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Journal of the Australian Health Promotion Association
RESEARCH ARTICLE

An ethical approach to health promotion in physiotherapy practice

Clare Delany A B D , Caroline Fryer C and Gisela van Kessel C
+ Author Affiliations
- Author Affiliations

A Children’s Bioethics Centre, Royal Children’s Hospital, 50 Flemington Road, Parkville, Vic. 3052, Australia.

B Department of Medical Education, University of Melbourne, Medical School Building, Grattan Street, Carlton, Vic. 3053, Australia.

C International Centre for Allied Health Evidence, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia.

D Corresponding author. Email: c.delany@unimelb.edu.au

Health Promotion Journal of Australia 26(3) 255-262 https://doi.org/10.1071/HE15052
Submitted: 1 June 2015  Accepted: 17 September 2015   Published: 27 October 2015

Abstract

Issue addressed: With increased emphasis on reducing the global burden of non-communicable disease, health professionals who traditionally focused on the individual are being encouraged to address population-level health problems. While physiotherapists are broadening their clinical role to include health promotion strategies in their clinical practice, the ethical foundations of this practice focus have received less attention.

Methods: We use a physiotherapy clinical scenario to highlight different physiotherapeutic approaches and to analyse underpinning ethical values and implications for practice.

Results: We suggest there are potential harms of incorporating health promotion into physiotherapy management of individuals if the population-based research does not resonate with an individual’s particular circumstances, capacity to change or view of what counts as important and meaningful. We propose that critical reasoning and ethical judgment by the physiotherapist is required to determine how health promotion messages applied in primary care settings might work to benefit and enhance a client’s well being rather than impose burdens or cause harm.

Conclusion: We suggest four ethical reasoning strategies designed to assist physiotherapists to frame and understand fundamental ethical principles of beneficence, harm, autonomy and justice when implementing health promotion and self-management approaches in clinical practice.

Key words: autonomy, physiotherapy ethics.


References

[1]  Carpenter C (1996) The evolving culture of physiotherapy. Physiother Can 48, 11–5.

[2]  Thornquist E (2001) Diagnostics in physiotherapy – processes, patterns and perspectives. Part I. Adv Physiother 3, 140–50.
Diagnostics in physiotherapy – processes, patterns and perspectives. Part I.Crossref | GoogleScholarGoogle Scholar |

[3]  Higgs J, Refshauge K, Ellis E (2001) Portrait of the physiotherapy profession. J Interprof Care 15, 79–89.
Portrait of the physiotherapy profession.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3MnltFSktw%3D%3D&md5=479534526bc36ac4f3f8c0c0d0890237CAS | 11705073PubMed |

[4]  Herbert R, Jamtvedt G, Birger Hagen K, Mead J, Chalmers I. Practical evidence-based physiotherapy. London: Churchill Livingstone; 2011.

[5]  Chan S, Clough A (2010) A critical evaluation of evidence-based practice of physiotherapy in musculoskeletal medicine. Int Musculoskelet Med 32, 163–6.
A critical evaluation of evidence-based practice of physiotherapy in musculoskeletal medicine.Crossref | GoogleScholarGoogle Scholar |

[6]  Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. New York: Oxford University Press; 2001.

[7]  Gillon R (1994) Medical ethics: four principles plus attention to scope. BMJ 309, 184
Medical ethics: four principles plus attention to scope.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2czhvFantw%3D%3D&md5=0e403b6c5a133281f70ff564f527d345CAS | 8044100PubMed |

[8]  Australian Physiotherapy Association. APA code of conduct. 2008. Available from: http://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/The%20APA/Governance/Code_of_Conduct_V2013.pdf [Verified 5 October 2015].

[9]  Mead N, Bower P (2000) Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 51, 1087–110.
Patient-centredness: a conceptual framework and review of the empirical literature.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD3cvltVCisw%3D%3D&md5=9e4b4d3469a637d5a8c6ec7f61ad6f0bCAS | 11005395PubMed |

[10]  Oliveira VC, Refshauge KM, Ferreira ML, Pinto RZ, Beckenkamp PR, Negrao Filho RF, et al (2012) Communication that values patient autonomy is associated with satisfaction with care: a systematic review. J Physiotherapy 58, 215–29.
Communication that values patient autonomy is associated with satisfaction with care: a systematic review.Crossref | GoogleScholarGoogle Scholar |

[11]  Perreault K (2008) Linking health promotion with physiotherapy for low back pain: a review. J Rehabil Med 40, 401–9.
Linking health promotion with physiotherapy for low back pain: a review.Crossref | GoogleScholarGoogle Scholar | 18509553PubMed |

[12]  O’Donoghue G, Cunningham C, Murphy F, Woods CA-HJ (2014) Assessment and management of risk factors for the prevention of lifestyle-related disease: a cross-sectional survey of current activities, barriers and perceived training needs of primary care physiotherapists in the Republic of Ireland. Physiotherapy 100, 116–22.
Assessment and management of risk factors for the prevention of lifestyle-related disease: a cross-sectional survey of current activities, barriers and perceived training needs of primary care physiotherapists in the Republic of Ireland.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC2crosFWhsQ%3D%3D&md5=adb35d886cfebc7594317b556cd5215aCAS | 24679374PubMed |

[13]  Dean E, de Andrade AD, O’Donoghue G, Skinner M, Umereh G, Beenen P, et al (2014) The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract 30, 261–75.
The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases.Crossref | GoogleScholarGoogle Scholar | 24252072PubMed |

[14]  Dallaire C, Hagan L, O’Neill M. Linking health promotion and community health nursing: conceptual and practical issues. In Stewart M, editor. Community nursing: promotion of Canadians’s health (pp. 317–32). Toronto: WB Saunders; 2000.

[15]  Bodenheimer T, Lorig K, Holman H, Grumbach K (2002) Patient self-management of chronic disease in primary care. J Am Med Assoc 288, 2469–75.
Patient self-management of chronic disease in primary care.Crossref | GoogleScholarGoogle Scholar |

[16]  Moseley AM, Herbert RD, Sherrington C, Maher CG (2002) Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro). Aust J Physiother 48, 43–9.
Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro).Crossref | GoogleScholarGoogle Scholar | 11869164PubMed |

[17]  Messier SP, Loeser RF, Miller GD, Morgan TM, Rejeski WJ, Sevick MA, et al (2004) Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial. Arthritis Rheum 50, 1501–10.
Exercise and dietary weight loss in overweight and obese older adults with knee osteoarthritis: the Arthritis, Diet, and Activity Promotion Trial.Crossref | GoogleScholarGoogle Scholar | 15146420PubMed |

[18]  Snodgrass SJ, Carter AE, Guest M, Collins CE, James C, Kable AK, et al (2014) Weight management including dietary and physical activity advice provided by Australian physiotherapists: a pilot cross-sectional survey. Physiother Theory Pract 30, 409–20.
Weight management including dietary and physical activity advice provided by Australian physiotherapists: a pilot cross-sectional survey.Crossref | GoogleScholarGoogle Scholar | 24559081PubMed |

[19]  Boll M, Boström-Lindberg E (2010) Physiotherapists’ understanding and approach to health promotion work in compulsory school: perceiving and supporting coherence. Physiother Theory Pract 26, 318–26.
Physiotherapists’ understanding and approach to health promotion work in compulsory school: perceiving and supporting coherence.Crossref | GoogleScholarGoogle Scholar | 20557262PubMed |

[20]  Alexander J, Bambury E, Mendoza A, Reynolds J, Veronneau R, Dean E (2012) Health education strategies used by physical therapists to promote behaviour change in people with lifestyle-related conditions: a systematic review. Hong Kong Physiother J 30, 57–75.
Health education strategies used by physical therapists to promote behaviour change in people with lifestyle-related conditions: a systematic review.Crossref | GoogleScholarGoogle Scholar |

[21]  World Health Organization. Global status report on noncommunicable diseases. 2010. Available from: http://www.who.int/nmh/publications/ncd_report2010/en/ [Verified 5 October 2015]

[22]  Edwards I, Richardson B (2008) Clinical reasoning and population health: decision making for an emerging paradigm of health care. Physiother Theory Pract 24, 183–93.
Clinical reasoning and population health: decision making for an emerging paradigm of health care.Crossref | GoogleScholarGoogle Scholar | 18569855PubMed |

[23]  Carter SM, Rychetnik L, Lloyd B, Kerridge IH, Baur L, Bauman A., et al (2011) Evidence, ethics, and values: a framework for health promotion. Am J Public Health 101, 465–72.
Evidence, ethics, and values: a framework for health promotion.Crossref | GoogleScholarGoogle Scholar | 21233436PubMed |

[24]  Puhl RM, King KM (2013) Weight discrimination and bullying. Best Pract Res Cl En 27, 117–27.
Weight discrimination and bullying.Crossref | GoogleScholarGoogle Scholar |

[25]  Buchanan D (2006) Moral reasoning as a model for health promotion. Soc Sci Med 63, 2715–26.
Moral reasoning as a model for health promotion.Crossref | GoogleScholarGoogle Scholar | 16911850PubMed |

[26]  Setchell J, Watson B, Jones L, Gard M (2015) Weight stigma in physiotherapy practice: patient perceptions of interactions with physiotherapists. Manual Ther
Weight stigma in physiotherapy practice: patient perceptions of interactions with physiotherapists.Crossref | GoogleScholarGoogle Scholar |

[27]  Delany CM (2005) Respecting patient autonomy and obtaining their informed consent: ethical theory—missing in action. Physiotherapy 91, 197–203.
Respecting patient autonomy and obtaining their informed consent: ethical theory—missing in action.Crossref | GoogleScholarGoogle Scholar |

[28]  Delany CM (2007) In private practice, informed consent is interpreted as providing explanations rather than offering choices: a qualitative study. Aust J Physiother 53, 171–7.
In private practice, informed consent is interpreted as providing explanations rather than offering choices: a qualitative study.Crossref | GoogleScholarGoogle Scholar | 17725474PubMed |

[29]  Dawson A (2010) The future of bioethics: three dogmas and a cup of hemlock. Bioethics 24, 218–25.
The future of bioethics: three dogmas and a cup of hemlock.Crossref | GoogleScholarGoogle Scholar | 20500759PubMed |

[30]  Anderson J, Honneth A. Autonomy, vulnerability, recognition, and justice. In Christman J, Anderson J, editors. Autonomy and the challenges to Liberalism: new essays (pp. 127–49). Cambridge: Cambridge University Press; 2005.

[31]  Wardrope A (2015) Relational autonomy and the ethics of health promotion. Public Health Eth 8, 50–62.
Relational autonomy and the ethics of health promotion.Crossref | GoogleScholarGoogle Scholar |

[32]  Mackenzie C, Stoljar N. Relational autonomy: feminist perspectives on autonomy, agency, and the social self. Oxford: Oxford University Press; 2000.

[33]  Mackenzie C (2008) Relational autonomy, normative authority and perfectionism. J Soc Philos 39, 512–33.
Relational autonomy, normative authority and perfectionism.Crossref | GoogleScholarGoogle Scholar |

[34]  Edwards I, Delany CM. Ethical reasoning. In Higgs J, Jones M, Loftus S, Christensen N, editors. Clinical Reasoning in the health professions 3rd edn (pp. 279–89). Boston: Elsevier; 2008.

[35]  Poulis I (2007) Bioethics and physiotherapy. J Med Ethics 33, 435–6.
Bioethics and physiotherapy.Crossref | GoogleScholarGoogle Scholar | 17664296PubMed |

[36]  Goldberg DS (2012) Social justice, health inequalities and methodological individualism in US health promotion. Public Health Ethics 5, 104–15.
Social justice, health inequalities and methodological individualism in US health promotion.Crossref | GoogleScholarGoogle Scholar |

[37]  Dawson A, Grill K (2012) Health Promotion: conceptual and ethical issues. Public Health Eth 5, 101–3.
Health Promotion: conceptual and ethical issues.Crossref | GoogleScholarGoogle Scholar |

[38]  Edwards I, Delany CM, Townsend AF, Swisher LL (2011) Moral agency as enacted justice: a clinical and ethical decision-making framework for responding to health inequities and social injustice. Phys Ther 91, 1653–63.
Moral agency as enacted justice: a clinical and ethical decision-making framework for responding to health inequities and social injustice.Crossref | GoogleScholarGoogle Scholar | 21885448PubMed |

[39]  Edwards I, Richardson B (2008) Clinical reasoning and population health: decision making for an emerging paradigm of health care. Physiother Theory Pract 24, 183–93.
Clinical reasoning and population health: decision making for an emerging paradigm of health care.Crossref | GoogleScholarGoogle Scholar | 18569855PubMed |

[40]  Purtilo RB (2000) A time to harvest, a time to sow: ethics for a shifting landscape. Phys Ther 80, 1112–9.

[41]  Trede F, Higgs J. Models and philosophy of practice. In Higgs J, Smith M, Webb G, Skinner M, Croker A, editors. Contexts of physiotherapy practice (pp. 90–101). Sydney: Elselvier; 2009.

[42]  Dean E, Al-Obaidi S, De Andrade AD, Gosselink R, Umerah G, Al-Abdelwahab S, et al (2011) The first physical therapy summit on global health: implications and recommendations for the 21st century. Physiother Theory Pract 27, 531–47.
The first physical therapy summit on global health: implications and recommendations for the 21st century.Crossref | GoogleScholarGoogle Scholar | 21612551PubMed |

[43]  Borrell-Carrió F, Suchman AL, Epstein RM (2004) The biopsychosocial model 25 years later: principles, practice, and scientific inquiry. Ann Fam Med 2, 576–82.
The biopsychosocial model 25 years later: principles, practice, and scientific inquiry.Crossref | GoogleScholarGoogle Scholar | 15576544PubMed |

[44]  Brunner E, De Herdt A, Minguet P, Baldew S, Probst M (2013) Can cognitive behaviour therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review. Disabil Rehabil 35, 1–10.
Can cognitive behaviour therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review.Crossref | GoogleScholarGoogle Scholar | 22607157PubMed |

[45]  Moreno-Peral P, Conejo-Cerón S, Fernández A, Berenguera A, Martínez-Andrés M, Pons-Vigués M, et al (2015) Primary care patients’ perspectives of barriers and enablers of primary prevention and health promotion – a meta-ethnographic synthesis. PLoS One 10, e0125004
Primary care patients’ perspectives of barriers and enablers of primary prevention and health promotion – a meta-ethnographic synthesis.Crossref | GoogleScholarGoogle Scholar | 25938509PubMed |

[46]  Lattanzi JB, Purnell LD. Developing cultural competence in physical therapy practice. Philadelphia: F.A. Davis Co.; 2006.

[47]  Corbin J, Strauss A. Unending work and care: managing chronic illness at home. San Francisco: Jossey-Bass Publishers; 1988.

[48]  Gillam L, Delany C, Guillemin M, Warmington S (2014) The role of emotions in health professional ethics teaching. J Med Ethics 40, 331–5.
The role of emotions in health professional ethics teaching.Crossref | GoogleScholarGoogle Scholar | 23760728PubMed |

[49]  Charon R, Montello M. Stories matter: the role of narrative in medical ethics. New York: Routledge; 2002.

[50]  White S, Fook J, Gadner F. Critical reflection in health and social care. Maidenhead, UK: Open University Press; 2006.

[51]  Delany C, Watkin D (2009) A study of critical reflection in health professional education: learning where others are coming from. Adv Health Sci Educ 14, 411–29.
A study of critical reflection in health professional education: learning where others are coming from.Crossref | GoogleScholarGoogle Scholar |

[52]  Guillemin M, Gillam L (2015) Emotions, narratives and ethical mindfulness. Acad Med 90, 726–31.
Emotions, narratives and ethical mindfulness.Crossref | GoogleScholarGoogle Scholar | 25853684PubMed |

[53]  Charles C, Gafni A, Whelan T (1997) Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med 44, 681–92.
Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango).Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s7osFSqtg%3D%3D&md5=763bbab74dcec0788c2e48425b3520d4CAS | 9032835PubMed |

[54]  Braddock CH, Edwards KA, Hasenberg NM, Laidley TL, Levinson W (1999) Informed decision making in outpatient practice: time to get back to basics. JAMA 282, 2313–20.
Informed decision making in outpatient practice: time to get back to basics.Crossref | GoogleScholarGoogle Scholar | 10612318PubMed |

[55]  Emanuel EJ, Emanuel LL (1992) Four models of the physician-client relationship. JAMA 267, 2221–6.
Four models of the physician-client relationship.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK383htFOrug%3D%3D&md5=9b5dc7f2aa33bba4fecd7821504d4babCAS | 1556799PubMed |

[56]  Hill T. The Kantian conception of autonomy. In Christman J, editor. The inner citadel: essays on individual autonomy (pp. 91–109). New York: Oxford University Press; 1989.

[57]  Dworkin G. The theory and practice of autonomy. Cambridge: Cambridge University Press; 1988.

[58]  Mill JS. On liberty (1865). In Gray J, Smith G, editors. On liberty in focus. London: Routledge; 1991.

[59]  Jensen G, Richert A (2005) Reflections on the teaching of ethics in physical therapist education: integrating cases, theory, and learning. J Phys Ther Educ 19, 78–85.

[60]  Patton M. Qualitative research and evaluation methods. 3rd edn. California: Sage; 2002.

[61]  Richardson B, Higgs J, Dahlgren M. Recognising practice epistemology in the health professions. In Higgs J, Richardson B, Dahlgren M, editors. Developing practice knowledge for health professionals (pp. 1–14). Edinburgh: Butterworth Heinemann; 2001.

[62]  Delany CM, Edwards I, Jensen G (2010) Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics; author response. Phys Ther 90, 1081–2.
Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics; author response.Crossref | GoogleScholarGoogle Scholar |

[63]  World Health Organization. Track 2: Health literacy and health behaviour. 2015.. Available from: http://www.who.int/healthpromotion/conferences/7gchp/track2/en/ [Verified 24 August 2015].

[64]  Jordan JE, Buchbinder R, Osborne RH (2010) Conceptualising health literacy from the patient perspective. Patient Educ Couns 79, 36–42.
Conceptualising health literacy from the patient perspective.Crossref | GoogleScholarGoogle Scholar | 19896320PubMed |

[65]  Loke YK, Hinz I, Wang X, Rowlands G, Scott D, Salter C (2012) Impact of health literacy in patients with chronic musculoskeletal disease–systematic review. PLoS One 7, e40210
Impact of health literacy in patients with chronic musculoskeletal disease–systematic review.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC38XhtVCitb7J&md5=6ba107d8be2793ecab1f78ae918723f8CAS | 22792242PubMed |

[66]  Edwards M, Wood D, Myfanwy D, Edwards D (2012) The development of health literacy in patients with a long-term health condition: the health literacy pathway. BMC Public Health 12, 130
The development of health literacy in patients with a long-term health condition: the health literacy pathway.Crossref | GoogleScholarGoogle Scholar | 22332990PubMed |

[67]  Wade DT, Halligan PW (2004) Do biomedical models of illness make for good healthcare systems? BMJ 329, 1398–401.
Do biomedical models of illness make for good healthcare systems?Crossref | GoogleScholarGoogle Scholar | 15591570PubMed |

[68]  Epstein RM, Morse DS, Williams GC, le Roux P, Suchman AL, Quill TE. Clinical practice and the biopsychosocial approach. In Frankel RM, Quill TE, McDaniel SH, editors. The biopsychosocial approach: past, present, future (pp. 33–66). Rochester: The University of Rochester Press; 2003.

[69]  Thornquist E (1990) Communication: what happens during the first encounter between patient and physiotherapist. Scand J Prim Health 8, 133–8.
Communication: what happens during the first encounter between patient and physiotherapist.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK3M%2FnsFWjug%3D%3D&md5=f4dd803758d09c3a805eb3fae8c5cbc8CAS |

[70]  Opsommer E, Schoeb V (2014) ‘Tell me about your troubles’: description of patient-physiotherapist interaction during initial encounters. Physiother Res Int 19, 205–21.
‘Tell me about your troubles’: description of patient-physiotherapist interaction during initial encounters.Crossref | GoogleScholarGoogle Scholar | 24711174PubMed |

[71]  Nielsen M, Keefe FJ, Bennell K, Jull GA (2014) Physical therapist-delivered cognitive-behavioral therapy: a qualitative study of physical therapists’ perceptions and experiences. Phys Ther 94, 197–209.
Physical therapist-delivered cognitive-behavioral therapy: a qualitative study of physical therapists’ perceptions and experiences.Crossref | GoogleScholarGoogle Scholar | 24029300PubMed |

[72]  Dixon KE, Keefe FJ, Scipio CD, Perri LM, Abernethy AP (2007) Psychological interventions for arthritis pain management in adults: a meta-analysis. Health Psychol 26, 241–250.
Psychological interventions for arthritis pain management in adults: a meta-analysis.Crossref | GoogleScholarGoogle Scholar | 17500610PubMed |

[73]  World Health Organization. The Ottawa Charter for health promotion. 1986. Available from: http://www.who.int/healthpromotion/conferences/previous/ottawa/en/ [Verified 5 October 2015].

[74]  Gregg J, O’Hara L (2007) Values and principles evident in current health promotion practice. Health Promot J Austr 18, 7–11.