Ethics for Physiotherapists

No Mask – No Service: Is It as Simple as That?

On a daily basis, physiotherapists have many decisions to make. Due to our training, experience and commitment to professional practice, we are often able to decide quickly and be confident that these decisions are ethical, even if they conflict with the preferences of our clients.

Provision of care during the pandemic has bestowed upon us the added responsibility of ensuring that public health orders are upheld. For several regions in Manitoba, there is a directive requiring that masks must be worn by all in indoor spaces.

Within this directive, there are some exceptions, including: “a person with a medical condition that is unrelated to COVID-19, including breathing or cognitive difficulties, or a disability, that prevents them from safely wearing a mask;”

This is open to much interpretation.

If a client refuses to wear a mask during an in person visit, the choice may appear quite clear, “No mask, no treatment”.  This decision may result in less than optimal outcomes for that client, but it is for the greater good, right?

An ethical dilemma occurs in a situation when at least two ethically correct (or incorrect) courses of action are in conflict.

As this decision could result in a person being denied care, it is our responsibility to ensure that the process for making this choice was carried out in an ethical manner.

The “Four Quadrant Approach” tool for ethical decision making was utilized to to ethically examine the decision-making process.  This approach guides the decision maker to consider the potential outcomes for all stakeholders affected by the final decision.


Step 1 – Determine the Ethical/Moral Issue?

This is not always straight forward, and there may be more than one.

Should I deny care provision for the client?

The duty to provide care conflicts with that to comply with the public health orders (ensure a safe environment for all clients, staff and therapists).

What is our obligation to enforce that masks are worn and worn properly?


Step 2- Analysis of the using the Four Quadrants

What are the Medical Implications? Considered by this presentation to be the highest valued quadrant*

Utilizes the concepts of Beneficence (doing good) and Non-maleficence (avoiding harm)

What do we know for sure about the implications of our decisions? “Good ethics start with good facts”*

  1. The spread of Sars-COV-2 is lessened significantly when people effectively cover their noses and mouths with cloth masks.
  2. Effective mask wearing provides the greatest protection for the other people in the space, while also providing some protection for the wearer.
  3. There are medical and cognitive conditions which would prohibit a person from safely wearing a mask.
    1. Does the client have such a condition?
    2. What might these conditions be?
  4. The treatment that the client has attended for is expected to result in improved health outcomes.

What are we unsure of?

  1. What is the risk of one person not wearing a mask when all other people are complying?
  2. Is there validity to the client’s subjective report to having a condition that exempts them from wearing a mask?
    1. What are the obligations for the therapist to ensure the accuracy of these reports?

Patient Preferences

Respect for Autonomy – Highly valued in Western society

  1. Does the client fully comprehend the consequences of not wearing a mask?
    1. Possibly no treatment
    2. Putting others and at risk
  2. Is a client’s respect for autonomy more highly ranked if the treatment is to take place in their own home?
    1. Do we have any responsibility or authority to request that any other people in the household wear masks?
  3. How will this decision affect the therapeutic relationship that I have developed with my client?

Quality of Life

Diversity exists amongst people as to what gives quality of life.

  1. Does mask wearing result in discomfort or could it have negative health implications for the client?
  2. Have alternative options for care provision been offered and explained
    1. Virtual sessions
    2. Private room
    3. Alternative treatment times
    4. Provision of disposable mask
  3. Do physiotherapists have an obligation to provide these alternatives?

Contextual Factors

Includes any other significant considerations

  1. The current “State of Emergency”
  2. Impact on others – Have all stakeholders interests been considered? (Client, other clients, staff, therapist)
  3. Justice- Have all stakeholders been treated equitably?
  4. Resource limitations – Does the decision prioritize any stakeholders over others in regard to service allocations?
  5. Cultural Considerations – Have cultural differences been well understood and considered, assisting the client in the decision-making process?

Step 3- What have we decided to do and Why?

This includes Ethical Decisions and Actions

Summarize the ethical considerations that were analyzed.

Document the decision and the justification in the patient’s record.


After the working through “The Four Quadrant Approach” your decision may or may not be the same as you had originally considered.  By utilizing the process, the decision maker can be assured that their decisions that have consequences have been ethically evaluated. They will be able to demonstrate prudence and transparency when implementing and justifying your decisions.


The CPM Ethics Committee welcomes comments or questions.