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Overview and Description

Physiatrists are rehabilitation physician specialists trained to care for patients with complex medical conditions, including brain injury, neuromuscular disorders, spinal cord injury, musculoskeletal injuries, pain syndromes, and cardiopulmonary disorders. As leaders of interdisciplinary teams, physiatrists are skilled in actively engaging multiple clinicians simultaneously and empowering patients in key decision-making processes. Because this unique paradigm is not typically employed in other areas of medicine, it is imperative that physiatrists have a firm understanding of the possible ethical scenarios they may encounter. This article will provide an overview of bioethical principles and their application in the field of physical medicine and rehabilitation (PM&R).

History of bioethics

Ethics is the study of moral principles that direct norms of conduct and what is morally permissible and impermissible. Medical ethics, often referred to as bioethics, provides a set of moral principles that guide the everyday practice of medicine.1 Social injustices over the years, particularly in the mid-20th century, paved the way for what is known today as biomedical ethics.

On a global scale, the Nuremberg Code, developed after World War II crimes of German physicians in Nazi concentration camps, was the first documented standard for conducting research, beginning with voluntary consent.2 Then, in the United States 40 years after the start of the Tuskegee syphilis study Congress established the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research to determine the ethical principles for conducting biomedical and behavioral research. It was from this commission that The Belmont Report was published in 1979 which delineated expectations in clinical medicine as compared to clinical research, as each has different goals. Three main principles were described: respect for persons autonomy, beneficence, and justice.2 In the same year, Beauchamp and Childress published the first edition of Principles of Biomedical Ethics.3This provided an approach to medical ethics based on four moral principles and attention to scope of application: autonomy, beneficence, non-maleficence, and justice.4 The four principles are commonly known as the four pillars of biomedical ethics.5

The Four Pillars


Beneficence is to do good and prevent harm. Initially in the Belmont report beneficence was recognized as a derivative of the Hippocratic oath to “do no harm” but given beneficence referred to underlying positive notions to do good, it became distinct from nonmaleficence, which is now defined as do no harm.6 With the goal of achieving a net positive benefit, one must recognize that what may be seen as good for one person may be harmful to another. Therefore, it is important to individualize risks and benefits in any treatment plan.


Nonmaleficence is the obligation to do no harm. This principle was embedded within beneficence in the Belmont Report, but it is important to recognize the difference and balance needed between the two. Nonmaleficence when clinically applied usually weighs risks and burdens to benefits that can be particularly important in another principle known as the doctrine of double effect. The doctrine of double effect refers to situations when actions try to bring about good, but harm also arises that may have been foreseen but unintended.5


Justice refers to fair and equitable treatment. Clinically this is commonly described as distributive justice which is treatment to each person equally according to “need, effort, contribution, merit or free-market exchanges.”5 An example of distributive justice is the allocation and utilization of scarce resources. This can be difficult to achieve not only for patients who are differently abled but also in the current general practice of medicine.

Medicine is currently practiced under a patient centered care model where treatment options are based on individual preferences rather than one size fits all.In their role leading interdisciplinary teams, physiatrists develop plans of care for patients with disabilities to optimize their quality of life. Physiatrists must carefully and judiciously consider the following seven core elements of patient centered care outlined by the New England Journal of Medicine in 20177

  • System’s mission, vision, values, leadership, and quality-improvement drivers are aligned to patient-centered goals.
  • Care is collaborative, coordinated, and accessible. The right care is provided at the right time and the right place.
  • Care focuses on physical comfort as well as emotional well-being.
  • Patient and family preferences, values, cultural traditions, and socioeconomic conditions are respected.
  • Patients and their families are an expected part of the care team and play a role in decisions at the patient and system level.
  • The presence of family members in the care setting is encouraged and facilitated.
  • Information is shared fully and in a timely manner so that patients and their family members can make informed decisions.


The last principle, autonomy, is one that people most often believe should prevail. Philosophers laid the foundation for autonomy holding the belief that “all persons have intrinsic and unconditional worth and therefore should have the power to make rational decisions and moral choices and should be allowed to exercise his or her capacity for self-determination.”5 Autonomy allows one to delegate decision making to another person if desired. Differences among cultures can lead to decreased reliance on the individual decision making and more on their family. It is important to understand patient preferences and values as an individual and not infer based on group membership or common cultural practice. Although highly prioritized, autonomy can be overridden if it would cause meaningful harm to another, if a person lacks capacity or if they are not competent.

Decisional Capacity and Informed Consent

Competence and capacity are often mistakenly used interchangeably in clinical practice, and it is important to distinguish them. Competency is the ability of an individual to participate in legal proceedings, which can only be formally determined by a judge, not a medical professional. Capacity is an essential element in the informed consent process for medical treatment and is determined by a healthcare provider. It is a common misconception that only psychiatrists or psychologists can determine capacity. Any licensed physician, physician assistant, or nurse practitioner can determine capacity. Lo suggests three simple questions which the physician can ask when determining decisional capacity8

  • Does the patient understand the disclosed information?
  • Does the patient appreciate the consequences of the choices?
  • Does the patient use reasoning to make his/her choice?

It is important to note that capacity can change and requires periodic reevaluation. Many temporary factors can impact a patient’s capacity. Patients participating in inpatient rehabilitation are frequently asked to make decisions in suboptimal conditions such as sleep deprivation, pain, or on sedating medications to name a few examples. It is the physiatrist’s responsibility to limit conditions negatively affecting patients’ cognition while determining capacity.

A unique challenge of decisional capacity frequently encountered in PM&R is patients with more significant deficits in communication, cognition, or capacity. For example, strokes and traumatic brain injuries can produce aphasia (difficulty comprehending or producing language), anosognosia (lack of awareness of their deficits), or prolonged loss of consciousness. Some of these patients require alternative communication and interpretive strategies, while others simply cannot adequately participate.

In patients without decisional capacity, a surrogate decision maker is utilized. Without a patient naming a surrogate or completing an advance directive for medical power of attorney, there is a hierarchy of legally determined “next of kin”. The role of the surrogate decision maker is to help infer the patient’s wishes and to make decisions in the patient’s best interest. Each state has its own hierarchy to determine next of kin, and it is important to familiarize oneself with their state’s laws. For example, Pennsylvania’s order for determining next of kin is the following from highest ranking to lowest9

  1. The individual’s spouse and any adult biological children from prior marriages (if applicable).
  2. All adult biological children
  3. Parents
  4. Adult brothers or sisters
  5. Adult grandchildren
  6. An adult who has knowledge of the individual’s preferences and values

The patient also may have completed a living will, a type of advance directive and legal document specifying desired and undesired treatments. Surrogate decision makers do not hold the same abilities as medical power of attorneys. It is also important to note that someone may have a durable power of attorney that is only for financial decisions and has a separate medical power of attorney. Appropriately interpreting and enacting advance directives and familiarity with state laws are not only a legal necessity but also important ethically. Decisions involving medical power of attorneys, next of kin, other family members, and living wills can quickly become complex and parties can reach divided or contradictory conclusions. Practitioners should not hesitate to consult legal representatives or a bioethics team when necessary.10

Informed consent and decisional capacity are virtually inseparable. Together they constitute the foundation for ethical clinical practice. Informed consent represents an interactive process between the patient and healthcare provider which must end in agreement prior to certain procedures or interventions. This process provides patients with information regarding the purpose of treatment, treatment options, risks and benefits of the intervention or procedure, and the opportunity for them to indicate their understanding prior to giving or withholding consent. For procedures, once consent is provided, a document reflecting this discussion is signed by both patient and physician and included in the medical record. Consent for research purposes is necessary to carry out research studies in an informed setting. In 1974 three crucial elements required for informed consent in research were outlined by the International Review Board (IRB) to ensure stricter protection of participant rights in research11

  • Disclosure of information to participants
  • Capacity of the patient (or surrogate) to decide
  • Voluntary nature of the decision

Special considerations are taken with research consent to minimize coercion or undue influence of vulnerable populations, such as children, pregnant women, immigrants, prisoners, or other at-risk populations.12

In comparison to research consent, there are five elements required to be documented for clinical consent outlined by The Joint Commission (TJC), an organization that accredits US health care programs and organizations11

  • The nature of the procedure
  • The risks and benefits and the procedure
  • Reasonable alternatives
  • Risks and benefits of alternatives
  • Assessment of the patient’s understanding of the other 4 elements

It is important to note that informed consent in both a research and clinical context ensures patient safety allowing the patient or healthcare proxy to partake in the decision-making process. Table 1 compares important elements impacting informed consent for clinical care and research consent.

Table 1: Comparison of Informed Consent and Research Consent

Informed Consent
PopulationPatientsStudy participants
Primary outcomeDirect patient careTo further knowledge
Detailed explanation provided?YesYes
Discussion of risks and benefits?YesYes
Financial Disclosure?YesYes
Who benefits?The individualSociety, future patients, possibly the individual
Compensation?NoIf appropriate
Requires IRB approval?NoYes (with exceptions)
Regulating organizationsThe Joint CommissionIRB, 1974 National Research Act, US Federal Regulations  

Ethics in Research

Whyte has explored some of the ethical ramifications of rehabilitation research as illustrated by efficacy studies.13 The concept of clinical equipoise is central to such research, meaning that there is a real uncertainty about whether a treatment is beneficial. The four pillars of autonomy, beneficence, nonmaleficence and justice, need to be scrupulously observed.3 In particular, selection bias in the choice of subjects and selective use of inappropriate statistics to influence conclusions are to be avoided.

Frontera discusses how scientific article publication is growing and is becoming ever more important in the field of physical medicine and rehabilitation.14 This requires physiatrists to understand the elements of scientific article writing, levels of scientific evidence, current rules of scientific reporting, and the importance of preventing scientific misconduct.12

Approach to Ethics in Rehabilitation

In 2015, the American Medical Association Journal of Ethics specified the following five ethical considerations in rehabilitation based on work by Kirschner et al2,15

  • Scarce resource allocation and the potential for discrimination against disabled people
  • The ethics of accommodating people with disability and chronic neuromuscular disorders, including medical settings
  • Identifying optimally inclusive nomenclature and terminology (e.g., “physical diversity” rather than “disability”)
  • Conflict between the goals of promoting acceptance and accommodation for persons with disability on one hand and securing resources for restoration of functional efficiency and meaningful mission on the other
  • The ethics of rehabilitating persons with neurological and behavioral disorders with anosognosia (deficits of awareness), in which maximizing rehabilitation may mean abandoning or overriding patient autonomy. 

Applying these ethical principles in rehabilitation with the four pillars allows for the attention to scope of application that Beauchamp and Childress discuss.4 There is a known obligation to follow all four principles, prima facie, unless principles conflict. Conflict  of principles is common particularly between beneficence and autonomy and in those situations finding common ground leads to beneficence encompassing autonomy, where the patient’s best interest is inherently linked to their preferences.6The most well-known approach to ethical considerations involves Jonsen’s four topics for organizing ethical reasoning: medical indications, patient preferences, quality of life, and contextual features.17 Contextual features refer to the social, institutional, financial, and legal settings that can influence medical decisions. Table 2 recreated by Verkey highlights this method.6,17

Table 2: Application of principles of ethics in patient care5, 17

Beneficence, nonmaleficenceClinical assessment
Nature of illness (acute, chronic, reversible, terminal)? Goals of treatment?
Treatment options and probability of success for each option?
Adverse effects of treatment and does benefit outweigh harm?
Effects of no medical/surgical treatment?
If treated, plans for limiting treatment? Stopping treatment?
Respect for autonomyPatient rights and preferences
Information given to patient on benefits and risks of treatment? Patient understood the information and gave consent?
Patent mentally competent? If competent, what are his/her preferences?
If patient mentally incompetent, are patient’s prior preferences known? If preferences unknown, who is the appropriate surrogate?
Beneficence, nonmaleficence, respect for autonomyQuality of life (QOL)
Expected QOL with and without treatment?
Deficits − physical, mental, social − may have after treatment?
Judging QOL of patient who cannot express himself/herself? Who is the judge?
Recognition of possible physician bias in judging QOL?
Rationale to forgo life-sustaining treatment(s)?
Distributive justiceExternal forces and context
Conflicts of interests − does physician benefit financially, professionally by ordering tests, prescribing medications, seeking consultations?
Research or educational considerations that affect clinical decisions, physician orders?
Conflicts of interests based on religious beliefs? Legal issues?
Conflicts of interests between organizations (clinics, hospitals), 3rd party payers?
Public health and safety issues?
Problems in allocation of scarce resources?

In 2013, Hunt and Ellsdeveloped the Patient-Centered Care Ethics Analysis Model for Rehabilitation (PCEAM-R) to guide ethical rehabilitative care given the complexity of the care team, patient’s degree of impairment/disability and a variety of possible interventions.16 This six-step process for ethical decision making is theoretically grounded in the International Classification of Functioning Disability and Health. It is accompanied by a detailed list of questions to provide a comprehensive and balanced assessment of each patient’s situation.16 The six steps of the PCEAM-R are

  • Identify the ethical issue(s) to address: What values and ethical principles are at stake and for whom?
  • Collect information: What do we need to know to be able to evaluate the issue(s)? This can be analyzed with the International Classification of Function, patient preferences, and goals.
  • Review and analyze: Do we need to reformulate the issue(s) and what can help us better understand it? Are there biases or assumptions being made?
  • Identify and weigh options: What are our options and what rationales support them?
  • Make decision(s): What is the best option and how should we implement it? Is this a consensus or who has the authority to make the decision?
  • Evaluate and follow-up: What was the outcome and how can we learn from it? Debriefing at the next meeting.

Blending the two approaches may be the best practice in physiatry to ensure justice for all patients of differing abilities. As said by Hunt and Ells“by following a process of comprehensive consideration consistent with well-established ethical principles, such models are a safeguard against simply taking sides or imposing one’s own views.”16 In physiatry, it is our duty to educate others and advocate on behalf of people with disabilities because disability in and of itself does not necessarily constitute a terminal illness to enact advance directives nor does it detract from someone’s intrinsic and unconditional worth. One example is cervical spinal cord injuries. Literature shows that patients still have a high quality of life regardless of their functional impairments. However, studies have been also done that show health care clinicians may rate the quality of life of patients with disability or chronic illness lower than the patients rate it themselves.17,18 Reversed roles may also be true. These differences can foster disagreement on treatment plans between the patient and the treatment team highlighting why a systematic approach must be followed to mitigate personal biases and beliefs. Additionally, consultation with the hospital medical ethics committee and/or risk management may be necessary to ensure proper ethical reasoning. We now look at one aspect on disagreement of treatment plan as it relates back to autonomy.

Refusing or Discontinuing Treatment

Following autonomy, patients have the right to decline or discontinue any treatment, so long as they have the capacity to do so. When patients make decisions that have major repercussions on their lives or welfare, it is important to closely reevaluate their capacity. Ridley described a case of a 23-year-old man with C3 quadriplegia admitted to a rehabilitation unit who later decided he preferred to die rather than live as a quadriplegic.19 After lengthy discussions with the patient, his family, and psychiatry, he was deemed to have capacity to stop his medical and rehabilitation therapies. He was transported to a nursing home near his family where he died 2 months later.

Patients and practitioners can frequently hold different opinions on a desired treatment plan due to many factors despite sharing common values. Sandman et al. illustrate many cases of patients with strokes declining nutrition recommendations due to lack of understanding of medical symptoms, denial of condition, or poor understanding of the therapy offered among other reasons.20 Echoing the importance of informed consent, the physiatrist has a responsibility to discuss the pros and cons of treatment, as well as any potential barriers, so that an informed decision can be made. More commonly, physiatrists encounter patients who decline to undergo or continue rehabilitation therapies.There are many valid reasons for refusing rehabilitation, including but not limited to

  • Concerns about loss of home services based on insurance policies
  • A patient’s need to provide care or support for a spouse with medical problems
  • Preference for the home environment as location for rehabilitation care
  • Financial concerns

Terminating rehabilitation should reflect a consensus amongst medical staff, the patient, and family. There are, however, other factors which may lead to discontinuing or changing treatment such as reaching the limits of insurance coverage, lack of functional improvement, medical issues interfering with treatment, or inadequate participation or cooperation by the patient. Terminating or changing treatment decision should be approached by the physiatrist and/or rehabilitation team and include a discussion of the reasons for terminating treatment and alternative options such as therapy at home, transfer to another facility, or outpatient follow-up care.

Future Trends

The COVID-19 pandemic led to moral distress in healthcare providers precipitated by scarcity of resources for healthcare delivery. Access or desire to obtain rehabilitation services such as home care and outpatient rehabilitation decreased secondary to many factors from healthcare worker shortages to social distancing. People with functional impairments who already depended on the support of others to perform activities of daily living and instrumental activities of daily living were further limited. It is known that a person’s function drives prognosis, and for those who already had functional limitations, not having access to care caused increased morbidity and mortality.

Technology advanced telemedicine increasing access to healthcare during the COVID-19 pandemic. Telemedicine, though not a suitable replacement for all face-to-face visits, was beneficial across most specialties, including rehabilitation. Technological advances continue to shape how modern-day medicine is practiced. Artificial intelligence (AI) and machine learning algorithms are being developed to help make decision making more efficient and accurate but ethical concerns have arisen with integration.21 Are the benefits ethically acceptable in the face of error and bias? Does AI allow for true informed consent and shared decision making? Without shared decision making, the physician patient relationship could revert from patient centered care to paternalism. One potential solution is increased collaboration between developers and stakeholders such as physicians.

Technology though is only one aspect of the future of medicine. As new developments in medical and surgical care preserve the lives of many individuals whose injuries or diseases would have otherwise been fatal previously, physiatrists can anticipate caring for more patients with severe functional impairments accompanied by complex ethical considerations.

On top of health inequities related to COVID-19, in 2020 in the United States racism was acknowledged as a public health crisis by many organizations, as well as state and local governments. Milwaukee County, Wisconsin, became the first community to declare racism a public health crisis in 2018, and in 2020, the CDC declared it a serious public health threat. 22,23 As the medical community turns its efforts with renewed energy to addressing Diversity, Equity, and Inclusion (DEI) disparities, it is imperative that medical trainees receive a structured bioethical education. Some progress has been made in both medical school and residency training. One element the Liaison Committee on Medical Education (LCME) sets for US medical school accreditation requires institutions to “ensure that the medical curriculum includes instruction for medical students in medical ethics and human values both prior to and during their participation in patient care activities and requires its medical students to behave ethically in caring for patients.”24 Similarly, the 2022 Accreditation Council for Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Physical Medicine and Rehabilitation currently specifies that residents show competence in “application of bioethics principles to decision making in the diagnosis and management of their patients.”24 Both organizations also include similar statements regarding DEI specifically in their accreditation guideline documents.24,25 While these are commendable first steps towards including bioethical education in medical training, more work is needed to create specific educational objectives and a more formal bioethical curriculum. Additionally, medical trainees need actionable steps to implement bioethical concepts from such a curriculum into their practice.

DEI goes beyond curriculums. Addressing diversity, equity and inclusion each separately from before admission to medical school is one place to start.26 This relates to social determinants of health (SDOH) and funding is needed for these social sciences and culture change.27 Such work is already being undertaken by institutions like the Cleveland Clinic, who published work on creating cultural change as a first step to promoting Diversity, Equity, and Inclusion initiatives. They based their work on the previously published framework to achieve organizational culture change by J Mierke and V. Williamson. The six steps are28,29

  • Identify the catalyst for change
  • Strategically plan for successful change
  • Engage and empower organizational members
  • Cultivate Leaders at all levels
  • Foster innovation, creativity, and risk-taking
  • Monitor progress, measure success, and celebrate (even the small changes) along the way

In addition to the six steps, two prerequisite conditions were set to have implementation and sustainability: transparency in communication and flexibility and adjustment to emerging situations. The Cleveland Clinic model could be employed by other organizations to build a “diverse, equitable, inclusive, antiracist and vibrant education community.”28,29

Physiatrists are faced with ethical challenges daily in their practice, making it imperative that their workforce receives robust bioethical education. Additionally, their lived experiences navigating ethical clinical scenarios makes them valuable additions to bioethics committees. In this way, physiatrists can impact larger conversations in the medical community about how to include bioethics as the foundation of gold-standard patient-centered care.


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  12. Manti S, Licari A. How to obtain informed consent for research. Breathe (Sheff). 2018;14(2):145‐152. doi:10.1183/20734735.001918
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Original Version of the Topic

Stanley F. Wainapel, MD, Karen Morice, MD. Ethical issues commonly managed during rehabilitation. 9/20/2014.

Previous Revision(s) of the Topic

Erika Trovato, DO, MS, Tiffany M. Lau, MD, Lawrence Chang, DO, MPH, Karen Pechman, MD. Ethical issues commonly managed during rehabilitation. 7/30/2020.

Author Disclosure

Erin Marie Kelly, DO
Nothing to Disclose

Michael Leff, MD
Nothing to Disclose