Code of Ethics for physical and occupational therapists reveals contents related to professional autonomy

Correspondence to: Emerson Fachin Martins – Universidade de Brasília, Faculdade de Ceilândia, Campus de Ceilândia, QNN 14, Área Especial, Ceilândia Sul – CEP: 72220-140 – Brasília (DF), Brazil – E-mail: efmartins@unb.br Presentation: july. 2013 – Accepted for publication: nov. 2013 – Financing source: none – Conflict of interests: nothing to declare. ABSTRACT | Despite the existence of a recent code of ethics, a study revealing the content inside the previous one could contribute for the better comprehension of the physical therapist’s social function. Therefore, the present study verified proportions of deontological and bioethical approaches that are present in this code identifying the predominance of contents to support the interpretation of the document. Textual and interpretative analyses were used to compare the code with two other sets of documents. The first set showed deontological approaches, while the second one presented bioethical ones. Textual units were identified for all documents and classified by bioethical (principles) and/or deontological (technique and virtue) approaches. For the code of ethics and each set of documents, 54.4, 55.7 and 57.7% of deontological contents were identified. The textual units classified in the code of ethics as professional or client autonomy had ratio of 2.15:1 (professional:client). The ratio previously presented was lower than the one observed in the set of documents with deontological approach (5.07:1 – professional:client) and it was the opposite for the documents regarding the bioethical approach (1.32:1 – client:professional). It was concluded that inside the codes of ethics and the set of deontological information there are corporate and law conceptions, resulting in the majority of contents reveling professional autonomy. This characteristic was different Code of Ethics for physical and occupational therapists reveals contents related to professional autonomy Código de ética para fisioterapeutas e terapeutas ocupacionais revela conteúdos relacionados à autonomia do profissional Código de ética para fisioterapeutas y terapeutas ocupacionales revela contenidos relacionados a la autonomía del profesional Leandro Corrêa Figueiredo, Aline Cristina Martins Gratão, Emerson Fachin Martins


INTRODUCTION
Even though the profession was created in the early 20th century 1 , the physical therapist could only count on its regulation forty years later, in 1969, with the publication of the decree-law 938 [2][3][4] . After its regulation, only in 1978, with the Resolution of the Federal Council of Physical and Occupational Therapy (COFFIT), a Professional Code of Ethics was published 5 .
From its publication until the current days, there are still courses that do not include disciplines to discuss moral judgment and ethics in the formation of physical therapists, that is, they do not consider the reports stating that the construction of ethical subjects is based on their education and professional formation 6 .
If discussions about ethics are ceasing to fulfill their role of building a professional during the formation of the physical therapist, the losses are perceived in the society, where professionals deal with the anguish and suffering of others 1,7 .
For the physical therapist, as well as for other professionals, the regulation and the evolution in the process of professional formation, and also the action guidelines, have always been addressed to technical aspects. The same is true for the relationship professional-client, submitting the attitudes of the profession into the background 8 .
Even if the knowledge about bioethics is present, it cannot be considered as an effective reality in the daily practice of health professionals, especially in the formation of a physical therapist, since the work of health professionals is conditioned to the Hippocratic ethics, being limited to the analysis and the fulfillment of rights and duties, which is predicted in professional codes of ethics and usually conceived according to the precepts of deontology 9,10 . When Physical Therapy courses have disciplines with subjects approaching bioethics, these are expressed by names involving the world ethics. The syllabus descriptions do not clarify if the contents will subsidize the decision making concerning health, life, death, dignity, solidarity, confidentiality, privacy, vulnerability, responsibility and quality of life [11][12][13] .
Alves et al. 14 studied the preparation of bioethical contents in Physical Therapy graduate courses and reported that the best results are obtained from the relationships with other health professionals for physical therapy students who had such contents in their formation. However, most of these disciplines only describes the Professional Code of Ethics 5 , thus not promoting discussions or introducing considerations with focus on bioethics, since the later came up many years after the conception of this code 6,8,11,15 .
Facing the deficiencies observed in the discussions about ethics and bioethics during the formation of the physical therapy, and taking the example of a similar study described for the Code of Ethics of Odontology 8 , it is likely that the previous code of ethics does not present contents including bioethical approaches. Therefore, this study aimed at verifying to what extent the deontological and bioethical contents were present in the former Professional Code of Ethics of Physical and Occupational Therapy (CEPFTO) 5 , designing the epistemological profile that could subsidize interpretations of the professional conduct and adaptations on the format and language of the code.

Theoretical bases and procedures of analysis
The study was designed in documentary source for the interpretative analysis of CEPFTO according to the methodology described by Pyrrho et al. 8 . The code of ethics was compared with two sets of documents: one set of a deontological theoretical reference, and another set with a bioethical one. Six texts were selected: three with deontological theoretical reference [17][18][19] , and three with bioethical references 14,15,20 , which formed a the contextual base to compare their contents with that of CEPFTO 5 . The texts for comparison were collected from the bases: Google Scholar and LILACS, from November 8 to 10, 2011.
The content analysis was guided by Bardin 21 , however, for the textual source. In his conceptions of content analysis, he claims that after using quantitative methods as a technique of qualitative analysis, the definition of a qualitative study is not philosophically and structurally opposed.

Organization of the categories of textual units and processing
Each document was fragmented into textual units that could correspond to paragraphs, sentences or words expressing content with textual meaning.
Textual units could be classified into one or more of the one to six categories resulting from the four bioethical principles (autonomy, beneficence, non-maleficence and justice) and the inclusion of two categories (virtue and technique) related to deontological principles. The textual units informing moral aspects that are not related to bioethical principles and those informing socially desired professional conducts were placed in the virtue category. Textual units informing about specific technical, legalistic and conceptual aspects of the profession were classified in the technical category. The autonomy category was subdivided into two other categories: professional autonomy and client's autonomy, depending on who was the beneficiary of the moral conduct.
Therefore, for each defined category, including the subdivision of the autonomy category, there was a matrix organized column in a total of seven columns worksheet of Excel, and each line of this matrix indicated one page of the analyzed document.
In order to calculate the sum of the total number of textual units in an organized way, after tagging the printed text, the number of textual units was inserted in the crossing cell corresponding to the page (line) in which it was identified for the category (column) of classification.
Besides the distribution of frequency in textual units, the proportionality ratio was calculated by the quotient of the most prevalent category over the least prevalent one, by informing the number of existing categories for one in relation to the other. Differences between proportions were detected by the χ 2 test, and significant differences were considered when p<0.05.

RESULTS
In CEPFTO (Figure 1), the categories expressing deontological contents were prevalent, followed by categories of bioethical principlism: justice; autonomy; non-maleficence and beneficence. Among the textual units that inform autonomy, professional autonomy was prevalent at a proportionality ratio of 2.15:1 (professional:client, Figure 2).
In deontological texts (Figure 3), the predominance of the technical category was observed (deontological), as well as professional autonomy (bioethics), but categories of deontological content were also prevalent, followed by the other categories of bioethical principilism: justice, beneficence and nonmaleficence. Among the textual units informing  autonomy, unlike the other analyses, the client's autonomy was prevalent at a proportionality ratio of 1.32:1 (client:professional, Figure 3).
No significant difference was found between the proportion of deontological and bioethical categories in CEPFTO when compared to the other sets of texts (deontological ones, in Figure 4A, or bioethical ones, in Figure 4B). There was also no significant difference between proportions in the comparison of sets of texts ( Figure 4C).
The predominance of textual units informing professional autonomy was observed both in CEPFTO and in the set of texts with deontological references. The ratio was the opposite only in the set of texts with bioethical reference, and textual units related to client's autonomy were prevalent. In all of the comparisons, the proportion between textual units related to the autonomy of different beneficiaries was significantly different, as observed in Figure 5.

DISCUSSION
A few studies about ethics and bioethics in the formation of the physical therapist were observed until now in Brazil 14,15 , pointing to universities that still do not contemplate such themes in the formation of the professional.
Results show that bioethical principilism alone would not be sufficient to define textual units. The inclusion of the technical and virtue categories (deontological ones) were essential and predominant in the content of most texts, which reinforces the deontological focus surrounding the professional codes of ethics 6,22 .
Such deontological emphasis can be explained by the concern for the devaluation of the professional, be it with Figure 2. Distribution of frequency of total textual units per category and deontological (technical and virtue) or bioethical contents (autonomy, non-maleficence, beneficence and justice) in deontological texts. To the right of the histogram there is the total percentage of textual units classified as deontological content, as well as the proportionality ratio between textual units subdivided into professional or client's autonomy % of the total textual units In spite of that, deontological contexts were proportionally less present than the ones observed in the Code of Ethics of Odontology 8 , suggesting that the processes of identifying questions and making decisions require skills and ethical knowledge. Even though it is mandatory for everybody, it can vary among professionals. C unfavorable conditions to his practice or even with the disrespect among professionals that generate the lack of humanization in the health field 23 . Hermann 24 points out that emotions, which belong to more humanistic questions, have been neglected for a long time in discussions about ethics, especially influenced by practical reason. Even though the differences between the codes of ethics have been demonstrated, little is known about the level of moral development and ethical decision making of the physical therapist in order to ground such a discussion 25,26 .
In the analyzed documents, CEPFTO was the only one in which the virtue category was prevalent over the technical category, even if these two were the most mentioned categories. Such a fact suggests that the valorization of honor, prestige and traditions of the profession, with prescriptive character, are strongly present in CEPFTO 10 .
The autonomy category aggregated more contents in comparison to the other bioethical categories, and in most of the documents professional autonomy was more prevalent than client's autonomy, which characterizes the therapist as the strongest bond of the therapist-patient relationship.
This priority relationship in professional autonomy shows an authoritarian or paternalist dimension of this relation, thus possibly enabling the expansion of autonomy while the therapeutic process progresses. Such a relationship can be justified in the historical process of the origin of Physical Therapy, which generated a relation of dependence and submission of the one that, at a specific moment in life, feels more fragile and depending on the other 27 .
It is possible to observe that CEPFTO is addressed to the therapist, based on prescriptions established and focused on the autonomy of this professional. It completely diverges from the image of bioethical texts, addressed to client's autonomy, and values the justice expressed by social equality.
Textual units categorizing beneficence were the least mentioned ones in CEPFTO, even though they are the ones that better clarify the role of the health professional. It is possible to observe that, after confronting the principles of beneficence and autonomy, they are diametrically opposed under the ideological point of view.
For beneficence, a consensus about what is good for the person is established, and a pattern is structured as to the way this person should think and act, thus creating the idea of disease as opposed to normality (statistical concept). Therefore, the idea of what is licit to the society is accepted, as the intervention over the socalled abnormal, even if against the person's will and disrespecting their autonomy, which generates what some researchers in the field call paternalism 28 .
As to the non-maleficence, scarcely found in all of the texts, implies not causing any damage, so it is necessary that health professionals are ethically committed in order to not cause unnecessary pain to the patient 29 . Among the three textual analyses, CEPFTO was the one that mostly presented non-maleficence content, even if at low frequency. This may be explained by the same description of Pyrrho et al. 8 : non-maleficence is a principle containing certain obviousness, since it is not expected that a health professional works with the opposite purpose.

CONCLUSION
The frequencies of deontological or bioethical contents in the analyzed code of ethics were very similar to the frequencies in deontological and bioethical texts. For textual units classified as autonomy, both in the code of ethics and in the deontological texts, corporate and legalist conceptions were prevalent, with an autonomy vision focused on the professional. This characteristic significantly diverged from the bioethical texts, which observed the predominance of value for autonomy focused on the client.