"ethic of care" in physical therapy practice and education: Challenges and opportunities, The

Journal of Physical Therapy Education, Winter 2000 by Romanello, Mary

ABSTRACT. Numerous forces affect the development of caring relationships between health care practitioners and their patients. The purpose of this article is to use moral philosophy to elucidate and discuss care and caring as we explore what it means to practice an ethic of care in the physical therapy work environment. We discuss the importance of an ethic of care to physical therapy practice, the barriers to an ethic of care found in contemporary physical therapy work, and considerations for educators attempting to develop an ethic of care in physical therapy students. Though we recognize the difficulty in building and maintaining caring relationships with patients in the present health care environment, we believe health care dynamics necessitate that we combine scientific and moral knowledge with caring skills in order to discover forms of physical therapy practice that consider the patient first while achieving physical therapy outcomes.

Key Words: Care, Ethic, Physical therapy.

The terms "care" and "caring" are important ethical concepts in our professional terminology, as is evidenced by their use in professional guides and language. Physical therapy practitioners often use the word "care" in discussing how we provide physical therapy services. We develop plans of care that give direction to treatment, and we consider ourselves members of a health care team. In the American Physical Therapy Association (APTA) Guide for Professional Conduct,1 intended to help APTA members interpret the Code of Ethics,2 principle 1.1 regarding attitudes of physical therapists states that physical therapists are to be guided by concern for the physical, psychological, and socioeconomic welfare of those individuals entrusted to their care. Although we use the term "care" in our discussions and references to physical therapy practice, the term evokes multiple meanings. Though the dictionary lists nine meanings of the word "care," the term can be socially constructed to have many more meanings or interpretations. A few examples include: to have cares or worries, to grieve, the object of attention, and caution in avoiding harm or danger.3 The concept of caring wields much influence in the physical therapy profession, but it is often a vague and unspecific descriptor of our ethical obligations to patients.

Our purpose here is to use moral philosophy to elucidate and discuss an ethic of care, and what it means to practice an ethic of care in a physical therapist's work environment. In doing so, we draw from the theories of care that have been a powerful influence in moral philosophy for almost two decades.4-11 After describing the importance of the ethic of care to the practice of physical therapy, we extend our discussion to explore the barriers to an ethic of care confronting physical therapy clinicians and educators practicing in contemporary work settings. We argue that, increasingly, the ethic of care is being replaced in practice by a simple, though inadequate, professional ethic based on benevolence. We conclude with suggestions for re-establishing the importance of, and the knowledge base relating to, the ethic of care in physical therapy education and practice.

INTRODUCTION TO AN ETHIC OF CARE

Care Literature in Philosophy

Traditionally, ethics has been the domain of duties and rules. One leading ethicist wrote that the typical approach to ethical dilemmas is a two-step process: we locate a rule (eg, "do this," "avoid that"), and then we assume or judge that it applies to our situation.12 Professional ethics in Western philosophical thinking has been the terrain of following correct ethical rules as set forward by professional role and professional cultures. Professional codes of ethics exist, but these rules are often too vague or broad to help us in our daily moral dilemmas. Examples from the APTA Code of Ethics include principle 3, "Physical therapists accept responsibility for the exercise of sound judgment,"2(p1) and principle 4, "Physical therapists maintain and promote high standards for physical therapy practice, education, and research. "2(p1) These rules give us little practical guidance for dealing with the everyday moral choices of physical therapy practice. In addition, the Code of Ethics2 only suggests for physical therapists to act benevolently, showing kindness toward the patient, and to demonstrate beneficence by promoting the patient's good as a requirement for right action. Codes of ethics often provide general rules that represent the general commitments of a profession, but they are neither self-justifying nor self-- clarifying. 13 These rules do not consider specific contexts or circumstances, nor are they clear in dictating right acts between two or more conflicting goods. Codes are important, but inadequate, lists of moral principles that only partially guide practitioners and educators in our field.

With the emergence of women's voices and experiences in philosophy and public life in the 20th century, alternative ethical models began to emerge, challenging the commonly held idea that morality was a domain of laws, rules, and duties. Drawing from traditional female experiences of caregiving, a group of philosophers have successfully refrained ethics not as a set of rules but as a relationship: