Ethical Decision-Making by Students in Physical and Occupational Therapy

Journal of Allied Health, Spring 2004 by Dieruf, Kathy

The professions of physical therapy (PT) and occupational therapy (OT) progressively have expanded their scope of responsibility, and practitioners often are placed in positions in which ethical decisions must be made. Few studies have reported the level of moral development and the effects of education on ethical decision making in PT or OT students. This research study was designed to determine the impact of the educational programs at the University of New Mexico (UNM) in PT and OT on the moral reasoning of the students as measured by the Defining Issues Test (DIT). The longitudinal design of this study followed two consecutive classes in each program (N = 94; 58 PT students and 36 OT students) from entry until graduation approximately 2 years later. The subjects completed a demographic survey and the DIT on the first day of class and again during their final semester (OT) or at graduation (PT). A factorial analysis of covariance was used to examine the effects of a professional degree program (PT and OT) and time (ENTRY and EXIT), after adjusting for the effects of age. The mean P score for this sample was between 45 and 46, which is within range for college and professional students. There was a significant relationship between age and the P score of the DIT. There were no significant differences between PT and OT students or between the entering and the exiting scores for either group of students. Based on the results of this study, these educational programs do not seem to be facilitating moral development in these students. The baseline level of moral development and the skills that PT and OT students use when making ethical decisions need to be established. Additional research is recommended with a larger sample size, including students in other locations. To optimize clinical practice, students must be taught how to make ethical as well as clinical judgments. Therapists must be capable of functioning in the changing health care environment, now and in the future. If the disciplines of PT and OT expect to graduate students who meet this challenge, the educational programs must take the responsibility for evaluating students and implementing curricula that facilitate ethical decision making. J Allied Health. 2004; 33:24-30.

DRASTIC CHANGES ARE occurring in health care, including advances in technology, managed care, and the ever-changing reimbursement by insurance companies.1 With these changes, health care professionals may be exposed to more ethical dilemmas than ever before, placing them in positions in which ethical decisions must be made. The professions of physical therapy (PT) and occupational therapy (OT) have expanded their roles in patient care and increased their autonomy in clinical decision making.2,3 As these professions have expanded their scope of responsibility, the need to address the moral development and ethical education of these professionals has become more critical.4

In 1976, The Hastings Center Report5 of the Commissions on the Teaching of Bioethics stated that future health care professionals need to receive preparation in ethics because of the increased moral and legal liability that will be placed on them in patient care decisions. Currently, most educational programs for physicians and other health care professionals are mandated to require ethics instruction in professional education. The type and the amount of content to include in any curriculum and the most appropriate methods for presenting ethics in a curriculum are not well established in the literature, however.6,7 The outcomes of teaching ethics also are unclear, because it still is unknown if this education makes a difference in professional values and clinical behaviors.8,9

Many articles address the curriculum and measures available in professions such as human or veterinary medicine and dentistry.10-12 There are limited articles, however, specifically addressing the role and magnitude of ethics education in PT or OT curricula.13-19 In 1979, Purtilo18 conducted a study of ethics courses in undergraduate education and concluded that despite a lot of activity and interest, the time committed and the topics covered varied tremendously. By 1991, little had changed as reported in a survey of PT schools in the United States, and content continued to be varied, with most PT programs including less than 20 total hours of ethical/legal instruction.15 Similar findings were reported by Brockett20 in OT programs in Canada. Several articles have been published addressing the recommended content and format for PT programs; however, the outcomes of this level of education still are unknown.21-23

Ethical Decision Making

In this study, ethical decision making (also called moral development or moral judgment) is based on the theory by Kohlberg,24-26 who identified justice as the universal principle. The correlative principles of equality, autonomy, and respect for the dignity of all humans as individual persons are derived from the concept of justice.27 Briefly, in this theory, Kohlberg provides three levels (each with two stages) of moral development known as preconventional morality, conventional morality, and postconventional or principled morality, Preconventional morality focuses on egocentric perceptions of right and wrong (stages one and two) and is the level of most children younger than age 9, some adolescents, and many adolescent and adult criminal offenders. In conventional thinking (stages three and four), consideration is given to how actions are viewed by others and adds the recognition of duty and social order. This is the level of most adolescents and adults in the United States and other societies. The highest level is the postconventional or principled morality level, where individuals are making decisions based on universal moral principles. This level adds social consensus about rights and the ability to use abstract moral principles. Postconventional morality includes stages five and six and is reached by a few adults (usually reached only after age 20).24~26'28 Stage six has been dropped except as a theoretical construct because of its absence in Kohlberg's longitudinal data.29