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p eech
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athology
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ustralia
MULTICULTURALISM AND DYSPHAGIA
pathologists and their professional associations with
arguments against resource allocation and prioritisation
which exclude children and people with disabilities from
speech pathology services.
It is clear that resources for health care need to undergo an
allocation process; however, how such decisions are made is
an ethical matter. If we want our clients to have access to a
“decent minimum” (Beauchamp & Childress, 2009, p. 260) of
health care, then the principles of “equal share” and “need”
can be drawn upon. Allocating resources on the basis of an
equal share for all belies the reality that some people have
more health care needs than others. It may also result in
virtually nobody getting effective care, “the jam being spread
so thinly it can no longer be tasted” (Sim, 1997, p. 127). The
alternative of providing different levels of health care accord
ing to need presents some challenges as well. A disproportionate
amount of service may be needed to achieve gains, for
example, for those whom we label “disadvantaged”. On the
other hand, a small amount of service may be all that is
required to achieve significant outcomes for some people in
so-called low priority categories. Body and McAllister (in
press) consider the ethics of health economics and provide
some discussion of factors to be considered in making
resource allocations across health services and within speech
pathology services themselves.
One of the outcomes of reducing services available in the
public sector has been the growth of private practice. While
recognising the many benefits of this trend to both clients and
the profession, workshop participants expressed concern
about standards in private practice, especially with regards to
knowledge of the evidence base and maintenance of fitness
for practice. It is worth noting that a majority of inquiries
about possible ethics complaints received at National Office
of Speech Pathology Australia pertain to service provision
within private practice.
Staying on top of the growing evidence base for our
practice and maintaining fitness for practice are concerns for
the whole profession, not just private practice. Earlier in this
paper we raised the issue of responsibility for CPD, which
becomes particularly important as consumer expectations and
knowledge of our evidence base increase with rising Internet
access and information literacy of the community. In this
context, and also that of changing scope of practice, ensuring
fitness for practice of new graduates, clinicians changing
work sectors (e.g., from health to disability, from education to
health), and rural and remote practitioners becomes a major
ethical obligation for employers, individuals and the
professional association. Ensuring the competence and
standards of practice for allied health assistants and other
support workers will also become a major ethical issue as
reshaping of the workforce occurs and delegation of some
speech pathology tasks becomes more common.
The ethical issues involved in delegation should not be
allowed to mask what Threats, writing in Body and McAllister
(in press), refers to as “protectionism”, however. In the
absence of evidence that speech pathologists deliver superior
treatment to that provided by assistants under their super
vision, Threats argues that there are ethical considerations (as
well as economic considerations) in allowing the extension of
speech pathology services using assistants and volunteers to
reach a greater number of people than the speech pathology
workforce alone could deliver.
While fiscal constraints, workforce concerns, population
trends and consumer preferences are driving shifts in resource
allocations and modes of service delivery, increasing litigation
is also driving management policies. As organisations seek to
limit risk and litigation, some practitioners in the workshop
reported incursions on clients’ autonomy and quality of life.
2008). Such conflicts highlight the needs for continued work
on expanding our evidence base and for advocacy at
individual and professional levels. McLeod, writing in Body
and McAllister (in press), suggests that reference to the
United Nations
Convention on the Rights of the Child
(1989) and
Rights of Persons with Disabilities
(2006) may provide speech
Table 1. Emerging ethical concerns for Australian
speech pathologists
Medical focus on saving lives versus quality of life
Resource allocation and prioritisation issues
Tension between service policies and values of
profession
Restricting rights of others by focusing on particular
service areas
Narrowing of services to some groups (e.g., fluency,
voice)
Families forced to seek private therapy due to decreased
service in public sector
Prioritisation – clinician choice versus service direction
Clients with speech and language alone – low priority
compared with clients with behaviour problems for
“early intervention”
Uneven decision making – acute versus disability
Tightening of eligibility for service related to age
How you engage with clients – limitations of service
available
Individual/one-size-fits-all decisions
Push for discharge versus completion of episode of care
Time limits imposed not evidence-based practice
Services to clients of non-English speaking backgrounds
especially in remote areas
Occupational Health and Safety (OH&S) risk manage
ment for organisation overrides client quality of life
Changing scope of practice
Consultancy role for speech pathologists
Expansion of roles in workplace in areas of care
planning, advocacy
Use of allied health assistants/support workers
Training needs
Clarification of roles
Accountability to whom? ward? team?
Safety and risk
Discipline specific versus multi-disciplinary student
placements
Managing expectations of clients
Private practice standards
Accreditation issues
Evidence based practice
What evidence? New/old evidence?
Hard to “manage” the evidence
Lack of evidence
Are we ethically bound to research areas with poor/
little evidence?
Fitness for practice
Problems with access to continuing professional
development (CPD)
Supervision re “standards” for rural and remote speech
pathologists
Access to professional development resources and
opportunities restricted by employers (e.g., backfill
time not available to go to CPD; firewalls prevent
access to Internet at work)