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.
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.