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JCPSLP
Volume 14, Number 2 2012
Journal of Clinical Practice in Speech-Language Pathology
person. Applying the ethical principle of
beneficence
helps
guide clinicians in determining whether their level of
expertise and limited involvement might do the person
good while avoiding any associated harms (principle of
non-
maleficence
) (see also Speech Pathology Australia, 2010).
The influence of the environment and communication
partners over the success or otherwise of any AAC
intervention must be considered (see Beukelman &
Mirenda, 2005; World Health Organization, 2001).
An ethical dilemma may arise when a particular AAC
intervention, such as the provision of a speech-generating
device, requires accompanying service hours for effective
use of the device which might not be available or
covered by existing funding arrangements. It might not
be considered ethical to conduct a full assessment, then
trial of a range of devices, and obtain funding to purchase
a device, if there is not also adequate follow-up support
to ensure that the device is useful and is not abandoned
through lack of support. Potential harms in such a situation
of failure and abandonment include communication
partners and the person with complex communication
needs being reticent to attempt other interventions that
might be better supported in the future (Williams et al.,
2008). Nonetheless, potential benefits to the person
of having the system available and the opportunity for
improvements in the communicative environment to occur
must also be taken into account.
Ethical dilemmas can also arise in relation to decisions
based on the relative costs of each AAC option that
might suit the person. Provision of a relatively cheap
communication aid (e.g., mobile technology AAC system)
might or might not be helpful if the communication aid
has so few individualisation options that the person can
only access some features of the device or only use it in
some situations (AAC-RERC, 2010). Nonetheless, while a
low-cost system might not meet all of the person’s needs,
it might provide some benefit as to warrant exploration as
an option for intervention to meet some of the person’s
communication needs. Speech pathologists, therefore,
have an ethical responsibility to (a) advocate on behalf
of clients to funding bodies and governments to remove
cost as a barrier to a person’s best option in AAC, and (b)
pursue follow-up support and training for the person and
communication partners that can be obtained through
distributors and manufacturers of the device, and also
through formalised peer-mentoring systems if these can
be arranged (Ballin et al., 2012). It is also important that
clinicians who are aware of unmet needs in relation to multi-
modal communication advocate for expanding resources
available to meet those needs.
Mobile technologies: an expanding
range of AAC options
The advent of mobile technologies (i.e., touch screen
devices that connect to the Internet) with AAC software
applications and switches to access mobile device AAC
apps (see Farrall, n.d.; 2012) has been hailed a paradigm
shift in the field and practice of AAC, owing to the much
wider availability and recognition of AAC in the community
and a much greater availability of speech aids to people
who previously did not have access to these (AAC-RERC,
2010). The introduction and development of mobile
technology AAC mean that speech pathologists and others
need to consider a wider range of options than previously
available in arriving at ethical decisions. Speech
necessarily involves the collaborative input of a range of
stakeholders including the person with complex
communication needs. However, the priorities over design
and inclusion of topics and vocabulary should rest with the
person’s own needs and preferences and not only those of
their communication partners (see McNaughton &
Beukelman, 2010). All people have a right to communicate
for themselves to the extent that they are able (World Health
Organization, 2010; United Nations, 2006). Thus, each
person’s communication system should be validated as
reflecting his or her own preferences and reflecting his or
her own voice. Establishing autonomy in communication is
of vital importance in the field of AAC, as people with
complex communication needs often rely upon
communication partners to set up a system that can be
accessed by them without influence. Access to the system
might also depend upon the involvement of a range of
communication partners in determining the person’s
message (e.g., partner assisted scanning, encoded
communication). Nonetheless, it is possible that a person
with complex communication needs may have direct and/or
indirect access to a communication aid, and continue to
maintain independence or autonomy in communication.
Many technologies are now available and in development
to support both direct and indirect independent access to
computers and communication aids, and reduce reliance
upon communication partners to assist in message
selection (e.g., various new switch technologies, eye gaze
technologies, brain computer interface technologies).
Where the speech pathologist considers that a person’s
AAC system might not represent his or her true voice, or
that the person does not have autonomy in expressing his
or her own thoughts, they have an ethical responsibility
to (a) raise these concerns with the person and their
communication partners so that further actions may be
taken to remove harms, and to help the person towards
an AAC system that does reflect their own views and
preferences; and (b) consult with the Speech Pathology
Australia’s Senior Advisor Professional Issues who would
then advise if it was a matter to go to the ethics board,
which involves a written complaint process.
Ethical resource allocation in AAC:
working within available resources and
seeking to expand resources
The ethics of resource allocation are highly relevant in the
field of AAC. The demands for AAC services are likely to
increase in line with increased survival rates associated with
developmental and acquired disabilities, the ageing of the
population, public awareness of AAC, and the possibilities
afforded by new assistive technologies. Adolescents and
adults with lifelong disabilities who use AAC are particularly
vulnerable to the impact of increased service demands that
are not matched with expanding resources, at a time when
they are in transition and moving to a greater need for
communicative autonomy (McNaughton & Beukelman,
2010). Ideally, clinicians strive to source the best available
research evidence for the AAC intervention and instructional
methods, and source resources that will be required for
each treatment option. However, not all necessary
resources might be available for all potential options. Thus,
speech pathologists may be faced with knowing they can
do
something
for the person with complex communication
needs, while realising that they might not be able to do
everything
that might be necessary or of benefit to the