ETHICS –
GOALS AND OBJECTIVES
COURSE DESCRIPTION
“Ethics – Texas Physical Therapy” is
a home study continuing education program for healthcare professionals. The course focuses on defining ethical
professional behavior of clinicians in a rehabilitation setting. Information presented includes sections on
the theoretical basis for ethical decision-making, the APTA’s Code of Ethics
and Guide for Professional Conduct, legal standards of behavior, and
hypothetical case scenarios.
COURSE RATIONALE
This course was developed to promote
and facilitate ethical behavior among therapists and other healthcare
professionals in the rehabilitation setting.
COURSE GOALS
1.
The student will understand the theoretical basis for ethical
decision-making.
2.
The student will review and be familiar with the APTA’s Code of Ethics
and Guide for Professional Conduct.
3.
The student will learn about legal standards of behavior as defined by
their state practice act and Board rules.
4.
The student will analyze and interpret hypothetical situations to
determine ethical behavior.
5.
The student will understand the basic rights of the patient.
6.
The student will learn about the legal and ethical considerations of
billing and coding.
7.
The student will understand the meaning and implications of “conflict of
interest”.
8.
The student will learn about appropriate relationships in the
rehabilitation setting.
COURSE OBJECTIVES
1.
Increase understanding of the process required for ethical
decision-making.
2.
Familiarize therapists and assistants with their profession’s Code of
Ethics.
3.
Review and interpret the laws and rules that govern rehabilitation
professionals.
4.
Develop improved problem solving skills relating to ethical dilemmas.
5.
Review and explain basic patient rights.
6.
Examine the ethical considerations involved with billing for rehab
services.
7.
Discuss the meaning and implications of conflict of interest.
8.
Review and examine appropriate relationships in rehabilitation.
COURSE INSTRUCTOR
Michael Niss PT
METHODS OF INSTRUCTION
Home study course available via
internet or written correspondence.
CONTINUING
EDUCATION CREDITS
Two (2) hours of continuing education
credit
CRITERIA FOR ISSUANCE OF CONTINUING EDUCATION CREDITS
A documented score of 70% or greater
on the written post-test.
DETERMINATION OF CONTACT HOURS
“Ethics – Texas Physical Therapy” will
require at least 2 hours to complete.
This estimate is based on the accepted standard for home study courses
of approximately 10-12 pages of written text (12 pt font) per hour. The complete text of this course is 27 pages
(excluding Bibliography and Post Test)
OUTLINE
page
Goals and
Objectives 1 start hour 1
Outline 2
Ethics 3
Why Ethics
are Important 3
Ethics vs
Morals 3
Ethical
Questions 3-4
Ethics
Theories 4-5
How to Make
Right Decisions 5-7
Provision of Services. §322.1 7-10
Texas
Physical Therapy Practice Act 12 start hour 2
APTA Code of
Ethics 12-13
APTA Guide
for Professional Conduct 14-21
Ethics Case
Studies 21-28
#1 – Confidentiality 21-22
#2 – Qualification of Practice 22-23
#3 – Informed Consent 23-24
#4 – Medical Necessity 24-25
#5 – Conflict of Interest 25-26
#6 – Relationships with Referral
Sources 26-27
Bibliography 27
Post-Test 28-29 end hour 2
ETHICS
The word "ethics"
is derived from the Greek word ethos (character), and from the Latin
word mores (customs). Together, they combine to define how individuals
choose to interact with one another. In philosophy, ethics defines what is good
for the individual and for society and establishes the nature of duties that
people owe themselves and one another. Ethics is also a field of
human inquiry ("science" according to some definitions) that examines
the bases of human goals and the foundations of "right" and
"wrong" human actions that further or hinder these goals.
Ethics is important on several levels.
ETHICS VS. MORALS
Although the terms "ethics" and "morals" are often
used interchangeably, they are not identical. Morals usually refer to
practices; ethics refers to the rationale that may or may not support such
practices. Morals refer to actions, ethics to the reasoning behind such
actions. Ethics is an examined and carefully considered structure that includes
both practice and theory. Morals include ethically examined practices, but may
also include practices that have not been ethically analyzed, such as social
customs, emotional responses to breaches of socially accepted practices and
social prejudices. Ethics is usually at a higher intellectual level, more
universal, and more dispassionate than morals. Some philosophers, however, use
the term "morals" to describe a publicly agreed-upon set of rules for
responding to ethical problems.
ETHICAL QUESTIONS
Ethical questions involve 1) responsibilities to the welfare of others
or to the human community; or 2) conflicts among loyalties to different persons
or groups, among responsibilities associated with one's role (e.g. as consumer
or provider), or among principles. Ethical questions include (or imply) the
words "ought" or "should".
Throughout history, mankind
has attempted to determine the philosophical basis from which to define right
and wrong. Here are some of the more
commonly accepted theories that have been proposed.
UTILITARIANISM
This philosophical theory
develops from the work of Jeremy Bentham and John Stewart Mill. Simply put,
utilitarianism is the theory that right and wrong is determined by the
consequences. The basic tool of measurement is pleasure (Bentham) or happiness
(Mill).
A morally correct rule was
the one that provided the greatest good to the greatest number of people.
SOCIAL
CONTRACT THEORY
Social contract theory is
attributed to Thomas Hobbes,
John Locke, and from the twentieth century, John Rawls.
Social contract theories believe that the moral code is created by the people
who form societies. These people come together to create society for the
purpose of protection and gaining other benefits of social cooperation. These
persons agree to regulate and restrict their conduct to achieve this end.
Under this theory you
determine if an act or rule is morally right or wrong if it meets a moral
standard. The morally important thing is not consequences but the way choosers
think while they make choices. One famous philosopher who
developed such a theory was Immanuel Kant (1724-1804).
Under this view an act or
rule is determined to be right or wrong by appeal to the common intuition of a
person. This intuition is sometimes referred to as your conscience. Anyone with
a normal conscience will know that it is wrong to kill an innocent person.
This view is based on the
theory that each person should do whatever promotes their own best interests;
this becomes the basis for moral choices.
This ethics theory proposes
that ethical behavior is a result of developed or inherent character traits or
virtues. A person will do what is
morally right because they are a virtuous person. Aristotle (384-322 B.C.) was
a famous exponent of this view. Aristotle felt that virtue ethics was the way
to attain true happiness. These are some of the commonly accepted virtues.
Autonomy: the duty to maximize the individual's right to make
his or her own decisions.
Beneficence: the duty to do good.
Confidentiality: the duty to respect privacy of information.
Finality: the duty to take action that may override the
demands of law, religion, and social customs.
Justice: the duty to treat all fairly, distributing the risks
and benefits equally.
Nonmaleficence: the duty to cause no harm.
Understanding/Tolerance: the duty to understand and to accept other
viewpoints if reason dictates.
Respect
for persons: the duty to honor
others, their rights, and their responsibilities.
Universality: the duty to take actions that hold for everyone,
regardless of time, place, or people involved.
Veracity: the duty to tell the truth.
The foundation for making proper ethical decisions is
rooted in an individual’s ability to answer several fundamental questions
concerning their actions.
Weighing the legality of
one’s actions is a prudent way to begin the decision-making process. The laws
of a geographic region are a written code of that region’s accepted rules of
conduct. This code of conduct usually
defines clearly which actions are considered acceptable and which actions are
unacceptable. However, a legitimate
argument can be made that sometimes what is legal is not always moral, and that
sometimes what is moral is not always legal.
This idea is easily demonstrated by the following situation.
It is illegal for a
pedestrian to cross a busy street anywhere other than at the designated
crosswalk (jaywalking). A man is walking
down a street and sees someone fall and injure themselves on the other side of
the street. He immediately crosses the
street outside of the crosswalk to attend to the injured person. Are his actions legal? Are they moral? What if by stepping into the street he causes
a car to swerve and to strike another vehicle?
Admittedly, with the
exception of policemen and attorneys, most people do not know all of the
specific laws that govern their lives.
However, it is assumed that most people are familiar with the
fundamental virtues from which these laws are based, and that they will live
their lives in accordance with these virtues.
Professional ethical behavior
as it is defined in this context relates to actions that are consistent with
the normative standards established or practiced by others in the same profession. For physical therapists and physical
therapist assistants, these ethical standards are documented in the APTA’s Code
of Ethics. All PT’s and PTA’s, even
those who are not members of the APTA, are bound to these guidelines. This is
because The APTA Code of Ethics is the accepted and de facto standard of
practice throughout the profession.
I think most people would
agree that the concept of fairness is often highly subjective. However, for
these purposes, we will define fairness as meaning deserved, equitable and
unbiased. Fairness requires the
decision-maker to have a complete understanding of benefits and liabilities to
all parties affected by the decision.
Decisions that result in capricious harm or arbitrary benefit cannot be
considered fair. The goal of every
decision should be an outcome of relative equity that reflects insightful
thought and soundness of intent.
This question presents as a
true reflection of the other three.
Legal, ethical, and fair are defined quite differently by most people
when judged in the comfort of anonymity versus when it is examined before the
forum of public opinion. Most often it
is the incorrect assumption that “no one will ever find out about this” that
leads people to commit acts of impropriety.
How would your decisions change, if prior to taking any actions, you
assumed just the opposite; “other people will definitely know what I have
done”. One sure sign of a poor decision
is debating the possible exposure of an action instead of examining the
appropriateness of it.
As mandated by the Texas Physical Therapy Practice
Act, the PT Board adopts rules to govern the practice of physical therapy in
the State. Rules are adopted, changed and repealed in response to developments
in physical therapy practice, administrative changes, or legislative mandates.
The rules are established as minimum standards, to ensure that the public is
adequately protected.
A complete copy of the State of
http://www.ecptote.state.tx.us/_private/PT_currentrules.pdf
Some of the sections that define professional and/or clinical conduct
are summarized below.
Provision of Services. §322.1
(a) Initiation of physical therapy
services
(1) Referral requirement. A physical
therapist is subject to discipline from the board for providing physical
therapy treatment without a referral from a qualified healthcare practitioner
licensed by the appropriate licensing board, who within the scope of the
professional licensure is authorized to prescribe treatment of individuals. The
list of qualifying referral sources includes physicians, dentists,
chiropractors, podiatrists, physician assistants, and advanced nurse practitioners.
(2) Exceptions to referral
requirement
(A) A PT may evaluate without
referral.
(B) A PT may provide instructions to any
person who is asymptomatic relating to the instructions being given without a
referral.
(C) Emergency Circumstances. A PT may provide
emergency medical care to a person after the sudden onset of a medical
condition manifesting itself by acute symptoms of sufficient severity without
referral if the absence of immediate medical attention could reasonably be
expected to result in a serious threat to the patient's health, serious
impairment to bodily functions, or serious dysfunction of any bodily organ or
part.
(D) Prior referrals. A physical therapist
may treat a patient for an injury or condition that is the subject of a prior
referral if all of the following conditions are met.
(i) The physical therapist must notify
the original referring healthcare personnel of the commencement of therapy by
telephone within five days, or by letter postmarked within five business days;
(ii) The physical therapy provided must
not be for more than 20 treatment sessions or 30 consecutive calendar days,
whichever occurs first. At the conclusion of this time or treatment, the
physical therapist must confer with the referring healthcare personnel before
continuing treatment.
(iii) The treatment can only be provided
to a client/patient who received the referral not more than one year
previously.
(iv) The physical therapist providing
treatment must have been licensed for one year. The physical therapist
responsible for the treatment of the patient may delegate appropriate duties to
another physical therapist having less than one year of experience or to a
physical therapist assistant. A physical therapist licensed for more than one
year must retain responsibility for and supervision of the treatment.
(3) Methods of referral. A referral may
be transmitted by a qualifying referral source in the following ways:
(A) a document (including an
electronically transmitted document or facsimile); or
(B) verbally, in person or by telephone.
If a referral is transmitted verbally, whether in person or by telephone, it
must be received, recorded and signed by the PT,
(b) Evaluation and screening.
(1) Evaluation. Physical therapy
treatment may not be provided prior to the completion of an evaluation of the
patient's condition by a PT.
(2) Reevaluation. A patient receiving
treatment must be reevaluated by a PT:
(A) at least once every 30 days, or at a
higher frequency as established by the PT; or
(B) In response to a change in the
patient's medical status that affects physical therapy treatment, when a change
in the physical therapy plan of care is needed, or prior to any planned
discharge.
(C) A reevaluation must
include:
(i) An onsite reexamination
of the patient, and
(ii) A review of the plan of care with
appropriate revision or termination.
(3) PTAs may screen patients designated
by a PT as possible candidates for physical therapy services. Screening entails
the collection of uniform information from all patients screened using a
predetermined, standardized format. The information collected is delivered to
the supervising PT. Only a PT may determine whether further intervention for
patients screened is necessary.
(c) Physical therapy plan of care
development and implementation.
(1) A written plan of care
must be developed for each patient by a PT.
(2) The plan of care must be updated
following the periodic reevaluation of the patient's condition.
(3) The plan of care or treatment goals
may only be changed or modified by a PT.
(4) Physical therapy treatment may not be
provided by a
(5) A
(6) A PT or
(d) Documentation of treatment.
(1) Each progress note in a patient's
permanent record completed by a
(2) A
(3) Physical
therapy aides may not write or sign physical therapy documents in the permanent
record. However, a physical therapy aide may record quantitative data for tasks
delegated by the supervising PT or
(e) Discharge. The supervising PT is responsible for
the content and validity of the discharge summary and must sign it. A
(a) It is the responsibility of each PT
and/or
(b) Supervision of PTAs.
(1) A
supervising PT is responsible for and will participate in the patient's care.
(2) A
supervising PT must be on call and readily available when physical therapy
services are being provided.
(3) A PT may
assign responsibilities to a
(4) The
supervising PT must hold documented conferences with the
(c) Supervision of physical therapy
aides.
(1) A
supervising PT or
(2) A PT or
The
62nd Texas Legislature enacted the Physical Therapy Practice Act in 1971. The
Act has been revised many times in the years since; most recently by the Texas
Legislature in August 2006. All rules adopted by the Board are based on the
Act.
A complete copy of the State
of
APTA CODE OF ETHICS
PREAMBLE
This Code of Ethics of the American Physical Therapy Association sets forth
principles for the ethical practice of physical therapy. All physical
therapists are responsible for maintaining and promoting 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 rights and dignity of all individuals
and shall provide compassionate care.
PRINCIPLE 2
A physical therapist shall act in a trustworthy 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
therapy practice, education and research.
PRINCIPLE 7
A physical therapist shall seek only such remuneration as is deserved and
reasonable for physical therapy services.
PRINCIPLE 8
A physical therapist shall provide and make available accurate and relevant
information to patients/clients about 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 health care professionals.
Purpose
This Guide for
Professional Conduct (Guide) is intended to serve physical therapists in
interpreting the Code of Ethics (Code) of the American Physical Therapy
Association (Association), in matters of professional conduct. The Guide
provides guidelines by which physical therapists may determine the propriety of
their conduct. It is also intended to guide the professional development of
physical therapist students. The Code and the Guide apply to all physical
therapists. These guidelines are subject to changes as the dynamics of the
profession change and as new patterns of health care delivery are developed and
accepted by the professional community and the public. This Guide is subject to
monitoring and timely revision by the Ethics and Judicial Committee of the
Association.
Interpreting
Ethical Principles
The
interpretations expressed in this Guide reflect the opinions, decisions, and
advice of the Ethics and Judicial Committee. These interpretations are intended
to assist a physical therapist in applying general ethical principles to
specific situations. They should not be considered inclusive of all situations
that could evolve.
PRINCIPLE
1
A
physical therapist shall respect the rights and dignity of all individuals and
shall provide compassionate care.
1.1
Attitudes of a Physical Therapist
A.
A physical therapist shall recognize, respect, and respond to individual and
cultural differences with compassion and sensitivity.
B.
A physical therapist shall be guided at all times by concern for the physical,
psychological, and socioeconomic welfare of patients/clients.
C.
A physical therapist shall not harass, abuse, or discriminate against others.
PRINCIPLE
2
A
physical therapist shall act in a trustworthy manner towards patients/clients,
and in all other aspects of physical therapy practice.
2.1
Patient/Physical Therapist Relationship
A.
A physical therapist shall place the patient/client’s interest(s) above those
of the physical therapist. Working in the patient/client’s best interest
requires knowledge of the patient/client’s needs from the patient/client’s
perspective. Patients/clients often come to the physical therapist in a
vulnerable state and normally will rely on the physical therapist’s advice,
which they perceive to be based on superior knowledge, skill, and experience.
The trustworthy physical therapist acts to ameliorate the patient’s/client’s
vulnerability, not to exploit it.
B.
A physical therapist shall not exploit any aspect of the physical
therapist/patient relationship.
C.
A physical therapist shall not engage in any sexual relationship or activity,
whether consensual or nonconsensual, with any patient while a physical
therapist/patient relationship exists. Termination of the physical
therapist/patient relationship does not eliminate the possibility that a sexual
or intimate relationship may exploit the vulnerability of the former
patient/client.
D.
A physical therapist shall encourage an open and collaborative dialogue with
the patient/client.
E.
In the event the physical therapist or patient terminates the physical
therapist/patient relationship while the patient continues to need physical
therapy services, the physical therapist should take steps to transfer the care
of the patient to another provider.
2.2
Truthfulness
A
physical therapist has an obligation to provide accurate and truthful
information. A physical therapist shall not make statements that he/she knows
or should know are false, deceptive, fraudulent, or misleading. See Section
8.2.C and D.
2.3
Confidential Information
A.
Information relating to the physical therapist/patient relationship is
confidential and may not be communicated to a third party not involved in that
patient’s care without the prior consent of the patient, subject to applicable
law.
B.
Information derived from peer review shall be held confidential by the reviewer
unless the physical therapist who was reviewed consents to the release of the
information.
C.
A physical therapist may disclose information to appropriate authorities when
it is necessary to protect the welfare of an individual or the community or
when required by law. Such disclosure shall be in accordance with applicable
law.
2.4
Patient Autonomy and Consent
A.
A physical therapist shall respect the patient’s/client’s right to make
decisions regarding the recommended plan of care, including consent,
modification, or refusal.
B.
A physical therapist shall communicate to the patient/client the findings of
his/her examination, evaluation, diagnosis, and prognosis.
C.
A physical therapist shall collaborate with the patient/client to establish the
goals of treatment and the plan of care.
D.
A physical therapist shall use sound professional judgment in informing the
patient/client of any substantial risks of the recommended examination and
intervention.
E.
A physical therapist shall not restrict patients’ freedom to select their
provider of physical therapy.
PRINCIPLE
3
A
physical therapist shall comply with laws and regulations governing physical
therapy and shall strive to effect changes that benefit patients/clients.
3.1
Professional Practice
A
physical therapist shall comply with laws governing the qualifications,
functions, and duties of a physical therapist.
3.2
Just Laws and Regulations
A
physical therapist shall advocate the adoption of laws, regulations, and
policies by providers, employers, third party payers, legislatures, and
regulatory agencies to provide and improve access to necessary health care
services for all individuals.
3.3
Unjust Laws and Regulations
A
physical therapist shall endeavor to change unjust laws, regulations, and
policies that govern the practice of physical therapy. See Section 10.2.
PRINCIPLE
4
A
physical therapist shall exercise sound professional judgment.
4.1
Professional Responsibility
A.
A physical therapist shall make professional judgments that are in the
patient/client’s best interests.
B.
Regardless of practice setting, a physical therapist has primary responsibility
for the physical therapy care of a patient and shall make independent judgments
regarding that care consistent with accepted professional standards. See
Sections 2.4 and 6.1.
C.
A physical therapist shall not provide physical therapy services to a
patient/client while his/her ability to do so safely is impaired.
D.
A physical therapist shall exercise sound professional judgment based upon
his/her knowledge, skill, education, training, and experience.
E.
Upon accepting a patient/client for physical therapy services, a physical
therapist shall be responsible for: the examination, evaluation, and diagnosis of
that individual; the prognosis and intervention; re-examination and
modification of the plan of care; and the maintenance of adequate records,
including progress reports. A physical therapist shall establish the plan of
care and shall provide and/or supervise and direct the appropriate
interventions. See Section 2.4.
F.
If the diagnostic process reveals findings that are outside the scope of the
physical therapist’s knowledge, experience, or expertise, the physical
therapist shall so inform the patient/client and refer to an appropriate
practitioner.
G.
When the patient has been referred from another practitioner, the physical
therapist shall communicate pertinent findings and/or information to the
referring practitioner.
H.
A physical therapist shall determine when a patient/client will no longer
benefit from physical therapy services. See Section 7.1.D.
4.2
Direction and Supervision
A.
The supervising physical therapist has primary responsibility for the physical
therapy care rendered to a patient/client.
B.
A physical therapist shall not delegate to a less qualified person any activity
that requires the professional skill, knowledge, and judgment of the physical
therapist.
4.3 Practice
Arrangements
A.
Participation in a business, partnership, corporation, or other entity does not
exempt physical therapists, whether employers, partners, or stockholders,
either individually or collectively, from the obligation to promote, maintain
and comply with the ethical principles of the Association.
B.
A physical therapist shall advise his/her employer(s) of any employer practice
that causes a physical therapist to be in conflict with the ethical principles
of the Association. A physical therapist shall seek to eliminate aspects of
his/her employment that are in conflict with the ethical principles of the
Association.
4.4 Gifts and Other
Consideration(s)
A.
A physical therapist shall not invite, accept, or offer gifts, monetary
incentives, or other considerations that affect or give an appearance of
affecting his/her professional judgment.
B.
A physical therapist shall not offer or accept kickbacks in exchange for
patient referrals. See Sections 7.1.F and G and 9.1.D.
PRINCIPLE
5
A
physical therapist shall achieve and maintain professional competence.
5.1
Scope of Competence
A
physical therapist shall practice within the scope of his/her competence and
commensurate with his/her level of education, training and experience.
5.2
Self-assessment
A
physical therapist has a lifelong professional responsibility for maintaining
competence through on-going self-assessment, education, and enhancement of
knowledge and skills.
5.3
Professional Development
A
physical therapist shall participate in educational activities that enhance
his/her basic knowledge and skills. See Section 6.1.
PRINCIPLE
6
A
physical therapist shall maintain and promote high standards for physical
therapy practice, education and research.
6.1
Professional Standards
A
physical therapist’s practice shall be consistent with accepted professional
standards. A physical therapist shall continuously engage in assessment
activities to determine compliance with these standards.
6.2
Practice
A.
A physical therapist shall achieve and maintain professional competence. See
Section 5.
B.
A physical therapist shall demonstrate his/her commitment to quality
improvement by engaging in peer and utilization review and other
self-assessment activities.
6.3
Professional Education
A.
A physical therapist shall support high-quality education in academic and
clinical settings.
B.
A physical therapist participating in the educational process is responsible to
the students, the academic institutions, and the clinical settings for
promoting ethical conduct. A physical therapist shall model ethical behavior
and provide the student with information about the Code of Ethics,
opportunities to discuss ethical conflicts, and procedures for reporting
unresolved ethical conflicts. See Section 9.
6.4
Continuing Education
A.
A physical therapist providing continuing education must be competent in the
content area.
B.
When a physical therapist provides continuing education, he/she shall ensure
that course content, objectives, faculty credentials, and responsibilities of
the instructional staff are accurately stated in the promotional and instructional
course materials.
C.
A physical therapist shall evaluate the efficacy and effectiveness of
information and techniques presented in continuing education programs before
integrating them into his or her practice.
6.5
Research
A.
A physical therapist participating in research shall abide by ethical standards
governing protection of human subjects and dissemination of results.
B.
A physical therapist shall support research activities that contribute
knowledge for improved patient care.
C.
A physical therapist shall report to appropriate authorities any acts in the
conduct or presentation of research that appear unethical or illegal. See
Section 9.
PRINCIPLE
7
A
physical therapist shall seek only such remuneration as is deserved and
reasonable for physical therapy services.
7.1
Business and Employment Practices
A.
A physical therapist’s business/employment practices shall be consistent with
the ethical principles of the Association.
B.
A physical therapist shall never place her/his own financial interest above the
welfare of individuals under his/her care.
C.
A physical therapist shall recognize that third-party payer contracts may
limit, in one form or another, the provision of physical therapy services.
Third-party limitations do not absolve the physical therapist from making sound
professional judgments that are in the patient’s best interest. A physical
therapist shall avoid underutilization of physical therapy services.
D.
When a physical therapist’s judgment is that a patient will receive negligible
benefit from physical therapy services, the physical therapist shall not
provide or continue to provide such services if the primary reason for doing so
is to further the financial self-interest of the physical therapist or his/her
employer. A physical therapist shall avoid overutilization of physical therapy
services. See Section 4.1.H.
E.
Fees for physical therapy services should be reasonable for the service
performed, considering the setting in which it is provided, practice costs in
the geographic area, judgment of other organizations, and other relevant
factors.
F.
A physical therapist shall not directly or indirectly request, receive, or
participate in the dividing, transferring, assigning, or rebating of an
unearned fee. See Sections 4.4.A and B.
G.
A physical therapist shall not profit by means of a credit or other valuable
consideration, such as an unearned commission, discount, or gratuity, in
connection with the furnishing of physical therapy services. See Sections 4.4.A
and B.
H.
Unless laws impose restrictions to the contrary, physical therapists who
provide physical therapy services within a business entity may pool fees and
monies received. Physical therapists may divide or apportion these fees and
monies in accordance with the business agreement.
I.
A physical therapist may enter into agreements with organizations to provide
physical therapy services if such agreements do not violate the ethical
principles of the Association or applicable laws.
7.2
Endorsement of Products or Services
A.
A physical therapist shall not exert influence on individuals under his/her
care or their families to use products or services based on the direct or
indirect financial interest of the physical therapist in such products or
services. Realizing that these individuals will normally rely on the physical
therapist’s advice, their best interest must always be maintained, as must
their right of free choice relating to the use of any product or service.
Although it cannot be considered unethical for physical therapists to own or
have a financial interest in the production, sale, or distribution of
products/services, they must act in accordance with law and make full
disclosure of their interest whenever individuals under their care use such
products/services.
B.
A physical therapist may receive remuneration for endorsement or advertisement
of products or services to the public, physical therapists, or other health
professionals provided he/she discloses any financial interest in the
production, sale, or distribution of said products or services.
C.
When endorsing or advertising products or services, a physical therapist shall
use sound professional judgment and shall not give the appearance of
Association endorsement unless the Association has formally endorsed the
products or services.
7.3
Disclosure
A
physical therapist shall disclose to the patient if the referring practitioner
derives compensation from the provision of physical therapy.
PRINCIPLE
8
A
physical therapist shall provide and make available accurate and relevant
information to patients/clients about their care and to the public about
physical therapy services.
8.1
Accurate and Relevant Information to the Patient
A.
A physical therapist shall provide the patient/client accurate and relevant
information about his/her condition and plan of care. See Section 2.4.
B.
Upon the request of the patient, the physical therapist shall provide, or make
available, the medical record to the patient or a patient-designated third
party.
C.
A physical therapist shall inform patients of any known financial limitations
that may affect their care.
D.
A physical therapist shall inform the patient when, in his/her judgment, the
patient will receive negligible benefit from further care. See Section 7.1.C.
8.2
Accurate and Relevant Information to the Public
A.
A physical therapist shall inform the public about the societal benefits of the
profession and who is qualified to provide physical therapy services.
B.
Information given to the public shall emphasize that individual problems cannot
be treated without individualized examination and plans/programs of care.
C.
A physical therapist may advertise his/her services to the public. See Section
2.2.
D.
A physical therapist shall not use, or participate in the use of, any form of
communication containing a false, plagiarized, fraudulent, deceptive, unfair,
or sensational statement or claim. See Section 2.2.
E.
A physical therapist who places a paid advertisement shall identify it as such
unless it is apparent from the context that it is a paid advertisement.
PRINCIPLE
9
A
physical therapist shall protect the public and the profession from unethical,
incompetent, and illegal acts.
9.1
Consumer Protection
A.
A physical therapist shall provide care that is within the scope of practice as
defined by the state practice act.
B.
A physical therapist shall not engage in any conduct that is unethical,
incompetent or illegal.
C.
A physical therapist shall report any conduct that appears to be unethical,
incompetent, or illegal.
D.
A physical therapist may not participate in any arrangements in which patients
are exploited due to the referring sources’ enhancing their personal incomes as
a result of referring for, prescribing, or recommending physical therapy. See
Sections 2.1.B, 4, and 7.
PRINCIPLE
10
A
physical therapist shall endeavor to address the health needs of society.
10.1
Pro Bono Service
A
physical therapist shall render pro bono publico (reduced or no fee) services
to patients lacking the ability to pay for services, as each physical
therapist’s practice permits.
10.2
Individual and Community Health
A.
A physical therapist shall be aware of the patient’s health-related needs and
act in a manner that facilitates meeting those needs.
B.
A physical therapist shall endeavor to support activities that benefit the
health status of the community. See Section 3.
PRINCIPLE
11
A
physical therapist shall respect the rights, knowledge, and skills of
colleagues and other healthcare professionals.
11.1
Consultation
A
physical therapist shall seek consultation whenever the welfare of the patient
will be safeguarded or advanced by consulting those who have special skills,
knowledge, and experience.
11.2
Patient/Provider Relationships
A
physical therapist shall not undermine the relationship(s) between his/her patient
and other healthcare professionals.
11.3
Disparagement
Physical
therapists shall not disparage colleagues and other health care professionals.
See Section 9 and Section 2.4.A.
Issued by Ethics and
Judicial Committee
American Physical Therapy Association
October 1981
Last Amended January 2004
John Jones PT, Sue
Brown (therapy receptionist), and Mary Smith (Therapy managed care
contracting), are in a private PT office discussing the fact that they are
treating Biff Simpson, a star NFL quarterback.
John says, “I can’t believe that I’m actually treating Biff
Simpson.” Mary asks, “How bad do you
think his injury is?” John replies, “I
saw his
Is
this a breach in confidentiality?
The information
contained in each patient’s medical record must be safeguarded against
disclosure or exposure to nonproprietary individuals. The right to know any medical information
about another is always predicated on a sound demonstration of need. Frequently, many individuals require access
to information contained in a patient’s medical record. Their right to access
this information is limited to only that information which is deemed necessary
for them perform their job in a safe, effective, and responsible manner.
The
first questions we must ask are “What information is being disclosed and do the
three individuals engaged in the conversation have a need to know this
information?”
John’s
first statement discloses the name of person receiving care, and his second
statement reveals private patient medical information. Certainly, as the primary therapist, John
would need to know the patient’s name and therapy related diagnosis in order to
provide care. Sue, the receptionist, may
also need this information to schedule appointments and perform other essential
clerical tasks. Mary, whose job it is to contract with managed care
organizations, most likely has no compelling reason to know either the
patient’s identity or any of his medical information. Therefore, the disclosure
to Mary of the patient’s identity and medical information is a breach of
patient confidentiality.
(APTA’s Guide for Professional Conduct,
Principle 2.3)
Case Study #2 –
Qualifications of Practice
You work in very busy outpatient rehab clinic. One of your coworkers is a physical therapy
aide who has worked in rehabilitation for more than 20 years. Frequently, she is called upon to perform
treatments that should be done by a PT or
Is the clinic providing ethical care to its patients?
The practice of physical therapy is closely regulated throughout the
In
this situation, the aide’s abilities and outcomes are considered
irrelevant. The key sentence in the
paragraph is: “perform treatments that should be done by a PT or
Case Study #3 – Informed Consent
Sam is a PT who has just received orders to begin ambulation with a
75-year-old woman who is s/p right hip ORIF.
He goes to her hospital room to evaluate her and begin ambulation. She says she does not want therapy today
because she is in too much pain. Sam
explains to her that the doctor has left orders for her to begin walking. The patient refuses. Sam leaves and returns the next day to try
again. Again, she declines treatment and
he leaves.
Under the guidelines of informed consent, were the therapist’s actions
adequate?
Informed
consent is the process by which a fully informed patient can participate in
choices about their health care. It originates from the legal and ethical right
the patient has to direct what happens to their body and from the ethical duty
of the therapist to involve the patient in her health care.
The
most important goal of informed consent is that the patient has an opportunity
to be an informed participant in their health care decisions. It is generally
accepted that complete informed consent includes a discussion of the following
elements:
·
the nature of
the decision/procedure
·
reasonable
alternatives to the proposed intervention
·
the relevant
risks, benefits, and uncertainties related to each alternative
·
the consequences
on non-treatment
·
the goals of
treatment
·
the prognosis
for achieving the goals
·
assessment of
patient understanding
·
the acceptance
of the intervention by the patient
In order for the
patient’s consent to be valid, they must be considered competent to make the
decision at hand and their consent must be voluntary. It is easy for coercive
situations to arise in medicine. Patients often feel powerless and vulnerable.
The therapist should make clear to the patient that they are participating in a
decision, not merely signing a form. With this understanding, the informed
consent process should be seen as an invitation for them to participate in
their health care decisions. The therapist is also generally obligated to
provide a recommendation and share their reasoning process with the patient.
Comprehension on the part of the patient is equally as important as the
information provided. Consequently, the discussion should be carried on in
layperson’s terms and the patient’s understanding should be assessed along the
way.
The
therapist’s actions were not sufficient.
None of the required information was offered to the patient. The most
important thing the therapist failed to explain to the patient was the consequences
of non-treatment. The patient cannot
make an informed decision regarding therapy without this information. It could be argued that her decision to
refuse therapy may have changed had she known that one of the consequences of
this decision could be the development of secondary complications. (i.e.
increased risk of morbidity or mortality). (APTA’s
Guide for Professional Conduct, Principle 2.4)
Case Study #4- Medical Necessity
Steve is a physical therapist and owns his own therapy clinic. He recently signed a contract with an HMO to
provide physical therapy services. The
contract stipulates that Steve will be compensated on a case rate basis. (A fixed amount of money per patient, based
on diagnosis) Steve has performed a
thorough cost analysis on this contract and has determined that the financial
“breakeven” point (revenue equals expenses) on each of these patients is 5
visits. He informs his staff that all
patients covered by this insurance must be discharged by their fourth visit.
Is limiting care in this manner ethical?
Therapists are obligated to propose and provide care that is based on
sound medical rationale, patient medical necessity, and treatment efficacy and
efficiency. It is unethical to either
alter or withhold care based on other extraneous factors without the patient’s
knowledge and consent.
In this instance, the decision to limit care is not ethical. The quantity of care is not being determined
by the medical necessity of the patient.
A therapist must be able to justify all of their professional decisions
(such as the discharging of a patient from clinical care) based on sound clinical
rationale and practices. (APTA’s Guide
for Professional Conduct, Principles 7.1.C and 8.1.C)
Case Study #5 – Conflicts of Interest
Debi Jones PT works in an acute care hospital. She is meeting with a vendor whose company is
introducing a new brace onto the market.
He offers her 3 free braces to “try out” on patients. The vendor states that if Debi continues to
order more braces, she will qualify to receive compensation from his company by
automatically becoming a member of its National Clinical Assessment Panel.
Does this represent a conflict of interest?
Yes, there exists a conflict of interest in this situation. Debi has two primary obligations to
fulfill. The first is to her patient. It
is her professional duty to recommend to her patient a brace that, in her
judgment, will benefit them the most.
The second obligation is to her employer, the hospital. As an employee of the hospital it is her
responsibility to manage expenses by thoroughly and objectively seeking
effective products that also demonstrate economic efficiency. The conflict of interest occurs when she
begins to accept compensation from the vendor in direct or indirect response
for her brace orders. Even if she truly
believes it is the best brace for her patient, and it is the most cost
effective brace the hospital could purchase, by accepting the money she has
established at least an apparent conflict of interest. Under this situation she is obligated to
disclose to all parties her financial interest in ordering the braces. This
disclosure is necessitated because the potential for personal gain would make
others rightfully question whether her objectivity was being influenced.
A conflict of interest is a situation in which a person has a private or
personal interest that influences the objective exercise of his or her
professional duties. As a professional you take on certain responsibilities and
obligations to patients, employers, and others. These obligations must take
precedence over a therapist’s private or personal interests.
In addition to avoiding all real instances of conflict of interest,
therapists must also avoid any apparent or potential conflicts as well.
An apparent conflict of interest is one in which a reasonable person
would think that the professional’s judgment is likely to be compromised, and a
potential conflict of interest involves a situation that may develop into an
actual conflict of interest.
How
do you determine if you are in a conflict of interest, whether actual,
apparent, or potential? The key is to determine whether the situation you are
in interferes or is likely to interfere with your independent judgment. A good
test is the ‘trust test’: Would relevant others (my employer, my patients,
professional colleagues, or the general public) trust my judgment if they knew
I was in this situation. Trust is at the ethical heart or core of this issue.
Conflicts of interest involve the abuse, actual or potential, of the trust
people have placed in professionals. This is why conflicts of interest not only
injure particular patients and employers, but they also damage the whole
profession by reducing the trust people generally have in therapists. (APTA’s Guide for Professional Conduct,
Principles 7.2.A 7.2.B)
Case Study #6 – Relationships with Referral Sources
Larry Jones PT owns a private practice.
Business has been poor. He decides to sublease half of his space to an
orthopedic surgeon. Larry’s current
lease is at $20/sq ft. The doctor wants to pay $15/sq ft. They come to a
compromise of $17/sq ft. Larry also agrees that if the doctor is his top
referral source after 3 months, he’ll make him the Medical Director of the
facility and pay him a salary of $500/month.
Is this an ethical arrangement?
No, this agreement is not ethical.
The most notable infraction involves offering to designate the physician
as Medical Director contingent upon the number of referrals he sends. This is undeniably a direct offer of cash for
patients. Another area of concern is the
rent. At first glance, the rent amount
of $17/sq ft seems fair because it was a compromise between the two parties. However, closer scrutiny reveals this to be
unethical. The fair market value for
rent has been established as $20/ft.
(Larry’s current rental agreement with his landlord) By discounting the doctor $3/sq ft on his
rent, Larry is giving a referral source something of value.
It
is unethical for a physical therapist to offer anything of value to
physicians or any other referral source in direct response for the referral
of patients or services. This
includes cash, rebates, gifts, discounts, reduced rent, services, equipment,
employees, or marketing. Many mistakenly
believe that it is a normal acceptable business practice to offer these things
to referral sources. It is not. In most states, the practice is not only
unethical, but it is also illegal.
Exchanges of valued items or services between therapists and referral
sources must never have any relationship to the referral of patients. Goodwill gifts of nominal value are
acceptable provided that no correlation can be made between the magnitude or
frequency of the gift giving and referral patterns. All business agreements and transactions
should always be well documented and most importantly, reflect fair market
value. (APTA’s Guide for Professional
Conduct, Principle 9.1.D)
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ETHICS –
POST-TEST
10. Which of the following
is unethical?