Home Search

Model Applications

By Nancy R Kirsch, PT, DPT, PhD

The initial Ethics in Action columns^1,2 set the stage for ethical decision making by reviewing terminology and establishing the context within which ethical decisions are developed. Now it is time to put our Realm-Individual Process-Situation (RIPS) model into action.

Sometimes, for example, ethical questions arise from the very best of intentions; how those intentions are perceived may turn a simple act of kindness into an ethical quandary. Consider the following case.

The Cost of Giving

Mike was in the third year of his Doctor of Physical Therapy (DPT) program. He was completing the second of his three rotations and was just a few months from graduation. He's been enjoying this clinical location and was strongly considering submitting an application upon graduation. Sharon, his APTA-certified clinical instructor (CI), went over his final evaluation with him late on a Thursday afternoon. In addition to a very positive evaluation, Sharon gave Mike a gift bag as a going-away present; it consisted of a few inexpensive odds and ends that were travel-related, as Mike's final clinical affiliation was to be out of state.

Mike wasn't quite sure what he should do in return. He felt he should return the thoughtful gesture, but he had no time to shop that evening and couldn't readily decide on a reciprocal gift. Suddenly he had a thought: His wife owned a spa, and Sharon often had remarked that she would love to be pampered for a day but felt it was an extravagance she literally could ill-afford. Mike quickly decided that giving Sharon a gift certificate for $150 to his wife's spa was both a perfect and easy solution to his conundrum. Before leaving the clinic the following day, Mike's last in the rotation, he left Sharon a thank-you card that contained the gift.

Mike never gave the situation another thought until many weeks later, during a discussion with a classmate who raised an eyebrow upon learning the monetary value of the gift to Mike's CI. At that point Sharon had neither acknowledged the gift nor shown up at the spa. Mike began to second-guess his action, questioning the ethics of the situation.

Let's look at this case through the prism of the four-step ethical decision-making process described in HPA Resource article "The Realm-Individual Process-Situation (RIPS) Model of Ethical Decision-Making"4 by Dolly Swisher, PT, PhD, Linda Arslanian, PT, DPT, MS, and Carol Davis, PT, EdD, FAPTA.

Step 1: Recognize and Define the Ethical Issue Realm. Mike had read the clinic's policy on accepting gifts from patients but was uncertain how that applied to gifts between a PT and a student. He was considering applying to this facility upon graduation, but might his gift be perceived as an attempt to influence the clinic's decision? The ethical issue here primarily is in the individual realm, as the most important consideration is the effect of Mike's gift on his CI's subsequent actions.

Individual process. Next, what does the ethical situation require of Mike, and does it require anything of anyone else? Mike initially failed to exhibit moral sensitivity. He did not recognize that his action created an ethical situation. Because Sharon neither responded to nor redeemed the gift, we don't know if she took any action beyond actively ignoring it. One might question whether she had the moral courage, in her role as a CI, to follow through and contact Mike to help him develop his ethical decision-making skills.

Situation. Classification of the ethical situation is the last part of the analysis in step one. For Mike, this is an ethical issue or problem. He gave the gift with good intentions, but he was naive in his role as a professional and did not recognize the challenge to values he posed by the type of gift he gave. Sharon's lack of acknowledgement and failure to help Mike develop his professional value system can be characterized as silence.

Reflecting upon and interpreting the information gathered in step one provides background for further decision making. This is similar to the way in which PTs make clinical decisions based on information gathered during clinical screens.

We've determined that the most important realm in this scenario is the individual one. Given that, we would expect some form of direct communication to ensue between Mike and Sharon. Posing some additional questions facilitates further fact-finding.

• What are the relevant facts and contextual information? Mike no longer is Sharon's student. Does her obligation to help him develop professionally extend beyond the student-CI relationship?
• Who are the major stakeholders? Beyond Mike and Sharon, can we identify anyone else who may be affected by this situation?
• What are the potential consequences, intended or unintended? Could Sharon get in trouble with her institution for accepting or not returning the gift? Could the situation influence Mike's desire to work at this facility?
• What are the relevant laws, duties, and ethical principles? Does the state practice act address this type of situation? Which ethical principle, as described in last month's Ethics in Action,² is involved: autonomy, beneficence, nonmaleficence, justice, or veracity?
• What professional guidance do we have? Pertinent documents include the APTA Code of Ethics (see box), the APTA Guide for Professional Conduct,⁵ and Professionalism in Physical Therapy: Core Values.⁶
• What are the results of the right-vs-wrong tests suggested in "The Realm-Individual Process-Situation (RIPS) Model of Ethical Decision-Making"⁴? The legal test: Did either the CI or the student do anything illegal? (Check the practice act.) The stench test: Does the situation feel wrong? Mike didn't find it uncomfortable initially. The front-page test: Would either party feel embarrassed were the gift to become public knowledge? The mom (parent) test: What would your parents (or another mentor you respect) do in the same situation? The professional ethical violation test: Are there principles in the three APTA professional-guidance resources cited above that address this issue? 

Step 3: Decide the Right Thing to Do

If all the tests are negative-that is, if the ethical situation seems to pass all the tests just mentioned-it is time to move on to this step. (Generally, if the situation does not pass one or more of the tests, there is no need to work through this step, because the right thing to do is clear. The need in that case is to marshal the moral courage to implement appropriate action.) Rushworth Kidder, in How Good People Make Tough Choices,⁷ offers three possible approaches to resolving a situation that may pose several appropriate courses of action.

• Rule-based: Follow only the principle you want everyone else to follow.
• Ends-based: Do whatever produces the greatest good for the greatest number.
• Care-based: Do unto others as you would have them do unto you. (The "Golden Rule.")

The approach most applicable in this scenario would seem to be care-based, as the central need is for resolution between two parties, Sharon and Mike.

Step 4: Implement, Evaluate, Reassess

In this step a decision is made, but the important feature of this step is the opportunity to evaluate the course of action chosen and determine if a change in policy or culture is required in order to achieve the best outcome.

This step offers opportunities for personal reflection and professional growth. As Swisher, et al put it: "What can you, as a professional, learn from this experience? What are your strengths and weaknesses in terms of the four [steps]?"⁴ Sharon elected not to accept the gift, but will she demonstrate the moral courage to contact Mike, discuss her concerns, and help him develop his moral compass? Will Mike reach out to Sharon to discuss his motivation in giving the gift and what he needed in order to recognize the ethical situation for what it was?

There may be other ways in which this situation could be analyzed. That's part of the professional dialogue in which we engage when we tackle ethical situations. If you have any thoughts you'd like to share about the scenario posed in this month's column, please feel free to contact me at the e-mail address below.

Next month we'll begin looking at issues of professional integrity-providing new opportunities to practice.
__________________
Nancy R Kirsch, PT, DPT, PhD, is a member of APTA's Ethics and Judicial Committee and is an associate professor of physical therapy in the University of Medicine and Dentistry's School of Health Related Professions in Newark, New Jersey. She can be contacted at kirschna@umdnj.edu.

References
1. Kirsch NR. A framework for thought and discussion. PT-Magazine of Physical Therapy. 2006;14(1).
2. Kirsch NR. Ethical decision making: terminology and context. PT-Magazine of Physical Therapy. 2006;14(2).
3. Glaser JW. Three realms of ethics: an integrative map of ethics for the future. In Purtilo RB, Jensen GM, Royeen CB, eds. Educating for Moral Action: A Sourcebook in Health and Rehabilitation Ethics. Philadelphia, PA: FA Davis. 2005;169-184.
4. Swisher LL, Arslanian, LE, Davis CM. The Realm-Individual Process-Situation (RIPS) Model of Ethical Decision Making. HPA Resource. 2005;5(3).
5. American Physical Therapy Association. APTA Guide to for Professional Conduct. Available here. Accessed December 21, 2005.
6. American Physical Therapy Association. Professionalism in Physical Therapy: Core Values. Available here. Accessed December 21, 2005.
7. Kidder RM. How Good People Make Tough Choices: Resolving the Dilemmas of Ethical Living. New York, NY: Fireside. 1995.

_{PT Magazine - March 2006}