Home Search

Issues of Professional Integrity

By Nancy R Kirsch, PT, DPT, PhD

In last month's Ethics in Action column¹ we took a real-life case and applied to it the Realm-Individual Process (RIPS) model of ethical decision making to illustrate the methodology. This column and the two that will follow it will use different scenarios to examine issues of professional integrity. A concluding column in this professional integrity arc, or grouping, will use reader feedback to look at ways in which issues raised by the three scenarios might be handled. Ethics in Action then will move on to a multi-part examination of a different ethical issue.

After reading the scenario below, look at the accompanying boxes, "Components of the RIPS Model" and "APTA Code of Ethics," consult the Ethics in Action column "Ethical Decision Making: Terminology and Context,"² and use the guiding questions within each of the steps to ethical decision making to help crystallize your thoughts about the following scenario.

Electric Slide?

A friend and colleague must leave work early, so you offer to see her last patient of the day, Mr Billings. Mr Billings has been in physical therapy for 2 weeks, following anterior cruciate ligament (ACL) repair. You carefully check the flow sheets and program protocol on the chart and follow the program outlined by your colleague. Mr Billings is very cooperative and well versed on his program; a model patient as you go through various aspects of his plan of care. At the conclusion of his exercise program you prepare him for electrical stimulation and ice; the flow sheets indicate he is responding well to the use of electrical stimulation for quadriceps muscle re-education.

Mr Billings is quite curious about the intervention, saying he "never had this before." Confused, you re-check the flow sheet, but it clearly states that electrical stimulation and ice were administered at the end of each of the patient's previous six sessions. Mr Billings gives every indication of being credible; it's hard for you to imagine that he simply forgot this aspect of his treatment plan.

When your colleague returns, you ask her for clarification. She responds that electrical stimulation is part of the physician's protocol for physical therapy after ACL repair, and that she uses it sometimes but not in every session. "It all evens out in the end," she reasons. She advises you not to worry about it, because you won't be seeing that patient again anyway.

You respect your colleague's professional expertise, but her response has raised several issues that concern you professionally.

• Into which realm or realms does this situation fall: individual, organizational/institutional, or societal?
• What does the situation require of you, the PT who stepped in for your colleague? 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 and your colleague?
• What type of ethical situation is this: a problem, dilemma, distress, or temptation? Would it be best, for personal or other reasons, for you to remain silent?

Ask yourself:

• What do you already know about the discrepancy between the documented interventions and what has actually happened with this patient? What else do you need to know?
• Who are the major stakeholders? In addition to you and your colleague, who else, or what entities, may be affected by this situation?
• What are the consequences of your action or inaction?
• May laws have been broken?
• What ethical principle or principles may be involved? Do any of the following resources provide professional guidance: the APTA Code of Ethics, the APTA Guide for Professional Conduct,³ or Professionalism in Physical Therapy: Core Values⁴? For example, do you see a relationship between this case and principles 2 and 9 of the APTA Code of Ethics? Do other principles strike you as being applicable?
• Finally, consider how this scenario stacks up against the tests posed by Rushworth Kidder in How Good People Make Tough Choices⁵: legal, stench, front page, mom, and professional ethical violation. To whit: Is it legal? Does the situation feel wrong? If you were your colleague, would you feel uncomfortable if the situation became 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 action, and do you have the moral courage to implement it? In making those determinations, in turn, consider the consequences of inaction, and whether collateral damage could result either from action or inaction.

If, however, you believe the scenario passes each of Kidder's 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 number of people.
• Care-based: Do unto others as you would have them do unto you. (The "Golden Rule.")

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 action you've chosen and think about whether a change in organizational policy or culture might keep this scenario from recurring.

Let's Talk

I mentioned at the outset of this piece that each arc of ethical scenarios will conclude with a column that will use reader feedback to look at ways in which the issues raised by the three scenarios might be handled. That's where you come in. Please become a part of the Ethics in Action column by adding your input to the discussion. E-mail your thoughts on this case, including how you would resolve it and how you reached your conclusions. You can reach me at kirschna@umdnj.edu.
____________________________
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. Model applications. PT-Magazine of Physical Therapy. 2006;14(3).
2. Kirsch NR. Ethical decision making:terminology and context. PT-Magazine of Physical Therapy. 2006; 14(2).
3. American Physical Therapy Association. APTA Guide to Professional Conduct. Available here. Accessed January 7, 2006.
4. American Physical Therapy Association. Professionalism in Physical therapy: Core Values. Available here. Accessed January 14, 2006.
5. Kidder RM. How Good People Make Tough Choices: Resolving the Dilemmas of Ethical Living. New York, NY: Fireside. 1995.

_{PT Magazine - April 2006}