ETHICS IN HEALTHCARE SETTING (THERAPY) 1

Ethics in Healthcare Setting (therapy)

Name

Institutional Affiliation
ETHICS IN HEALTHCARE SETTING (THERAPY) 2

Ethics in Healthcare Setting (Therapy)

Ethical dilemma

The client a 19 year old Chinese female has been diagnosed with a mild learning

disability with a little bit of developmental delay. She came for the therapy planning session but

her goal and that of her caregiver (the father) differ due to the fact that the caregiver wants

occupational therapy that is based on telerehabilitation while the client wants non-technology

clinic based one on one session with a therapist. After turning 19 years she is now legally an

adult and would like her to have more influence in the direction of her therapy. She wants to

stick to her choice or otherwise forego therapy. Coming from a Chinese family the culture is

patriarchal in nature with the father having a lot of say in family member’s decisions including

health. The client has come for her first session and both she and the father strongly express their

different wishes for the intervention paths.

Client’s goal is to improve nonverbal communication skills (body proximity, tone and

loudness of voice, body language and posture, and facial expressions) so that she can start a part-

time job. The client’s father heard from a close friend that telerehabilitation works and he insists

on this though due to lack of enough medical background knowledge he fails to understand that

it might not work for his daughter. According to the therapist, the telerehabilitation might not

work for nonverbal communication skills/ social skills. Nonverbal communication skills training

may best be addressed through one on one session in the clinic (Kavale & Mostert, 2004).

Telerehabilitation has been shown to have the following advantages: easy access to services,

better clinical support and educational benefits (Castillo & Hilkey, 2004; Cason, 2014; AOTA,

2016).

Despite the efficacy of telerehabilitation the choice presents with several ethical issues.
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The fathers request is impacting the principle of autonomy which gives the client the right to

make decisions about their own care (Perry et. al., 2009). The therapist is required to ensure that

the client makes a written voluntary informed consent without duress from the father. Cultural

factors are also in play especially the issue of social stigma and patriarchal decision making. The

father may prefer to treat his daughter from home because of the stigma associated with mental

illness in the Chinese community (Yang et. al., 2013). Further to this patriarchal culture is in play

with a male family member being the head of family and consequently having the final say in

family decisions including the health care. The father may feel he is just fulfilling his familial

duty.

An ethical dilemma is occurring because the therapist has to select from two intervention

options the client’s choice, the father’s choice or a possible alternative choice. The therapist has

to select from: option one client uses clinic based one on one therapy sessions option two client

uses telerehabilitation for therapy option three is home therapy without technology initially but

slowly expose client to technology. The dilemma is that selection of any of the listed options

compromises an ethical principle represented by the other alternative options.

Possible options and ethical schools of thought

Three possible treatment options are: option one client uses clinic based one on one

therapy sessions option two is client uses telerehabilitation for therapy option three is home

therapy without technology initially but slowly expose client to technology. Decision on

interventions will now be evaluated using deontological, consequentialist and virtue theories

which result in different choices (See Table 3 and Table 4 in appendix).

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Bioethical Principles and the Stakeholder Roles

Bioethical principles that are applicable in occupational therapy practice and intervention

selection include: beneficence, nonmaleficence, utility, respect for person, truthfulness, fidelity,

confidentiality, non-comparative justice, universality and autonomy (AOTA, 2015).The priority

principles at play in this ethical dilemma are beneficence/non-maleficence, truthfulness and

autonomy (AOTA, 2015). Stakeholders are each impacted by the principles in different ways as

summarised below. Further summary is found in table 2 in the appendix.

Table 1

Bioethical Principles

PRINCIPLE RATIONALE/EXPLANATION

1. Beneficence/ Beneficence requires that therapists to show concern for the well-being and

Nonmaleficence safety of clients who receive their services (Beauchamp & Childress, 2013).

All therapists’ actions should benefit the client through doing good with the

therapist acting for the best interest of the client (AOTA, 2015) Closely

related to beneficence is nonmaleficence which requires the therapist to do no

harm the therapist must use professional judgment to analyze and minimize

harmful procedures that the client may be exposed to (AOTA, 2015). The

clinic based one on one therapy option will be beneficial because it will fulfill

the client’s desire and will up hold the principles of client centered care

telerehabilitation may not benefit the patient as her decision will have not

been implemented, option three will benefit the client and the father in terms

of strong family relations (Perry et. al., 2009). In terms of maleficence clinic

based one on one individual therapy option may result in a narrowed skill set.

Option two the use of telerehabilitation may reduce the client’s level of social

contact option three does not respect clients wishes. Regarding stakeholder

roles in terms of beneficence and non-maleficence the client, the father and
ETHICS IN HEALTHCARE SETTING (THERAPY) 5

the therapist want care options that are beneficial to the client and do no harm

to the client.

2. Truthfulness Truthfulness requires that the occupational therapist shall provide the client

with accurate comprehensive and objective information as a representative of

the profession (AOTA 2015). Transparency requires the therapist to provide

the client with full disclosure about the benefits and risks of the all the

available interventions with reasons to undertake or not undertake a selected

intervention (AOTA, 2015). Vulnerability is applicable to clients with

disabilities especially the pressure they may feel to try out new technology

and telerehabilitation interventions with the hope that one will work. Clients

and caregivers must be able to trust in the honesty of the client-therapist

relationship with the therapist endeavoring to provide factual information at

all times (AOTA, 2015). Clients and the father will expect full disclosure of

information from the therapist about the type and duration of interventions

and also any adverse events to be expected.

3. Autonomy This principle requires occupational therapists to respect the right of their

clients to privacy, self-determination, consent and confidentiality (AOTA,

2015). This means that the occupational therapists are required to treat the

client according or her desires based on the accepted standards of care and

ensure that the client’s confidential information is protected. It also involves

more that acknowledging the client as a mere agent but realizing that they

have rights such as having personal views, choice and taking actions that are

based on these beliefs, opinions and values (AOTA, 2015). Autonomy is

valued by all the stakeholders but to different degrees the client and the

therapist value individual autonomy but the father values collective autonomy

based on familial ties.

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Resolution of ethical dilemma

In this case deontological ethics will be used to make the decision (Baumane-Vitolina,

Cals, & Sumilo, 2016). AOTA principles and standards of ethical practice will also apply with

the decision based on autonomy (AOTA, 2015). The duty of the therapist is first to the client

therefore the client’s autonomy is at the core of this decision. The client’s choice of clinic based

one on one therapy was thus selected. The decision is based on autonomy standards that require

respect for the expressed wishes of the client, voluntary informed consent and client education

on benefits, risks and outcomes of intervention. At the same time the principle of autonomy also

calls for collaboration of stakeholders. The therapist will make a concerted effort to incorporate

the father in the care through caregiver education. He will be educated about the benefits of

implementing his daughter’s choice, the role he will play and also what progress to expect. The

occupational therapist will take into account the culture of the client in this case it’s values are

based on family therefore the therapist will work with the father who is the decision maker in the

family to get his support for the treatment and also keep him appraised of the treatment process

and outcomes whenever possible (Yang et. al., 2013). AOTA ethical principle 3 of autonomy and

standard B requires establishment of a collaborative relationship with clients and relevant

stakeholders to promote shared decision making (AOTA, 2015). Based on this the therapist will

endeavor to incorporate the father as part of care.

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References

AOTA. (2015). Occupational therapy code of ethics (2015). American Journal of Occupational

Therapy, 69.

AOTA. (2016). The American Occupational Therapy Association Advisory Opinion for the

Ethics Commission Ethical Considerations Relevant to Emerging Technology-Based

Interventions. Retrieved from https://www.aota.org/-

/media/corporate/files/practice/ethics/advisory/telehealth-advisory

AOTA. (2010). The American Occupational Therapy Association Telerehabilitation Position

Paper. Retrieved from https://ajot.aota.org/article.aspx?articleid=1865191

Baumane-Vitolina, I., Cals, I., & Sumilo, E. (2016). Is Ethics Rational? Teleological,

Deontological and Virtue Ethics Theories Reconciled in the Context of Traditional

Economic Decision Making. Procedia Economics and Finance, 39, 108-114.

Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics. Oxford University

Press, USA.

Cason, J. (2014). Telehealth: A rapidly developing service delivery model for occupational

therapy. International Journal of Telerehabilitation, 6(1), 29.

Castillo, R., & Hilkey, J. (2004). Assistive Technology for Individuals with Learning

Disabilities: Through the lens of Occupational therapy practice framewok: Domain and

Process. AOTA Continuing Education Series, 1-8. Retrieved from www.aota.org

Kavale, K. A., & Mostert, M. P. (2004). Social skills interventions for individuals with learning

disabilities. Learning Disability Quarterly, 27(1), 31-43.

Perry, J., Beyer, S., & Holm, S. (2009). Assistive technology, telecare and people with

intellectual disabilities: ethical considerations. Journal of Medical Ethics, 35(2), 81-86.

ETHICS IN HEALTHCARE SETTING (THERAPY) 8

Tanner, K., Hand, B., O’Toole, G., & Lane, A. (2015). Effectiveness of Interventions to Improve

Social Participation, Play, Leisure, and Restricted and Repetitive Behaviors in People

With Autism Spectrum Disorder: A Systematic Review. American Journal of

Occupational Therapy, 69(5), 6905180010p1. doi: 10.5014/ajot.2015.017806

Yang, L. H., Purdie-Vaughns, V., Kotabe, H., Link, B. G., Saw, A., Wong, G., & Phelan, J. C.

(2013). Culture, threat, and mental illness stigma: identifying culture-specific threat

among Chinese-American groups. Social science & medicine, 88, 56-67.

ETHICS IN HEALTHCARE SETTING (THERAPY) 9

Appendix

Table 2

Summary of bioethical principles

PRINCIPLE RATIONALE

Dominant Highly dominant

Principles
4. Beneficence/ Focus on action that is good for the health and welfare of the
Nonmaleficence patient/Do no harm whether intentional or unintentional
5. Autonomy Each person reserves the right to exercise their autonomy and
should be allowed to make informed choice about care
6. Truthfulness Clients should be told the truth at all times even if it is
uncomfortable
7. Other (Still applicable but less dominant in the above scenario)
important
principles
8. Utility Therapist should select interventions that promote greatest level
of happiness while minimizing unhappiness for stakeholders
9. Fidelity Therapist is required to respect and uphold integrity of
professional standards based on virtue of caring interventions
should be based on professional standards.

10. Confidentiality The client’s clinical information should only be shared with
legally authorized users to maintain client’s right to privacy.
11. Non-comparative The therapist should treat the client according to their rights and
Justice what they are entitled to in terms of care.

12. Comparative The therapist should utilize the best way to distribute scarce
Justice occupational therapy resources with focus on optimum care.

Non applicable
principles
13. Universality A system of ethics can be applied universally for individuals
with similar situations. This may not be applicable to all
individuals as each client presents with unique needs as in the
case above.

Table 3

Intervention options and bioethical principles

 ETHICS IN HEALTHCARE SETTING (THERAPY)
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ACTION POSSIBLE OUTCOMES ETHICAL PRINCIPLES

THAT SUPPORT THE
ACTION
1. One-on-one session at the clinic Improved social skills for Autonomy
patient Beneficence
Patients choice is respected and
patient is happy
2. Telerehabilitation option Patient becomes techno savvy Non-maleficence
and father is happy
3. Home therapy without Creates a win win situation Truthfulness
technology initially but slowly patient benefits from continued
expose client to technology therapy and advantages of
technology.
Client is able to trust in
therapist as decision is based on
full disclosure.

Table 4

Summary of intervention options

Deontological Teleological/Consequentialist/Utilitar Virtue

Deontology. Deontological theories
state that the morality of an action is
based on the agent’s intention and not
the consequences of the action
(Baumane-Vitolina et. al., 2016).
Option based on deontology is as
follows therapist will implement the
client’s demands of one-on-one session
at the clinic. The caregiver will be
informed that client may not benefit
from tele-rehabilitation in order to
prevent her from dropping out of
therapy as therapist believes that the
client has a potential to improve as long
as she is in therapy
ian
Consequentialism. Consequentialist
theories determine the morality of an
action based solely on the outcomes of
an action either positive or negative
(Baumane-Vitolina et. al., 2016).
Option based on consequentialism is as
follows client will be convinced about
the pros of technology and tele-
rehabilitation although risk losing her if
she chooses to forego therapy with the
final positive outcome being a
harmonious family and a convinced
and functional client.
Virtue. Virtue ethics determine
morality by focusing on the person and
not his actions. The focus on virtue
ethics is the individual’s behavior in the
workplace and his intentions
(Baumane-Vitolina et. al., 2016).
Option based on virtue ethics is as
follows home therapy without
technology initially but slowly expose
client to technology