Today, science is advancing at a remarkable rate. However, scientific advances will benefit human beings if they are morally supported. This is the case with all sciences, including medical sciences. In fact, ethics plays a pivotal role in medicine.

Physiotherapy is one of the fields of medical science that have grown significantly in recent years. Evaluation, diagnosis, and treatment of a wide range of disorders and diseases are offered in physiotherapy. Non-compliance with ethical principles limits physiotherapists’ clinical practice and can harm patients. This code of ethics has been designed and introduced in order to surmount such limitations and prevent resultant harms. Ethical agencies in physiotherapy around the world have provided similar ethical codes.

It is not possible to develop medical codes of ethics without considering the beliefs, values, ​​and moral principles of the affected society. Iran’s governmental policies in the field of health emphasise a core of morality, aligned with the Iranian Constitution and the Article 1 of the Civil Law of the Islamic Republic of Iran which give priority to ethico-islamic principles. the Islamic Republicof Iran has also developed and publicised various ethical guidelines, including the General Guide to Professional Ethics for Professionals Affiliate with the Medical Council of the Islamic Republic of Iran, as well as general and specific national biomedical research ethical guidelines, which implies the importance of prosessional ethics in the Iranian society. Given that the purpose of such moral centredness is to uphold standards in the fields of medical treatment, research, and education, the first step to achieve this goal is to establish clear guidelines. Therefore, there is a need to establish a code of ethics for physiotherapy for professionals, researchers, professors, and students.

This research has been undertaken using a methodological and scientific approach in line with previous attempts to compile codes of ethics for physiotherapy, and it is hoped that it will complement the previous efforts of researchers in this field. The principles presented in this research have been drafted according to international codes and keeping in mind the cultural, social, and ideological concerns of Iranian society. These principles are structured in three sections: ‘Ethics in providing physiotherapy services’, ‘Research ethics in physiotherapy’, and ‘Ethics in physiotherapy education’. Each section has various chapters and axes, covering the pertinent codes of ethics.

These ethical guidelines are recommended for implementation to the competent authorities, including professional institutions, and also the relevant organisations.

1.1.3. Professionals are obliged to follow nationally approved diagnostic and treatment guidelines to the extent feasible.

1.1.4.  Professionals must provide merely those services that they have received relevant training in and of which they possess sufficient knowledge, skills, and experience.

1.1.5. Professionals must examine and evaluate patients in physiotherapy practice in order to plan and implement appropriate treatment interventions.

1.1.6. Professionals shall not leave tasks that require professional skills, knowledge, and judgement to be done by incompetent coworkers.

1.1.7. Professionals must continue to improve their knowledge and maintain their professional competence.

1.1.8. Professionals must refer the patient to the competent practitioners and specialists whenever necessary and are not permitted to receive any gain for this referral.

1.1.9. Professionals must supervise the performance of their employees or assistants thoroughly in order to make sure that their performance is in accordance with professional and ethical guidelines.

1.1.10. Professionals must provide the required facilities to manage emergencies that may occur during patient treatment, and must have sufficient knowledge to act in such cases. They are also obliged to promptly provide further medical interventions to treat the emergency medical condition.

Axis 2: Respect for the patient’s privacy, confidentiality, and preferences

1.2.1. Professionals are obliged to maintain the confidentiality of the patient’s information and shall not disclose medical or personal patient information to others, except upon the request of judicial authorities.

1.2.2. Professionals must provide patients with their medical records upon request.

1.2.3. Professionals must be aware that patient information, including images, should not be shared on social media.

1.2.4. Professionals are obliged to respect patients’ privacy and refrain from simultaneous physical examination of multiple patients. Patients should be dressed appropriately during the examination and the interventions should be done by a same-sex professional as much as circumstances permit.

1.2.5. Professionals must be aware that when the patient’s information needs to be disclosed to a third party, this can only be done with the authorisation of the patient or the surrogate decision-maker.

1.2.6. Professionals are committed to respect the patients’ rights to information, self-determination, and decision-making, and to ensure their informed consent to the treatment or the intervention prior to its implementation.

Axis 3:  Honesty and veracity

1.3.1. Professionals are obliged to honestly provide information about the nature of their services to patients and colleagues who need to make decisions about utilising them.

1.3.2. Professionals have the right to advertise their services, but they shall not use emotional, unfair, misleading, or deceptive claims and statements.

1.3.3. Professionals are obliged to present their academic degree and licence correctly, and shall not use titles that do not correspond to their training and competency status.

1.3.4. Professionals should not use their professional or business affiliations in a way that restricts service delivery or misleads others.

1.3.5. Professionals have a responsibility to ensure that patients understand the nature of the services provided and, in particular, the estimated costs before the service is provided to them.

1.3.6. Professionals are required to record and maintain accurate and sufficient records and documents in the field of patient assessment and provided services, based on specialised and legal standards and needs.

1.3.7. Professionals can provide the patient with their predictions about the disease and its treatment process, but shall not give false information or guarantees about the efficacy of the service.

1.3.8. Professionals are required to inform the patient about the occurrence of an error or injury to the patient.

Axis 4: Compassion and empathy

1.4.1. Professionals shall treat patients with empathy and compassion.

1.4.2. Professionals are obliged to refrain from interventions and procedures that are solely done to prevent patients’ complaints.

1.4.3. Professionals are obliged to do their best to empathise with patients and avoid indifference or loss of self-control and becoming emotionally overwhelmed.

1.4.4. Professionals are obliged to communicate any error causing harm to the patient, while apologising and explaining the compensatory measures they have taken.

1.4.5. Professionals are obliged to take measures to prevent the future recurrence of errors and reduce the extent of the harm that the error has caused and communicate it to the patient.

1.4.6. Professionals are obliged to communicate the error to the patient proxy when the patient lacks decision-making capacity, including in the case of minors, patients with intellectual disability, and patients with decreased consciousness.

2.1. Professionals are required to deliver care to all individuals seeking rehabilitation services, regardless of age, sex, race, colour, nationality, religion, faith, moral beliefs, personal preferences, political beliefs, disability, and health status.

2.2. Professionals are obliged to schedule patients fairly.

2.3. Professionals are obliged to ensure that the fees being charged for providing care are reasonable and fair and based on legally approved tariffs.

2.4. Professionals are not entitled to a fee for services that are not provided.

2.5. The provision of specialised services should be commensurate with the needs of patients and without any discrimination.

2.6. Justice must be promoted in human and financial resource allocation, and in cases of limited resources, it is necessary to decide according to the priorities approved by the clinical ethics committees of medical universities or the Iranian Physiotherapy Association.

3.1. Professionals are obliged to treat patients with courtesy and to refrain from offensive behaviour.

3.2. Professionals are obliged to respect patients’ time and prioritise the patient’s interests.

3.3. Professionals are obliged to take sufficient care and caution to avoid injury to patients.

3.4. Professionals are obliged to take the precautions to avoid injury to patients during treatment procedures.

3.5. Professionals are obliged to serve the interests of the patient while providing care.

3.6. Professionals do not have the right to provide services that are not necessary for the patient.

4.1. Professionals are obliged to be aware of and act on the rights and responsibilities they have towards the public, society, colleagues, and their profession.

4.2. Professionals are obliged to contribute to public education programmes and the promotion of public knowledge.

4.3. Professionals shall assist professional authorities in emergencies.

4.4. Professionals shall not participate in activities that threaten the interests of their profession and are obliged to attune their professional behaviour to social norms not to harm the integrity of the profession and patient care.

4.5. Professionals are obliged to avoid conflicts of interest and shall disclose any conflicts of interest to patients and other stakeholders if its unavoidability is approved by clinical ethics committees (a scientific association or university).

5.1. Professionals are obliged to demonstrate respect while communicating with their colleagues.

5.2. Professionals are obliged to show respect, courtesy, and humility towards faculty members.

5.3. Professionals are obliged to treat students and young colleagues with dignity.

5.4. Professionals are required to respect the administrative hierarchy in service provider organisations.

5.5. As it is essential to maintain the public’s trust in the profession of physiotherapy, professionals are obliged not to disclose the scientific and technical errors of their colleagues to patients and to avoid communicating prejudice towards and distrust of their colleagues.

5.6. Professionals are obliged to respectfully communicate colleagues’ errors to them and support them in providing information about the error to the patient or their proxy.

5.7. Professionals are obliged to inform the competent authorities when the colleagues involved in the error are not willing to communicate it to the patient.

6.1. Professionals are obliged to be aware of and comply with the ethical rules and national laws governing their profession.

6.2. When regulations are deemed to be in conflict with the moral values held by professionals, the conflict shall be resolved through official institutions and scientific associations.

6.3. Professionals shall not engage in unethical or illegal practices.

6.4. Professionals have the right to refuse to provide services that involve illegal actions.

6.5. Professionals should be aware that they will be subject to disciplinary interventions by ethics committees or legal authorities when they do not comply with ethical or legal rules.

1.1. Professionals shall cooperate and participate in research activities to improve the quality of the provided services.

1.2. Researchers are obliged to submit the research proposal of a clinical trial in accordance with the relevant guidelines.

1.3. Researchers are obliged not to inappropriately use the ideas of others in proposing a research project.

1.4. Researchers are required to disclose the research sponsors and any form of conflict of interest.

1.5. Researchers are obliged to make the results of their research accessible in order to improve the profession, while respecting the rights and interests of all research stakeholders.

1.6. Researchers are obliged to follow the national research ethical guidelines before, during, and after conducting research. They shall also adhere to the principles of publishing ethics and the national guidelines when disseminating research findings.

Axis 1: Before conducting research

2.1.1. Researchers are obliged to describe the design and performance of the research study according to a specified protocol and submit it to the relevant scientific committee and an approved research ethics committee before the study begins. Research conducted in the private sector is also subject to this Guideline.

2.1.2. Researchers are obliged to strictly adhere to the approved research protocol. Following approval, changes to the research protocol shall be reviewed and approved by the relevant research committee and research ethics committee.

2.1.3. Researchers are obliged to ensure that the risk of injury to research participants is minimised in the research design.

2.1.4. Researchers shall not inflict harm and injury on research participants or restrict their autonomy for the reason of benefiting society or advancing science.

2.1.5. Necessary measures must be implemented in health-related research to prevent, diagnose, treat, and compensate injuries to research participants before conducting the research.

2.1.6. In research involving patients as participants, the benefits shall outweigh the risks. The relevant research ethics committee has the authority to determine this.

2.1.7. In research involving healthy participants, the acceptable harm shall not be greater than that ordinarily encountered in daily life. In identifying the risks encountered in daily life, the risks that participants confront due to their job, age, time, and place are not taken into account.

2.1.8. The practicality, simplicity, convenience, expediency, and economical value of the research cannot be a justification for exposing the participants to additional risk through the research.

2.1.9. If the research involves increased risk of harm to participants belonging to socioeconomical disadvantaged groups, the research ethics committee must ensure that the participants understand research harms.

2.1.10. Involving research participants in the research without disclosing relevant information is forbidden, unless the study participants have knowingly waived their right to information.

2.1.11. Researchers are obliged to obtain informed consent without any coercion, threats, undue influence, or seduction; otherwise, the consent obtained is invalid and is not legally binding.

2.1.12. If the researcher realises that the participants are facing a serious health threat during the research, he or she is obliged to terminate the research and initiate an  appropriate intervention to eliminate the threat.

2.1.13. Research involving vulnerable groups (children, prisoners, prisoners of war, refugees, the intellectually disabled, and the mentally ill) is prohibited, unless it benefits the members of that group.

2.1.14. Vulnerable groups, especially the disabled and elderly, shall not be included in the research population as a preferred class due to their particular circumstances, such as availability, and on the other hand, they shall not be deprived of the benefits of participation in research.

2.1.15. When the disabled and elderly who have limitations in terms of transportation, are the subjects of research, researchers should, as far as possible, approach them in their living quarters to collect data.

2.1.16. The research methods in use should not be in conflict with the religious and cultural norms of the community.

Axis 2: During the conduct of the research

2.2.1. Researchers are obliged to explicitly disclose any conflicts of interest, especially when they arise from research funding.

2.2.2. The reason for participant selection must be approved by the research ethics committee, when the researcher, organisationally or academically, is in a higher position than the participants, leading to the possibility of coercion of research participants and calling into question the validity of the informed consent.

2.2.3. Researchers are required to explain the method and purpose of the research, potential harms, benefits, and the nature and duration of the research to the extent required by participants, answer their questions properly, and subsequently mention these in the consent form.

2.2.4. It is the responsibility of the researcher to ensure that the participants understand the provided information. In cases where another person provides the information to the participants, the researcher is not disclaimed.

2.2.5. If, in the opinion of the researcher, providing some information to the participants in the research study can leads to distortions in the results, any withholding of information must be approved by the research ethics committee, and the researcher must explain formally how they will  inform the participants subsequently.

2.2.6. In clinical trials that have a case–control design, participants shall be informed that they may be randomly assigned to either a control or a placebo group.

2.2.7. In cases where participants in the study receive a placebo treatment and are unaware of the type of treatment (drug), the researcher should make arrangements such that, if necessary, information about the treatment (drug) can be made available to the participants or their physician.

2.2.8. Human research participants should know that they can leave the research study at any time, without having to explain to the researcher the reason for their unwillingness to cooperate.

2.2.9. The participant shall be informed about and supported to manage the adverse consequences of withdrawal from the study.

2.2.10. Researchers are obliged to consider information about the participants as ‘secret’ and will be kept confidential. They shall inform the participant in advance if there is a limitation on confidentiality.

2.2.11. When research involves vulnerable groups (minors, the mentally retarded, people suffering from dementia, and psychiatric patients), in accordance with article 2.1.13, approval by the ethics committee is required, and the written consent of the legal guardian shall be obtained.

2.2.12. If the research participant does not have dementia or psychotic symptoms at the beginning of the study and develops these conditions during the research, his/her prior consent is invalid, and written consent must be obtained from his/her legal guardian.

2.2.13. Participants who, at the beginning of the research process, were psychotic or under the legal age, shall give written consent if their capacity to consent is restored or acquired during the research, and the prior consent from the legal proxy will no longer be valid.

Third axis: After conducting the research

2.3.1. Any physical damage or financial loss that is imposed on the participants through the research shall be compensated according to the existing laws.

2.3.2. All rights of research stakeholders (participants, researchers, and the funding organisation), including their intellectual properties, shall be protected while publishing or reporting the findings of the research.

2.3.3. Researchers are obliged to inform beneficiaries about the results of the research.

2.3.4. Researchers are obliged to inform participants if a disease or defect is diagnosed in them through the research and to help treat them as much as possible.

2.3.5. While publishing the research results as scientific articles, researchers are required to adhere to the standards of research publication. In particular, the authorship of the manuscript should be carefully considered so that only those who meet them be identified as the author(a) of the article.

2.3.6. Researchers are required to report the personal information of the participants anonymously when publishing the research results, and participants shall be informed and give consent if it is necessary to mention the identifying information.

Axis 1: making efforts to improve students’ knowledge

1.1.1. Professors are obliged to do their best to advance students’ knowledge.

1.1.2. Professors are obliged to become familiar with the principles of education as well as modern teaching methods and to use the appropriate teaching methods to achieve the educational goals.

1.1.3. Professors are obliged to have sufficient mastery of the educational content and to ensure that the content provided is accurate, up-to-date, and relevant to the objectives of the course.

1.1.4. Professors are obliged to make every effort to improve their academic proficiency and update their knowledge.

1.1.5. Professors are obliged to refrain from commenting on a question if they do not know the answer and to refer the student to usable resources and references.

1.1.6. Professors are required to use valid principles and methods of evaluation (especially in terms of predictability and transparency).

1.1.7. Professors are required to use a variety of motivational methods and to try to prioritise incentive methods over punitive ones.

1.1.8. Professors are obliged to allocate sufficient time to solve students’ educational problems.

Axis 2: Ethical guidelines for clinical education

1.2.1. As the professor is a role model for students, they are obliged to observe the ethics of patient care during clinical education.

1.2.2. Professors are obliged to ensure that patients know members of the healthcare team and their professional status, as well as to teach students to introduce themselves and ask permission while examining a patient.

1.2.3. Professors are obliged to ensure that the educational process does not deprive patients of appropriate and timely treatment.

1.2.4. Professors are obliged to accept students’ feedback on possible errors in the process of diagnosis, treatment, and clinical education, and to take appropriate measures to protect the patient’s rights, while avoiding any negative effects on student–patient interactions.

Axis 3: Adherence to cultural and social norms

1.3.1. Professors are obliged to educate and evaluate students fairly, impartially, and without discrimination.

1.3.2. Professors are obliged to avoid romantic relationships with students as long as there is a direct educational relationship.

1.3.3. Professors shall obey the rules of confidentiality and refrain from disclosing the personal information of students.

1.3.4. Professors are obliged not to ruin the self-esteem, personality, and dignity of the students while interacting with them and to avoid behaviours that can degrade and drop the self-esteem of students.

1.3.5. Professors are obligated to maintain discipline and punctuality and to value students’ time.

1.3.6. Professors have a duty to treat students with empathy and benevolence and to strive for their moral growth and development.

2.1. Professors are obliged to respect the status and dignity of their colleagues and cooperate with them in developing and empowering students.

2.2. Professors shall be aware of, respect, and adhere to the educational goals, policies, and standards of the educational institution.

2.3. Professors must pay attention to professional commitments during clinical teaching.

2.4. Professors are required to participate ­­in continuing professional education, as required.

Axis 1: Striving for the proper use of knowledge

3.1.1. Students are obliged to respect the scientific expertise of the professor, pay attention to his/her teaching, and strive for the optimal use of knowledge.

3.1.2. Students are required to observe discipline and punctuality in the educational process and in educational environments.

3.1.3. Students are obliged to complete assignments carefully and turn them in on time.

3.1.4. Students are obliged to actively participate in the education process, to strive to improve their academic proficiency, and to update their knowledge.

Axis 2: Ethical guidelines for students during clinical training

3.2.1. Students are obliged to observe the ethics of patient care during clinical education.

3.2.2. Students shall introduce themselves prior to examining the patients and seek permission from them.

3.2.3. Students are obliged to refrain from engaging in medical interventions in which they have not received sufficient training or acquired the needed skills except in the presence of the professors and under their direct supervision.

3.2.4. Students are obligated to report any errors that might cause harm.to professors as soon as possible

3.2.5. Students shall provide appropriate feedback to the professor in cases where there is a strong possibility of an error having been made by the professor in the patient’s diagnosis or treatment.

Axis 3: Adherence to cultural and social norms

3.3.1. Students are obliged to treat their professors fairly and impartially while evaluating and providing them with feedback.

3.3.2. Students are obliged to demonstrate respect, courtesy, and humility in communication with the professors.

3.3.3. Students are obligated to refrain from romantic relationships with the professors as long as there is a direct educational relationship.