The Future of Exercise Physiology:
A Matter of Ethics
Larry Birnbaum, PhD, MA, EPC
Much has been written on professions and
professionalization, including what makes a profession a profession [1].
Virtually all descriptions of a profession include autonomy as one of the
key characteristics of a profession. Professionals must be able to
govern themselves, set their own standards (of practice), develop their
own code of ethics, and establish accreditation and certification practices
to assure consistent quality in educational programs and competency of
individual practitioners [2]. If an entity blocks professionals from
determining their own future, that entity is doing a great disservice to
the profession. Indeed, their obstructive behavior is unethical.
It can only harm the profession. Autonomy is essential to a profession.
In essence, autonomy means self-governance [3].
Operating under the auspices of a larger
umbrella organization that includes several other professions in its membership
is not self-governance. Doing so does not allow the profession to
determine its own future. It is constrained by the umbrella organization.
It must receive approval for all it does by the umbrella organization.
How can the umbrella organization have the best interests of this profession
at heart when it must also serve other professions, some of which may be
competing in one way or another (e.g., clinical practices) with the profession
in question. This situation obviously poses a conflict of interest
and is unethical.
Recently, Wattles [4] described two situations
that clearly illustrate this latter point. He discussed CMS proposed
rule changes that would mandate that any "physical therapy" services provided
incident to physician care be delivered by or under the direct supervision
of a physical therapist. As Wattles states, the proposal represents
a concerted effort to exclude many allied health providers, including exercise
physiologists, from CMS reimbursement for services. The ASEP leadership
worked with a dozen organizations to oppose the CMS rule change.
The ACSM and AACVPR organizations would not support the coalition because
it would present a conflict of interest to their membership. Wattles
also stated, “What would the physical therapists in ACSM think if ACSM
were to support the coalition?”
The second situation involved a bill introduced
in Indiana (SB 360) primarily to address direct access to physical therapy
without a physician referral. It included a hidden provision that
would have allowed physical therapists to provide fitness and wellness
services to asymptomatic individuals in a non-medical setting without a
physician referral. Since the fitness industry was unregulated, the
bill essentially would have provided regulation by default (i.e., only
physical therapists could provide these services). The Indiana Association
of Exercise Physiologists, with help from ASEP, opposed and helped to defeat
the bill. ACSM and AACVPR did not oppose the bill because it would
have been a conflict of interest and may have turned the ACSM physical
therapists' membership against the organization [4].
Clearly ACSM and AACVPR do not represent
the best interests of exercise physiologists. Why then would exercise
physiologists choose to belong to ASCM and not ASEP? It is understandable
that an exercise physiologist would belong to both or to ASEP only, but
why an exercise physiologist would choose to belong to ACSM only does not
make sense. Until ASEP was founded, ACSM did nothing to advance the
professionalization of exercise physiology. What it has done since
is reactionary, rather than carefully planned and in consideration of the
best interests of exercise physiologists. Since ACSM’s membership
includes several different professions, it runs the risk of disenfranchising
one profession if it attempts to advance the cause of another. Again,
the conflict of interest becomes a major issue. This has been so
vividly demonstrated in the recent events described by Wattles [4].
Perhaps an explanation for the illogical
behavior of those exercise physiologists who chose ACSM over ASEP is an
inherent resistance to change. This seems to be a prevalent characteristic
of human nature. We do not like change. We resist change.
Indeed, we exert a tremendous amount of energy fighting change, yet change
is inevitable and constant. Change is part of our lives. We
must continuously adapt to our changing environment. The environment
for exercise physiologists has changed. It is essential that we establish
ourselves as a profession and become autonomous, self-governing, self-directed.
To do anything less is unethical.
McDonald [5] defines a conflict of
interest as "a situation in which a person, such as a public official,
an employee, or a professional, has a private or personal interest sufficient
to appear to influence the objective exercise of his or her official duties.”
If you substitute organization for person, the definition of conflict of
interest reads, “a situation in which an organization has a private or
personal interest sufficient to appear to influence the objective exercise
of its official duties.” McDonald [5] adds that there are three
key elements in his definition.
First, there is a private or personal
interest. This may be a financial interest, but it could also be
another sort of interest, such as providing a special advantage to a spouse
or child (or a given profession). Taken by themselves, there is nothing
wrong with pursuing private or personal interests; for instance, changing
jobs for more pay or helping your daughter improve her volleyball skills.
Second, the problem comes when this
private interest comes into conflict with the second feature of the definition,
an "official duty" -- quite literally the duty a person or organization
has because it has an office or acts in an official capacity. A professional
person or organization takes on certain official responsibilities, by which
it acquires obligations to clients or others. These obligations are
supposed to trump private or personal interests. And this is what
poses the conflict of interest for ACSM. ACSM is obligated to represent
all of its member professions in the capacity of sports medicine.
It cannot represent the interests of just one member profession when those
interests conflict with one or more other member professions.
Third, conflicts of interest interfere
with professional responsibilities in a specific way, namely, by interfering
with objective professional judgment. Clients as well as the public
in general expect professionals and professional organizations to be objective
and independent. Here again ACSM cannot be objective and independent
in its representation of any one member profession. ACSM’s actions
are dependent on and, therefore, biased by all other member professions.
References
1. Boone, T. (1999). Rising to the Level
of Profession. Professionalization of Exercise Physiologyonline.
Vol 2 No 2 [Online]. http://www.asep.org/asep/asep/feb1.htm
2. Birnbaum, L. (2003). Planting Seeds.
Professionalization of Exercise Physiologyonline..
Vol 6 No 2 [Online]. http://www.asep.org/asep/asep/PlantingSeeds.html
3. World Medical Association (2003).
World Medical Association Declaration on Professional Autonomy and Self-Regulation.
[Online] http://www.wma.net/e/policy/a21.htm
4. Wattles, M. (2004). The
Recent ACSM and AACVPR Initiative Regarding Exercise Physiology.
Professionalization of Exercise Physiologyonline..
Vol 7 No 11 [Online]. http://www.asep.org/asep/asep/ACSMinitiative.html
5. McDonald, M. (2003). Ethics
and Conflict of Interest. The W. Maurice Young Centre for Applied
Ethics. University of British Columbia. [Online]. http://www.ethics.ubc.ca/people/mcdonald/conflict.htm
