It has been said that every clinical decision involving a patient has a moral or ethical dimension. The physical therapist’s response to this ethical circumstance requires that the therapist possesses the moral courage to formulate a reply to the ethical situation and implement a decision that will benefit the patient. The ability to act ethically on behalf of a patient’s needs is inherent in the notion of professionalism. In our society, a professional is regarded as possessing more than a body of knowledge and technical expertise. A true professional is expected to perform a valuable service to society. In exchange for autonomy to make decisions on behalf of vulnerable patients and on behalf of society, a professional is expected to abide by high ethical standards. In essence, they are expected to exercise professional expertise responsibly, and to make accountable decisions that are in the patient’s and society’s best interests (Swisher, 2005). The American Physical Therapy Association (APTA), recognizing the intimate relationship between professionalism and ethics, has adopted a consensus document that identifies the core values of professionalism in physical therapy practice. These core values can be viewed as guiding principles for the ethical treatment of patients, especially those older individuals who are entrusted to our care. The core values are accountability, altruism, compassion and caring, excellence, integrity, professional duty and social responsibility (APTA, 2003).

Morality is defined by Purtilo as guidelines that are designed to preserve the fabric of society. Ethics, on the other hand, can be viewed as ‘a systematic reflection on and analysis of morality’ (Purtilo & Doherty, 2011). As such, ethics is based on principles that provide a conceptual framework within which it is possible to place perceptions of ethical cases and problems. These principles allow the imposition of some sense of artificial order on a story, and they affect people’s response to it. Ethical concepts are tied to society’s customs, manners, traditions and institutions. In essence, these concepts define how members of a society deal with the world.

Professional ethics that arise in the context of healthcare provide guidelines that are ultimately no different from those that arise from religious, philosophical, cultural and other societal sources (Purtilo & Doherty, 2011). Ethical situations in geriatrics are similar to ethical situations in other aspects of healthcare, but the context in which situations arise may be more complex. Therefore, similar reasoning processes can be utilized as a basis to answer questions of morality when dealing with older individuals.

The foundational principles of biomedical ethics that govern geriatric rehabilitation professionals include the following ethical duties and rights:

Secondary ethical duties inherent in healthcare include the following:

Traditional bioethical principles may have limited value in guiding ethical decisions that must be made daily when caring for geriatric patients in today’s complex healthcare environment. Virtue ethics is another theory that may provide the physical therapist with additional insight into ethical care. Virtue ethicists look at character rather than rules for moral guidance in patient care decisions. Grounding oneself in virtue provides a foundation for acting in a certain way when interpreting and applying ethical principles. Therefore, virtue ethics is considered as a theory of being that focuses on the character of the moral agent rather than on the acts of that agent. For example, a virtue ethicist would look at the patience of the therapist treating the older individual, rather than judge the lack of productivity that resulted from the therapist taking additional time to address the complex concerns of an older patient. A virtue is defined as a good habit that balances excesses and deficiencies. As agents, physical therapy practitioners may apply virtue ethics to geriatric care by developing trusting relationships with patients, being compassionate, and developing a deep awareness of the lives and wishes of the patient. Compassion is considered a cardinal virtue of physical therapists treating geriatric patients, and moral and ethical actions are guided by that compassion. Respect for human dignity is another important virtue to consider when dealing with older individuals. Respect involves more than good manners. It acknowledges both personal and inherent dignity. Personal dignity refers to privacy or breach of patient confidence. The concept that every human has inherent dignity represents the deeper virtue or aspect of respect. Vulnerable older adults, including those with diminished cognitive capacity, are worthy of the type of respect that supersedes good manners and leads us to assume our role as moral agents (Pellegrino & Thomasma, 1993; Nalette, 2001; Jonsen et al., 2006).

Regardless of the ethical theory, when physical therapists deliberate an ethical concern or attempt to determine a solution to an ethical situation, the goal should be to provide a caring response. In spite of competing loyalties, the primary loyalty must be to the patient, and the caring response must lead to a conclusion with purposeful action. Purtilo states that care means ‘seeking the deepest understanding of what that other person really needs. Care is what you pay attention to. And that’s important within the health professional–patient relationship’ (Ries, 2003). Ethically, it means going beyond evidence-based practice that simply looks at the results of research studies and, instead, incorporates the essence of true evidence-based practice, which includes client-centered goals in patient care. This may involve helping the patient to understand how your knowledge and expertise may benefit them, and empowering older patients to make decisions that are in their best interests. It means listening to the older individual’s story, and respecting their ideas, concerns and perspectives as you jointly develop a meaningful plan of care (Ries, 2003).

The World Confederation of Physical Therapy (WCPT) has adopted ethical principles that are recognized as prototypes for member organizations to develop their own code of ethics or code of conduct (see Box 75.1). The ethical principles articulated by WCPT can offer ethical guidance for physical therapists providing care for geriatric patients. Specifically, the first principle states that physical therapists respect the rights and dignity of all individuals. This principle directs practitioners to respect patients regardless of age, gender, race, nationality, religion, ethnic origin, creed, color, sexual orientation, disability, health status or politics. It implies the patient/client’s right to the highest quality services, make an informed decision, have access to their physical therapy data, and confidentiality. The second principle requires that physical therapists comply with laws and regulations that govern the practice of physical therapy in the country in which they work. It specifies that physical therapists have a right to advocate for patient/client access to those who have a capacity to benefit from services. In addition to licensing laws, this principle implies that therapists in the United States of America who treat older individuals have knowledge of the legal implications of informed consent. It also implies that therapists understand the regulations related to Medicare reimbursement. The third principle states that physical therapists accept responsibility for the exercise of sound judgment. Inherent in this principle is the notion of professional independence and autonomy and the idea that a therapist is qualified to make judgments regarding the physical therapy plan of care. Implied is that the therapist is working within the scope of the profession, is competent based on knowledge and skill, has made an appropriate assessment and determined a diagnosis, and will implement the plan of care based on the assessment and diagnosis. This principle also addresses the fact that physical therapists must not delegate to another health professional or support worker any activity that requires the unique skill, knowledge and judgment of the physical therapist, that the therapist should encourage consultation with referring practitioners when the recommended treatment program is not appropriate, and states that physical therapists have the right to expect cooperation from colleagues. The fourth principle directs physical therapists to provide honest, competent and accountable professional services. This principle directs therapists to ensure that behaviour and conduct is professional at all times, to deliver timely patient/client-specific physical therapy interventions in line with the individual’s goals, and to ensure that patients/clients understand the nature of the service being provided, including costs. It directs therapists to keep adequate client records and to disclose those records only to individuals who have a legitimate right to access the information contained in the documentation. Finally, this principle requires physical therapists to undertake a continuous, planned, personal development program in order to maintain and enhance professional knowledge and skills. Included in this principle is the notion that ethical practice takes precedence over business practices in the provision of physical therapy services. The fifth principle states that physical therapists must be committed to providing quality services. As stated, this principle requires physical therapists to be aware of current standards of practice, and to participate in continuing professional development to enhance basic knowledge, to support research and keep up to date with best evidence and implement it in their practice, and to support quality education in academic and clinical settings. The sixth principle identifies the physical therapist’s entitlement to just and fair remuneration for services rendered. The seventh principle directs therapists to provide accurate information to patients, other agencies and the community regarding physical therapy services. This principle recommends that physical therapists participate in public education programs to provide information about the profession, and to provide truthful information to inform the public and referring professionals about the profession. It permits advertising, provided that therapists do not use false, fraudulent, misleading, deceptive, unfair, or sensational statements. The eighth principle expects physical therapists to contribute to the planning and development of services that address the health needs of the community. This principle obliges therapists to work toward achieving justice in the provision of healthcare for all people, and may be particularly applicable in view of the needs and access to care provided for geriatric clients under the current constraints imposed by healthcare regulations and financing in the US healthcare delivery system (WCPT, 2011).