It’s a wrap!

I got inspiration from other bloggers and made a bubble mind map.

Thanks to all the fellow participants and course leaders. This kind of an online free course is a really good example of accessibility. Let’s do it again 🙂



The right to die

Since I’m a major cinephile (TM The Lonely Island), I would like to start by recommending a great movie about euthanasia. “Mar Adentro” (“The Sea Inside”) is the story of RamĂłn Sampedro (played by one of my favourite actors, Javier Bardem) who fought 30 years for the right to end his life with euthanasia. When I thought about this movie and read Tony Nicklinson’s thoughts, it came to me that the people who are in these kind of situations and want (or don’t want) euthanasia, have to be prioritized and heard first in the debate. It’s very simple: if this is your everyday reality, other people don’t have the right to tell you how you should live or end your life. I believe that people who are terminally ill or suffer from locked-in syndrome or other similar condition should have the legal option of assisted suicide. Of course, there are those who adapt to their situation and live fulfilling lives, there are those who hope and wait for a miracle or new treatment options and finally, there are those who choose euthanasia – all of these options should be available and not judged. However, there are important requirements for euthanasia: the person has to have the mental capacity to fully understand what he/she is doing and the person should not be able to perform suicide on their own due to a physical incurable condition. That excludes euthanasia for healthy people who are suicidal. Calling suicide “the last human right” and wanting to aid healthy people commit suicide is pretty extreme, therefore I can agree with only some of Dignitas’s and Minelli’s activities that conform with the aforementioned criteria.

We can legalize euthanasia but when it comes down to it, who would agree to do it? Logically the loved ones of the person who have seen the suffering. Also some healthcare professionals. But this is the tricky part: their mission is to save lives, not to help people die. However, it could also be argued that one of the most important principles in medical ethics, primum non nocere (first, do no harm), could be understood as doing nothing and therefore, not prolonging suffering. One step further would be to assist in ending that suffering and I believe it is up to each healthcare professional to decide whether helping someone to die is something they find acceptable or not. No one should be, under any circumstances, forced to perform euthanasia on their patients.

There is also the conflict between people who want to promote the rights of people with disabilities and pro-euthanasia groups. However, I believe you can at the same time be pro-euthanasia AND promote the rights of people with disabilities. The difference is that when it comes to euthanasia, the person wants to die because they’re in pain, feel that they don’t want to live etc, not because they feel discriminated against in the society. It’s a fine line, but just because someone with an incurable condition wants to die, doesn’t mean that another person with a similar condition couldn’t live a fulfilling life. Unfortunately, there are some people who support euthanasia and have eugenic views which is just not acceptable.

Reading through what others wrote on the topic was very thought-provoking. Since I am not a religious person, reading Hamza’s post was very interesting. I really liked what he said about dying: since we don’t have the ability to choose the situation surrounding our birth, we should have the ability to choose the situation surrounding our death. Bruce raised the conflict between embracing disability and euthanasia, and gave a somewhat positive “spin” on suffering which was a new perspective for me.

The healthy man does not torture others – generally it is the tortured who turn into torturers – Carl Jung

When it comes to the topic of torture, there’s no question: I am against torture in all circumstances. Why? Mainly because allowing torture (even if it is in some very rare occasions) always contradicts human rights. And it’s a slippery slope because when you start making small exceptions, it can lead to bigger exceptions etc. And who should have the power to decide what these rare occasions are? Who should calculate with human lives, e.g. torturing x people might save y lives etc ? It’s easy to say: that’s a bad person who doesn’t deserve human rights, it’s harder to say: that’s a bad person who still has rights and we have to accept these rights. No one should be stripped of their rights. Isn’t the main idea NOT to act like the very person who is thought to have done something so appalling to deserve torture? Not to become like them? I think Jackie’s quote from Gandhi described really well my thoughts about the principle “an eye for an eye”. I would like to live in a world where the Code of Hammurabi no longer applies…

What is more, we can never be 100% sure that the person under question really is guilty. Although I totally agree with Chantelle who quoted Jason Michelich: “The argument cannot be that we should not torture because it does not work. The argument must be that we should not torture because it is wrong.”, I also think the following quote from the article about “Zero Dark Thirty” can be used as an additional argument to why torture is unacceptable: “Indeed, many prisoners have been tortured to death without ever revealing secrets, while many others—including some of those who were brutalized during the Bush years—have fabricated disinformation while being tortured. Some of the disinformation provided under duress during those years, in fact, helped to lead the U.S. into the war in Iraq under false premises.” The first quote is more of a moral argument, the other one, utilitarian. Together they provide a strong case against any torture in any circumstances.

And what about medical professions aiding in torture despite the fact that they should always remain impartial? Needless to say, it’s an ethical catastrophe when those who should preserve and value life, decide to aid in torture. One of the most unfortunate examples being Nazi Germany…

Between a rock and a hard place: morality and equality

I wrote the post on morality, then peeked at the next topic and realized that I had already combined the two. So I hope it’s ok to write this as a 2-in-1 post.

"Rock, Hard Place" Road Sign with dramatic clouds and sky.

What makes discussing morality tricky is the fact that almost everybody thinks their behaviour and values are moral. That being said, it never seizes to unpleasantly surprise me how “normal” it is to make sexist, racist and homophobic comments, remarks and jokes in the Estonian society.

Therefore I have sometimes found myself facing a moral dilemma: to speak up or to remain silent when these kind of comments emerge from casual conversations during physiotherapy. On the one hand, physiotherapy is not the time nor the place to start challenging someone’s belief systems, let alone changing them. On the other hand, I have sometimes tried to explain (briefly and politely) that our facility is a “hate-free space” and that kind of comments are not welcome. Unfortunately, by doing that I risk undermining our patient-therapist relationship. How would you tackle these kind of situations?

In these moral dilemmas I felt I had “the moral upground” but there have also been situations where my own views have been challenged. For example, it was hard for me to understand certain behaviours until a woman explained it by simply telling me her story. It was a wonderful feeling of “enlightenment” and for that reason I’m a strong believer in the power of personal stories that can make all the difference. Our patients’ stories make us develop as humans.

Of course it goes without saying that despite these different moral dilemmas we should aim to treat our patients equally and objectively. I use the word “aim” because it can be hard to critically analyze your own worldview and understand if you really are treating all your patients equally. So what can help you?

In my first post I mentioned EQUASS (European Quality in Social Services) and I would like to explain how this quality assurance system has helped us to provide better and more equal care for our patients/clients. First, we compiled a code of ethics, the staff read it, discussed it and signed it. Without this code it would be harder to know if all the specialists understood the ethical principles similarly. Second, each time a patient/client comes to our facility, we sign an agreement with them. We have written down their rights and obligations, stressing that they will be treated equally and not discriminated on the basis of gender, age, sexuality, race, nationality, religion, political views etc. Doing this with each person helps to keep the topics of ethics and equality constantly in the picture, they should not be forgotten just because “there’s too much real physiotherapy stuff to do”.

Edit: reading Cecil’s, Chantelle’s and Adam’s posts and comments to their posts made me better understand the context of South Africa and think about different forms of discrimination. On the one hand, it could be argued that I am not capable of really understanding problems with racism since I live in a society where I hardly ever see or meet for example, black people. On the other hand, I constantly see problems arise on the basis of nationality, which is also a form of discrimination. The saddest part is how many people who are discriminated against, can also be the ones who discriminate in another context. And it never occurs to them that all forms of discrimination are unacceptable…

Let’s talk about empathy!

For my master’s thesis I made interviews with young men with traumatic SCI, collecting their stories and asking them, among other things, what they value in physiotherapists. All of them emphasized the importance of a good client-physiotherapist relationship: “having one’s heart in it”, good communication skills, positivity, listening, motivating, friendliness, trust, respecting client’s autonomy etc. “To have one’s heart in it” (roughly the same expression in Estonian, so I hope nothing gets lost in translation) – isn’t it a beautiful way to say that the therapist is empathetic, committed to the person and their therapy? Therefore, I believe empathy is necessary to build a good “rapport” with the client. I guess it can’t be learned and also it’s hard to pinpoint what exactly makes the therapist empathetic but somehow our clients immediately recognize and appreciate it.

Also, reading Wendy’s post made me think about different ways empathy can be expressed. But I would argue that “pushing” people doesn’t have to be contradictory to being empathetic. If “pushing” means “we’re in this together, I’m going to help you achieve the goals you set, I know you can do it, I believe in you, I won’t let you quit” etc, then this definitely is a deep empathetic connection between the client and the therapist. I won’t help my clients by crying with them or lingering on their problems. However, I can help them by letting them know that I understand it’s hard for them but at the same time being constructive and using the tools that I have, i.e. physiotherapy skills. And being professional doesn’t mean I can’t show my clients that I care. My experience so far shows that the “rapport” works best if it entails caring, trust and “pushing” people to achieve new goals. If a client can do something they couldn’t do before, then we share this successful experience.

It’s a complicated topic, so I hope you can navigate through this hodgepodge of thoughts…



My name is Liina and I’m from Estonia, a microscopic European country by the Baltic Sea. Last year I graduated from the University of Tartu and received my Master’s degree in physiotherapy. During my 6 years of study I have also spent one year at The University of Toronto as  an exchange student.

I have been working in the Estonian rehabilitation system as a physiotherapist since 2010, mainly with adults who have musculoskeletal or neurologic problems, but also a little with geriatric clients and children. During the last months I have also been busy helping to implement the EQUASS (European Quality in Social Services) certification programme in our facility, and ethics is one of the core themes in EQUASS.

I have always been interested in bioethics and since there weren’t enough ethics courses in my curriculum, this one caught my attention immediately. Taking a course like this “forces” you to step back from your everyday work and reflect on it from a different perspective. Simply put, I hope this course will be an intellectual challenge and help me do my everyday work better. And last but not least, taking a course (even if it is an online course) from a university in South Africa, Cape Town is a unique opportunity.

And also I’m at home with my newborn daughter who likes to sleep a lot and leaves her parents enough time to take part in interesting courses and projects 🙂

Finally, I would like to share with you one of my favourite physio memes: