PEPonline
Professionalization
of Exercise Physiologyonline

An international electronic
journal for exercise physiologists
ISSN 1099-5862
Vol 3 No 6 June 2000

 

An Exercise in Ethics: Case Analysis 
with Implications for the Exercise Physiologist 
Case Report

Greg E. Bradley-Popovich, MSEP, MS, CSCS
Doctor of Physical Therapy Scholar
Department of Physical Therapy
School of Pharmacy and Allied Health Professions
Creighton University
Omaha, NE 68178


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
Copyright ©1997-2000 American Society of Exercise Physiologists. All Rights Reserved.

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