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Theoretical frameworks used to discuss ethical issues in private physiotherapy practice and proposal of a new ethical tool

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Abstract

In the past, several researchers in the field of physiotherapy have asserted that physiotherapy clinicians rarely use ethical knowledge to solve ethical issues raised by their practice. Does this assertion still hold true? Do the theoretical frameworks used by researchers and clinicians allow them to analyze thoroughly the ethical issues they encounter in their everyday practice? In our quest for answers, we conducted a literature review and analyzed the ethical theoretical frameworks used by physiotherapy researchers and clinicians to discuss the ethical issues raised by private physiotherapy practice. Our final analysis corpus consisted of thirty-nine texts. Our main finding is that researchers and clinicians in physiotherapy rarely use ethical knowledge to analyze the ethical issues raised in their practice and that gaps exist in the theoretical frameworks currently used to analyze these issues. Consequently, we developed, for ethical analysis, a four-part prism which we have called the Quadripartite Ethical Tool (QET). This tool can be incorporated into existing theoretical frameworks to enable professionals to integrate ethical knowledge into their ethical analyses. The innovative particularity of the QET is that it encompasses three ethical theories (utilitarism, deontologism, and virtue ethics) and axiological ontology (professional values) and also draws on both deductive and inductive approaches. It is our hope that this new tool will help researchers and clinicians integrate ethical knowledge into their analysis of ethical issues and contribute to fostering ethical analyses that are grounded in relevant philosophical and axiological foundations.

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Notes

  1. The proportion of physiotherapists working in the private sector is approximately 33 % in Sweden, 40 % in Denmark (Praestegaard and Gard 2013), 43 % in Canada (CIHI 2012) and between 46 and 60 % in Australia, depending on the province (AIHW 2013).

  2. For the sake of simplicity, no distinction has been made between the terms “theoretical framework” and “conceptual framework” though they differ somewhat. We have chosen to use “theoretical framework” throughout because we refer to an ethics or bioethics based framework used to analyze and solve ethical issues raised by the private practice of physiotherapy.

  3. See the second, third and fourth rows of Table 2.

  4. The eight layers of the ‘iceberg’ model of informed consent: “Layer 1—What physiotherapists do in practice; Layer 2—How physiotherapists understand and interpret informed consent; Layer 3—Physiotherapy literature about informed consent; Layer 4—Legal obligations and guidelines; Layer 5—Ethics-based models of practice of informed consent; Layer 6—Principles of biomedical ethics; Layer 7—Theories of autonomy; Layer 8—Foundational ethical theories” (Delany 2007, p. 172).

  5. These shortcomings also exist in other health disciplines, such as occupational therapy for example.

  6. Beauchamp and Childress' Four Principles of Biomedical Ethics (2013)—beneficence, non maleficence, autonomy and justice—blend utilitarianism and deontological ethics.

  7. For example, health professionals sometimes consider only their own patients at the expense of those waiting for services or those who, for various reasons, do not have access to services (Drolet 2013). Applying universalist approaches in ethics can help health professionals to consider not only their patients, but also those who are waiting for services or have a legitimate right to services.

  8. The ten steps entail the following instructions: Step 1: Describe the situation in order to identify the ethical issues; Step 2: Identify and criticize your spontaneous moral reactions; Step 3: List and check the main hypothesis that explain the situation; Step 4: Identify and analyze the ethical issues; Step 5: Define the main alternatives and their consequences for all the stakeholders; Step 6: Identify terms, phenomena, procedures, standards, principles, values or virtues to be clarified; Step 7: Clarify terms, phenomena, procedures, standards, principles, values or virtues to be prioritized; Step 8: Prioritize terms, phenomena, procedures, standards, principles, values or virtues; Step 9; Make a decision and justify it with convincing arguments; Step 10: Evaluate the decision and the action taken (free translation, Drolet 2013, p. 225).

  9. Contrary to Kuczewski (1998), we believe that these four ethical perspectives are not identical. Many philosophical controversies among utilitarians, deontologists and virtues ethicists show how these approaches to ethics differ in many respects.

  10. Kant published his Metaphysics of Morals in 1797.

  11. Internal preferences describe how individuals wish to live their own lives; external preferences describe how an individual would like others to live their lives (Provencher 2008).

  12. Still today, many philosophers are searching for the perfect ethical theory, a single approach that would serve to tackle and solve all the ethical issues faced by humankind.

  13. It is possible that, as Beauchamp and Childress conceive it, the normative and axiological elements from empiricism are inspired by the common morality, but this is not what we refer to here. We refer to a casuistic approach that uses a narrative approach to examine the particular vision of people facing an ethical issue. In other words, we refer to the fact that individuals consider the values and principles of ethical theories from a broader perspective that encompasses their own values and beliefs which may or not have links with the common morality.

References

  • Australian Institute of Health and Welfare. 2013. Allied health workforce 2012. National health workforce series no. 5 Cat. no. HWL 51. Canberra: AIHW.

  • Aristotle. 1959. Éthique à Nicomaque. Paris: Vrin.

    Google Scholar 

  • Beauchamp, T.L. 2004. Does ethical theory have a future in bioethics? Journal of Law, Medicine & Ethics 32: 209–217.

    Article  Google Scholar 

  • Beauchamp, T.L., and J.F. Childress. 2013. Principles of biomedical ethics. Oxford: Oxford University Press.

    Google Scholar 

  • Begin, L. 1995. L’éthique par consensus? In Hôpital et éthique: Rôles et défis des comités d’éthique clinique, ed. M.-H. Parizeau, 176–189. Québec: Les Presses de l’Université Laval.

  • Bentham, J. 1789. An introduction to the principles of morals and legislation. London: T. Payne, and Son.

  • Carpenter, C., and B. Richardson. 2008. Ethics knowledge in physical therapy: A narrative review of the literature since 2000. Physical Therapy Reviews 13(5): 366–374.

    Article  Google Scholar 

  • Canadian Institute for Health Information. 2012. Physiotherapists workforce, 2012. Ottawa: CIHI.

    Google Scholar 

  • Clawson, A.L. 1994. The relationship between clinical decision-making and ethical decision-making. Physiotherapy 80: 10–14.

    Article  Google Scholar 

  • Daniels, N. 1979. Wide reflective equilibrium and theory acceptance in ethics. The Journal of Philosophy 76(5): 256–282.

    Article  Google Scholar 

  • Daniels, N. 1996. Justice and justification. Reflective equilibrium in theory and practice. Cambridge: Cambridge University Press.

    Book  Google Scholar 

  • Delany, C.M. 2007. In private practice, informed consent is interpreted as providing explanations rather than offering choices: A qualitative study. Australian Journal of Physiotherapy 53: 171–177.

    Article  Google Scholar 

  • Delany, C.M., I. Edwards, G.M. Jensen, and E. Skinner. 2010. Closing the gap between ethics knowledge and practice through active engagement: An applied model of physical theory ethics. Physical Therapy 90(7): 1068–1078.

    Article  Google Scholar 

  • DePoy, E., and L.N. Gitlin. 2010. Introduction to research: Understanding and applying multiple strategies. St.Louis: Elsevier Mosby.

    Google Scholar 

  • Drolet, M.-J. 2013. De l’éthique à l’ergothérapie. La philosophie au service de la pratique ergothérapique. Québec: Presses de l’Université du Québec.

  • Drolet, M.-J., and A. Hudon. Les professionnels de la santé ont-ils un devoir d’advocacy? Ethica: Revue interdisciplinaire de recherche en éthique, in press.

  • Dworkin, R. 1999. Les droits comme atouts. In Anthologie historique et critique de l’utilitarisme. III. Thèmes et débats de l’utilitarisme contemporain, ed. C. Audard, 216–237. Paris: Presses Universitaires de France.

  • Edwards, I., A. Braunack-Mayer, and M. Jones. 2005. Ethical reasoning as a clinical-reasoning strategy in physiotherapy. Physiotherapy 91: 229–236.

    Article  Google Scholar 

  • Fortin, M.-H. 2010. Fondements et étapes du processus de recherche. Méthodes quantitatives et qualitatives. Montréal: Chenelière éducation Inc.

    Google Scholar 

  • Gadamer, H. 2001. La philosophie herméneutique. Paris: Presses Universitaires de France.

    Google Scholar 

  • Geddes, L., E. Finch, and K. Graham. 2005. Ethical choices: A moral and legal template for health care practice. Physiotherapy Canada 57(1): 113–122.

    Article  Google Scholar 

  • Gilligan, C. 1982. In a differente voice. Psychological theory and women’s development. Cambridge: Harvard University Press.

    Google Scholar 

  • Gorman, I. 2004. POPTS: Focus on patient choice. PTmagazine May, 8.

  • Habermas, J. 1992. De l’éthique de la discussion. Paris: Flammarion.

    Google Scholar 

  • Honderick, E. 2004. POPTS are the least of our problems. PTmagazine April, 8.

  • Hudon, A., M.-J. Drolet, and B. Williams-Jones. The ethical issues raised by private practice physiotherapy are more diverse than first meets the eye: Recommendations from a literature review. Physiotherapy Canada, in press.

  • Hudon, A., M. Laliberté, M. Hunt, V. Sonier, B. Williams-Jones, B. Mazer, et al. 2013. What place for ethics? An overview of ethics teaching in occupational therapy and physiotherapy programs in Canada. Disability & Rehabilitation (0): 1–6.

  • Hunt, M.R., and C. Ells. 2013. A patient-centered care ethics analysis model for rehabilitation. American Journal of Physical Medicine and Rehabilitation 92(9): 818–827.

    Article  Google Scholar 

  • Jensen, G.M., and B. Greefield. 2012. Ethics education: Developing habits of mind through the use of pedagogical content knowledge. Physical Therapy Reviews 17(3): 149–156.

    Article  Google Scholar 

  • Kant, E. 1986. Œuvres philosophiques, tome III. Paris: Gallimard.

    Google Scholar 

  • Kaiser, J.M., and J. Brown. 1988. Ethical dilemmas in private rehabilitation. Journal of Rehabilitation October/November/December, 27–30.

  • Kiles, M. 2005. Solution to POPTS is education. PTmagzine July, 8.

  • Kirsch, N.R. 2006a. Ethicsinaction. When matters of reimbursement, time management, profitability, and convenience collide. PTmagazine May, 42–46.

  • Kirsch, N.R. 2006b. Ethicsinaction. Terminating the patient-PT relationship: Case one. What’s influencing the decision to discharge? PTmagazine September, 38–41.

  • Kirsch, N.R. 2007a. Ethicsinaction. Suspected impairment: Case one. When exercising patience may adversely affect patients. PTmagazine January, 39–42.

  • Kirsch, N.R. 2007b. Ethicsinaction. Suspected impairment: Analysis. An examination of ethical scenarios presented in recent columns. PTmagazine April, 44–48.

  • Kirsch, N.R. 2007c. Ethicsinaction. Reimbursement matters: Case one. Ultrasound for everybody? PTmagazine November, 46–48.

  • Kirsch, N.R. 2008a. Ethicsinaction. Confidentiality Issues: Case one. A PT assesses is obligations. PTmagazine July, 38–40.

  • Kirsch, N.R. 2008b. Ethicsinaction. Confidentiality issues: Analysis. An examination of ethical scenarios presented in recent columns. PTmagazine November, 38–44.

  • Kirsch, N.R. 2009. Ethicsinaction. Professional behavior: Case one. Too much togetherness. PTmagazine June, 10–13.

  • Kirsch, N.R. 2010a. EthicsinPractice. Certified deception. When letters spell out a problem. PTinMotionmagazine May, 44–45.

  • Kirsch, N.R. 2010b. EthicsinPractice. Matter of vitals concern. Seeking insight from the new Code of Ethics for the Physical Therapist about a troubling clinical scenario. PTinMotionmagazine July, 44–46.

  • Kirsch, N.R. 2012a. EthicsinPractice. When is more too much? A seeming pattern that may be a tretch. PTinMotionmagazine February, 50–51.

  • Kirsch, N.R. 2012b. EthicsinPractice. Sunset provision? The law, compassion, religion, and a dusky situation. PTinMotionmagazine November, 42–45.

  • Kirsch, N.R. 2013. EthicsinPractice. Mind over mentor? A protégé struggles to trust her professional judgment. PTinMotionmagazine April, 46–48.

  • Kolhberg, L. 1986. A current statement on some theoretical issues. In Lawrence kohlberg. Consensus and controversy, ed. S. Modgil and C. Modgil, 485–498. Philadelphia: The Falmer Press, Taylor and Francis Inc.

  • Kornblau, B.L., and S.P. Starling. 2000. Ethics in rehabilitation. A clinical perspective. Thorofare: SLACK incorporated.

    Google Scholar 

  • Kuczewski, M. 1998. Casuistry and principlism: The converge of method in biomedical ethics. Theoretical Medicine and Bioethics 19: 509–524.

    Article  Google Scholar 

  • Leventhal, A. 2005. POPTS and referrals. PTmagazine September, 9.

  • Mill, J.S. 1863. Utilitarianism. London: Parker, son, and bourn, west strand.

    Google Scholar 

  • Nafpliotis, H. 2005. Effort, sacrifice needed to end POPTS status quo. PTmagazine July, 8–10.

  • Nidorf, J.F., and M.C. Morgan. 1987. Cross-cultural issues in adolescent medicine. Primary Care 1: 69–82.

    Google Scholar 

  • Nussbaum, M.C. 2000. Women and human development. The capabilities approach. Cambridge: Cambridge University Press.

    Book  Google Scholar 

  • O’Hearn, M. 2004. Solution to POPTS. Rests in hands of PTs. PTmagazine January, 8.

  • Osterhues, D. 2004. POPTS: An appropriate relationship. PTmagazine March, 8–9.

  • Praestegaard, J., and G. Gard. 2011. The perceptions of Danish physiotherapists on the ethical issues related to the physiotherapist-patient relationship during the first session: a phenomelogical approach. BMC Medical Ethics 12(21): 1–11.

    Google Scholar 

  • Praestegaard, J., and G. Gard. 2013. Ethical issues in physiotherapy—Reflected from the perspective of physiotherapists in private practice. Physiotherapy Theory and Practice 29(2): 96–112.

    Article  Google Scholar 

  • Praestegaard, J., G. Gard, and S. Glasdam. 2013. Practicing physiotherapy in Danish private practice: en ethical perspective. Medicine, Health Care and Philosophy 16: 555–564.

    Article  Google Scholar 

  • Provencher, M. 2008. Petit cours d’éthique et politique. Montréal: Les Éditions de la Chenelière.

    Google Scholar 

  • Rawls, J. 1971. A theory of justice. Cambridge: Harvard University Press.

    Google Scholar 

  • Resnik Mellion, L. 2001. Balancing ethical challenges in a managed care environment. PTmagazine July, 48–51, 68.

  • Roubal, P.J. 2005. Prohibit POPTS. PTmagazine May, 5–8.

  • Saffels, N. 2004. Address physicians emplying non-PTs. PTmagazine January, 8.

  • Saint-Arnaud, J. 2009. L’éthique de la santé. Guide pour une intégration de l’éthique dans les pratiques infirmières. Montréal: Chenelière Éducation.

    Google Scholar 

  • Saporta, A., and B.E. Gibson. 2007. Ethics of self-referral for profit: Case example of a physician-owned physiotherapy clinic. Physiotherapy Canada 59(4): 266–271.

    Article  Google Scholar 

  • Scarpelli, E. 2004. POPTS inhibit competition. PTmagazine March, 8.

  • Schaefer, K. 2004. POPTS deprive patients of choice. PTmagazine March, 8.

  • Sen, A.S. 1990. Equality of what? In Tanner lectures on human values, ed. S. McMurrin. Cambridge: Cambridge University Press.

    Google Scholar 

  • Singer, P. 1979. Practical ethics. Cambridge: Cambridge University Press.

    Google Scholar 

  • Singleton, M.C. 1987. Independent practice—On the horns of a dilemma: A special communication. Physical Therapy 67(1): 54–57.

    Google Scholar 

  • Swisher, L.L. 2002. A retrospective analysis of ethics knowledge in physical therapy 1970–2000. Journal of American Physical Therapy Association 82(7): 692–706.

    Google Scholar 

  • Swisher, L.L., L.E. Arslanian, and C.M. Davis. 2005. The realm-individual process-situation RIPS model of ethical decision making. HPA Resource 53(1): 3–8.

    Google Scholar 

  • Tahan, M. 2005. POPTS benefit patients. PTmagazine May, 5–8.

  • Toffolo, J.J. 2004. POPTS, Self-referral and APTA’s vision statement 2020. PTmagazine October, 8.

  • Tumolo, J. 2000. Sell me the goods. Are product sales a survival tactic or an ethical breach? Advance for physical therapy & Rehab Medicine. http://physical-therapy.advanceweb.com/Article/Sell-Me-the-Goods.aspx. Accessed 10 Aug 2013.

  • Viel, J.P. 2004. POPTS are wrong. PTmagazine April, 8.

  • Weinstock, D. 2006. Profession éthicien. Montréal: Les Presses de l’Université de Montréal.

    Google Scholar 

  • Welk, F.J. 2004. To the editor. PTmagazine October, 8.

  • Windson, B. 2005. POPTS, market forces, and autonomy. PTmagazine September, 8.

  • Wojciechowski, M. 2005. Physician ownership of physical therapy services. PTmagazine April, 34–40.

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Acknowledgments

We thank the reviewers for their valuable feedback on the initial version of this article. We would also like to thank Egan Valentine, professor in the Department of Modern Languages and Translation at the Université du Québec à Trois-Rivières, for translating the initial text into English. The first author’s research is supported by the Fonds d’animation à la recherche from the Université du Québec à Trois-Rivières. The second author is supported by a fellowship from the MENTOR program in collaboration with the Canadian Institutes of Health Research (CIHR), the Quebec Research Rehabilitation Network (REPAR) and the Fonds de recherche du Québec—Santé (FRQ-S). Financial support for this research was also received from Dominion of Canada General Insurance administered by the Physiotherapy Foundation of Canada.

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Authors and Affiliations

  1. Université du Québec à Trois-Rivières, 3351 boul. des Forges, C.P. 500, Trois-Rivières, Québec, G9A 5H7, Canada

    Marie-Josée Drolet

  2. École de réadaptation, Université de Montréal, C.P. 6128, Succursale Centre-ville, Montréal, Québec, H3C 3J7, Canada

    Anne Hudon

  3. Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal, 2275, Laurier Avenue East, Montréal, Québec, H2H 2N8, Canada

    Anne Hudon

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  1. Marie-Josée Drolet
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Correspondence to Marie-Josée Drolet.

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Drolet, MJ., Hudon, A. Theoretical frameworks used to discuss ethical issues in private physiotherapy practice and proposal of a new ethical tool. Med Health Care and Philos 18, 51–62 (2015). https://doi.org/10.1007/s11019-014-9576-7

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