Esther Munalula Nkandu, pictured while giving a presentation at the WCPT Congress in Vancouver
Esther Munalula Nkandu, pictured while giving a presentation at the WCPT Congress in Vancouver

Why physical therapists need to go beyond the science and into ethics

Should physical therapists be more aware of the ethical issues that surround the care of their patients? Esther Munalula Nkandu, Chair of WCPT’s Africa Region, believes so, having studied for an innovative Masters degree in bioethics held across three European universities.

During the nine-month programme, Esther Munalula Nkandu has been surprised at the different viewpoints on ethical issues that have emerged between different professions and cultures – in areas as diverse as palliative care, research, right to die, disability and quality of life.

Physical therapists, she believes, should come forward more to express their views on such issues, because of their unique professional viewpoint and their close working relationship with people with disabilities and their families. Their knowledge of how quality of life can be achieved in very difficult circumstances can provide a very different perspective from that of most other clinicians and scientists.

“It came as quite a surprise to me, for example,” she says, “that others on the course saw palliative care as about end of life, whereas physical therapists – in Africa at least – see it as about quality of life, including end of life.”

“In Zambia, we start palliative care when a disease starts to disable someone – when, for example, they can’t be accommodated by a hospital any more, but their condition needs to be managed and they need to be made comfortable over a long period. But in the Netherlands, for example, the understanding is that it’s about death and dying. Maybe this is because in some countries there’s more emphasis on right to die and duty to relieve unbearable suffering.”

The international Masters degree is a collaboration between the University of Leuven in Belgium, the University of Nijmegen in the Netherlands and the University of Padova in Italy, with each university presenting programme participants with a different aspect of ethical theory. Esther, who is Chair of the Ethics Board at the University of Zambia, is studying with doctors, philosophers and scientists.

“I wanted to look at some of the issues behind research and practice,” she says. “It’s been an education to see different perspectives on different bioethical issues, from assisted suicide to consent, and how professionals’ views about what is morally right is so dependent on the culture they come from.”

“Advances in science are raising all sorts of questions, and our investigations showed, for example, that there is a push for more abortions as parents become aware of a child’s disabilities at an earlier and earlier stage. The problem is that disability is being defined by those who are not disabled – mainly philosophers, doctors and other health staff – so how can they define what is a good life? They are driving the treatment decisions, and to me, there are lots of red lights that start flashing. I think physical therapists need to be sensitised to these issues, and communicate what they can do to improve quality of life when people have a severe illness or disability.”

This is particularly important, she says, with so much international discussion about people’s “right to die” when affected with life-limiting illness or severe disability.

“We need to be aware of the climate in which we’re working,” she says. “If other professions are beginning to dictate on these issues, it is important that physical therapists make the most of any opportunity they have to assert their professional values, and their role in rehabilitation.”

Esther is writing her thesis on some of the issues surrounding regulations governing research, in particular the rules about the use of human tissues in research collected from developing countries.. Such issues are again important for physical therapists because the information gleaned from such samples affect how much is known about patients, and patients’ sense of power or powerlessness within health systems.

“The Masters programme has been a great experience and I’ve been on a wonderful learning curve,” she says. “As physical therapists, we often focus on the science but we aren’t so sensitive to the ethics surrounding it, and this has given me the opportunity to see our work in a much deeper light.”