This is the second post from Cath Cruse-Drew.
It strikes me that at its root, Physiotherapy codes of practice in the UK contain more than a passing resemblance to Kantian moral theory.
Adhering to a rule-based code, the principles governing our practice underline the obligation to observe laws and regulation, to take responsibility, and therefore to be accountable for one’s actions in the expression of one’s duty of care; to act with integrity, honesty and openness (do not lie); to respect and support individual’s autonomy (dignity) and to strive for excellence. The code is necessarily abstract, but from it the implication is that judgements, about what is right and wrong in our clinical and personal behaviour, can be drawn. This in turn lays claim to a kind of moral authority on the part of those writing, enforcing and adhering to ‘the code’. Do principles become prejudices despite the support of a moral theory and a well-constructed argument? This requires thought, challenge and justification in equal measure.
The invention of a moral standard, ‘truth’, or authority could be seen to be undemocratic, a form of medical arrogance and a failure to reflect diversity. Thus, our code might reflect the values of the members of our professional bodies, but not the populations we serve. However, this relativistic point of view could result in a code so broad it might allow practices that were harmful or unfair, without means of redress. Given that, rightly or wrongly, UK Physiotherapy is largely an individualised, customised, rights-and-duty based profession, how does it fit into a resource-scarce system which tries to achieve the greatest welfare for the majority of its population? UK Public Health Policy is often embedded in these Utilitarian principles, where someone, somewhere will suffer for the benefit of someone else because there simply isn’t enough money to go around. What happens when these moral theories clash? I suspect that our innate moral opinions, which perhaps attracted us to a Physiotherapy career in the first place, have been endorsed by codes of practice learned as students and consented to when fully fledged members of professional bodies. It’s little wonder then, that in the workplace here, Physios can feel indignation, confusion, anxiety and everything in between, at the injustices of policies for their patients. Even John Rawl’s theories of justice do not seem to provide us with a clear answer. His idea of a reflective equilibrium in which ‘competent moral judges’ re-examine and revise principles as a form of justification are open to the same criticisms about moral authority that we first started with.
While there isn’t going to be an answer anytime soon to settling the differences between moral theories in health care settings, studying them has certainly helped me to reconcile some of their tensions by recognising when and where clashes appear; to challenge my own moral psychology and its effect on patients, families and colleagues; to question received wisdom and inherited professional identity and to hopefully get better at steering a course through the moral quagmire that surrounds healthcare.
It would be great to hear your own experiences wherever you are practicing in the world.
Ashcroft RE, ‘Could Human Rights Supersede Bioethics?’ 10 Human Rights Law Review 639 (2010)
Kant I, Groundwork of the Metaphysics of Morals (Start Publishing LLC 2013)
McNamee M and Schramme T, ‘Moral Theory and Theorizing in Healthcare Ethics’ [Springer] 14 Ethical Theory and Moral Practice 365 (2011)
Toulmin S, ‘The Tyranny of Principles’ 11 The Hastings Center Report 31 (1981)