R e f l e c t i v e A r t i c l e T e a c h i n g H e a l t h C a r e E t h ic s i n P h y s i o t h e r a p y E d u c a t i o n : P r o p o s a l f o r S o u t h A f r i c a A B S T R A C T : This p a p e r p rese n ts view s o f the role o f the p h ysio th era p y p rofession during the A p a rth e id era in South A frica. I t a n a lyses a sp ec ts o f the Truth a n d R e c o n c ilia tio n C o m m issio n d o c u m e n t a n d f i n a ll y s u g g e s ­ tio n s are m a d e to p r e v e n t s im ila r s itu a tio n s fr o m d e v e lo p in g e v e r again. K E Y W O R D S: ETH IC S, TEAC H IN G , E D U C A T IO N M0LAT0U HM ( NEE LEBELOANE) BSc (MEDUNSA), Dip.tert. Ed (UP) Department of Physiotherapy, University of Pretoria INTRODUCTION Throughout history, groups of health care professionals, including physiothe­ rapists form ulated ethical policies and declarations called The Code o f Ethics. The Code o f Ethics are self regulatory laws to guide practices and behaviours o f professional mem bers (Purtillo 1983; Engelhardt, 1996; Loewy, 1996). The Code o f Ethics has been influenced by m any issues such as religion, science and law. These have made it difficult to guarantee the interpretation and im ple­ mentation o f The Code o f Ethics in clin­ ical practice. This is due to the fact that health professionals are often reactive rather than pro-active in anticipating ethical issues. HISTORICAL BACKGROUND Since medieval times, religion has con­ tributed greatly to health care on issues such as charity, virtue and holistic heal­ ing. Religion, on the other hand, has also had a direct or indirect contribution to som e o f the m ost im m oral system s experienced in modern times. Examples o f these are the contribution o f the Dutch Reform ed Church to Apartheid in South A frica and the possible role o f the Catholic Church during the Nazi era. In m odern times, religion is still regarded as an important determ inant o f ethical behaviour and there is failure to recog­ nise that many influences, inspirations and beliefs have also guided good deeds in health care ( Loewy, 1996). As m edicine becam e m ore scientific, health care progressively becam e dom i­ nated by value free, objective and quan­ titative science. Moral beliefs had limited roles in shaping the future o f health care practice. E m phasis was given to the application o f scientific principles to cure disease and this led to the neglect o f the social context in which diseases take place. O ther role players becam e inter­ ested in health care and their interest was not only health but profits and political benefit, and they were w illing to achieve their aims at all costs (Callaghan and Bok, 1980; Engelhardt, 1996; Loewy, 1996 ). As health care professionals disen­ gaged them selves from social actions and health care delivery, politicians filled their places. Health care suffered from m oral neglect and this led to the exploitation o f health by political and legal disciplines to their own advantage. Ethics was reduced to law. The health profession failed to recognise that what is legal is not necessarily ethical but that ethics is the basis o f the law (C alla­ ghan and Bok, 1980; Engelhardt, 1996; Loewy, 1996). THE SOUTH AFRICAN CONTEXT A partheid was a socio- political and constitutional system based on deep racism that deprived black people o f respect and dignity o f person. It was system ic and institu tio n alised in all areas o f civic life and m anifested in health care as: v • rigid segregation o f health care faci­ lities • disproportionate allocation o f physical and financial resources In addition to the above, black pa­ tients were treated in overcrow ded and dirty facilities, resulting in a lack o f pri­ vacy and confidentiality. Professionals and personnel at health care institutions were expected to put the law and security o f the state ahead o f their ethical com ­ m itm ent to a patient’s well being. The Truth and R econciliation Com ­ mission (TRC) was set up by the dem o­ cratic South African government in 1995, with a m andate to exam ine “as com plete a picture as possible o f the causes, nature and extent o f the gross violations o f hum an rights”. The role played by health professionals in the creation and maintenance o f an environm ent in which hum an rights had been violated was also to be exam ined (P rom otion o f National Unity and Reconciliation Act 1995 3(1) (d)). The physiotherapy pro­ fession had an opportunity to m ake subm issions to the TRC, acknow ledging how they contributed to the creation and m aintenance o f Apartheid. The physio­ therapy profession identified the need to im prove the teaching o f health care ethics and educate physiotherapists on CORRESPONDENCE: HM M olatoli (nee Lebeloane) Faculty o f M edicine D epartm ent o f Physiotherapy U niversity o f Pretoria P.O. Box 667 Pretoria 0001 South Africa Tel: (012) 463-6734 E-mail: (012) linky@ m w eb.co.za SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 4 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:linky@mweb.co.za aspects o f human rights as one o f the most im portant issues to prevent future violations o f human rights in health care (Physiotherapy TRC submission docu­ ment 1998). THE TEACHING OF HEALTH CARE ETHICS The subject o f health care ethics does not enjoy the same attention and status as other scientific subjects within the health p ro fe ssio n a l’s education. The teaching o f health care ethics has always been eclectic, scarce and frequently placed at the periphery o f the medical curriculum ( Pond’s Report, 1987; Bur­ ling et al, 1990; A shcroft et al, 1998). In 1996 Lebeloane conducted a study on the status o f health care ethics at South A frican universities, the results showing that it is still in its infancy and taught at a very superficial level. There is a growing acknow ledgem ent that health care ethics has an important place within the education o f health care professionals. There is also a concerted effort by medical training institutions to formalise the teaching o f this subject. In Britain, the General M edical Council set up a com m ission in 1987 that produced the Pond Report. In 1998 another com ­ m ission made recom m endations on the content and the implementation o f health care ethics in medical training in the UK (Ashcroft et al, 1998; Pond Report, 1987). In A m erica, T he H asting C entre, an Institute o f Society, Ethics and Life Science em barked on a most extensive research project between 1977 and 1979. The aim o f this project was to assess the status, problems and possibilities asso­ ciated with the teaching of ethics in H igher Education. The report recom ­ mended that if any course o f ethics is to be held in high esteem , it should at least attend to five general educational goals (Callaghan and Bok, 1980). These are to: 1. stim ulate moral imagination 2. raise aw areness o f ethical issues, 3. develop analytical and communication skills, 4. improve tolerance o f ambiguity and diversity 5. elicit a sense o f moral obligation to social responsibility. S ince the mid 1970’s health care ethics has been gaining a high profile and becom ing more prom inent within the literature o f the nursing and medical professions. However, despite the con­ stant and ever growing attention given to this com ponent in clinical practice by other health care professionals, physio­ therapy continues to neglect to address the issue (G uccionne 1980; B arnit 1993; C law son 1994; Triesenberg 1996). The objective o f this review was to discuss the five general educational goals of health care ethics in relation to South Africa, with the hope that it will facili­ tate the discussions on education in South Africa and internationally. EDUCATIONAL GOALS OF HEALTH CARE ETHICS To meet the demand of society the goals o f teaching health care ethics have to meet the immediate and future needs o f the profession. They should be broad to include cognitive know ledge o f health care ethics, affective and directive skills. The five general education goals are hereby discussed in relation to health care ethics o f physiotherapy in South Africa. 1. To stimulate m oral im agination South A frica does not have a history of resp ect o f moral issues and rights. Students entering physiotherapy train­ ing bring divergent moral values in the form o f their individual character and p erso n ality traits. T h ese w ere shaped by their fam ilies, different cul­ tures and socio-political backgrounds. Physiotherapy training should aim at im proving the awareness o f students w ith regard to moral issues around health care, m aking them understand the relationship o f these to everyday human rights issues. There is an argum ent that morality cannot be taught and that the teaching o f health care ethics cannot reshape the student’s personality and ensure ethical practice in the future. However, there is no denying that students do not graduate with their character unaltered or m odi­ fied by their training. W hat is important to note is that students enter physiothe­ rapy training as lay people with their own attitudes and behaviours. Through edu catio n and socialisatio n the gap between personal and professional ethi­ cal fram ew ork is bridged. The teaching o f health care ethics is not to inculcate upon students moral beliefs nor to change their personal beliefs. However, physio­ therapy has an obligation to expose new m em bers to eth ical values that are consistent with their professional roles (Callaghan and Bok, 1980; Hafferty and Frank, 1994). It should also provide stu­ dents with insights and perceptions that reflect their personal and professional knowledge, behaviour and practice. 2. To raise an a w a re n e ss of ethical issues Moral behaviour and action involves recognition that a moral issue exists. Ethical dilem m as occur in everyday clinical practice and it is im portant that physiotherapists have the ability to iden­ tify and anticipate potential ethical con­ flicts (G uccionne, 1980; A ndre, 1992; B arnit, 1993). The TRC docum ent states that the physiotherapy profession lacked a cul­ ture o f hum an rights. It also gives the reader the perception that the South Afri­ can physiotherapy profession believes by virtue o f having not transgressed the code o f ethics o f the profession they were ethical in their practice. This is evident from the statem ent that “physio­ therapists adhered to ethical principles in the treatm ent o f their patients, but most did not think to challenge the requirem ents o f the apartheid era in respect o f separate w aiting room s and treatm ent areas and other areas o f petty apartheid” (Physiotherapy subm ission TRC docum ent 1998). The question we should ask of ourselves is how ethical was physiotherapy practice if it func­ tioned within the Apartheid system? For physiotherapists to practice in South Africa, their code of practice had to be aligned with the policies o f the country, which were immoral. These policies o f Apartheid transgressed all the basic principles o f health care ethics such as respect o f person, justice, confi­ dentiality and beneficience. The profes­ sion displayed in the TRC docum ent an inability to see the relationship between human rights and health care ethics, and that there was nothing “petty” about Apartheid. O ne m ay therefor conclude that physiotherapy practices were also unethical, be that intentional or uninten­ 8 SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) tional and the physiotherapy profession in South Africa therefor lacked aw are­ ness of ethical issues. The need to identify and clarify ethical issues within physical therapy practice increases as the profession assumes responsibility o f those areas o f direct domain... The physical therapist o f today in defining the limits o f his legal and professional autonomy must examine the practice o f his profession from an ethical point o f view (Guccionne, 1980). Barnit (1998) in a survey o f occupa­ tional therapists and physiotherapists identified 107 day to day ethical issues experienced in clinical practice. Unless physiotherapists are aware o f these ethi­ cal issues the profession will continue to have problems guaranteeing actions and behaviours o f its m embers in practice that are ethical and credible. M any authors (G uccionne 1980; Purtillo 1983; Clawson 1994; Triesen- berg 1996; Barnit 1998; TRC Physiothe­ rapy docum ent, 1998) have challenged the physiotherapy profession to prom ote and provide ethical education in physio­ therapy education. It is important that physiotherapy education ensures that future generations are aware o f ethical issues, will not claim sins of omission and lack o f knowledge about human rights abuses as an excuse for not stand­ ing up to be counted. It is important for the profession to restore its image and c red ib ility w ithin the country and internationally. Triesenberg (1996) said: ‘The integrity and diligence with which a profession examines its unique ethical issues, understands its ethical interac­ tion and develop method o f educating its students will largely determ ine the moral perspective o f that profession’ . 3 . To develop analytical an d com m uni­ cating skills Physiotherapists in South A frica were reluctant to respond to the TRC subm is­ sion document as they felt that there was no point in dwelling on the past (TRC document, 1998). Five years after the new dispensation, transformation of the pro­ fession is slow and very painful for some because there is still a reluctance to criti­ cally discuss the legacy of Apartheid in physiotherapy education and services, and to look at ways to facilitate change. Health care ethics m ust endeavour to equip students with skills to analyse, reason and handle ethical issue raised in practice in a way that will improve ethical judgem ent and quality practice (B urling et al, 1990; C hristakis and Feudtner, 1993; Kopelman, 1995). With­ out the ability to make ethical decisions, treatments by physiotherapists have the potential to jeopardise the professional credibility and advancem ent o f the pro­ fession (Carson, 1994). Physiotherapy practice m ost often brings into play different role players (patients, family, other staff members) with different expectations and with potential for conflict. Students need to have negotiation and interpersonal skills to distinguish between facts, opinions, values and reasoned arguments and in the process be able to justify their deci­ sions based on evidence and learn to defend their views and reasons. 4 . To im prove tolerance o f am b igu ity an d diversity In South A frica there has been a great evolution in the openess and ex p res­ sion o f diversity. This has placed great challenges on public, health care and training institutions, to accept that there are m any different races and not only one way o f expressing and appreciating the meaning o f life. This diverse society desires to be cared for by people who are sensitive, understanding and respect their various backgrounds and beliefs. By taking different points o f view into account students should be able to consider moral perspectives and under­ stand issues that cause moral conflict. These abilities will help them explore and define their own personal, social and professional values and their expecta­ tions o f others in health care. 5. To elicit a sense of m oral obligation an d social responsibility Physiotherapy p ractitioners in South A frica believe in a ‘hands o n ’ clinical practice where the patient’s social back­ ground is neglected (Physiotherapy TRC document, 1998). Their perception is fre­ quently that their moral obligation and responsibility is lim ited to individual patients only. They fail to recognise their responsibility in influencing the socio­ political processes that im pact on pro­ fessional practice. The profession needs to recognise that ethical issues and education do not only revolve around individuals. The profession has a responsibility and obligation to society to speak and p a rtic ip a te in d e c isio n s and issues that im pinge on its professional fields. Im portant issues in South A frica are: • Trade off between tertiary rehabili­ tation and com m unity based rehabili­ tation • A llo c a tio n o f re so u rc e s b etw een urban and rural sectors • A ccess and availability of physiothe­ rapy service in the public sector • A ccess and relevancy o f physiothe­ rapy education M orality dem ands that p h y sio th e­ rapists be prepared to stand up against social and political structures to oppose injustices and inequitable practice in health care. Students need to be exposed to com ­ munity issues that impact on health, such as poverty, lack of clean water and sanita­ tion, unem ploym ent and violence. They also need to interact with com m unities to understand how cultural and religious beliefs influence society in the way they define illness, suffering and disability. T hese will provide the students w ith opportunities to learn that health is not lim ited to disease and that there are other factors that im pact on disease and so influence the healing process. CONCLUSION The legacy o f apartheid in South Africa cuts deep w ithin the p h y siotherapy profession. Physiotherapists are facing a great challenge to bridge the gap between white and black professionals and in this way to unite the profession. W hite phy­ siotherapists may expect the profession to forget the past and to m ove forward b u t fo r th e b la c k p h y s io th e ra p is ts confession is not enough if it does not involve critical reflection and positive action to make amends. It is only when real change takes place within the pro­ fession that they will be able to let go and forgive. Education o f physiothera­ pists about human rights and ethical behaviour within the undergraduate cur­ riculum has been identified as one way SA J o u r n a l o f Ph y sio t h e r a p y 1999 V o l 55 No 4 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) o f achieving reconciliation and a sense o f unity. It is envisaged that education in ethics will ensure that future generations o f physiotherapists do not forget the past but will understand that rules should not be followed blindly. REFERENCES A sh c ro ft R, B aron D , B enatar S , B e w le y S 1998 T e a ch in g m ed ica l e th ic s and law w ithin the m e d ic a l e d u c a tio n : a m o d e l fo r the U K curriculum. Journal m edical ethics, 24, 188 - 1 9 2 A ndre J 1992 L earning to see: m oral grow th during m ed ica l training. Journal o f m ed ica l e th ic s,, 18; 142- 147 Barnit R 1993 W hat g iv e s y ou sle e p le ss nights? E th ica l p r a c tic e in O c c u p a tio n a l T herapy, B ritish Journal o f O ccu p a tio n a l Therapy, June, 5 6 (6 ), 2 0 7 - 2 1 5 Barnit R 1 9 9 8 , E thical d ilem m a s in o c c u p a ­ tional therapy and p h y sica l therapy: a su rvey o f practitioners in the U K N a tio n a l H ealth Service. Journal o f m edical eth ics, 24: 193 -1 9 7 B a y lis F, D o w n ie J 1991 E th ics ed u ca tio n for C anadian m ed ica l stu d en ts. A c a . M ed , 66: 4 1 3 -4 1 4 B u rlin g SJ; L u m ley JSP; M cC arthy L SL ; M ytton JA; N o la n JA; S isso u P; W illia m s DG; W right LJ 199 0 R e v ie w o f the tea ch in g o f m ed ical e th ic s in L on d on m ed ica l sc h o o ls . Journal o f M ed ica l E th ics, 16, 2 0 6 -2 0 9 C allahan D , B o k S 1 980 T h e tea ch in g o f E th ic s in H ig h e r e d u c a tio n . H a stin g s on H udson; H astin gs Center, N e w York C arson R 19 9 4 T e a ch in g e th ic s in the c o n te x t o f the m ed ica l h u m an ities. Journal o f M ed ical E th ics, 2 0 , 2 2 9 - 2 3 4 . C h ristak is D A , Feudtner C 1993 E thics in a short w h ite coat: T he ethical d ilem m a s that m e ­ d ical students confront. A ca .M e d . 68: 2 4 9 - 2 5 4 C la w so n A L 1 9 9 4 T he rela tio n sh ip b etw een c lin ic a l d e c is io n m akin g and eth ica l d e c isio n m akin g. P hysiotherapy 8 0 (1 ) 10-14 C u lv er et al 1985 B a sic curricular g o a ls in m ed ica l e th ic s. N . E n g l J. M ed , 3 1 2 : 2 5 3 - 2 5 6 E n g e lh a r d t H T 1 9 9 6 T h e F o u n d a tio n o f B io e th ic s. O xford u n iversity p ress, N e w York French S 199 2 H ealth care in M u lti -eth n ic so c iety . P hysioth erapy, 7 8 (2 0 ): 174- 180 G u c c io n e A A 1 9 8 0 E thical iss u e s in p h y sica l practice: A su rvey o f p h y sic a l therapist in N e w E n glan d . P h y sica l T herapy,6 0 : 1 2 6 4 -7 2 H afferty F, Franks R 199 4 T h e hidden curricu­ lum , e th ic s tea ch in g and the structure o f m ed ­ ical e d u ca tio n . A c a M ed , 11: 861 -871 L e b e lo a n e H M 1996 T he R e v ie w o f Ethics tea ch in g in P hysiotherapy sc h o o ls in South A frica , U n p u b lish e d L o e w y E H 199 6 T extb ook o f H ealth Care E th ics. P len u m Press, N e w York. P ro m o tio n o f N a tio n a l U n ity and R e c o n ­ cilia tio n A c t 1995 3 (1 ) (d) P u r tillo R 1 9 8 7 C o d e o f E th ic s in P h y ­ siotherapy: A r e tro sp e ctiv e v ie w and look ahead. P hy sio th er a p y P r a c tic e d : 2 8 -3 4 P urtillo and C a sse ll 1983 E thical D im e n sio n in the H ealth P r o fe ssio n . W .B Saunders, N e w York P ond R eport in the tea ch in g on M e d ic a l E thics in the U K 1987 S u b m is sio n by the P hysioth erapy p ro fessio n to the Truth and R e c o n c ilia tio n C o m m is sio n , 1998 C a p e Tow n T riesen b erg H L 199 6 T h e id en tifica tio n o f e th ica l iss u e s in p h y sica l therapy p ractice. P h y sic a l T h er a p y ,7 6 :1 0 9 7 -1 1 0 7 T H E U K ’ S L E A D I N G A G E N C Y F O R P H Y S I O T H E R A P I S T S WORKING IN THE UK NEEDN’T BE A PUZZLE # Friendly advice on: • State Registration • UK entry • A ccom m odation # W idest choice of posts # Top rates of pay # CPSM fees reim bursed # FREE Indem nity Insurance* For o u r FREE ‘W orking H olidays in B ritain’ b ro c h u re , c o n ta c t Debi Faulder m c s p s r p m e c i o n TOLL-FREE 0800-99-3055 (24 H ours) o r Fax o n 09 44 181 207 6894 or E-mail: lo cum s@ corinth.co.uk ’Subject to th e Terms o f the Policy You'll be amazed hnw CORINTH MEDICAL can help! Corinth Medical 5 Theobald Court, Theobald Street Borehamwood, Herts, W D6 4RN, UK 10 SA J o u r n a l o f Physiotherapy 1999 V o l 55 N o 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:locums@corinth.co.uk