Invited Commentary

Applying ethical reasoning within clinical practice is crucial to holistic patient care. In their article, Delany et al1 use insights from 2 retrospective analyses of physical therapy ethics knowledge2,3 as the springboard for their applied model of physical therapy ethics. Both Swisher2 and Carpenter and Richardson3 identified gaps that exist between ethics knowledge and clinical practice. Hence, Delany et al1 propose a model to close this gap. The article concludes by applying the model to a clinical scenario to assist the reader in exploring its application. This discussion is timely within the profession. As a registered physical therapist in Ontario, Canada, my College of Physiotherapists of Ontario4,5 instituted a revised Code of Ethics and Standards for Professional Ethics in October 2009. The revised American Physical Therapy Association (APTA) Code of Ethics for the physical therapist and Standards of Ethical Conduct for the Physical Therapist Assistant take effect July 1, 2010.6 The profession's evolution has been influenced by increased complexity, enhanced professional autonomy, expanded scope of practice, direct access,1,7 and interprofessional collaboration. These factors are present across health care delivery systems, jurisdictional boundaries, and professional contexts and will continue to challenge the profession and individual physical therapists. As a result, the application of ethical decision making in everyday practice is essential. Two relevant purposes for codes of ethics, described in the literature, delineate: (1) the responsibilities of the individual and (2) the accountability to the broader community. They have been described as “fostering a ‘moral self-understanding,’ and creating a professional moral community”7(p804) or as “educating and providing guidance to members of the profession [in ethical decision making and conduct]; and promoting the ‘social contract,’ public accountability, and societal expectations.”7(p804) Conceptually, these purposes resonate with the 2 themes of agency and connectedness expressed by Delany et al.1Agency articulates the roles and obligations of the autonomous practitioner in his or her ability to affect a situation. It means being “capable of deliberating, thinking, deciding, and acting in accordance with personal and professional moral standards and principles.”8(p69)Connectedness describes the interrelationships among all parties with whom therapists interact to provide care. It can be conceptualized, as stated above, in terms of a social contract. However, a “contract” often is viewed as prescriptive. Other authors have used terms such as “covenant” or “communion.” The term “covenant” embodies commitment, empathy, and creativity,9 and the term “communion” implies caring and togetherness.10 Agency and connectedness are significant features underpining moral action. When studying the moral personality of brave exemplars (recipients of the Canadian Medal of Bravery) and caring exemplars (recipients of the Caring Canadian Award) and matched comparisons, Walker and Frimer10 found that both groups of exemplars demonstrated stronger personality variables of agency and communion than comparison groups (P<.001). The active engagement applied ethics model is grounded in the themes of agency and connectedness. I infer from Delany and colleagues’ description1 that their model is intended to reframe more “traditional” ethical decision-making models. As such, they have distilled more complex or detailed models into 3 simple components: to listen actively, to think reflexively, and to reason critically. Furthermore, these steps resonate with 3 core components of the clinical decision-making process. However, the model is not simplistic. It presupposes engagement and, by distilling complexity into simplicity, implies the need for a sound understanding of ethics by the practitioner. Both of these characteristics are essential for integrating ethical and clinical decision making.8 For me, there are 3 important requirements for the type of engagement that is central to implementing this model: moral sensitivity, moral imagination, and moral courage. Moral sensitivity was described by Rest in his Four Component Model as “the awareness of how our actions affect other people”11(p23) and implies an ability to interpret a situation. Without moral sensitivity, a physical therapist may not identify an ethical situation and cannot thoughtfully engage in the 3 steps of the model. Moral imagination includes being able to put oneself in the place of others and to envisage various ways of acting in the situation,12 perhaps what Delany et al1 meant as curiosity. These are important features for active listening (step 1) and critical reasoning (step 3). Moral courage gives the physical therapist the ability to act, often in the face of fear or other barriers.13 Moral courage also been described by Rest11 as moral character. In my reading of this model, carrying through with the selected course of action is not explicitly included in the 3 steps. More recently, these 3 concepts—moral sensitivity, moral imagination, and moral courage—have been encapsulated by Weaver et al in their definition of ethical sensitivity: Ethical sensitivity is the capacity to decide with intelligence and compassion, given uncertainty in a care situation, drawing as needed on a critical understanding of codes of ethical conduct, clinical experience, academic learning and self knowledge, with an additional ability to anticipate consequences and the courage to act.14(p610) They caution that if a practitioner is “merely doing a job, if others must point out the presence of an ethical issue…if professionals are certain that they know in advance what is morally right to do, or if professionals address situations as solely technical,”14(p612) ethical sensitivity is absent. I would argue it also would preclude a physical therapist from having the capacity to apply the active engagement model. This model moves away from the direction taken in the revised APTA Code of Ethics. In revising the Code of Ethics, there was a shift away from stating a few general principles to using an expanded format detailing the actions required by the physical therapist to achieve a given principle.7 Without including expanded detail, a code of ethics may be too vague7 to be useful. Swisher and Hiller stated, The primary arguments advanced for the expanded format of the documents were the educational value of more specific guidance for physical therapists and physical therapist assistants, the enhanced public accountability of published consistent normative standards of conduct, and the opportunity for the membership and their representatives in the [House of Delegates] to have greater input into ongoing dialogue about ethical matters.7(pp814–815) Interestingly, the College of Physiotherapists of Ontario,4 in revising its Code of Ethics, took the opposite approach. The College moved from a prior code with specification to an acronym (Respect, Excellence, Autonomy and well being, Communication, collaboration and advocacy, Honesty and integrity) supported by overarching principles and educational modules. It could be argued that, in addition to presupposing a level of ethical sensitivity, the 3 steps in the active engagement model are too general to be useful. Perhaps to overcome this, Delany et al1 explicitly or implicitly incorporate 3 adjuncts to support the model's implementation. First, they augment each step of the active engagement model with facilitating questions (their Tab. 2). The questions help the physical therapist delve into the intended scope of each of the 3 steps. Second, they utilize the richness of a narrative. By using stories, poems, and even theatre, health care professionals discover the issues and the people embedded in the narrative, infusing reasoning with mindfulness.15,16 Delany et al1 use Sally's story to bring alive their active engagement model for the reader and reveal the power of personal written narrative. Finally, Sally, a clinician for 3½ years, approached Dr Delany, a known expert in ethics, to relate her story. This demonstrates the benefit of a mentor to help work through difficult ethical and clinical situations and the influence of the different characteristics of novice and expert clinicians on clinical reasoning.17 The interface between professional knowledge and ethical values defines clinical practice.18 Delany et al1 are to be commended for seeking to bridge this interface by describing and applying their active engagement model. I hope that their article, in the context of current practice and the implementation of the revised ATPA ethics documents, stimulates lively discussion. Although the profession has morally matured, this journey must continue. As autonomous practitioners, we have an obligation to take seriously our role as moral agents. As educators, we need to provide learning opportunities for both pre- and post-licensure physical therapists to enrich their ethical sensitivity. As a profession, we must demonstrate leadership and research to further advance moral dialogue in physical therapy.

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