The diversity and contextuality of ethical situations in South American countries, Spain and Portugal – a qualitative analysis.

An international ethics study (Fryer et al., 2021) investigating the type and frequency of ethical situations included 1.212 participants from 94 countries, but only 15 participants from South America. The study aimed to close this existing gap of knowledge. This paper focuses on the contextual understanding of ethical issues that participants provided in an open question at the end of the study.

The questionnaire by Fryer et al., 2021, was translated into the Spanish and Portuguese language, including 13 new ethical situations outside the original questionnaire, and was presented in an online survey. The participants were asked about sociodemographic details, knowledge of ethical codes and decision-making, and the frequency that participants experienced specific ethical issues within four contextual categories:

1. Physiotherapist and patient interaction,
2. Physiotherapist and other health professionals including other physiotherapists,
3. Physiotherapists and the system and
4. Professional and economic ethical situations.

The last item (Q73) optionally asked participants to describe an ethical situation they had experienced which was not covered by existing response options. Four researchers coded all individual responses. New ethical situations identified were then coded thematically.

607 individuals from 9 South American countries, Spain and Portugal took part in the survey. 98 responded to Q73, with 63 living in South America and 35 in Europe. 64 of the respondents to Q73 were female, with a mean age of 41.34 (SD 10.77) and 34 were male with a mean age of 39.59 (SD 12.53). The 98 responses were allocated to 5 different categories: blank and unrelated content, ethical situations directly related and indirectly related with the original survey questions, and new issues. 74 responses were appropriate for further analysis, in which we identified 92 ethical issues. 76 of these ethical issues described varieties of ethical situations as outlined in the survey questions (e.g. professional misconduct, lack of recognition of physiotherapists’ role in healthcare), shedding light on complex contextual influences. Furthermore, we identified 16 new ethical situations, revealing a diverse range of rarely investigated ethical challenges. These new ethical situations were summarized in 4 new themes:

1. Inadequate compensation of physiotherapist and devaluation of physiotherapy services
2. Exploitation of physiotherapist and violation of social and labour rights 
3. Navigating interpersonal violence and negligence within patients’ environment
4. Professional disrespect towards physiotherapist based on their gender.

This study revealed the complexity of ethical practice in the investigated countries, including inadequate compensation and exploitation of physiotherapists, gender-based professional disrespect, and observation of family violence and negligence. Ongoing exploration and dialogue regarding (un)ethical experiences in the field are needed to understand how physiotherapists can be supported effectively to respond to the challenging contexts they work in.

Physiotherapists need protection of their rights, autonomy and integrity against systemic pressures. A socio-cultural understanding by the profession is required to inform effective support and professional ethics training for physiotherapists in South America, Spain and Portugal.