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.
March 7, 2008 at 12:49 am
Sorry this is not exactly giving you stories Linda, but it extends our discussion from yesterday.
I believe that ethics is at the heart of occupational therapy. In this I tend towards Margalit’s definition of ethics as the area that deals with thick relations and morality as that which deals with thin relations. He defines these as following: “Thick relations are grounded in attributes such as parent, friend, lover, fellow-countryman. Thick relations are anchored in a shared past or moored in shared memory. Thin relations, on the other hand, are backed by the attribute of being human. Thin relations rely also on some aspects of being human, such as being a woman or being sick. Thick relations are in general our relations to the near and dear. Thin relations are in general our relations to the stranger and the remote”. I cannot completely agree with Margalit that the boundaries between thick and thin relations are this clear. As professions who profess to care our work necessitates us to have thick relationships with our clients, and the system we are working within means that thin relationships are all that seems possible. The core of occupational therapy requires that we behave ethically towards people, yet morality is as much as our employer can expect of us.
In listening to our clients we begin to hear a challenge to go further than the system we are working in might permit. In my study of carers of people with severe brain injury this challenge was articulated very clearly. This was from a mother who had been through fifteen years of caring for her son with severe brain injury. As an experienced carer she said of all the professionals that she came into contact with “nobody every stuck their neck out for us….. most people are only assessed for services that are already available. This means that not only did we fail to get what we need at the time, but also there was no ongoing record being made of services that were needed which did not already exist”. We know too many stories of our failures. We hear it in that carer’s voice. We can also see it in the badly designed ramp for the person with huntington’s chorea (a story I heard two days ago), where the therapist failed to listen to the client or even begin to predict what her future needs might be; we can see it in the punitively small shower that is fitted for overweight client with muscular dystrophy (one of my experiences of “following on” from another occupational therapist); These are stories of occupational therapists who have failed ethically, yet who have acted with an approximate form of morality.
How can we bring the ethics of thick relationships into the workplace? Levinas talks about how we are absolutely obliged to do everything that we can for our neighbour, what he calls “the face”. However, in dealing with multiple others we begin to approach the task with organisational efficiency. This is necessary for the sake of justice, because, as Levinas points out, justice imposes a limitation on one person’s obligation to the face of the other. He believes that the implementation of justice requires the intervention of the state, and this has brought about much that is good in our permutations of the welfare state. Yet the fate of the therapist in this system is to always have a “bad conscience” (194) The two essential questions for us as occupational therapists and as human beings are: how can we preserve our own humanity? How can we preserve the humanity of those we serve. These two questions are interconnected. We need to honour the suffering of those we work with, even if we cannot help in any other way. As Levinas put it “what then does one seek? Not a hidden power, but a source of kinship for mature persons. Also the assurance that it is not totally absurd to have suffered”.
Resource constraints are usually given as the reason for not behaving ethically, with this sense of kinship with mature people. Victor Frankl, facing the bureaucratic brutality of the Nazi concentration camp, in conditions of the most overt physical brutality said “there were always choices to make. Every day, every hour, offered the opportunity to make a decision, a decision which determined whether you would not submit to those powers which threatened to rob you of your very self, your inner freedom; which determined whether or not you would become the plaything of circumstance, renouncing freedom and dignity to become moulded into the form of the typical inmate”. It may seem extreme to compare the bureaucratic systems within which we care to the horror of the concentration camp, yet his dilemma and response essentially echoes that of anyone trying to survive and care in a large and bureaucratic institution.
In behaving ethically it is first necessary to appreciate that the caring professional is as demoralised and dehumanized as the person they are working with. It manifests in different ways, the patient has the suffering created by the disease and the systems that are intended to help. The caring professional faces their own helplessness in the face of suffering the constraints that the system puts upon their good will. An ethical response requires something like what the mother of one young man with a brain injury called “answerability” which is “…each person’s obligation first to imagine what another is going through and then to answer, with his or her own life, for what he or she has experienced, so that what has been witnessed and understood will not remain ineffectual” (p.195).
Frank talks about the ethical project as one of “the renewal of generosity”. The ethical project for occupational therapists is not about addressing our failures, because I don’t think that there is much to be learned from them. However, examples where therapists have “stuck their necks out” have a huge amount to teach us about the issues that arose through that action. I think that in telling these stories we can begin to explore the boundaries and possibly even challenge them. They can certainly extend our thinking about the way that ethics is embedded in our practice.
Frank, Arthur W. 2004 The renewal of generosity: illness, medicine, and how to live. The University of Chicago Press.
Frankl, Victor. 1992 Man’s search for ultimate meaning. Boston: Beacon Press
Johansen, Ruthann Knechel 2002 Listening in the silence:seeing in the dark. Reconstructing life after brain injury. University of California Press: Berkeley, Los Angeles.
Emmanuel Levinas. Is it Righteous to be? Interviews with Emmanuel Levinas, ed. Jill Robbins (Stanford, Calif: Stanford University Press, 2001, 180
Avishai Margalit 2002 The Ethics of Memory. Harvard University Press: Cambridge, Massachusetts.
March 7, 2008 at 3:56 am
Hi Linda, just passing by. I thought my eye sight was good but I can hardly see the font, its so small. have fun with this blog. Cant think of anything controversial to say! Sarah (a midwife who has lots in common with OTs)
March 7, 2008 at 7:47 am
Sarah -
In Explorer, use View>Text size>Larger, or in Firefox use View>Text size>Increase to make the text bigger.
March 16, 2008 at 2:25 am
This contribution is from Sian Griffiths who was unable to access this comment box:
A lot of this depends on how we view ourselves and our own personal paradigms, beliefs and values, when it comes to morality and ethical reasoning.
My moral code may be different to that of another person, if I follow my moral code will I be behaving morally? I will believe I have done the “right” thing and will sleep at night. Taking the example of the ramp and Linda’s doing the right thing for the right person (but not connecting with that person) The idea of “right” belongs to whom? the therapist or the client? As a therapist I am called to a home to see a client in a wheelchair. The client has had a bilateral amputation and I follow all the assessment protocols to the letter about range of movement and postural control and follow the guidelines regarding the design of the ramp. I can go away in the belief that I have done the right thing; I have been good, the person should be safe and can use the ramp, and therefore I have behaved ethically.
Yes but as an occupational therapist you would not do that you say ; you would of course also consider what the client, family etc want. This is what Linda was suggesting, but I have to believe that this client (all clients) will be different to all the other clients, are the guidelines not right? You believe I should have had a different moral code and by measuring my activity by your moral code I would not have behaved morally. The idea of “right” here belongs to who?-(I think this takes us into applied, normative and descriptive ethics).
Are we looking for an objective justification a moral realism – that there is an objective right moral code? or do we hold to a view of moral relativism, that moral or ethical positions are relative to our social, cultural or personal circumstances.
April 2, 2008 at 9:57 pm
In relation to the ramp, in the example let’s suppose that the ramp was built to specifications. However, the point being made by the person telling the story was that the husband was a builder and he could have done a good job. This would have engaged him with his wife’s condition and it could have been an exercise that brought the family together. In collaborating to design and build a ramp for his wife the therapist might have been able to move into realms of education and family therapy that are not accessible through a straight compensatory approach.
We can all understand that this might have been “impossible” for a therapist going through the contracting procedure. However, I imagine that in the past no occupational therapist worth their salt would have missed an opportunity like this. This brings me to my point. Occupational therapy is more necessary than ever when care is bureaucratised. An essential ethical dilemma is one where the whole meaning of our practice is threatened. In the ramp example the occupational therapist was not able to obtain the full therapeutic benefit possible from the building of the ramp. This was an ethical dilemma, even if she seemingly did a good job of the ramp.
It may not be possible for us to challenge the system single-handedly. Yet as a humanistic enterprise our validity as occupational therapists rests on the possibility of generousity. Taking the time can be subversive if there is a possible cost to the therapist in terms of falling behind with assessments and reports. There would be consequencces to not using the “right” contractors. There can be real impatience in a team when one person takes the time to talk to people, leaving everyone else to “carry the can”. There is another level of pressure that comes from “life”, when the children are at home without their mum who is being an ethical therapist.
Efficiency is the highest virtue in a bureaucracy. We need to think carefully about the value of being a human being in this context, for the sake of our patients and for our own sakes. I think that occupational therapy at its best is made up of small acts of subversion. This is why I ask the question, “can you think of a time when you stuck your neck out for a patient/client?” What were the benefits to your sense of yourself as a therapist (and human being)….what difficulties were presented by the institution to this small act of subversion? Another way of saying it might be “what supports and what does not support an occupation frame of reference?”
April 11, 2008 at 1:30 am
Hi Mary, You say that “An essential ethical dilemma is one where the whole meaning of our practice is threatened”. I wonder how often I hear about such threats from therapists when for instance they cannot work in a client-centred way because of the environment. Maureen Firtzgerald said in the response on the Canadian site (sorry you don’t have access to this!) that there are different versions of client-centred practice which is an interesting thought. Generally there is a lot of frustration with the boundariess set by the sytem that prevent OTs working in their preferred (ideal?) way. I like the idea of small acts of subversion – is this a constant reality? In which case it will be qite an exhausting process. Why can we not influence the environment to be more consistant with our ‘way of working’?