Réflexions critiques sur les dimensions éthiques des pratiques de la réadaptation Critical Reflections on the Ethical Dimensions of Rehabilitation Practices

L’éthique est une discipline philosophique qui s’intéresse notamment aux valeurs, aux principes, aux droits et aux devoirs qui devraient présider la vie individuelle et collective [1]. En tant que discipline réflexive et critique qui s’intéresse au vivreensemble, l’éthique a plusieurs objets d’intérêt. La réadaptation peut faire partie de ceux-ci. La réadaptation, quant à elle, correspond à « un ensemble de mesures qui aident des personnes présentant ou susceptibles de présenter un handicap à atteindre et maintenir un fonctionnement optimal en interaction avec leur environnement » [2, p.108]. En d’autres mots, la réadaptation peut être définie comme l’ensemble des services permettant aux personnes qui vivent une situation de handicap de maintenir ou de développer leurs capacités physiques et mentales afin d’être en mesure d’effectuer les activités qu’elles souhaitent réaliser et de participer, si tel est leur souhait, à la vie collective [3]. La réadaptation est donc une stratégie de santé et mieux-être importante, d’inclusion sociale ainsi qu’une composante majeure de plusieurs systèmes de santé.


Critical Reflections on the Ethical Dimensions of Rehabilitation Practices What is Rehabilitation Ethics?
Ethics is a philosophical discipline that focuses in particular on the values, principles, rights and duties that should govern individual and collective life [1]. As a reflective and critical discipline interested in living together, ethics has several objects of interest. Rehabilitation can be one of them. Rehabilitation, on the other hand, is "a set of measures that help people with or likely to have a disability to achieve and maintain optimal functioning in interaction with their environment" [2, p.108]. In other words, rehabilitation can be defined as the set of services that enable people with disabilities to maintain or develop their physical and mental capacities in order to be able to perform the activities they wish to perform, and participate, if they so wish, in community life [3]. Rehabilitation is therefore an important strategy for health and wellness, social inclusion, and a major component of many health systems.
However, unlike other areas of health care such as medicine or nursing, to date the ethical dimensions of rehabilitation practice have not been studied extensively. Although a growing body of literature provides various ethical perspectives on different dimensions of rehabilitation practices, it remains limited. This special issue aims to contribute, to a certain extent, to filling this gap by proposing multiple and sometimes critical perspectives on rehabilitation ethics.
To introduce this issue, we begin by further defining what rehabilitation is to us. Next, we examine some examples of ethically difficult situations that may arise in various rehabilitation contexts. Although this list of examples is not exhaustive, it shows how varied and numerous the ethical dimensions of rehabilitation practices are. Also, although these rarely involve issues related to life or death, this list reflects the fact that the ethical issues of rehabilitation practices can be complex and difficult to resolve. Finally, we summarize the texts included in this special issue to give a foretaste of what awaits the reader as well as to update some of the links between the texts that constitute this special issue dedicated to rehabilitation ethics. We believe that these writings offer the reader fresh and enriching perspectives on ethical issues that are specific to rehabilitation. We hope that the fact that these texts have been grouped together in this issue will contribute to a better understanding of the boundaries and challenges of this undoubtedly rich and innovative field of bioethics scholarship.

What is rehabilitation?
Rehabilitation can be defined as a health service that focuses on promoting the function and independence of people with disabilities or difficulties in performing their activities due to illness (acute or chronic), injuries due to accidents (work, road or other) or complex or discriminatory social, political or environmental contexts [2,3]. As an adaptation strategy, it is practiced by different health professionals (audiologists, doctors, kinesiologists, occupational therapists, physiatrists, physiotherapists, prosthetists, social workers, and speech-language pathologists to name but a few 3 ), generally, but not exclusively 4 , in private clinics or public health institutions, as well as in various practice settings ranging from home services to tertiary services. Although rehabilitation has a relatively recent historyapproximately 100 years depending on the disciplines [4] it is now part of the contemporary landscape, if not part of the range of care and services available to individuals, groups and communities with functional difficulties.

What are the ethical issues raised by various rehabilitation practices?
Many situations or practices in the field of rehabilitation raise important ethical issues, sometimes in a distinctive way, that is, specific to rehabilitation. These situations or practices require careful analysis to identify the best ethical avenues to address them. Here are some examples: • support (or not) for patients' choices that may compromise their personal safety (e.g., when deciding whether to discharge for return to home); • carrying out activities with and for patients in vulnerable situations to defend and promote their rights, needs and interests, in a context where they are not always able to promote and defend their own rights, needs and interests; • reporting (or not) to authorities the road safety risks of a patient with multiple disabilities that compromise their ability to drive a road vehicle; • power and hierarchy issues related to health care and social services practice and decision-making as well as the roles of rehabilitation professionals on interdisciplinary teams; • the practice of rehabilitation in an Aboriginal or multicultural context where complex accommodation requests are discussed; • justice issues in the distribution of technical or technological aids, personal assistance and other types of adaptations or resources, in the context of resource scarcity; • managing institutional waiting lists in the context of growing needs, performance pressures and resource scarcity; • issues related to how third-party payers (insurers) influence access to rehabilitation services, shape rehabilitation services and influence the autonomy of professionals; • value tensions between rehabilitation strategies and other more biomedical health care.
These few examples show that ethical issues permeate rehabilitation practices. However, most rehabilitation professionals have little ethical training [5] and often feel helpless in the face of these issues, which have the potential not only to affect the quality of care and services provided, but also to affect the health and well-being of professionals [6]. Moreover, since one of the paradigms of rehabilitation is focused on promoting or even restoring optimal patient functioning, it follows that rehabilitation influences rehabilitation ethics in some way. For example, rehabilitation is based on a participatory model, in that therapy is generally not done "to" someone, but "with" someone, at his or her request and generally in order to achieve a life project that is close to his or her heart. Thus, rehabilitation comes with the active participation of patients in collaboration with their loved ones [7], in a context where both the professional and the patient (and their loved ones) are considered experts: one being the expert in rehabilitation and the other the expert in their condition, one holding scientific knowledge and the other experiential knowledge. Rehabilitation is therefore an opportunity for a meeting, i.e., the meeting between at least two experts who hold equivalent, different, but certainly complementary and essential knowledge. Moreover, many ethical issues in rehabilitation concern the risk, or even the choices considered risky, of patients [8], which raises tensions between promoting safety and respecting people's autonomy [9]. Here again, the knowledge of two experts meets: those of professionals who identify health and safety risks and those of patients who are linked to authentic experiences and meaningful values and life projects. Justice and equity are also central concerns in rehabilitation ethics [1,7], especially in a context of scarce resources or unequal or even inequitable distribution of resources. Ethical issues also relate to social visions of disability (which sometimes cause disability), even in the rehabilitation sector, as well as structural and systemic factors that limit people's (both patients and professionals) ability to function and thrive.

What does this special issue dedicated to rehabilitation ethics contain?
Addressing themes such as the conceptualization of the concept of ethical issues, the practice of advocacy, sexuality, prioritization of references, ethics education, medical assistance in dying, what motivates people to work in the private sector and equity in access and provision of physiotherapy services, this special issue includes eight texts that offer a varied overview of contemporary ethical concerns in rehabilitation. As the reader will be able to see, these ethical concerns are of various kinds, in that some texts address ethical issues experienced in clinical practice with patients (micro-environment), while some deal with organizational practices (meso-environment), and still others discuss broader ethical issues, i.e., societal (macroenvironment). Thus, like Glaser [10], the contributors to this special issue show that the three areas of ethicsmicroenvironment, meso-environment and macro-environmentare linked to particular ethical concerns that require their own modalities and analyses. The fact that the texts in this issue address these three areas of ethics reveals the richness and complexity of the reflections and themes explored. A scan of the texts in this issue reveals that they are written in French or English, which is one of the strengths of this special issue. Another of its strengths lies in the variety of research methods used by the authors to address the themes they have chosen to develop. As the reader will see, some texts offer theoretical reflections, others present the results of literature reviews, while others report the results of empirical data collection or formulate a claim. This thematic, linguistic and methodological variety shows that applied ethics in rehabilitation has different faces and is practiced in different ways.
More specifically, this special issue begins with an article written by Marie Goulet and Marie-Josée Drolet that presents the results of a critical review of the literature discussing various ethical issues in occupational and physiotherapy. In this conceptual article, the authors articulate a meta-ethical reflection on the state of conceptualization of ethical issues in these professions. They make worrying observations about how these issues are conceptualized in the 80 articles they have analyzed. Moreover, they show that ethical conceptualization is marginal and that it often leaves room for amalgams, imprecisions and conceptual confusion, which are important in the end.
This text is followed by an article by Emilie Blackburn, Evelyne Durocher, Debbie Feldman, Anne Hudon, Maude Laliberté, Barbara Mazer and Matthew Hunt who are interested in a central concept of rehabilitation practice and autonomy, again through a review. In this article, the authors review the literature to determine how rehabilitation professionals respond to patient autonomy. To do this, they conducted a scoping review and identified and analyzed 63 articles. Their study highlights the different ways that autonomy is approached as an essential component of rehabilitation practice, while drawing attention to certain tensions related to its respect. The article is enlightening in many ways. First, it shows how a central concept of bioethics, autonomy, is founded and implemented in the particular context of rehabilitation. Second, it provides an in-depth and graduated account of the different approaches or responses to autonomy in the specific context of rehabilitation: supporting, promoting, respecting and advocating for patient autonomy. This article thus clarifies the conceptual foundations of a key ethical concept of rehabilitation practice.
The next article, written by Kevin Reel and Sylvia Davidson, deals with a subject that is not well covered in rehabilitation, namely sexuality. This activity is certainly one where issues of autonomy are important, significant and require special attention. Illustrating their discussion with case studies, the authors argue that sexuality is highly relevant in the context of rehabilitation care, but is often unaddressed or ignored due to health professionals' lack of comfort, competence and familiarity with the subject. The authors discuss how clinicians' individual attitudes and moral commitments intersect with their public responsibilities as health professionals. Based on this analysis, they present a model to support rehabilitation professionals in this area of practice. To do this, they combine the Canadian Client-Centred Empowerment Model (CCCM) [11] with Davis and Taylor's ex-PLISSIT approach [12] and propose the Ex-PLISSIT Empowerment Model. Thus, in addition to the fundamental questions relating to possible ethical tensions between individual, social and professional values, the article also provides concrete advice to those seeking to better respond to sexuality in rehabilitation.
The next article, written by Simon Deslauriers, Marie-Hélène Raymond, Maude Laliberté, Anne Hudon, François Desmeules, Debbie Feldman and Kadija Perreault, discusses the ethical issues related to the prioritization of requests for access to physiotherapy services and therefore the management of physiotherapy waiting lists. Based on the results of a 2015 survey on how Quebec's ambulatory physiotherapy departments prioritize patients, they identify three main areas of ethical concern and threats to equity. First, they describe how access to physiotherapy for patients with chronic diseases is limited by the prioritization of acute patients in most demand prioritization systems. As a result, patients with chronic diseases face very long waiting times. Second, the authors describe significant variability in the way requests for access to physiotherapy are prioritized and suggest that this variability reflects a lack of consensus on how best to provide access to physiotherapy services. Third, they also note that the information on which decisions on the prioritization of requests are made is highly variable. Finally, after discussing these sources of ethical concerns, the authors review several tools and conceptual frameworks that can guide decisions on prioritizing applications and make recommendations for how physiotherapy services could be provided in a more equitable manner. Overall, this text articulates an important analysis of an urgent ethical issue concerning the mesoenvironment.
Marie-Ève Caty, Marie-Dominique Lessard and Annie-Kim Robertson are also interested in ethical education in speechlanguage pathology. This subject is still poorly studied in rehabilitation ethics when compared to other fields such as physiotherapy or occupational therapy. Specifically, the authors examined, through a survey of Canadian university programs in speech-language pathology, how future speech-language pathologists are prepared to address the various ethical issues they will encounter in their practice. Their results provide a portrait of professional ethics training and they have identified the various teaching methods used in three Canadian master's programs in speech-language pathology. Without a doubt, this article provides essential insights into the quantity and quality of professional ethics teaching in the field of speech-language pathology and opens the door to future research in this area.
A second article by Kevin Reel argues, this time, that medical assistance in dying should not be restricted to individuals whose death is not reasonably foreseeable. Examining the regulatory context of medically assisted dying in Canada, Reel describes this situation as a potentially discriminatory overgeneralization. The inclusion of an article on medical assistance in dying in this special issue on rehabilitation ethics may seem a priori inconsistent, but this is not the case, as Reel focuses mainly on people with disabilities or who are currently living with a disability, many of whom are or have been involved in rehabilitation. Examples include a person with a significant spinal cord injury and an individual who has suffered a serious stroke. The author examines the links between such situations and the ethical principles of rehabilitation. He also suggests ways for clinicians to overcome the resulting ethical issues. Finally, this article draws attention to how policies and law shape clinical practices, while emphasizing the importance of examining these policies and the legal dimensions of practices in light of the concrete experiences of those involved.
A commentary written by Marie-Josée Drolet, Chantal Pinard and Rébecca Gaudet then offers a reflection on the motivations of occupational therapists to opt for the private practice of the profession. Using the Quadripartite Ethics Framework or Tool [1], which offers four complementary lenses for conducting ethical analysis, the authors analyze the empirical data they have collected on the motivations of these professionals to work in this area of practice.
A letter written by three physiotherapists -Shaun Cleaver, Simon Deslauriers and Anne Hudoninvites their physiotherapy colleagues, and even their profession, to pay more attention to the ethical issues related to equity in the provision and delivery of physiotherapy services. They believe that it is crucial to address these issues within the profession, as access to care and service delivery is limited in several ways (e.g., rural and remote geographic locations, Aboriginal communities, chronic disease patients).
In conclusion, what emerges from these texts is that rehabilitation practices are linked to ethical issues that are, to say the least, varied and often worrying. Although ethical reflection in the field of rehabilitation is currently emerging, it already points to undoubtedly complex concerns, sometimes shared by other health professionals and sometimes distinct from those encountered by more biomedically-oriented professionals. We hope that this special issue will open the door to authors already interested in the ethical dimensions of rehabilitation, as well as to new authors who are open to enriching reflection in this fascinating field of rehabilitation ethics. Because this area, like the other areas of bioethics, needs both plural and critical perspectives to pursue its development.
Good reading!