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

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

To say that [caring] does not require time and energy, to deny that one can become worn out in doing good, to obscure the fact that real dangers and risks may be necessitated, is simply to lure people into a false understanding of caring that is unlikely to prove enduring.25(p105)

Caring relationships in physical therapy practice entail risks for the therapist, such as doing too much for the patient or the patient providing no acknowledgment of or response to the therapist's efforts. Sometimes the therapist does too much for the patient by minimizing the patient's role in the treatment plan rather than developing a plan with the patient that can be incorporated into the patient's daily activities. The patienttherapist- relationship may lack reciprocity if the patient refuses to share treatment expectations, hopes, and fears or demonstrates little effort in the recovery process.

These risks of physical therapy treatment can create conflict. The physical therapist may experience conflict when, for example, engrossment is divided by incompatible demands of several individuals or groups. Incompatible demands can exist when an insurance company decides to discontinue treatment against the recommendations of the therapist. The physical therapist's understanding of the normal course of treatment and the patient's extenuating factors (complications of the condition or additional pathology) may warrant an extension of treatment authorization, yet an insurance provider may deny further remuneration regardless of these factors.

Another risk of caring involves the therapist becoming overburdened with the responsibilities as the one-caring. Engaging in caring relationships requires enormous energy and time in a job that is already demanding and stressful. The therapist may, in addition, have to engage in political battles, expending significant energy to fight institutional or legislative mandates that deny treatment to those patients in need.

Finally, caring relationships may generate conflict when the therapist works with a patient who wants to engage in activities or treatments that the therapist believes are opposed to the patient's best interests. For example, a patient may choose to ambulate without an assistive device despite lower-extremity stability and balance problems that could result in falls and subsequent injury. The ethic of care requires that the therapist find a way to work with the patient's desire for more freedom of movement without engaging in activities that will cause more harm. These experiences frequently create conflict and stress for the therapist. Such situations may also induce guilt in the physical therapist if the treatment results fail to meet the patient's goals or desired outcome.

As Bellah24 suggested, one can become worn out from daily dealings with these risks of caring, particularly those that create conflict. Noddings6(p38) argued that conflict and guilt are inescapable risks of caring and recommended that we not waste time on guilt, but that we act on those things that can be remedied by action. Purtilo and Haddad26 also remind us that we, as professionals, may find ourselves in positions where we must define the limitations of our involvement. Defining our limitations, however, does not mean minimizing an ethic of care. As Purtilo and Haddad stated, "Placing care at the center of relationships becomes crucial when human suffering is involved because caring is a salve to human suffering."26(p219) An ethic of care may require, at times, that we define the limitations of our professional involvement, but the caring relationship must nevertheless remain central to physical therapy work.