The ethical implications of research and education in the massage therapy profession.

As a therapist operating my own practice, I am constantly reminded of the ethical aspects of my work in dealing with situations involving clients and the everyday running of my business. Professional boundaries and ethical practices are recognized within our profession as an important aspect of our work, as evidenced by mandatory classes on ethics in most U.S. states and also by the clearly stated ethical codes and practices set out by our professional organizations. The reasoning behind these measures is clear. Ethical declarations and a thorough understanding of them and their application are needed. They set standards of integrity. They help to define massage therapy as a profession and have significant repercussions on how massage therapists are perceived by the public.

Because ethical standards are essential in our profession, this article addresses the connection between research, education, and ethics. The intention is to highlight the importance of research from an ethical perspective, not only for end-users of research, but also with regard to ethical considerations within the research world itself.

How are research, education, and ethics intertwined? How tightly are they linked? And how does research affect our ethics from both a global perspective and that of individual therapists in practice?

One part of the Association of Bodywork and Massage Professional’s Code of Ethics(1) says:

I shall actively participate in educating the public regarding the actual benefits of massage, bodywork, somatic therapies and skin care.

It also says:

I shall not make false claims regarding the potential benefits of the techniques rendered.

The American Massage Therapy Association’s Rules of Ethics(2) state that practitioners shall

be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results.

And from the National Certification Board for Therapeutic Massage and Bodywork’s Code of Ethics,(3) members are expected to

consistently maintain and improve professional knowledge and competence, striving for professional excellence through regular assessment of personal and professional strengths and weaknesses and through continued education training.

Similar declarations can be found in the ethical codes of other professional organizations. Considering the increasing quantity—and importance—of research in our profession,(4) and applying our understanding of professional ethics, it is apparent that keeping up to date with research findings could be viewed as an ethical responsibility. New research findings may uncover therapeutic benefits that we never learned in school. Conversely, some things we were taught in massage school have been overturned by the latest research. For example, many of us may have been taught that massage helps to release lactic acid from muscle tissue after exercise; research refutes that claim.(5)

The flow of information from the research world may require a restructuring of existing knowledge, and that knowledge will continually evolve. The assimilation and application of that knowledge is one of the fundamental principles of an “evidenced informed practice,” accompanying clinical experience, and the examination of factors specific to each client. The representation and importance of research literacy for therapeutic decision-making and outcomes is further described in such models as the “evidence funnel,”(6) covering the sources and processes for assessment of best evidence. The ability to find, interpret, and evaluate research are arguably as important to the evidence-informed practitioner as is competency in recording the client’s medical history or physical examination findings. The evidence-informed practitioner also recognizes the fact that new information will continue to flow from research.

Clearly, schools and educators play a crucial role in the dissemination and application of research findings. The new information that emerges from research must be well integrated into the profession’s educational and information systems for us to reap the full benefit. This integration of research findings into our profession’s training programs should be considered an ethical necessity.

Another area in which we must be cognizant of ethics is within the world of research itself, because an awareness of the ethical challenges and weaknesses that can arise in research has implications for massage therapists as research consumers. Ethical issues that have been identified in biomedical and behavioral research may also pertain to research in massage therapy. In “Science and ethics in conducting, analyzing, and reporting psychological research,”(7) Rosenthal describes and reviews the ethical implications of causism, a “tendency to imply a causal relationship where none has been established” (that is, the data are insufficient to support the claim), and data dropping as two specific examples. These, along with misrepresentation of findings, instances of poor research design, and an assortment of weaknesses in methodology can result in low-quality research. It follows that an uncritical acceptance of research by the massage community, and most of all by massage therapists, is a mistake, and that awareness of the ethical and methodologic issues common to any subfield of research is imperative. Further, the increased development of critical thinking and research literacy skills in massage therapists would result in a more synergistic relationship between the research community and practitioners. Because one of the components of translational research is to develop and foster such a relationship,(8) considerable benefit would accrue to the profession as a whole.

It is undeniable that education plays a pivotal role in ethics and research and that it is a crucial element in the formation of evidence-informed practice. Education of massage therapists in research literacy and critical thinking and a recognition that we must be discerning consumers of research are paramount in putting our ethical declarations into practice. Consequently, the ways in which we educate the public about our profession, a fundamental task in which we all are continually engaged, are also affected.

Important questions with ethical implications therefore arise. What does a therapist do if research shows that a particular modality has no therapeutic effect? What does the teacher of that modality do? What does the profession do? What is our stance as a profession from an ethical perspective?

When adherents of a specific modality are confronted with research findings showing that that modality has no therapeutic effect, I have often heard or read these three objections:

“More research is needed.”

“If the public wants it, and they believe it works, then we should supply it.”

“If I see results in my practice, then that’s all I need. All I want to do is help my clients.”

The first objection may well be valid, because a lot of research remains to be done in our field, and the strength of a claim ultimately depends on the quality of the research into the given modality. However, if numerous high-quality studies show that the modality has no therapeutic effect, the ethical value of putting more time and money into “validating” the modality is questionable. Could such reflexive demands for “more research” in response to demonstrated ineffectiveness be seen as a form of protectionism by the profession? It is not the role of science to validate or protect that which we value, and if we are to look to research for validation in everything we do or as a means to protect a modality, it will lead to an erosion of our ethical core. Furthermore, considering that our profession has a proliferation of modalities, it is unrealistic to argue that all modalities will be validated.

Regarding the second objection, it is unquestionable that the forces of supply and demand are strong, but to say that their interaction is the reason to provide a modality is ethically askew, even if the service delivered does no direct harm to the public. Additionally, if a modality has been shown to have no therapeutic effect, is it not our responsibility to educate the public that it has been shown to be ineffective in clinical trials? Indeed, this issue is clearly addressed in our written codes. It is our ethical responsibility to ensure that any claims we make about a modality are truthful, and by extension, it can be argued that it is unethical to sell classes that train students in modalities shown to have no therapeutic effect. The commodification of our modalities may be powerful, but allowing the principles of the marketplace to be stronger than the obligation to be ethical is wrong.

I believe the third objection is the most likely to be encountered, and it is intuitively compelling, given that our clients are undoubtedly the people that matter the most. Witnessing the apparent “before and after” effect of our work many times over in a clinical setting can lead to deep-seated belief in a specific modality. However, the reason we need research is that such clinical observations are prone to well-known biases and distortions. We must check those observations against research because we require an objective analysis to establish cause and effect or, in other words, to ensure that the modality actually does what we assume it must be doing. But if research contradicts our clinical observations, or our intuition, can we ethically ignore or discard that discrepancy?

Having invested time, energy, and money to be trained in a modality and then being confronted with new information showing that that modality may have no therapeutic effect is undoubtedly an unpleasant and uncomfortable situation. The attachment to the modality could even go so far as to be an emotional one. Of course, the power of choice will always lie with the therapist. It is my hope that the ethical core of the therapist will make the right choice and that our profession will accept what good science is showing us; for in doing so, we are using science to raise our own levels of integrity and the universal integrity of the profession. Each of us has a role to play, and we should not view ourselves as detached. The decision that each therapist makes will affect the profession as a whole.

To conclude, it is reasonable to deduce that the link between research, education, and professional ethics is strong. Examination of our ethical codes indicates that it is our responsibility to keep up to date with research findings and to apply them in our work. The decisions that we make as a profession—from every angle and by every participant, whether it be researchers, policymakers, educators, or therapists in practice—will have a significant influence on the true ethical barometer of our field.