Ethical Decision-Making in Therapy Practice.

Ethical Decision-Making in Therapy Practice

Sim J. Newton, MA 02158-1626, Butterworth-Heinemann, 1997, paperback, 160 pp, illus, $25.

The author has a different and scholarly approach to ethics in the health care arena. His approach efficiently combines 2 major elements. Within a context that is cross-cultural (primarily the United States and the United Kingdom) and transprofessional (especially occupational therapy, physical therapy, and speech therapy), he focuses on the aspects of health care ethics that he judges to be most relevant to the real-life, everyday practice of clinicians in the rehabilitation professions. To some extent, he also incorporates legal and professional issues as they relate to ethical practice or ethics in general.

Each chapter is replete with references, which indicates that the subject matter has been researched carefully and thoughtfully. In addition, Sim uses figures and tables to clarify, emphasize, or compare major concepts and ideas discussed in a particular chapter. The theoretical aspects of ethics are balanced and illustrated by case studies and examples taken from the clinical practice of occupational therapists, physical therapists, and speech therapists.

The first 2 chapters discuss the basic concepts and principles of ethical theory in order to provide a foundation for understanding ethical decision making, conflicts, and behavior in the clinic setting. The first chapter addresses the role of ethics in health care and then defines and elaborates on some of the basic terminology. It draws clear distinctions between the legal, ethical, and professional accountability of therapists and it also differentiates among ethics and law, prudence, and professional etiquette. The discussion of the difference between ethics and law is particularly informative.

Chapter 2, "Ethical Decision-Making," examines the primary principles that usually inform ethical analysis and decisions (eg, beneficence, nonmaleficence, respect for autonomy, respect for persons, and justice) in detail. The process of making ethical decisions is illustrated by comparing 3 theoretical approaches: action based on moral principles (deontology), consequences of action (consequentialism), and the cultivation of moral dispositions (virtue ethics). These principles and approaches are applied and integrated throughout the subsequent chapters, providing the theoretical framework for resolving the concrete ethical issues that therapists face.

The remaining chapters continue the application of these concepts by presenting the ethical ramifications of selected issues common to the clinic setting. Chapter 3 analyzes the pros and cons of telling the truth to patients about therapy and their diagnosis and prognosis and discusses the involvement of patients' relatives in decision making. It also examines the patient's right to know and paternalism, when a therapist, acting on his or her belief in what is best for the patient, overrides that patient's judgment.

Chapter 4 explores informed consent mainly from the standpoint of treatment rather than research and includes the legal as well as the ethical aspects. Sim emphasizes the need for patient consent prior to and during an intervention. Patient adherence, a frequent problem for therapists, is discussed as a consequence of consent.

The chapter on confidentiality links privileged information to both patient privacy and the fiduciary relationship between therapist and patient. It introduces the interesting concept of the "circle of confidentiality"--"people with whom confidential information can legitimately be shared." This concept highlights the situational variability and the scope of the need to know. Permissible breaches of confidentiality also receive thoughtful attention.

Chapter 6, "Death and Dying," has merit for physical therapists, because they may treat dying patients, they may be involved in team decisions to discontinue ethical implications of euthanasia and do-not-resuscitate orders are well covered and anchored in real-life situations.

The chapter on resource allocation discusses a very timely and pertinent subject, given the contemporary financial climate in health care. Beginning with the right to health care and the role of the therapist, this chapter outlines the 3 cardinal ethical influences on health care allocation: effectiveness, efficiency, and equity'. It compares 3 general approaches to evaluating the efficiency of interventions: cost-effectiveness analysis, cost-benefit analysis, and cost-utility analysis. The text, however, focuses primarily on a type of cost-utility analysis, the quality-adjusted lite year (QUALY). Cost-containment strategies available to therapists are argued on the basis of the ethics involved.

At first glance, chapter 8, "Code of Ethics," appears to be self-explanatory; however, the text not only presents the codes of the therapy professions, it also gives critiques in the positive sense of the term and encourages an evaluation of the code of ethics. The author issues caveats that ethical codes are not infallible and do not take the place of the therapist's own ethical thinking. On the contrary, he argues that ethical codes provide a set of general rules or guidance for daily decision making in routine situations.

The final chapter, "Other Topics: Advocacy, Suicide, Care of Older People, and HIV Infection," discusses ethical considerations regarding specific situations and patient groups. Patient advocacy, a role increasingly recommended for therapists, recognizes patient vulnerability, a vulnerability that should be protected but that also could be exploited or misdirected by the therapist. A patient's suicide or attempted suicide creates moral conflicts and almost certainly has an impact on the therapist's emotional and psychological well-being. Because elderly people represent an increasing proportion of the population and are placing larger demands on health care services, the discussion of this patient group revolves around the ascendant issues of resource allocation. The ethical issues surrounding therapy for patients with HIV are addressed through questions such as "Who needs to know the client's status?"

This book could serve well as a text for students in occupational therapy, physical therapy, and speech therapy. It also would be a good resource for therapists who want an ethics refresher or need help with ethical problems arising at work. Anyone looking for a recipe approach to ethical decision making will be disappointed because reading the book and digesting it require thoughtful reflection. To a certain extent, each chapter stands alone because the author carefully defines terminology, systematically synthesizes ethical theory and applies it to clinical practice, and emphasizes major points in a concluding statement. New insights may be gained, especially with respect to resource allocation, do-not-resuscitate orders, ethical codes, and patient advocacy. In summary, the book is of high quality, taking a scholarly yet practical approach to ethics, a complicated area where there are no ready or easy answers.

Ruth U Mitchell, PhD, PT University of North Carolina at Chapel Hill Chapel Hill, NC

Dr Mitchell is Professor Emerita in the division of physical therapy. Her areas of expertise include ethics, professional issues, geriatrics, and community, health.