundred seven questionnaires were returned,
% N
representing a 46 percent response. Of these, 187
a. Under 3 0 years old 61.3 186
(41.5%) were usable. Major demographic character-
b. Female 85.4 185
c. 6 years or l e s s total physical ther- 58.1 184 istics are presented in the respondents' profile (Tab.
apy work e x p e r i e n c e 1). Primary and secondary issues were grouped on the
d. Baccalaureate d e g r e e 72.7 187 basis of the kind of concern each expressed. F o u r
e. Employed in a c u t e general facili- 42.8 187 groups of concerns were identifiied: decisions regard-
ties
ing the choice to treat, obligations deriving from the
f. Employed in an urban area 43.5 184
g. Learned about professional ethics 59.9 181 patient-therapist contract, moral obligation and eco-
in P.T. c o u r s e only nomic issues, and a physical therapist's relationship
h. had 3 or more therapists available 69.0 187 with other health professionals. A single item that
to d i s c u s s actual ethical problems examined conflicts between values also merited dis-
cussion.

TABLE 2
Decisions Regarding the Choice to Treat
Frequency Difficulty
n % n %
1. Establishing priorities for patient treatment when High 67 36.0 Ext 9 4.9
time or resources are limited. Mod 70 37.6 Mod 74 40.7
Min 46 24.7 Min 89 48.9
None 3 1.6 None 10 5.5
N = 186 100.0 N = 182 100.0
D m a x = .237a D max = .201 a
2. Discontinuing treatment for patients who habitually High 13 7.5 Ext 23 14.3
disregard instructions such as for home programs, Mod 61 35.3 Mod 62 38.5
treatment regimens, and safety instructions. Min 88 50.9 Min 65 40.4
None 11 6.4 None 11 6.8
N = 173 100.0 N = 161 100.0
D max = .186 a D max = .181 a
3. Continuing treatment with a terminally ill patient. High 25 14.4 Ext 22 13.2
Mod 63 36.2 Mod 72 43.1
Min 80 46.0 Min 52 31.1
None 6 3.4 None 21 12.6
N = 174 100.0 N = 167 100.0
D max = .216 a D max = .124 b
Nursing Homes and Chronic Care Facilities
High 1 6.2
Mod 12 75.0
Min 3 18.8
None 0 0.0
N = 16 100.0
Dmax = .312 C
4. Continuing treatment to provide psychological sup- High 30 16.5 Ext 34 20.0
port after physical therapy treatment goals have Mod 69 37.9 Mod 60 35.3
been reached. Min 72 39.6 Min 64 37.6
None 11 6.0 None 12 7.1
N = 182 100.0 N = 170 100.0
D max = -19 a D max = .179 a
Nursing Homes and Chronic Care Facilities
High 7 43.8
Mod 6 37.5
Min 3 18.8
None _0 0.0
N = 16 100.0
D max = .313 c
a
p < .01.
b
p < .05.
c
p < .1.

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 Decision to Treat
The first group of concerns to be considered con-
sisted of four related primary issues regarding who
should be treated (Tab. 2). More than 70 percent of
the respondents perceived the basic question of estab-
lishing priorities for patient treatment when time or
resources are limited as moderately or highly fre-
quent. This questionnaire item was also rated at least
moderately difficult by slightly more than 45 percent
of all those who had experienced the problem. Using
the frequency and the difficulty criteria, responding
therapists also regarded discontinuation of treatment
on the grounds of habitual noncompliance as a second
primary issue of professional ethics. Third, contin-
uation of treatment with the terminally ill is a priority
issue, especially for therapists in nursing homes and
chronic care facilities, for whom the frequency of this
situation is greater than for other therapists. Fourth,
continuation of treatment to provide psychological
support after physical therapy treatment goals have
been reached is a primary issue for over half of the
responding therapists, again more frequent for ther-
apists working in nursing homes and chronic care
facilities.
When deciding whom to treat, a therapist is re-
quired, in part, to consider two important aspects of
this type of professional judgment. First, it is becom-
ing apparent that the increase in the number of
patients needing physical therapy knowledge and
skills could become overwhelming. The expansion of
physical therapy into new areas, in which the profes-
sion offers a unique viewpoint, forces the choice of
which patients shall be treated and which shall not.
Even when research into the efficacy of treatment
for certain types of patients sheds some light on this
matter, the therapist is still confronted with a second,
and perhaps more important, consideration—per-
sonal beliefs and values. Underlying all therapists'
ethical decisions are the values that help to direct
their choices. 13 The extent to which a person values
psychological support for patients beyond the usual
physical therapy intervention, as well as what he
thinks is an appropriate response to the needs of a
dying patient, bear heavily on what he will choose to
do. Conflict between personal values and professional
values, or between the profession's values and soci-
ety's attitudes, may easily arise. The professional
organization's declaration of its values sometimes is
helpful in these instances. However, beyond this dec-
laration, each physical therapist must decide what he
values as a health professional. Educators may need
to provide the student with the opportunity to ex-
amine his own values as he is formally and informally
socialized into the profession.
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Patient-Therapist Contract
The therapist's professional relationship to a pa-
tient is a major source of moral obligation. Basic
questions concerning the often-unspoken contract be-
tween patient and therapist were apparently not a
problem to the respondents. The primary issue in
patient-therapist interaction emerged from a conflict
concerning professional adjudication between a
patient's needs or goals and a family's needs or
goals (Tab. 3). The respondents identified this dilem-
ma as the primary issue of the second group of con-
cerns.
The nature of the patient-therapist contract has
changed as physical therapy has increased its function
and scope within the health care system. The first of
six secondary issues in this group of concerns stems
directly from this change, which augmented the ed-
ucation component of clinical practice. A problem in
defining the physical therapist's role in the initial
education of a patient or family regarding diagnosis
or prognosis was encountered often enough to war-
rant attention. This situation was experienced with
high frequency by 45 percent of all therapists whose
primary employment was in pediatric facilities or
school-system settings. Students pursuing careers in
the treatment of developmental disabilities should be
urged to consider the ethical aspects of this problem
in clinical judgment. Two other secondary issues
whose frequency merit discussion are questions about
informing a patient or family about the limitations of
treatment and assuring that the patient or family have
input into treatment and discharge planning.
The three remaining secondary issues in this group
of concerns emanate from the patient's expectations
of the therapist. First, the knowledge that a therapist
might be expected to bring to the treatment situation
was examined in an item that questioned the assump-
tion of personal responsibility for continuing educa-
tion. Over 84 percent of the respondents noted that
decisions allowing them to keep up with new treat-
ment ideas had to be made with either moderate or
high frequency. The limits of the clinician's obligation
to update his practice are unclear. Continuing edu-
cation is well-recognized as an essential of providing
quality health care. However, the growth of physical
therapy knowledge and the increasing cost of contin-
uing education courses also demand consideration.
The final two secondary issues pertaining to pa-
tient's expectations are encountered in actual treat-
ment: weighing the effects of treatment against the
discomfort created by the procedure and maintaining
a patient's sense of personal space and dignity during
treatment. Both of these issues are usually addressed
in the classroom and the clinical education of the
PHYSICAL THERAPY
 student, and this survey's results suggest that this
practice should continue. Each of these items was
rated only minimally difficult by more than half of
the respondents. This may be attributable to the
attention these issues have received in the respon-
dent's education.
Moral Obligation and Economic Issues
Some economic issues have a moral component,
and the respondents identified both a primary and a
secondary issue of professional ethics relating to eco-
nomics (Tab. 4). Decisions about whether to represent

TABLE 3
Obligations Deriving from the Patient-Therapist Contract
Frequency Difficulty
n % n %
1. Determining professional responsibilities when a High 8 4.4 Ext 16 9.5
p a t i e n t s n e e d s or g o a l s conflict with the family's Mod 64 35.4 Mod 71 42.0
n e e d s or g o a l s . Min 97 53.6 Min 65 38.5
None 12 6.6 None 17 10.1
N = 181 100.0 N = 169 100.0
D max = . 2 0 5 a Dmax = .155 a
2. Defining the limits of the physical therapist's role High 32 17.9 Ext 8 4.7
in the initial education of a patient/family regarding Mod 70 39.1 Mod 53 31.0
diagnosis or prognosis. Min 70 39.1 Min 90 52.6
None 7 3.9 None 20 11.7
N = 179 100.0 N = 171 100.0
D max = . 2 8 9 a
Pediatric Facilities and School System Settings
High 9 45.0
Mod 6 30.0
Min 5 25.0
None 0 0.0
N = 20 100.0
D max = . 4 5 a
3 . Informing a patient/family about the limitations of High 52 28.0 Ext 5 2.7
treatment. Mod 83 44.6 Mod 51 27.7
Min 49 26.3 Min 102 55.4
None 2 1.1 None 26 14.1
N = 186 100.0 N = 184 100.0
Dmax = .239a
4 . Assuring that the patient/family h a s input into High 62 34.8 Ext 8 4.5
treatment and discharge planning. Mod 83 46.6 Mod 29 16.4
Min 32 18.0 Min 103 58.2
None 1 0.6 None 37 20.9
N = 178 100.0 N = 177 100.0
D max = . 3 1 5 a
5. Assuming personal responsibility for continuing High 73 39.5 Ext 14 7.7
education to k e e p up with new treatment ideas in Mod 83 44.9 Mod 61 33.5
order to maintain quality of care. Min 26 14.1 Min 73 40.1
None 3 1.6 None 34 18.7
N = 185 100.0 N = 182 100.0
D max = . 3 4 3 a
6. Weighing the effects of treatment against the dis- High 36 19.5 Ext 8 4.4
comfort created by the procedure. Mod 81 43.8 Mod 62 34.3
Min 64 34.6 Min 94 51.9
None 4 2.2 None 17 9.4
N = 185 100.0 N = 181 100.0
D max = . 2 2 8 a
7. Maintaining a patient's s e n s e of personal s p a c e High 51 29.0 Ext 2 1.2
and dignity when treatment requires arrangements Mod 65 36.9 Mod 17 10.2
s u c h a s c l o s e proximity and group settings. Min 50 28.4 Min 108 65.1
None 10 5.7 None 39 23.5
N = 176 100.0 N = 166 100.0
Dmax= .193a
a
p < .01.

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 TABLE 4
Moral Obligation and Economic Issues
Frequency Difficulty
n % n %
1. Deciding whether to represent certain n e c e s s a r y High 36 25.0 Ext 23 17.8
patient s e r v i c e s in a way that would meet third- Mod 51 35.4 Mod 49 38.0
party-payer limitations. Min 42 29.2 Min 47 36.4
None 15 10.4 None 10 7.8
N = 144 100.0 N = 129 100.0
Dmax= .146a Dmax = . 1 7 2 a
Nursing Home or Chronic Care Facilities
High 9 69.2
Mod 2 15.4
Min 1 7.7
None 1 7.7
N = 13 100.0
D max = . 4 4 9 a
2. Withholding or limiting physical therapy s e r v i c e s in High 12 10.3 Ext 21 38.2
order to improve work conditions, salaries, staff/ Mod 14 12.1 Mod 16 29.1
patient ratios, etc. Min 29 25.0 Min 13 23.6
None 61 52.6 None 5 9.1
N = 116 100.0 N = 55 100.0
Dmax = . 1 7 3 b
a
p < .01.
b
p < .1.

TABLE 5
Physical Therapist's Relationship to Other Health Professionals
Frequency Difficulty
n % %
1. Maintaining a patient's/family's c o n f i d e n c e in High 23 12.7 Ext 8 4.8
other health professionals regardless of personal Mod 77 42.5 Mod 62 36.9
opinions. Min 68 37.6 Min 75 44.6
None 13 7.2 None 23 13.7
N = 181 100.0 N = 168 100.0
Dmax = . 178a Dmax = . 2 0 2 a
2. Determining criteria for delegating duties to s u p - High 58 34.3 Ext 5 3.2
portive personnel. Mod 63 37.3 Mod 42 26.6
Min 37 21.9 Min 88 55.7
None 11 6.5 None 23 14.6
N = 169 100.0 N = 158 100.0
Dmax = . 2 1 6 a
3 . Reporting questionable practices of another phys- High 6 3.8 Ext 37 43.0
ical therapist to the appropriate person. Mod 5 3.1 Mod 28 32.6
Min 75 47.2 Min 17 19.8
None 73 45.9 None 4 4.7
N = 159 100.0 N = 86 100.0
Dmax = .256a
4. Reporting questionable practices of a physician to High 5 2.9 Ext 52 43.0
the appropriate person. Mod 28 16.2 Mod 26 21.5
Min 88 50.9 Min 31 25.6
None 52 30.1 None 12 9.9
N = 173 100.0 N = 121 100.0
Dmax = . 1 8 a
5. Reporting questionable practices of another health High 7 4.2 Ext 35 29.2
professional w h o is not a physical therapist or a Mod 22 13.2 Mod 42 35.0
physician to the appropriate person. Min 90 53.9 Min 31 25.8
None 48 28.7 None 12 10.0
N = 167 100.0 N = 120 100.0
Dmax = .15a

a
p < .01.

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 certain necessary patient services in a way that would
meet the present limitations imposed by third-party
payers are not uncommon or easy to make. Almost
70 percent of those therapists working primarily with
patients in nursing home and chronic care facilities
perceived a high frequency of the need to make this
decision. The source of conflict is the difference be-
tween what a physical therapist may value as neces-
sary for patients and what society regards as essential
to the health of those who are dependent upon it.
TABLE 6
Conflicts Between Two Ethical Principles
1. Deciding what to do when two of my ethical prin-
ciples or values are in conflict.
a
p < .01.
There is, at present, no simple resolution to this
conflict. Those physical therapists concerned with this
issue should participate forcefully in changing societal
concepts of adequate and essential health care.
In light of developments in other health profes-
sions, which have included strikes by physicians and
nurses, 14 one question examined the issue of curtail-
ment or limitation of physical therapy services in
order to improve work conditions, salaries, staff/pa-
tient ratios, and the like. Most of the respondents
perceived this item as inapplicable to their present
situations. Of those therapists who regarded this event
as a possibility, most had no personal experience of
it. However, slightly over 38 percent of those who had
experience with this problem reported that it was an
extremely difficult decision to make. Further exami-
nation of this issue may become necessary.
Relationship to Other Health Professionals
The last group of issues considered the physical
therapist's relationship to other health professionals
(Tab. 5). Maintaining a patient's or family's confi-
dence in other health professionals regardless of per-
sonal opinions has traditionally been an issue of
professional ethics, 8-11 and the data collected show
that it was perceived to be the primary issue of this
group. The response that a therapist makes in situa-
tions of this type is derived, in part, from the place
the profession holds within the health care team with
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respect to peers and superiors. That place has changed
considerably with the development of the profession
and will continue to do so. 1 5 , 1 6
Four secondary issues were examined in this group
of concerns. Determinations of the criteria for dele-
gating duties to supportive personnel occur frequently
enough to constitute a secondary issue of professional
ethics. Respondents did not frequently make deci-
sions to report the questionable practices of another
physical therapist, physician, or other health profes-
Frequency Difficulty
n % n %
High 2 1.1 Ext 26 20.8
Mod 25 14.2 Mod 50 40.0
Min 100 56.8 Min 44 35.2
None 49 27.8 None 5 4.0
N = 176 100.0 N = 125 100.0
Dmax = .21 a
sional. However, such a decision clearly poses mod-
erate difficulty in the case of another health profes-
sional and extreme difficulty in the cases of another
physical therapist or a physician, when it needs to be
made.
Identification of Ethical Decisions
Ethical dilemmas arise when two or more ethical
principles or values conflict with each other in a given
situation. Despite the fact that respondents perceived
seven primary issues and they recognized the diffi-
culty of making decisions when principles conflict,
they did not perceive themselves as making a choice
between conflicting principles or values with any
great frequency (Tab. 6). Although respondents rec-
ognized that a difficult decision had to be made in
some instances, they probably had not identified it as
a decision of ethical choice. The moral point of view
requires that some unique aspects of a situation be
explored. Failure to recognize that a moral point of
view is required is a first step toward unethical be-
havior. The educational implication of this data is
inescapable: in order to meet all the challenges of
clinical practice, physical therapy students must be
taught how to make ethical as well as clinical judg-
ments. To prepare future clinicians less adequately
could jeopardize the integrity and the autonomy that
physical therapy as a health profession has so ar-
duously worked to achieve.
1271
 CONCLUSION
Complex ethical issues have emerged with the de-
velopment of the profession. These issues pose an
important challenge to the clinician and require that
he develop skill in making ethical judgments in
professional practice. This study was undertaken to
achieve several objectives. First, to establish priorities
of concern so that the APTA can respond to the more
pressing ethical questions of its members. Second, to
identify the issues of professional ethics so as to
encourage discussion among physical therapists and
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PHYSICAL THERAPY