In this Q&A, Andrea Sturm and Ian Edwards talk about ethical dilemmas and challenges that we all face due to the coronavirus pandemic. Ian Edwards is an ethics expert and has mentioned in many physiotherapy resources, some of which you may be familiar with, including a recent international ethics study. It is an interesting conversation with some take-away lessons for all of us.
AS: Hello Ian! As always, it's a pleasure talking to you. We met a few years ago when we conducted an interview for our Physiopedia online course "Applied Ethical Thinking". You highlighted your concept of "The Ethical Reasoning Bridge" and its components for us.
What I really like is the flexibility that allows the ER bridge to be adapted to any specific context, whether cultural or situational, without losing sight of the key elements. It is one of the few ethics concepts known to me that encompasses our professional obligations and duties as well as the individual circumstances of the patient and his system. At the same time, the ambiguity and versatility of every kind of human interaction is respected. That is the key in unprecedented times like ours.
It is easy for me to see that this was not developed by someone who sits behind a table and theoretically philosophizes about ethical questions. What were the professional or personal circumstances that led you so deep and lively into professional ethics?
IE: Thanks Andrea. It is good to speak to you again. I became interested in professional ethics or in particular teaching ethics after I returned as a mature student to continue my physiotherapy studies. After working as a physiotherapist in other cultures, I became interested in the question "Why do people do what they do?". But such a question is really like the hub on a wheel, with spokes related to culture, poverty, health and injustice, war and conflict, and the multitude of influences that result from each of these influences. And of course you cannot ask such a question in relation to others without asking yourself – as a person and as a medical professional. For me, professional ethics was never just about teaching others what the nuts and bolts of a professional code of conduct are, or warning the students about the possible consequences of non-compliance with such codes. It was much more about exploring the moral terrain between "what we should do" and "what we should actually do" and understanding what is happening to us and within us in this room. And that is what "The Ethical Reasoning Bridge" tries to explain as a model.
AS: At the moment our profession is facing enormous challenges due to the new form of the corona virus, which keeps the world in suspense. PT clinics are blocked if this is felt by governments or because of the personal responsibility of an individual therapist towards his vulnerable client or himself. Choosing the right thing often leads to financial bottlenecks among these colleagues, which are not always offset by national emergency plans.
A lack of PPE (Personal Protective Equipment), not only in resource-poor countries but almost all over the world, sometimes overly threatens health care workers when they work on the front line of health care to rescue infected people. It is about medical-ethical values and also about the previous understanding of the profession. Our current PT generations – with the exception of colleagues who work for the military or in conflict zones – have typically not faced procedures such as triage or handling security issues when helping others. We also have loved ones who are important to us and who are concerned about our wellbeing.
You have worked in conflict zones and war-torn countries where a lack of personal security and resources was common. What do you think about the ethical challenges of this crisis and how have you responded to your own dilemmas regarding such problems?
IE: Yes, I think there are parallels to working in war zones and working in places like hospitals that imitate war zones during this pandemic. Risk management is certainly a common thread. Unfortunately, risk management is not a perfect calculation or science that offers a 100% guarantee that everything will turn out well. The last time I worked in Afghanistan, we received daily updates on our mobile phones that informed us of current "incidents" and whether or not it was safe to go to work and which ways we should or shouldn't go come there. Interestingly, at that time we also used the term “lock” to describe times when we were locked up in our homes in times of unrest. Staying safe as health workers is a reality that can take different forms at different times depending on the context. Technology is critical, whether in the form of helpers in Afghanistan who receive SMS updates or in the form of healthcare workers who have the right PSA to treat patients with Covid19. In addition to technology and expertise, working in unsafe situations also requires strategies to monitor your own levels of stress and well-being. And besides technological and psychological support strategies, I think there is also an ethical perspective that underpins the ability to work in such situations. And that has to do with promoting conviction and belief in the value of what you do to put yourself in danger.
When you think about the value of your work, you will inevitably notice the increased vulnerability that others around you experience. It was sobering to see the other effects of Covid19. Health inequalities have led to a sharper focus as the poor suffer the most from being locked up and unable to work. And those with poor health and limited access to healthcare are even more vulnerable to the more serious or even fatal effects of Covid19. And in another sense, we have even seen in Australia how racism whirled its ugly head in those days when non-Anglo-Australians were abused on the streets or in public transport. It is therefore another form of ethics to expand our focus as health professionals from the purely physiological effects of the virus on patients to one that also recognizes the harm that is done to people in other ways.
AS: Thank you for highlighting these important issues, Ian. After a fruitful and productive life as a PT clinician and academic at the University of South Australia, you have retired but are still involved in some research projects and have written a single author's book on ethics. I would be interested to know what power drives you to continue to work for our profession while you can easily get up all day at Seacliff Beach or hike in the Flinders?
IE: I only became a physiotherapy teacher in the last part of my career and I am grateful for this opportunity and the satisfaction it brought me. But I have to say that I have never had more fun teaching than in Afghanistan. Although I mentioned some of the dangers of being there above, I also learned to appreciate the rewards. My Afghan colleagues' thirst for information and their persistence in learning in very challenging situations both at work and in the general situation around them have always inspired me. My most recent letter reflects how I have been challenged both personally and ethically at different times during my introduction to Afghanistan and subsequent teaching visits there. The way through all of this was, at least in part, to see what my Afghan colleagues (and other Afghans) could teach me.
I am now free to write about these things, relying more on my personal experience than on ethics textbooks. I can also use plain text rather than academic language. And I enjoyed that.
AS: I am convinced that all your contributions to the profession are highly valued. To be honest – it would be a shame if you kept all your knowledge and experience to yourself. Thank you for the interview, Ian. Stay safe in these challenging times!
Andrea Sturm is a PT clinician, educator and researcher with an interest in ethics and mental health from Austria. She is a Physioplus tutor and developed her online programs for ethics and mental health. She recently created a new short course on mental health for patients and health professionals during the Covid19 pandemic.
Ian Edwards contributed to several books and chapters:
Edwards I & Delany C 2019. Ethical thinking. In: Clinical thinking in the health professions. Higgs J, Jensen GM, Loftus S and Christensen N eds. 4th Ed. Elsevier: London, pp. 169-180.
Delany C & Edwards I 2020. From ethical thinking to ethical acting. In: Clinical Thinking and Decision Making in Physiotherapy: Facilitation, Evaluation and Implementation. Musolino GM and Jensen GM eds. Slack Inc: Thorofare, NJ, pp. 47-56
The second teacher: lessons from Afghanistan. Ian Edwards 2020.
