1. Tubbs, James B. PhD

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Q: One of my physical therapy patients does not seem to be benefiting from continued therapy, so I believe the therapy should be discontinued. However, the agency that employs me is pressuring me to continue the therapy because it is being reimbursed by the patient's insurance company. How should I respond?


All healthcare professionals share a common moral commitment-and moral obligation-to provide benefit, whether curative or palliative, for those in their care. A corollary to that obligation, however, is the recognition that treatments or therapies that are not beneficial are not morally required. But can nonbeneficial therapies also be morally wrong? That seems to be the question underlying the case at hand. Providing therapy merely for financial gain might be considered immoral. And there is also the question of justice: can it be just or fair to expend limited financial and professional resources to provide therapy that is not expected to yield its intended benefits?


Now, if one has good reason to believe that a particular therapy causes net harm rather than benefit for the patient, then there would be clear grounds for refusing to provide that therapy and perhaps for convincing others not to provide it, either. In this case, however, the claim put forward is simply that the patient "does not seem to be benefiting" from the therapy. Generally speaking, a physician orders physical therapy and an insurance provider treats that order as a covered benefit because/when it is tied to the goal of improvement of health function. If there is good reason to believe that goal can never be met with the prescribed therapy, then it may represent little more than an unwelcome nuisance to the patient (and may appear to be fraud, from the insurance company's point of view). Of course, a regimen of physical therapy also entails caring interpersonal contact and professional investment that may provide the patient with "benefits" (emotional, aspirational, motivational) beyond simply measurable improvement in physical functioning; but those benefits are not funded by insurance.


That being said, the first obligation of the therapist who concludes that his or her interventions are nonbeneficial is to communicate that assessment (and all reasons for it) to the person with overall responsibility for the patient's treatment plans-the prescribing physician. The physician, after all, is ultimately responsible not only for ordering all treatments and therapies but also for justifying their necessity to the insurance provider. It may happen, of course, that the physician is employed by and/or may agree with or accede to the wishes of the healthcare agency that is pressuring for continuation of the physical therapy. If that happens, and if the physical therapist is offered no medical judgment or rationale for continuing the therapy other than simply because it is being reimbursed, then several possible options for forms of conscientious resistance may present themselves. The first and most obvious approach would be to seek other routes in pressing one's case: a supervisor within the agency, perhaps, or an affiliated ethics committee, if available. A further option would be to continue the therapy as ordered but to document in the patient's chart, clearly and consistently, the patient's lack of progress, reasons why the therapy should be considered nonbeneficial, and how and when that assessment was reported to the responsible physician and the home healthcare agency. A possible last resort, especially if/when the therapist believes the patient is also inconvenienced or annoyed by the treatments, would be to conscientiously refuse to participate further in that therapy, notify the appropriate supervisor of his or her reasons, and be prepared to deal with potential disciplinary consequences.