Ethical Issues in Physical Therapy Practice

Transcription

1 Ethical Issues i Physical Therapy Practice A Survey of Physical Therapists i New Eglad ANDREW A. GUCCIONE, MS This survey was a attempt to idetify which ethical decisios are most frequetly ecoutered ad are most difficult to make for practicig physical therapists. A questioaire that described 30 situatios with a ethical dimesio was set to 40 America Physical Therapy Associatio members practicig i New Eglad. A total of 17 (41.) usable questioaires was retured. Issues raised by items were desigated as primary, secodary, or opriority. Seve primary ad 11 secodary ethical issues were idetified. I brief, these issues ivolve the decisio about which patiets should be treated, what obligatios are etailed by that decisio, who should pay for treatmet, ad what duties derive from the physical therapist's relatioship with other health professioals, icludig physicias. Some of these decisios are more frequet i certai types of employmet facilities tha i others. Sources of ethical coflict ad the role of the professioal orgaizatio i defiig moral values for the professio are discussed i this paper, ad implicatios for educatio are preseted. Key Words: Ethics, medical; Ethics, professioal; Physical therapy. The eed to idetify ad clarify ethical issues withi a health professio icreases as the professio assumes resposibility for those areas of direct patiet care i its domai. A brief compariso of the 193 America Physiotherapy Associatio CODE OF ETH ICS with its 1977 America Physical Therapy Associatio (APTA) couterpart reflects the developmet of physical therapy as a professio i its ow right. 1 The physical therapist today, i defiig the limits of his legal ad professioal autoomy, must examie the practice of his professio from a ethical poit of view. By doig so, he carefully guards the rights of patiets, maitais his itegrity as a professioal, ad promotes the ideals of physical therapy as a professio. Mr. Guccioe was a cadidate for the degree of Master of Sciece i Physical Therapy at Sarget College of Allied Health Professios, Bosto Uiversity, whe this study was coducted. He is curretly Staff Physical Therapist, Physical Therapy Departmet, Massachusetts Rehabilitatio Hospital, 12 Nashua St, Bosto, MA (USA). Adapted from a paper preseted at the Fourth Aual Covetio of the Massachusetts Chapter, America Physical Therapy Associatio, Hyais, MA, April 197. This article was submitted April 2, 1979, ad accepted Jauary 4, 190. Thompso has suggested that there are three sources of coflict for health professioals makig ethical decisios. 2 First, coflicts may arise betwee a idividual's private covictios ad his coceptio of the requiremets of his professioal role. Secod, ethical dilemmas may be ecoutered whe the attitudes, values, ad goals of oe professio coflict with those of aother. Fially, the ethos (ideology) of a professio ad that of the society i which it fuctios may be i coflict. Professioal ethics has developed i respose to these sources of coflict, ad the APTA CODE OF ETHICS ad the guidelies for its iterpretatio emerge historically ad sociologically with that developmet. 1 The CODE may be regarded as a attempt to cousel physical therapists makig ethical judgmets by assertig the ideals of the professio ad by defiig some of the limits of professioally ad morally acceptable behavior. Cotiuig documetatio of the ethical cocers of practicig physical therapists is essetial to maitai timely cousel. The twofold purpose of this study was to idetify which ethical problems were perceived by physical therapists to be the most frequetly ecoutered ad 1264 PHYSICAL THERAPY

2 the most difficult to solve i their daily professioal practice. Simply stated, ethics, or moral philosophy, is critical, aalytical thikig about the behavioral expressios of huma iterdepedece ad what is the morally right thig to do. Curretly, the complexities of medical practice have give rise to ethical questios that demad the participatio of both medical persoel ad academic ethicists i discussig the issues ivolved. These discussios have served, at least, to defie what some of the problems are, but cotiuig dialogue is eeded to determie more adequately the rage of morally soud solutios. Topics that have received attetio iclude abortio, euthaasia, the right to health care, the patiet's rights while receivig health care, ad the limits of experimetatio with huma subjects. Although the physical therapist is cocered with these issues as a iformed member of the health care team, his ivolvemet i the decisios they require is sometimes ot directly evidet. All moral dilemmas occur withi a cotext of proposed actio. 2-4 Some ethical problems are specific to physical therapists because what they do is differet from what physicias, urses, ad other health professioals do. Other ethical problems ivolve physical therapists i oly limited or peripheral ways. Because of the cotext of certai ethical problems, the ethics of health care professioals has bee recogized as a area of study aki to, but distict from, medical ethics. I order to select a defesible choice, a decisiomaker first adopts a poit of view from which to iterpret the facts. Ay poit of view adopted will emphasize oe kid of fact over aother, perhaps equally importat, kid. The moral poit of view is distiguished from others by the kid of justificatio give i support of a particular choice. For example, the decisio to perform passive rage of motio because it will achieve certai treatmet goals is reasoig from the therapeutic poit of view. If a therapist cites a legitimate physicia referral as his reaso for performig passive rage of motio, the he has justified his choice from the legal poit of view. If his choice of passive rage of motio is defeded o the grouds that it is the oly procedure that would avoid uecessary harm to the patiet, the decisio has bee made accordig to the moral poit of view. Purtilo's discussio of the physical therapist as ethicist is a sigificat cotributio toward defiig the moral poit of view for a health professioal. 3 Geerally, o cliical decisio is made without aalyzig the situatio from several poits of view, but each poit of view is uique i the kid of questios it asks about a proposed actio. Whe a alterative is compatible with oe poit of view ad icompatible with aother, the uiqueess of differet viewpoits is more obvious. I these istaces, the multiple dimesios of judgmets made by physical therapists are apparet. Whe the choice is easily compatible with several viewpoits, however, there is a tedecy to collapse distictios ad regard the decisio as a therapeutic judgmet oly, igorig ethical ad other dimesios of the situatio. Ethical Issues i Physical Therapy The ethical dimesio of actual cliical practice is ot well documeted i the literature. Ethical developmet has bee cited as a basic objective of physical therapy educatio, ad several authors have oted a ethical dimesio i the routie fuctios of the physical therapist. 3,6-11 Behavior guided by a ethical code has bee described as idetifyig physical therapy as a professio rather tha a techology ad as cotributig to professioal stature. 1,10,11 Ofte, physical therapists have bee ecouraged to exhibit particular behaviors. Exact recommedatios have bee made, for example, o selectio of topics for discussio with patiets, " 10 the uses of proper vocal toe whe speakig with patiets, 9,10 presetatio of a modest appearace, 9 cooperatio with ad ultimate deferece to the physicia's judgmet cocerig patiet treatmet, -11 ad maiteace of a patiet's digity ad his cofidece i his physicia. " 11 There has bee little discussio of the moral priciples behid these expectatios, ad the ways i which they pose problems for the therapist have ot always bee idetified. If the uderlyig priciples are ot made explicit, recommedatios for particular behaviors are o more compellig tha remarks o professioal etiquette. Physical therapy educatio that does ot cover ethical theory, as well as applicatio, may iadvertetly trivialize the importace of ethical behavior. Discussios of professioal ethics ca seem overwhelmigly complex, ad the questio of where to begi is posed as ofte as the questio of what to do. A guidig assumptio of this study is that, while all ethical problems are importat, attetio should be directed first to those ethical issues that affect ad perplex the majority. The results of this survey provide a focus for that attetio. METHOD Subjects Four hudred fifty members of the APTA were selected at radom from the total APTA membership i the six New Eglad states (N = 2,017) as of Volume 60 / Number 10, October

3 December The sole criterio for iclusio i the study was that a therapist be employed i some aspect of therapy excludig educatio. A major assumptio of this study is that problems of professioal ethics origiate withi the specific cotext of cliical practice. Therapists whose primary employmet is i academic educatio do ot experiece that cotext o a daily basis. Also, educators ad graduate studets were ot icluded because they might be more sesitive to the complexities of some ethical issues ad thus skew the results. Istrumet Thirty items that described situatios suggestive of ethical problems were preseted to the sample i a questioaire format. Iasmuch as demographic differeces are ofte a source of variatios i respose, data were collected o age, sex, total years of physical therapy work experiece, ad highest educatioal level obtaied, as well as the respodet's preset type of employmet facility, level of his positio, settig of employmet, ad state. Iformatio o sources of cotact with issues of professioal ethics ad the umber of physical therapists available to discuss actual ethical problems was also collected. Procedure Respodets were asked to score items accordig to the frequecy with which they had ecoutered a situatio of the type described i their ow professioal practice ad the difficulty they experieced i reachig a decisio i those istaces. The frequecy measure had five levels: high, moderate, miimal, oe, ad ot applicable. The difficulty measure had four levels: extreme, moderate, miimal, ad oe. Assumig that ethical problems arise out of a particular cotext, accurate measuremet of the difficulty of a item requires at least miimal experiece with it. I cases i which a respodet reported havig o experiece with the situatio described by a item, or thought it iapplicable to him, the difficulty ratig was excluded from the results. Data Aalysis The Kolmogorov-Smirov Oe-Sample Test was employed to determie the sigificace of the distributio of resposes o both the frequecy ad the difficulty scales. 12 This test measures the agreemet betwee a theoretical cumulative distributio of resposes ad a observed cumulative distributio. If resposes are divided almost equally amog the levels of a scale, there will be o sigificat differece betwee the theoretical ad the observed distributios. I order to cosider a level o a scale to be a sigificat preferece of the respodets, it must be demostrated that the dissimilarity betwee a theo1266 retical array of data values ad the actual or observed array could ot have happeed by chace. The absolute value of the maximum deviatio (D m a x ) betwee the theoretical ad the observed arrays determies whether a sigificat preferece exists for oe of the possible respose choices. The rigor of this test is great for small groups, ad, thus, i some of the breakdows of resposes reported below, oly the. 1 level of cofidece was reached. I order to determie which issues warrat attetio accordig to the frequecy ad the difficulty criteria, a arbitrary lower limit was imposed. The issues raised by items that were ot perceived as at least moderately frequet or at least moderately difficult by a miimum of 3 percet of the respodets were rejected as priority issues (Figure). The issues covered i those items that met both the frequecy ad the difficulty criteria levels were desigated primary issues of professioal ethics for physical therapists. The items that met either the frequecy or the difficulty criterio level, but ot both, were desigated secodary issues of professioal ethics. 1. Decidig criteria for allowig a patiet/family t o refuse treatmet. 2. Acceptig gratuities or gifts from patiets/families. 3. Decidig what to do whe my values ad beliefs are at o d d s with a patiet's/family's values ad beliefs. 4. Settig t h e limits e c e s s a r y to maitai professioal relatioships with patiets/families.. Cotrollig a c c e s s to privileged or cofidetial iformatio about a patiet/family. 6. Choosig a form of d r e s s that a s s u r e s professioal respect ad maitais idetity a s a physical therapist. 7. Decidig whe I d o ot have a d e q u a t e therapeutic kowledge to treat a patiet.. Settig fiacially soud fees that maitai a patiet's ability to receive treatmet. 9. Providig a c c u r a t e iformatio to cos u m e r s about t h e c o s t s of treatmet. 10. Determiig methods for makig the particulars of physical therapy services kow t o health care cosumers Decidig t h e limits for stadig by my ow ethical priciples. Figure. Issues that did ot meet either criterio. PHYSICAL THERAPY

4 a. b. c. d. e. f. g. h. TABLE 1 Characteristics Profile of Uder 30 years old Female 6 years or less total physical therapy work experiece Baccalaureate degree Employed i acute geeral facilities Employed i a urba area Leared about professioal ethics i P.T. course oly had 3 or more therapists available to discuss actual ethical problems Respodets N RESULTS AND DISCUSSION Two hudred seve questioaires were retured, represetig a 46 percet respose. Of these, 17 (41.) were usable. Major demographic characteristics are preseted i the respodets' profile (Tab. 1). Primary ad secodary issues were grouped o the basis of the kid of cocer each expressed. Four groups of cocers were idetifiied: decisios regardig the choice to treat, obligatios derivig from the patiet-therapist cotract, moral obligatio ad ecoomic issues, ad a physical therapist's relatioship with other health professioals. A sigle item that examied coflicts betwee values also merited discussio. TABLE 2 Decisios Regardig the Choice to Treat Establishig priorities for patiet treatmet whe time or resources are limited. Discotiuig treatmet for patiets who habitually disregard istructios such as for home programs, treatmet regimes, ad safety istructios. Cotiuig treatmet with a termially ill patiet. Nursig Homes ad Chroic Care Facilities Cotiuig treatmet to provide psychological support after physical therapy treatmet goals have bee reached. Nursig Homes ad Chroic Care Facilities Frequecy N = 16 Dmax =.7 a N = D max =.16 a N = 174 D max =.216 a N = D max =.312 C N = 12 D max = -19 a _0 N = 16 D max =.313 c N = D max =.201 a N = D max =.11 a N = 167 D max =.124 b N = 170 D max =.179 a b p <.0. c p <.1. Volume 60 / Number 10, October

5 Decisio to Treat Patiet-Therapist Cotract The first group of cocers to be cosidered cosisted of four related primary issues regardig who should be treated (Tab. 2). More tha 70 percet of the respodets perceived the basic questio of establishig priorities for patiet treatmet whe time or resources are limited as moderately or highly frequet. This questioaire item was also rated at least moderately difficult by slightly more tha 4 percet of all those who had experieced the problem. Usig the frequecy ad the difficulty criteria, respodig therapists also regarded discotiuatio of treatmet o the grouds of habitual ocompliace as a secod primary issue of professioal ethics. Third, cotiuatio of treatmet with the termially ill is a priority issue, especially for therapists i ursig homes ad chroic care facilities, for whom the frequecy of this situatio is greater tha for other therapists. Fourth, cotiuatio of treatmet to provide psychological support after physical therapy treatmet goals have bee reached is a primary issue for over half of the respodig therapists, agai more frequet for therapists workig i ursig homes ad chroic care facilities. Whe decidig whom to treat, a therapist is required, i part, to cosider two importat aspects of this type of professioal judgmet. First, it is becomig apparet that the icrease i the umber of patiets eedig physical therapy kowledge ad skills could become overwhelmig. The expasio of physical therapy ito ew areas, i which the professio offers a uique viewpoit, forces the choice of which patiets shall be treated ad which shall ot. Eve whe research ito the efficacy of treatmet for certai types of patiets sheds some light o this matter, the therapist is still cofroted with a secod, ad perhaps more importat, cosideratio persoal beliefs ad values. Uderlyig all therapists' ethical decisios are the values that help to direct their choices. 13 The extet to which a perso values psychological support for patiets beyod the usual physical therapy itervetio, as well as what he thiks is a appropriate respose to the eeds of a dyig patiet, bear heavily o what he will choose to do. Coflict betwee persoal values ad professioal values, or betwee the professio's values ad society's attitudes, may easily arise. The professioal orgaizatio's declaratio of its values sometimes is helpful i these istaces. However, beyod this declaratio, each physical therapist must decide what he values as a health professioal. Educators may eed to provide the studet with the opportuity to examie his ow values as he is formally ad iformally socialized ito the professio. The therapist's professioal relatioship to a patiet is a major source of moral obligatio. Basic questios cocerig the ofte-uspoke cotract betwee patiet ad therapist were apparetly ot a problem to the respodets. The primary issue i patiet-therapist iteractio emerged from a coflict cocerig professioal adjudicatio betwee a patiet's eeds or goals ad a family's eeds or goals (Tab. 3). The respodets idetified this dilemma as the primary issue of the secod group of cocers. The ature of the patiet-therapist cotract has chaged as physical therapy has icreased its fuctio ad scope withi the health care system. The first of six secodary issues i this group of cocers stems directly from this chage, which augmeted the educatio compoet of cliical practice. A problem i defiig the physical therapist's role i the iitial educatio of a patiet or family regardig diagosis or progosis was ecoutered ofte eough to warrat attetio. This situatio was experieced with high frequecy by 4 percet of all therapists whose primary employmet was i pediatric facilities or school-system settigs. Studets pursuig careers i the treatmet of developmetal disabilities should be urged to cosider the ethical aspects of this problem i cliical judgmet. Two other secodary issues whose frequecy merit discussio are questios about iformig a patiet or family about the limitatios of treatmet ad assurig that the patiet or family have iput ito treatmet ad discharge plaig. The three remaiig secodary issues i this group of cocers emaate from the patiet's expectatios of the therapist. First, the kowledge that a therapist might be expected to brig to the treatmet situatio was examied i a item that questioed the assumptio of persoal resposibility for cotiuig educatio. Over 4 percet of the respodets oted that decisios allowig them to keep up with ew treatmet ideas had to be made with either moderate or high frequecy. The limits of the cliicia's obligatio to update his practice are uclear. Cotiuig educatio is well-recogized as a essetial of providig quality health care. However, the growth of physical therapy kowledge ad the icreasig cost of cotiuig educatio courses also demad cosideratio. The fial two secodary issues pertaiig to patiet's expectatios are ecoutered i actual treatmet: weighig the effects of treatmet agaist the discomfort created by the procedure ad maitaiig a patiet's sese of persoal space ad digity durig treatmet. Both of these issues are usually addressed i the classroom ad the cliical educatio of the 126 PHYSICAL THERAPY

6 studet, ad this survey's results suggest that this practice should cotiue. Each of these items was rated oly miimally difficult by more tha half of the respodets. This may be attributable to the attetio these issues have received i the respodet's educatio. Moral Obligatio ad Ecoomic Issues Some ecoomic issues have a moral compoet, ad the respodets idetified both a primary ad a secodary issue of professioal ethics relatig to ecoomics (Tab. 4). Decisios about whether to represet TABLE 3 Obligatios Derivig from the Patiet-Therapist Cotract Determiig professioal resposibilities whe a patiets eeds or goals coflict with the family's eeds or goals. Defiig the limits of the physical therapist's role i the iitial educatio of a patiet/family regardig diagosis or progosis. Iformig a patiet/family about the limitatios of treatmet. Assurig that the patiet/family has iput ito treatmet ad discharge plaig. Assumig persoal resposibility for cotiuig educatio to keep up with ew treatmet ideas i order to maitai quality of care. Weighig the effects of treatmet agaist the discomfort created by the procedure. Maitaiig a patiet's sese of persoal space ad digity whe treatmet requires arragemets such as close proximity ad group settigs. Frequecy N = 11 D max =.20 a N = 179 D max =.29 a Pediatric Facilities ad School System Settigs N = 20 D max =.4 a N = 16 Dmax = a N = 17 D max =.31 a N = 1 D max =.343 a N = 1 D max =.22 a N = 176 D max =.193 a N = 169 Dmax =.1 a N = N = N = N = N = N = Volume 60 / Number 10, October

7 TABLE 4 Moral Obligatio ad Ecoomic Issues Decidig whether to represet certai ecessary patiet services i a way that would meet thirdparty-payer limitatios. Nursig Home or Chroic Care Facilities Withholdig or limitig physical therapy services i order to improve work coditios, salaries, staff/ patiet ratios, etc. Frequecy N = 144 D max=.146 a N = 13 D max =.449 a N = N = 129 D max =.172 a N = D max =.173 b b p <.1. TABLE Physical Therapist's Relatioship to Other Health Professioals Maitaiig a patiet's/family's cofidece i other health professioals regardless of persoal opiios. Determiig criteria for delegatig duties to supportive persoel. Reportig questioable practices of aother physical therapist to the appropriate perso. Reportig questioable practices of a physicia to the appropriate perso. Reportig questioable practices of aother health professioal who is ot a physical therapist or a physicia to the appropriate perso. Frequecy N = 11 Dmax =. 17 a N = 169 D max =.216 a N = N = N = N = 16 D max =.202 a 42 N = N = 6 Dmax = a N = 121 D max =.1 a N = 120 Dmax =.1 a 1270 PHYSICAL THERAPY

8 certai ecessary patiet services i a way that would meet the preset limitatios imposed by third-party payers are ot ucommo or easy to make. Almost 70 percet of those therapists workig primarily with patiets i ursig home ad chroic care facilities perceived a high frequecy of the eed to make this decisio. The source of coflict is the differece betwee what a physical therapist may value as ecessary for patiets ad what society regards as essetial to the health of those who are depedet upo it. respect to peers ad superiors. That place has chaged cosiderably with the developmet of the professio ad will cotiue to do so. 1,16 Four secodary issues were examied i this group of cocers. Determiatios of the criteria for delegatig duties to supportive persoel occur frequetly eough to costitute a secodary issue of professioal ethics. Respodets did ot frequetly make decisios to report the questioable practices of aother physical therapist, physicia, or other health profes- TABLE 6 Coflicts Betwee Two Ethical Priciples 1. Decidig what to do whe two of my ethical priciples or values are i coflict. Frequecy N = N = 12 Dmax =.21 a There is, at preset, o simple resolutio to this coflict. Those physical therapists cocered with this issue should participate forcefully i chagig societal cocepts of adequate ad essetial health care. I light of developmets i other health professios, which have icluded strikes by physicias ad urses, 14 oe questio examied the issue of curtailmet or limitatio of physical therapy services i order to improve work coditios, salaries, staff/patiet ratios, ad the like. Most of the respodets perceived this item as iapplicable to their preset situatios. Of those therapists who regarded this evet as a possibility, most had o persoal experiece of it. However, slightly over 3 percet of those who had experiece with this problem reported that it was a extremely difficult decisio to make. Further examiatio of this issue may become ecessary. Relatioship to Other Health Professioals The last group of issues cosidered the physical therapist's relatioship to other health professioals (Tab. ). Maitaiig a patiet's or family's cofidece i other health professioals regardless of persoal opiios has traditioally bee a issue of professioal ethics, -11 ad the data collected show that it was perceived to be the primary issue of this group. The respose that a therapist makes i situatios of this type is derived, i part, from the place the professio holds withi the health care team with sioal. However, such a decisio clearly poses moderate difficulty i the case of aother health professioal ad extreme difficulty i the cases of aother physical therapist or a physicia, whe it eeds to be made. Idetificatio of Ethical Decisios Ethical dilemmas arise whe two or more ethical priciples or values coflict with each other i a give situatio. Despite the fact that respodets perceived seve primary issues ad they recogized the difficulty of makig decisios whe priciples coflict, they did ot perceive themselves as makig a choice betwee coflictig priciples or values with ay great frequecy (Tab. 6). Although respodets recogized that a difficult decisio had to be made i some istaces, they probably had ot idetified it as a decisio of ethical choice. The moral poit of view requires that some uique aspects of a situatio be explored. Failure to recogize that a moral poit of view is required is a first step toward uethical behavior. The educatioal implicatio of this data is iescapable: i order to meet all the challeges of cliical practice, physical therapy studets must be taught how to make ethical as well as cliical judgmets. To prepare future cliicias less adequately could jeopardize the itegrity ad the autoomy that physical therapy as a health professio has so arduously worked to achieve. Volume 60 / Number 10, October

9 CONCLUSION Complex ethical issues have emerged with the developmet of the professio. These issues pose a importat challege to the cliicia ad require that he develop skill i makig ethical judgmets i professioal practice. This study was udertake to achieve several objectives. First, to establish priorities of cocer so that the APTA ca respod to the more pressig ethical questios of its members. Secod, to idetify the issues of professioal ethics so as to ecourage discussio amog physical therapists ad to promote applicatio of the ideals expressed i the APTA CODE OF ETHICS to actual situatios. Third, to summo the attetio of academic ethicists so they ca offer their cousel o the issues raised. Fourth, to alert educators to the eeds of their studets i order to meet the challeges of ethical professioal practice. Fifth, to provide a opportuity for physical therapists to lear about ad reflect upo the issues of professioal ethics as they have experieced them. Ackowledgmet. Grateful appreciatio is expressed to Jae Coryell, PhD, Sarget College of Allied Health Professios, Bosto Uiversity, for her assistace. REFERENCES 1. Purtilo RB: The America Physical Therapy Associatio's code of ethics. Phys Ther 7: , Thompso IE: The implicatios of medical ethics. J Med Ethics 2:74-2, Purtilo RB: Uderstadig ethical issues. Phys Ther 4:9-243, Jameto A: The urse: Whe roles ad rules coflict. Hastigs Cet Rep 7(4):22-, Callaha ME, Addoms EC, Schulz BF: Objectives of basic physical therapy educatio. Phys Ther Rev 41:79-797, Addoms EC, Callaha ME, Schulz BF: Fuctios of the physical therapist. Phys Ther Rev , Marto T: Ethics. Phys Ther Rev 30:17, 190. Huppert CR: Orgaizatio of a iservice traiig program i a physical therapy departmet. Phys Ther Rev 30:174-17, McLoughli CJ: Ethics ad the physical therapy techicia Physiotherapy Rev 21:203-20, Hardebergh H: Ethics for the physical therapist. Physiotherapy Rev 26:1-3, Haskell ME: Essetials of professioal ethics i physical therapy. Phys Ther Rev 29:29-296, Siegel S: Noparametric Statistics for the Behavioral Scieces. New York, McGraw-Hill Book Co, 196, pp Purtilo RB: Essays for Professioal Helpers: Some Psychosocial ad Ethical Cosideratios. Thorofare, NJ, Charles B. Slack, Ic Yeager J: Why I had to strike. Am J Nurs 77:74, Carli EJ: The revolutioary spirit. Phys Ther 6: , Hogshead H: Resposibility: A modality for the ext decade. Phys Ther 4:-91, PHYSICAL THERAPY