Ethical Challenges in Inpatient Rehabilitation: A Neuropsychological Perspective on Four Core Issues

Introduction

Ethical decision-making for neuropsychologists in inpatient rehabilitation is rarely straightforward. Unlike outpatient practice, where patients typically have stable capacities, and clinicians can engage in considered deliberation when ethical questions arise, inpatient rehabilitation disrupts this structure. It creates unique vulnerabilities due to interdisciplinary pressures, institutional systems, and professional responsibilities. Indeed, common ethical dilemmas may include fluctuating patient consent capacity with medical status, clinicians being asked to exceed their scope of practice, and non-psychologist colleagues misinterpreting sensitive psychological findings in electronic records. Patient vulnerability in this setting is heightened: individuals in inpatient rehabilitation frequently make decisions under suboptimal conditions, including sleep deprivation, pain, and sedating medications, and the rapid evolution of medical and cognitive status demands continuous re-evaluation rather than static assessment (Johnson-Greene, 2018).

These individual-level challenges are compounded by the interdisciplinary team model, which includes daily rounds, family meetings, and discharge planning and inherently requires broader information sharing than traditional psychological practice, potentially pressuring clinicians to exceed their scope of competence or to prioritize institutional efficiency over individual needs. Institutional imperatives such as insurance timelines and hospital bed turnover further heighten the risk of boundary blurring, making this setting uniquely vulnerable compared to other practice contexts.

Despite these apparent complexities, empirical literature specifically addressing ethical challenges unique to inpatient rehabilitation neuropsychology remains limited. While robust ethical frameworks exist for other settings, the distinctive intersection of medical acuity, interdisciplinary embedding, and neuropsychological practice has received less systematic attention (Bush, 2018). This gap stresses the value of practice-based guidance tailored to the realities of this setting.

This article highlights pressing ethical issues in inpatient rehabilitation and provides practical, evidence-informed strategies with reflective prompts. Our goal is to equip neuropsychologists with frameworks to uphold professional integrity and foster patient-centered care (Caplan, 1982). To ground this discussion, we examine four core domains in which ethical tensions most often arise: informed consent and capacity, confidentiality, professional competence, and boundary management.

Core Ethical Challenges and Practical Approaches

Informed Consent and Capacity Assessment: A Dynamic Assessment

Informed consent is the process by which patients are given sufficient information to voluntarily agree to procedures or assessments (APA, 2017, Standard 3.10). Yet, research suggests that fewer than 50% of patients in acute care settings fully understand standard consent procedures (Falagas et al., 2009). In inpatient rehabilitation, this is magnified: patients often experience fluctuating cognitive capacity due to factors such as acute injury, fatigue, and medication effects.

Capacity refers to an individual’s functional ability to understand relevant information, appreciate consequences, reason about options, and communicate a choice (Grisso & Appelbaum, 1998). Importantly, capacity is not a static, all-or-nothing state; it is task-specific and time-sensitive. A patient may be competent to consent to a blood draw in the morning but later that same day may lack the capacity to weigh the risks of a complex surgical procedure. Psychologists must therefore move beyond a one-time assessment, engaging in ongoing monitoring and re-evaluation of a patient’s ability to understand information, appreciate consequences, reason about options, and communicate choices (Grisso & Appelbaum, 1998; Appelbaum, 2007; Moberg & Kniele, 2006).

Recent research emphasizes the importance of dynamic capacity assessments in acute care settings (Palmer & Harmell, 2016), including frequent monitoring and re-evaluation of evolving capacity (Moberg & Kniele, 2006). When proxy decision-makers are necessary, ensure their choices align with the patients’ known values, advocating for the patient’s dignity and autonomy. For pediatric cases, balancing minor assent with parent consent requires careful navigation of developmental autonomy and best interests (Bush & Pimental, 2018).