Ethical Reasoning

I was having an interesting conversation with a colleague yesterday about what the most important ethical issues are in occupational therapy practice. A number of ideas were tossed around eg. does the usual list (eg autonomy, benificience etc. as described by Barnitt, 1993) set us up for a rather carefully measured approach to this topic and a non-interactive responsiblity ie. doing the right thing for the right reason but not necessarily connecting with the person you are working with. Perhaps another major issue is what happens when you  cannot / do not proceed with your input – should you have started in the first place? I would be intereseted in comments on this – what are your ethical dilemmas in practice? Can they be addressed by Barnitt’s list of ethical dilemmas? As she says: ‘what give you sleepless nights’? another way of thinking about it might be ‘what makes you feel really proud of your practice’?  Mary Butler’s comments on ethical reasoning should be of interest (this is who I was talking too!)

Mary raises the issue of moral responsibility (see comments) I wonder if this is an old fashoned notion of professionalism. In the current climate our employers want  technical expertise as a measure of doing a good job (eg. outcome measures) rather than the non-specifics of a moral position. Besides everyone has different moral standpoints – what might be wrong for me could be perfectly OK for you. As for thick and thin relationships – seems odd to equate relationships with our clients to those with our family (ie. thick relationships). That aside, is our human response to another person the guiding principle in ethical reasoning?

Just came across another OTs ‘take’ on an ethical dilemma. This was about whether or not it was ethically OK to treat someone who has a hand injury and stated his goal was to gain enough function to punch his rival. If you go down the route of believing that the clients goals are central to OT practice, then there is always the possiblity that you might not agree with the client’s aspirations.  The question is what do you do? Refuse to treat the client? Try to change his/her goals? Move to a  new area of work to avoid personal conflicts? Such a situation may not be unethical for a different therapist.

Teaching Ethical Reasoning:

“A central theme of ethics education is the uncovering of multiple social contexts that influence practice, and the acknowledgment that individuals may behave in ways that are inconsistent with their basic beliefs, depending on the context in which a situation occurs (Lewins 1996). Ethics education needs to consider these social contexts and locate ethical dilemmas within legal, political, economic, social and organisational spheres. It is particularly important for ethics education to focus on the organisational interface, as this is the area in which many ethical conflicts are experienced. If social workers are to uphold their ethical responsibilities to challenge unjust and oppressive structures and to operate from a standpoint of social justice, then as students, they need to be taught the skills to effectively advocate on behalf of clients and use appropriate ethical decision-making processes. The educational process needs to incorporate a strong focus on exploring and challenging personal and professional values with a view to students taking ownership of these values in the interests of ethical practice and accountability. ”

This it taken from the an article about Social Work ethics education.  The issues seem very similar to those experienced by occupational therapists – multiple social contexts and needing to work within social / political contexts that might appose professional ethics.

Empathy & Moral Practice

I was reading literature from nursing re empathy and was interested in their observations and in particular the relationship to moral aspects of practice. This link is strongly promoted by Reynolds et al (2000). Points made include that the sensitivity to the person and to their perspective is highly relevent to the moral domain of practice. Empathy, she says, “is central to accurate moral perception, moral judgement and moral action”. One central question is ‘what is empathy’? For instance is it an aspect of personality, an emotion that can be experienced or is it an observable skill? Is empathy necessary to be therapeutic?  There are said to be 3 components of empathy – cognitive (ability to identify and understand anothers feelngs), behavioural (ability to convey understandings of anothers perspective) and therapeutic (ability to take appropriate action).

Reynolds then goes on to discuss barriers to empathy and a course that taught empathy. The empathy scale used could be of value. However its worth while looking at how health professionals understand empathy. Kunyk & Olsen (2001) provide an overview of nursing perspectives and identify 5 ways of conceptualising empathy. These are

• empathy as a human trait:  culturally conditioned; possibly innate and cannot be taught.
• empathy as a professional state: a learned penomenon, clinical, therapeutic based on choice of response. Can be nurtured through cognitive development and personal growth.
• empathy as a communication process: results of this is that the client feels understood. Based on innate abilities, becoming more sensitive to others feelings and learned ways of responding helpfully to  peoples expressions of feelings. (seems similar to the OT communication course)
• empathy as caring: the outcome is action ie. clients physical and emotional needs are met.
• empathy as a special relationship: implies a reciprocal relationship, friendship.

This summary of the nursing literature is likely to represent discrepancies in the use of the term empathy in OT. Although I suspect that we more commonly refer to client centered practice rather than empathy. The different modes of empathy could also be related to ‘thin’ and ‘thick’ relationships that Mary refers to in her comments.

Reynolds, W., Scott, P. A., & Austin, W. (2000). Nursing, empathy and perception of the moral. Journal of Advanced Nursing, 32(1), 235-242.

Kunyk, D., & Olson, J. K. (2001). Clarification of conceptualizations of empathy. Journal of Advanced Nursing, 35(3), 317-325.

Clinical Reasoning – an introduction

Hello to those who make it to this blog. I teach a post graduate paper in clinical reasoning and have set this blog up primarily for the occupational therapy students in Otago, New Zealand. However, I am happy to have comments from anyone interested – the more the better. This is intended to be an informal dialogue about clinical reasoning.  The various pages provide some information about specific topics – they are not intended to cover all the information about these topics – rather to stimulate discussion.

Although not a requirement, I suggest that you make an attempt to purchase / read this book: Clinical Reasoning: Forms of Inquiry in a Therapeutic Practice by Cheryl Mattingly & Maureen Hayes Fleming (available from Amazon)

Just been having a few thoughts after the teleconference tonight.  One group brought up the idea of reasoning related to working as a consultant in a work assessment situation. The outcome being that the work environment is modifed suitably in order that the client can get back to do their job. Is this conditional reasoning though? It had a very procedural feeling ie. the alternations were made in response to deficits which is the heart of prccedural reasoning. Now, if you were looking at issues in the life of the person beyond the immediate work environment and were taking into account how they viewed their situation – their hopes and aspirations, then you may well be moving into both interactive and conditional reasoning.

Another confusing aspect can be the client who is seen to have little ‘insight’ – if they seem unable to imagine their future in some realistic way does this mean that conditional reasoning is abandoned in favour of a more procedural approach_ ie. where the therapist who is aware of the potential risks in the situation makes decision on their behalf.