ETHICS IN PHYSICAL THERAPY

Caring, Character, and Principles

Prepared by: Mildred Roldan, PTRP

Health Care Complex Task Models:
1. Biomedical-centered models - technical and theoretical
knowledge in restoring physical health

2. Patient-centered models - patient needs and desires as

the locus in healing

3. Code-centered models - key role of a code of ethics in

unifying and ensuring shared moral commitment
throughout a profession
4. Care-centered models - caring professionals who are
devoted to helping patients

5. Relationship-centered model - care relationships,

including those between physical therapists and patients,
between physical therapists and other health
professionals, and between physical therapists and wider
communities
 Pew-Fetzer Task Force: (Relationship-centered model)

• Importance of the interaction among people as the

foundation of any therapeutic or healing activity

• Primary relationship is between the health-care

professional and the patient

• Legal (contractual)

• Moral relationships
Characteristics of Professional-patient relationships:
• Concern for patients
• Sensitivity to their needs
• Empathy for their suffering
• Respect for their rights
• Value of health understood holistically as biopsychosocial

* The task force highlights the need for patients’ trust and
participation in the healing process
Meanings and Dimensions of Patient Care:
(1) Care-giving - providing health-care services
(taking care of patients)

(2) Exercising due care - meeting appropriate standards in

providing health care

(3) Caring for patients as persons - providing professional

services with attitudes and values of concern for
patients

(4) Manifesting the virtue of caring

Character and the Virtue of Caring:

Virtues: Habits or tendencies to feel, perceive, reason, and

act in morally valuable ways—ways beneficial to
others and to oneself

Virtue of Caring: Reliable tendencies to promote the

health of patients according to appropriate standards,
motivated (at least significantly) by concern for their
well-being
 CARING:
• Sensitivity (perceptiveness to morally relevant features
of contexts)
• Empathy (identifying with the feelings of others)
• Compassion (in response to suffering)
• Kindness(nuanced and sensitive helpfulness)
• Conscientiousness(in meeting responsibilities)
 Three Categories of Virtues:
I. Self-Valuing and Self-Directing

A. Self-Valuing: Self-respect, self-caring, self-love, authenticity,

humility, proper pride, nobility, integrity

B. Self-Directing
a. Cognitive: Wisdom, prudence, foresight
b. Volitional: Self-control, self-discipline, temperance,
courage, determination, perseverance,
responsibility, integrity
c. Skill: Competence, craftsmanship, excellence
II. Reciprocity
A. Justice, fairness, tolerance

B. Trust: Honesty, truthfulness, trustworthiness

C. Gratitude, cooperativeness, reliability, dependability,

civility, sense of community
III. Caring About and for Others

A. Nonmaleficence: Non-recklessness, non-negligence,

non-vengefulness, non-fanaticism

B. Beneficence: Caring, benevolence, compassion, kindness,

considerateness, sensitivity, tactfulness,
politeness, altruism, generosity, loyalty
Gilligan’s Ethics of Care:
Heinz Dilemma: (Lawrence Kohlberg)
Heinz is married to a woman who is dying of cancer but
who physicians believe might be saved by a very expensive
radium-compound drug. A pharmacist in a European town
where Heinz lives controls the drug and will provide it, but
at ten times the cost to make it. Heinz cannot afford the
drug, nor can he find friends who will loan him the money
to buy it. After trying to convince the pharmacist to lower
the price or to let him pay for it later, Heinz breaks into the
pharmacy and steals the drug. The question is whether he
was justified in doing so.
 Conclusion:
• Those who said Heinz should worry about himself
primarily were at the preconventional level
• Those who argued that Heinz should not steal the
drug because stealing is wrong were at the
conventional stage
• Those who reasoned that Heinz was justified in stealing
the drug maintained that the rules “Save lives” or “Help
one’s wife ”override the rule “Do not steal” illustrated
higher stages of moral development
* Ethics of care means effectively balancing their needs
with the needs of others (Carol Gilligan)
 Kohlberg’s and Gilligan’s Schemes of
Moral Development:
LEVELS OF MORAL DEVELOPMENT:
1. Preconventional

Kohlberg’s Justice Perspective:

Self-centered, with concern for
(1) avoiding punishment and
(2) satisfying one’s own needs

Gilligan’s Care Perspective:

Self-centered: Viewing one’s own
needs as all that matters
2. Conventional

Kohlberg’s Justice Perspective:

Expectation-meeting, with concern for
(3) pleasing others and
(4) meeting society’s expectations

Gilligan’s Care Perspective:

Self-sacrificing: viewing others’ needs
as more important
3. Postconventional

Kohlberg’s Justice Perspective:

Autonomous recognition to
(5) social agreements and
(6) universal rules

Gilligan’s Care Perspective:

Mature care ethic: able to reason
toward a balance of one’s own and
others’ needs

* In general, psychologists cannot be relied upon to

indicate what the best way of moral reasoning is.
The Evolution of Caring:

Frans De Waal
Vast majority of altruism in the animal kingdom is only
functional altruism – not aware how the behavior will
impact the other or whether the other will return the
service

* In contrast, humans are “hard-wired” to act with some

decent minimum level of help for others
 Taxonomy of altruistic behavior: Frans De Waal
James Rest
Moral Action:
1. Moral reasoning:
Take multiple perspectives

2. Moral sensitivity:
Recognizing that something is troublesome

3. Moral motivation:
Willingness to engage in problem solving

4. Moral courage:
Willingness to take a stand
Emotional Responses: (Greenfield)
• Often unintended or even unrecognized, play a daily
part in clinical work and shape the way people perceive
and interpret their surroundings
• Moral reasoning cannot be entirely separated
from emotion

* Emotional responses CANNOT BE the origin of

moral decisions
Principles of Biomedical Ethics:

Four Basic Moral Principles:

(Tom L. Beauchamp and James F. Childress)

1. Respect for autonomy:

Value the autonomy (self-determination, self-governance)
of patients, and use it as a guide that limits what services
may be provided to them

2. Nonmaleficence:
Do not harm patients
3. Beneficence:
Promote the good of others

4. Justice:
Treat patients fairly, not violating what they are entitled to,
and support fair procedures and background institutions
in health care
Beneficence Toward Strangers:

 Beneficence Continuum: (Beauchamp and Childress)

-Spectrum of Moral Action
Supererogatory Acts: (Four qualities)
(1) They are optional

(2) They exceed what is commonly perceived as obligatory

(3) They are intentionally undertaken to promote the

welfare of others

(4) They are morally good and praise-worthy in themselves,

not merely undertaken from good intentions

* Supererogatory Acts benefit the recipient and do not

harm the giver in any significant way
Specific Beneficence: Acts performed for partners, spouses,
children, parents, and friends

General Beneficence: Acts performed for strangers

* There must be some decent minimum level that is

obligatory for all citizens
CASE 2.2
Refusal to Rescue
In 1998 Martin Dyckman retold the story of an event in his
home state of Florida. A man, self-reported to be a good
swimmer, watched a young boy drown in a canal.The man
looked over his back to make sure no one observed him
doing nothing when a rescue would have been so easy. He
later stated that he let the boy drown because he hated all
people of that color, regardless of any other consideration.
CASE 2.4
Sherrice Iverson
Sherrice Iverson’s father was playing slots at the Primadonna
Resort on the California-Nevada border. Sherrice was seven
years old and probably bored. Jeremy Strohmeyer, age 18,
engaged her in a game of hide and seek. Jeremy was there
with his friend David Cash Jr., also age 18, who was aware of
all this. But Sherrice, in an effort to get away, ran into the
women’s restroom. She was followed by Jeremy who
cornered her in a stall and proceeded to rape and murder
her. David went into the restroom and looked over the stall
door and saw what was happening but could not get Jeremy’s
attention according to his sworn testimony. He returned
every few minutes to check on his friend. Jeremy then joined
David in the casino. They drove to Las Vegas to continue
gambling. Jeremy told David he had killed the girl, but David
told no one what was occurring or what did occur until he
was interrogated.

* In none of the cases above did any of the observers

break any laws because of the “freedom to not act”
Good Samaritan Laws (USA)
• Apply only to those medical professionals or technicians
responding to the physically injured and protect them
only from civil and criminal charges if things go badly.
• Do not reward beneficence; they merely prevent
misfortune for care providers.
• Providers are free to not respond if they so choose

* Argument: Imposing positive responsibilities, no matter

how narrowly drawn, infringe on a citizen’s autonomy.
 Professionals and the Beneficence Continuum:

 Beyond the obligatory become obligations

 Distinguishes health-care professions from some

other professions

 More is expected of health-care professionals in their

private lives also
Why Be Moral?

1.1 Why a person should avoid cheating or paying a bribe,

even when other people are doing so
[It would make a person dishonest rather than a person
of integrity]

1.2 Why should the standards of professional ethics in

physical therapy be heeded
[Doing so results in responsible professionals]
2. Prove to me that morality pays (worthwhile) in terms of
my self-interest (challenge to justify the entire moral life)

Plato:
Moral person is happier than the immoral person and,
hence, morality pays

“Virtue is as it were the health and comeliness and

well-being of the soul, as wickedness is disease, deformity,
and weakness.”
Other philosophers: Morality is an enlightened view of
one’s self-interest—that is,
one’s well-being

* As moral beings, people adopt a moral point of view to

have such attitudes of respect and caring and to try to
act on them
Ethical Egoism:
 The view that people ought always and only to care only
about their own self-interest

 Refutations:
1) It is logically inconsistent
- appealing only to people who already care about
and respect others

2) It is self-defeating
Psychological Egoism:
 All humans are always and only motivated by desires to
get what they believe are benefits for themselves

 Arguments that support this view: (Justifications)

1) People always act on their own desires

Refutation: It is the object (target) of the desire that
determines whether it is self-seeking, not
the mere fact that it is “my desire”
*Refutation – to prove that it is wrong
2) People always seek to gain pleasure for themselves
(from satisfying their desires) or to avoid pain
Refutation: Pleasures are attached to and derive from
activities, relationships, and things.

3) An ulterior self-seeking motive for any human action

can always be imagined
Refutation: It does not follow, however, that the actual
motive is self-seeking
4) When any human action is examined closely, some
element of self-seeking and some kind of benefit for
the agent are found
Refutation: It does not establish that the entire or
sole motive is self-seeking
Complex Motivation:

 Predominant Egoism: Most people, most of the time,

are primarily motivated by a concern for their
self-interest

 Mixed Motive Thesis: Most human actions have

multiple motives, often combine legitimate self-seeking
with concern for others
 Categories of the Motives of Professionals:

Craft Motives:
Desires to meet the standards of technical excellence
as well as to seek creative solutions to technical problems

Compensation Motives:
Desires to earn a living, have job stability, gain professional
recognition, exercise power and authority, and other
primarily self-oriented desires
Moral Concern:

(1) Integrity Motives - desires to meet one’s responsibilities

and maintain one’s moral integrity

(2) Caring Motives - desires to promote the good of others,

for their sake