Ethics in Rehabilitation: A Clinical Perspective

Abstract

In Ethics in Rehabilitation: A Clinical Perspective, Kornblau and Burkhardt argue that funding structures, limited resources, and evolving practice requirements are common sources of ethical challenges for rehabilitation professionals. In a recent empirical study of rehabilitation nurses, the most frequently reported ethical conflicts were related to concerns about resource allocation, specifically disagreements about medical or institutional practice, patients' rights, and payment issues.1 It is thus worth asking which criteria or tools should be used to address these dilemmas. The authors draw our attention to this field of inquiry by providing an overview of some basic knowledge to approach ethical dilemmas in rehabilitation. The purpose of this very well organized and clearly written book is to give clinicians tools for analyzing ethical conflicts in their particular legal, social, and political contexts. The authors draw on their backgrounds in occupational therapy, public health, health care ethics, and law to present an approach that illuminates this important subject. They navigate with ease from discussions of political and social contexts and the key legal principles that affect ethical decision making to a presentation of useful clinical tools. The overview of ethical theory is rather thin, and somewhat simplistic, but nonetheless integrates pragmatic and helpful clinical illustrations. It should be noted that the socio-political context and the legal framework set out in the book are those of the United States; Canadian and international contexts are not discussed. While it covers many important topics that are relevant to rehabilitation professionals, this text will be of particular interest to clinical ethics educators, as the second section provides a catalogue of 140 ethical dilemmas related to a wide range of practice issues in rehabilitation. Taking the reader through a logical, step-by-step framework, Kornblau and Burkhardt present a structure for analyzing an ethical dilemma, built around questions that should be asked to ensure a complete and nuanced analysis. This tool, oddly enough, is called CELIBATE (Clinical Ethics and Legal Issues Bait All Therapists Equally); it consists of several steps: identifying the problem and the facts, the interested parties, and the nature of their interests; examining the potential ethical and legal dilemma; asking whether more information is needed; brainstorming action steps; analyzing them; and choosing a course of action. This structured and formal analytic grid is a strength, as the criteria are organized so that the reader learns practical rules of thumb with which to evaluate ethical dilemmas. Such a grid can help clinicians to carefully consider aspects of a dilemma and can have important pedagogical uses for clinicians seeking tools to sharpen their ethical analysis. An important limitation of the authors' ethical framework, at least for rehabilitation professionals, is that CELIBATE does not include any specific rehabilitation-oriented content. Moreover, a more societally focused language could be integrated; current codes of ethics in physical therapy, including that of the Canadian Physiotherapy Association, have been revised to move beyond focusing on the individual realm of ethical obligations and address the organizational and societal realms.2 Finally, CELIBATE would be strengthened by adding an additional step that encourages clinicians to reflect critically on the outcome of the situation and how the decision-making process was experienced by all involved.3 Another innovative tool from this book is a list of practical hints to help clinicians act in a legal and ethical manner (e.g., place the patient's interest above all, handle situations as they arise, yearn to learn); this list should be an essential desk reference for all clinicians! In Ethics in Rehabilitation: A Clinical Perspective, Kornblau and Burkhardt provide a rich and nuanced overview of rehabilitation ethics in the United States, with some useful ethical tools to address particular dilemmas. While not specifically aimed at a Canadian audience, the book provides a thorough guide to ethical thinking and practice in a clinical context, and should therefore be of interest to physiotherapists working in Canada, whether as practitioners or as educators. The authors offer pragmatic tools to empower rehabilitation professionals in their day-to-day ethical judgments, especially in a context of scarcity in which limited public health care resources create a need for fair and effective management of these services for the population.