Chapter 3; Section A

Understanding the APTA Code of Ethics (HOD 06-00-12-23)

The American Physical Therapy Association (APTA), the only national organization that represents physical therapists, has created and defined a code of ethics. Further in the Guide to Professional Conduct (Guide) and Code of Ethics (Code) ethics is discussed. These documents provide the guiding force to all physical therapists in the United States. Though not all physical therapists or physical therapist assistants are members to this organization, all ARE affected by the Code and the Guide. These documents have been attached to this course for reference. The next section will discuss the Code and provide examples of application of this code to the rehabilitation field. Though presented from the normative theories published by the APTA, all discussions herein are equally applicable to occupational therapy, speech language pathology, and all other rehabilitation professionals such as athletic trainers, kinesiotherapists, music therapists, etc.

The APTA Code of Ethics begins with a preamble. It states:

This Code of Ethics of the American Physical Therapy Association sets forth principles for the ethical practice of physical therapy. All physical therapists are responsible for maintaining and promoting ethical practice. To this end, the physical therapist shall act in the best interest of the patient/client. This code of Ethics shall be binding on all physical therapists.

The preamble does fully describe that all physical therapists must abide by the Code. Failure to do could result in a report to the therapists own licensing board. All physical therapy licensing boards for each state have acknowledged and accepted this Code as the guiding to their own practices. Thus, a physical therapist cannot state that they are not aware of an ethical principle or that they are not required to follow such a Code. The issue of APTA membership is NOT part of this Code.

The APTA Code of Ethics has defined 11 principles, referred to by number (Principle 1, Principle 2, etc).  These principles were developed through a number of years with many revisions. The 11 are based in the four general medical ethics principles discussed. However, these principles provide a more solid foundation for clinicians. The next sections will discuss each principle individually.

Principle 1 - A physical therapist shall respect the rights and dignity of all individuals and shall provide compassionate care.

Principle 1 integrates autonomy (rights of the individual) with beneficence (provide care) and justice (all individuals). This principle further highlights the belief of the organization that physical therapists must see that individuals have dignity and be treated with compassion. These thoughts are hard to quantify. What is compassionate? What constitutes dignity? These are defining principles and thoughts that need to be self-examined by all clinicians.

All people have a bad day when they may be short-tempered or short-sighted. An errant comment such as a thought that the “patient was not trying hard enough” or providing a derogatory label (such as the “patient is an old codger” or a “blue-collar” worker) demonstrate a failure to respect the dignity of an individual or provide truly caring care. To develop a compassion that is lasting may be a difficult to skill to master. These principles will require self-reflection frequently in order to live up to the Code.

Principle 1 discusses the attitude of the clinician. Issues such as cultural differences are felt to be encompassed within this principle. The clinician needs to be guided by concern (beneficence) in the treatment of clients. Further, the clinician should not be involved in harassment, abuse or discrimination of others.

Principle 2 - A physical therapist shall act in a trustworthy manner towards patients/clients, and in all other aspects of physical therapy practice.

Principle 2 reflects a portion of justice – the concept of treating all in a fair manner. This principle pulls forward the word “trust.” The idea that a physical therapist my be able to be trusted and must trust others. Pieces of many state licensure issues arise from the lack of trustworthy behavior. For example, a physical therapist was reported to a licensing board after having a sexual relationship with a patient. Further, that patient complained to the licensing board pointing out that in addition to the inappropriate personal boundary intrusion exhibited by this physical therapist, the therapist further discussed some of her other patients with this patient. Obviously, several areas of trust were violated in this all-too-common scenario. A therapist may never have a personal relationship with a patient that is involved with treatment from that therapist. Discussing any patient’s care with any other person other than the treating medical team is also not trustworthy and is a violation of the Health Insurance Portability and Accountability Act (HIPAA) as well.

Principle 2 dissects the patient/clinician relationship. Clients have a trust toward clinicians that requires the clinician to live-up to basic expectations such as trust, skill, knowledge and experience. Clients are in a vulnerable position and should not be exploited. A specifically ethical issue may arise when terminating the client/clinician relationship. Through open, collaborative discussions, this relationship must be clearly severed whether the client is transferred to another clinician OR the interventions or treatment has come to an end.

Formal documents have been developed that assist clinicians in fulfilling issues that arise out of Principle 2. Consider that HIPAA regulations now require that all client information must remain confidential requiring health care providers to actually provide clients with this information in writing. Further, clients must consent to treatment by signing patient forms that allow clinicians to provide treatment. Also, many health care providers also have discharge summaries that are also signed by the client when treatments have been completed.

Principle 3 - A physical therapist shall comply with laws and regulations governing physical therapy and shall strive to effect changes that benefit patients/clients.

Principle 3 is a broad-brushed approach to reflecting on the many laws and regulations that physical therapists must deal with daily. Physical therapy is governed by State Practice Acts that succinctly point out what physical therapists may or may not do in each state. State Practice Acts do differ from state to state. Thus, physical therapists who are licensed in multiple states must comply with the specific acts for the state in which the therapist is practicing at the time. State Practice Acts further outline how a physical therapist may have their license suspended, revoked, or cancelled. These Acts should never be taken lightly.

Physical therapy practice is also regulated by federal Medicare policies and state and federal Medicaid policies. Thus, in scenarios that compare patients with differing funding sources for care, a physical therapist DOES need to consider what the regulations are that govern physical therapy. With the rise in managed Medicare programs and the advent of Part D sponsors, many seniors assigned their Medicare benefits to a Managed Medicare program. Thus, the regulations that now govern care provision to a senior in a Managed Medicare product must comply with that product and are not necessarily Medicare any longer. Local Medical Review Policies (LMRP) are specific policies for each product. It is possible that there are conflicting LMRPs that a physical therapist must consider with different patients within one clinic.

The last phrase of Principle 3 charges physical therapist to continue to pursue changes to laws and regulations that seem to not be in the best interests of patients. In recent years there has been much efforts from the APTA itself and state chapter constituents to resist the imposition of Medicare Part B caps. At the writing of this course, the caps have once again been pushed back another year. It has only been through multiple lobbying efforts and tireless work from physical therapists nationwide that these sweeping Medicare B changes have not been forced on the provision of Medicare Part B physical therapy services to standard Medicare beneficiaries. However, public this debate has been, the Managed Medicare products have instituted caps and prior authorizations under the belief that such constraints will halt the rise of medical costs.

Principle 4 - A physical therapist shall exercise sound professional judgment.

Principle 4 seems too obvious. A simple statement, Principle 4 succinctly notes the need for professional judgment. Professional judgment means that the physical therapist considers the practice of physical therapy, the need for evidenced-based clinical practice, and the ability to apply such practice in an unquestionable manner. The lack of professional judgment has been the fodder of many physical therapy issues or state licensure complaints. Consider the practice of a physical therapist who delegated physical therapy evaluations, treatments, and discharge summaries to a trusted physical therapist assistant. Physical therapist assistants are not trained in evaluations or discharges. Further, it takes the skills of a physical therapist to provide a thorough evaluation and creation of a treatment plan for a physical therapist assistant. A true lack of professional judgment caused this unfortunate incident to be reported to a licensure board and caused multiple licensure issues for the physical therapist.

Clinicians who promote questionable products in advertising or through continuing education forums further may be having a lapse of professional judgment. If the therapist is receiving reimbursement for such endorsements, than a conflict of interest and potential professional judgment problem exists. All such advertising and endorsements must be labeled as such. Clarity is important to avoid any ethical dilemmas.

Practice arrangements also fall under Principle 4. Participation in businesses, partnerships, corporations or other entities does not exempt clinicians from their obligations to clients. Hiding behind employers, partners, or stockholders as a response for lack of appropriate professional judgment is a violation of Principle 4. Clinicians may point to employer practices that are in conflict with ethical principles. Thus, it is the duty of the clinician to seek to eliminate any aspects of employment that are in conflict with such ethical principles.

Next: Chapter 3; Section B