Being critical to me is not about learning how to systematically review an article or deciding whether someone has used the right statistic test in their study. Rather, it’s about asking fundamental questions about what I believe in, why I believe in those things, and what those things make possible and what they deny. I’ve tried to illustrate these principles this week with some posts that are superficially about sex and sensuality, but are really about how physiotherapists treat people.
Sometimes this means subverting fundamental beliefs and upturning things that seem so obvious and taken for granted (quotidian, to use the fancy word), so that you can be sure that your moral compass is still pointing in the right direction. This can sometimes be a risky practice, particularly when you make your questioning visible to others. After all, who wants someone coming along challenging deeply held beliefs? But it’s so vitally important for a profession like physiotherapy, which is searching for how to remain as relevant in the 21st century as it was in the 20th. And it seems on the basis of the feedback I’ve had this week that I’m not the only one concerned about the direction our profession is taking.
One of my biggest concerns is with the blind faith that we have placed in ethical guidelines. These guidelines are now so commonplace that it’s hard to imagine a time when they didn’t exist. The World Confederation for Physical Therapy’s 2007 Declaration of [Ethical] Principles, are similar to those you will find published by the CSP, APTA, APA and elsewhere, with most borrowing directly from Beauchamp and Childress’s four founding principles of autonomy, non-maleficence, beneficence, and justice (Beauchamp and Childress’s, 1994).
It’s a brave person who argues that there’s something fundamentally flawed about these guidelines – particularly when they are designed to explain how to be good. It’s hard to argue that physiotherapists should not ‘respect the rights and dignity of all individuals’ (WCPT), or that ‘Physical therapists shall act in a respectful manner toward each person regardless of age, gender, race, nationality, religion, ethnicity, social or economic status, sexual orientation, health condition, or disability (APTA). My problem is thought that these guidelines might actually make ethical ‘abuses’ possible.
I’m not talking here about the kinds of things that get therapists struck off (sexual impropriety, fraud, etc.), but the kinds of subtle abuses that pass for normal, everyday physiotherapy practice.
For generations, physiotherapists have encouraged, no mandated, that we learn to treat bodies like machines; assessing and treating the faulty body part and using physical means to return patients to normal. I’ve argued elsewhere that we did this to remove the sensuality from touch. But what did this simple, and understandable response do to our profession?
It made us believe that anatomy, physiology and pathology were core subjects, when all along it should have been people at the core. It made us think that having the social status that came with having the power to fix people was a good thing, and that we should do whatever we could to secure more of that (or ‘Recognise their role as advocates for the physiotherapy profession’ as the CSP puts it). And it made us believe that if we had a set of ethical principles to guide our conduct, abuses wouldn’t happen.
But they do not and never will. I do not want to be accused of hyperbole here, but think about other organisations that have ethical guidelines. Did it stop some of them abusing their power? I’d like to bet that all of those failed finance companies who stole people’s savings in the Global Financial Crisis had whole departments making up sets of ethical principles. Did the American Psychological Association not have ethical guidelines when it colluded with the American Government to promote and practice torture after 9/11 (link)? Did the fact that there were 10 supposedly ‘holy’ commandments prevent church leaders abusing children? One of England’s biggest mass murderers was a GP (Harold Shipman). Did ethical guidelines stop him?
Of course, ethical guidelines don’t cause these abuses and people who draft, support and promote them are not at fault. We will always be able to argue that there were rogue practitioners who failed to comply with the ethical guidelines and that is the reason for abuse. But this fails to address the kinds of systematic and instrumental abuses that ethical guidelines make possible.
Part of the problem is that they are based on the seemingly obvious belief that ethics can be rational: that we can arrive at guidelines through reason and objectivity. But believing that science can provide us with our moral compass is about as dangerous as thinking can get. Was it not the Nazis who believed that the Aryan race was biologically superior, and that the killing of Jews, political activists, homosexuals and disabled people was a scientific necessity?*
People can use belief systems like science to justify all manner of abuses. But there have always been voices of dissent too. These voices are easy to find because they are usually the ones that challenge us to think differently. The Dada art movement in the 1920s and 30s is one of my favourite examples.
Dadaism was partly responsible for surrealist art and the kinds of art that make you ask ‘what on earth is that’? It pioneered the use of new techniques like collage and mixed media (like scrapbooking today), and focused on things that were deliberately ridiculous and trivial. Dadaism, though, was far from trivial. It emerged out of a disgust with the machinery of killing that had seen millions of people slaughtered in World War I. Dadaists could not believe that humanity had ‘progressed’ to the point where such things could be justified by the same kinds of reason that underpin all claims to rightness and the truth. So their art was deliberately anti-establishment, anti-science, anti-art. Pablo Picasso, Jackson Pollock, Damien Hurst all followed the Dadaists in using art to counter the cynicism of reason.
Returning to my bigger point, the problem with ethical guidelines guidelines is that they ‘evacuate ethical decision-making of its ambivalence and discomfort’ and ‘offer a set of best-practice guidelines to produce ethical “outcomes,” to pre-empt lawsuits, and to safeguard the putative goodness of one’s good conscience’ (Murray & Holmes, 2009, p.1).
Ethical guidelines make it possible for physiotherapists to treat ‘the stroke patient’ and the research ‘subject’; they allow for the belief that the origins and insertions of gracilis are more important than an understanding of people’s lived experience or the social determinants of health; they say that it’s okay to show a video of three men manhandling a passive female model as long as the men are using ‘physiotherapeutic techniques’ (link).
Thinking critically about ethical guidelines, one might well conclude that ‘real’ authentic ethical practice demands, first and foremost, that we reject ethical guidelines and look elsewhere for advice on how we might practice otherwise. You could do worse.
References
Beauchamp, T.L. and Childress, J.F. (2009). Principles of Biomedical Ethics. Oxford: Oxford University Press.
Murray, S. J., & Holmes, D. (2009). Introduction: Towards a critical bioethics. In S. J. Murray & D. Holmes (Eds.), Critical interventions in the ethics of healthcare: Challenging the principle of autonomy in bioethics (pp. 1-14). Farnham: Ashgate.
* We should remember that the eugenic ideas that were the basis of National Socialism in Germany were also very popular throughout Europe between 1880 and 1920, and that many prominent figures were eugenicists. Eugenics and social darwinism have also had a strong historical influence on the practice of physical therapies.
I think the need for this excellent article has arisen because of the trending shift towards mistrusting the presented patient narrative, and replacing the ethical underpinnings with super-imposed ethics which favour the operator. It’s a power-grab, which will inevitably back-fire sometime in the future. And it needs exposing.
“One of my biggest concerns is with the blind faith that we have placed in ethical guidelines.”
I am uncertain who has a blind faith in ethical guidelines – there continues to be a field of philosophy that deals with ethics, because there is no consensus on these issues due the inherent ambivalence in the philosophy of ethics. Who is exercising such faith? Are you constructing a bit of a straw-man here?
“My problem is that these guidelines might actually make ethical ‘abuses’ possible…the kinds of subtle abuses that pass for normal, everyday physiotherapy practice.”
Later in the posting, you state: “Thinking critically about ethical guidelines, one might well conclude that ‘real’ authentic ethical practice demands, first and foremost, that we reject ethical guidelines”. But that ‘abuses’ remain possible under current ethical guidelines does not necessarily require that current standards be disposed of, but that they require updating/expansion, no?
“For generations, physiotherapists have encouraged, no mandated, that we learn to treat bodies like machines; assessing and treating the faulty body part and using physical means to return patients to normal…It made us believe that anatomy, physiology and pathology were core subjects, when all along it should have been people at the core. It made us think that having the social status that came with having the power to fix people was a good thing, and that we should do whatever we could to secure more of that…And it made us believe that if we had a set of ethical principles to guide our conduct, abuses wouldn’t happen.”
I am having difficulty following how this is related to ethics – but admit to occasionally being thick-headed and naive. This seems to be an argument against therapists who (as part of a larger culture) are dualistic – it is an argument against therapist’s limited understanding of philosophy and complexity ensconced in unjustified certainty. I wholeheartedly agree that therapists ‘core’ education falls short, but did the core requirements for education arise from ethical guidelines, or vice versa? What is informing ‘core’ curricula?
“We will always be able to argue that there were rogue practitioners…this fails to address the kinds of systematic and instrumental abuses that ethical guidelines make possible.”
Do the guidelines make abuses possible, or were the abuses already possible, and are not abolished (outliers notwithstanding) by ethical standards? Wouldn’t a conversation regarding the limitations of current ethical guidelines then follow?
“Ethical guidelines make it possible for physiotherapists to treat ‘the stroke patient’ and the research ‘subject’; they allow for the belief that the origins and insertions of gracilis are more important than an understanding of people’s lived experience or the social determinants of health; they say that it’s okay to show a video of three men manhandling a passive female model as long as the men are using ‘physiotherapeutic techniques’”
Admittedly, it had been years since I looked at the APTA’s Code, and the irony was not at all lost on me after looking at watching the video Eric Kruger shared; the code lists as its values: compassion, integrity, altruism, professional duty, excellence, social responsibility and accountability. I (too) fail to see any of these values represented in the video linked, but wonder how we standardize the values of each respective therapist, and how does the therapist balance their own values against those of each individual patient? Is there a way to determine whose values are most ‘righteous’?
Would it be more fair to directly question (assault?) the values of therapists, less the ethical guidelines they are supposed to adhere to?
Thank you, Dave – you are doing a lot of good work here, sir. It is very much appreciated.
Respectfully,
Keith
Hi Keith
Thanks for the fantastic, considered comments on my blogpost. You raise some really good points here.
I can see why it might seem like I was setting up a straw man argument. I suppose this is part of the problem of blogposts, where a lot of the detail and complexity is assumed, and there isn’t the room to make long-form arguments. (Well, there is, but not many people would read it!)
I suppose my comment about blind faith related to three things: the relative lack of engagement with ethics in the physiotherapy literature (excepting the work of Delaney, Edwards, Gibson, Hudon, Praestgaard and a few others); the homogeneity of ethical guidelines produced by our regulatory authorities; and the struggles many humanistic educators have in establishing a strong ethical position in their physiotherapy curricula.
My argument is really that physiotherapists can comply with current ethical guidelines and still practice in ways that are dehumanise and dispassionate. Our ethical guidelines emphasise the same kinds of reductive, objective thinking that has a long history in the west, and there is a powerful connection between these modes of thinking and historically ‘rational’ modes of oppression.
Ethics based on dominant truths are used by people all the time to assert powerful social positions at the expense of other, oppositional viewpoints. Naturally, these dominant positions are bolstered by ethical guidelines that codify and justify their conduct. The critical feature of ‘western’ ethical frameworks is that they are putatively based on reason and logic, and are therefore un-contestable. This holds if we believe that reason and logic are absolute and totalising, but many now hold the view that they are historically contextual social constructs, and are amenable to deformation and change. Murray and Holmes make this point much more elegantly in their book Critical Interventions in the Ethics of Healthcare, which is very much worth the read.
So yes, I do believe that more than merely ignoring abuses, the guidelines make abuses possible. This is a perverse situation, because the people who design our ethical guidelines are undoubtedly acting in good faith. But one only has to look at the lack of widespread critique of videos like the one Eric posted up (and there are literally thousands of others like it), to know that physiothearpy does not see these as intolerant. Surely that must make us ask where our ethical compass is pointing in the right direction, or maybe it is and the majority of the profession are happy with the idea of treating the body-as-machine?
“I suppose my comment about blind faith related to three things:…(3) and the struggles many humanistic educators have in establishing a strong ethical position in their physiotherapy curricula.”
The third of your points related to “blind faith” stuck with me (not that the others were lacking)- Admittedly, I am not well-read in the history of ethics of medicine, or PT in particular; as your average bloke working in the US, I (as my previous reply might indicate) lay much of the problems observed in the video on the feet of academics who are not able (interested?) in graduating informed clinicians who are humble and inquisitive with an appreciation for the complexity of the therapeutic encounter but instead teach/preach of a rather mechanistic view of the person receiving “care”. As I have no connections in academia, I would be fascinated to understand the challenges that ‘humanist educators’ face in their efforts to yield influence PT curricula.
“Surely that must make us ask where our ethical compass is pointing in the right direction, or maybe it is and the majority of the profession are happy with the idea of treating the body-as-machine?”
I appreciate your position, but fear that my own experiences with clinicians in the states differs greatly from what you present here. Perhaps the logical and scientific modes that you write of in the formulation of these inadequate guidelines are somehow implicit, but I can count on my hands the number of PTs who even consider the ethics of how they handle/interact with patients, and I have only met them online, never in the workplace. Obviously, even fewer engage with the literature (related to ethics) to the extent that you have illustrated here. In my estimation, the idea of treating the body-as-machine remains overwhelmingly pervasive, and even those who tip their hat to psychology and neuroscience still consider their hands to simply serve as an input into a mysterious black box.
I am pondering the premises laid out in the intro text you linked above. It makes me wish that I had pursued philosophy in my more formative years as I often need to re-read material that comes much easier for others to engage with.
Your engagement is valued – thank you.
Hi Keith.
I wouldn’t say your experiences of practice are that much different to those I know of, particularly in New Zealand, Australia and the UK. I also think that most of the people in the other 25 or so countries represented in the Critical Physio Network (CPN) would say the same. This is one of the reasons for embarking on a rather ambitious book project that I hope to have ready this time next year. To my mind, the problem is so deeply rooted in the structure and design of the profession that it seriously threatens our future viability (hence part of the reason for titling the book ‘The End of Physiotherapy’). I do believe though that we have to become a little more sophisticated in our analyses and recognise that alongside the problems, there are many benefits to us treating the body-as-machine. If this weren’t the case, we wouldn’t still be doing it.
My hope is that the people who come together in the CPN bring some critical insights to bear on our practice; recognising what is amazingly good about the physical therapies, and at the same time opening doors to the possibility of thinking otherwise.
The ‘tag line’ for the CPN is ‘A positive force for an otherwise physiotherapy’ and I think that beautifully captures what we would like more people to be doing in the profession.
Once again, thanks for your thoughtful and dynamic comments Keith.
Dave