Structure of Ethics Teaching in Physical Therapy
RUTH B. PURTILO, PhD
Courses called "Ethics" have long been included in physical therapy education programs. This paper reports the findings of a survey designed to assess current practices in teaching ethics in baccalaureate-level physical therapy programs. Of 59 questionnaires sent, 29 were returned and analyzed. The findings are compared with similar recent surveys of medical and nursing schools. Sugges tions are made for assuring that the high standard of teaching maintained in other areas of physical therapy professional preparation also are maintained in ethics teaching. Key Words: Education, Ethics.
Courses called "Ethics" have long been offered in physical therapy education programs. The content of such courses often has emphasized accepted behaviors (etiquette, appropriate dress, or bedside manner) rather than addressing more substantive moral dilem mas facing the health professional and the health care system. The same can be said of medical and nursing education programs. Today, a shift is taking place in medical education toward examining theoretical frameworks that can be applied to a wide range of ethical issues. This atten tion to basic theoretical concepts is due in large part to the growth of the discipline of "medical ethics." The formal teaching of medical ethics is increasingly becoming a part of medical school curricula.1 Somewhat less clear is the status and function of medical ethics teaching in health fields other than medicine. This remains true despite the fact that, in some instances, the nonphysician health professionals play a significant role in sharing responsibility—or may even have to assume full responsibility—for awesome ethical decisions. For instance, Ramsey sug gests that the chief problem of the dying is how not to die alone.2 Taken literally, this would require the
Dr. Purtilo was a doctoral candidate in Ethics at the Harvard Graduate School of Arts and Sciences at the time this paper was written. Her mailing address is 39 Spring St, Shrewsbury, MA 01545. Parts of this paper are adapted from Dr. Purtilo's article, "Ethics Teaching in Allied Health Fields," Hastings Center Report, April 1978, pp 14-16. This article was submitted May 16, 1978, and accepted January 15, 1979.
1102
physician to be physically present with every hospi talized, dying patient 24 hours a day. Ramsey ob viously does not mean to suggest this, but rather that the physical and psychological support will be shared by all health care providers. Jonsen and Garland, in their discussion of critical issues in newborn intensive care, maintain that "nurses have a special professional relationship to the infant, the parents, and physicians in the provision of intensive care. Their role in deci sions about continuation of therapy for endangered infants merits full discussion and articulation "3 Furthermore, a number of models for hospital ethics committees have nonphysician health professional members. In short, nonphysician health professionals are in volved in ethical decision-making processes and in creasingly will be asked to participate in determining moral policy. As such, they ought to have enough exposure to the subject of ethics to gain at least a basic understanding of ethical theory as it affects actual decision making and moral policy. A recent survey revealed that nurses seem to be moving increasingly toward the formal teaching of ethics, placing emphasis on frameworks for address ing a wide range of ethical dilemmas.4 They have begun to acknowledge unique ethical questions grow ing out of their unique position within the health care network. This acknowledgment, in turn, has given rise to an awareness that simply attempting to extend the teaching of bioethics as taught to physicians is a mistake.1 The result has been a surge of interest in developing a better understanding of ethical issues PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
A Survey
Volume 59 / Number 9, September 1979
medical schools' and Aroskar's study of 86 baccalau reate nursing programs.4 Hopefully, more studies of this type will be forthcoming in other fields. The purpose of this paper is to report the findings of a survey designed to assess the format and extent to which ethics is currently being taught in physical therapy. Although much additional data will ob viously be needed to fully analyze the content and scope of ethics teaching in physical therapy, this study provides a useful base and model for further investi gation into the area. METHOD
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
and a hard look at how ethics ought to be addressed in a nursing curriculum.6 A key question for nurse educators, as well as for physical therapist and other nonphysician health professional educators, is whether members of their profession can gain an adequate understanding of ethics through continuing education and informal discussion on specific issues, or whether formal teach ing at the student level is preferable. Using the former methods to teach ethics to physicians already in prac tice has met with limited success in affecting the physicians' approach to difficult questions.7,8 The findings could be similar for nonphysicians. Indeed, the Hastings Center Report of the Commission on the Teaching of Bioethics, published in 1976, recommends that teaching ethics to students in nursing and other nonphysician professional schools be emphasized (al though not to the exclusion of emphasizing ethics in continuing education courses).9 Among the argu ments for teaching ethics at this level of preparation is the practical consideration of the high interest in ethical questions and an increasing number of quali fied instructors within such schools at present. The report reflects the general position that students need to receive preparation in ethics because of the in creased moral and legal liability to be placed on these future health professionals for patient care decisions. The health professional is seen in a unique position "between physician and patient" in problems of au thority and responsibility.9 Less is known about the status and proper function of ethics teaching in the allied health professions than in either medicine or nursing. Collectively, the allied health professions face questions of authority and responsibility very similar, although not necessarily identical, to nursing. For example, they share the concern voiced by Aroskar, a nurse: "Can nurses be ethical in the health-care structure as it now exists?"4 Allied health professionals also share with nurses a level of income, power, and prestige that is lower than physicians. I maintain that, because of basic similarities in regard to many ethical questions, the same conclu sions about the efficacy of teaching medical or nurs ing students can be made for allied health students. Continuing education and other practice-based dis cussions for graduates should be encouraged, but not to the exclusion of teaching a formal course in ethics to students. Many readers will agree in principle that ethics ought to be presented to students in medicine, nurs ing, and allied health professions. However, little empirical data are available for comparison of such attempts or for assessing present practices. Notable exceptions are Veatch and Sollitto's study of 107
During the spring of 1976, we surveyed 59 bacca laureate-level physical therapy programs, the total number of such programs according to a list provided by the American Physical Therapy Association. A questionnaire was sent to the chairman of the depart ment. It was not specified who should complete the form. In almost all cases the chairman completed it, although in a few cases the person(s) responsible for teaching the ethics course(s) did so. Twenty-nine (50%) responses were received and analyzed. The questionnaire had two parts: Part 1 was de signed to obtain information about the methods by which ethics is taught in the physical therapy curric ulum per se. Respondents were asked to indicate whether: the sole means of discussing ethical issues depended on faculty responses to questions as they arose (Method 1), ethics was offered as part of a course ("part-course") in the physical therapy curric ulum, and, if so, what the course consisted of (Method 2), or ethics was offered as a full course in the physical therapy curriculum (Method 3). A space to specify a fourth method was provided, but because all of the respondents checked one of the other categories, this fourth category was dropped from the analysis. The second part of the study assessed the extent to which physical therapy students were exposed to ethics ma terial outside of their physical therapy courses. RESULTS AND DISCUSSION Part 1: Ethics Within the Physical Therapy Curriculum
The findings for Part 1 are summarized in Table 1. 1. Response to Students' Questions As They Arise Programs relying entirely on Method 1 were con sidered to have no formal course offerings in ethics. The five respondents in this category seemed to be lieve that an attempt to respond to students' concerns and to point out ethical dimensions within the whole
1103
TABLE 1
Exposure to Ethics Courses Within Physical Therapy Curricula (N = 29) Number (%) 5 (17%) 18 (62%) 6 (21%)
range of courses is important, without using a more formal course approach to ethics. By comparison, Veatch and Sollitto report that all but 10 of the 107 medical schools responding to their questionnaire provided some specific form of medical ethics teach ing, and they suggest that medical ethics teaching was limited to course or part-course frameworks. One can assume from that report that less than 10 percent of medical ethics teaching relied solely on Method 1 of the present study. It is somewhat harder to compare Aroskar's results with the present study.4 She reports that 66 percent of nursing school respondents said that ethical aspects were integrated throughout the curriculum. Aroskar notes further, however, that nursing schools are moving away from the traditional organization of material into courses so that some who reported the "integrated" approach may indeed provide formal teaching in ethics by combining it with other topics. She reflects on the ambiguity built into her study by failing to clarify more specifically such terms as "courses" and "integrated":
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
Method 1. Faculty response when students pose questions 2. Part of a course is devoted to ethics 3. A full course is devoted to ethics
this "part-course" type of arrangement than did the medical schools. Eighteen respondents checked this category, showing that in physical therapy programs the "part-course" in ethics is the most commonly used method.
Of equal interest is the choice of topics with which ethics material is combined to make a full course. Physical therapy educators most frequently combined ethics with administration, human relations, or com munications courses.
Assessing the findings in this part of the study may show what physical therapists perceive ethics to be and in which of the three areas—administration, human relations, or communications—they believe that ethics plays its most important part. The course combinations might also be the result of the devel opment of physical therapy programs having certain content areas traditionally being taught together. My guess is that the vestiges of this trend are seen in the above findings. I did not ask how much actual time was devoted to ethics in the combined courses. Almost all respondents offered this information anyway, re porting that the course was divided quite evenly. However, the responses in this category could be misleading in terms of actual time devoted to ethics theory rather than to issues. 3. A Full Course in Ethics The final category was those programs that offered at least one full semester or quarter course in ethics. Six respondents checked this category.
Aroskar reported that six (7%) nursing programs required students to take a full course in ethics.4 Veatch and Sollitto reported that 50 of the 69 medical school respondents offering a course in which ethics was discussed in conjunction with other topics also offered courses in medical ethics only, although not all the latter were required courses.1 Only one physical therapy program reported having a required course It is clear that in future studies, including our own, in ethics plus a required course that combined ethics investigators should find alternative terms to avoid with other topics as well. Almost all of the full courses were listed as "medical ethics" rather than as "phys possible confusion. ical therapy ethics" or "professional ethics." Teachers 2. A "Part-Course" in Ethics Veatch and Sollitto report that, of 97 medical for full courses and courses combined with other schools surveyed, "many that responded positively topics were almost exclusively what the Hastings Cen when asked whether their school offers courses spe ter Report of the Commission on the Teaching of cifically in medical ethics, in fact seemed to offer Bioethics termed the "competent amateur." The courses in which medical ethics was discussed, but "competent amateur" is one not fully trained in both these courses were more clearly or normally identified the allied health field and an area of philosophy, as something else."1 This was the case in 69 of the particularly ethics. These findings are consistent with schools, 19 of which provided no further medical Aroskar's findings within nursing schools, although ethics offerings. As noted above, some of the nursing she also found some attempts to have an ethicist and schools reporting an "integrated" approach also prob a nurse engage in team teaching.4 One physical ther ably combined ethics material with other topics. In apy program also reported such a team teaching my study, the group surveyed relied more heavily on approach. .. .When the integrated approach is the only one in use, it may mean that some teaching is not done at all or is not evaluated, depending on the teacher. If ethics is considered a rigorous discipline in which students should study schools of thought, learn certain facts, and read and reflect on various problems, then a more specific course with well-prepared teachers and curric ulum structure is necessary.4
1104
PHYSICAL THERAPY
TABLE 2 Exposure to Ethics Outside of Physical Therapy Curricula
In addition to faculty re sponses when ethical ques tions arise, students are ex posed to
Number
Elective course in Ethics
Clinical conference with occu pational therapy students Discussion with clergy 2. In addition to a part-course within the physical therapy curriculum, students are ex-, posed to
Elective course in Ethics
Required seminar with medical students and medical technol ogy students Clinical conference with occu pational therapy students Seminar with other health fields 3. In addition to a required full course within the physical therapy curriculum, students are exposed to
Elective course in Ethics
Elective course + workshop with nursing and medical stu dents Weekend seminar with other allied health fields + elective
Part 2: Ethics Outside of the Physical Therapy Curriculum
The second part of the questionnaire provided one additional related category of responses that merits careful scrutiny if the picture of course offerings is to be accurate. Responses to Part 1 all are indications of what is offered within physical therapy curricula as such. Students within these programs, however, often have some "elective" time for attending courses of fered by faculty in other areas and for participating in discussions about ethics questions in workshops and seminars. Thus, the respondents were asked the amount and type of student involvement with such courses, seminars, workshops, and clinical confer ences. They were also asked how much time and what type of interdisciplinary involvement such methods provided. The results are presented in Table 2. Two pertinent observations can be made from this table. First, students in physical therapy are exposed to more ethics material, including formal classwork, than a study of the professional curricula alone sug gests. Second, programs that give priority to the dis cipline of ethics within their own curricula also en courage their students to become involved in courses Volume 59 / Number 9, September 1979
and other settings in which ethics material is being presented or discussed. Programs that require a full course or "part-course" in ethics are also more likely to offer interdisciplinary and other exposures to ethics material than are programs that offer no formal coursework in ethics. It is not obvious from this survey that the need for adequate courses and ethics materials is currently being met, or that faculty and financial support is increasing appreciably.
CONCLUSION
Physical therapy programs are attempting to offer their students an exposure to ethics. The amount of time and the format vary widely. The importance of ethics to the allied health professionals and programs is in a state of flux. For example, I have met several persons within the last year currently enrolled in doctoral programs in ethics or philosophy who also have degrees in one of the allied health professions. Most of these people express an interest in going back to teaching in their allied health field. Furthermore, federal and foundation grants are becoming available for developing ethics teaching programs for the allied 1105
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
Additional Type of Exposure
Method
Acknowledgment. This work was supported by funds from the Harvard Interfaculty Program in Med ical Ethics and the Joseph P. Kennedy Jr. Foundation in Medical Ethics.
REFERENCES
1. Veatch RM, Soilitto S: Medical ethics teaching: Report of a national medical school survey. JAMA 35:1030-1033, 1976 2. Ramsey P: The Patient as Person. New Haven, Yale Univer sity Press, 1970, p 134 3. Jonsen AR, Garland MJ: Critical issues in newborn intensive care: Conference report and policy proposal. Pediatrics 55: 756-768, 1975 4. Aroskar M: Ethics in the nursing curriculum. Nurs Outlook 25:23-29, 1977 5. Jameton A: The nurse: When roles and rules conflict. Hast ings Cent Rep 7:22-23, 1977 6. Steinfels MO: Ethics, education and nursing practice. Hast ings Cent Rep 7:20-22, 1977 7. Levine M: Ethics rounds in a children's medical center: Eval uation of a hospital based program for continuing education in medical ethics. Pediatrics 60:202-208, 1977 8. Singer P: Letter to the editor: Can ethics be taught in a hospital? Pediatrics 60:253-255, 1977 9. Report of the Commission on the Teaching of Bioethics. Hastings-on-Hudson, NY, The Hastings Center, Institute of Society, Ethics and the Life Sciences, 1976
Clinicians, Researchers, Teachers . . . this important monograph is now available.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION • Presents rationale for differing theories on how TENS works • Provides entire current literature search • Includes these outstanding articles prepared by clinicians, researchers, and teachers: Perspectives on Central Nervous System Respon siveness to Transcutaneous Electrical Nerve Stimulation— Steven L. Wolf, PhD Introduction to the Use of Transcutaneous Electri cal Nerve Stimulation Devices-Gerald N. Lampe, BS Electrode Placements for Transcutaneous Electri cal Nerve Stimulation— Jeffrey S. Mannheimer, MA Postoperative Pain and Transcutaneous Electrical Nerve Stimulation: A Model to Critique Literature and Develop Documentation Schema—Meryl Roth Gersh, MMS Peripheral Nerve Excitability: Implications for Transcutaneous Electrical Nerve Stimulation — David C. Howson, BS
1106
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
health professions. Both of these factors will undoubt edly stimulate an increase in attention given to the teaching of ethics. At the moment, however, the perceived need for teaching ethics has outdis tanced the supply of qualified teachers and the ability to visualize completely what ought to be offered, both in content and format. To assure that the teaching process in the physical therapy field does not develop haphazardly, several steps can be taken: 1) further delineate the role of the physical therapist within the health care network, emphasizing the areas of overlap with and differences from nursing ethics and physician ethics; 2) develop guidelines for the proper content and formats for ethics courses as they are introduced into physical therapy programs, including considerations of inter disciplinary vs. intradisciplinary approaches; and 3) develop teaching materials that emphasize unique areas as well as the areas commonly shared with medicine and nursing. The recent attention directed to these three considerations in nursing ethics pro vides a model for reflection and action upon similar considerations in the allied health professions.
Clinical Report on the Use of Specific TENS UnitsPatsy L. McKelvy, CDR, MSC, USN Relationship of Selected Clinical Variables to Cur rent Delivered During Transcutaneous Electrical Nerve Stimulation— Steven L. Wolf, PhD, Meryl R. Gersh, MMS, and Michael Kutner, PhD Bibliography on Electroanalgesia—Debra H. Hamer, BS, and David C. Howson, BS Single copy —$2.50 Bulk orders: 10 copies-$2.00 ea; ea; 50 copies or more-$1.00.ea
25 copies-$1.50
Send name, address, number of copies wanted, and check made to the American Physical Therapy Asso ciation to APT A, 1156 15th St NW, Washington, DC 20005.
PHYSICAL THERAPY
RUTH B. PURTILO, PhD
Courses called "Ethics" have long been included in physical therapy education programs. This paper reports the findings of a survey designed to assess current practices in teaching ethics in baccalaureate-level physical therapy programs. Of 59 questionnaires sent, 29 were returned and analyzed. The findings are compared with similar recent surveys of medical and nursing schools. Sugges tions are made for assuring that the high standard of teaching maintained in other areas of physical therapy professional preparation also are maintained in ethics teaching. Key Words: Education, Ethics.
Courses called "Ethics" have long been offered in physical therapy education programs. The content of such courses often has emphasized accepted behaviors (etiquette, appropriate dress, or bedside manner) rather than addressing more substantive moral dilem mas facing the health professional and the health care system. The same can be said of medical and nursing education programs. Today, a shift is taking place in medical education toward examining theoretical frameworks that can be applied to a wide range of ethical issues. This atten tion to basic theoretical concepts is due in large part to the growth of the discipline of "medical ethics." The formal teaching of medical ethics is increasingly becoming a part of medical school curricula.1 Somewhat less clear is the status and function of medical ethics teaching in health fields other than medicine. This remains true despite the fact that, in some instances, the nonphysician health professionals play a significant role in sharing responsibility—or may even have to assume full responsibility—for awesome ethical decisions. For instance, Ramsey sug gests that the chief problem of the dying is how not to die alone.2 Taken literally, this would require the
Dr. Purtilo was a doctoral candidate in Ethics at the Harvard Graduate School of Arts and Sciences at the time this paper was written. Her mailing address is 39 Spring St, Shrewsbury, MA 01545. Parts of this paper are adapted from Dr. Purtilo's article, "Ethics Teaching in Allied Health Fields," Hastings Center Report, April 1978, pp 14-16. This article was submitted May 16, 1978, and accepted January 15, 1979.
1102
physician to be physically present with every hospi talized, dying patient 24 hours a day. Ramsey ob viously does not mean to suggest this, but rather that the physical and psychological support will be shared by all health care providers. Jonsen and Garland, in their discussion of critical issues in newborn intensive care, maintain that "nurses have a special professional relationship to the infant, the parents, and physicians in the provision of intensive care. Their role in deci sions about continuation of therapy for endangered infants merits full discussion and articulation "3 Furthermore, a number of models for hospital ethics committees have nonphysician health professional members. In short, nonphysician health professionals are in volved in ethical decision-making processes and in creasingly will be asked to participate in determining moral policy. As such, they ought to have enough exposure to the subject of ethics to gain at least a basic understanding of ethical theory as it affects actual decision making and moral policy. A recent survey revealed that nurses seem to be moving increasingly toward the formal teaching of ethics, placing emphasis on frameworks for address ing a wide range of ethical dilemmas.4 They have begun to acknowledge unique ethical questions grow ing out of their unique position within the health care network. This acknowledgment, in turn, has given rise to an awareness that simply attempting to extend the teaching of bioethics as taught to physicians is a mistake.1 The result has been a surge of interest in developing a better understanding of ethical issues PHYSICAL THERAPY
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
A Survey
Volume 59 / Number 9, September 1979
medical schools' and Aroskar's study of 86 baccalau reate nursing programs.4 Hopefully, more studies of this type will be forthcoming in other fields. The purpose of this paper is to report the findings of a survey designed to assess the format and extent to which ethics is currently being taught in physical therapy. Although much additional data will ob viously be needed to fully analyze the content and scope of ethics teaching in physical therapy, this study provides a useful base and model for further investi gation into the area. METHOD
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
and a hard look at how ethics ought to be addressed in a nursing curriculum.6 A key question for nurse educators, as well as for physical therapist and other nonphysician health professional educators, is whether members of their profession can gain an adequate understanding of ethics through continuing education and informal discussion on specific issues, or whether formal teach ing at the student level is preferable. Using the former methods to teach ethics to physicians already in prac tice has met with limited success in affecting the physicians' approach to difficult questions.7,8 The findings could be similar for nonphysicians. Indeed, the Hastings Center Report of the Commission on the Teaching of Bioethics, published in 1976, recommends that teaching ethics to students in nursing and other nonphysician professional schools be emphasized (al though not to the exclusion of emphasizing ethics in continuing education courses).9 Among the argu ments for teaching ethics at this level of preparation is the practical consideration of the high interest in ethical questions and an increasing number of quali fied instructors within such schools at present. The report reflects the general position that students need to receive preparation in ethics because of the in creased moral and legal liability to be placed on these future health professionals for patient care decisions. The health professional is seen in a unique position "between physician and patient" in problems of au thority and responsibility.9 Less is known about the status and proper function of ethics teaching in the allied health professions than in either medicine or nursing. Collectively, the allied health professions face questions of authority and responsibility very similar, although not necessarily identical, to nursing. For example, they share the concern voiced by Aroskar, a nurse: "Can nurses be ethical in the health-care structure as it now exists?"4 Allied health professionals also share with nurses a level of income, power, and prestige that is lower than physicians. I maintain that, because of basic similarities in regard to many ethical questions, the same conclu sions about the efficacy of teaching medical or nurs ing students can be made for allied health students. Continuing education and other practice-based dis cussions for graduates should be encouraged, but not to the exclusion of teaching a formal course in ethics to students. Many readers will agree in principle that ethics ought to be presented to students in medicine, nurs ing, and allied health professions. However, little empirical data are available for comparison of such attempts or for assessing present practices. Notable exceptions are Veatch and Sollitto's study of 107
During the spring of 1976, we surveyed 59 bacca laureate-level physical therapy programs, the total number of such programs according to a list provided by the American Physical Therapy Association. A questionnaire was sent to the chairman of the depart ment. It was not specified who should complete the form. In almost all cases the chairman completed it, although in a few cases the person(s) responsible for teaching the ethics course(s) did so. Twenty-nine (50%) responses were received and analyzed. The questionnaire had two parts: Part 1 was de signed to obtain information about the methods by which ethics is taught in the physical therapy curric ulum per se. Respondents were asked to indicate whether: the sole means of discussing ethical issues depended on faculty responses to questions as they arose (Method 1), ethics was offered as part of a course ("part-course") in the physical therapy curric ulum, and, if so, what the course consisted of (Method 2), or ethics was offered as a full course in the physical therapy curriculum (Method 3). A space to specify a fourth method was provided, but because all of the respondents checked one of the other categories, this fourth category was dropped from the analysis. The second part of the study assessed the extent to which physical therapy students were exposed to ethics ma terial outside of their physical therapy courses. RESULTS AND DISCUSSION Part 1: Ethics Within the Physical Therapy Curriculum
The findings for Part 1 are summarized in Table 1. 1. Response to Students' Questions As They Arise Programs relying entirely on Method 1 were con sidered to have no formal course offerings in ethics. The five respondents in this category seemed to be lieve that an attempt to respond to students' concerns and to point out ethical dimensions within the whole
1103
TABLE 1
Exposure to Ethics Courses Within Physical Therapy Curricula (N = 29) Number (%) 5 (17%) 18 (62%) 6 (21%)
range of courses is important, without using a more formal course approach to ethics. By comparison, Veatch and Sollitto report that all but 10 of the 107 medical schools responding to their questionnaire provided some specific form of medical ethics teach ing, and they suggest that medical ethics teaching was limited to course or part-course frameworks. One can assume from that report that less than 10 percent of medical ethics teaching relied solely on Method 1 of the present study. It is somewhat harder to compare Aroskar's results with the present study.4 She reports that 66 percent of nursing school respondents said that ethical aspects were integrated throughout the curriculum. Aroskar notes further, however, that nursing schools are moving away from the traditional organization of material into courses so that some who reported the "integrated" approach may indeed provide formal teaching in ethics by combining it with other topics. She reflects on the ambiguity built into her study by failing to clarify more specifically such terms as "courses" and "integrated":
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
Method 1. Faculty response when students pose questions 2. Part of a course is devoted to ethics 3. A full course is devoted to ethics
this "part-course" type of arrangement than did the medical schools. Eighteen respondents checked this category, showing that in physical therapy programs the "part-course" in ethics is the most commonly used method.
Of equal interest is the choice of topics with which ethics material is combined to make a full course. Physical therapy educators most frequently combined ethics with administration, human relations, or com munications courses.
Assessing the findings in this part of the study may show what physical therapists perceive ethics to be and in which of the three areas—administration, human relations, or communications—they believe that ethics plays its most important part. The course combinations might also be the result of the devel opment of physical therapy programs having certain content areas traditionally being taught together. My guess is that the vestiges of this trend are seen in the above findings. I did not ask how much actual time was devoted to ethics in the combined courses. Almost all respondents offered this information anyway, re porting that the course was divided quite evenly. However, the responses in this category could be misleading in terms of actual time devoted to ethics theory rather than to issues. 3. A Full Course in Ethics The final category was those programs that offered at least one full semester or quarter course in ethics. Six respondents checked this category.
Aroskar reported that six (7%) nursing programs required students to take a full course in ethics.4 Veatch and Sollitto reported that 50 of the 69 medical school respondents offering a course in which ethics was discussed in conjunction with other topics also offered courses in medical ethics only, although not all the latter were required courses.1 Only one physical therapy program reported having a required course It is clear that in future studies, including our own, in ethics plus a required course that combined ethics investigators should find alternative terms to avoid with other topics as well. Almost all of the full courses were listed as "medical ethics" rather than as "phys possible confusion. ical therapy ethics" or "professional ethics." Teachers 2. A "Part-Course" in Ethics Veatch and Sollitto report that, of 97 medical for full courses and courses combined with other schools surveyed, "many that responded positively topics were almost exclusively what the Hastings Cen when asked whether their school offers courses spe ter Report of the Commission on the Teaching of cifically in medical ethics, in fact seemed to offer Bioethics termed the "competent amateur." The courses in which medical ethics was discussed, but "competent amateur" is one not fully trained in both these courses were more clearly or normally identified the allied health field and an area of philosophy, as something else."1 This was the case in 69 of the particularly ethics. These findings are consistent with schools, 19 of which provided no further medical Aroskar's findings within nursing schools, although ethics offerings. As noted above, some of the nursing she also found some attempts to have an ethicist and schools reporting an "integrated" approach also prob a nurse engage in team teaching.4 One physical ther ably combined ethics material with other topics. In apy program also reported such a team teaching my study, the group surveyed relied more heavily on approach. .. .When the integrated approach is the only one in use, it may mean that some teaching is not done at all or is not evaluated, depending on the teacher. If ethics is considered a rigorous discipline in which students should study schools of thought, learn certain facts, and read and reflect on various problems, then a more specific course with well-prepared teachers and curric ulum structure is necessary.4
1104
PHYSICAL THERAPY
TABLE 2 Exposure to Ethics Outside of Physical Therapy Curricula
In addition to faculty re sponses when ethical ques tions arise, students are ex posed to
Number
Elective course in Ethics
Clinical conference with occu pational therapy students Discussion with clergy 2. In addition to a part-course within the physical therapy curriculum, students are ex-, posed to
Elective course in Ethics
Required seminar with medical students and medical technol ogy students Clinical conference with occu pational therapy students Seminar with other health fields 3. In addition to a required full course within the physical therapy curriculum, students are exposed to
Elective course in Ethics
Elective course + workshop with nursing and medical stu dents Weekend seminar with other allied health fields + elective
Part 2: Ethics Outside of the Physical Therapy Curriculum
The second part of the questionnaire provided one additional related category of responses that merits careful scrutiny if the picture of course offerings is to be accurate. Responses to Part 1 all are indications of what is offered within physical therapy curricula as such. Students within these programs, however, often have some "elective" time for attending courses of fered by faculty in other areas and for participating in discussions about ethics questions in workshops and seminars. Thus, the respondents were asked the amount and type of student involvement with such courses, seminars, workshops, and clinical confer ences. They were also asked how much time and what type of interdisciplinary involvement such methods provided. The results are presented in Table 2. Two pertinent observations can be made from this table. First, students in physical therapy are exposed to more ethics material, including formal classwork, than a study of the professional curricula alone sug gests. Second, programs that give priority to the dis cipline of ethics within their own curricula also en courage their students to become involved in courses Volume 59 / Number 9, September 1979
and other settings in which ethics material is being presented or discussed. Programs that require a full course or "part-course" in ethics are also more likely to offer interdisciplinary and other exposures to ethics material than are programs that offer no formal coursework in ethics. It is not obvious from this survey that the need for adequate courses and ethics materials is currently being met, or that faculty and financial support is increasing appreciably.
CONCLUSION
Physical therapy programs are attempting to offer their students an exposure to ethics. The amount of time and the format vary widely. The importance of ethics to the allied health professionals and programs is in a state of flux. For example, I have met several persons within the last year currently enrolled in doctoral programs in ethics or philosophy who also have degrees in one of the allied health professions. Most of these people express an interest in going back to teaching in their allied health field. Furthermore, federal and foundation grants are becoming available for developing ethics teaching programs for the allied 1105
Downloaded from https://academic.oup.com/ptj/article-abstract/59/9/1102/4559674 by Washington University, Law School Library user on 12 February 2019
Additional Type of Exposure
Method
Acknowledgment. This work was supported by funds from the Harvard Interfaculty Program in Med ical Ethics and the Joseph P. Kennedy Jr. Foundation in Medical Ethics.
REFERENCES
1. Veatch RM, Soilitto S: Medical ethics teaching: Report of a national medical school survey. JAMA 35:1030-1033, 1976 2. Ramsey P: The Patient as Person. New Haven, Yale Univer sity Press, 1970, p 134 3. Jonsen AR, Garland MJ: Critical issues in newborn intensive care: Conference report and policy proposal. Pediatrics 55: 756-768, 1975 4. Aroskar M: Ethics in the nursing curriculum. Nurs Outlook 25:23-29, 1977 5. Jameton A: The nurse: When roles and rules conflict. Hast ings Cent Rep 7:22-23, 1977 6. Steinfels MO: Ethics, education and nursing practice. Hast ings Cent Rep 7:20-22, 1977 7. Levine M: Ethics rounds in a children's medical center: Eval uation of a hospital based program for continuing education in medical ethics. Pediatrics 60:202-208, 1977 8. Singer P: Letter to the editor: Can ethics be taught in a hospital? Pediatrics 60:253-255, 1977 9. Report of the Commission on the Teaching of Bioethics. Hastings-on-Hudson, NY, The Hastings Center, Institute of Society, Ethics and the Life Sciences, 1976
Clinicians, Researchers, Teachers . . . this important monograph is now available.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION • Presents rationale for differing theories on how TENS works • Provides entire current literature search • Includes these outstanding articles prepared by clinicians, researchers, and teachers: Perspectives on Central Nervous System Respon siveness to Transcutaneous Electrical Nerve Stimulation— Steven L. Wolf, PhD Introduction to the Use of Transcutaneous Electri cal Nerve Stimulation Devices-Gerald N. Lampe, BS Electrode Placements for Transcutaneous Electri cal Nerve Stimulation— Jeffrey S. Mannheimer, MA Postoperative Pain and Transcutaneous Electrical Nerve Stimulation: A Model to Critique Literature and Develop Documentation Schema—Meryl Roth Gersh, MMS Peripheral Nerve Excitability: Implications for Transcutaneous Electrical Nerve Stimulation — David C. Howson, BS
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health professions. Both of these factors will undoubt edly stimulate an increase in attention given to the teaching of ethics. At the moment, however, the perceived need for teaching ethics has outdis tanced the supply of qualified teachers and the ability to visualize completely what ought to be offered, both in content and format. To assure that the teaching process in the physical therapy field does not develop haphazardly, several steps can be taken: 1) further delineate the role of the physical therapist within the health care network, emphasizing the areas of overlap with and differences from nursing ethics and physician ethics; 2) develop guidelines for the proper content and formats for ethics courses as they are introduced into physical therapy programs, including considerations of inter disciplinary vs. intradisciplinary approaches; and 3) develop teaching materials that emphasize unique areas as well as the areas commonly shared with medicine and nursing. The recent attention directed to these three considerations in nursing ethics pro vides a model for reflection and action upon similar considerations in the allied health professions.
Clinical Report on the Use of Specific TENS UnitsPatsy L. McKelvy, CDR, MSC, USN Relationship of Selected Clinical Variables to Cur rent Delivered During Transcutaneous Electrical Nerve Stimulation— Steven L. Wolf, PhD, Meryl R. Gersh, MMS, and Michael Kutner, PhD Bibliography on Electroanalgesia—Debra H. Hamer, BS, and David C. Howson, BS Single copy —$2.50 Bulk orders: 10 copies-$2.00 ea; ea; 50 copies or more-$1.00.ea
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