Occupational therapy students' perspectives of ethics in two countries: South Africa and the United States of America.

OBJECTIVES: Worldwide, health-care students, including occupational therapy students undergo ethics training. Ethics training facilitates students' critical thinking, objective analysis and clinical reasoning skills to promote impartiality and minimize bias in decision-making. The aim of the study was to explore and describe similarities and differences in occupational therapy students' perceptions and experiences of an ethical dilemma.
METHODS: The study employed a descriptive qualitative approach. Eighty occupational therapy students from South Africa and the United States of America (USA) participated in the study as part of an online international ethics module. Data were collected from students' written analyses of a case study engaging them in an ethics reasoning process and were analyzed thematically.
RESULTS: Three themes emerged: Personal views and biases, ethical approaches, and practical alternatives and implications. Both groups of students from South Africa and the USA approached the case in a similar manner using their knowledge of ethics, principles, and approaches. They also applied the steps of an ethics reasoning process to guide their decision-making. All occupational therapy students from both countries highlighted Ethics of Care as an integral basis for their reasoning.
CONCLUSION: There is a need amongst educators to identify, share, and discuss similarities and differences in how health-care practitioners address ethical issues, using the ethics reasoning process as a guide. The international occupational therapy community needs to further the profession's meta-ethical discourse to guide clinical application within a diverse and globally connected workforce.

Introduction

Occupational therapists worldwide follow a code based on their country’s professional organization. Ethics are very important components of adhering to professional practice. The World Federation of Occupational Therapists has a code of practice[1] to which all occupational therapy associations in different countries adhere. The occupational therapy associations develop and revise their code of ethics and professional conduct based on their contextual needs. South Africa has a code of practice and professional conduct for occupational therapists practicing in the country. This was developed by the Occupational Therapy Association of South Africa.[2] In April 2015, the representative assembly of the American Occupational Therapy Association (AOTA) voted unanimously to approve the 2015 OT Code of Ethics, which reflects the most prevalent ethical challenges in practice across the US. Worldwide, occupational therapy students undergo ethics training as preparation for the ethical dilemmas they will encounter in practice.[3]

Ethics theory and principles are similar worldwide. Health-care professionals in many countries abide by a code of ethics drawn from ethics theory and principles. Based on this, it can be argued that there is a commonality in the way that health-care professionals practice ethically. However, context differs from country to country, and it can be argued that ethical dilemmas may, therefore, be different. According to Drolet et al.,[4] an ethical dilemma is a situation opposing at least two possible, and desirable, but irreconcilable, actions. In addition, health-care professionals’ perceptions of ethical dilemmas may differ, as may their handling of these ethical dilemmas. The aim of the study was to explore occupational therapy students’ perceptions and experiences of an ethical dilemma within two countries – South Africa (SA) and the United States of America (USA), as part of a research project funded through the University of Missouri South Africa Exchange Program (UMSAEP).

The case of Rebecca Arendse[5]

One frigid July day Rebecca Arendse, age 61, was found dead of hypothermia in her makeshift home – a cardboard box covered by a rug – on a Cape Town City street. A non-government organization had reported her unusual living arrangements to the police two weeks earlier. Social workers had visited her, offering food and help in moving to a city shelter. A psychiatrist had visited her and declared her an “endangered adult,” part of the procedure that would have allowed the authorities to hospitalize her under seventy-2-h protective custody. However, before the order could be carried out – the first time, the city had attempted its implementation – Rebecca Arendse died. Before she joined the ranks of Cape Town’s homeless street people, Rebecca had lived a rather different life. One of a family of 13 children in Worcester, she had graduated from a university in the Western Cape. However, she was hospitalized as a schizophrenic for 10 years and underwent intense therapy offered by the multi-disciplinary team. When she was released from the hospital, her daughter said, she was a changed woman. In 1999, Rebecca came to Cape Town to live with her sister and then entered a mental hospital. She was later released from the institution and decided to strike out on her own. That meant living on the public assistance, taking medication, and going to a state clinic. In 2000, she failed to appear for recertification interviews with social workers and from then on – until her death – she lived on the streets.

Could Rebecca’s death have been prevented? How far do society’s obligations extend toward those who are in need but who refuse to conform? Does society have different obligations to intervene in protecting those it considers mentally ill?

Methods

The study employed a descriptive qualitative approach to explore and describe the occupational therapy students’ perceptions and experiences of an ethical dilemma in context and to establish the similarities and differences experienced by them. A total of 80 occupational therapy students from a university in South Africa and the students from an academic institution in the USA participated in the study as part of their ethics course. Data for the study were collected from the students’ written narratives about their perceptions and responses to an ethical case. All of the students’ written narratives were analyzed thematically. Thematic analysis allows themes to emerge directly from the data. The analysis was done by following the six steps of analysis as suggested by Braun and Clarke.[6] These steps included familiarization with the narratives of the occupational therapy students and identifying the patterns of codes and the meaning thereof, generating initial codes and develop categories from the different codes. The different categories were then sorted into potential themes and the themes were named. Data were also analyzed using word cloud as a technique to give greater prominence to words that appeared more frequently in the narratives, thus enabling the researchers to identify similarities and differences between the two groups of occupational therapy students from SA and the USA.

The study was submitted to, and received ethical clearance (HS/16/2/47) from, the research ethics committee of one of the universities. All the occupational therapy students’ identities remained confidential and they were only identified as a student at their respective institution.

Results

From the thematic analysis, three themes emerged: Personal views and biases, ethical approaches, and practical alternatives and implications. The themes and related categories are presented in Table 1.

Table 1

Themes and categories from the thematic analysis of occupational therapy students’ perspectives of ethics

Theme 1: Personal views and biases

This theme deals with both the SA and USA occupational therapy students’ personal perceptions of the factors influencing Rebecca’s case and revealed their biases, which might have influenced their different views.

Health system and society

All occupational therapy students from both countries perceived that the health system and society influenced the outcome of the case. All occupational therapy students from both countries considered how the health system influenced the procedures followed in the case. They were of the opinion that certain protocols and procedures should have been followed within the decision-making process and that clients should be better monitored with a faster turnover regarding decision-making. The majority of occupational therapy students from both countries felt that Rebecca had choices as an individual and was responsible for her own decisions, for example, Rebecca could refuse treatment if she wished or be referred to a retirement home. Some of the occupational therapy students from SA questioned whether the preparation for discharge of Rebecca was adequate.

“One must also keep in mind that it was Rebecca’s choice to try make it out on her own and it isn’t clear as to what preparation with Rebecca’s was done by the facility and how ready she was to be discharged or if she was discharged due to the overflow at the facility.” (SA participant).

The timing of when to intervene was mentioned as a factor that influenced the outcome; therefore, the majority of occupational therapy students from both countries noted the importance of dealing with a vulnerable person such as Rebecca timeously.

“I believe that the police, social worker, or psychiatrist could have prevented her death if any one of them had put her in the 72-hour protective custody when they initially contacted her instead of sending another person out to speak with her.” (US participant)

The majority of occupational therapy students from both countries felt that it is society’s responsibility to protect people with mental illness. All of the occupational therapy students from both countries spoke of how society stigmatizes and discriminates people with mental illness due to their lack of knowledge. Some of the occupational therapy students expressed the need for resources to be available for people living with mental illnesses. Most of the SA occupational therapy students highlighted factors such as limited finances and resources as factors that influence how people with mental illnesses are cared for. Furthermore, some of the SA occupational therapy students talked about the disorganization of the public and government health system as well as staff burnout due to the limited resources. A few SA occupational therapy students perceived that this also could result in unethical behavior by staff.

“In essence the health care system should not be held solely responsible with regard to the prevention of death of Rebecca, but rather society with regard to the virtue ethics as well as ethics of care and deontological theory to do good and protect as well as intervene in the Rebecca’s case to ensure she was cared for appropriately. Her family form part of this society and it is therefore also in their hands to provide care for the client and intervene with regards to protecting her.” (SA participant)

Personal background and experiences

Personal background and experiences influenced the majority of occupational therapy students’ from both countries thinking and reasoning, and included religion and culture as well as family, and occupational therapy students’ experiences of mental illness and stigmatization. This background influenced how they viewed homeless people within their particular context (SA or USA). Even though there are resources available for homeless people, most of the occupational therapy students from both countries indicated that people with mental illness are more likely to end up living on the streets.

“When a person has a mental health disorder, they often feel shunned by society. There are still stigmas with those who have mental health disorders. When you add homelessness to the equation, it exacerbates the feelings. In America, people will often treat homeless people as if they do not exist. Often time’s people will not even give them a second glance. There is a need for social justice. Instead of turning our head, what can we do to help?” (US participant)

Based on their experiences of mental illness, some occupational therapy students from SA believed Rebecca’s refusal of treatment were part of her mental illness. They questioned whether she had the mental capacity, capability, and competence, to make decisions. They also considered the side effects of medication. Some occupational therapy students from both countries believed that Rebecca required a support system, including society and her family.

Ethical reasoning and decision-making

All the occupational therapy students from both countries followed the ethical reasoning process as a guide for their decision-making regarding Rebecca’s case. They supported their reasoning with relevant acts and laws from the respective countries (USA and SA). All occupational therapy students from both countries highlighted the Ethics of Care as an integral basis for their reasoning. By reasoning around factors such as Rebecca’s age, her physical condition, mental illness, and her nutritional state, the Ethics of Care approach was foregrounded, and this was done by all of the occupational therapy students from both countries.

“With regard to society as a whole together with the virtue ethics and ethics of care theory, one then expects society to derive happiness from doing the right thing.” (SA participant)

Principlism provides a practical approach for ethical decision-making that includes the moral principles of respect for autonomy, beneficence, non-maleficence, and justice.[7] The majority of the occupational therapy students from both countries applied the principlism approach to the case. The ethical dilemma in the case of Rebecca was the conflict between the application of the principles of autonomy, Rebecca’s right to self-determination, and beneficence, the providers’ responsibility to confer a clinical benefit and prevent harm. One participant summarized the essence of the ethical dilemma succinctly:

“The ethical question that I identified in this case is that should Rebecca have stayed institutionalized against her will in order to keep her safe and alive instead of respecting her right to make her own decision to stay in the streets which eventually lead to her death?…” (SA participant)

Biomedical Ethics was the ethical theory used to teach both groups of students from the USA and SA. Furthermore, students were also provided with the code of ethics of the professional associations of occupational therapy in each respective country. The principle of autonomy was highlighted more by the USA students in their reasoning.

On the other hand, the principle of beneficence was perceived by some occupational therapy students from both the USA and SA as being violated as they felt that authorities could have acted more decisively due to Rebecca’s mental illness. They felt that clients who are a danger to themselves or others require protection at all times.

Professionalism

The definition of professionalism is the health-care providers’ contract with society.[8] The majority of both groups of occupational therapy students felt that the professionals needed to take responsibility for Rebecca instead of abdicating their responsibility as a health-care professional.

“I have found that some professionals within the health sector are quick to “pass the buck,” or in other words are not keen on taking on responsibility that is not within their job description or does not benefit themselves.” (SA participant)

All the occupational therapy students from both countries were of the opinion that it is a professional responsibility to be informed and knowledgeable as a health-care professional. One participant stated that if the case is viewed from a deontological point of view, then society does indeed have obligation to those who refuse to conform, although it is not necessarily good at abiding by these obligations.

“The safety net for individuals like Rebecca should be rigorous and “enforced” by inter-disciplinary professionals. But we as professionals in health care and social work DO have something at stake - employment, licensure, and the upholding of ethical standards which are supposed to guide our respective practices.” (US participant)

Both groups of occupational therapy students viewed the importance of a multidisciplinary approach to managing the case of Rebecca. Some occupational therapy students from the US mentioned the “revolving door syndrome” where patients are treated, discharged, relapse, and require re-admission. Many from both countries commented about the need for effective post-discharge support services for people with mental illness.

Theme 2: Ethics approaches

This theme deals with the ethics approaches taken by the students when working through the case. Ethical approaches include the use of normative theories as well as systematic methods, such as a steps approach or frameworks used to resolve ethical conflicts. The differences and similarities between the ethical approaches of participant groups are explored.

Organizational ethics barriers

With both student cohorts, there was a strong use of theory to guide practice and yet, some students from both countries often commented on the organizational barriers or systems level problems that may impede ethical action. The following participant response demonstrates how students often differentiated between identifying the ethical course of action and the practicality of being able to execute said action.

“The deontological theory emphasizes the importance of moral duties, obligations, and principles. Somewhere in Rebecca’s treatment, her therapy providers felt they did not have an obligation to physically check on her after she failed to attend. While they could not force her to complete treatments, they could have discovered, or notified those who could discover Rebecca’s homeless status and began the steps necessary to treat her at a mental hospital sooner, which could have prevented her death. The problem with this is that resources are limited, and deciding who should be responsible for trying to locate Rebecca after she had failed to attend her check-ins is difficult.” (US participant)

The reference to systems-based limitations was often the result of using ethical frameworks that stress the identification of practical alternatives to resolve an ethical conflict. The case of Rebecca resulted in a negative outcome, which was arguably precipitated by social system inadequacies related to the care of those with mental illness.

“The Mental Health Care Act (2002) did not make provision for immediate action to take place, therefore within the 48 h period she had passed away. This highlights the adverse effects that the 48 h period had on Rebecca’s life, and had it not been there she could have been admitted immediately to provide her with safety and the necessary health-care services. Therefore, if the Mental Healthcare Act (2002) had made provision to such emergencies then Rebecca’s death could have been prevented.” (SA participant)

Normative theories

Use of normative theories to complete the ethical analysis predominated the student responses from both the US and SA. While the majority of both groups often referenced both consequential and deontological approaches when identifying the ethical conflict, some of the South African students in particular contrasted deontological and utilitarian theories. This was often precipitated by the use of a systematic framework.

“The third step of the ethical reasoning framework is to compare the ethical issue from a Utilitarian and Deontological perspective.” (SA participant)

While some of the US students referenced consequential theory, in that they acknowledged there was bad consequence in the case they were less likely to reference this approach as a means to reconcile the ethical conflict. In contrast, some of the SA students applied utility arguments to the case as a means to attempt to reconcile or prevent the ethical conflict from occurring.

“Application of [utilitarianism] to Rebecca’s case would have been to trace and call Rebecca’s family and put them in a group/family therapy to re-unite them and educate them about Rebecca’s disorder. That would have created greater good…” (SA participant)

The majority of both groups of occupational therapy students used deontological arguments to frame their approach but pulled from different deontological theories. The majority of the American students primarily used the Principles of Biomedical Ethics to frame their ethical arguments, while most of the South African students focused on the moral duty or imperatives as outlined by Immanuel Kant as well as a duty to uphold rights related to human dignity. Kant believed that persons cannot be used as a means to an end, and focused his work on demonstrating through reason that there are categorical imperatives which must be universally adopted.[9] According to his categorical imperative, one should “Act only according to that maxim whereby you can at the same time will that it should become a universal law without contradiction.”[9]

“Deontology is an ethical theory pioneered by Immanuel Kant. It holds the premise that one should do what is right or act morally regardless of the consequences.[.

As noted above, most of the students from the US focused on ethical principles outlined in the Principles of Biomedical Ethics proposed by Beauchamp and Childress.[7] While this principles-based approach (principlism) differs from Kant’s universal law theory, in the rules themselves as well as the concept of absolute duty, it still subscribes to a deontological normative theory. The Principles of Biomedical Ethics is arguably the most commonly used framework in contemporary Western health-care ethics,[10] and thus not surprising that it was the most dominant theme in all the US student analysis. Furthermore, this theory contributes significantly to the development of the American Occupational Therapy Association’s Code of Ethics, which was a required document in the US student’s course curriculum.[11] Specifically, almost all US students identified the conflict between respecting Rebecca’s autonomy and adhering to the principle of beneficence as the predominant ethical concern.

“If beneficence means promoting good by … by removing harm, the psychiatrist should never have let Rebecca leave that mental hospital… …Although I agree with the belief that patients should have the right to make the final say when it comes to their health decisions,… when a mental health disorder is consuming a patient such as Rebecca, her decisions probably won’t reflect an accurate depiction of her beliefs/values.” (US participant)

One of the primary drawbacks to the use of theories in clinical ethics is that they are predicated on societal norms. Normative ethical theories gloss over meta-ethical discourse that may elucidate varying values among stakeholders and moral arguments that are influenced by social and cultural contexts.[12] This is because normative ethics is the practice of putting forward the correct moral principles and rules based on the majority view. This criticism was touched on by some of the students when applying a deontological approach as it often has negative consequences for the minority, as epitomized by the case.

“[Deontological Theory] overlooks the potential for conflicting obligations, overemphasizes the rules, and underemphasizes the consequences of action.” (SA participant).

This common critique of the moral absolutism of Kantian ethics and other rule-based deontological approaches lead to the incorporation of more situational theories in responding to the case. Virtue ethics appeared in some responses of the SA students and was framed as the need to respond empathetically to patients. The framing of the virtue ethics approaches overlapped significantly with the ethics of care theory. The majority of students from South Africa gravitated toward framing their response through virtue ethics, whereas most of the US students framed their response through the lens of Ethics of Care.

Proponents of virtue theory argue that secondary to the complexity of most ethical problems, the right action is not adequately addressed through a set of rules and therefore the moral agent must also rely on one’s virtue which has been cultivated in experience.[13:33] In virtue ethics, right action is understood in reference to what a virtuous person would do,[9] as noted by the SA students’ argument regarding what a “virtuous” health-care provider would do.

“Deontology is the theory of doing the right thing where Aristotle is the theory if virtue ethics thus her as the social worker took an oath to care for this person and to be responsible for Rebecca.” (SA participant)

Ethics of care is reflective of virtue ethics in that it is less focused on the action itself, but rather the context and relationship that guides the action. The Ethics of Care is a theory that can be traced back to the work of Carol Gilligan, who objected to the notion that an ethic of principles is a higher order of moral development than an ethic based on relationships (Gilligan, 1982). It deviates from virtue ethics in that it is less focused on the character of the moral agent and more on a moral responsibility to care for others.

“Ethics of Care theory, because it focuses on the relationships of the actors in the case…In the case of Rebecca, it is the responsibility of the government and community to care for the homeless.” (US participant).

Acknowledging the limitations of normative theories and the need to incorporate a caring response to address the client’s needs was one of the most pervasive approaches used by both occupational therapy student groups.

Theme 3: Practical alternatives and implications

This theme deals with the practical alternatives and implications suggested by all the students from both countries that would have provided a more positive outcome to the case. The theme includes the roles and responsibilities of all stakeholders, considerations of mental health and context, and the policies, acts, and procedures available to guide decision-making.

Roles and responsibilities of stakeholders

From the findings, it was evident that the multidisciplinary team had a big role to play, and this was the focus of all the occupational therapy students’ perceptions. All the occupational therapy students from both countries felt that a holistic approach, including the various stakeholders would have been more beneficial for managing Rebecca. One participant stated:

“If everybody worked together as team, Rebecca could have still been alive.” (SA participant).

Both groups of occupational therapy students detailed the stakeholders’ roles in dealing with Rebecca. They included the police, social worker, psychiatrist, occupational therapist, the community organization, and the family. Furthermore, the majority of occupational therapy students from both countries believed it was the role of the social worker to do regular visits, and inform Rebecca of options and alternatives available to her regarding services. The social worker should also have worked closely with the family regarding Rebecca’s social circumstances, and provided food, shelter, and education regarding mental illness, thus preventing further risks. Most of the occupational therapy students from both countries perceived the main role of the psychiatrist to be an assessment of Rebecca and medical intervention. Notably, the majority of occupational therapy students from SA and the US agreed that it was the role of the psychiatrist to provide immediate intervention to ensure that Rebecca was placed under 72-h protection.

All occupational therapy students from both countries identified that the occupational therapist had a role to play before, and after, Rebecca’s discharge.

“… independent living skills,… ADLs and medication management,… and assist[ance] with community reintegration. Assisted with a work regimen program to get Rebecca into the working community to support herself, …groups to assist and increase her social skills, …and community support systems for clients with schizophrenia.” (US participant).

All the SA and US occupational therapy students stated that health-care professionals should be guided by the code of ethics of their country’s associations.

“As stated in the National Association of Social Workers Code of Ethics, “Social workers should take reasonable steps to avoid abandoning clients who are still in need of services.”[.

All the occupational therapy students were in agreement that involvement and support from family were crucial. Reasons were that the family was familiar with Rebecca’s pre- and post-morbid personality and that they had a responsibility to support and care for her.

“Lack of support in the form of social connections, such as family or friends from a support/community group, is a factor that contributes to homelessness in those diagnosed with schizophrenia (Timms, 2005).” (US participant).

All occupational therapy students agreed that the police had a responsibility and role to play in ensuring that Rebecca was protected from harm and felt that close communication between the police and the social worker was important.

“The police and social worker would have to first ensure Rebecca understands what is happening and why so as to refrain from involuntary police custody. This would have given Rebecca the basic needs of food, warmth, and shelter that would have prevented the hypothermia from starting and killing her.” (SA participant).

Client in context

Both groups of occupational therapy students recognized the need to understand the client in context. The majority of occupational therapy students from both countries highlighted the importance of identifying and educating the individual with mental illness, referred to in the case of Rebecca as an “endangered adult.” If someone is declared an endangered adult, this should be taken seriously, and the safety and health of the person should be taken into consideration.

“In South Africa, we have one fundamental right to life. Therefore the health professionals involved in cases like this should ensure that the client’s safety and right to life are respected, by ensuring that they are taken out of their dangerous living arrangements, until health care is available for them.” (SA participant)

The majority of both groups of occupational therapy students considered Rebecca’s state of mind and how this influenced her decision making ability and compliance with taking medication.

“… she was not mentally capable to make those types of decisions on her own.” (US participant).

All the occupational therapy students believed that it was the role of the health professionals to consider the client’s context, and therefore to educate Rebecca about the implications of weather conditions on her health and quality of life.

“Educating Rebecca about the severe weather could had helped her know that it was not safe for her to be outside in the cold weather. This could have allowed her the sense to go into a building and warm up or try and find a temporary shelter.” (US participant)

In addition, most of the occupational therapy students from both countries mentioned the need to consider the client’s age and stage of development.

“… with her being an older adult increases her fatality risk due to hypothermia.” (SA participant).

Both groups of occupational therapy students highlighted the detrimental effect of Rebecca’s living conditions as a homeless person on the streets and the influence on her lifestyle and quality of life. They agreed that it was crucial for health-care professionals to know about and prepare the client for reintegration into, the community post-discharge, with regular follow-ups.

“The role players during that time should have taken the deontological stance of realizing that being in those living conditions and being mentally ill was infringing on her quality of life in that moment.” (SA participant).

In South Africa, most urban communities have homeless shelters for those in need run by non-governmental organizations and volunteers. Shelters are used on a voluntary basis by individuals and uphold strict rules to ensure their safety and security. Shelters often require a minimum payment per night, which includes a bed, two basic meals, and sanitation. From the findings, the US context is different in that the majority of the occupational therapy students referred to homeless facilities and programs that are staffed by teams of health-care professionals. The difference in the contexts of the two countries was reflected in how all of the occupational therapy students approached Rebecca as the client in her context. This is shown in the following quotes:

“The community should be caring for the homeless by doing what they can to support them, through charity drives, soup kitchens, and homeless shelters …” (SA participant).

“Get Rebecca involved in a homeless health outreach program that consists of a multidisciplinary team of occupational therapy, medical, nursing, social work, psychology, welfare, and alcohol and drug clinicians.” (US participant).

Policies, acts, and procedures

The majority of the occupational therapy students from both groups highlighted that policies and procedures need to be developed, implemented, and revised. Furthermore, most of the occupational therapy students from the two groups emphasized the importance of referrals and record-keeping, In addition, patients should be prepared for discharge and there should be appropriate follow-up within stipulated timeframes. Systems should be in place for non-attendance at follow-ups, particularly for persons with mental illnesses. Most of the occupational therapy students were of the opinion that the timeframe from discharge to first follow-up should have been shorter.

“Psychiatric hospitals should provide extensive care to ensure that their clients (discharged) have somewhere to go afterward by creating a team of professionals that can provide extensive care to them once discharged to ensure safety and compliance.” (SA participant)

All the occupational therapy students from both countries stressed the importance of post-discharge care for Rebecca to support her reintegration into the community. Interestingly, only some of the US occupational therapy students suggested that Rebecca should receive weekly home visits.

“One other alternative could have been to have Rebecca attend a support group along with the weekly home visits with the social worker.” (US participant)

Although all the occupational therapy students from both countries considered legislation and law in their ethics reasoning, this tended to be mentioned superficially rather than engaged with in-depth.

“Rebecca has the right to have her basic needs meet according to the laws of South Africa.” (SA participant)

Most of the occupational therapy students from the two countries mentioned various policies and acts pertaining to mental health but questioned whose responsibility it was to implement them.

“… the government is obliged to provide according to the laws and legislations of the Mental Health Act.” (SA participant)

Society’s responsibility

All the occupational therapy students from SA and the US believed that society has an obligation toward caring for individuals who are homeless and who have a mental illness, particularly in contexts with limited resources.

“… society takes the role [attitude] of caring for each other…” (SA participant)

“Changes in society have diminished the traditional support offered by neighbors and families.” (US participant)

Discussion

In the study, we explored and described occupational therapy students’ perceptions and experiences of an ethical dilemma in context. Furthermore, we explored the similarities and differences experienced by the students. Students came from two universities in South Africa and the USA and worked on the same case which described the situation of a homeless woman with a mental illness who lived and died on the streets of Cape Town, South Africa. Important to note is that South Africa is described as a middle-upper income country, whereas the US is a high-income country.[17] The implication is that the two countries’ health systems and the allocation of resources differ.

Both groups of students approached the case in a similar manner using their knowledge of ethics, principles, and approaches. They also applied the steps of an ethics reasoning process to guide their decision-making. There were quotes from both SA and USA students that supported the findings.

Deontological theory is a common ethics approach stemming from the Greek word deon, meaning “duty.” Deontology emphasizes the importance of moral duties, obligations, and principles, not consequences (Pojman, 2006). The rightness or wrongness of an act may depend on other situations, such as whether it aligns with or is done for the sake of certain moral rules or principles. While deontologists may agree that ethical reasoning should be based on certain moral principles or duties, they often disagree regarding which ethical principles to apply and/or how to define duty. This was observed in the two student groups. For the South African students, deontological themes, including autonomy and harm reduction were present, but there was also a prominent representation of consequential arguments, including utility-based arguments. Reference to family support and utility arguments related to promoting community health over individual rights took on greater prominence with South African students. The US students focused on a deontological approach highlighting autonomy with respect to the case of Rebecca as an individual. One reason for these differences may be the pedagogical approaches used in teaching, for example, deontological in the US versus utilitarian in South Africa. In addition, healthcare and occupational therapy practice are different in the two countries. In South Africa, there is a focus on primary health care, which incorporates a population/community-based approach to practice.[18] In the US, the health-care system continues to focus on a biomedical model of illness, with limited access to resources that promote a community-based approach.[19] Furthermore, there may well be cultural differences within each of the student groups. These may be on an individual level as well as at a group level. The South African student group encompasses cultural diversity in terms of ethnicity, religion, language, and socioeconomic status. The concept of educating practitioners regarding cultural competence stems from the need to reduce health disparities resulting from provider bias.[20] The differences could be attributed to the pedagogical biases of the instructors, as well as occupational therapy practice; it may also signify the influence of cultural differences between groups.

Potentially more interesting than the differences are the similarities in ethics reasoning. In both student groups, the strongest ethical theme is care. This is consistent with other research that shows clinicians primarily use an Ethics of Care approach and is more relationship-oriented during decision-making even when trained in a deontological model.[21] Thus, the study may reveal opportunities to incorporate non-traditional ethics theories and complex cases into clinical ethics education. Traditional ethics education is static, generally presented in print format and lacks the nuance and complexity of real-world clinical care challenges. This type of training and education does not significantly influence future ethical behavior.[22] Limitations of these approaches may be linked to their focus on cognitive variables associated with knowing the right course of action, and failure to address behavioral variables needed to navigate complex systems-level problems. If the methods used in the classroom do not translate to practice, exploring new approaches to learning is required.

Implications for practice

The study revealed that health-care professionals, specifically occupational therapists in two different contexts (SA and US), make use of similar approaches in reasoning through ethical dilemmas. This insight may help occupational therapy educators to develop clinical ethics curricula that account for a care model which is most prevalent in clinical practice. In addition, there should be closer collaboration between health and law instructors to develop relevant curricula that include a focus on law and legislation, with law educators teaching relevant aspects of the law. This would equip occupational therapy students with skills and knowledge to better integrate law and legislation in their ethics reasoning and decision-making processes. It will also increase awareness regarding barriers to executing ethical actions in practice.

As part of the ethics of care approach, the ethics of solidarity would be a realistic approach to consider when adopting a population approach and to accommodate cultural diversity in context. “Solidarity is based on notions of interdependence which involves mutual and physical responsibility to others and the sharing of a common set of principles, which is often linked to devotion to one’s family or community.”[23]

Conclusion

This study sought to explore and describe similarities and differences in occupational therapy students’ perceptions and experiences of an ethical dilemma. Although there were some differences, there were mainly similarities in students’ perceptions of ethical practice. In conclusion, the key similarities were that students in both countries applied the steps of an ethical reasoning process to guide their decision-making using ethics of care approach. It was interesting that the key difference was that due to the pedagogical difference in teaching, students from the US used a deontological approach whereas students from the SA used a utilitarian approach in the case of Rebecca. Cultural differences were manifested in all of the students’ ethical reasoning, which was embedded in the different contexts of their two countries.

Furthermore, the study leads to the strengthening of internationalization of occupational therapy ethics education and facilitated student learning through the development of an international, online, and interdisciplinary ethics module for health sciences students. The study created an international understanding of occupational therapy students’ perceptions and experiences of ethical dilemmas across two countries. Students from the two countries had the opportunity to share their knowledge and experiences of ethical dilemmas in occupational therapy practice within different health systems.