Face to face with ethics


The advent of the coronavirus has posed some dilemmas when it comes to usual physiotherapy practice.

Like many areas of society, the COVID-19 virus has presented previously unimaginable challenges for the physiotherapy profession in Australia.

Despite the clarity offered by the federal government that physiotherapy was an essential service and could continue to operate, and the welcome advocacy of the APA for measures such as telehealth funding, in the early months of this year many individual physiotherapists were left to decide morally what was the right course of action for them to take in terms of their own practice; in essence should they continue to see patients face to face or not?

Compounding the decision for those working in private practice was the financial viability of their businesses to withstand a downturn or complete cessation in trading, as well as a sense of concern and obligation for employees.

Making ethical decisions about the right course of action does not simply entail complying with the law.

Considering varying ethical theories against the dilemma of continuing to conduct face-to-face appointments can provide a useful framework, not just for considering our action during the immediate coronavirus crisis, but also as we consider what kind of profession we should rebuild for the future.

Normative ethical theories are broadly divided into two categories: deontological theories, which consider the rightness of an action based on principles and our duty at the time without any consideration for the effects of those actions; and utilitarian theories, which state there is no intrinsic moral rightness in a particular action and that any decision should be based solely on the consequences of that decision.

In addressing the ethical dilemma of continuing to see patients face to face or not, it is instructive to consider these two approaches against the medical and health ethics principles of nonmaleficence (do no harm), beneficence (do good), autonomy and justice (fairness of access).

Physiotherapists do not undertake the Hippocratic Oath, but even if not explicitly stated, the principle of nonmaleficence is widely held within the profession.

A deontological view would state that as a guiding principle, not harming others should always guide our decision-making, and that we should do so without consideration of the consequences or environment we find ourselves in.

To that end, the deontological stance is really only concerned with the duty, or rightness of the care we are providing a particular patient at that time.

As a profession, we have been directed, and attempted independently, to follow this principle to varying degrees for each patient we have continued to see, through screening and exclusion of potentially symptomatic patients and implementing a raft of enhanced hygiene measures.

Physiotherapists who were worried about continuing to offer face-to-face appointments were largely concerned about the potential spread of the virus in the broader community and in so doing were making a utilitarian assessment.

One of the limitations of the utilitarian view is that the consequences of a decision cannot truly be known at the time of making the decision. However, two points are worth making in support of a utilitarian stance.

At the time of consideration, the number of daily cases in Australia was certainly escalating (the curve was still rising) and the efficacy of early social distancing measures was not known. At the least, there was uncertainty about the level of risk of community contagion.

The second point is that in terms of the principle of nonmaleficence, the physiotherapy profession was being considered differently to other sectors of the Australian community, such as massage therapy, where at face value the time risk of individual exposure was broadly comparable to physiotherapy but the risk to the community was considered sufficient to cease practice.

This discrepancy, justified by our services being considered essential, had the potential to leave people conflicted.

Whatever path people take to formulate their own values and moral behaviours, the belief that individually and as a profession our intrinsic function is to try to help people is clearly justified.

From a deontological view, beneficence is the most frequently inferred guiding principle of our duty; we are daily trying to help those we work with.

If we were to take an absolutist approach, as long as we are seeking to help, nothing else matters.

This sentiment contains something of the stoic, good Samaritan view that pervades healthcare during this time of crisis, including the acceptance that health workers place themselves at elevated personal risk, and resonates comfortably with the notion of us as a profession providing essential services.

The most commonly considered form of utilitarianism, Act utilitarianism, evaluates the rightness of an act against the greatest good done to the greatest number of people, and in so doing provides a mechanism to evaluate the relative good of a decision for different people.

In the COVID-19 context, this leads to the question of how we consider the benefit to an individual attending a face-to-face physiotherapy appointment against the benefit to the community of that person not attending.

As a society we have been prepared to adhere to the inconvenience and economic consequence of social distancing restrictions in order to prioritise the health, and potentially lives, of mass numbers of the community. In this context, the crux of the dilemma confronted by some physiotherapists may well fall to the simple consideration of physiotherapy as a uniformly essential service.

Put simply, while important and undoubtedly delivered with benevolent intent, it is hard to find many instances where the benefit of a face-to-face physiotherapy appointment for an individual patient exceeds the good of limiting the contagion of a potentially lethal virus within the community.

To some extent the principles of autonomy and justice merge, as the dilemma is essentially one of providing access to face- to-face services.

As it is applied in health, the principle of patient autonomy does clearly not afford the stance that it is our duty to provide any treatment or service the patient demands regardless of consequence. This would lead to the collapse of any meaningful modern health system and continuing to provide face-to-face services simply because patients wanted us to is to abdicate any professional ethical judgement.

Commitment to the principle of justice determines who we allow to access our services and who we do not. We have been comfortable following guidelines relating to patients not attending if they are in anyway symptomatic or have been in contact with coronavirus sufferers.

Would we have been more comfortable if there had been clearer guidance within our profession of what truly constituted an essential service? Perhaps the acknowledged widespread downturn in patients attending all manner of health services, including appointments with general practitioners, suggests that to some extent the community has made this decision for us.

Finally, it is worth considering the economic and human cost to the organisations and businesses delivering physiotherapy services during this time.

Like many sectors of the economy, some physiotherapy practices, many built up with good reputations and hard work over many years, may struggle to remain solvent. A number of physiotherapists will undoubtedly find themselves with reduced work opportunities or unemployed.

It is entirely and reasonably virtuous that we seek to maintain our businesses and support our colleagues and staff. However, it should not be considered cold-hearted to enact a broader ethical view.

As long as there is no COVID-19 vaccine, comparing the risk of community contagion with the cost of economic hardship is a non-equivalence.

At the time of writing, the signs are encouraging that Australia is succeeding in its containment strategy and that life will return towards a version of normal at some point. Unlike those who have lost their lives to the coronavirus, physiotherapy, both as individual businesses and more broadly as a profession, has an opportunity to rebuild and distinguish itself through the strong ethical and evidence-based care it provides the Australian community. 

>> Matt Lancaster, FACP, Specialist Sports Physiotherapist (as awarded by the Australian College of Physiotherapists in 2015).


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