Kaitlyn Powell
Dr. Rosato
VTTH 300 D: Ethics and the Human Good
21 April 2015
Ethical Dilemmas in the Discharge of Patients from Hospitals: An Occupational Therapist
Perspective
An occupational therapist’s main priority is their client. However, is there a point where
the therapist must put their needs before their clients? If so, where does that point lie, and is it
ethical for the therapist to do so? One such situation where these questions arise is during the
process of discharging patients from hospitals. Occupational therapists provide dignified and
ethical care for their patients; however, due to outside pressure from clients, other professionals,
and hospitals during the discharge of patients from hospitals, therapists must choose to either
abandon their morals and therefore sacrifice the internal goods of their practice in order to satisfy
the needs and wants of their higher-ups, or maintain their morals and risk their jobs to insure the
safety and success of their clients.
Occupational therapists are responsible for helping individuals to develop or restore skills
that are useful in every day life. They take the “occupational” approach, which means the
therapy consists of the activities the patient wants to learn (“Occupational Therapy”). For
example, therapists will help young children learn to write or tie their shoes, or they will help
stroke victims relearn how to use a fork to eat dinner by using these tasks as their therapy. Often
times the therapist will provide modified utensils or settings to allow their client to perform these
tasks on their own (“Occupational Therapy”). Occupational therapists work with a variety of
patients such as children, rehabbing clients, stroke victims, and the elderly. Because of the
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variety of patients they work in many settings such as schools, nursing homes, private practices
and hospitals. Aside from the physical benefits that OTs provide for their clients, therapists also
help to restore and maintain the dignity of their patients by preserving their ability to do basic
human activities on their own (“Occupational Therapy”).
Occupational therapists hold themselves to a high standard of ethics. Their Ethical Code
is laid out by the American Occupational Therapy Association, which names seven core values
of an occupational therapist. The Code addresses the concerns of the stakeholders in
Occupational Therapy, which include the practitioners, clients, researchers, educators, students,
as well as others (Reed, 1). The core values apply to all of the stakeholders listed, and they are:
altruism, equality, freedom, justice, dignity, truth, and prudence (Reed, 1). Each of these values
is defined in terms of the relationship between therapist and client. Altruism refers to the
therapist’s ability to place the patient’s needs above his or her own. Equality has to do with the
therapist treating patients and fellow practitioners with fairness, and freedom is the idea that the
client’s desires must guide the therapist’s intervention. Similar to freedom is justice, which is the
formation of fair and impartial relationships between clients and therapists, as well as adhering to
their area of practice’s laws and standards. Dignity is about the promotion of the patient’s
individuality by helping the client to become independent in activities that are meaningful to
them, regardless of their disability level (Reed, 2). Truth and prudence have to do with providing
accurate information, as well as using their “clinical and ethical reasoning skills, sound
judgment, and reflection to make decisions to direct them in their areas of practice” (Reed, 2).
The Occupational Therapy Code of Ethics and Ethics Standards also outlines seven
principles of Occupational Therapy that are reflective of the seven virtues. The seven virtues are
beneficence, non-maleficence, autonomy and confidentiality, social justice, procedural justice,
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veracity and fidelity. Beneficence and non-maleficence is the concept that therapists will do all
they can to help their client, and have an obligation to not intentionally harm them (Reed, 3-4).
Occupational Therapists, as professionals, have autonomy over their profession to treat their
patients as they wish as long as it is within the bounds of the standards, and they also have the
right to maintain confidentiality with their clients regarding treatment options and other
decisions. Social and procedural justice both have to do with equal use of resources and equal
treatment for all clients, and veracity is about the accurate transfer of information and ensuring
the client’s understanding (Reed, 6-8). Finally, fidelity is the idea that therapists must keep their
promises and commitments to their clients (Reed, 9). All of the principles and virtues of
occupational therapy are threatened when an OT must question their morals. Because of the
inconsistencies in their work, therapists will make decisions on a case-by-case basis, and
overarching principles wont always apply in a black-and-white fashion.
The fourteen virtues and principles of occupational therapy are the internal goods of the
practice, all of which must be applied in order to reach the end of the institution. Internal goods
are defined as those qualities and abilities that come from working towards excellence in that
practice (MacIntyre, 175). For example, prudence is one of the virtues of occupational therapy,
and it is one that comes from striving to be a good therapist. Similarly, altruism is a virtue as
well, one that might come naturally to some but that is sincerely developed over years of
assisting others on their journey to autonomy. Because occupational therapy is also an
institution, it necessarily has an end. The end of an institution is what that thing is when it is in
its’ very best state. The end of occupational therapy as an institution is bettering the lives of
clients who seek out therapy, as well as restoring the dignity to those patients. A therapist who is
achieving the end of OT is one who does this for his or her clients. As discussed, one who
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achieves the end of one’s institution will also benefit from the development of the internal goods,
in this case the fourteen virtues and principles of occupational therapy.
In the field, oftentimes the temptation of external goods of occupational therapy will
draw a therapist away from achieving the end of the institution. For example, a high pay scale,
prestigious status, the impressiveness of the degree, and things of this nature will bring
individuals into the field for the wrong reasons, and these people will not pursue the end of the
institution, but will pursue their own purpose. A purpose differs from an end in that an end
belongs to the thing itself, while the purpose is a human intention imposed on a thing
(Sokolowski, 509). These therapists with their own purposes for the field, when tested morally,
will be more willing to fold than those pursuing the ends of the institution because they lack the
sincere desire to better their institution. There are two possibilities when a supposed ethical
dilemma arises, which is why the evaluation of these ethical dilemmas must be evaluated. Either
there is a sincere dilemma where there is no right or wrong option, in which a therapist must
apply their skills and virtues as best they can to ensure the most ethical solution, or the therapist
has their own intentions which leads them to choose the solution that best fits their needs.
One such situation where the morality of the therapist and the ethical dilemmas collide is
during the process of discharging patients from hospitals. Discharge planning is defined as “the
primary means to ensure that patients needs will be met in the post discharge environment”
(Atwal & Cadwell, 244). The process of discharging a patient from the hospital first involves
home visits from the therapist to assess the safety of the home and potential modifications to the
living space (Drummond, 389). These home visits also included primary caretakers for the
victims, where the therapist could teach them how to effectively perform transports and activities
of daily living, as well as work with necessary equipment provided for those activities
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(Drummond, 389). After the home visits, occupational therapists will have meetings with other
professionals of different disciplines. (Atwal & Caldwell, 244). From there, decisions on the
patient’s future will be solidified—these are the areas where ethical dilemmas will arise. The
four main virtues of Occupational therapists that are threatened during the process of discharge
planning are autonomy, beneficence, non-maleficence, and justice (Atwal & Caldwell, 248-249).
During the home visits, occupational therapists will be faced with clients and care takers
whose main concern is getting their loved one’s home. The therapist’s main concern is getting
the client healthy, and these two goals are not always identical—a therapist might encounter
homes that are unlivable for their client, such as a high level apartment with no elevators for a
client with trouble walking. In these situations a therapist has to choose their patient’s autonomy
or their own beneficence. Oftentimes an individual’s desires and what is best for them do not line
up exactly, putting the therapist in the position of accepting an inferior outcome than they have
planned for their clients.
During the process of patient discharge, occupational therapists are recognized along with
physiotherapy and speech and language therapy practitioners face the most ethical dilemmas
(Atwal & Caldwell, 244). Some of these issues arise because successful patient discharge is
dependent on the collaboration of interdisciplinary professionals. Each of these professionals will
have completed their own level of graduate education and will have their own code of ethics that
they have to uphold. While generally all of these professionals will have the success of the
discharge as their main goal, they will have different ways of going about that as well as
different ideas on which solutions are moral and which solutions are not (Atwal & Caldwell,
244). Another problem is with the availability of resources for patients. Misdistribution leads to
a lack of availability, putting therapists in the position of having to choose who receives what
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they need, and who has to go without. This greatly threatens the virtues of equality justice—how
does one decide who goes with and who goes without while still upholding the fair treatment of
all clients? Does the person with the worst condition get the better treatment, or does the person
with the best prognosis? Either way, someone will have to be excluded, and could be missing out
on necessary treatments that would allow them to be discharged. And, in the case of those who
don’t receive the treatment, is it safe to discharge them without it, and better yet, is it ethical? In
such a situation the therapist would have to decide which of their virtues they hold higher—the
dignity of their patients by allowing them to go home and not live in a hospital, or their nonmaleficence, which prevents them from doing that which they believe could harm their patient?
In either situation their moral code is being broken; however it is a decision that cannot be
avoided, as its effects will be played out on human lives.
Another area of contention is in the discussion of autonomy. Therapists, as professionals,
have the autonomy to decide what treatment paths to follow, and if and when to abandon them.
However, clients also have a certain level of autonomy when it comes to their treatment.
Therefore, the client can make decisions regarding his or her treatment that the therapist has not
been consulted on -and therefore might not agree with- but have to follow regardless (Atwal &
Caldwell, 248). A classic example of this is when a patient has decided that they want to go
home, and have set up their date to leave without consulting their therapist, who might not
believe their patient to be ready for discharge. Does the occupational therapist uphold their
patient’s autonomy by allowing them to leave, or do they prevent their patient from leaving in
the name of beneficence and non-maleficence? It always boils down to which virtue trumps
which virtue, and who actually knows best, client or therapist?
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Beneficence raises some ethical dilemmas of its own when it comes to discharging
patients. Beneficence is the concept that occupational therapy practitioners must only do good
for their patients, and do everything they can to benefit their patients within occupational therapy
standards (Reed, 3). However, some therapists might be restricted by education levels or
certifications, which prevent them from prescribing certain equipment. Atwal and Caldwell
describe a situation where a therapist prescribed a hoist for a patient despite not having the
proper authorization to do so (248). In this case, the hoist took two extra weeks to arrive and did
not fit under the bed properly. The patient’s discharge was unnecessarily pushed back by three
weeks. The therapist faced an ethical dilemma—should she go beyond her authorization to
provide what she thought necessary, or should she potentially ignore the principle of nonmaleficence by allowing her patient to be discharged without this equipment she believed to be
essential? In this case her solution ended up being the less ethical decision of the two, but as the
therapist who prescribed the hoist said, “it really is quite stressful” (Atwal & Caldwell 248).
Non-maleficence and beneficence often get lumped together; however, there is a
difference between the two. While beneficence is an obligation for the therapist to do good
things for their clients, non-maleficence prevents an occupational therapist from knowingly
allowing harm to come to their patient, whether through ignorance or through being witness to
mistreatment of or misbehavior by the client. Also under non-maleficence, therapists have an
obligation to act on behalf of their clients when they are impaired or otherwise unable to speak
for themselves in order to preserve their autonomy. However, advocating for patient’s rights can
sometimes go against what even the therapist thinks best. For example, a client might feel that a
certain treatment is doing more harm than good and decide they no longer want to receive it.
Even if the therapist feels that the treatment is necessary to get the patient to a state where they
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are allowed to be discharged, their code of ethics obliges them to advocate for the patient’s
autonomy (Atwal & Caldwell, 248-249). This makes occupational therapists rather unpopular at
times. Doctors, neurologists and physical therapists don’t want to hear another professional
telling them what they should and shouldn’t do for their patient, especially when they know that
what they are doing is working. So, the temptation is to attempt to convince the patient that the
doctors know best, or even ignore the complaints to avoid the backlash of their peers. In this
case, it is evident that the ethical solution is to protect the autonomy of the client; however,
occupational therapists will face blame for slowing the discharge process, which can cloud their
judgment.
A final fundamental virtue of occupational therapy is justice, which boils down to
respecting the rights of each individual that one encounters, including practitioners, peers,
clients, and their caretakers. The occupational therapist’s ability to preserve this respect is
threatened by the hospitals they work in. Therapists are under pressure to move patients and clear
beds in order for more patients to enter. This leads to therapists cutting corners to clear beds,
which absolutely breeches the code of ethics, and is also disrespectful to the client. However, this
dilemma is caused by outside pressure from the medical institution and all the blame cannot be
placed on the occupational therapist—the high expenses and high profit oriented medical
institutions place unnecessary pressure on their employees which forces them to question their
morals in order to keep their jobs.
Occupational therapy is a practice whose internal goods are under attack. The end of
occupational therapy as an institution is not being achieved because the morals that comprise the
internal goods are threatened by ethical dilemmas, especially during the process of discharging
patients from hospitals. The virtues of Occupational therapists that are most susceptible to ethical
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corruption are autonomy, beneficence, non-maleficence, and justice. Occupational therapists aim
to provide dignified and ethical care for their patients; however, due to outside pressure from
clients, other professionals and hospitals during the discharge of patients from hospitals,
therapists must stare ethical dilemmas in their faces and determine which of their virtues they
have to abandon.
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Bibliography
Atwal, Anita, and Kay Caldwell. "Feature Article Ethics, Occupational Therapy And Discharge
Planning: Four Broken Principles." Australian Occupational Therapy Journal 50.4
Drummond, Aer, et al. "Occupational Therapy Predischarge Home Visits For Patients With A
Stroke (HOVIS): Results Of A Feasibility Randomized Controlled Trial." Clinical
Rehabilitation 27.5 (2013): 387-397. SPORTDiscus with Full Text. Web. 22 Mar. 2015.
MacIntyre, Alasdair C. After Virtue: A Study in Moral Theory. 2nd ed. Notre Dame, Ind.: U of
Notre Dame, 1984. Print.
“Occupational Therapy: Improving Function While Controlling Costs.” AOTA. American
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<http://www.aota.org/About-Occupational-Therapy/Professionals.aspx>.
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Homenko, Craig Jackson, Debora Slater, and Loretta Foster. "Ethics." - AOTA. American
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<http://www.aota.org/Practice/Ethics.aspx>.
Sokolowski, Robert (2004). What is Natural Law? The Thomist 68 (4):529.