Perceived bioethical issues in cancer rehabilitation: a qualitative study among Italian physiotherapists

Gianluca Bertoni; Simone Battista; Valentina Conti; Marco Testa; Sara Patuzzo Manzati

doi:10.33393/aop.2025.3299

Authors

Gianluca Bertoni Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Campus of Savona - Italy, Department of Clinical and Experimental Sciences, University of Brescia, Brescia - Italy and Training Unit, Azienda Socio-Sociosanitaria Territoriale di Cremona, Cremona - Italy https://orcid.org/0000-0002-1223-5048
Simone Battista School of Health & Society, Centre for Human Movement and Rehabilitation, Salford, Greater Manchester - UK https://orcid.org/0000-0002-7471-1951
Valentina Conti School of Medicine and Surgery, University of Milan-Bicocca, Milan - Italy
Marco Testa Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genoa, Campus of Savona - Italy https://orcid.org/0000-0001-8643-7200
Sara Patuzzo Manzati Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona - Italy https://orcid.org/0000-0001-6800-505X

DOI:

https://doi.org/10.33393/aop.2025.3299

Keywords:

Bioethics, Neoplasm, Physiotherapy, Qualitative Research, Rehabilitation

Abstract

Introduction: Literature on bioethics in physiotherapy, particularly in cancer management, is limited. This study explores the perceived bioethical issues in cancer rehabilitation by Italian physiotherapists.

Participants: Thirty-one physiotherapists (Age: 42 ± 10.5 years; 20 women, 11 men) with expertise in cancer rehabilitation were purposefully selected.

Data Collection: Six online focus groups were conducted, guided by a focus group guide based on existing literature and refined by experts in cancer rehabilitation and bioethics.

Data Analysis: Sessions were recorded, transcribed, and analyzed using Braun and Clarke’s ‘Reflexive Thematic Analysis’.

Results: Four primary themes emerged: 1) Challenges of (Non)-Disclosure in Diagnosis and Prognosis – ethical difficulties around withholding diagnosis or prognosis information; 2) Balancing Hope and Realism in Patient and Caregiver Expectations – navigating hope versus realistic rehabilitation goals; 3) Weighing Efficacy and Safety in Cancer Rehabilitation – balancing treatment outcomes with patient safety; 4) Decisions on Withdrawing Treatment – ethical considerations in discontinuing treatment.

Discussion: These themes highlight common ethical dilemmas faced by physiotherapists in cancer rehabilitation, mirroring broader healthcare challenges. Addressing them requires a nuanced understanding of ethical principles within the cancer rehabilitation context.

Conclusions: The study provides insights into the bioethical issues in cancer rehabilitation, stressing the need for a patient-centered approach to navigate these challenges effectively.

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References

Smith SR, Zheng JY, Silver J, Haig AJ, Cheville A. Cancer rehabilitation as an essential component of quality care and survivorship from an international perspective. Disabil Rehabil. 2020;42(1):8-13. DOI: https://pubmed.ncbi.nlm.nih.gov/30574818/ https://doi.org/10.1080/09638288.2018.1514662 PMID:30574818 DOI: https://doi.org/10.1080/09638288.2018.1514662

Schieroni MP. La riabilitazione in oncologia. La presa in carico multidisciplinare e i percorsi riabilitativi diagnostico-terapeutici dei pazienti affetti da tumore. Edizioni Medico-Scientifiche; 2017.

Shih YA, Wang C, Jin S, Feng W, Lu Q. Decision Making of Artificial Nutrition and Hydration for Cancer Patients at Terminal Stage-A Systematic Review of the Views From Patients, Families, and Healthcare Professionals. J Pain Symptom Manage. 2021;62(5):1065-1078. DOI: https://pubmed.ncbi.nlm.nih.gov/33933623/ https://doi.org/10.1016/j.jpainsymman.2021.04.013 PMID:33933623 DOI: https://doi.org/10.1016/j.jpainsymman.2021.04.013

Ahn E, Shin DW, Choi JY, et al. The impact of awareness of terminal illness on quality of death and care decision making: a prospective nationwide survey of bereaved family members of advanced cancer patients. Psychooncology. 2013;22(12):2771-2778. DOI: https://pubmed.ncbi.nlm.nih.gov/23839783/ https://doi.org/10.1002/pon.3346 PMID:23839783 DOI: https://doi.org/10.1002/pon.3346

Luna-Meza A, Godoy-Casasbuenas N, Calvache JA, et al. Decision making in the end-of-life care of patients who are terminally ill with cancer - a qualitative descriptive study with a phenomenological approach from the experience of healthcare workers. BMC Palliat Care. 2021;20(1):76. DOI: https://pubmed.ncbi.nlm.nih.gov/34049535/ https://doi.org/10.1186/s12904-021-00768-5 PMID:34049535 DOI: https://doi.org/10.1186/s12904-021-00768-5

Potter VR. Bioethics: Bridge to the Future. Prentice-Hall; 1971.

Casella C, Graziano V, Lorenzo PD, Capasso E, Niola M. Unreasonable obstinacy: Ethical, deontological and forensic medical problems. J Public Health Res. 2018;7(3):1460. DOI: https://pubmed.ncbi.nlm.nih.gov/30687677/ https://doi.org/10.4081/jphr.2018.1460 PMID:30687677 DOI: https://doi.org/10.4081/jphr.2018.1460

Percival T. Medical Ethics. London: Russell for J. Johnson, St. Paul’s Church Yard and R. Bickerstaff, Strand; 1803.

Simon M. Déontologie Médicale. J.B. Bailliere; 1845.

Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Oxford University Press; 1977.

Morrison RS, Meier DE. Clinical practice. Palliative care. N Engl J Med. 2004;350(25):2582-2590. DOI: http://www.ncbi.nlm.nih.gov/pubmed/15201415 https://doi.org/10.1056/NEJMcp035232 PMID:15201415 DOI: https://doi.org/10.1056/NEJMcp035232

Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients’ perspectives. JAMA. 1999;281(2):163-168. DOI: https://pubmed.ncbi.nlm.nih.gov/9917120/ https://doi.org/10.1001/jama.281.2.163 PMID:9917120 DOI: https://doi.org/10.1001/jama.281.2.163

Hofmann B. On the triad disease, illness and sickness. J Med Philos. 2002;27(6):651-673. DOI: https://pubmed.ncbi.nlm.nih.gov/12607162/ https://doi.org/10.1076/jmep.27.6.651.13793 PMID:12607162 DOI: https://doi.org/10.1076/jmep.27.6.651.13793

Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125(9):763-769. DOI: https://pubmed.ncbi.nlm.nih.gov/8929011/ https://doi.org/10.7326/0003-4819-125-9-199611010-00010 PMID:8929011 DOI: https://doi.org/10.7326/0003-4819-125-9-199611010-00010

Hofmann B. Ethical issues with colorectal cancer screening-a systematic review. J Eval Clin Pract. 2017;23(3):631-641. DOI: https://pubmed.ncbi.nlm.nih.gov/28026076/ https://doi.org/10.1111/jep.12690 PMID:28026076 DOI: https://doi.org/10.1111/jep.12690

Morgan G. Issues and Ethical Considerations in Pharmaco-oncogenomics. Adv Exp Med Biol. 2019;1168:91-101. DOI: https://pubmed.ncbi.nlm.nih.gov/31713166/ https://doi.org/10.1007/978-3-030-24100-1_6 PMID:31713166 DOI: https://doi.org/10.1007/978-3-030-24100-1_6

Caplan AL. Cancer and bioethics: caring and consensus. Cancer. 2008;113(7)(suppl):1801-1806. DOI: https://pubmed.ncbi.nlm.nih.gov/18800390/ https://doi.org/10.1002/cncr.23647 PMID:18800390 DOI: https://doi.org/10.1002/cncr.23647

Tan GA, Peiris CL, Dennett AM. Cancer survivors maintain health benefits 6 to 12 months after exercise-based rehabilitation: a systematic review and meta-analysis. J Cancer Surviv. 2022;1-22. DOI: https://link.springer.com/article/10.1007/s11764-022-01322-9 PMID:36547801 DOI: https://doi.org/10.1007/s11764-022-01322-9

Rogers LQ, Courneya KS, Oster RA,et al. Physical activity intervention benefits persist months post-intervention: randomized trial in breast cancer survivors. J Cancer Surviv. 2023 Dec;17(6):1834-1846. DOI: 10.1007/s11764-022-01329-2. PMID: 36723801. DOI: https://doi.org/10.1007/s11764-022-01329-2

Praestegaard J, Gard G. Ethical issues in physiotherapy--reflected from the perspective of physiotherapists in private practice. Physiother Theory Pract. 2013;29(2):96-112. DOI: https://pubmed.ncbi.nlm.nih.gov/22765019/ https://doi.org/10.3109/09593985.2012.700388 PMID:22765019 DOI: https://doi.org/10.3109/09593985.2012.700388

Poulis I. Bioethics and physiotherapy. J Med Ethics. 2007;33(8):435-436. DOI: https://jme.bmj.com/content/33/8/435 https://doi.org/10.1136/jme.2007.021139 PMID:17664296 DOI: https://doi.org/10.1136/jme.2007.021139

Kulju K, Suhonen R, Leino-Kilpi H. Ethical problems and moral sensitivity in physiotherapy: a descriptive study. Nurs Ethics. 2013;20(5):568-577. DOI: https://pubmed.ncbi.nlm.nih.gov/23329778/ https://doi.org/10.1177/0969733012468462 PMID:23329778 DOI: https://doi.org/10.1177/0969733012468462

Richardson RW. Ethical issues in physical therapy. Curr Rev Musculoskelet Med. 2015 Jun;8(2):118-21. DOI: https://doi.org/10.1007/s12178-015-9266-y PMID: 25864102 DOI: https://doi.org/10.1007/s12178-015-9266-y

Delany CM, Edwards I, Jensen GM, Skinner E. Closing the gap between ethics knowledge and practice through active engagement: an applied model of physical therapy ethics. Phys Ther. 2010;90(7):1068-1078. DOI: https://pubmed.ncbi.nlm.nih.gov/20448105/ https://doi.org/10.2522/ptj.20090379 PMID:20448105 DOI: https://doi.org/10.2522/ptj.20090379

Ladeira TL, Koifman L. Bioethics in the physical therapist’s clinical practice: conceptions by faculty members and students. Rev bioét (Impr). 2021;29(3):588. DOI: http://dx.doi.org/10.1590/1983-80422021293494

Aguilar-Rodríguez M, Marques-Sule E, Serra-Añó P, Espí-López GV, Dueñas-Moscardó L, Pérez-Alenda S. A blended-learning programme regarding professional ethics in physiotherapy students. Nurs Ethics. 2019;26(5):1410-1423. DOI: https://pubmed.ncbi.nlm.nih.gov/29458314/ https://doi.org/10.1177/0969733017748479 PMID:29458314 DOI: https://doi.org/10.1177/0969733017748479

Finch E, Geddes EL, Larin H. Ethically-based clinical decision-making in physical therapy: process and issues. Physiother Theory Pract. 2005;21(3):147-162. DOI: https://pubmed.ncbi.nlm.nih.gov/16389696/ https://doi.org/10.1080/09593980590922271 PMID:16389696 DOI: https://doi.org/10.1080/09593980590922271

Edwards I, Braunack-Mayer A, Jones M. Ethical reasoning as a clinical-reasoning strategy in physiotherapy. Physiotherapy. 2005;91(4):229-236. DOI: https://doi.org/10.1016/j.physio.2005.01.010 DOI: https://doi.org/10.1016/j.physio.2005.01.010

Guccione AA. Ethical issues in physical therapy practice. A survey of physical therapists in New England. Phys Ther. 1980;60(10):1264-1272. DOI: https://pubmed.ncbi.nlm.nih.gov/7443788/ https://doi.org/10.1093/ptj/60.10.1264 PMID:7443788 DOI: https://doi.org/10.1093/ptj/60.10.1264

Presidenza del Consiglio dei Ministri, Comitato Nazionale per la Bioetica. Bioetica e riabilitazione. 2006 Mar. Online https://bioetica.governo.it/media/3113/p71_2006_bioetica-e-riabilitazione_it.pdf (Accessed September 2024)

Pace P, Cisari C. Riflessioni bioetiche in medicina riabilitativa. Italian Journal of Rehabilitation Medicine. 2008;22(3):219-224. https://www.minervamedica.it/en/journals/medicina-riabilitativa/article.php?cod=R47Y2008N03A0219

Hudon A, Laliberté M, Hunt M, et al. What place for ethics? An overview of ethics teaching in occupational therapy and physiotherapy programs in Canada. Disabil Rehabil. 2014;36(9):775-780. DOI: https://pubmed.ncbi.nlm.nih.gov/23865909/ https://doi.org/10.3109/09638288.2013.813082 PMID:23865909 DOI: https://doi.org/10.3109/09638288.2013.813082

Swisher LL. A retrospective analysis of ethics knowledge in physical therapy (1970-2000). Phys Ther. 2002;82(7):692-706. DOI: https://doi.org/10.1093/ptj/82.7.692 PMID:12088466 DOI: https://doi.org/10.1093/ptj/82.7.692

Michel TH. Do physiotherapists have a role in palliative care? Physiother Res Int. 2001;6(1):v-vi. DOI: https://pubmed.ncbi.nlm.nih.gov/11379257/ https://doi.org/10.1002/pri.208 PMID:11379257 DOI: https://doi.org/10.1002/pri.208

Priscila Costa B, Duarte LA. Bioethical reflections about the finitude of life, palliative care and physical therapy. Rev bioét (Impr). 2019;27(3):510-515. DOI: http://dx.doi.org/10.1590/1983-80422019273335 DOI: https://doi.org/10.1590/1983-80422019273335

Chigbo NN, Ezeome ER, Onyeka TC, Amah CC. Ethics of physiotherapy practice in terminally ill patients in a developing country, Nigeria. Niger J Clin Pract. 2015;18(7)(suppl):S40-S45. https://journals.lww.com/njcp/fulltext/2015/18001/ethics_of_physiotherapy_practice_in_terminally_ill.7.aspx https://doi.org/10.4103/1119-3077.170826 PMID:26620621 DOI: https://doi.org/10.4103/1119-3077.170826

Spill GR, Vente T, Frader J, et al. Futility in Rehabilitation. PM R. 2019;11(4):420-428. DOI: https://pubmed.ncbi.nlm.nih.gov/30851075/ https://doi.org/10.1002/pmrj.12152 PMID:30851075 DOI: https://doi.org/10.1002/pmrj.12152

Jedličková A. [Ethical aspects in oncology]. Vnitr Lek. 2023;69(E-1):3-10. DOI: https://pubmed.ncbi.nlm.nih.gov/36931869/ PMID:36931869 DOI: https://doi.org/10.36290/vnl.2023.009

Culyer AJ. Ethics, priorities and cancer. J Cancer Policy. 2017;11:6-11. DOI: https://doi.org/10.1016/j.jcpo.2016.09.007 DOI: https://doi.org/10.1016/j.jcpo.2016.09.007

Luciano M, Sampogna G, del Vecchio V, et al. The family in Italy: cultural changes and implications for treatment. Int Rev Psychiatry. 2012;24(2):149-156. DOI: https://pubmed.ncbi.nlm.nih.gov/22515465/ https://doi.org/10.3109/09540261.2012.656306 PMID:22515465 DOI: https://doi.org/10.3109/09540261.2012.656306

Sampogna G, Luciano M, Del Vecchio V, et al. The effects of psychoeducational family intervention on coping strategies of relatives of patients with bipolar I disorder: results from a controlled, real-world, multicentric study. Neuropsychiatr Dis Treat. 2018;14:977-989. DOI: https://pmc.ncbi.nlm.nih.gov/articles/PMC5903484/ https://doi.org/10.2147/NDT.S159277 PMID:29692615 DOI: https://doi.org/10.2147/NDT.S159277

Garelli F. The church and Catholicism in contemporary Italy. J Mod Ital Stud. 2007;12(1):2-7. DOI: https://www.tandfonline.com/doi/abs/10.1080/13545710601132672 https://doi.org/10.1080/13545710601132672 DOI: https://doi.org/10.1080/13545710601132672

Callahan I, Loscocco K. The Prevalence and Persistence of Homophobia in Italy. J Homosex. 2023;70(2):228-249. DOI: https://pubmed.ncbi.nlm.nih.gov/34185631/ https://doi.org/10.1080/00918369.2021.1945337 PMID:34185631 DOI: https://doi.org/10.1080/00918369.2021.1945337

Corbellini G. Scientists, bioethics and democracy: the Italian case and its meanings. J Med Ethics. 2007;33(6):349-352. DOI: https://jme.bmj.com/content/33/6/349 https://doi.org/10.1136/jme.2007.020586 PMID:17526686 DOI: https://doi.org/10.1136/jme.2007.020586

Monaco S, Renzi A, Galluzzi B, et al. The Relationship between Physiotherapist and Patient: A Qualitative Study on Physiotherapists’ Representations on This Theme. Healthcare 2022. 2022 Oct 25;10(11):2123. DOI: https://doi.org/10.3390/healthcare10112123 DOI: https://doi.org/10.3390/healthcare10112123

Moser A, Korstjens I. Series: Practical guidance to qualitative research. Part 1: Introduction. Eur J Gen Pract. 2017;23(1):271-273. DOI: https://pubmed.ncbi.nlm.nih.gov/29185831/ https://doi.org/10.1080/13814788.2017.1375093 PMID:29185831 DOI: https://doi.org/10.1080/13814788.2017.1375093

Kitzinger J. Focus Groups. Qualitative Research in Health Care: Third Edition [Internet]. 2007 Nov 26; 21–31. DOI: https://onlinelibrary.wiley.com/doi/full/10.1002/9780470750841.ch3 (Accessed September 2024) DOI: https://doi.org/10.1002/9780470750841.ch3

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349-357. DOI: https://pubmed.ncbi.nlm.nih.gov/17872937/ https://doi.org/10.1093/intqhc/mzm042 PMID:17872937 DOI: https://doi.org/10.1093/intqhc/mzm042

Campbell S, Greenwood M, Prior S, et al. Purposive sampling: complex or simple? Research case examples. J Res Nurs. 2020;25(8):652-661. DOI: https://pubmed.ncbi.nlm.nih.gov/34394687/ https://doi.org/10.1177/1744987120927206 PMID:34394687 DOI: https://doi.org/10.1177/1744987120927206

Mayer RS, Engle J. Rehabilitation of Individuals With Cancer. Ann Rehabil Med. 2022;46(2):60. DOI: https://doi.org/10.5535/arm.22036 DOI: https://doi.org/10.5535/arm.22036

Rolfe DE, Ramsden VR, Banner D, Graham ID. Using qualitative Health Research methods to improve patient and public involvement and engagement in research. Res Involv Engagem. 2018;4(1):49. DOI: https://pubmed.ncbi.nlm.nih.gov/30564459/ https://doi.org/10.1186/s40900-018-0129-8 PMID:30564459 DOI: https://doi.org/10.1186/s40900-018-0129-8

Battista S, Manoni M, Dell’Isola A, et al. Giving an account of patients’ experience: A qualitative study on the care process of hip and knee osteoarthritis. Health Expectations. 2022 Mar 9; DOI: https://doi.org/10.1111/hex.13468 DOI: https://doi.org/10.1111/hex.13468

Braun V, Clarke V. Thematic Analysis: A Practical Guide [Internet]. SAGE Publications; 2021. Online https://books.google.se/books?id=mToqEAAAQBAJ (Accessed September 2024)

Ayre J, McCaffery KJ. Research Note: thematic analysis in qualitative research. J Physiother. 2022;68(1):76-79. DOI: https://pubmed.ncbi.nlm.nih.gov/34895882/ https://doi.org/10.1016/j.jphys.2021.11.002 PMID:34895882 DOI: https://doi.org/10.1016/j.jphys.2021.11.002

Gazzetta Ufficiale della Repubblica Italiana. Law 219/2017‘Provisions for informed consent and advance treatment directives.’. 2018 Jan 16;12. Online (Accessed September 2024)https://www.gazzettaufficiale.it/eli/id/2018/1/16/18G00006/sg

Di Paolo M, Gori F, Papi L, Turillazzi E. A review and analysis of new Italian law 219/2017: ‘provisions for informed consent and advance directives treatment’. BMC Med Ethics. 2019;20(1):17. DOI: https://pubmed.ncbi.nlm.nih.gov/30832644/ https://doi.org/10.1186/s12910-019-0353-2 PMID:30832644 DOI: https://doi.org/10.1186/s12910-019-0353-2

Triezenberg HL, Purtilo R. The identification of ethical issues in physical therapy practice. Phys Ther. 1996;76(10):1097-1107. DOI: https://pubmed.ncbi.nlm.nih.gov/8863763/ https://doi.org/10.1093/ptj/76.10.1097 PMID:8863763 DOI: https://doi.org/10.1093/ptj/76.10.1097

Maltser S, Cristian A, Silver JK, et al. A Focused Review of Safety Considerations in Cancer Rehabilitation. PM R. 2017 Sep 1; 9(9S2):S415-28. DOI: https://doi.org/10.1016/j.pmrj.2017.08.403 https://pubmed.ncbi.nlm.nih.gov/28942913/ DOI: https://doi.org/10.1016/j.pmrj.2017.08.403

Lee RT, Moore JA. Integrative Oncology and Ethics. Ethical Challenges in Oncology: Patient Care, Research. Educ Econ. 2017;101-119. DOI: https://doi.org/10.1016/B978-0-12-803831-4.00006-3 DOI: https://doi.org/10.1016/B978-0-12-803831-4.00006-3

Rodriguez MA, Lewis-Patterson P, Palos GR. Ethical Issues in Cancer Survivorship. Ethical Challenges in Oncology: Patient Care, Research. Educ Econ. 2017;85-100. DOI: https://doi.org/10.1016/B978-0-12-803831-4.00005-1 DOI: https://doi.org/10.1016/B978-0-12-803831-4.00005-1

Benjamin RS, Benjamin NB. Clinician Experience: Some Current Ethical Considerations. Ethical Challenges in Oncology: Patient Care, Research. Educ Econ. 2017;121-126. DOI: https://doi.org/10.1016/B978-0-12-803831-4.00007-5 DOI: https://doi.org/10.1016/B978-0-12-803831-4.00007-5

Hoover TC, Buzdar A. Ethical Considerations in Human Subjects Research: Emerging Issues in Cancer Research. Ethical Challenges in Oncology: Patient Care, Research. Educ Econ. 2017;145-157. DOI: https://doi.org/10.1016/B978-0-12-803831-4.00009-9 DOI: https://doi.org/10.1016/B978-0-12-803831-4.00009-9

Bioética R, Ladeira TL, Koifman L. Bioethics in the physical therapist’s clinical practice: conceptions by faculty members and students. Rev bioét (Impr). 2021;29(3):588. DOI: http://dx.doi.org/10.1590/1983-80422021293494 DOI: https://doi.org/10.1590/1983-80422021293494