Table 2. Quotes to illustrate the six themes

A. Managing Healthcare Resource Constraints

Participants were aware of their ethical responsibility to act in the patient’s best interest in the provision of care but felt the pressure of finite resources and financial constraints (QN1). They described how they struggled to fulfill their professional obligations whilst at the same time managing patients’ expectations about availability of resources. Some therapists found loopholes to bypass government funding  requirements. One participant (P26) summarised it as being a “discrepancy between the ideal care for the nation as a whole versus what is ideal for the patient’s health right before my eyes”. Some participants spoke about how key performance indicators (KPIs) intended to manage healthcare costs can drive change in organisational and clinician behaviour to practice defensively rather than using evidence-based practice to meet patients’ needs. Participant 09 described it as “funding drives behaviour” and gave the example of how a KPI that tracks fall rates may sway clinicians to be overly conservative to prevent falls, rather than challenging patients’ balance to maximise recovery. A lack of clear workflows and integration between different clinical settings was another ethical challenge preventing best available care for patient. Community and private practice physiotherapists indicated that they lack access to medical records and diagnostic results to seek clarity on a patient’s condition. This resulted in therapists feeling frustrated, as they had to delay treatment or proceed without a clear understanding of the patient’s medical status (QN2). 

B. Conforming to Healthcare Norms in Singapore

For some participants, the allocation of only senior clinicians to private patients and junior clinicians to subsidised patients was viewed as unjust practice, where allocation of clinicians’ expertise is not based on the needs of patients. Participant 15 shared that the subsidised patients tended to be more complex cases as they may not have the resources to seek medical attention early (QN3). Most participants acknowledged this as an accepted practice in Singapore’s healthcare system and not just specific to physiotherapy, with participant 39 highlighting that “no one addresses it”. Adding to the social class differentiation, nearly all participants commented on the acceptance of hierarchical differentiation in healthcare with doctors at the top. Many participants spoke about paternalism being widely practiced and accepted by patients, and shared incidents where doctors dictated treatment plans, and even overrode patients’ wishes. Participants felt obliged to comply regardless of their own professional judgement (QN4).

Familialism may also compromise patients’ autonomy. Participants shared stories where family members dominated decision-making or demanded withholding information from patients. There were also geriatric patients who chose to relinquish their autonomy to their children. Many participants viewed this as an accepted part of Asian norms (QN5). A few participants stressed that many Singaporeans still hold conservative views and highlighted the importance of remaining sensitive to racial, religious, and cultural differences. For example, participant 22 disclosed that it is not accepted practice for male physiotherapists to place electrocardiogram (ECG) leads on a female patient even with the patient’s consent and a chaperon present. 

C. Negotiating the Complexity of the Work Environment

Organisations have to manage the financial cost of patient care and ensure business sustainability. With resource limitations, clinicians face the challenge of conflicting obligations to their organisation and their patients. Participant 13 expressed her frustration and resentment that physiotherapy outcomes are determined by organisational financial values (QN6). Another participant (P31) shared how she had to discharge patients “prematurely” to meet organisational expectations. Other participants coped by settling for minimum treatment and doing no harm to patients (QN7). 

Adding to this complexity was a negative work culture, expressed by participants as the pressure to conform to the organisation’s expectations, norms, and practices. Examples given included unreasonable workloads, biasness towards preferred staff, belittling remarks, fault-finding, and masked threats of poor appraisals. Staff were expected to conform and follow the rules, leading to a culture of fear, where safety incidents went unreported for fear of repercussions. This was further perpetuated by the lack of supervisors’ moral courage, who ignored such ethical infringements, thus normalizing ethical silence as accepted behaviour. Participant 13 disclosed her moral distress when her concerns regarding fraudulent behaviour by a colleague who falsely documented and charged for services, were disregarded by her seniors. Some participants dispiritedly added that often no action was taken and they either learnt to accept the status quo and found their own solutions or left the organisation (QN8). 

D. Adapting to the Intricacies of Different Healthcare Settings

1) Acute settings: The different organisational structure and systems in each setting gave rise to specific ethical concerns. Many ethical issues in the acute settings related to the structured systems, established practices and workflows. One such practice was physiotherapists not being allowed as first contact practitioners in public institutions. Patients can only be seen with a referral from doctors and only be treated for the problem for which they were referred. This was ethically challenging for physiotherapists wanting to manage patients holistically (QN9). Several participants also raised concerns regarding minimal charging per session. In some acute settings, the on-call duty was rostered for all physiotherapists, regardless of their inpatient competency or speciality. Concerns were raised about whether this was ethically good clinical practice and in patients’ best interests.  

2) Community settings: Some participants commented that community settings have varied and diverse services, making it difficult to implement guidelines that are applicable and fair to all services. This can encourage clinicians to circumvent the rules to benefit their patients. In integrating a patient back to their community, the patient’s psychological, social, and family issues can become the major consideration. Participant 02 shared her dilemma in having to factor in the caregiver’s coping ability when progressing a patient with mental health issues, who had little comprehension of fall risks, to independent mobility (QN10). A few participants commented that community physiotherapists generally have greater independence and flexibility in their work schedule, but this can engender accountability issues in terms of documentation and the standard of services provided. Some participants felt that the lack of awareness of community services available and an unsubstantiated perception that community physiotherapists are not as skilled, may deter some patients from continuing their care in the community and could have contributed to a shortage of community allied health professionals. 

3) Specialised institutions: For some specialised institutions where healthcare is not the core business, physiotherapists reported being constrained by the organisational goals when caring for their patients. The needs of the organisation and the deliverables expected factored greatly in both the patient’s and clinician’s decision-making. Consequently, the best interest of the patient may not take precedence (QN11). Participants commented that the hierarchical order in such institutions tended to be more overt, with instructions directed by leaders in charge rather than team discussions.

4) Private practice clinics: Participant 27 described the business aspect of private practice as having to wear two hats: one as a clinician and one as a businessman. This can lead to maximising profits through overcharging, overservicing and maximising insurance claims. Participant 27 further disclosed that most people kept it hushed, “it’s one of those things that everyone knows is happening, but no one wants to rock the boat”. Participant 29 shared how he had to see post-op cases twice weekly, regardless of whether it was necessary, “because that’s just the way things are done” and how the cost of treatment or number of sessions needed for recovery consistently matched the insurance claim limits (QN12). Other participants raised issues which bordered on being illegal. One common example shared was fee-splitting, whereby commission was given for the referral of patients. Private clinicians commented that private practice is loosely regulated, with no standardisation or best practice guidelines and that there is little collaboration or accountability to the profession. They further elaborated that private practice is very competitive, with some clinicians making exaggerated claims about their skills or effectiveness of their treatment. 

E. Balancing Professional Obligations and Personal Wellbeing

Participants described conflicts between their work responsibilities and their personal wellbeing. They shared their insecurities about whether they had positively fulfilled their professional obligations. Demanding expectations or long working hours imposed by organisations forced some participants to sacrifice their personal life, compromise their mental health and even sustain work-related injuries. Participants detailed episodes of transferring or ambulating patients without equipment or sufficient manpower (QN13). The nature of physiotherapy often requires close physical contact with patients. Participant 34 disclosed her distressing encounter with a patient with mental health issues, who repeatedly touched her inappropriately but denied it. On why she continued treatment, she replied that she needed to do her job and convinced herself that it was probably accidental (QN14). Participant 11 shared his dilemma with regard to treating female patients when there was a lack of chaperones. To protect staff from allegations of misconduct, it is accepted practice to leave the consultation room door open, leading to a possible violation of patients’ privacy (QN15). Participants also disclosed unethical and even illegal incidents which reflected the therapists’ conflict between protecting themselves and their professional responsibilities. These included false documentation of clinical notes, dishonesty about treatment errors, or not reporting safety violations.

Having self-doubt about one’s competency, whether it is due to inexperience, being out of practice or due to a lack of access to resources led some participants to question whether they had done patients a disservice or whether they were practicing beyond their capability. At times, clinicians also found it challenging to bill patients for physiotherapy services, especially if patients had financial difficulties.

F. Advocating for Patients: The Predicament of Relationships

Several participants highlighted the crossing of professional boundaries as an ethical concern. This included patients constantly calling or messaging, asking for free advice or personal favours. The nebulous zone where a professional relationship crossed over into friendship or even a dependency worried many participants. Numerous participants shared their turmoil when dealing with special populations such as patients with mental health conditions. The dilemma of overriding a patient’s autonomy became harder to resolve when the patient’s safety was at risk or where there was a possibility of detrimental consequences. Participant 41 pondered about the unspoken power differential between the patient and the healthcare professional, which can lead to patients feeling pressured to consent to treatment (QN16).

Another common dilemma expressed by participants was gaining caregivers’ and families’ support. Family members felt justified in their demands as the payer and viewed themselves as the spokesperson. Some participants expressed their helplessness with family members unwilling to pay for needed services or equipment (QN17).

Participants shared views about maintaining collegiality and not disrespecting colleagues’ viewpoints, specifically when there were conflicting patient management strategies. Some participants resented the loss of their professional autonomy but yielded to maintain harmony, and to avoid confusion for the patient. A number of participants reinforced this strong sense of fraternity, including unwillingness to expose wrongdoing even if colleagues had crossed ethical and legal boundaries (QN18). Some participants spoke about the move towards transdisciplinary practice in Singapore and the blurring of professional boundaries. One participant (P04) elaborated on resource limitations in home-based therapy, prompting her to take on other healthcare roles to prescribe home equipment and even change patients’ wound dressings. She expressed her dilemma in having to consider the patient’s perspective, her organisation’s views, and her own competency as well as the professional and legal implications of providing the wrong advice. 

Further analysis revealed that the ethical challenges encountered mapped to the three overall spheres of ethics previously identified by Glaser (2005) and Sippel et al. (2015), namely the micro, meso and macro spheres. Ethical issues at the micro sphere centered around physiotherapist-patient relationships, physiotherapist’s interactions with colleagues and their own needs. The meso sphere consists of four quarters that represented the four settings, and issues included structural problems and challenges related to organizational resources or systems. The macro sphere comprises ethical issues rooted in the influence of cultural, sociological, religious, economic, and political contexts (Sippel et al., 2015). The modified illustration of spheres of ethics with the meso sphere encircling the micro sphere and the macro sphere encircling the meso sphere, show the connection and interdependence of all three spheres (Figure 2).

Figure 2. Spheres of ethics (six themes)

IV. DISCUSSION

This study is the first to report on the clinical ethics issues faced by physiotherapists practicing in Singapore. It also provides some insights into the influence of context in ethical decision-making. The six themes identified were further organised into  micro, meso and macro spheres or contexts of ethics. The micro sphere themes included ethical issues that have previously been identified in other physiotherapy study findings (Delany et al., 2018; Fryer et al., 2021; Praestegaard & Gard, 2013; Sturm et al., 2022). The notable points of difference specific to Singapore were themes residing in the meso and macro spheres. These themes offered potential insights into the particular context of physiotherapy practice in Singapore. One example in the meso sphere is the influence of different healthcare settings (acute, community, specialised institutions, and private practice) on ethical dimensions of physiotherapy practice within Singapore’s healthcare system. There were differences in the predominance or perceived importance of certain ethical issues due to each setting’s unique organisational structure and systems. These findings appear to reflect current literature which reported on differences in physiotherapists’ ethical experiences due to the influence of healthcare settings (Cantu, 2018, 2019; Hudon et al., 2015).

At the macro sphere, participants reported that fulfilling government set KPIs or outcome measures which determined healthcare funding exerted indirect pressure on them. They grappled with patients’ expectations of advocacy on their behalf and societal expectations of cost containment (Dronberger, 2003). In meeting the requirements, participants had to balance their view about what was a good enough treatment constrained by the system, versus the best treatment available. The findings suggest that having to meet quantitative statistical numbers such as discharge rates was interpreted by some therapists as neglecting the quality of care and negatively affecting the therapist-patient relationship. This finding is consistent with that of Hudon et al. (2015), who highlighted institutional and economic influence on the quality of physiotherapy service and  public trust. Another theme in the macro sphere concerned the negative effects of hierarchies and power differentials, which therapists believed led to paternalistic practice. Factors contributing to paternalism can include time limitations on treatment, patient’s literacy levels, societal values of respecting seniority and the accepted practice of patients handing over decision-making to authority or their family. Familialism is prevalent in Singaporean culture, where a family centric approach or interest will outweigh individual’s autonomy (Krishna, 2012). It is viewed as an accepted part of Asian values and needs to be acknowledged in order to provide the best possible care for the patient. Ethical issues related to familialism have also been reported by studies in the African context (Chigbo et al., 2015; Nyante et al., 2020; Sippel et al., 2015).

A. Relevance to Ethics Education

There is agreement that ethics cannot be taught independent of context, with a focus only on the epistemic knowledge, but that it needs to incorporate the dynamic influence of macro, meso and micro factors (Barradell, 2017; Cantu, 2018; Greenfield et al., 2015; Ladeira & Koifman, 2017). The themes in this study can directly inform the ethics curriculum, highlighting to students the influence of resource constraints, local healthcare norms, organisational culture, challenges of different settings, as well as balancing multiple obligations. Beyond awareness, students must be equipped with the abilities and skillsets to address and navigate these ethical situations. Elaboration on each theme’s implications for the local ethics curriculum is outlined in Table 3.