The WCPT’s policy statement asserts (updated website 11/10/16) that “… physical therapists, as autonomous professionals, should have the freedom to exercise their professional judgment and decision making, wherever they practice, so long as this is within the physical therapist’s knowledge, competence and scope of practice…”. They also state that “The actions of individual physical therapists are their own responsibility, and their professional decisions cannot be controlled or compromised by employers, members of other professions or other individuals” (http://www.wcpt.org/policy/ps-autonomy (last accessed 16/11/16).
These two claims appear normative and aspirational but may not reflect the reality experienced by many therapists across the globe (or even across the NHS). The WCPT claims seem to suggest that therapists’ freedom to decide and freedom from interference by others is (or ought to be) all but absolute, on condition that they practice within their scope of practice. Indeed if therapists are fully responsible for their actions, they ought to be able to say that those actions were free from external interferences. Who would not want to agree with such a notion about professional freedom?
But as critical practitioners we may want to probe this issues a bit further.
Obvious limitations to freedom
The WCPT claim could be said to reflect liberal ideas about the personal autonomy and independence of individuals in society.
But in the context of the actual complexities of any human-activity system whose outcomes depend on the effectiveness and efficiency of its collaborating agents and interdependent parts, independence seems an alien concept. So to have freedom to decide needs to be in the interest of the system/organisation and its service users primarily.
In healthcare (e.g. CBR, private practice, complex specialist units etc) it therefore seems inconceivable that any one agent (irrespective of role) should have absolute freedom. Within the context of any health/social care organisation, comprising some kind of hierarchical structure, therapists require delegated authority and/or support from others in order to undertake their defined range of activities. Within the therapeutic relationship the therapist requires consent/permission from the service user or patient. These kinds of limitations to our freedom I think are understood by us all.
But a claim that we as autonomous professionals ought to be free to decide without undue interference in the therapeutic process, deserves at least some critical exploration.
Why explore “freedom to decide” further?
I assume that we would all agree that we as therapists collaborate with other agents (within and across health/social care settings) as appropriate and that, to some extent at least, everybody is dependent on the actions and support of others. This principle of interdependency applies to all agents, clinical, managerial, clerical, professional non-professional, service users etc. This is a philosophy and a reality that everybody would subscribe to. That however does not necessarily mean that all agents appreciate this principle equally or that they understand the role of other (relevant) agents fully.
Our narrative about our professional autonomy includes the notion that we are free to act in accordance with our decisions. We say that the clinical choices we make are informed by our reasoned judgments, experiences, knowledge, “the evidence”, our intuitions, patients’ preferences their capabilities and our assessment of their’ potential, among other things. The same narrative seems to reflects the experience that we enjoy freedom from undue interference by other agents who are external to the therapeutic relationship and intervention.
But maybe it would it be better to say that we need to believe that we enjoy that kind of freedom in order to make the narrative more cohesive, convey a sense of rationality and make it fit with our perception of our role and to convince ourselves and others accordingly. You may say that this is a bit harsh, but it is reasonable to say that globally (and even within the NHS) therapists’ experiences of ‘freedom to decide’ vary very considerably. If this is true, it would mean one of several things: ‘freedom to decide’ is not a universally agreed concept: different agents have different perspectives about the need for others to have clinical freedom. In other words ‘freedom to decide’ would be a relative concept, which is co-constructed and mutually agreed by relevant agents in a particular setting.
If we all wrote down our description of freedom (in the context of our professional role as a therapist) we’d end up with quite a few different equally valid ones, but they would all have certain similarities. I’d define ‘freedom’ for now, as having the capability and the opportunities to choose from available or self-generated options about the kind and duration of treatment (in collaboration with the patient) free from overriding external interferences.
This definition can be rightly criticised for focusing narrowly on the patient treatment/management and not on the wider role of the physiotherapist. But in my defence it is probably enough to get on with and also, if a therapist’s freedom is curtailed re the kind/duration of treatment decisions, it will certainly be limited with respect to wider issues such as strategic service planning, service-development, role expansion, and resource utilisation, planning and undertaking audits, research etc.
I should declare that I am a freedom-sceptic and believe that it is relative, context-dependent and temporally variable for two reasons. First one is internal: the options we allow ourselves to choose from are influenced (if not determined) by our individual history including our believes, biases, as well as our social, psychological and educational history. The second reason is to do with external factors (freedom from…). If agents who are external to the therapeutic relation prescribe available options about the kind and duration of the treatment, then our deciding/choosing will be framed and bounded (at least to some extent) in a way we ourselves would not have chosen for ourselves or for our patients, given our knowledge of alterative (possibly more effective) approaches.
How we manage imposed constraints is likely to vary between agents. Rather than rejecting imposed restrictions to our practice we could decide to accept and internalise them and act accordingly. However by complying, we would in fact be acting for external reasons: a form of heteronomy (i.e. the opposite of autonomy). We would not be meeting the responsibilities we have towards our patients and it could also be said that the patient’s trust in us would be misplaced. By complying with imposed protocols and/or prescribed treatment options we may not be acting in their best interest. We’d certainly not be acting truthfully and with authenticity.
Complying with externally imposed constraints might be effective as a short term survival strategy, but would inevitably cause us to experience internal conflict and dissatisfaction and a sense of feeling dis-empowered. We might seek proxy measures of success such as easily measurable outcome criteria/targets instead of clinical outcomes.
The agent (e.g. the commissioner, the team-lead, manager) who imposes their preferences (and insists on compliance) in the short/medium term at least, seems to be the most power-dominant agent. Within a marketised healthcare system they could take their contract elsewhere. The question if this kind of strategy would generate the best outcomes and value for money for patients and society has not been tested, as far as I am aware.
Much more could be said about these issues, but the point is that where power and authority are unequally distributed, the least powerful agent’s freedom to decide/act may be compromised. These issues are organisational and systemic as well as inter-relational issues. Power-dynamics between individual (groups of) agents and within the system (and within all of its constituent parts) define what it actually means to have “freedom from…” and to have “freedom to…” in our daily practice.
There are individual and profession-specific, internal, issues around our “freedom” as well and we will explore those further in my next blog.