A patient admitted to the acute-care service after a stroke was evaluated for dysphagia with a modified barium swallow study (MBS). The speech-language pathologist (SLP) noted significant aspiration for all consistencies, and the patient was not able to comply with trial compensatory techniques. Twenty-four hours later, the patient was more alert and could follow simple directions but not to the level of engaging in dysphagia therapy. The patient was not able to participate in his own care decisions. The SLP expected further improvement and supported placement of a PEG tube for feeding until such time as the patient would be better able to cooperate in a treatment program. The patient did not have written medical directives. The family member with durable power of attorney for medical decisions denied the feeding tube placement, saying that her relative would not want such an extraordinary treatment. What is the next step the SLP should take?
A pediatric patient in the outpatient clinic of a medical center presented with multiple articulation and phonological errors. The SLP concluded the child had a phonological disorder that could improve with intervention, and the parents were anxious for the child to receive the services. The parents said that they could not pay for the services unless they received insurance reimbursement. If the submitted diagnosis is developmental apraxia, the services will be reimbursed by insurance. If the diagnosis is recorded as articulation/phonological disorder, the services will not be covered. Since the child would benefit from services and cannot get them otherwise, may the apraxia diagnosis be used?
SLPs employed in an outpatient medical setting are subject to high productivity standards that must be met in order to support the departmental budget and to avoid personnel cutbacks. Fairly often, an SLP notes that a patient could achieve maximum benefit from fewer sessions than are allowed under the patient’s diagnostic category, but the department will remain fiscally stronger if recommendations are made so that the maximum number of allowable sessions is provided. How should the SLP proceed with recommendations?
A rehabilitation program has had an open position for an SLP for some months. The rehabilitation director, an occupational therapist, met a recently retired SLP at a social event and encouraged her to apply for the position. The applicant spent the last 30 years providing services in a school system. Some weeks pass, and the retired SLP is hired for the rehab program and reports to work. The rehab director introduces her to other staff for the first time and asks one of the SLPs to assist in orienting the new SLP to the patient workload and clinic procedures. Once the rehab manager walks away, the recently hired SLP states that she has no training or skills in dysphagia, aphasia, or cognitive/communication disorders with adults. She indicates to the SLP designated to assist with orientation that she should “Teach me everything I need to know as quickly as possible.” What are the ethical implications for each of the SLPs?
While these scenarios involve different stakeholders and settings, the need to think and behave in an ethical manner is consistent from example to example. This chapter is designed to provide the professional employed in the medical setting with the resources and tools to respond to such dilemmas ethically and professionally.
21.1 Scope of the Chapter
Ethical principles are as definitive for a profession as a scope of practice. Indeed, ethical principles are relatively stable over time and are consistent across practice settings, even as the scope of practice evolves and changes. In this chapter, the relationship of the profession of speech-language pathology to its ethical tenets is discussed. Codes of ethics of other professions are addressed when they are relevant to the foundations for the practice of speech-language pathology. A framework for ethical decision making is proposed, with an emphasis on issues specific to the medical setting, while a distinction is made between ethical and legal issues. Sources of support for facing ethical dilemmas within the medical setting and resources available from professional organizations are suggested. The overarching theme of the chapter is the use of ethical principles to guide workplace decisions and behaviors.
A basic assumption in the discussion is that professionals are providing evidence-based care for patients and are utilizing the most current information available in determining what their services will be. It is impossible to separate ethical practice from the delivery of competent assessment, intervention, and decision making, and the latter is assumed in the scope of this chapter. One cannot provide services ethically without knowledge and skills, and those elements of current practice are the expected underpinnings in the discussion to follow.
21.2 Perspectives on Ethics from the Evolution of a Profession
All professions evolve in similar ways, from early practice of a needed service through stages that include formalizing training, establishing professional organizations, and regulating the practice through laws and statutes. Individuals engaged in a profession render a helpful service for which they are compensated, and the members of the profession govern themselves in a way that serves the public good. 1 Prestige and autonomy are afforded to individuals who practice a profession, and members of the profession form organizations that work to define the scope of responsibility, the types and levels of training, the necessary skills and knowledge to be qualified to render professional services, and the code of conduct by which all members must abide. Establishing such codes means that professional responsibility is shared by all members. Those same members disseminate and publish the expectations for adherence to the code of conduct and also enforce penalties for violations. 1 A profession’s code of conduct, generally referred to as a code of ethics, holds professionals to higher standards than statutes or laws that regulate the practice of the profession.
There is intent, when a professional organization establishes a code of ethics, that the principles contained in the code will be applicable across practice settings and all individuals who practice the profession. The guidance of the code of ethics is neither exceptional nor unique when professionals practice in a medical setting. What may be unique to the medical setting is that ethical decisions may have a more immediate impact on the quality of life of the persons served than in some other settings. As in all settings, and especially when speech-language pathology is practiced in the medical arena, an ethical perspective is essential and must be a fundamental component of every decision.
21.3 Speech-Language Pathology and the Code of Ethics
The Board of Ethics, a semi-autonomous body within the American Speech-Language-Hearing Association (ASHA), develops and revises the Code of Ethics 2 that governs the approximately 136,000 SLPs who are certified members, certificate holders, and individuals in the certification process. 3 Based on the most recently completed member counts, 4 approximately 38% of the total number of SLPs affiliated with ASHA, or almost 36,000, work in a health care setting. Approximately one-third of those professionals identify a hospital as the primary workplace. The other two-thirds work in nonresidential and residential health care facilities. With a robust workforce providing services in health care facilities, ASHA’s ethical tenets affect a broad professional and patient base in the health care environment.
Various levels of ethical guidance exist simultaneously within the profession of speech-language pathology. All individuals who apply for membership or some level of affiliation with ASHA (student member, associate, international affiliate, certificate holder) agree to abide by the ASHA’s Code of Ethics. All ASHA affiliates and members also agree to report observed violations of the code by fellow members to the Board of Ethics. In this way, adherence to the ethical principles is jointly upheld by all those who comprise the profession. In most instances, state credentialing regulations also include reference to adhering to a code of ethics and those codes are typically based on the ASHA Code of Ethics. Due to the complex nature of the legislative process, state codes of conduct are generally not revised when there are minor revisions to the ASHA Code, and there can be some nonsubstantive differences between the national and state guiding documents. Employment settings may have their own codes or credos that are more general, and such codes are quite common in medical settings. Credos are developed in relationship to the vision and mission of the institution, and they do not supplant a professional code of ethics or state regulations, but they may serve to focus individuals who work in those settings on additional behaviors that are expected.
21.3.1 ASHA’s Code of Ethics
ASHA’s Code of Ethics 2 is based on four guiding principles that are elaborated by supporting and explanatory rules. Additionally, a preamble describes the individuals who must be guided by the code and the nature of the code, which is characterized as both “aspirational and inspirational.” 2 The guiding principles relate to the most basic of professional responsibilities and specific obligations for valuing the welfare of patients, for providing competent and responsible services, for practicing honestly and fairly in relating to the public, and for upholding the dignity of the profession.
Principle of Ethics I—Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner. 2
Responsible service delivery, which ensures the best possible outcomes for patients, is at the core of the Code of Ethics. Since the profession exists to serve persons with communication needs, it is a fundamental value that those who are served must be able to rely on a painstaking focus on their personal welfare. This focus on the welfare of those served extends to include those who serve as research subjects for professionals who are building the scientific foundations of the profession as well as to the nonhuman research subjects who support laboratory investigation. The supporting rules for Principle of Ethics I include attention to competent service delivery; utilization of all necessary resources, including referral; and nondiscriminatory practices in both services and research. Also inherent in Principle I are guidelines for use of appropriate credentials and representation of credentials of support personnel. Guidance for the circumstances under which services may be delegated to others, such as students or support personnel, is contained in the rules for this principle. Information to support a response to the first ethics scenario at the beginning of the chapter can be found in the rules associated with Principle I.
The rules in the other sections of this principle, while applicable to all practice settings, are particularly germane to the medical setting. In the context of changes in health care regulations and a focus on patient outcomes, the provision for fully informing patients regarding effects of services and products and continually evaluating the effectiveness of those services and products is essential, as is providing sufficient notice when services are to be terminated. Regulations for protection of patient information, as governed by applicable law, are supported by the ethical tenets of Principle I. Other rules relate to charging appropriately for services rendered and representing services accurately. The second ethical scenario described at the beginning of the chapter involves a dilemma that can be guided by the rules in this principle. Principle I also affirms the requirement that professionals must withdraw if service delivery is adversely affected by health conditions or substance abuse. All of the rules in Principle I support an environment, whether in a health care setting or elsewhere, in which the right to appropriate services focused on patient welfare is paramount.
Principle of Ethics II—Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance. 2
Corollary to the patient’s welfare is the delivery of competent services by a qualified provider. Professionals must provide services within their scope of practice when using their credentials to support such service delivery. Even fully credentialed practitioners may not be trained to provide certain services, as in the final scenario provided at the beginning of the chapter, and the rules associated with Principle II will guide a response to that dilemma. Practitioners must be prepared to seek assistance from others when they do not have the appropriate skills or training to treat a patient and should also expect to gain formal training in areas outside their expertise from professional and educational providers when necessary to function in a particular employment setting.
The rules supporting Principle II focus not only on competent service delivery but also on the maintenance of a high level of competence, including engaging in lifelong learning. Patients in medical settings present with highly complex and interrelated conditions, many of which may have an impact on communication, cognition, and swallowing. Appropriate treatment may be complicated by the patient’s inability to participate effectively in his or her medical care and by conflicts among family members or others as to what constitutes appropriate care. Due to their effect on quality of life and the possibility of life-or-death impact on patients in the medical setting, practitioners in such settings must be ever vigilant in developing new skills and knowledge, gaining clear understanding of the patients’ values and needs, and effectively collaborating with other professionals in the medical environment.
Principle of Ethics III—Individuals shall honor their responsibility to the public by promoting public understanding of the professions, by supporting the development of services designed to fulfill the unmet needs of the public, and by providing accurate information in all communications involving any aspect of the professions, including the dissemination of research findings and scholarly activities, and the promotion, marketing, and advertising of products and services. 2
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