A n i s s u e o f h a n d s - o n m e n t o r i n g . T he initial column in this series on ethical considerations related to improper conduct focused on a physical therapist (PT) who became aware of inappropriate behavior on the part of a colleague and had to determine how best to address the situation.' List month, we looked at what might happen when a patients behavior puts a student physical therapist {SPT) on the spot.^ This final scenario in the series involves a recent- graduate PT s interactions with her PT supervisor. As you read, use the Realm-Individual Process-Decision Making (RIPS) model of ethical decision-making-^ to help guide your thoughts on the issues presented and potential ways of addressing them. Avoidance Therapy After reading the following scenar- io, look at the accompanying boxes- Components of the RIPS Model (at right) and the APTA Code of Ethics on the facing pageconsult the Ethics in Action column "Ediical Decision Making: Terminology and Context,"^ and use the guiding questions within each of the steps to ethical decision-making to help further crystallize your thoughts. Sally graduated from her DPT program about a year ago and initially was thrilled to be ojfered a fiill-time job at the hospital at which shed completed her second clini- cal affiliation. Shed felt very comfortable at the startimpressed by staff's skills and knowledge, gratified by their eagerness to mentor her, and warmed by their kindness and good humor. Among her PT mentors is Paul, the hos- pital's associate director of inpatient physi- cal therapy. Early in her employment he began encouraging Sally to practice therapy techniques on him, partiailarly where he has the most interest and expertisethe loiver extremities, hips, and trunk. She initially welcomed this attention and saw nothing improper in it: He was, after all, a well-respected administrator, married, with three children. But he ff-adually has become more demanding, sometimes insisting that she practice techniques on him in a private treatment roomso she doesn't get "dis- tracted, " he says. As these sessions have become more frequent, Sally has felt more and more uncomfortable. She has beenfrnding herself actively trying to avoid Paul, and this has meant sometimes making treatment deci- sions based partially on staying away from himrather than completely on what is in the patient's optimal interest. Yesterday, for example, Paul decided to treat his patient on a mat near where Sally was working with her own patient, so she instructed her patient to move on to another activity even though the move was a little premature. It wasn't the first time she'd found herself cut- ting an intervention shortor uprooting a patient so as put physical distance betweetj Paul and her. But Sally doesn't quite feel comfortable approaching anyone at the hospital about her discomfort with Paul. She wonders if she's misinterpreting his motives, and she feels, at any rate, that he could convincingly fttstify his actions were he to be confrvnted about them. Sally worries that airing her concems will only damage her credibility and future at the hospital She tells herself, too, that her efforts to avoid Paul haven't Components of the Realm Individual (relationship between individuals) Organizational/ Institutional (good of the organization) Societal (common 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) 62 adversely affected patients in any significant way "I'm a good therapist who Just needs to be a little creative sometimes regarding how and where I treat patients, "she assures herself StilL the question of whether she should rake any sort of action nags at her. 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? : What does the situation require of Sally? Which individual process is most appropriate: moral sensitivity, moral judgment, monil motivation, or moral courage? Are there implica- tions for action on the parts of any- one besides her? What about Paul? Is he aware of the awkward position in which he has placed Sally? Are any of Sally's colleagues aware of his behavior toward her? :* What type of ethical situation is this: a problem, dilemma, distress, or temptation? -: What are the potential barriers to Sally taking action? Step 2: Reflect Ask yourself: : What is known about Paul, his past behavior, and staff perceptions of his behavior? :' What does Sally know about her rights in the workplace iind her options for confidential discussion of die situation? : Who are the major stakeholders? In addition to Sally, her patients, and Paul, who or what else may be affected by this situation? > What are the potential consequences of Sally's action or inaction on her, Paul, patients, and stall? : Might her aaion or inaaion 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 2 and 4 of the APTA Code of Ethics? Which principles, if any, strike you as being applicable to Sally? To Paul? To anyone on staff who is aware of what's going on? Finally, consider how this scenario stacks up against the tests posed by Rushworth Kidder in How Good People Make Tough Choices^: legal, stench. Iront page, parents, and professional ethical violation. In other words: Is something illegal going on? Does the situation feel wrong? Would the hospital's reputation suffer were all the details to become public? What might parents do if faced APTA Code of Ethics (HOD 06-00-12-23) Preamble This Code of Ethics of the American Physical Therapy Association sets forth principles for the ethical practice of physi- cal therapy. All physical therapists are responsible for maintaining and pro- moting ethical practice. To this end, the physical therapist shall act In the best interest of the patient/client. This Code of Ethics shall be binding on all physical therapists. Principle 1 A physical therapist shall respect the righfe and dignity of all individuals and shall provide compassionate care. Principle 2 A physical therapist shall act in a trustwor- thy manner towards patients/clients, and in all other aspects of physical therapy practice. Principle 3 A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients/clients. Principle 4 A physical therapist shall exercise sound professional judgment. Principle 5 A physical therapist shall achieve and maintain professional competence. Principle 6 A physical therapist shall maintain and promote high standards for physical ther- apy practice, education and research. Principle 7 A physical therapist shall seek anIy such remuneration as is deserved and reason- able for physical therapy services. Principle 8 A physical therapist shall provide and make available accurate and relevant information to patients/clients abaut their care and to the public about physical therapy services. Principle 9 A physical therapist shall protect the public and the profession from unethical, incompetent, and illegal acts. Principle 10 A physical therapist shall endeavor to address the health needs of society. Principle 11 A physical therapist shall respect the rights, knowledge, and skills of colleagues and other heolth care professionals. 63 with a similar circumstance involving their child? Can any ethical violations be detected within the APTA resotirces 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 quesdons become what kind of action, and has Sally the moral courage to implement it? Also, what is the potential for collateral damage based on her action or inaction? How might Sallys inaction affect patients? What are patients" rights regarding the effects on their care of PTs' personal issues? If you believe the scenario passes each of Kidder' s tests, then its time to look at the three possihie approaches he presents for determining the right thing to do, and also to look at whether any barriers loom to implementing that response: :* Rule-biised: 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 wotild have them do tinto you. (The "Golden Rule.") Ask as well; Are there are potential bar- riers to implementing any given decision? Are there related ramifications for the clinic, its PTs, and/or current and fiiture patients? Step 4: Implement, Evaluate, Reassess Having determined in your own mind the right thing to do and the best way to implement that decision, reflect on the course of action youVe chosen for Sally and think about whether a change in tJie department' s policies or culture might prevent the scenario from recurring. Let's Talk This column arc will conclude in September with an analysis of all three scenarios related co improper conduct. In the meantime, please let me hear from you! (Note my e-mail address below.) Tell me what your thoughts about these casesyour 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 coun- try are doing. % N a n c y f t K k s d i , P T , D P T , P h D , J u d i c i a l C o m m i t t e e , i s a n a s s o c i a t e p r o f e s s o r o f p h y s i c a l t h e r a p y i n t h e U n i v e f s i t y o f M e d i c i n e a n d f k n t t s t r y ' s S T / K W / o f H e a l t h R e b t e d P r o f e s s i o n s i n H e r n t k . H e w j e r s e y , a n d o w n e r a f N o i t h e m H i l l s P h y s i c a l J h e w p y i s s o d a t e s i n F h n d e r s , f i e w j m e y . S h e c a n b e c o n t a c l B d a t k i f s c h n o @ i m l n j . e ( i u . References 1 . KirschNR. Improper condua: O L V one. PTM^azine of Physical V xmpy. 201 )7:l^(5):34-.V), 2. Kirsch NR. Impnipcr condua: case two. PT^Magaziiu ofliryiimlThrmpy. 2007i1 ' i(6):34-37- 3. Swisher l.t.. Aisianian I.t!, Llavis CM. ITic iralni-indi- vldua] priKJSi-situacion (RIPS) niodfl of ethical ditision making. HPA RtuiuTce. 20O' );' )(3):1 .3-a. 1 , Kirsch NR. Ethical ciecision making: lerminiitogj' andcon- icxi. PTMagaanf of Phyacal Thmpf 2nO6;I4(2):38- 40. 5. American Phy^cal Therapy Associaiion. APTA Guide for Protessional Cni i dua. Available at www.apta.org/AM/ Tcroplatc.ctm?Sec(ion=E[hics_and_LcgnLissues I &CON rENTIL>=2478]&TEMPLArE-/ CM/ Cont cnt Di spky. ctm. Atccsscd Fchruary 21 , 2(K)7. 6. Ameri an Phyiioil Therapy Associaiion. Professionalism in Physical therapy: Core Values. Available ai www.apia.iirg/ AM /Tern pl ai cdm fSeciion=I' ro lixsio na Us m 1 & Templace^^ / Ta^-dPi i gt / r^t^ed ["ageDisplay,d' m& ITI.I t)=y7fl(;Cx)nte ntlD=21 2t' ..i. Attcsscd f-ebriury 21 , 2007. 7. Kidder RM. Hnu; Good Pmplr Make Tnufi) O wka: Resolving liie Dihtmun of Eihicd Uvtng. New York, NY: Hnsitte. 1 995, 6 4 l u l y 2 0 0 7