As you are patiently waiting for your clinician in the corridor to give you your patient load for the day, you scroll through your Facebook reading about the horrific rape and murder of a 19-year-old UCT student. When you clinician arrives in the physiotherapy department, she gives you a list of patients you need to see. As she goes through my list, she takes a long pause and says: “Luyanda Botha”. Without knowing, you start frowning and stand for a moment in disbelieve. Your clinician notices it and says: “I expect you to treat Mr Luyanda Botha in an ethical and respectful manner.”

Over the past 4 years of studying physiotherapy, we have had lectures on ethical principles. In the past, I have treated patients whom have raped and killed and I have managed to treat them with the same dignity and respect I would treat any other patient. However, recently I became aware that I was facing an ethical dilemma as I was slowly becoming reluctant when I had to treat Mr A. According to an article, an ethical dilemma involves the need to choose between two or more morally acceptable options or between equally unacceptable courses of action, when one choice prevents the selection of the other (Ong, Yee & Lee, 2012). Initially when I met Mr A, I had the feeling of empathy for the 63-year-old man whom have been a victim to gang violence. As I was busy writing up my physiotherapy notes for the session, I overheard the nurses talking about Mr A. As it turns out, Mr A has been in the Pollsmoor Maximum Security Prison doing a 45-year prison sentence for raping and murdering women. I started experiencing the feelings of anger and less empathy towards Mr A. Furthermore, I feared that these feelings would change and interfere with the way I treat him for the following days.

Healthcare professionals are confronted with a range of ethical and regulatory issues in today’s ever-changing practice environments. Doing what is best for the patient is often influenced and may be compromised by external factors, such as one’s own beliefs and moral views (Richardson, 2015). Ethics can be explained as a discipline of thought and study, in terms of the moral principles of human behaviour. In essence, it is about the right and wrong in conduct, often in accordance with implicit rules or standards as accepted within society (Kirby, 2009). From a health point of view, it focuses on protecting patients’ freedom, well-being and interests (Verheyden, 2012). The conduct of most health professionals is guided and regulated by specific ethical standards and codes of conduct world-wide. These standards serve to protect society, but more specifically the patients. Hoffman (2015) agrees that these standards and code of conducts define ethical principles, describe the health professionals’ obligation to the patients’, the aim to raise accountability, commitment and professional integrity while promoting compliance to these standards. In addition, these codes can empower and equip health professionals to make informed decisions in the healthcare sectors which may pose ethical dilemmas and challenges (Hoffman & Nortje, 2015). Unfortunately, these written codes do not ensure that the health professionals refrain from unethical behaviour towards patients.  Unethical behaviour has been a frequent topic of controversy and discussion within our society. This reaction may be in response to recent events, which has highlighted the actions of others, which we deem as unethical behaviour or morally wrong.

In 1996, The National Health Act was drawn up which is a framework of basic human rights for patients in South Africa (Health24, 2017). Also known as The Patients’ Rights Charter, which was implemented in order to ensure that all patients, regardless of race, gender, religion and socioeconomically issues, had the right to accessible and safe health services. In addition, health professionals are obliged to protect, uphold and promote patients’ rights in a legal and ethical manner. According to the South African Society of Physiotherapy (2008), ethics can be broadly categorised into these four ethical principles:

• Beneficence (to do most good)
• Non-maleficence (to not cause harm)
• Justice (to treat all equally and fairly)
• Autonomy (each person has the right to make his/her own decisions. (SASP First Line Practitioners Status of Physiotherapy, 2008).

Nonetheless, a blogger acknowledges that the society we create, the values we promote and the people we care for all have an impact on rape (Sabey, 2016). In essence, rapists are not born that way. What people do and who they become may be influences to what type of opportunities they were given during childhood and how their socioeconomical environment influenced them. A post written on SAferspaces acknowledges that Gender Based Violence (GBV) may be more prevalent in society where a culture of violence and male superiority exists (Machisa, et al., 2011). It creates a manifestation in men feeling entitled to engage in sexual activities with women, strict punishment of transgression as in this cases men believe women have low social value and power. Between 28% and 37% of adult men report having raped a women (Machisa, et al., 2011).

An article written by authors Meyer and Mitchell (2011) conducted a research study  to understand if male rapists vary from other criminals in their perceptions of women and/or how their caregivers treated them. There are three well-known theoretical models of sexual violence. The first model is called the Hierachical Meditational Confluence model (HMC), which states that an abusive home environment or hostility develops sexual aggression (Meyer & Mitchell, 2011). The second model suggests that physical, verbal or emotional abuse may lead to antisocial behaviour and unemotional responses, both which lead to sexual compulsion. The third model created by Ward and Beech argue that interactions of the biological (genetics and society), ecological (social learning experiences and cultural experiences) and neuropsychological (motivation, emotion, behavioural controls and perception) systems can all lead to sexual offending (Meyer & Mitchell, 2011). The study concluded that rapists were more likely to report more severe levels of abuse from their parents than robbers. Some interesting facts which the study noted was that there is no evidence that the perception of women and rapists differ and additionally, that rapists have fewer sisters than robbers. For this reason, perhaps the fewer female influences in the families influences the ability for the rapist to learn appropriately and respectively interact with other women.

Back in 1926, Francis Peabody said: “the secret of caring for your patient, is caring for your patient.”

Although this is a compelling state and often common sense but, what if I don’t care for my patient? More particularly, what if my response and reaction to that patient is negative which may be driven by social or moral disapproval? According to Hill (2010), although one decides to treat the patient to the best of one’s ability and in an ethical manner regardless of their history, compassion and empathy may be lacking.

Thankfully, I did not have to treat Luyanda Botha. After conducted a thorough search of relavent articles and blogs with regards to the ethical way to treat a rapist, I believe that I will be able to treat a rapist, to the best of my ability (ethically and morally). However, I don’t believe I will conduct myself in the same way in terms of a physiotherapist-patient relationship. Will I have empathy and compassion for a rapist who have been assaulted by a community? Probably not. Nevertheless, the patient’s impairments will be managed from a medical point of view, his condition will improve and he will be discharged from hospital. Ultimately, it is important to develop and explore and range of interventions which may be an effective way to address GBV in South Africa (Machisa, et al., 2011). For example, many organizations have been created and are focused on working with people in order to empower women in South Africa. Another form is tackling specific drivers of GBV, such as substance absuse and gangsterism. Moreover, perhaps if research can be done on evaluating parenting styles implemented on rapists, it may have potential to reduce the amount of sexual violence (Meyer & Micthell, 2011).

References:

Health24. (2017, March 14). Know your rights and responsibilities. Retrieved from Health 24: https://www.health24.com/Medical/Cancer/Campaigning-for-cancer/Know-your-rights-and-responsibilities-20120721

Hill, T. E. (2010, July 9). How clinicians make (or avoid) moral judgments of patients: Implications of the evidence for relationships and research. Philosophy, Ethics, and Humanities in Medicine. https://doi.org/10.1186/1747-5341-5-11

Hoffmann, W.A. & Nortjé, N., 2015, ‘Ethical misconduct by registered physiotherapists in South Africa (2007–2013): A mixed methods approach’, South African Journal of Physiotherapy 71(1), Art. #248, 7 pages. http://dx.doi.org/10.4102/sajp.v71i1.248

Kirby, M., 2009, ‘Chapter 3-Article 1: Scope’, in H.A.M.J. Ten Have & M.S.

Machisa, M., et al., 2011, Genderlinks, and Gender and Health Research Unit, South African Medical Research Council (MRC) Johannesburg.

Meyer, C. A., & Mitchell, T. L. (2011). Rapist Development: An Investigation of Rapists’ Attitudes Toward Women and Parental Style. Psi Chi Journal of Psychological Research, 16(1), 43–52. https://cdn.ymaws.com/www.psichi.org/resource/resmgr/journal_2011/spring11jnmeyer.pdf

Ong, W., Yee, C., Lee, A. (2012). Ethical dilemmas in the care of cancer patients near the end of life. Singapore medical journal, vol. 53, issue 1, pp. 11-6

Peabody FW: The care of the patient. JAMA 1927, 88: 877-882.

Richardson, R. W. (2015, June 18). Ethical issues in physical therapy. Current Reviews in Musculoskeletal Medicine. Humana Press Inc. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4596180/pdf/12178_2015_Article_9266.pdf

Sabey, J. (2016, October 12). The federalist: We Need To Rethink How We Treat Rapists. Retreived on 9^th of September 2019 from https://thefederalist.com/2016/10/12/need-rethink-treat-rapists/

South African Society of Physiotherapy, 2008, ‘First Line Practitioners Status of Physiotherapy’.

Verheyden, C.N., 2012, ‘A 5-year review of ethics complaints to the American Society of Plastic Surgeons’, Plastic and Reconstructive Surgery 129(2), 531–536. http://dx.doi.org/10.1097/PRS.0b013e31822b62d4