From Persuasion to Coercion: Responding to the Reluctant Patient in Rehabilitation
- L. Anderson, PhD, MHealSci, DipPhysio, Bioethics Centre, University of Otago, PO Box 56, Dunedin 9001, New Zealand.
- C. Delany, PhD, MHlth&MedLaw, MPhysio, BAppSc(Physio), Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia.
- Address all correspondence to Dr Anderson at: Lynley.anderson{at}otago.ac.nz.
Abstract
Early mobilization of patients while in hospital has been demonstrated to provide better outcomes for patients and use fewer resources. Physical therapy–based rehabilitation is central to achieving those goals. Successful rehabilitation requires that patient's and therapist's goals align, and this is commonly the case. However, occasionally, physical therapists will come across patients who are competent but reluctant to mobilize. This situation leaves the physical therapist in an ethical quandary: either accept the patient's right to refuse proposed treatment or utilize other strategies to encourage the patient to adhere to treatment. Practically, physical therapists will use a range of treatment pressures, including persuasion, offering incentives, inducements, possibly threatening or coercing, and even explicitly overriding the patient's wishes (compulsion). Deciding which treatment pressure is ethically acceptable involves the physical therapist balancing his or her therapeutic view of what is in a patient's best interests against the therapist's ethical responsibility to respect patient autonomy. This article evaluates some common strategies used by physical therapists to influence, persuade, or perhaps pressure patients to adhere to rehabilitation. The work of Szmukler and Appelbaum is utilized in analyzing treatment pressures. The authors conclude that there is a spectrum of treatment pressures, with some (persuasion and incentives) being more acceptable than others (threats and compulsion). As physical therapists balance health system pressures for rapid turnover of beds with obligations to benefit patients within limited reimbursement models, while respecting the patients' autonomy, they must be mindful of the effects of treatment pressure on patient care.
Early mobilization of patients following surgery, illness, or accident has been demonstrated to provide better outcomes for patients and less time in the hospital using high-cost resources.1–4 Physical therapy–based rehabilitation has a large part to play in achieving those goals.5,6 However, effective rehabilitation requires patient cooperation with treatment goals and instructions. Occasionally in practice, physical therapists will come across patients who are competent but who do not share the goals of the therapist or who opt not to adhere to the proposed treatment. Poor adherence to treatment is a common phenomenon across many health disciplines, including physical therapy.7–9 This poor adherence leaves the physical therapist with an ethical decision to make: either accept the patient's autonomous right to refuse the proposed treatment or use some other strategy to encourage the patient to adhere to treatment.
At a practical level, physical therapists will use a range of strategies and treatment pressures to get people moving, including persuading the patient, offering incentives, inducements, possibly threatening or coercing, and sometimes even explicitly overriding the patient's wishes. Deciding which treatment pressures are ethically acceptable is an example of ethical reasoning because it involves the physical therapist balancing his or her therapeutic view of what is in a patient's best interests against the therapist's ethical responsibility to respect patient autonomy.10–12
Although there is growing interest in physical therapists' ethical obligations and the nature of their ethical reasoning,13–16 to date there has been no ethical evaluation of strategies used by physical therapists to influence, persuade, or perhaps pressure patients to adhere to rehabilitation. In order to analyze these types of strategies, we draw from a spectrum of treatment pressures presented by Szmukler and Appelbaum.17 Some authors have focused on specific types of persuasive strategies, such as nudging whereby a person is influenced but still retains substantive freedom of choice and is able to resist the influence.18–20 The advantage of the Szmukler and Appelbaum framework is that it sets out a typology of persuasion strategies that enables reflection on philosophical aspects of this area of physical therapist practice, including underlying assumptions and goals of a therapist's strategies to influence a patient.21 They analyzed the ethical acceptability of different types of treatment pressures commonly used in community-based mental health care. In that clinical context, patients who have mental health conditions and who reside in the community are regarded as vulnerable to treatment pressures because of the social stigma surrounding mental illness and because of the threat of compulsory detention should they not adhere to treatment.22
We suggest that patients in rehabilitation contexts may be similarly vulnerable to treatment pressures because their baseline freedom to make choices is diminished by their health or because they are within the confines of a rehabilitation institution.23,24 For example, pain associated with their condition or disability, fear about their prognosis,25 disempowerment as a result of being out of their own environment,24 challenges to bodily integrity,26 uncertainty about recovery,27 and fear of insufficient reimbursement all contribute to this vulnerability. Despite obvious differences among the groups, we argue there are sufficient similarities to apply Szmukler and Appelbaum's 2 main aims of inquiry to the physical therapy rehabilitation setting: (1) outline the possible spectrum of treatment pressures evident (as they apply to physical therapy rehabilitation) and (2) draw distinctions among these treatment pressures based on ethically relevant features to consider when the exercise of such treatment pressures can be justified.
We begin by first outlining key ethical principles relevant to the rehabilitation setting. We then use a brief but typical case example to define and distinguish among ethical implications of different types of treatment pressures that may be used by a physical therapist in the rehabilitation setting. For ease of discussion, the patient will be referred to as male and the physical therapist as female throughout this article.
Ethically Relevant Features of the Rehabilitation Context
Providing Benefits and Minimizing Harms
The foundational health care ethical values and principles of beneficence and nonmalfeasance, respect for autonomy, and justice underpin the goals and methods of physical therapy rehabilitation.28–30 In the rehabilitation context, providing treatment that is beneficial to patients is often interpreted as providing treatment that uses evidence-based early mobilizing protocols, and physical therapists have increasingly strong evidence about the effectiveness of their rehabilitation interventions. For example, early mobilization can prevent deep vein thrombosis,31 urinary tract and respiratory infections,1,32 loss of muscle bulk,2 neuromuscular weakness,33 and bed sores and more generally can prevent dependency and processes of becoming institutionalized.2 In the area of rehabilitation following stroke, there is strong evidence supporting the benefits of early walking and mobilization.34 Benefiting a patient also encompasses a patient-centered approach where the physical therapist seeks out and integrates a patient's view of the rehabilitation journey into a collaborative and shared decision-making approach.35,36
Respecting Patient Autonomy
Alongside the important ethical concern to ensure a treatment is evidence-based is the ethical value of respect for patient autonomy. At a clinical level, respect for autonomy involves providing sufficient information and support to enable a competent patient to make a voluntary choice about care.10,29 This extends to a competent patient being able to refuse life-saving treatment even where such refusal may lead to death.37 If patients can refuse life-saving treatment, they also can refuse to engage in physical therapy. The principle of respect for autonomy requires the physical therapist to acknowledge that a competent patient may be guided by values other than the physical therapy outcomes of physical improvement and mobilization.
According to Dworkin,38 autonomous decisions involve both first- and second-order considerations, where “first order” refers to initial desires and preferences such as wanting to avoid walking after surgery because of pain and discomfort and “second order” refers to a more critical thinking capacity to consider how an initial preference aligns with other values such as wanting to regain good physical health or function in a particular way. From this ethics theory perspective, Dworkin suggested that autonomy is “a second-order capacity to reflect critically upon one's first-order preferences and desires, and the ability either to identify with these or to change them in light of higher-order preferences and values.”38(p108) Applied to the clinical setting, a patient may have a first-order preference of avoiding pain or discomfort and staying in bed. Having the benefits of moving and the risks of not moving explained to the patient enables the patient to use higher-order preferences to decide whether to participate in the rehabilitation agenda.
Justice and Fair Use of Resources
Early mobilization aligns with a modern hospital administration's desire to use resources judiciously by keeping hospital stays short and achieving a rapid turnover of beds or by movement of patients from high-cost areas to low-cost areas.39 Indeed, hospital stay length is often used as an indicator of efficiency.40 An example is health care delivery in the context of managed care organizations, where practitioners must negotiate between or balance dual and sometimes conflicting purposes of making profits and providing high-quality care.41
Physical therapists are an integral part of these types of structures delivering rapid movement of patients out of the hospital or to lower-cost services with the outcome of increasing access to services at a lower cost, enabling the hospital to treat and, therefore, benefit more patients.4,5 Although clearly a laudable goal of rehabilitation, the capacity to contribute to “throughput,” or early patient discharge, means there could potentially be pressure on physical therapists to mobilize patients quickly regardless of whether the patient agrees.
In most practice situations, the ethical principles of autonomy, beneficence, avoidance of harms, and justice are not in conflict. The patient receives and understands information about the benefits and risks of and alternatives to a proposed treatment plan, the patient accepts the need to mobilize early, and the physical therapist is able to provide a clinically demonstrable benefit for the patient and use resources judiciously. However, sometimes these principles do not align; a patient may choose not to engage in the rehabilitation plan or may not view it as a priority for his or her health and well-being. The physical therapist may find himself or herself stuck between a patient who does not want to mobilize and a health service that is focused on rapid turnover of beds. The physical therapist must then decide which principle takes precedence and, subsequently, what course of action to take.
We now turn to the work of Szmukler and Appelbaum17 and their spectrum of treatment pressures. The spectrum of treatment pressures developed by Szmukler and Appelbaum17 begins with persuasion as the least ethically problematic and extends to compulsion (Table). The list on the right side of the Table represents our amended spectrum of treatment pressures. We have changed the order from that described by Szmukler and Appelbaum.17 In particular, we have swapped the position of interpersonal leverage and inducements because, as we discuss below, we view inducements as less ethically problematic.
Szmukler and Appelbaum's Spectrum of Treatment Pressures and Current Authors' Amended Spectrum
Two case examples (Mr F and Mr G) are presented in this perspective article (see Box). With reference to these cases, the following sections describe and analyze the possible treatment pressures that a physical therapist may use. The physical therapist has an ethical choice about what action to take. She can either accept Mr F's refusal, or she can attempt to get him to adhere to treatment using any of the treatment pressures listed above. Accepting Mr F's refusal may meet with the ethical expectation of respect for patient autonomy, but may not satisfy the goal of benefiting the patient or the demand for rapid bed turnover. We will now consider each point on the spectrum of treatment pressures.
Box. Case Examples: Mr F and Mr G
A 78-year-old, competent man, Mr F, has had a scheduled total knee replacement. According to the postsurgical protocols of the orthopedic surgeon, Mr F is scheduled to get out of bed today. The physical therapist comes to see Mr F to initiate the process and informs him of the rehabilitation plan and what he will be required to do. Mr F says he does not want to get out of bed until after his visitors have left and after he has received pain relief. The physical therapist negotiates a time to see Mr F. The physical therapist returns at the designated time, but Mr F refuses to engage with treatment. What should the physical therapist do?
Mr G is a 78-year-old, competent man who has recently had a cerebral hemorrhage. To date, he has refused all attempts to mobilize. He is currently at increased risk of a deep vein thrombosis and pulmonary embolism and is beginning to lose confidence in his abilities due to his perceived deficits. His family is very concerned about him and actively pushing for him to mobilize and come home.
Persuasion
Here is an example of what the physical therapist might say in response to Mr F's refusal:
You really do need to get up today. Getting moving will help prevent clots in your legs and complications with your breathing, and you will be able to get home faster.
The statement above illustrates the way in which a physical therapist might try to persuade Mr F to get out of bed according to postarthroplasty protocols.42 The use of persuasion is premised on the idea that if Mr F understands the benefits of mobilizing and the risks of not mobilizing, he may be more inclined to accept the treatment. By explaining the need for physical therapy, the physical therapist is treating Mr F as the competent adult that he is—one who is able to understand and use reason in his decision making about overcoming the short-term discomfort of moving now, over the longer-term harms of staying in bed. This type of persuasion or education represents an example of respect for autonomy and makes persuasion a positive ethical obligation in circumstances where a person may not have an adequate understanding of the risks and benefits of a proposed treatment. If Mr F continues to refuse, the physical therapist may again negotiate a time later that day or the next day. The physical therapist may even compromise on the goals (with the idea that some treatment is better than none). Each of these actions falls under the ethical ideals of shared decision making and patient-centered care.43,44
Inducements
If you walk to the door, I'll go and get that magazine you wanted.
This example of the physical therapist offering an inducement to Mr F appears more ethically problematic. It promotes a type of first-order choice for Mr F to obtain a reward rather than encouraging him to critically consider the various reasons why moving may be beneficial in his situation. From an ethical perspective, an inducement may be acceptable where it does not leave the patient worse off. Cohen argues that it may be ethically legitimate to influence an individual's choice as long as the inducement is easy to avoid and does not involve deception, concealment, or misrepresentation.18 If Mr F adheres to treatment, he will receive something: the magazine. If he does not engage, he will not receive the magazine from the physical therapist. On the basis that he does not need the magazine or will not suffer if he does not have it, he will not be worse off. Using inducements or rewards are common in pediatrics, where a young child will sometimes receive stickers or “courage beads” after a procedure.45 However, it could be argued that such incentives, when transposed from a pediatric setting to an adult setting, infantilizes the adult patient. Therefore, a physical therapist needs to be cognizant that inducements may diminish or downplay a person's capacity to consider second-order or longer-term preferences, an important part of autonomous decision making.38 However, if a person is able to review the inducement objectively by thinking about how it fits in with his or her desires and wishes, using an inducement is ethically unproblematic. The patient is still able to consider for himself or herself whether the inducement is desirable and important. Although inducements are less than ethically ideal, we think they are at least transparent to a competent patient46 and, therefore, potentially less harmful than interpersonal leverage. That is why we placed inducements in a different position on the spectrum of treatment pressures than Szmukler and Appelbaum.17
Interpersonal Leverage
I love coming to see you, Mr F. You are one of my favorite patients—you are always so cooperative.
If you don't get up, I will be so disappointed in you, Mr F. I suppose I expected more from you.
These kinds of statements are more ethically problematic than inducements, as we believe they manipulate an already vulnerable person in a less transparent way, such that a patient may not be consciously aware of the impact. Such statements take advantage of the patient's desire to be a “good patient” and may make it difficult to say “no.” In rehabilitation settings, patients may spend long periods of time with, and become dependent on, their therapist—especially where the physical therapist has a degree of control over patient discharge, placement, access to services, or funding.15 This context makes the use of interpersonal leverage more ethically troubling because the treatment pressure is leveraged from this trusting relationship and the therapist, in effect, manipulates the desire of the patient to please. In these situations, it may be a form of unreasonable manipulation because it plays on a person's guilt in an attempt to effect behavior change.47 These statements also involve making a judgment about the patient and placing a label of “a favorite” or “a disappointment” on the patient.48 Although it may be harder to establish interpersonal leverage in a situation where the patient is expected to be in the hospital for only a few days, a physical therapist can play on a patient's desire to be perceived well so as not to upset the individuals upon whom the patient depends.49
Interpersonal leverage also might be achieved through the physical therapist utilizing the patient's concerned family member to support the physical therapist's treatment regimen or by using the family member's concern to manipulate the patient. For example, in the case of Mr G, there may be a temptation for the therapist to draw on the concern of relatives as a means of greater interpersonal leverage or, as illustrated in the example below, as a threat. Mr G has a more medically complex presentation, which means simple mobilization is not necessarily the only appropriate clinical response.
Threats
If you don't get out of bed, I am going to call your daughter and tell her you're being difficult.
If you don't get up today, I'll make sure you don't get any further rehabilitation.
Threats are coercive because they leave people worse off if they do not do as they are told. Here, it is important to make a distinction between a threat and inducement as an offer. As stated earlier, inducements generally do not leave the person worse off. Threats, on the other hand, generally do leave the person worse off if he or she does not adhere to treatment. For example, “Hand over your money, or I will shoot you” is clearly a threat,50 whereas “Come and walk to the doorway for me, and I will get you that magazine” is an inducement or offer. For the purposes of this article, it is enough to consider that threats are unacceptable because they are coercive, whereas offers are usually acceptable because they are not coercive. However, coercive offers do exist; an example from Feinberg involves a millionaire offering to pay for a child's life-saving surgery, but only if the mother becomes his mistress.50(p229) This is an example of a coercive offer, as it utilizes the advantageous position of the rescuer to limit the options of the mother.
Szmukler and Appelbaum17 suggested that inducements and threats should be analyzed together, as they both involve conditional propositions. The relevant moral distinction between an inducement (a reward proposed in return for a particular behavior) and a threat (a proposal to remove a privilege or right if specific behavior is not followed) hinges on whether the proposed condition or inducement will be or could be perceived by the patient as making him or her worse off if he or she does not accept it.51 Mr G, for example, may feel coerced if a physical therapist says, “If you don't carry through with your rehabilitation, you may have to go into a rest home.” What is important here is whether the statement is true or not. If it is true, Szmukler and Appelbaum suggested that such a statement represents an example of an unwelcome prediction rather than a coercive threat. The distinction between the 2 treatment pressures is important. The statement is not coercive if it is indeed true. Instead, it is a reasonable prediction of an unwelcome event. Allowing or actively promoting deception is another way in which patient liberty and autonomy can be threatened, and we discuss deception now.
Deception as a Form of Threat
That's right, you won't be able to get home if you can't do 2 flights of stairs.
If this statement is true, it is not deception. If this statement is not true and the physical therapist knows it is not true, the physical therapist is engaging in deception. Furthermore, a physical therapist who fails to correct a false belief because by doing so, the patient would no longer adhere to treatment is similarly engaging in deception and thereby diminishing a person's capacity to weigh information and form a decision about his or her preferences.50 This type of deception may be interpreted by the therapist as benign because although it interferes with a person's choice, it promotes a beneficial outcome for the patient. We suggest, however, that it nevertheless removes choice for the patient because he or she is not receiving accurate and transparent information. Brody proposed transparency as a way of enabling patients to be aware of a clinician's values and goals and to enable them to voluntarily rethink their own values and goals.46
There are further possible examples of deception that might occur in this typical case scenario (eg, when the physical therapist hides the purpose of a particular action so that therapeutic aims can be met without the patient realizing it). If Mr F was unwilling to bend his knee following a total knee replacement, the physical therapist may ask him to “just sit on the edge of bed” with his leg unsupported below the knee while she takes extra time to get ready in the knowledge that Mr F will be unable to sustain a quadriceps muscle contraction and so the knee starts to bend. This example complies with one of the key aims of treatment but without his awareness. This may appear to be quite a low-level deception, but it does remove the opportunity for Mr F to be actively involved in choosing and collaborating with the therapist about his rehabilitation, a central tenet of the principle of respect for patient autonomy.
A further form of deception is when choice is limited to a minor aspect of care rather than to the substantive treatment methods. An example of this form of deception might be where the physical therapist says:
Time to get out of bed. I'll get your walking frame, and you put on your dressing gown. Where would you like to walk to?
This exchange demonstrates a specific framing of available choices and, importantly, an absence of transparent information.52 A choice is offered (where to walk to), but consent has not been obtained for the central treatment process (the mobilization). This form of deception is utilized in the actions of a parent who might say, “Time to get ready to go to Grandma's. Do you want to wear the red or pink dress?” The choice about going to Grandma's is not offered; the only choice on offer is that of dress color.
A more troubling deception is if the physical therapist were to state “this won't take long” or “this won't hurt” and the treatment does take some time or results in considerable discomfort. All of these examples involve a level of deception that overrides a patient's capacity to choose and diminishes trust within the therapeutic relationship with the current and future therapists.53,54
Compulsion
Anecdotally, we understand that overriding patients' expressed wishes sometimes does happen. An example would be when a competent patient refuses to engage in a mobilization program, and 2 people might physically pull the patient out of bed despite the patient's clear protestations. This is the most ethically problematic form of treatment pressure because it ignores a competent patient's wishes and fails to respect his or her autonomy.
In the case of Mr F, overriding his autonomy may have the immediate desired consequences of getting him moving, but it fails to engage him with the aims of rehabilitation and potentially damages his trust in future caregivers.
Discussion
According to the typology of treatment pressures presented in this article, persuasion best preserves a patient's capacity to reason and make autonomous choices. We define respect for a patient's autonomous choice as enabling a person to thoughtfully consider personal values and analyze how any proposed treatment fits within his or her values, reasoning, and desires. As stated earlier, it is important to recognize that this ideal of autonomous decision making is already diminished within a health care setting where the agenda and systems are set by others.24 On some occasions, a person's capacity to think about options and to critically examine choices can be affected by illness, anxiety, or medications.55 The combination of being in a clinical environment with differing imperatives and the influence of illness, anxiety, or medications may make it difficult for a patient to plan ahead and respond to information, and a physical therapist must recognize these influences. Based on this understanding of respect for autonomy, when trying to persuade a person toward a particular course of treatment or to adhere to a treatment requirement, the onus is on the therapist to ensure that his or her communication and persuasion are ethically acceptable. The therapist should disclose information and assist the patient in his or her deliberations about how to weigh what matters personally to the patient rather than resort to interpersonal leverage, coercion, and compulsion.
An important implication of our analysis of treatment pressures is that therapists should be aware of how their actions represent their ethical responsibility to respect their patients' autonomous choices. Such respect entails more than providing information about benefits of treatment; it requires therapists to preserve and enhance and not diminish a patient's capacity to exercise choice.10,28
Our analysis suggests that the use of treatment pressures in physical therapy may be acceptable when it involves persuasion and inducements because both persuasion and inducements can still preserve and respect the autonomy of the patient. Physical therapists using any treatment pressure need to:
Recognize where their actions fall along the spectrum of treatment pressures.
Be aware of when and how their actions might result in limiting patient autonomy.
Have sound ethical justifications for their actions.
Be prepared to provide greater ethical justification, as their actions lie further along the treatment pressure spectrum.
Ensure the use of autonomy-limiting techniques are the minimum necessary.
This article has focused on competent patients refusing to engage in rehabilitation, but there will be times when a patient may be incompetent insofar as lacking the ability to reason. Where the consequences of refusal to engage are irreversible or likely to cause significant harm and the patient is not competent, the physical therapist may be justified in acting in the patient's best interests and overriding the patient's refusal—subject to legal requirements. A further example where the choices of a competent person may be overridden is where his or her choices are likely to cause harm to others.56,57
As stated earlier, treatment pressures may result from a desire to benefit the patient or from a need to meet service expectations of getting patients moving from high-cost to low-cost areas. In poorly resourced areas, the pressure exerted on physical therapists could possibly be high. It is not unexpected that such concerns could result in pressure being translated to the patient either consciously or unconsciously.
Conclusion
Respecting patient autonomy is one of the fundamental ethical principles of physical therapist practice. This principle must be balanced with other ethical principles to ensure that treatment benefits a patient, using evidence-based principles of clinical practice and meeting health service expectations of judicious use of resources. Where these goals conflict, a physical therapist will need to decide what form of action may be necessary to engage the patient with therapeutic goals of care. We suggest that physical therapists, like other health professionals, require skills and agency to analyze the moral dimensions of the actions they use in getting patients to engage in therapy. Our analysis of the ethical implications of using different types of treatment pressures aims to assist therapists to be more cognizant of this moral dimension of their work.
Footnotes
Both authors provided concept/idea/project design and writing. Dr Anderson provided project management and institutional liaisons. Dr Delany provided consultation (including review of manuscript before submission).
- Received October 11, 2015.
- Accepted February 24, 2016.
- © 2016 American Physical Therapy Association