As exercise
physiology continues to develop as a profession, issues that challenge
the exercise professional's integrity will increasingly occur. Ethics
is a system to assist in the analysis of such challenges. This article
reviews basic ethical principles and terminology, and provides a sample
case analysis with application of ethical concepts.
KEY WORDS: Code of ethics,
ethical principles, professionalism
Introduction
THE DISCIPLINE OF ETHICS
may be perceived by some to be a lofty, esoteric subject to be debated
among scholars. However, ethics has ready application for the clinician
or academician of many health care disciplines, including that of exercise
physiology. Purtilo (1) suggests three ways in which ethics
has usefulness in everyday life:
-
to analyze moral problems
-
to assist in resolving
moral conflicts, and
-
to take action when confronted
with an moral issue.
Exercise physiology does not
exist in a vacuum apart from ethical issues. In fact, exercise physiologists
in a number of employment environments are likely to encounter situations
that could be categorized as ethical issues. Patient-practitioner
confidentiality, reimbursement from third-party payers, and over-utilization
of services are just a few areas in which exercise physiologists are likely
to experience ethical distress during the course of their careers.
This article revolves around a ubiquitous moral problem: sexual harassment.
Because the movement towards
the professionalization of exercise physiology is relatively new, some
graduates of exercise physiology programs may not have gained exposure
to concepts in professional ethics. Therefore, the purposes of this
article are:
-
to briefly review key concepts
of professional ethics, and
-
to apply these concepts to an
actual case report of possible sexual harassment involving an exercise
physiology professional.
Review
of Ethical Principles and Terminology
Initially, the language
of ethics can seem quite foreign and daunting. However, in time,
the terminology becomes more natural, and the effort required to learn
the language is a small inconvenience given the power it confers to those
willing to apply ethical principles to their critical analysis of situations
that threaten any aspect of professionalism. Additionally, the language
of ethics can help one articulate problematic situations in which one previously
could only sense that something was amiss but was unable to explain one's
discontent to oneself or others.
"Ethics" may be succinctly
defined as "a systematic reflection on morality". Furthermore, according
to Purtilo (1), it is "the discipline that provides a language, some methods,
and guidelines for studying the components of personal, societal, and group
morality to create a better path for yourself and others".
Two major ethical theories
can be used broadly to describe moral issues in health care. The
"deontological" theory is driven by duties and rights of persons, and is
a system that holds the means, as opposed to the ends, to be of greatest
importance. In contrast, the "teleological" theory is driven by goals,
and places the greatest emphasis on the ends (1). Although the two
theories are most often compatible in that one can do the "right" thing
while respecting other's rights to achieve the best possible outcome, at
times achieving a particular end -- no matter how good for society -- may
infringe on the rights of some people.
Whereas ethics theories are
quite broad, ethical principles are much more specific. Six ethical
principles are commonly recognized, regardless of the ethical theory one
chooses to apply. The principles (1) are as follows:
-
nonmaleficence (doing no harm)
-
beneficence (doing good)
-
fidelity (keeping a promise)
-
autonomy (exercising or respecting
personal freedom)
-
veracity (telling the truth),
and
-
justice (distributing benefits
to those deserving of the benefits)
After contemplating an ethical
problem, a person may decide what right course of action to follow.
Purtilo (1) elaborates on the types of ethical problems. If the person
knows what h/she wants to do, but is unable to execute a planned course
of action due to a barrier, then the person experiences a psychological
unrest referred to "ethical distress".
Type A ethical distress describes
the situation in which a person can identify the barrier to his or her
course of action. In Type B ethical distress, a person knows the
course h/she wants to take but cannot identify with certainty the barrier
that restricts the course of action. Ethical distress is but one
kind of ethical problem. Another example is an ethical dilemma in
which a person (moral agent) realizes there are two or more acceptable
but mutually exclusive courses of action that may be taken. A third
kind of ethical problem is referred to as a locus of authority problem,
which involves determining who should have the authority to make an important
moral decision (i.e., be the moral agent). Purtilo (1) suggests a
six-step process to formalize ethical reflection when a problem arises,
which is:
1. Gather relevant information
(i.e., fact-finding).
2. Identify the type of
ethical problem (e.g., ethical distress, ethical dilemma,
locus of authority).
3. Use ethics theories to
analyze the problem (e.g., deontology, teleology).
4. Explore the practical
alternatives.
5. Complete the action.
6. Evaluate the process
and outcome (i.e., retrospective analysis).
Case
Description
A series of incidents which
could be perceived as constituting sexual harassment occurred during a
graduate exercise physiologist's one-month teaching internship. On
the guest instructor's second day at the host college, a female student
in one of the guest instructor's courses passed by him and said, “Hi big
guy” as she patted him on the shoulder. This served as their first
introduction. Several days later during a laboratory experience that
required partially disrobing, the student said to the visiting instructor,
“Well, take off your clothes and climb up on my lab table.” Finally,
on the student's last day of finals, she invited him to go to a bar with
her classmates. The guest instructor suggested to no one, including
the student in question, that any impropriety had occurred during his visit.
Following the second incident,
the intern was able to assemble the following profile of the female student.
She was a first-year student enrolled full-time in the program and was
an "A" student. She was in her mid-thirties and had two children
under the age of 10 who lived with her. Lastly, she had been recently
separated from her husband of approximately 12 years.
Type
of Ethical Problem
This case primarily was
a problem of ethical distress (Type B) in which the guest instructor recognized
the presence of a moral impropriety but the newness of his professorial
role as well as his uncertainty of the student’s intentions served as barriers.
A source of further distress was his recognition of the fact that he could
have been imagining the flirtation or could even have inadvertently instigated
it. Thus, he was wrestling with his own perception of the situation.
Was there indeed something wrong, or was he making a mountain out of a
mole hill? Was the student simply joking and trying to make the guest
instructor comfortable in his new environment?
A concern of the guest instructor
was that the student’s suggestions would be overheard by another classmate
or another instructor who may have mistakenly believed the guest instructor
to be reciprocating in the flirtation. Because the visiting instructor
was married, his apparent condonation or approval of the flirtation could
have had familial implications beyond professional consequences.
Although I am certain the
American Society of Exercise Physiologists (2) strives to ensure the rights
of students and demands professional conduct toward students, it remains
unclear how students are expected or required to interact with one another.
Because of this circumstance in which a student was assessing another student,
it could be argued that an additional problem regarding locus of authority
is applicable to this case. Perhaps, if anyone were to have rightful
agency in this situation, it would have been the guest instructor.
However, because of the intern's student status, he was uncertain if he
was entitled to be in authority. I am not suggesting that an individual
should ever have to endure sexual harassment. As Purtilo (1) explains,
inaction does not necessarily have neutral moral consequences. Rather,
I am trying to convey that in this particular circumstance, addressing
a transgression may have been handled more professionally and tactfully
by the intern's advisor.
Problem
Analysis via Application of Ethical Theories
From a deontological perspective,
the visiting instructor felt a sense of duty as a temporary faculty.
However, his sense of duty was more so centered on helping the student
avoid similar situations in the future as opposed to seeking punishment
of the student. His concern was also consistent with the principle
of beneficence, or helping the student. Deontological theory, which
emphasizes respect for individual rights, also applies to this situation
due to the perceived lack of mutual respect.
A confounding factor that
inhibited the intern's reconciling the problem was the fact that the student
exhibited exemplary academic performance and was otherwise cordial, courteous,
and sometimes shy. Therefore, from a teleological perspective, the
intern was uncertain if his reporting the episodes of perceived harassment
would accomplish the greatest good or if it would disproportionately mar
the student’s reputation in the eyes of the faculty.
Several ethical principles
are involved in this case. Nonmaleficence was breached when the intern
perceived "violation". Adapting a phrase from Purtilo's book (1),
if I want to flirt with you, my autonomy ends where your eyes, ears, or
skin begins. Perhaps the visiting instructor's passivity was a breach
of beneficence because he may have benefited the student or her future
colleagues by bringing to the student's attention her self-defeating (and
potentially criminal) behavior. Yet, there was tension between beneficence
and nonmaleficence because the intern was uncertain what would truly help
the student versus what would harm the student. Although there was
no overt lying involved, could the principle of veracity have been violated
by the student instructor's failure to report these incidents? In
other words was he lying to his superiors by omission? In this situation,
it could be argued that autonomy and veracity may have been in conflict.
Alternative
Actions
At least three reasonable
action pathways may have been appropriate for this situation. First,
the student instructor could have tactfully addressed the situation in
private with the student. Perhaps he could have said something to
the effect of "You've been very friendly to me since I've arrived as an
instructor. Thank you for trying to ease my transition. Pardon
me for asking, but have you been something more than friendly, or am I
simply misreading the situation?"
Another option would
have been for the student instructor to approach his supervisor or the
department chair with the situation. The supervisor may have known
the student more personally and also may have been aware of any similar
conduct. The supervisor could have served as a mediator between the
student and the student instructor. Or, after consulting with his
supervisor, the supervisor may have encouraged the student instructor to
personally address the student and report back to the supervisor for further
informed discussion.
A third alternative action,
but least direct of the alternatives, is for the student instructor to
have related the information to his academic advisor at his home institution.
This would have been the least likely alternative to "make waves" and the
advisor -- with the advisor's expertise -- could have offered guidance
as to how to proceed.
In Purtilo's (1) explanation
of ethics and the professional student, the author states, “As a student
yourself you may recognize a tendency to discredit your own feelings, intuitions,
and judgments”. Although the student instructor may not have been
a stranger to either side of flirtation, he was relatively unaccustomed
to a professorial role, particularly with older students. Assuming
the visiting instructor sincerely desires to teach, it is important that
he learns how to command respect, even if he employs an egalitarian teaching
model which emphasizes equality between students and the professor.
Purtilo (1) cites several mitigators of student agency, including the nature
of the student role, the character of the student-professor relationship,
and inexperience regarding life situations in general. All
of these mitigators may have factored into the intern's inaction.
Reflection
with Emphasis on ASEP Guidelines
The ASEP has been instrumental
in developing
conduct guidelines by which exercise physiology students
and professionals should abide. Clearly, the flirtatious student's
behavior was inappropriate and in conflict with Article II of the ASEP
Student Constitution, which states the purpose of the Constitution (3):
"To make a commitment to quality and integrity [emphasis added]
in exercise physiology through adherence to the ASEP's formalized code
of professional responsibility." Moreover, the student's actions
violated certain tenets of the ASEP Code of Ethics (4). The fourth
tenet reads, "Exercise physiologists are expected to conduct health and
fitness, preventive, rehabilitative, educational, research, and other scholarly
activities in accordance with recognized legal, scientific, ethical, and
professional standards." Also applicable is the ninth tenet, which
states, "Exercise physiologists should participate in and encourage critical
discourse to reflect the collective knowledge and practice within the exercise
physiology profession to protect the public from misinformation, incompetence,
and unethical acts."
In a sense, the visiting
instructor also breached the ASEP's standards, as the Code of Ethics (4)
indicates in the sixth tenet: "Exercise physiologists are expected to call
attention to unprofessional health and fitness, preventive, rehabilitative,
educational, and/or research services that result from incompetent, unethical
[emphasis added], or illegal [emphasis added] professional behavior."
Had he been cognizant of this clause prior to his affiliation with the
host program, the intern may have been more assertive in addressing the
situation by feeling a sense of duty to the profession of exercise physiology.
Regardless of the female student's intent, the intern probably did not
do the student a favor by remaining completely passive. If she were
overtly flirting, then reprimand was surely fitting as this would be deemed
unacceptable professional behavior in either a clinical or academic setting.
However, even if she were not intentionally implying physical intimacy,
then perhaps her communication style should have been brought to her attention
so that she was aware of the need for professional language to avoid the
opportunity for misinterpretation. As Purtilo (1) cautions, "Once
you graduate you will no longer have the formal ethical and legal protection
to make poor judgments that you have as a student."
In a report (5), the ASEP
President, Dr. Robert Robergs, had this to say about standards in the field
of exercise physiology: "...it is not enough if we as professionals of
exercise physiology do not also increase our professional credibility in
all that we do each day. This is the major challenge we all face
as exercise physiologists." When one reflects on these statements
and the magnitude of commitment required of exercise physiologists to further
their profession, it appears that both the student and the intern in this
case failed to take the appropriate courses of action.
The severity of the student's
improprieties could be properly assessed only if the student’s intentions
were made known. Therefore, more initial fact gathering, that is,
Step 1 of ethical decision making, (1) was necessary to take this case
beyond a speculative ethical blip. The only person who could explain
the intentions was the female student. Unfortunately, without more
prerequisite fact-finding, the intern must resign himself to pondering
the student's intentions and the possible ramifications of the situation.
Conclusion
The ASEP has developed guidelines
for professional conduct that can also serve to create an awareness of
any transgressions against what is generally considered to be congruent
with professional behavior. In essence, professional standards help
to finely adjust our moral barometers. Ethics provides us with the
tools to help evaluate and resolve situations that conflict with our professional
standards. As exercise physiology continues to develop as a profession,
perhaps coursework in healthcare ethics will become increasingly incorporated
into exercise physiology curriculum to better equip exercise physiologists
who will undoubtedly face ethical problems in their personal or professional
lives.
References
1. Purtilo, R. (1999). Ethical
dimensions in the health professions. (3rd edition). Philadelphia, PA:
W. B. Saunders.
2. American Society of Exercise
Physiologists (1997-2000). Table of
contents [Online]. Available: www.css.edu/ASEP/ [2000, February].
3. American Society of Exercise
Physiologists (1999). ASEP
Student Chapter of American Society of Exercise Physiologists: Constitution
[Online]. Available: www.css.edu/users/tboone2/asep/jan14d.htm [2000, February].
4. American Society of Exercise
Physiologists (1999). Code
of ethics [Online]. Available: www.css.edu/users/tboone2/asep/ethics.htm
[2000, February].
5. Robergs, R. A. (1998).
President's
report: 1998-1999 goals and objectives [Online]. Available: www.css.edu/users/tboone2/asep/presid.htm
[2000, February].
About
the Author
Greg
Bradley-Popovich holds Master's degrees from West Virginia University
in Exercise Physiology and Human Nutrition. He is currently a Doctor
of Physical Therapy (DPT) scholar at Creighton University in Omaha, Nebraska
where he is researching the use of creatine supplementation as an intervention
in medical conditions. He is a free-lance fitness and sports nutrition
writer whose ultimate ambition is teaching on the university level while
promoting a multidisciplinary approach to fitness, wellness, and rehabilitation.
Address correspondence to:
Greg Bradley-Popovich
5635 N. 106th Plaza #12
Omaha, NE 68134
(402) 492-9124
gregebp@aol.com
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American Society of Exercise Physiologists. All Rights Reserved.