Principles of Healthcare Ethics
As stated above, professional ethics involve decisions about right and wrong.  Ethical principles provide guidance to help us make decisions.  There are four accepted principles of health care ethics:  respect for autonomy, nonmaleficence, beneficence, and justice.  These principles are general guidelines that can be used to make ethical decisions in health care.

Respect for Autonomy
This principle has to do with every person’s right to make their own decisions based on their personal beliefs and values.  In order for patients to make their own decisions, health care practitioners must make available the appropriate information.  Before working on a client or patient, health care practitioners must discuss the plans of care and provide specific information about the treatment, including the patient’s goals for their therapy.  Informed consent is derived from this principle.

All patients in hospitals and other healthcare facilities must sign a general consent for medical care and treatment, and many massage and bodywork practices also require their clients to sign a general consent for treatment.  A general consent usually specifies touching the client in a therapeutic manner.  General consent is not the same as informed consent to surgery or other invasive procedures, which is much more specific.  Failure to obtain informed consent for an invasive procedure may lead to medical negligence or malpractice suits, while failure to obtain general consent to touch may lead to battery cases.  Battery is also committed when one procedure has been agreed upon and a different one is performed without the patient’s knowledge and consent.  Several such cases of unauthorized procedures have reached the courts.  In all of the cases that I’m aware of, money was awarded to the plaintiff with the ruling that it’s always a patient’s/plaintiff’s decision whether or not to undergo specific procedures.
Remember, if a patient/client refuses a procedure, don’t do it.  Fundamental to this issue is the right of all individuals to control what happens to his/her body, including decisions about whether or not to accept proposed treatments.  This right cannot be taken away except in exceptional circumstances, such as in those situations where consent is implied, e.g., in emergency situations where the life of someone is threatened or when the situation poses a risk of significant injury to a person if certain applications are not performed.  Even then, only applications deemed absolutely necessary can be performed and only a physician can determine if an emergency exists.  As soon as possible, competent patient consent should be obtained.  Implied consent does not apply if a patient is coherent enough to talk or gesture, if the patient’s family is available or if there is evidence of some kind that the patient does not want treatment, such as a living will or DNR order.

Informed Consent Issues
It’s the duty of the healthcare professional performing a treatment to explain the risks and benefits and obtain the client’s informed consent.  However, an assistant may witness the signing of the consent. If the client does not understand English, an interpreter should be found.  All consents and consent processes should be documented.  Most hospitals and other healthcare facilities have their own rules concerning the informed consent process and you need to be familiar with them if you plan to work there.

Disclosure Requirements
In order for a patient to make an informed decision about whether or not to have a particular treatment, s/he must have enough information, including:

  • Nature and purpose of treatment
  • Risks and consequences of treatment
  • Alternatives to treatment
  • Consequences of refusal of treatment (so that the patient/client can make an informed refusal)

Failure to adequately explain related risks to a procedure or the extent of these risks may result in a liability for the healthcare professional.  The risks of a proposed treatment may be explained to a patient in two different ways: from the professional’s perspective or from the patient’s perspective.  In most states, what a health professional tells a client is judged by what other health professionals tell their clients in similar situations.  In other words, the actions of the health professional are judged against the actions of his/her peers.  However, many states are now leaning toward the patient/client’s perspective, which means any side effects that are pertinent to a particular client should be told to this client regardless if other health professionals tell their clients of this particular risk.  This is to ensure that this particular client is fully informed of risks and benefits that may affect him/her so s/he can make an informed decision about his/her particular healthcare. 

Exceptions to Disclosure
There are some cases in which informed consent is not necessary, such as with minor procedures or when there is no time to obtain it.  Minor procedures are those that do not involve great risks, such as drawing blood or most massage and bodywork practices.

Who May Give Consent
In order to give consent, the patient must be competent; otherwise consent must be obtained elsewhere.  Competencyis defined as the ability to understand the nature and consequences of the procedure or treatment the patient is being asked to undergo.  People who are considered incompetent may include:

  • Minors (unless they are validly married in some states, or in the armed forces or accepted in some other way as competent)
  • People who are determined by a court of law to be unable to make medical decisions
  • Elderly persons with diminished mental capabilities
  • Surrogate decision makers exist for those who are considered incompetent.  Who these surrogates are depends on the reason for incompetency.  For example, parents or legal guardians consent for minors, conservators consent for those deemed incompetent by courts and relatives consent for the elderly with diminished mental capabilities.  A surrogate may also include an adult who has been appointed by the patient through power of attorney for healthcare.

If none of these exist, the court becomes the surrogate and healthcare professionals must obtain a court order to proceed with treatment.  If there is a living will or some other handwritten directive made by the person while competent, then these decisions should be given precedence even after that person loses competency.  The living will needs to comply with the state’s standards in which the person is located or it will have no binding effects.  Living wills, if done correctly as set forth by state law, become effective without court involvement or the involvement of any other surrogate decision maker.  A more formal document than the living will is known as an advanced healthcare directive, which is usually typewritten.  This document must also comply with state law.  Doctors may be required to comply with the wishes expressed in the document.  In some states, directives allow for protection from liability when followed. States also determine the extent to which these directives are binding on healthcare providers.  When a surrogate is called upon to make a decision, these decisions must be for the best interest of the incompetent person.  Using living wills or directives as guidance, a surrogate can refuse treatment for the incompetent person on his/her behalf just as a competent adult patient has the right to refuse treatment.  Most courts allow this if the patient is terminally ill or comatose.  However, if the patient is severely debilitated but not comatose or terminally ill, courts may rule in the state’s interest to preserve life rather than in the surrogate’s right to refuse treatment.  According to a ruling by the U.S. Supreme Court in 1983, the right to refuse treatment is not absolute.  Remember, the patient’s comfort should always be considered and those treatments that enhance comfort may not be withheld from a dying patient.

Consent in Special Cases

Restraints—There are specific requirements, both federal and state, regarding the application of restraints and consent to restraints in nursing homes, many hospitals and other healthcare facilities.
Reproductive rights of minors—The ability of a minor to consent varies from state to state whether that consent is needed for treatment for sexually transmitted diseases or for birth control.
Mental health treatment—Careful attention must be given to federal and state laws regarding involuntary commitment, consent and right to refuse.  Involuntary commitment is not an easy thing to achieve, and must be backed by extreme evidence of danger to oneself or others.
Research studies—Consent forms must be signed by the patient or surrogate before experimental treatment of any kind can be performed and the consent forms must comply with federal law disclosure requirements.
Law enforcement—Sometime police officers capture someone and want that person’s stomach pumped for evidence or his/her blood drawn for drug tests.  Both of these procedures may violate that person’s rights, in which case it’s best for the healthcare professional to check hospital or laboratory policy before proceeding.  Sometimes religious beliefs prevent a patient’s consent to certain procedures.  If the doctors are aware of these beliefs, then consent is not implied.  However, if the doctors are not aware of the patient’s religious beliefs and prohibitions, then courts will usually rule in favor of implied consent.  This holds true even with minors. If the doctor is aware of a minor’s religious beliefs and prohibitions to certain procedures, consent is not implied and the hospital must get a court order to proceed.  The court will usually allow procedures only in the case of minors and not in the case of competent adults.  In other words, courts will allow a competent adult’s decision to refuse life‐saving treatment.

It is important to be truthful when informing the client or patient about aspects of their treatment.  Only if they know the truth can they make well-informed decisions about their care.  In today’s healthcare setting, a patient should be informed if a specific treatment procedure will or will not be covered by the patient’s insurance.  This may have an effect on whether the patient chooses to proceed with the treatment. 

Respect of Privacy
If a client or patient does not feel that their privacy is respected, they may not provide adequate information to the healthcare practitioner.  This may lead to miscommunication about treatment options.  The confidentiality of patient and client information is a main aspect of respect of privacy.  As stated above, breach of confidentiality is considered a quasi-intentional tort from a legal standpoint.  All patient information, including patient records, must be handled with the utmost confidentiality.  This is why Congress established HIPAA, as a way to set rules and guidelines for the management of patient information. 

The principle of nonmaleficence is an obligation, as a provider of health care services, not to intentionally inflict harm on the patient or client.  Since health care providers want to help people as part of their professional obligation, it follows that they would not harm people.  However, there are circumstances when we may have to decide if continuing a treatment may cause more harm than good.  Nonmaleficence is often a consideration in end-of-life decisions about the continuation of treatment for a terminal patient.  If you are caring for these patients, it is important to be prepared for the patient, family members or surrogates to talk to you about ceasing some treatment that is being provided.  As a member of the health care team, it is important that you inform the appropriate professionals about the situation, keeping in mind the privacy of the patient and family.  For example, if a hospice patient tells you in confidence that they want to die and want to be taken off of life support and they ask you not to tell their family, how would you handle it?  Would you inform the health care team members?  How would you respect the patient’s privacy and still keep their best interest in mind?

The principle of beneficence is a moral obligation to provide benefit to others.  In health care settings, practitioners do this by preventing harmful things from happening (like preventing falls) and by providing treatments that benefit the patient or client.  If we omit a treatment that would provide benefit due to the cost of providing the treatment or lack of time, we must be careful not to infringe on this obligation or the obligation of justice (see below).  On the other hand, if we override a patient’s personal preferences for treatment based on our belief that we know what is best for the patient, we would be practicing paternalism.  This does not respect the patient’s autonomy.  For example, if a patient refused a treatment that you know would provide benefit, how would you handle it?  Would you insist, or coerce?  You can see how these ethical principles overlap and can be more complex in individual circumstances.

The principle of justice implies that all persons in similar situations receive a fair amount of benefit while assuming a fair amount of burden.  There are three types of justice:  compensatory, procedural, and distributive.  Compensatory justice involves providing compensation for wrongs that have been done.  If a health care provider is involved in a law suit, is performing as an expert witness or is the member of a jury, s/he is involved in compensatory justice.  Procedural justice has to do with how laws are carried out.  As stated earlier, health care practitioners must abide by all the laws at the local, state and federal levels or they may be subject to the implications of procedural justice.  Distributive justice has to do with the fair distribution of benefits and burdens.  This usually involves the fair distribution of resources in health care.  In a time of cost containment and lack of resources (staff, time, etc.), it is important to determine how we will fairly manage the distribution of these resources.  It is important that the patient or client understand their potential burden of payment for services not covered by their insurance before they receive the services.  For example, if services are provided to a client or patient and they are expecting their insurance to cover these services and then the insurance denies the claim, is this reasonable burden to expect the patient to assume?  Questions like these are difficult to answer, but if the patient is informed and communication is open, it is less likely to create a legal or ethical dilemma.

Professional Roles and Boundaries
Boundaries are behavioral, physical, verbal, emotional, sexual and intellectual limits that protect the integrity of the therapeutic relationship.  Clients have needs that the healthcare professional has the ability to meet.  When a client has a need and pays someone else to fix the need, a power differential is created.  This may cause feelings of vulnerability in the client.  Healthcare professionals need to be aware of these issues and set limits or boundaries around their own behavior.  When they do so and follow through with these limits, they are more able to maintain focus on the client’s needs without taking advantage of them or abusing their own power.  These boundaries give the clients a safe space in which to develop trust in the professional and confidence in his/her abilities.  Clients are then able to talk about their needs and even express feelings of discomfort or mistreatment, if necessary.  Boundary violations are often subtle, and people may not even be consciously aware of them.  However, their impact may be extensive; they may undermine professionalism as well as trust in the healthcare industry.  Following are some of the specific warning signs of boundary issues:

Perception:   Upon becoming aware of a particular behavior, ask yourself how the behavior would look to others and if this behavior is what other professionals would do.

Time:  While treating a client, ask yourself if you are spending more time with this particular client than with any other client.

Meeting time and place:  When meeting with clients, document the time spent.  Do you treat other clients at this time and in this place?

Gifts:  Do you feel obligated to the client due to receiving a gift?  Did other professionals receive a similar gift?

Forms of address:  When talking with the client, be aware of any difference in greeting.  Do you greet this client in a manner similar to other clients?

Style of dress:  Do you change the way you dress when attending to this particular client, compared to other clients?

Making exceptions:  Are you making exceptions for a particular client.  Helping someone is a nice gesture but if this behavior is repeated several times for one particular client, boundary violations may be involved.

Meeting personal needs:  Do you ever feel that you are the only one who can do the job right for this client?  Such thoughts reveal that you may be meeting your needs through your job or through time with this client.

Self disclosure:  If you notice you are talking about personal issues that are unrelated to the current experiences of the client, it would be a good time to reevaluate your behavior for boundary violations.

Communication:  It’s your responsibility to establish proper boundaries and to communicate these boundaries to the client and to others so if the client behaves badly for any particular reason, it has already been established that you will not accept this behavior.  Setting boundaries and following through will help to decrease the vulnerable feelings of clients as well as the occurrence of transference reactions.  Transference is when client’s needs or unresolved issues get transferred to the healthcare professional.  When this happens, clients disclose very personal information that is inappropriate for the therapeutic relationship.  Touch can intensify this process, so healthcare professionals must remain aware and be prepared to treat clients with transference issues in an appropriate manner.  Therapists must swiftly and diplomatically return the communication to a professional dialog.  Therapists must be aware of the possibility of countertransference.  Countertransference is when unresolved feelings and issues of the therapist get transferred to the client.  Countertransference removes the focus from the client and puts it on the therapist.  This results in therapy that is less effective for the clients, possibly
alienating or even harming them.  During countertransference, a healthcare professional may feel:

  • A positive or negative emotional charge toward a particular client.
  • Anger or irritable feelings toward a client who remains ill or unchanged, or who refuses to follow the therapist’s treatment plan.
  • Intense emotions toward a client during treatment, such as exhaustion, depression, exhilaration and uneasiness.
  • Recurring feelings of a sexual or friendly nature toward clients.
  • Desire for and expectation of praise from clients or disappointment when you do not receive praise.
  • Assisting clients with personal things outside the context of the therapy sessions, such as helping them with their shopping or assisting them around their home.

A healthcare professional who is experiencing countertransference should seek help from a supervisor or psychotherapist.  

Boundary violations generally include four elements: role reversal, secrecy, double‐bind and indulgence of professional privilege.

Role reversal is when the client becomes the therapist, in that the client supplies praise or advice so that the roles have been reversed.  In these situations, the therapist’s needs become more important than those of the client.

Secrecy is when the healthcare professional shares certain information with others or keeps information and/or behavior from the client or others.  For example, the therapist gives extra time or attention to a client and tells the client not to tell anyone else about this.

Doublebind is when two contradictory messages are sensed by the client, which results in a conflict.  The client may feel a desire to terminate the relationship with the therapist, while simultaneously feeling a need for the therapist’s continued help.  For example, if a therapist shares confidential information with a client, the client may sense a breach in confidentiality and, at the same time, not want to terminate the therapeutic relationship because it is helping.  This type of communication binds the client in that it the client feels trapped by the nature of the inappropriate interaction.

Indulgence of professional privilege is when the healthcare professional uses information received from the client for his/her own purposes or interests.  For example, the therapist takes information from the clients intake form for personal use.

A physical boundary is the distance around one’s personal space that one needs for feelings of comfort and safety.  Violations of physical boundaries occur when someone enters into another’s personal space without being invited.  This can be intentional, as in a well-intentioned but unwelcome hug, or it can be unintentional.  In the case of massage therapy, physical boundaries may be subtle, as in the case of touching in a way that arouses the client, or they may be obvious, as in touching an inappropriate area of the client’s body.  Touch that is too lingering or too invasive also falls into this category of invasion of physical boundary.  Violations may also include smells and aromas that the client finds offensive, the application of heat and cold when consent is not given, or the use of the therapist’s own body during treatment.  It is important to make sure that the client has privacy when undressing and dressing and that the client has a clear choice about what clothing they will keep on or whether they will wear a gown.  As per state law, appropriate draping procedures should always be observed.  The practitioner should obtain informed consent from the client to work on certain parts of the body, like high on the thigh, buttocks, front of the hip near the genital area, stomach and on the chest around breast tissue.  Touching these areas are the most likely to be misconstrued as a breach of physical boundaries. In yoga therapy, touch that is incidental to the process of providing the therapy is considered justified. However, touch that is performed for its therapeutic effect is out of the scope of practice and the therapist would have to have a massage therapy or physical therapy license. 

Physical boundary needs may be increased for the survivor of abuse or any trauma brought on by a previous breach of boundaries.  In such situations, it is important for the therapist to adjust their sense of boundaries so that the client or patient feels safe and that their boundaries are respected. 

It is the responsibility of the therapist to set clear boundaries for themselves, as well.  Violations may be as blatant as sexual advances from the client, but may include uninvited hugs or client initiated exposure of intimate areas of their body.  Whether the violations are subtle or obvious, they should be addressed in a professional manner.  The physical boundaries of the therapist are even more at risk if the setting is the therapist’s home, especially if the client is new and no other person is at home with the therapist.  In such situations, setting a policy of safety is crucial.  The therapist can set a policy that they will not treat new clients or anyone they do not know well unless another adult is near.

Therapists should also set time boundaries with clients during the initial conversation on the phone or during the first visit so that the client knows what to expect regarding time boundaries.  Let the client know how long the massage or treatment will be, given the objectives or reason for the treatment.  It is also important to explain that the first session may take longer due to intake processing and assessment. 

Dual Relationships
Dual relationships happen when interactions between people cross one or more relationship roles.  For example, you might meet someone at a social event and then later establish a professional relationship with this person in a healthcare setting.  Healthcare professionals should avoid dual relationships with clients and patients as much as possible.  It may be in the therapist’s best interest to avoid all dual relationships in order to keep roles and boundaries clear.  These situations may pose a risk for both the therapist and the client due to power differential and boundary differentials.  For example, if you are treating a friend, they may expect special favors or special boundaries, which put you in an uneasy position.  How you handle your dual relationships is ultimately your decision.  However, remember to keep the focus on the client during therapy and be as conscious and professional as you can with your boundaries.

Supervision and Support
Many times, difficulties such as transference, countertransference, and dual relationships may arise for the therapist.  Questions may occur to the therapist, such as “Should I go to the social event at the client’s house?” or “Should I accept the client’s invitation for coffee?” Answers to such questions must be made in a constructive manner without causing strong feelings of rejection.  Also, as mentioned above, therapists may have feelings of attraction to the client or attachment to outcomes – all of which can affect the client/therapist relationship.  When this occurs, it is a good idea to seek help through professional or peer supervision, which can provide a place to explore ideas and work through these kinds of experiences.  Peer supervision offers a solid support system to the therapist for working with the occasional challenging client.
As you can see, supervision acts as a guide that enhances self-understanding and direction toward constructive answers through questions of the therapist’s thoughts and feelings during the times of difficulty. This helps to uncover core issues of the problem and makes for smoother sailing for the therapist. Supervision also provides a place for self-care, support, nurturance and appreciation from others for the good and vital work a therapist does.


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