The identification of ethical issues in physical therapy practice.

Identification and examination of the ethical issues facing a profession is an important activity[1] and is considered a mark of professionalism. During the past 20 years, there has been an increased interest in ethical issues. With this increase in interest, there has been a concurrent increase in publications relating to medical ethics. Much of this literature has related to medicine and nursing.[2] Only in the last few years have other health professions begun to address the ethical issues specific to their professions. The need for these other health professions to address their unique ethical issues has become more urgent as these professions have expanded their scope of responsibilities, placing practitioners into positions in which ethical decisions must frequently be made.

In recent years, the profession of physical therapy has increased its autonomy in decision making and has expanded its role in patient care.[3] These changes can be seen by examining the changes that have been made in the practice acts of nearly every state to give physical therapists some degree of autonomy in practice. This increase in autonomy has increased the ethical considerations for physical therapists and has served to focus more clearly the responsibility of physical therapists to identify and discuss ethical questions that arise in the practice of physical therapy. An example of this change can be observed by examining the increased role that physical therapists now have in the supervision of support personnel. Physical therapists are required to supervise a larger number and a more diverse group of assistants, aides, and related health care professionals. With this increase in the supervisory role come additional questions of authority, professional autonomy, responsibility, and quality of care. Other examples can be seen in the variety of business opportunities available to physical therapists. These business arrangements introduce a number of questions relating to patient autonomy, utilization of services, and equity in billing. Any change in practice creates a new set of ethical considerations.

In response to these recent changes in practice, there has been an increased interest in ethical issues facing physical therapists and in ethical decision making. Prior to 1970, there were only a handful of articles that broadly considered the responsibility of physical therapists to the physician and the patient.[4-8] The concepts of ethics described in these articles were represented in terms of appropriate professional behavior and etiquette rather than considerations of ethical decisions or issues.

These articles defined good professional behavior for that period in the history of physical therapy, but then, did not address how to approach ethical decision making or what ethical issues are associated with the practice of physical therapy. The first Code of Ethics for the American Physical Therapy Association (APTA) was developed in 1935.[9] The establishment of a code as well as subsequent articles in the 1940s and 1950s, [4-8] however, indicated that the profession believed ethical behavior should be expected of its members. The responsibility of physical therapists to behave in an ethical manner was emphasized in subsequent literature.[9-16] This more recent literature identified physical therapists as professionals who were responsible for making ethical decisions[13,14,17,18] and who needed to understand the ethical principles involved in such decisions.[12] This perspective was presented by Guccione, in 1980, when he stated

The need to identify and clarify ethical issues within a health profession increases as the profession assumes responsibility for those areas of direct patient care in its domain.... The physical therapist today, in defining the limits of his legal and professional autonomy, must examine the practice of his profession from an ethical point of view.[17(p1264)]

Purtilo, in 1979, also emphasized the changing role as she stated

In short, nonphysician health professionals are involved in ethic decision-making processes and increasingly will be asked to participate in determining moral policy.[18(p1102)]

In 1980, Guccione[17] reported on a survey of 450 APTA members in New England in which he identified 7 primary and 11 secondary ethical issues in physical therapy. Identification of issues facing physical therapists helped to identify physical therapy as a profession with issues particular to itself and placed additional responsibility on the profession to address these issues. Guccione indicated in his conclusions that he wanted to establish priorities for action by APTA and encourage discussion, promote study, and direct education for physical therapists. No follow-up articles were written on any of the primary issues identified by Guccione. These issues were

1. Establishing priorities for patient treatment when

time or resources are limited. 2. Discontinuing treatment for noncompliant patients. 3. Continuing treatment with a terminally ill patient. 4. Continuing treatment to provide psychological support

after physical therapy, goals have been reached. 5. Determining professional responsibilities when a

patient's needs or goals conflict with the family's

needs or goals. 6. Deciding whether to represent certain necessary

patient services in a way that would meet third-party

payer limitations. 7. Maintaining a patient's or family's confidence in

other health care professionals regardless of personal

opinions.

Two of the secondary issues were considered in subsequent literature. The issues were (1) informing patients about limits of treatment or informed consent and the duty of physical therapists to report misconduct by colleagues (ie, whistle blowing).

Articles that included discussion of ethical issues facing physical therapy were published in the 1980s and 1990s. The two issues that received the most attention were informed consent[18-20] and patient compliance.[11,19,21,22] Other issues that have been examined include the right to health care[18] and the treatment of patients with acquired immunodeficiency syndrome (AIDS).[23,24] During the 1980s and 1990s, however, there were still very few articles that addressed ethical issues in physical therapy.

This study was undertaken to assist in the process of identifying ethical issues that are important in the practice of physical therapy. The identification of important ethical issues facing physical therapists may provide a stimulus for increased discussion of those issues.

Methodology

The Delphi technique was chosen as the research method for this study. The Delphi technique is a commonly used method for determining consensus in social science research.[25-30] The Delphi method was developed in the early 1950s and was initially used in Future's research.[28-31] "Future's research" refers to research that attempts to predict future trends and outcomes. This technique consists of a series of questionnaires that are completed by a selected panel of experts. The purpose is to achieve consensus within a group of experts but to avoid the psychological distractions of group interaction.[25] There are typically three or four rounds of questionnaires, with the responses to each questionnaire providing the material for the development of the subsequent questionnaire.[29] The purpose of this process is to reach agreement among the group of experts on the specific statements.

The first questionnaire of the series is composed of broad questions that are intended to elicit open responses from the panel of experts. The composition of the questions in the second round are based on the responses of the panel members to the initial broad questions of the first questionnaire. The second questionnaire is intended to provide the panel with a compilation of the results of the initial questionnaire as well as questions to clarify the specific issues identified by the individual panel members. This questionnaire also provides the panel with a list of specific areas of consensus and areas of disagreement. The third questionnaire provides the panel with a compilation of the results of the second questionnaire and additional data on the opinions and comments of the other panel members. This questionnaire describes areas of agreement between the experts and also presents minority opinions. The third questionnaire provides the panel with an opportunity to make revisions and respond to the information presented from the results of the second questionnaire. If consensus is not obtained following the third questionnaire, then a fourth questionnaire would need to be constructed. Three questionnaires are usually considered sufficient, as little meaningful change usually takes place between the third and fourth rounds.[26]

The Delphi Panel of Experts

The choice of the panel of experts is an important step. In my study, the panel of experts was composed of 6 members. These experts were chosen by polling members of the Judicial Committee of APTA. Each member who had served on the judicial Committee during the last 10 years was asked to identify five individuals who they considered to be experts in ethical issues for physical therapy. They were asked to write the names on a form provided and return this form to the investigator. Their responses remained anonymous. Of the 12 current or former Judicial Committee members contacted, nine responses (75%) were received. An individual was then selected for the panel of experts if he or she was identified by more than one judicial Committee member as an expert. By use of this method, 6 individuals were identified as experts and included on the panel. All Co of the potential panel members consented to participate in the study.

The final composition of the panel was quite diverse, with representation from the East, West, South, and Midwest regions of the United States. There were four male and two female panel members. This gender ratio does not reflect the current composition of the physical therapy profession. According to statistics provided by APTA, the physical therapy profession is approximately 76% female and 24% male.[32] Five of the panel members were physical therapists with extensive backgrounds in clinical practice. Four of these five physical therapists possessed advanced academic degrees. Three of the six panel members had academic appointments. All members of the panel have had additional experience in ethical issues relating to physical therapy as speakers, instructors, authors, or as members of state or national judicial committees.

The Delphi Instrument

The initial questionnaire of the Delphi instrument used in this study was composed of five questions. For the purpose of this report, I will focus on the first two of these questions. The first two questions dealt with present and future ethical issues facing physical therapists. The questionnaires for the second and third rounds of the Delphi instrument contained a compilation of the data received in the preceding questionnaire and requested that the panel consider their earlier responses in light of the additional information.

The first two questions of the initial questionnaire consisted of the following broad statements:

1. List the ethical issues that you feel are currently most

important for physical therapists to address. 2. List any other ethical issues that you feel will become

important for physical therapists within the next 10

years.

Each question was designed to elicit an open response in which the panel members could write as much or as little as they felt necessary.

The initial statements were then compiled and divided into groups of similar statements. The statements identified were supported by differing numbers of panel members. Some statements were supported by all the panel members, and some statements were supported by only one panel member.

The next step in the process was to determine the degree of consensus within the panel on the statements made. Questionnaire B presented the panel members with the statements of the other panel members and asked them to respond to these statements. This questionnaire was designed to allow for clarification of the specific issues and to develop statements that accurately represent various issues. It was intended to give panel members information on the views of the other members of the panel to assist them in responding to further questions. Consensus was sought on the issues listed. The purposes of questionnaire B, therefore, were

1. To obtain clarification on the issues. 2. To obtain agreement on the content of the

statements. 3. To obtain consensus on the issues derived from the

first questionnaire. 4. To identify any issues that were omitted from the

results of the first questionnaire.

The first two questions of questionnaire B reflected the same two questions contained in questionnaire A. For question 1 each of the 23 statements of ethical issues were listed as well as the statements made by the panel members in each of these 23 topic areas. The panel members were then asked to

1. Agree or disagree with the statement. 2. Suggest changes to clarify the statement. 3. Identify any panel statements that did not fit under

this topic area. 4. Rephrase the panel statements that did not fit to

clarify their distinctiveness from the ethical issues as

written.

The same procedure was followed for question 2, which dealt with the eight future ethical issues.

Questionnaire C was developed based on an analysis of the information received in questionnaire B. This questionnaire was designed to allow the panel to reach consensus on which statements to include in a listing of ethical issues facing physical therapy and of practice issues that have ethical ramifications.

Question 1a of questionnaire C listed the consensus choices and asked the panel members to confirm their choice or make changes as necessary. Question 1b listed the statements that were chosen by the majority of the panel members and provided the panel members with the statements made by the panel members in questionnaire B. The panel members were asked to accept or reject these statements and to provide any comments they felt necessary. The same procedure was followed in question 1c with the issues that were rejected by the majority of the panel members in questionnaire B. This process was also followed in question 1d with new questions that were introduced by the panel members in questionnaire B.

Question 2 of questionnaire C dealt with future ethical issues. The same procedure was followed for question 2 as was outlined for question 1 of questionnaire C.

Results

The participation of the six chosen panel members in the three rounds of the study was good throughout the study. In the first round, all six panel members completed the questionnaire and responded to all questions. This provided the investigator with a large variety of responses from which to develop the second round of questions. The second questionnaire was the longest of the three questionnaires given to the panel, and it required the panel members to consider the responses of the other panel members in determining their answers to the questions. Five of the six panel members completed the second questionnaire. The third questionnaire was less complex than the second questionnaire. This questionnaire asked the panel members to either agree or disagree with the statement of issues presented in rounds 1 and 2. Five of the six panel members responded to the third questionnaire. The results of the study presented in this article provided information in the two topic areas of current ethical issues in physical therapy and future ethical issues in physical therapy.

Current Ethical Issues

The first portion of this study identified current ethical issues in physical therapy. The panel members were given the broad directive in question 1 of "List the ethical issues that you feel are currently most important for physical therapists to address." This open-ended question allowed the panel members to identify a wide variety of ethical issues.

The question resulted in a total of 41 responses by the panel members. The number of issues indicated by the individual panel members varied from four to nine issues. Some issues were included by all panel members, and some issues were only listed by one member. From the list of 41 statements of ethical issues, 23 unique issues were identified. The 23 statements of current ethical issues are listed in Figure 1.

* The inequity of the provision of health services within the current health care system * The determination of appropriate utilization and supervision of personnel other then physical therapists (e.g., physical therapist assistants,

physical theraphy aides, certified athletic trainers) in the treatment of patients referred for physical therapy * The involvement of physical therapists in business relationship that limit professional autonomy or have the potential for financial abuse * The overutilization of physical therapy services * The qualification of physical therapists as the entry point into the health care system * The delineation of professional expertise and practice in relationship to other health care providers * The accountability of physical therapy education program * The identification of what constitutes informed consent for physical therapy evaluation and treatment * The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and

physical therapy students * justifiability of fees charged for services and reasonable rate of return * Defining the proper ethical limits of intervention: When doing everything possible may not be in the best interests of the patient * Truth in advertising * Fraud in billing * Sexual abuse by physical therapists * The treatment or nontreatment of patients with acquired immunodeficiency syndrome by physical therapists * Maintaining of clinical competency by physical therapists * Compliance of physical therapists with the need for supportive documentation for services and charges rendered * Resolving the conflicts that sometimes occur between what is permitted by law and what is not permitted by the Code of Ethics * The lack of research evidence to support clinical practice techniques * The lack of cultural diversity within the physical therapy profession * Adhering to the ethical guidelines for the use of human subjects in clinical research * The use of ethics and the disciplinary process to achieve personal gain Figure 1. Initial list of current ethical issues from questionnaire A, question 1.

The 23 ethical issues that were identified in the initial round of the study were the starting point for determining a list of consensus ethical issues facing physical therapy. In the next two rounds of the Delphi study, the panel members were asked to consider this list of ethical issues while also considering the statements of the other panel members. They were asked to modify the statements if they felt it would clarify the issue. They were also instructed to add additional statements if they felt a new statement was needed. At the completion of three rounds of the study, a positive consensus was achieved on 10 of the original 23 statements. Three of the statements were also considered near-consensus items. An item was considered a near-consensus item if only one panel member dissented. There was also negative or near-negative consensus on 6 of the 23 statements. Of the remaining 4 statements, there was a majority, vote to accept 2 statements and a majority vote to reject statements.

The results obtained after three rounds of questionnaires had identified 10 statements as consensus choices and 3 statements as near-consensus choices. These 13 statements are listed in Figure 2. A fourth round for this question was not considered necessary because 19 of the 23 statements were at or near consensus and the final 4 statements did not show substantial change between the second and third questionnaires.

Consensus Choices

* The determination of the appropriate level of training, and supervision of supportive personnel other than physical therapists

who assist in the delivery of physical therapy treatments * The overutilization of physical therapy services * The identification of the factors that constitute informed consent * The protection of the patient's right to confidentiality with therapists, personnel under the supervision of the therapists, and

physical therapy students * The justification of appropriate fees charged for the services rendered by physical therapists * The maintenance of truth in advertising * The identification and prevention of sexual misconduct (abuse) with patients by physical therapists * The maintenance of clinical competence by physical therapists * The adherence to ethical guidelines for the use of human subjects in clinical research * The endorsement of equipment or products in which the physical therapist has a financial interest

Near-consensus choices

* The involvement of physical therapists in business relationships that have the potential for patient exploitation * The identification and elimination of fraud in billing for physical services * The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care

without regard to the patients' personal or social characteristics Figure 2. Final list of ethical issues identified by panel of experts in questionnaire C, question 1.

Future Ethical Issues

The second goal of this study was the identification of ethical issues that are likely to face physical therapists in the future. In questionnaire A, the panel was asked to list additional ethical issues that could become important issues for physical therapists within the next 10 years. The panel members identified 12 statements as future ethical issues. Eight specific issues were identified from the 12 statements of ethical issues. Three of the six panel members also stated that all of the issues identified as current issues would be likely, to remain in the future. One panel member stated, "I don't expect the issue to change substantially in the next 10 years, and I doubt that many of the current issues will be totally resolved in the next 10 years, either." The 8 original statements of the future ethical issues are listed in Figure 3.

* The response of physical therapists to environmental issues of pollutants and health hazards associated with specific treatment modalities * Discriminating in employment opportunities within physical therapy private practices * The duty of physical therapists to report misconduct in colleagues * Defining the limits of personal relationships within the professional setting * How to address the issue of encroachment of other disciplines into the practice of physical therapy * The utilization of treatment techniques without research to verify the degree of effectiveness * The use of advertising in physical therapy practice. * The sexual and physical abuse of patients by physical therapists or those supervised by physical therapists Figure 3. Initial list of future ethical issues identified by panel members in questionnaire A, question 2.

The results of, the second round of the study achieved consensus on four of the statements of future ethical issues. The third round of the Delphi study did not provide any change in the results obtained from the second round. The three rounds of questionnaires identified the four, consensus future ethical issues, which are listed in Figure 4. A fourth round was not considered necessary as the responses of the panel did not show any changes between the second and third questionnaires.

* The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical

theraphy treatment * The duty of physical therapists to report misconduct in colleagues * The need for therapists to define the limits of personal relationships within the professional setting * The sexual and physical abuse of patients by physical therapists or those supervised by physical therapists Figure 4. Final list of future ethical issues identified by panel of experts in questionnaire C, question 2.

The responses of the panel members to the first two questions of this study, relating to current ethical issues and future ethical issues, resulted in the 16 distinct ethical issues that are listed in Figure 5. These 16 ethical issues have been included in a list as important issues facing physical therapists and constitute the final results of this study I have combined both current and future ethical issues in the final list because a majority of the panel members felt that current ethical issues will remain in the future and future issues must be dealt with today. The distinction between future ethical issues and current ethical issues An,as not clear, and it seemed appropriate to combine all of the ethical issues into one composite list.

* The overutilization of physical therapy services * The identification of the factors that constitute informed consent * The protection of the patient's right to confidentially in interactions with therapists, personnel under the supervision of therapists, and

physical therapy students * The justification of appropriate fees charged for the services rendered by physical therapists * The maintenance of truth in advertising * The identification and prevention of sexual and physical abuse of patients by physical therapists or those supervised by physical therapists * The maintenance of clinical competence by physical therapists * The adherence to ethical guidelines for the use of human subjects in clinical research * The endorsement of equipment or products in which the physical therapist has a financial interest * The determination of the appropriate level of training, utilization, and supervision of supportive personnel other than physical therapists

who assist in the delivery of physical therapy treatments * The involvement of physical therapists in business relationships that have the potential for patients exploitation * The identification and elimination of fraud in billing for physical therapy services * The responsibility of physical therapists to provide adequate therapy services to all patients according to their need for care

without regard to the patients' personal or social characteristics * The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical

therapy treatment * The duty of physical therapists to reports misconduct in colleagues * The need for therapist to define the limits of personal relationships within the professional setting Figure 5. Final list of current and future ethical issues identified by panel of experts.

Discussion

The 16 issues identified in this study dealt with a wide variety of topics relating to different aspects of physical therapy practice. Further examination of these issues suggested three classifications of issues. For the purpose of discussion, the 16 issues have been divided into the following groups: (1) issues that relate to patient rights and welfare, (2) issues associated with professional responsibility and role, and (3) issues involving business relationships and economic considerations.

Dividing the issues into specific categories helps to focus the discussion on areas of general concern and to understand the relationships between various issues. There is necessarily some overlap of categories, as an issue in one category may also affect another category, of issues. An example of this overlapping of categories is that a professional issue man, also have an impact on patient welfare. The issues have been assigned to their specific category based on my, determination as to what constituted the primary, focus of that issue. This classification has been done for the purpose of discussion and with the understanding that there could be other groupings of these issues that are equally as valid.

Patients' Rights and Welfare

Issues were included in this category of issues if the primary focus of the concern related directly to the therapist interaction with the patient and involved the individual rights of the patient. Six issues were identified as belonging to this classification (Fig. 6). These issues focus on personal interaction and human rights and deal with informed consent, confidentially, sexual and physical abuse, social characteristics, and personal relationships. Of the ethical issues identified in this section, the issue of the patient's right to informed consent has been most frequently discussed in physical therapy literature.[19,20,33,34] The ethical implications of this issue were examined by Coy[19] and Purtilo,[20] and the issue was discussed from a legal perspective by Banja and Wolf[33] and Scott.[34] Guccione also identified the issue of informed consent as a secondary, issue in his 1980 study.[17] The only other issue from this category that has been discussed in the physical therapy literature is the issue of providing services without consideration of a patient's social characteristics. This issue was discussed by Sim and Purtilo[24] relative to the treatment of patients with AIDS. The remaining issues in this category have not yet been considered in the physical therapy literature. This omission includes the important issues of physical and sexual abuse, confidentiality, and the limits on personal relationships. The implications of these issues on the welfare and rights of patients are great and suggest a need for immediate discussion and study.

* The identification of the factors that constitute informed consent * The protection of the patient's right to confidentiality in interactions with therapists, personnel under the supervision of therapists, and

physical therapy students * The identification and prevention of sexual and physical abuse of patients by physical therapists or those supervised by physical therapists * The adherence to ethical guidelines for the use of human subjects in clinical research * The responsibility of physical therapists to provide adequate physical therapy services to all patients according to their need for care

without regard to the patients' personal or social characteristics * The need for therapists to define the limits of personal relationships within the professional setting Figure 6. Issues relating to patients' right and welfare.

Professional Issues

The second category of issues was designated as professional issues. The issues in this category dealt primarily with policies that affect the delivery, of physical therapy services and with physical therapists' interactions with other health professionals. The five issues identified as belonging to this classification are overutilization of services, maintaining clinical competence, supervision of personnel, the environment, and reporting misconduct of others (Fig. 7). The only issue of this group that has been discussed in the physical therapy literature is the reporting of misconduct by colleagues, which was addressed by Banjalo in 1985. In that article, Banja presented a clear description of the ethical principles and issues associated with whistle blowing.

* The overutilization of physical therapy services * The maintenance of clinical competence by physical therapists * The determination of the appropriate level of training, utilization, and supervision of supportive personnel other than physical therapists

who assist in the delivery of physical therapy treatments * The responsibility of physical therapists to respond to the environmental issues of pollutants and health hazards associated with physical

therapy treatment * The duty of physical therapists to report misconduct in colleagues Figure 7. Issues of professional role and responsibility.

Guccione,[17] in his 1980 study, identified as secondary issues three of the five issues that were classified as professional issues in the current study. The ethical issues identified in both Guccione's study and the current study related to (1) the use of support personnel, (2) the reporting of misconduct by colleagues, and (3) the responsibility of therapists to maintain clinical competence. Professional issues that have not been discussed include overutilization of services, utilization of support services, and maintenance of competence and standards. These are important issues that have a major impact on our relations with other organizations and professions. The recent examination of the health care industry has brought many of these issues into policy discussions and decisions. It is important that physical therapists engage themselves in those discussions and consider the policy changes from an ethical as well as an economic point of view. To assist in determining the appropriate ethical position for the profession of physical therapy through these changing times, we need further study and discussion of the ethical implications of the policies being considered.

Business and Economics

The third category of issues related to business relationships and economic factors. For an issue to be included in this category, its primary focus had to be related to financial considerations. The five issues in this category dealt with appropriate fees, advertising, endorsement of equipment, exploitive business relationships, and fraud in billing (Fig. 8). These are all issues that determine how physical therapists conduct themselves in relation to the business aspects of the profession. The fair and appropriate use of resources is an important consideration for all health care providers. The current discussions at the national level on the containment of health care costs emphasized the importance of the examination of these issues by individual health professions. In this examination, it is again important to identify and discuss the ethical considerations as well as the financial issues.

* The justification of appropriate fees charged for the services rendered by physical therapists * The maintenance of truth in advertising * The endorsement of equipment or products in which the physical therapist has a financial interest * The involvement of physical therapists in business relationships that have potential for patient exploitation * The identification and elimination of fraud in billing for physical therapy services Figure 8. Issues involving business relationships and economic factors.

None of the issues identified in this category have been discussed from an ethical perspective in the physical therapy literature. Guccione[17] did not identify, any of the issues listed in this category as either primary or secondary issues. There has been an absence of formal discussion on the important ethical issues relating to business interaction. This appears to be an area that has great potential and need for exploration and study.

Limitations

My study was designed to stimulate and help clarify the discussion of ethics within the profession of physical therapy. The results of this study should be viewed in the context of the study's limitations. The first limitation was the small size of the panel of experts and whether they were representation of all experts. To choose a panel, it was necessary, to outline specific procedures prior to the study,. These procedures were then followed throughout the study. This process identified a panel of six experts. This is a relatively small panel size but not necessarily a problem for a Delphi study. The primary problem associated with a small panel is that the number of issues that are identified would be limited to the experiences of the small number of panel members. This could lead to some important issues being overlooked. The panel should represent a broad constituency and diverse opinions.

The six-person panel used in this study appeared to represent a large portion of the physical therapy community, but it is still likely that some issues may have been overlooked due to the small size of the panel. As described earlier, the panel consisted of four men and 2 women. This gender ratio does not accurately reflect the population of physical therapists in the United States, which is 76% female and 24% male.[32] This discrepancy could result in a bias toward issues of concern to male therapists and less emphasis on issues that have greater impact on female therapists. It would therefore be prudent not to consider this study as all-inclusive or to limit the discussions of ethical issues in physical therapy to only the ethical issues identified in this study. Important ethical issues could have been overlooked by the panel of experts participating in the study.

Another limitations was the focus on the development of general statements about ethical issues. These representations removed the contextual information from the issues in an attempt to create more generic statements that reflect many specific instances. Because ethical action takes place in specific situations in which the particular context defines the ethical issue, this removal of context creates the risk of making these statements of issues too generic to be useful or meaningful. To address that limitation, the purpose of the study needs to be considered. The purposes of this study were to identify ethical issues that warrant further analysis and to stimulate discussion. The initial step in this process needed to be a broad one that could initiate additional study. The broad statements of the ethical issues identified in this study need to be understood as representing constellations of similar specific issues, which then need to be separated by further studies. This study was useful in identifying these broad issues but did not address specific cases. The results of the study also suggest the need for a series of more focused studies on the particular broad issues that could then identify the specific forms the issue may take. That type of study would provide a way to examine the particular cases and stories associated with the issue. The process for coming to an understanding about the ethical components of our practice requires many steps, and this study should be viewed as only one of the steps toward that understanding.

Recommendations and Conclusion

Within each of the three categories, I believe that there is an identified need for further study. Areas of inquiry that could provide important additional information include (1) a comprehensive examination of the broad issues identified in the study to identify the specific instances and problems, (2) a broad study of clinicians to identify additional ethical issues that may have been omitted in this study and to identify the importance of these issues in practice, and (3) a study to examine the methods and substance of the current teaching of ethics within physical therapy curricula, and (4) a series of studies to examine the effects of various teaching methods on the moral development of physical therapy students. Each of these areas of future study has great potential for adding to the understanding of ethical thought and action in physical therapy practice.

In order to broaden the discussion of ethics within physical therapy, a comprehensive study was needed to identify the ethical issues that are important to the current practice of physical therapy. This study was undertaken to fulfill that need. The ethical issues presented in Figure 5 provide us with a list of important ethical issues that warrant examination. The Delphi method used in this study provides a high degree of confidence that the 16 issues identified in this study are ethical issues of some importance to physical therapy practice. A panel of experts have agreed that these issues should be included as a part of a list of important ethical issues facing physical therapy. Although there may be other ethical issues that were overlooked in this study, I believe that the 16 issues listed provide a good starting point for the study of ethical issues facing physical therapists. Some additional goals of this study were to generate greater discussion of ethical issues and to promote additional study of the specific issues that were identified.

Ethical decision making and ethical action have long been an important component of professional development. Discussion of ethical issues relating to physical therapy, however, has been limited in the physical therapy literature. This deficit needs to be addressed as physical therapy develops as an autonomous profession. The integrity and diligence with which a profession examines its unique ethical issues, understands its ethical interactions, and develops methods for educating its students will largely determine the moral position of that profession. Physical therapists have begun that process, but additional study is needed to understand and clarify the issues relating to the practice of physical therapy. Increased dialogue among physical therapists and further study will help us chart the best moral course through the many changes facing our profession.

References

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