Patients are entitled to expect that their therapeutic encounter with a reflexologist will provide benefit in the form of symptomatic relief or enhanced well-being. So too, patients are entitled to expect that their encounter with a reflexologist will not cause them harm. These expectations (reflected in law as rights) are encapsulated in the ethical duties of beneficence (benefiting) and non-maleficence (not harming) – ethical principles that are at the heart of all healthcare relationships. The therapeutic relationship is a ‘fiduciary’ relationship, whereby patients trust practitioners with access to their personal information and permit close touch, trusting that the reflexologist will be motivated, at all times, by the patient’s interests. These duties form the basis of reflexology codes of ethics and are a central plank of Western and non-Western healing traditions (Stone 2002). As in most complementary and alternative (CAM) therapies, the notion of what constitutes ‘benefiting’ in reflexology is somewhat wider than within conventional medicine. Whereas medical benefit usually involves the removal of symptoms, reflexology may benefit patients by preventing illness from arising or may improve the patient’s mental outlook on his or her condition through relaxation. Equally, however, the notion of harm is somewhat broader, and can include not just physically injuring a patient, but also causing emotional harm, or preventing the patient from seeking more appropriate treatment. Therapists must always avoid making inappropriate claims for reflexology, and indeed are bound by the laws pertaining to specific conditions, for example, not guaranteeing to cure cancer, not providing maternity care except in an emergency and not attempting to treat sexually transmitted disease.

To be able to benefit patients, reflexologists must be competent. Competence requires both technical proficiency, including keeping up to date with advances in research and clinical practice, and ethical literacy. This means the ability to analyse and reflect upon ethical dilemmas arising in practice. As many reflexologists work single-handedly in private practice, therapists must recognise their own limits of competence and should be willing to refer on where necessary, either to a more experienced reflexologist, or to another CAM practitioner, or to a medical doctor, as appropriate. Whilst holistic therapists can, conceptually, offer some level of benefit to all patients, practitioners must be realistic about not treating patients, or not continuing to treat patients, for whom little benefit is likely.

‘Best practice’ demands not just high standards of pre-registration training, but also a commitment on the part of the reflexologist, once qualified, for continuing professional development (CPD) and, where possible, supervision of practice (Mackereth 2001). In the statutory health sector, CPD is increasingly regarded as a requirement to remain on a professional register, and it is likely that CAM professions will adopt this principle too. Reflexologists should also keep themselves up to date with current research in order that practice can be based on the best available evidence. Whilst individual practitioners may not wish to become research active, they should nonetheless undertake audit of their practice to ensure that they are delivering consistent and acceptable outcomes.

Increasingly, codes of ethics now stipulate that reflexologists must themselves be in good physical and mental health in order to be able to treat patients effectively and safely. Working as part of a multidisciplinary team, or being in receipt of supervision, may help an individual to acknowledge a period where it is not prudent to practice. Failure to do so may result in a fitness-to-practice hearing and removal from a professional register.

The ethical duty to benefit patients is mirrored by a legal and professional duty of care requiring practitioners to treat patients with all due care and skill. Reflexologists who fall short of their duty of care and cause patients harm may be found negligent if sued in a civil court, or they might have to face a fitness-to-practice hearing before a professional body. Patients are more likely to resort to legal action when they are unable to seek redress through any other means. Negligence may arise out of any sphere of a reflexologist’s activities, such as failure to diagnose adequately or correctly, negligent treatment or negligent failure to disclose risks to the patient before providing treatment.

Negligence does not require the patient to demonstrate that the reflexologist intended to cause the patient harm. In determining whether a reflexologist has been negligent, a court would, broadly speaking, apply the ‘Bolam test’ of professional negligence. This test derives from the legal case of Bolam v. Friern Hospital Management Committee 1957. Although it has been slightly modified by subsequent case law (Hope et al. 2008), its main principle holds good, which is that the standard of care owed by a reflexologist to a patient is that which could be expected of a reasonably skilled and competent reflexologist acting in the given circumstances. Reflexologists must act in accordance with practice which would rightly be accepted as proper by a responsible body of professional opinion. This allows considerable latitude for how reflexologists treat, as it means that practitioners will only be negligent if they act in a way which no reasonable practitioner would have acted. In ascertaining ‘reasonableness’, the court would look to national standards and professional requirements in place at the time of the incident, such as National Vocational Qualifications, or the standards contained in the CNHC’s code of ethical conduct, and/or evidence would be sought from an expert witness. The absence of a single professional standard within reflexology at the time of writing presents difficulty in ascertaining the appropriate standard of reasonableness. Currently, the incidence of litigation against reflexologists arising out of their professional practice is minimal, and this is reflected in the low premiums for personal professional indemnity insurance which are paid by clinical reflexologists. Paradoxically, the rate of litigation may increase as reflexology becomes more popular and visible.

Safe, effective therapy requires safe, effective boundaries. Boundaries denote the safe and appropriate limits of professional relationships, based, at all times, on the best interests of the patient. When boundaries are breached, for example by practitioners acting in a sexually inappropriate way, or by practitioners becoming overly reliant on their patients to meet their own emotional or financial needs, this can result in serious and enduring harm to patients. It is always the professional’s responsibility to set and maintain clear boundaries (CHRE 2008). Although reflexologists are no more likely to abuse the relationship of trust than any other health professional, allegations of professional abuse have been raised against the range of regulated and unregulated health professions (Halter et al. 2007). Moreover, the particular dynamics and the context of the complementary and alternative medicine (CAM) relationship may increase the likelihood of boundary violation by both therapist and patients. For example, many reflexologists work in sole private practice out of their own homes or visit patients in their homes; they do not work as part of a team, and may not receive any sort of professional supervision. They may treat friends or friends of friends, or others with whom they have a dual relationship, and may actively cultivate a relaxed, ‘easy-going’ atmosphere, as distinct from a sterile, clinical environment. Each of these factors may exacerbate the risk of unclear boundaries (Stone 2008).