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The current socioeconomic and political climate in our country, especially surrounding the national health care debate, raises ethical concerns for occupational and physical therapists in regards to distributive justice, or the fair distribution of health care services in society. Justice, along with beneficence, non-maleficence and autonomy, comprise the core biomedical ethical principles which guide our professions (Scott, 2009).
Both the American Occupational Therapy Association (AOTA) and the American Physical Therapy Association (APTA) address the issues of social justice and responsibility in their respective codes of ethics. OT Principle 4 states that "Occupational therapy personnel shall provide services in a fair and equitable manner." (Occupational Therapy Code of Ethics and Ethics Standards, 2010). Similarly, PT Principle 8 states: "Physical therapists shall participate in efforts to meet the health needs of people locally, nationally or globally," (Code of Ethics and Ethical Standards for the Physical Therapist, 2010).
 Both professional ethic codes mention consideration of pro bono services. OT Principle 4G states: "Consider offering pro bono ("for the good") or reduced-fee occupational therapy services for selected individuals when consistent with guidelines of the employer, third-party payer, and/or government agency." Likewise, PT Principle 8A states that "Physical therapists shall provide pro bono physical therapy services or support organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured."
Both professional organizations list information about pro bono services on their respective websites. However, at the time of this review, APTA offered significantly more resources, with 89 articles as compared to AOTA's 7 articles (excluding duplicate entries). The range of AOTA's information about pro bono service appears narrow, relative to the breadth of APTA's information. For example, AOTA posts articles where the word "pro bono" occurs in one or two statements, while APTA posts specific guidelines and considerations for pro bono practice, a review of pro bono services by setting, and three educational podcasts for physical therapists interested in pro bono practice. Additionally, the majority of AOTA's articles are at least five years old, while APTA's articles are more current, dating to 2012. A literature search of occupational therapy pro bono services revealed no additional information.
Guidelines and Considerations for Pro Bono Practice
APTA (2009) outlined four ways that therapists could meet their pro bono ethical requirement:
1. Provide no-cost or reduced-cost professional services to uninsured individuals;
2. Donate therapeutic services to charitable organizations;
3. Participate in volunteer activities to improve access to therapy;
4. Donate money to groups that offer professional services to individuals with limited resources.
AOTA (2005) advised occupational therapists to be knowledgeable about financial requirements from federal and state laws, regulations governing Medicare and Medicaid reimbursement, and private insurance guidelines, including managed care and fee-for-service models. Similarly, APTA (2011) reminded physical therapists of their responsibility to comply with licensure laws, standards of practice, and state and federal laws, whether or not a fee for service is charged. Waving of co-pays or patient deductibles reportedly may be considered fraudulent, since there are often contractual agreements between third-party payers and providers that must be honored. It is important that providers have a consistent office policy regarding fee reductions (APTA, 2011).
Bisagni and Scott (2011) raise the question: Why do so few physical therapists provide pro bono services? The authors speculate that concern about liability may be a contributing factor. They discuss that state charitable immunity laws may protect health care volunteers who provide free services, with the exception of situations involving patient abuse. In cases where patients pay a reduced fee for service, a therapist's individual liability insurance may provide protection, except when there is illegal contact with patients.
In addition to liability concerns, it is my opinion that occupational and physical therapists may not participate in pro bono services because they perceive that they do not have the time. Administrative pressures for high productivity already make it challenging for therapists to balance the job with family/life obligations, let alone volunteer work. Other contributing factors may include therapists' decreased awareness of their profession's code of ethics, legal guidelines, and/or opportunities for pro bono practice. Alternately, therapists may prefer to volunteer in their local churches, schools, or communities, rather than at their place of employment.
Bisagni and Scott (2011) also raise the question: Should the APTA specify the number of hours per year that physical therapists are expected to provide pro bono services, as is done in the field of law? According to the American Bar Association, a lawyer should attempt to provide at least 50 hours of free legal services per year to individuals with limited incomes or to charitable organizations for these individuals (Bisagni and Scott, 2011). Currently it is not a violation of Principle 8A if a physical therapist does not provide pro bono services. Therapists can still fulfill their ethical obligations by supporting organizations that meet the health needs of people who are economically disadvantaged, uninsured, and underinsured (APTA, 2010). However, in my opinion, both occupational and physical therapy professions should consider quantifying a minimal number of pro bono hours expected annually, such as four hours per year, or the equivalent monetary value of four hours of a therapist's time.
Pro Bono Services by Setting
On their website, APTA (2012) provides excellent examples of pro bono opportunities for physical therapists in five settings:
5. Your practice setting;
6. Your local community;
7. A different US state or jurisdiction;
8. Other countries;
9. Disaster relief.
APTA (2012) posts additional helpful links, including International Volunteer Opportunities and Organizations, Haitian Relief Effort, and Evaluating Charitable Organizations, as well as professional networking opportunities through the link Cross Cultural and International Special Interest Group (CCISIG). Occupational therapists interested in exploring pro bono service are also encouraged to review these excellent online resources.
Integrating Pro Bono Clinics Into Curriculum
An exciting development in professional therapy education is the concept of student-run and faculty supervised pro bono clinics (Bisagni and Scott, 2011). A review of on-line occupational and physical therapy educational resources reveals that physical therapy educators may have more experience integrating pro bono clinics into college curriculum than occupational therapy educators at this time. AOTA lists only one institution, Rockhurst University, which offers entry level occupational and physical therapy students the opportunity to work in their pro bono health clinic at the Kansas City Free Health Clinic (AOTA, 2012).
Reis (2010) describes five additional university affiliated pro bono clinics for physical therapy students:
10. Nazareth College in Rochester, NY;
11. University of Florida in Gainesville, FLA;
12. University of South Alabama in Tuscaloosa, AL;
13. University of South Florida in Tampa, FLA;
14. Widener University in Chester, PA.
The author also provides information about the Society of Student Run Free Clinics (SSRFC), which promotes networking among physical therapy faculty and students interested in pro bono practice.
Bisagni and Scott (2011) discuss two additional university-affiliated pro bono clinics which feature physical therapy: Samuel Merritt University in Oakland, CA, and the University of Kentucky in Lexington, KY. These clinics primarily started as medical student-run clinics, but grew to offer physical therapy services. Additionally Quinnipiac University in Hamden, CT, recently posted information for students about pro bono physical therapy services (Quinnipiac, 2012).
In APTA conference proceedings (2009), a panel of educators discusses the value of providing physical therapy services to the uninsured from an academic perspective. They describe a pro bono clinic operated by Mercy Catholic Medical Center, staffed by physical therapy students from The University of the Sciences in Philadelphia in Philadelphia, PA. The clinic is run by first, second, and third year students. Licensed physical therapists supervise the older students, and the older students mentor the younger students. Additionally, the conference highlighted the international experiential learning program at Arcadia University in Philadelphia, PA, which exposes DPT students to clinical practice in a developing country.
Conclusion
Altruism typically guides clinical practitioners into the fields of occupational and physical therapy. Clinicians in both professions have ethical obligations to see that their services are allocated according to the principle of distributive justice. Both professional organizations in America address the provision of pro bono services in their codes of ethics. However, the majority of occupational and physical therapists tend not to engage in pro bono services.
Factors contributing to this tendency may include therapists' concerns about liability, administrative expectations for high productivity, time constraints, and difficulty achieving a work / life balance. Other factors may be decreased awareness of one's professional code of ethics, legal guidelines, and/or opportunities for pro bono practice, as well as engagement in volunteer activities outside of one's profession. Qualitative and quantitative research into therapist's perceptions about pro bono practice may further illuminate this subject.
At this time, the physical therapy profession appears to have more experience providing pro bono services to uninsured and underserved populations than the field of occupational therapy. APTA currently offers more online education, resources, and networking than AOTA for clinicians interested in pro bono practice. Occupational therapists interested in exploring pro bono opportunities are encouraged to investigate the APTA website. Additionally, it is recommended that AOTA expand their professional guidelines, resources, and opportunities for pro bono service specific to occupational therapists. Occupational therapy educators are especially challenged to develop more student and faculty staffed pro bono clinics as part of their clinical fieldwork curriculum.
In light of the current socioeconomic, political, and health care environment in this country, it is recommended that both occupational and physical therapy associations consider quantifying a minimum number of pro bono hours per year in their respective codes of ethics.
Resources
Bisagni, F., and Scott, R. (2011). Doing good while doing well: Pro bono service delivery in PT practice and education. Retrieved 8/17/12 from http://physical-therapy.advanceweb.com/Archives/Article-Archives.
Quinnipiac University (2012). Quinnipiac students provide pro bono physical therapy services. Retrieved 9/1/12 from http://www.quinnipiac.edu/news-and-events/quinnipiac-students-pro
Reis, E. (2010). Free to lead: student-run pro bono clinics are benefiting patients and future PT's. Retrieved 8/18/12 from http://www.apta.org/PTinMotion/2010/3/Feature/FreetoLead/
Scott, Ron (2009). Promoting Legal and Ethical Awareness: A Primer for Health Professionals and Patients. St. Louis, MO: Mosby, Inc., an affiliate of Elsevier Inc.
Slater, D. Y. (2005). The American Occupational Therapy Association advisory opinion for the ethics commission: ethical issues about payment for services. Retrieved August 17, 2012, from www.aota.org.
Kathleen Kennedy Cianca is an occupational therapist with 35 years of experience in pediatrics. She is currently enrolled in a MHS program at the University of Indianapolis. Cianca has expertise in the evaluation and treatment of children with feeding, neurodevelopmental, sensory processing, and fine motor difficulties. She is certified in pediatric neurodevelopmental treatment and administration of the Sensory Integration and Praxis Tests. Cianca has worked in a wide variety of settings, including home-based early intervention, pre-schools, elementary school, private practice clinic, and children's hospitals, including Children's Hospital Medical Center (CHMC) in Cincinnati, OH, for 15 years and Nationwide Children's Hospital (NCH) in Columbus for 14 years. She co-founded the Interdisciplinary Feeding Team at CHMC in 1998, as well as the Interdisciplinary Feeding Evaluation Team at NCH in 2004, where she remains an active team member.
Pro Bono Practice Association Resources
American Occupational Therapy Association. (2010). Occupational therapy code of
ethics and ethics standards. American Journal of Occupational Therapy, 64.
American Occupational Therapy Association. (2012). OTCAS program description.
Retrieved 8/17/12 from www.aota.org.
American Physical Therapy Association (2010). Code of ethics and ethic standards for
the physical therapist. Retrieved August 17, 2012, from www.apta.org.
American Physical Therapy Association (2009). Guidelines: pro bono physical therapy
services HOD G06-93-21-39. Retrieved August 17, 2012, from www.apta.org.
American Physical Therapy Association (2010). Considerations for pro bono physical
therapy practice. Retrieved 8/17/12 from www.apta.org.
American Physical Therapy Association (2010). Clarification on principles and
Standards. Retrieved 8/17/12 from http://www.apta.org/ProBono/Considerations/.
American Physical Therapy Association (2009). Pro bono clinics provide strong
academic justification, panel says. Retrieved 8/18/12 from
http://www.apta.org/PTinMotion/2009/9/Feature/PT2009Highlights/
American Physical Therapy Association (2010). Pro bono services by setting. Retrieved
8/17/12 from http://www.apta.org/ProBono/ServicesbySetting/
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