Has the new code of ethics for physiotherapists incorporated bioethical trends ?

Advances in health technology incorporate bioethical discussions in texts that address professional care. Would the new code of ethics for physiotherapists have incorporated such discussions? Given the issue, we aimed to verify the ratio of deontological and bioethical approaches in the new code of ethics when compared to the old one, investigating relationships between professional and client autonomies in healthcare. Content analysis methods were applied to written documents in order to verify in what proportion deontological and bioethical approaches are present in the new code. The bioethical approaches compose the large part of the content in this new code (53%) specially related to the justice category which represents 21,9% of the total textual units found. Changes in the new document reveal bioethical influences in the conception of the new code, which still did not modify the relationship between professional and client autonomies, revealing the need for further discussions.

Resumen ¿El nuevo código de ética para los fisioterapeutas ha incorporado las tendencias de la bioética? Los avances tecnológicos en salud incorporan debates bioéticos en textos relacionados con la atención recibida por los profesionales. ¿El actual código de ética para los fisioterapeutas incorporó estas discusiones? Ante esta pregunta, con el objetivo de comprobar proporciones de los enfoques deontológicos y bioéticos en el nuevo código de ética en comparación con su versión anterior, se han investigado las relaciones entre la autonomía profesional versus el cliente en el cuidado de la salud. Métodos de análisis de contenido se aplicaron en los documentos escritos con el fin de verificar la proporción de contenidos categorizados en deontológicos y bioéticos en el nuevo código. Los enfoques bioéticos forman la mayor parte de los contenidos de este nuevo código (53%), principalmente relacionados con la categoría de justicia que constituye el 21,9% de las unidades textuales encontradas. Los cambios en el documento actual revelan influencias bioéticas en el diseño del nuevo código de ética que todavía no cambió la relación de la autonomía profesional frente al cliente, dejando al descubierto la necesidad de nuevas discusiones sobre el tema. Professional codes of ethics consist in documents with the main objective of regulating the relationships between professionals of the same professional category, as well as the relationship between these professionals and the society, in the attempt to solve ethical conflicts that arise in the exercise of their professions 1-3 . These conflicts are characterized by situations in which the professionals are faced with two or more alternatives of conduct and seek to rely on the contents of their professional code in order to establish a moral judgment that will base their decision in a context the involves populations in situations of vulnerability and dependence [2][3][4] .
Although the basis provided by the professional code is expected to be sufficient for the solution of most ethical conflicts, studies show that this document alone is not sufficient to guide ethical and moral conducts, either due to flaws in professional training or to limitations in the contents of such documents 2,5 . In the attempt to meet needs not addressed by the code, health professionals begin to take ownership of discussions in the field of bioethics that reflect debates and concerns with the modes of organization and meanings assumed by the care for people with disabilities 6 .
Mentioned by the first time in 1927 by Fritz Jahr, the concept of bioethics became more concrete with the publication of the book "Bioethics: bridge to the future", by Potter, in 1971 7 . besides the book, the first discussions explicitly influenced by bioethics were also presented in the form of a report by the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1978 and modified by Beauchamp and Childress in 1979 3,7,8 . The emergence of issues driven by bioethics is followed or accompanied by the design of most ethical codes in force for Brazilian health professionals; so even if textual fragments that may be related to bioethics are found in those documents, they were not written with basis on or directly influenced by these discussions [9][10][11] .
The first publication of the code of ethics for physiotherapists is from 1978, in a single document that included occupational therapists. Since then, almost forty years went by until the elaboration of the codes of ethics for these professionals, which were presented in separated versions in 2013 12,13 . Even having been published before the bioethical discussions, 45.6% of the text fragments identified in the old version of the code of ethics for physiotherapists and occupational therapists could be classified as having a bioethical approach, as shown by Figueiredo et al. 9 This study also added that in the previous version there was predominance of corporate and legalist conceptions that prioritized the autonomy of the professional over that of the client 9 .
As a new version of the professional code of ethics for physiotherapists was published, the present study had the aim to asses the recent publication of the document for the proportion of deontological and bioethical approaches, as well as to asses both versions. Acknowledgment of these ratios allows us to draw an epistemological profile which contributes to view of the conduct and care by the physiotherapist, considering adjustments in form and language in the code of professional ethics.

Theoretical and procedural bases of analysis
The methods used for the analysis of the written documents were proposed for the code of ethics of oral health professionals 14 and reproduced in the analysis of the old version of the code of ethics for physiotherapists and occupational therapists 9 . Content analysis followed what was proposed by Bardin 15 , but for text sources and with the inclusion of frequency distribution analysis of text fragments by category. We opted for the frequency distribution of text units by fragmentation and subsequent categorizations, since this way of processing does not rule out the method of content analysis 16 .
In her conception of content analysis, Bardin says that the definition of qualitative study is not philosophically or structurally contradicted when using quantitative methods as a technique of qualitative analysis 15 . The author describes content analysis as an investigation technique that has, as final goal, the objective, systematic and quantitative description of the content manifested in communication.

Organization of test units into categories and their processing
The text of the new version of the ethical code for physiotherapists was divided into text units corresponding to paragraphs, sentences or words that express content with textual meaning possible to be classified into categories. As previously described 9,14 , text units may be classified in categories related to the principles of bioethics (autonomy, beneficence, nonmaleficence and justice), as well as the deontological principles (virtue and technique).
The decision to include categories from the deontological approach was taken considering that the categories of bioethical principlism alone would not be enough to qualify text fragments from documents of this type. As defined in previous studies 9, 14 , categories "virtue and technique" allow us to better establish the distinction between text units with a more deontological approach and those with an approach more influenced by bioethical discussions.
The "autonomy" category of bioethical principlism was divided in two subcategories -(1) professional autonomy and (2) client autonomy -, as this would, depending on who was the beneficiary of the moral conduct, allow for the distinction of the type of autonomy mentioned and would show which predominates in the document. A matrix spreadsheet in the Excel software was used for the calculation of the frequency distribution of text units identified and organized by categories in the document.
For each of the seven categories previously defined (professional autonomy, client autonomy, beneficence, nonmaleficence, justice, virtue, and technique) there was a columns in the Excel spreadsheet. Each column was composed of juxtaposed cells formed by the crossing of every line in the matrix, which, in turn, indicated in every line the page of the document from which the the fragments (text units) had been taken. From this matrix, it was possible to include, in each cell, the the total of fragments identified as text units per page.
Before inserting in the cell the number of text units in each page, (line of the matrix) and by category (column of the matrix), text units were identified and highlighted on the printed document. Once inserted in the spreadsheet, the sum of text units by category was automatically calculated by the formula in the last cell of each column. These sums were used to plot the charts presented in this paper.
The ratio of text units observed by category in the new version of the professional ethical code was compared to the expected ratio, based on the proportions already published for the prior analysis of the code of ethics 9 . Discrepancies between the ratios were detected through a chisquare test, considering p < 0.05 as the threshold for significant differences.

Results
The new version of the ethics code presented almost twice as many text units as the previous one: 228 units were observed, an increase of 110. In the previous version, the most and least prevalent categories were "virtue" (deontological approach) and "beneficence" (bioethical approach), respectively. In the new text, the mos prevalent category was also "virtue", and the leas prevalent one was "client autonomy" (bioethical approach), as shown in Table 1.
Text units classified as belonging to the bioethical approach (53%) predominated in the new version of the professional cos of ethics, representing a little over half of the text units classified in the document (Figure 1). the values of the categories with the most and the least text units for each document are highlighted.
With the exception of the "justice" category (21.9%), from the bioethical category, predominant categories in the document were "virtue" (28.1%) and "technique" (18.9%), which belong to the deontological approach. In decreasing order of text unit categories come the remaining ones from the bioethical approach: "professional autonomy" (11.8%), "nonmaleficence" (7%), "beneficence" (6.6%) and "client autonomy" (5.7%). Figure 1 also shows that there is a ratio of about two text units of professional autonomy to each unit referring to client autonomy. The comparison between the new version of the ethical code and the previous one ( Figure 2) shows that, previously, the deontological approach predominated (54.2%), and now, the focus has passed to the bioethical approach (53%), although the difference is small.  The large change observed refers to the bioethical category "justice", which, in the new document, surpassed the "technique" category, from the deontological approach. It was also observed that the "beneficence" category had more text units in the new version of the document.
The analysis of the ratio between "professional autonomy" and "client autonomy" (Figure 3) found that the first still predominates, although with a 0.9% decrease in the new version. Note that the chi-square test detected significant differences (p < 0,05) only when the remaining categories were analyzed separately.

Discussion
The present study compared two versions of the professional code of ethics for physiotherapistsconceived before 12 and after 13 the consolidation of bioethics as a field of study in Brazil -and analyzed the insertion of this line of thought in the proposals for organization and in the meaning of labor processes assumed in the health care given by physiotherapists 6 .
The previous version of the document had 34 articles and the new version is composed of 57 articles, with and increase of 110 new text units, that it, the new version of the document has more propositions and concepts of bioethics. Consider, however, that even in the previous document almost half of the fragments could be classified as part of the bioethical approach 9 . On the other hand, due to the historical moment in which the first document was conceived, it is not possible to say that these contents were influenced by bioethical discussions, which only started to be published later.
It was surprising to find that, almost forty years later, in the new version of the document, text units that refer to virtue, defined here as a deontological approach, still predominate in the document. Besides, even the new version showing predominance of text units related to the bioethical approach (Figure 1), the document still has 47% of text units from the deontological approach. This could be justified by the evidence that most physiotherapy courses still have a curriculum focusing on ethical deontological and procedural issues, suggesting a need for bioethical discussions in this undergraduate area 1,17 . The need is not exclusive of physiotherapy courses, according to Siqueira-Batista et al. 18 , who showed the need to debate bioethical questions in the education of several careers of health professionals, mainly in the relationship between work environment and users.
Another important point to be considered is that most undergraduate courses are still based on the Diretrizes Curriculares Nacionais (National Curricular Guidelines) of the undergraduate physiotherapy course, which refer the theme "bioethics" only as part of general knowledge and not specific to the physiotherapist, different from what happens to the term "ethics" 1,17 . This way, such need may reflect the difficulty of professionals to deal with situations that involve bioethical conflicts during their professional practice, especially in the relationship between work environment and users; for example, in situations described by Siqueira et al. 18 , which occur with several health professionals in the Estratégia Saúde da Família (Brazilian Family Health Strategy).
Regarding the new version of the professional ethics code, perhaps main bioethical influence is in the text units relative to "justice", which appears as the second category with the most text units found. Factors that may have increased the number of text units in the "justice" category are the ones involving social issues, like equity in the access, services priorities, among many in our Sistema Único de Saúde -SUS 5 (Unified Health System).
It is important to highlight that, different from the first version of the code of ethics and deontology for physiotherapy (1978) 12 , the new version (2013) 13 came after the definition of health as a citizenship right, stated by the 1988 Constitution 30 and by the Lei Orgânica da Saúde (Health Organic Law) (8.080), of September 19, 1990 31 . In this new historical context, the present version of the code could have incorporated discussions on the values from the ideals of the new Health System, mainly the notions of "equity" and "universality" of access. In describing the emergence of Brazilian bioethics in the context of public health, Porto and Garrafa 32 point out that the strengthening of the anti-hegemonic ideal in health culminated in the Brazilian health reform and resulted in significant movements of health workers throughout the country. The highlight on the actors supports the hypothesis of incorporation, in the code of ethics, of discussions on equity in access and other SUS guidelines.
"Beneficence", although also appearing few times in the new version, stopped being the least frequently found text unit, suggesting a better relationship between therapist and patient, matured by several bioethical discussions 21,26,28,29 . This adds to the maturing of the discussions on the consolidation of the profession of physiotherapist. Since the regulation of the profession, what used to be procedure -physical therapy -was configured as a professional category in society and, in recent years, it has assumed the status of science (physiotherapeutic knowledge).
These stages in the process of improvement of physiotherapy (procedure, profession, and science) show that today physiotherapy is not only technical, but includes reflections in various fields of knowledge, which leads to the growing numbers of physiotherapists. These, in turn, increasingly get Master's and Doctor's degrees, reaching prominent positions in teaching and research in Brazil 33 , which has certainly contributed to the recognition of the area.
Another important aspect, already present in the previous version of the code 13 and that reappears in the new one, is the ratio of text units revealing the autonomy of the professional in relation to that of the client. Despite the small variation found in the new version (0.9%), the code of professional ethics for physiotherapists highlights professional autonomy. This may lead to the so-called "paternalism", representing the figure of the health professional the one with the right to choose 8,14 and mus be set aside with the improvement of bioethical reflections, defining autonomy as the choice of what is best for the client based on the reflection between the parties. This means the professional may be the one to chose as long as the client is completely clear on the issues under discussion and grants that right to the professional; otherwise, client autonomy must prevail. Autonomy must be permanently discussed in the initial training of physiotherapists, since the results of the study by Alves et al. 1 , of 2008, pointed that half of the undergraduate physiotherapy students from two universities could not answer if it was necessary to respect client autonomy. As observed, the method to identify the ratio of deontological and bioethical approaches, initially propose by Pyrrho et al. 14 , is quite adequate for reflections on codes of professional ethics. In the comparison of the rations observed in studies of the old 12 and the new professional codes for physiotherapists 13 , the equivalence of the rations is clear, although the bioethical focus predominates in the present version.
The presence of the deontological approach in almost half of the contents analyzed allows us to conclude that, although deontological codes are not enough to ensure professional ethics, they are not dispensable to the point of being completely replaced by bioethical discussions which should, ultimately, be restricted to the ethical conscience of the ones involved. Despite the notorious and recognized importance of bioethics for the improvement of society and of health practices, it is necessary to recognize that deontology is important in the circumscription of the professional activity, establishing rights and duties in the relationship between the professional and the patient.

Final Considerations
Although almost half of the contents of the new version of the professional code of ethics for physiotherapists is constituted by deontological concepts, we conclude that bioethical reflections are present and have come to predominate, coming closer to humanist issues. We believe that reinforcing bioethical discussions in the initial training of physiotherapists, as well that of the present leaders of trade unions and professional councils, could contribute to a more thorough incorporation of the bioethical discussions in the activity of the physiotherapist.
Source of financing: University of Brasilia.