Ross:

Thanks for your post. I can not tell if you are from the US. From your
salutation of "cheers" I would gather you are from the UK or one of her
recent
colonies.

crm3a wrote:

> There are certain problems with the simplest of ethical decisions.  Do you,
> as the therapist , really give the patient a "true" informed consent knowing
> full well that the patient depends on your interpretation and biases to make
> his or her choice.

If your from the US you are ethically required to give full informed
consent.
Recognizing that you are not going to have a 30 minute discussion and a
15 page
form to put a hot pack on someone. Informing the patient of your
professional
opinion (bias) is part of the process.


> If you are a person from a western based health
> discipline then rubbing your daughters chest to the point of sub-cutaneous
> haemorrhage would seem to be an odd way to treat a chest cold.  If you were
> a vietnamese massage practitioner this variation of folk medicine would seem
> completely "normal " to you (and surprisingly I've seen it work to great
> effect).


 You mean that rubbing someones chest will cure the person of a viral
 infection? I'd like to see a study demonsrating that one!

> I think that the bias of the practitioner often clouds all else and I don't
> know how you are supposed to get around that.  If you personally believe in
> a certain set of values you will transmit that to your patient.   Please
> scroll down to inserted comments if you like.

You will never eliminate bias in human interaction. I don't think
patients want
us to be unbiased. Patients come to see me because I am an expert in my
specialty. They want to know what my biases are. That's part of why the
see me
and not some new PT who doesn't have experience. Isn't experience a form
of
bias? Doesn't society value experience. 

>
> -----Original Message-----
> From: Douglas M. White <[log in to unmask]>
> To: [log in to unmask] <[log in to unmask]>
> Date: February 18, 1999 7:58 PM
> Subject: Re: TNS - Contraindications
>
> >Well said. I too would like to see more emphysis on ethical reasoning in
> >PT education. Everything has a risk/benefit relationship. Our patients
> depend on us to know the risks as well as the benfits.An informed patient
> can then make a decision to consent or not to the treatment. Its as simple
> as that.
>
> Is it?  Do you think that  a patient truly realizes that you can kill  or
> cripple him or her when you do your cervical rotational manipulation?  The
> patient trusts you and inherently is guided by your feelings/behaviours(I
> can just hear local physios saying"sure you could get hurt with this Mrs
> Jones but only  one in four of us will cripple/kill a patient  once in our
> careers").  Information isn't just having things explained to you and there
> is a possibility that patients may not be capable of comprehending
> what/why/how something is occurring.  There have been a couple very critical
> studies concerning supposed "informed consent".
>

Informed consent is not perfect. Under most circumstances, most
patients, in my
experience, can be sufficiently informed that they can make an informed
decision
and feel comfortable about it. Because there are patients or
circumstances where
the informed consent process is inherently flawed does that mean we
should
abandon informed consent for every one?

>
> -Do you really tell each back pain patient that comes in I think you have
> "X".  McKenzie says do this, Maitland says do that and Cyriax says do
> something else.  Here are the good and bad pointy of each treatment.  Which
> would you rather have?  This would truly be informed consent with patient
> directed decision making.  Most practitioners would find this type of
> approach impractical.  Also the abilty to use the "placebo effect" in a
> useful way is severly hampered by a truly informed approach.

I don't say McKenzie this or Cyriax that because they have not/did not
do the
research. In fact, much of the recent research by others has seriously
questioned
the pedantic approaches of these two. I hope the day is near when we can
move
away from being disciples of gurus who won't do the research to
substantiate
what they are preaching. I think my patients expect me to know the
research and to incorporate it into my treatment approach. This is a
check against an informed consent which is based all on opinion with no
evidence to support it. 

The placebo effect is not something I do in treatment. Nor is it
something US
health insurance companies will pay for. If you want to use a placebo
there are
a lot cheaper ones than PT.

>
> >Douglas M. White, PT, OCS
> >Milton MA USA
> >
> >Chee Wee, Tan wrote:
> >
> >> Dear Ross,
> >>
> >> Thank you for your reply.
> >>
> >> I've posted the comments in response to some of the
> >> postings sent. Someone commented that TENS is acceptable
> >> for a patient with a terminal condition even if it was
> >> contraindicated. Essentially, that is doing harm with the
> >> aim of doing good. Is that justified?
>
> >> I agree with you that the patient is more important than
> >> any person's treatment philosophy. However, I also consider
> >> arming myself with ethical reasoning skills a priority. How
> >> would you know if what you're doing professionally is
> >> moral?
>
> Big problem here.  Whose morality?  It often comes down to an arguement that
> is not decidable because you are arguing belief systems.  If I was a person
> who had different moral beliefs than you I could justify things to myself,
> very logically, without being considerate of your point of view.
>
> Conscience? Surely, as professionals, one can't be
> >> accountable to patients just basing it on conscience. I'm
> >> not debunking the importance of this faculty but trying to
> >> build on what we already possess by rigorous discipline of
> >> the thought. For example, all humans reason, but physios
> >> build on that by training it with a certain rigour that
> >> ensures their clinical reasoning is optimal. That is accountability to
> the patients.
>
> I am afraid I can't follow what you are trying to get at here.  The only
> thing I think I understand from your comment is that "rigour" in "clinical
> reasoning" will somehow make us more accountable to patients.  I think that
> you should consider that reasoning is of itself value neutral and that you
> can quite reasonably make up logical statements that are false.  This is
> often what sustained groups like the KKK and the Nazis party.  I f you
> demontrate poor reasoning your thinking is "fallacious" irrespective of the
> truth/falseness of what you say.  You can't depend on logic to get you
> through any form of moral dilema.
>
> > I'm a physiotherapy student and sometimes, I wished the
> >> college had more input as to ethical reasoning. Then again,
> >> it may be just me dozing off in lectures ;p
> >> Yours
>
> >> Chee Wee
>
> ?Which university?  ;')
>
> Cheers, Ross.


%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%