California Physical Therapy: Ethical DecisionsPage 3 of 9

2. Professionalism

Healthcare providers recognize they have a special relationship with their patients that is based on trust; indeed, trust is one of the pillars of the professionalism on which the healthcare relationship rests. When patients have an injury or disability, their increased vulnerability creates special challenges within the general population and within the healthcare system.

All physical therapy providers are faced with the challenges of a swiftly changing medical environment that includes redefining of roles, advances in education, and increases in the scope and nature of practice—factors that challenge professional behaviors and demand ethical decision-making skills. Yet, even though physical therapists understand the need to make ethics-based clinical decisions, they may have had no training for doing so. Education and training to manage ethical decision-making should always be integral to clinical preparation (Miles, 2016; Brody, 2014; Murrell, 2014).

Public demands transparency

Physical therapists (PTs) are generally independent professionals delivering services directly to patients. In addition, PTs are increasingly completing clinical doctorates; all the CAPTE-accredited schools require that Doctor of Physical Therapy be the entry-level degree (CAPTE, 2016). This raises public expectations of the level of practice. The public’s demand for transparency and the growing visibility of other healthcare providers have increased the pressure on allied health providers and other non-physicians to be more accountable for their actions.

Pellegrino (1999) refers to physical therapy as a “relatively new” profession, one in which “ethical maturity has not yet completely evolved.” That statement of almost twenty years ago is in some respects still true as PTs struggle with ethical decision-making in many clinical situations (Hightower, 2012).

Dove (1995) speaks of the loss of trust the public has in professionals in the helping fields and how the loss of trust can be prevented with appropriate education in professional ethics (Sokol, 2015; Sutherland-Smith, 2011). This requires that knowledge of ethical behavior by clinicians be disseminated to the public to help maintain and, if necessary, restore trust. It is critical that this begins in the entry-level education program, where breeches of ethical behavior should not be tolerated (deOliveira, 2015; Rawson, 2013; Nijhof, 2012; Pantic, 2012).

A fiduciary obligation

Scott (1998) reasoned that loyalty to the patient can be very difficult to reconcile with the organizational priorities and financial pressures associated with care today. In addition, it should be noted that physical therapists have a fiduciary (financial) obligation toward their patients.

Physical therapists and physical therapist assistants are today confronted with ethical situations in which it has become increasingly difficult to deliver care effectively. For example, in a 2003 study of more than 450 practicing physical therapists, 64% of the respondents felt that the number of ethical issues confronting PTs in the past ten years had increased, and 97% felt they either stayed the same or increased. Less than 2% of the respondent’s felt the number of issues decreased (see table) (Kirsch, 2003). These findings are consistent with those in other health fields (Kaldjian, 2013; Hightower, 2012).

Source: Kirsch, 2003.

Change in Number of Ethical Issues Facing Physical Therapists
(2003 Study)




No response












The responsibility of a profession to manage its own ethical “house” was identified more than thirty years ago. Andrew Guccione (1980) stated: “The need to identify and clarify ethical issues within physical therapy increases as the profession assumes responsibility for those areas of direct care in its domain.”

Susan Sisola (2013) further identified the responsibility of practitioners, stating: “The privilege and influence that accompany professional practice obligate healthcare providers to look beyond literal or superficial interpretations of their ethical code, and to consider the complexities of the ethical issues evident in the current practice environment” (Knapp, 2013; Avey, 2009; Avolio, 2009; Hannah, 2008; Sisola, 2003).

Healthcare ethics are unique. Often patients cannot choose who they want as a healthcare provider. They are vulnerable to variations in care and to potential exploitation, and the result of poor behavior on the part of the practitioner can have dire consequences (Caldicott, 2014; Mansbach, 2012; Hren, 2011, Barnett, 2005,).