b y N a n c y R K i r s c h , l > T , D F T , P h D

A m a t t e r a f i n t e r v e n t i o n .
pride ourselves on being
a caring, "hands-on" profes-
sion, but what happens when
the physical contact may be inappropri-
ateregardless of the instigator? This
month, we begin a series of three columns
on issues of improper conductsexually
tinged impropriety in particular. The sub-
ject will be approached from three differ-
ent perspectives, but each case will require
making a judgment about the behavior.
As you read, use the Realm-Individual
Process-Decision Making (RIPS) model of
ethical decision-making' to decide if the
behavior is inappropriate and if those who
become aware of the behavior have ethical
challenges they must address.
After reading the following scenar-
io, look at the accompanying boxes
Components of the RIPS Model (below
right) and the APTA Code of Ethics on
page 36consult the Ethics in Action
column "Ethical Decision Making:
Terminology and Context,"^ and use the
guiding questions within each of the steps
to ethical decision-making to help crystal-
lize your thoughts.
You are in the office working on your
documentation and overhear two of your
colleagues, Bob and Jim, talking about a
patient Bob had seen that moming (They
are speaking in hushed tones and clearly are
unaware you can hear them.) Bob describes
the patient as having been young and pretty,
and offers Jim details of his thorough evalu-
ation of her cervical spine and thoracic area.
He says she was a very cooperative patient
who disrobed and put on a gown as he had
directed at the beginning of the evaluation.
She did appear to be a little uncomfortable.
Bob tells Jim, but Bob assured her that this
simply was part of a thorough evaluation.
Bob goes on to say that after his complete
assessment of her cervical spine he palpated
her breasts, telling her that mammary mas-
sage has been shown to alleviate cervical
pain. Jim expresses surprise that the patient
was so compliant, whereupon Bob ff-ggles
and facetiously notes his " way with women."
N o, seriously. Bob continues, mammary
massage is a theoretical concept hed heard
mentioned during a course he'd taken a
few months before. He'd been intrigued by
the idea at the time. Bob says, but couldn't
imagine ever actually employing it on a
patient.
But that morning's patient. Bob says,
seemed to be the perfect individual on which
to try the technique, as she'd been sent to the
clinic by a nearby state residential facility for
people with developmental disabilities. It's
unlikely Bob tells Jim, that she'll mention
his choice of intervention to anyoneand
it's questionable, at any rate, whether any-
one would take serious stock in what she
said. Bob emphasizes to Jim that this was
a one-time, spur-of-the-moment action that
he has no intention of repeating with any
other patient.
Bob then leaves the room to treat another
patient Shortly thereafter Jim looks at you
and can tell from the uneasy expression you
can't quite wipe off your face that you over-
heard most if not all of the conversation. Jim
says in a calm, steady voice, " You heard Bob.
It was a one-shot thing that won't happen
again. Just let it go." You are left to consider
your options.
Step 1: Recognize and Define the
Ethical Issue
Ask yourself:
Into which realm or realms does this
situation fall: individual, organiza-
tional/institutional, or societal?
Components of the
Realm
Individual (relationship
between individuals)
Organizational/
Institutional (good of the
organization)
Societal (confimon good)
RIPS Model
Individual Process
Moral Sensitivity
(recognize situation)
Moral Judgment
(right or wrong)
Moral Motivation
(moral values above
other values)
Moral Courage
(implement action)
Ethical Situation
Issue or Problem (values
are challenged)
Dilemma (right vs right
decision)
Distress (right course
of action blocked by
a barrier)
Temptation (right vs wrong
situation)
Silence (values are
challenged but no one
is addressing it)
3 4 * M a y 2 0 0 7
i *
What does the situation require of
you? Which individual process is most
appropriate: moral sensitivity, moral
judgment, moral motivation, or moral
courage? Are there implications for
action on the parts of anyone besides
you? Bob? Jim?
What type of ethical situation is this:
a problem, dilemma, distress, or
temptation?
Are there barriers to you doing what
you think you should do?
Step 2: Reflect
Ask yourself:
What do you know about the patient?
How serious is her cognitive impair-
ment? Has your fecility policies regard-
ing PTs' treating patients of the oppo-
site gender?
Who are the major stakeholders? In
addition to you and your colleague,
who or what else may be affected by
this situation?
What are the potential consequences
of your action or inaction?
Might your action or inaction break
any laws?
What ethical principle or principles
may be involved? Do any of the fol-
lowing resources provide professional
guidance: the APTA Code of Ethics,
the APTA Guide for Professional
Conduct,^ and/or Professionalism in
Physical Therapy: Core Values?'* For
example, do you see a relationship
between this case and principles 1, 2,
and 9 of the APTA Code of Ethics?
Do other principles strike you as per-
haps being applicable? Which do you
feel apply to you and which apply to
Bob and/or Jim?
Finally, consider how this scenario
stacks up against the tests posed by
Rushworth Kidder in How Good People
Make Tough Choices'^: legal, stench, front
page, mom, and professional ethical vio-
lation. In other words: Is something
illegal going on? Does the situation feel
wrong? Would you feel uncomfortable
were the details of the situation (includ-
ing your inaction, if you chose not to
do anything) to become public? What
would your mother/parents do if faced
with similar circumstances? Can you
detect any ethical violations within the
APTA resources listed previously?
Step 3: Decide the Right Thing to Do
If the scenario fails any of the tests
described in the previous step, this step is
superfluous. In that case, action must be
taken; the questions become what kind of
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PT ma g a z i n e 3 5
acdon, and do you have the moral cour-
age to implement it? In making those
determinations, in turn, consider the con-
sequences of inaction, and whether col-
lateral damage could result from either
acdon or inaction.
If, however, you believe the scenario
passes each of Kidders tests, it's time
to look at the three possible approaches
Kidder presents for determining the right
thing to do, and also to look at whether
you foresee any barriers to implementing
your response:
Rule-based: Follow only the principle
you want everyone else to follow.
Ends-based: Do whatever produces
the greatest good for the greatest num-
ber of people.
Care-based: Do unto others as you
would have them do unto you. (The
"Golden Rule.")
Ask yourself as well: Are there are any
potential barriers to implementing your
decision? Are there ramificadons for the
clinic, your colleagues, and/or current and
future patients?
Step 4 : Implement, Evaluate, Reassess
' Having determined in your own mind
the right thing to do and the best way to
implement your decision, reflect on the
course of acdon you've chosen and think
about whether a change in your clinic's
organizational policy or culture might pre-
vent this scenario from recurring.
Again, this month's column is the first
in a series on issues related to matters of
sexual impropriety. This column arc will
conclude in September's issue with an
analysis of all three cases. In the meantime,
please let me hear from you! (Note my
e-mail address.) Tell me your thoughts
about these cases^your resolutions and
how you arrived at them. And please share
your insights with other PTs and PTAs,
, as well. Use Ethics in Action as a teaching
tool, as many of your colleagues across the
country are already doing. (^
N a n c y R K i r s t h , F T , D P T , P h D , a m e m b e r o f A F I A ' s E t h i c s a n d
J u d i c i a l C a m m i t t e e , i s a n o s s o d o t e p w f e s s a r o f p h y s i c a l h r a p y i n
h U n i v e i s i t y o f M e d i d n e a n d D e n t i s t r y ' s S f / i o o / o f H e a l t h R e l a t e d
P r a f e s a o n s i n H e m r k , N e w J e r s e y , a n d a p a r t n e r i n N o r t h e m H i l l s
P h y s i c a l T h e r a p y A s s o c i a t e s i n f l a n d e r s , N e w J e r s e y . S h e c a n h e
c o n t v c t e d a t k i r s c h n a @ u m d n j . e d u .
1 .
2 .
Swisher LL, Arslanian LE, Davis CM. The realm-indi-
vidual process-situation (RJPS) model opethicil decision
making. HPA Resource 2OO5;5(3): 1,3-8.
Kirsch NR. Ethical decision making; terminolog)' and con-
text. PTMagazine of Physical Therapy. 2006;l4(2):38-
40.
3. American Physical Therapy Association. APTA Guide for
Professional Conduct. Available at www.apra.org/AM/
Template.cfm?Section=Ethics_and_Legal_Issues 1 &CON
TENTID=2' i 781 &TEMPLATE=/CM/ContentDisplay.
cfm. Accessed February 21, 2007.
4. American Physical Therapy Association. Professionalism in
Physical therapy; Core Values. Available at www.apta.otg/
AM/Template.cfm?Section=ProfessionaIism 1 &:Template=/
Tagged Pagc/TaggedPageDisplaycfm&TPUD=97&Conte
ntID=21263. Accessed February 21, 2007.
Kidder RM. How Good People Make Tough Choices:
Resolving the Dilemmas of Ethical Living. New York, NY;
Fireside. 1995.
5.
APTA Code of Ethics (HOD 06-00-1 2 -2 3)
Preamble
Thi s Co de o f Ethi cs o f the Ameri can
Physi cal Therapy Asso ci ati o n sets f o rth
pri nci ples f o r the ethi cal practi ce o f physi -
cal therapy. Al l physi cal therapi sts are
respo nsi ble f o r mai ntai ni ng and pro -
mo ti ng ethi cal practi ce. To thi s end, the
physi cal therapi st shall act i n the best
i nterest o f the pati ent/ cli ent. Thi s Co de
o f Ethi cs shall be bi ndi ng o n all physi cal
therapi sts.
Principle 1
A physi cal therapi st shall respect the ri ghts
and di gni ty o f all i ndi vi duals and shall
pro vi de co mpassi o nate care.
Principle 2
A physi cal therapi st shall act i n a trustwo r-
thy manner to wards pati ents/ cli ents, and
i n all o ther aspects o f physi cal therapy
practi ce.
Principle 3
A physi cal therapi st shall co mply wi th
laws and regulati o ns go verni ng physi cal
therapy and shall stri ve to ef f ect changes
that benef i t pati ents/ cli ents.
Principle 4
A physi cal therapi st shall exerci se so und
pro f essi o nal judgment.
Principle 5
A physi cal therapi st shall achi eve and
mai ntai n pro f essi o nal co mpetence.
Principle 6
A physi cal therapi st shall mai ntai n and
pro mo te hi gh standards f o r physi cal ther-
apy practi ce, educati o n o nd research.
Principle 7
A physi cal therapi st shall seek o nly such
remunerati o n as i s deserved and reaso n-
able f o r physi cal therapy servi ces.
Principle 8
A physi cal therapi st shall pro vi de and
make avai lable accurate and relevant
i nf o rmati o n to pati ents/ cli ents abo ut thei r
care and to the publi c abo ut physi cal
therapy servi ces.
Principle 9
A physi cal therapi st shall pro tect the
publi c and the pro f essi o n f ro m unethi cal,
i nco mpetent, and i llegal acts.
Principle 10
A physi cal therapi st shall endeavo r to
address the health needs o f so ci ety.
Principle 1 1
A physi cal therapi st shall respect
the ri ghts, kno wledge, and ski lls o f
co lleagues and o ther health care
pro f essi o nals.
3 6 ' M a y 2 0 0 7