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Abstract

As an increasingly more global profession, occupational therapy faces ongoing ethics issues when working to address the occupation-based needs of individuals, groups, and society at large. While the ethical implications and sources of conﬂict may vary based on geographic location, practice setting, and role, many ethical issues encountered in occupational therapy settings transcend country, ethnicity, and cultural afﬁliations.

Introduction

The occupational therapy profession did not coin the term “occupation” nor were occupational therapy providers the ﬁrst to reference occupation as a means to heal (Gordon 2009). However, the profession’s scope of practice, distinct value, and unique approach to health and well-being is predicated on the use and value of occupations. The World Federation of Occupational Therapists (WFOT) deﬁnes occupational therapy (or ergotherapy as some countries call it) as:

a client-centred health profession concerned with promoting health and well-being through occupation. The primary goal of occupational therapy is to enable people to participate in the activities of everyday life. Occupational therapists achieve this outcome by working with people and communities to enhance their ability to engage in the occupations they want to, need to, or are expected to do, or by modifying the occupation or the environment to better support their occupational engagement (WFOT 2010).

The aforementioned deﬁnition of the World Federation of Occupational Therapy (WFOT) suggests that the ultimate goal of occupational therapy is improved health with occupation being the means toward that outcome. By enabling individuals to engage in meaningful occupations, it is surmised that their health and wellness will then improve. For example, occupational therapists will teach hemiplegic patients how to compensate for the loss of motor ability, thereby enabling them to increase independence in undertaking self-care tasks or return to work. Because of this connection between meaningful occupation and health, occupation can itself become a form of therapy. For example, if a client was experiencing decreased ﬁne motor dexterity, then the occupational therapist would address manipulation of fasteners (buttons, zippers, snaps, etc.) during the occupation of dressing in order to address performance skills.

This connection between occupation and health also makes clear that some types of occupation can endanger health, whether it be work involving hazardous chemicals, brain damage induced by sports, or the continuous stress of working at a minimum wage. Hence, occupational therapy practice is also concerned with improving occupational safety.

In all of the approaches mentioned so far, occupation is a means to some other end, that is, better health. However, some deﬁnitions of occupational therapy move beyond the one provided by the WFOT in that they presume meaningful occupation itself to be the end goal of the therapeutic interventions by the occupational therapist rather than improved health. In this understanding of occupational therapy, occupation is essential to human nature, and because of this, human beings ﬂourish by occupying themselves. A person’s health status remains important but not as the ultimate goal of therapy. Occupational therapists promote engagement in occupations for those who have sustained a disability or have experienced decreased occupational engagement secondary to illness, injury, conﬂict, or natural disaster.

Generally, occupational therapists do not explicitly distinguish the aforementioned two understandings of the relationship between occupation and health. But as will later become clear, this distinction can impact the outcome of other ethical debates, for example, about the duties of occupational therapists vis-à-vis occupational injustices and responsibility to the individual client as well as the health of communities and large populations.

In the occupational therapy literature, the word “occupation” is understood very broadly. While it does include “occupation” in the narrow sense of “employment” or “line of work,” occupation encompasses just about every meaningful activity with which human beings can occupy their time. The WFOT deﬁnes occupations as “the everyday activities that people do as individuals, in families and with communities to occupy time and bring meaning and purpose to life” (WFOT Position Statement on Human Rights). Thus, occupational therapists provide services that enable people to engage in activities of daily living (ADL) such as bathing, eating, dressing, as well as instrumental activities of daily living (IADL) such as care of others, ﬁnancial and home management, shopping, and even spiritual activities. Education, work, play, and leisure are also identiﬁed as areas of occupation and even rest and sleep. All occupations are considered to have ethical import and relate to not only individual persons but also organizations and populations. Therefore, from the inception of the profession, one could argue that occupational therapy and ethics have been inextricably linked.

History Of Occupational Therapy Ethics

The history of occupational therapy has long been associated with the “moral treatment movement,” which was based on societal beliefs of the time including “a set of principles that govern humanity and society, faith in the ability of the human to reason, purposeful work as moral obligation, and the supreme belief in the individual” (Bing 1981, p. 502). The profession’s holistic point of view of actively involving the patient in treatment planning was predicated on the moral treatment movement, and from its inception occupational therapy integrated basic ethical principles such as respect for autonomy and beneﬁcence. In addition, this emphasis on holistic care tends to move basic human rights to the foreground of attention, speciﬁcally occupation-related human rights. Within the occupational therapy profession, occupational rights are widely considered to be not merely an individual issue but a political concern related to the health of populations (Taff et al. 2014). The emergence and rapid growth of occupational therapy in countries around the world and the globalization of the profession as a whole have brought an increased focus to population-based concerns related to access and the limited occupational opportunities of certain groups.

Today occupational therapy education is available in about 80 of 206 countries worldwide. These numbers do not account for educational institutions that do not seek approval by the WFOT (2015). The WFOT has issued a code of ethics, last revised in 2004. But the code is intentionally brief and broad, leaving it up to national occupational therapy associations to develop more detailed codes that are speciﬁc to national needs and circumstances. At a national level, occupational therapists are expected to abide by the legally binding codes of practice issued by the health professions’ boards or the practice associations in their respective country or state. Generally, ethical standards are an important component of these codes of practice. Some national organizations, including the American Occupational Therapy Association, have adopted a code of ethics independent of the profession’s practice act (AOTA 2015). The national codes of practice and codes of ethics reﬂect each country’s speciﬁc and diverse contextual parameters. But many of the foundational concepts that guide the practice of occupational therapy remain common to all geographic areas of practice, reﬂecting ethical considerations and challenges that occupational therapists around the world face with some regularity.

Many of the ethical issues covered in occupational therapy codes of ethics are similar to other health care professions, such as issues of billing and reimbursement; inappropriate admissions, discharges, or treatment past the point of progress; issues related to patient conﬁdentiality; blurring of professional and personal boundaries; decision-making capacity to consent or refuse treatment; and ethical issues of restraint and seclusion. In a study among Swedish occupational therapists, a number of ethical dilemmas were identiﬁed in rehabilitation, most of which revolved around the need to strive and support patient participation in decision-making, treating the client with respect, and prioritizing interventions and resources (Kassberg and Skar 2008). A study in the United Kingdom identiﬁed seven ethical tensions in occupational therapy practice: (a) resource and systemic issues, (b) upholding ethical principles and values, (c) client safety, (d) working with vulnerable clients, (e) interpersonal conﬂicts, (f) upholding professional standards, and (g) practice management (Bushby et al. 2015). In the United States, many ethical concerns relate to organizational ethics issues such as reimbursement-driven decision-making and excessive pressure to meet productivity standards (Slater and Brandt 2009), as well as the moral management of error to ensure patient safety (Scheirton et al. 2007).

As mentioned, all of the aforementioned ethical issues are faced by many different health professions. There are, however, also ethical challenges which are speciﬁc to or at least much more prevalent with occupational therapy because of the speciﬁc focus on occupation. These challenges are the main focus of this overview.

Persons With Disabilities

While occupational therapy was initially associated with mental health, the rise of physical disabilities due to industrial accidents, tuberculosis, and World War I resulted in an expansion of practice. This expansion was further boosted by changes in the public perception of disabilities. Prior to World War I, disability was not generally considered a social problem. However with increasing numbers of individuals being injured due to work or war, the need to provide medical services to the disabled became more widely acknowledged (Gritzer and Arluke 1985). This shift in societal values led to the growth of occupational therapy practice and the eventual global adoption of the profession.

Occupational therapists’ traditional focus of enabling persons to be occupationally engaged explains the central role that disabilities take on in the occupational therapy literature and practice. As a result, occupational therapy also becomes mired in the ongoing debates about the very concept of a disability and, secondarily, the moral evaluation of this phenomenon. The most vehemently debated question is whether disability is a trait of an individual person, describing some kind of somatic or mental shortcoming in the person that reduces his or her occupational capacity, or whether a disability instead describes a socially imposed barrier on people. For example, it is only when society insists on written text as the primary mode of communication that dyslexia is a disability; in oral cultures, that disability simply does not exist. If many, or even most disabilities, are indeed social constructs, from anosmia to autism and from infertility to intellectual disability, a fundamental ethical question for occupational therapists arises: should they focus their therapeutic activities on enabling the disabled individual to compensate for, or even overcome these socially imposed barriers, or should they instead seek to change society and reduce the very imposition to these barriers?

A related ethical quandary for occupational therapists is the ethical status of a disability. In the occupational therapy literature, disability is generally assessed negatively as a condition that should be undone as much as possible, whether through prevention, therapy, or at least compensatory adjustments. The problem with this interpretation of disability is the inevitable negative evaluation of disabled persons. The idea that being disabled somehow lessens the value of one’s life, and even renders the disabled person a lesser person, is unintentionally but inevitably reinforced by this understanding of disability.

In response, one ﬁnds many instructions in the literature to strive for morally neutral conceptions and language. For example, rather than talking about “disabled persons,” the occupational therapist should refer to them as persons with a disability. Rather than being a pathological condition or disorder that must be rectiﬁed, in this perspective disability is simply a different way of being, neither better nor worse. That does not, however, deny the reality that some persons, including disabled persons, may experience more challenges than other individuals in securing meaningful occupations, and occupational therapists can assist them in that quest through targeted therapies.

The third and most recent strand in the disability literature takes this line of reasoning one step further, insisting that it is not possible to differentiate between abled and disabled persons. Rather, humankind is characterized by all types of diversity, including in the area of abilities. The challenge, then, is not merely to include disabled persons (which act already assumes they are naturally excluded) but to appreciate and respect the difference in the same way as we have come to do with gender, age, and ethnicity.

This third perspective is not prevalent in the occupational therapy profession which, despite its afﬁnity with the social sciences, primarily identiﬁes itself as a health-care ﬁeld and as such views most disabilities as disorders that can be relived through therapeutic interventions. At the same time, human dignity is a key ethical principle in occupational therapy practice. Dignity takes on this normative function because it captures the idea that human beings have an intrinsic and inalienable value that is independent of ability and hence also of disability.

Aging Induced Occupational Justice Challenges

Disabilities can strike any person, but disablement is not considered, at least not by most occupational therapists, to be a normal part of the human condition. Aging, however, is. Aging naturally reduces people’s ability to be engaged in the types of occupations that they once were engaged in and other people around them are engaged in. This is the result of slowly decreasing physical ability and ﬁtness, mental decline, changes in appearance, changes in family structures (such as children growing up and moving away), and the pace of new developments in society (most notably the ever-faster technological changes). Occupational therapy practitioners utilize their understanding of the aging process to enable older adults to participate in meaningful activities in their desired environment, given their individual abilities and personal attributes.

Ethical challenges can arise for occupational therapists when this therapeutic objective cannot easily be reconciled with other important goods. For example, occupational therapists are often tasked with assessing an older person’s ability to renew his or her license to drive a motor vehicle. When the person’s ability to drive safely is declining, the occupational therapist will have to balance the beneﬁt of that person’s ability to continue driving with the equally evident danger to his or her own health and life, as well as that of other participants in trafﬁc. Similar challenges present themselves when occupational therapists are tasked to undertake a functional capacity assessment, the outcome of which could determine a person’s access to a particular line of work.

Warfare, Natural Disasters, And Economic Depressions

The ethical balancing act required of occupational therapists in the examples mentioned above becomes magniﬁed when the competing interests become structural in nature. Many occupational therapists consider it a professional duty to ensure fair access to occupations for all people. But not all occupations provide unlimited access. Occupational scarcity tends to become acute during armed conﬂict or after natural disasters. When people’s social fabric frays, homes are destroyed, jobs disappear, and children’s playgrounds turn into mineﬁelds, opportunities for meaningful occupation diminish dramatically. The migration that frequently ensues can further reduce the availability, evoking acute conditions of occupational scarcity. Such occupational scarcity is a major concern in any context, but it is particularly so when people are traumatized, socially marginalized, and particularly vulnerable. For it is exactly then that meaningful occupation in daily personal and community activities can have therapeutic outcomes during disaster recovery (AlHeresh et al. 2013). Occupational scarcity brings with it the ethically challenging task of rationing. What criteria can be used to justify that some, but not others, will be given access to this scarce commodity? When occupational therapists seek to promote occupational access for migrant and other marginalized populations, this can also place them in conﬂict with the hosting communities who may see migrants as unwelcome competitors for a scare resource.

Occupational therapists working in areas ravaged by war and natural disasters cannot escape such difﬁcult occupational justice questions. But occupational therapists working in relatively peaceful countries are not immune from similar ethical challenges. Even in those countries, there is limited availability to certain occupations. For example, income generating employment is a limited occupational resource which periodically worsens to full-ﬂedged economic depression. Whereas some countries leave it up to market forces to allocate this resource, others try to regulate access, for example, through a mandatory retirement age. Depending on the justice perspective adopted, a ﬁxed retirement age can be seen as a form of age-based discrimination or as a form of both respecting aging and enabling younger people to become occupied. Further complicating the ethical evaluation of such labor policies is the lack of consensus on their impact on the health of the people involved. These types of dilemmas provide occupational therapists with evident opportunities to bring to bear their speciﬁc expertise in an attempt to advance occupational justice. But it also evokes complicated questions about the roles and professional responsibilities of occupational therapists. When does such promotion of occupational access change from a healthcare practice to social work or politics?

Occupational therapy as a health discipline inevitably is guided by concepts and theories that shape traditional health disciplines such as medicine, nursing, and physical therapy. Opponents within the OT profession of this biomedical model have criticized the profession for ignoring the social and political environments that shape occupation and people’s ability to engage in occupations. They suggest that rather than align with the aforementioned health disciplines, occupational therapy should ally itself with education, social work, community development, and law. Thus, the question remains whether occupational therapy should focus on the occupational needs of the individual or occupational engagement for society at large. Perhaps there is room for the profession to continue to contribute in both facets with the common ethical tenet of addressing occupational engagement regardless of barrier or context.

Conclusion

Occupational therapy has historically been concerned with unfair treatment of individuals and marginalization of vulnerable persons. The profession also acknowledges that “health disparities, disease, and disability are a problem not just for individuals but for the global society” (Taffet al. 2014, p. 326). If occupation is central to human well-being, then any lack of access to meaningful occupation becomes a source of ethical concern for occupational therapy professionals.

The strengths of occupational therapy related to the broad scope of the profession are also some of the most noted limitations, secondary to the inability to clearly articulate the role and focus of practice. The vast range of services, both clinically and geographically, contribute to ongoing ethical debates regarding the future role of occupational therapy professionals across the globe.

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