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Thirty-First Mary McMillan Lecture |
RB Purtilo, PT, PhD, FAPTA, is Director, Center for Health Policy and Ethics, Creighton University, 2500 California Plaza, Omaha, NE 68178 (USA) (rpurtilo{at}creighton.edu)
 | Abstract |
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Dr Purtilo has been a visiting professor or named lecturer to more than 30 different colleges and universities worldwide. Her publications, primarily on ethics in health care, include 8 books and more than 70 articles and chapters.
In addition to being involved in APTA, Dr Purtilo has served as President of the American Society of Law, Medicine, and Ethics and was a founding member of the Society of Bioethics Consultation. She is a member of many other professional organizations, including the American Association of Bioethics, the American Philosophical Association, the Society for Health and Human Values, and the World Confederation for Physical Therapy.
Dr Purtilo has been recognized by APTA as a recipient of the Golden Pen Award, the Helen Hislop Award for Outstanding Contributions to Professional Literature, and a Catherine Worthingham Fellowship.
| Introduction |
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 TopAbstract Introduction The First Season: The...The Second Season: The...The Third Season: The...References |
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In talking to several McMillan lecturers about their experience, I learned that each lecturer prepared for this day a little differently. I began last fall by setting a schedule to read every previous McMillan lecture. They were wonderful! But by January I was terrified. I realized I had nothing to say that had not already been said—and better.
Then one day I read a quote from the great Nebraska plains novelist, Willa Cather, who wrote in O Pioneers!: "There are only two or three human stories and they go on repeating themselves as fiercely as if they had never been told before."1 I realized that there are some important human stories in physical therapy that bear repeating and that my job today is to help remind you of some of them related to our ethical foundations. I hope to say something that will be worthy of your remembering in order to tell future generations!
So, to the Nebraska Chapter of the American Physical Therapy Association (APTA) who nominated me, which itself was quite a process, to the many colleagues and friends who wrote letters of support, to the selection committee, to the APTA staff who attended to every detail, and now to you who came today, thank you for this grand opportunity to be a voice to the stories.
My husband, Vard Johnson, was my most constant encouragement over the months as this lecture did begin to take shape. Thank you, Vard, for all the ways you honor the work of this profession and have commemorated this moment with me already.
Jan Richardson told me that the selection committee thought it fitting to focus on the ethics of our profession as we begin a new millennium. The turn of a millennium does create a natural pause in human history, a "comma" inserted into time. It is a time to look back on what was and to welcome the arrival of a new season in human history.
Dag Hammarskjöld probably was having an evening that felt like the end of one millennium and knew he would awaken to a new one when he wrote in Markings:
Night is drawing nigh.
For what has been-thanks,
For what shall be-yes!2
For what has been-thanks, comma, and for what shall be-yes! In those natural "commas" during our headlong rush through life, something wonderful happens! Fresh air blows into our spirit so that reflection and creativity can thrive. Therefore, having made it through a winter that midway coughed us out on the other side of Y2K, bodies and computers more or less intact, it is a fitting, fresh-air time to prepare the soil and begin the ethical planting for future generations.
What do we need to include in a millennial ethics that will yield a "yes" from our professional progeny and assure society's acceptance of us as professionals? The good news is that in any period of a profession's task to grapple with its ethics, there are only 2 time-tested strains of seeds to sow: (1) the seed of care and (2) the seed of accountability. The seed of care sends the essence of a profession's commitment deep into the soil of society. Accountability sprouts ethical duties and responsibilities so that society has a basis of measuring what it reasonably can expect from the profession. These 2 strains—due care and accountability—are the "staple crops" of professional ethics. The only tending a profession needs to give to these enduring strains is to be sure they will adapt to the social conditions—the peculiarities—of a given time and place: what I call the social landscape.
Webster's dictionary tells us that a landscape is "the aggregate landforms of a region."3 I live in a part of the world where the condition of the physical landscape can make a difference in the world's well being. Flooded wheat fields in Nebraska will drive up bread prices in Macon, Georgia, and pasta prices in Milan. If the good topsoil in the nation's breadbasket blows away, a drought will ensue and people in Tennessee, Thailand, or Timor may feel it. At the same time, year after year farmers and others realize the world's largest harvests, partially as a result of responding knowledgeably to a landscape that is yielding to powerful external forces.
Just as US heartland farmers must know the conditions of the soil for their seeds to take root and grow, so must we become intimately familiar with the human community in which we offer our professional services. Aristotle called ethics "practical philosophy," its methods simply tools for developing "habits of thought" for reflection on complex and changing social realities. Ethical insights are not sequestered in our minds or sealed in the heavens. Forget navel-gazing or stargazing for answers! The tools of ethics are designed for sifting through muddy details of everyday life, examining them for why, to whom, and how we must show care and be accountable.
Today I will describe 2 major seasons or periods in physical therapy's history when we correctly "read" the social landscape and could conclude with confidence that society was ready for us to plant the seeds of our professional ethic. These 2 seasons of physical therapy's ethical identity are the Period of Self-Identity and the Period of Patient-Focused Identity. In the Period of Self-Identity, we established the moral foundations for a true professional relationship with physicians and other health care professionals. In the Period of Patient-Focused Identity, we established the moral foundations for a true professional relationship with our patients and clients.
I will devote the final minutes of this lecture to a proposition that as our self-identify and our patient-focused identity continue to mature today, we are approaching a third season in a seriously shifting social landscape that appears unfamiliar to us who are accustomed to focusing primarily on the physical therapist's relationships with professional teammates or individual patients. I am calling this emerging season physical therapy's Period of Societal Identity. In this most recent period, our task will be to establish the moral foundations for a true professional partnering with the larger community of citizens and institutions.
These 3 periods do not have discreet endpoints in which the stubble of the first successful harvest is cleared for the next planting. The contribution of each previous period is required to provide the appropriate conditions for the next to be added.
| The First Season: The Period of Self-Identity |
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In 1935, a group of physiotherapists convened in Atlantic City and drafted a "Code." Today, when I read the document to physical therapist students, many are amazed. No wonder! Listen:
1a. Diagnosing, stating the prognosis of a case and prescribing treatment shall be entirely the responsibility of the physician. Any assumption of this responsibility by one of our members shall be considered unethical.
1b. The patient shall be referred back to the physician for periodical examinations.
2b. [re: Announcements:] A statement that the work is medically supervised should appear in the announcement.4
... and so on. Both literally and figuratively, the physical therapist promised to stand up when the physician came into the room. And look cheerful. All the time.
That now seems so, well, "retro!" But let's look closely at what was happening. Notice that the patient is not the explicit focus of these statements. The items in this code, sown like apple seeds across the lord's landscape, is about the physical therapists' relationship to physicians! That bold, bright generation of physical therapists, all women, declared, "We're here! And this is what you can expect from us." Furthermore, as codes have as their function to be public statements, they were also saying, "The land we are working is society's soil—it doesn't belong to you physicians!" As Carl Rodgers would say, we had "individuated!"
I submit that their timing was perfect. These therapists had read, correctly, a shifting social landscape that was enduring a worldwide depression and would, a few short years later, feel the corrosive effects of a world war and the challenges of social reconstruction following it, as well as face the global ravages of the polio epidemic. Indeed, the entire social terrain of the western world would force physicians down from the mountaintops to labor shoulder to shoulder with nurses and whoever else would share the crushing burden of health care in these extreme circumstances. They found physical therapists ready. Because physical therapy had planted a professional ethical identity, however new and fragile and however constrained its arena of accountability may seem today, its members were positioned to move from serfdom to strong moral partnership.
Sociologists5 tell us that in this period the health care team was born, and we were positioned to help provide comprehensive coordinated care for a population of patients that could benefit more from a team's services than anything we might have offered on our own. Over the next quarter of a century, our heightened professional standing in the health professions would spring not only from an increasing area of expertise, but also from our place at the negotiating tables of policy, because through our code and team activities we were present and proved we could be morally accountable for the success (or lack of success) of our specific contributions on the health care team.6 Thanks to those awesome women in 1935, we were able to take the first steps toward whom we could become. They helped us heed the words inscribed on the ancient Delphic oracle: "KNOW THYSELF" (before taking on the rest of society)!
| The Second Season: The Period of Patient-Focused Identity |
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The most significant social landscape shift in this period was the introduction in 1957 of "informed consent" into the legal fabric of the physician-patient relationship and its subsequent spread to all clinical and human studies environments.
This mechanism itself partially came about as a result of a post-World War II landscape strewn with new thinking about the scope of individual rights. New rights were articulated through the United Nations Declaration of Human Rights, the US Civil Rights Movement, Medicare and Medicaid legislation, the American Hospital Association Patient's Bill of Rights, and the constitutional right to privacy, to name some. In this rights-intensive territory, the individual's interests became the ideological, political, and economic standard of policy so that health care professionals had only to follow what was happening in the rest of society to give patients a stronger voice in decisions affecting them. In fact, patients would meet us more than halfway in our journey from a paternalistic model to a partnership (and, eventually, advocacy) model.
An additional significant aid was the team notion I described in the discussion of our self-identity period. Its emphasis on equal standing among members helped to create an ethos that was more inclusive.
But with all of these factors at play—informed consent mechanisms, rights language, team models—still our initial attempts to make patients decision-making partners were clumsy. In the old mountainous kingdom, patients had been passive recipients. Unfortunately, team members, long accustomed to taking the lordship model as normative, often transferred lordship behavior to the whole health care team. All too often, patients (correctly) experienced it as a team gang-up on them. I remember one glaring example from my experience as a young therapist. A patient assigned to me was 16-year-old John, who had become partially paraplegic when a tree house he was building for his young sister collapsed on him. His ideas about his rehabilitation goals put him at odds with just about all of us. One day, I earnestly told him that he, too, was a key component of the rehabilitation team, so he really must be more cooperative. He just as earnestly replied, "Yeah, you're the players, and I'm the football."
Learning how to partner, let alone advocate, took all of us laboring together. I, like many in this audience, took my own tentative steps in the new, freer, plains landscape: The first APTA paper I ever presented, scared to my toes and grateful that only a handful of people showed for this 7:10 AM session on the last day of conference, was on informed consent. (I had just begun to study ethics and wanted to share this with my colleagues). Within 5 minutes into the presentation, several people had walked out, presumably to go find something more relevant to listen to. My professional "big sister," Catherine Perry Wilkinson, stayed the whole time, though she had already heard me practice that talk aloud in our room at least a dozen times. And afterward, 2 young men who had also stayed to the end came up. The short, taut-muscled, dark wavy-haired one with twinkly eyes told me, "Keep working on this issue! It will help us treat patients with respect, and that is the most important thing we can do." He introduced himself as Charles Magistro. The other guy, softer, rounder, kept nodding in agreement. Before he turned to leave, he said, "Oh sorry, the name's Gene. Gene Michels." Their affirming words sent me skipping all the way back to my room—and ethics studies!
They were right about informed consent, though I, myself, didn't know how right at the time. In fact, it is taking many years for this tender new seedling to root down in the furrows that had been prepared for it by the larger society. Today, it has a prominent place in our Standards of Practice for Physical Therapy and other major documents. (It was featured on the front page of the nation's newspapers on Monday, and it continues to be a focus of medical and policy journal articles, especially in regard to its role in clinical research).
Our transformation to a patient-centered identity required attention in other areas as well. Our Code of Ethics continued to be our most visible public statement. In the early 1970s, I became the youngest—and greenest—member of the APTA Ethics Committee (then called the Judicial Committee, recently renamed the Ethical and Judicial Committee). There, I joined toilers who were working to weed out of the Code of Ethics the emphasis on the size and content of an ad a physical therapist could place in the yellow pages of the telephone directory. The overriding ethical dilemma we struggled with seemed to be: When are capital letters morally permissible?
For all our good work, our efforts were but one season of uprooting, planting, and cultivating new ethical guidelines, each in its own time when the societal soil was ready. Those who have followed since my 1970s experience have continued the process of refining our Code of Ethics, Standards of Practice for Physical Therapy, and Guide to Physical Therapist Practice7 and our educational guidelines and research documents toward more patient-focused advocacy.
So, to all of these contributors, too, on behalf of us all, "thanks!"
During the early years of this second season, physical therapy also took the risk of embracing a formally trained "ethicist." My interest in ethics was generated by my own clinical practice and heightened by questions from my wonderful physical therapist students at Boston University. Adelaide McGarrett, who had already taken the risk of hiring a young, ponytailed instructor just back from Africa and intent on now saving the rest of the world with physical therapy, encouraged me. I entered graduate studies with trepidation, afraid that theology and philosophy would be too daunting for someone in a physical therapist uniform. My suspicions were quickly confirmed: I had at least heard of God, but in my first week, when a young fellow student relayed what he had discovered in his fourth reading of Wittgenstein, I remember thinking, "I don't even know how to spell Wittgenstein!"
But there was a far more overriding fear, too. As I wrestled with God, Wittgenstein, Nietzche, and Kant, I felt I was losing my connection with physical therapy, the profession I loved. How would physical therapists understand what an "ethicist" could contribute, when I wasn't certain myself? Sure enough, in one of my first invited physical therapy talks during my ethics studies, I was introduced as an "ethnicist" and shortly after that as a "Methodist-in-training!" One day, I tearfully poured out my anxiety to Nancy Watts. She drew herself up to maybe 8 feet tall and replied in an authoritative, but caring, voice, "Don't think for a moment we will ever let you go, Ruth." Nancy herself never let me go, and for her—and many others'—support at key moments, I am deeply grateful. I want to share just a couple other examples.
Carol Davis, that young 60s radical who stood up in the House of Delegates to say we should take political positions on key issues (some of us thought we had met Angela Davis in a blond wig), called me every day to encourage me when my mother was dying from cardiac failure during the same weeks I had to complete my dissertation. And one especially low day before comprehensive exams when I felt myself "going down the tubes," I called Colleen Kigin. She told me to switch on my TV. We sat for the next 2 hours, ears to respective telephone receivers, watching together "The Incredible Shrinking Woman," who, of course, does go down the drain—and survives! Finally, as a new "certified" ethicist teaching my first physical therapy ethics course at the newly opened MGH Institute of Health Professions, I was visited by 2 of the brightest graduate students I would ever work with, Bette Ann Harris and Lee Nelson. They just wanted to be sure I really had intended to include Martin Buber's torturous, impossible-to-understand I & Thou8 in the required reading section. When I said, "Yes, it's about respect," Bette Ann finally replied, hesitatingly, "Well, if that's what he's trying to say ..." Both have since gone on to become exemplars of what he was trying to say. Oh, and I've since dropped Buber from my reading list. Too torturous.
Why share these snippets of my own experience with you at such a moment as this? Because I am certain these colleagues and others were not quite sure where I would fit in the end. However, they were so much in the practice of expressing care and making another accountable for what was important to that person that they were able to direct support and encouragement my way when I needed it the most. What more is the ethics of physical therapy all about than this?
I joyfully thank the whole constellation of bright lights that guided me through that forest and back home to this profession, this moment, at this podium. It was a great gift you gave to me, just as it is when you give to patients, clients, students, and others.
I have since happily given up my role as the sole formally trained physical therapist ethicist. Younger people with fresh approaches constitute an impressive team with whom I count it a great privilege to partner, to mentor, and to be mentored by. Together with everyone here, we are learning that the basic tenets of our professional ethics (based on a strong self-awareness and patient-focused loyalty) are instilling themselves deep into the grain of our collective being. And none too soon.
| The Third Season: The Period of Societal Identity |
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Physical therapy, with all its new innovations, is in the same seedbag of new possibilities. And there is deep criticism that some of these new seeds of "opportunity," marketed as "progress" may serve society's values best by being left in the silos, unsown.
This criticism often pinpoints the health care professions' highly personalized and individualized approach to patient care as the basis of the problem. Both our technology and the professional skilled personnel who provide the services are targeted. The criticism goes something like this: The post-World War II period yielded an impressive harvest of individual rights and values, but those shoots were sown so heedlessly to create our present health care empire that their roots now threaten to strangle other important values in the larger community.
The one phrase that most fully captures the criticism is: "You cost too much. The price is too high." One aspect of this "price," though not the only important one, is money. I want to say something about money. Not only are we being pinched financially regarding future expansion of physical therapist services and educational programs. Note our recent scrape with the 1997 Balanced Budget Act: It was clear and convincing evidence that some US policy-making bodies, especially business and government, want to snip off the seedpods of our current personalized patient practices in an attempt to diminish our propagation and thereby decrease the money society pays us for the services we are already offering. We call our charges "just remuneration"; society's institutions of business and government call them insurance premium hikes, higher taxes. Citizens often respond that health care today is just a "rip-off."
Still, I am often astonished to encounter unwillingness among my physical therapy colleagues to do the homework needed to argue convincingly to society that it is getting a great value for our services. We can be convincing through the use of evidence-based outcomes data and other aggregate data that could counter superficial criticism about various interventions we offer to individual patients. These data can be buttressed with stories of individual cases. But our loyalty to individual patients' cases and old familiar approaches seem to leave us unprepared at times to enter into critical policy decisions because we so distrust all decisions based on pooled, aggregate data. This resistance renders us guilty of making an idol of the individual—and, in the end, cheating the very patients we propose to serve.
We need reliable data and rigorous documentation to support when and why our present practices are merited. We need to let lay fallow those practices that have not been submitted to careful review for their effectiveness and cost-efficiency. Such accountabilities on our part will put costs to society into the larger perspective of what it is sacrificing if cuts are made on a more superficial analysis of our contributions. They will also prepare us for a considered response to critics of specialization, doctoral-level preparation, and clinical residencies because, in the eyes of the larger community, these trends are self-interested with the potential simply to make physical therapist services and education "more expensive."
At the same time, we must pay attention not to rush and uproot our time-tested strain of patient-focused identity because we see land-leveling machinery in the distance. It is one thing to accurately arrange data about our practices to bring information into an aggregate form that allows us an effective voice as a partner with society; it is another to let our basic identity be plowed under to make way for something entirely different. One recent article in the medical literature proposed that the best path the professions can follow today is to be a nonbiased "broker" between the traditional patient orientation of professional ethics and the duty to do whatever it takes to cut costs.9
We can do better. We can diligently nest the ideals of the profession into the very center of society's priorities. I have 2 brief, basic suggestions regarding how this can be accomplished, and I know you will be able to add others.
First, we can use our strong self-identity to remind society what a health care profession—and the profession of physical therapy specifically—is designed to do. There is absolutely no time for any more whimpering about not knowing exactly who we are. We do know. We know enough. A health care profession is designed to address the health care needs of individuals who can benefit from professional services. Accordingly, from this understanding of self, physical therapists must demand appropriate care for all patients who can benefit more from physical therapy interventions than from those of any other group or by any other means, then partner with society to find the resources to make this possible.
Second, we can use what we have learned from our successes in developing a patient-focused identity to make a compelling case for how we can work with society to ensure that a well-defined area of basic patient needs can be met in the new season. We are making some important strides in this area. For example, in 1999, APTA urged PT Team, APTA's 17,000-member grassroots network, to partner with patients in supporting key legislation.10 Together, arms linked, they could contact members of Congress to sponsor bills to redress the shortcomings of some health plans that had cut physical therapist services that were essential to those patients' appropriate care. That is the right idea.
But taken alone, no one approach is sufficient. For example, attempts to contain costs must not be affirmed if they are implemented simply for additional profit to be realized. As I am sure you know, some current cost-containment measures are needlessly trimming people from eligibility for basic care, especially among working poor people, minorities, and children. We can form coalitions with socially marginalized groups, and with organizations created to help give them voice, to let them know it goes against the essence of a profession to trim people before trimming unnecessarily large margins of profit, trimming administrative overstaffing, or trimming lethargy regarding old practices. If we are complicit in accepting or welcoming the unnecessary pruning of people whose suffering could be prevented or ameliorated, but whose well-being goes unattended for want of physical therapist services, we should drop our claim to professional status now, while we can still walk out of the emerging landscape under our own power. This is about the seed germ—the essence—of our "professing" identity, and all the privileges society has accorded us on that basis—and no other.
There is one prior task we have to accomplish if we are to be successful in meeting the new challenges, even in the 2 general ways I've suggested. We must first plant deeper respect for all people, no matter their color, sex, age, ethnicity, or other personal characteristics. When we do, it will make our claim more plausible when we argue for providing services to anyone who needs them.
As you know, this will be difficult because we are so diversity challenged in our profession. On the encouraging side, in recent years. the profession has learned some of the benefits of embracing diversity, so our numbers among ourselves do gradually look better. And our actions toward patients, subjects, students, and others also continue to show more genuine understanding of the gains all around when differences are appreciated as distinct gifts. Our language has improved thanks to Suzanne "Tink" Martin and others who have shown us how to incorporate nonbiasing terminology into our communications.11 Our Vision Statement affirms "cultural sensitivity."
But we are not there yet. Just look at how PALE this audience is! Ninety-three percent of the physical therapists in APTA list themselves as "white." More than that speak English as their first language. If we compared ourselves proportionately with people likely to need our services in North America alone, fewer than a third of us in this ballroom should have that profile. And, of course, we are not equally culturally sensitive to all cultures. There is the enigma of the disability culture. How many physical therapists still find "disabled" and "normal" contradictory terms?
Our contribution of enrichment for the millennial landscape will have to include greater diversity within our own ranks at all levels, especially in leadership positions, and many additional changes in our attitudes and practices. A fundamental requirement for successful completion of our educational programs must be cultural competency. I am talking about making cultural competence as nonnegotiable a graduation requirement—and tested for as rigorously—as competence in pathokinesiology.
In short, societal critics today call us to a partnership that accepts constraint and makes prudent use of resources in the name of the common good of the human community. It is up to us to take society's concerns seriously under advisement, then accept only those conditions that honor true public spiritedness and fidelity to our promise. Our promise is to show care and accept responsibility for the well-being of all members who can benefit more from our services than anything else society can offer to prevent or ameliorate the suffering that our expertise allows us to address effectively. The very core of being professional demands it, and it is the key to survival in the new millennium.
Looking back, looking ahead, finding a propitious time for harvesting, uprooting, planting, and, again, harvesting. Dag Hammarsjköld beckoned us to be both thankful and full of anticipation as we survey the larger social landscape at any moment in time. And our experience with our own developing professional ethics is teaching us that there is an appropriate time for taking advantage of each new season. We have learned from the past that as we emerged, singing "Here we are!", we were able immediately to join a larger group of health care professional allies and fellow sowers. By being attentive to what constitutes good ethical practice, we were able to plant seeds of patient-centered professionalism into fertile soil. We have enjoyed the fruits of a society where the importance of the individual increasingly has been recognized and respected through laws, policies, and practices. As we go into the future, it is important to remember that each new moment is also a new beginning.
Any one of us here, as we look around this auditorium, probably recognizes people who were "there at the beginning" to help us understand what to be and do when faced with those 2 or 3 important human stories. Thirty-eight years ago, young Susie Isernhagen, Marty Feretti, and I stood in the front row in our shorts and halters on our first day of physical therapy classes, looking askance at each other. Jack Allison announced, noticing our furtive glances, "You will have to get used to working with each other before you can work with patients and go out into society! You are in for a grand adventure!" He was right.
I think if she were here, Mary McMillan would join us in saying, in a loud voice, "For ALL that has been—THANKS, inserting that comma into time, For ALL that can be—YES!"
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| Footnotes |
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Requests for reprints should be directed to the corresponding author of the article. Students and other academic customers may receive permission to reprint copyrighted material from Physical Therapy by contacting the Copyright Clearance Center Inc, 222 Rosewood Dr, Danvers, MA 01923. Similar inquiries by all others should be made to the APTA Editorial Office, Attn: Physical Therapy.
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