JCPSLP Vol 17 Supplement 1 2015_lores

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JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology 23
millennia past, health professionals have striven to practice
ethically. This desire was driven mainly from altruistic
principles of client-centred care and a need for
professionals to be seen as acting with integrity so as not to
impugn the good name of their professions. These
motivations undoubtedly still remain but are now located
within contexts of increasingly complex societies and
workplaces. Four pressures facing speech language
pathologists are: increasingly complex caseloads,
increasing workplace pressures, increasing litigation and
increasing demands for evidence-based practice. Given the
diverse settings in which speech-language pathologists
work, the inadequacy of biomedical approaches as
frameworks for discussions of ethics in speech pathology is
also considered.
Increasingly complex caseloads
Increasing neonatal and adult trauma survival rates,
lifesaving and life-prolonging medical and surgical
technologies and procedures, increasing adult trauma
survival rates, and the ageing of the population, among
many other advances in modern medicine, have lead to
increased rates of disability in schools and community
settings. As a result, health professionals now routinely
work with clients with complex, life-threatening or disabling
conditions. The case study of Mary in the Ethics Education
Package illustrates just such a case. Key features of the
case study include:
• Mary is 32 years of age; she has spastic quadriplegia,
severe dysphagia, aspiration of all food and fluid
consistencies, severe communication impairment and is
malnourished;
• team members recommend only non-oral feeding;
• Mary and family want to continue oral feeding (issues of
quality of life and autonomy);
• nursing staff and paid carers fear risks of oral feeding.
This case study involves conflict between all the ethical
principles and duties outlined earlier. Consideration of
ethical issues in this case is compounded by the fact that
Mary lives with a chronic disability, staff are engaged in
long term, caring relationships with her, and care about her
quality of life. For these reasons, codes of ethics which are
founded only on biomedical principles are inadequate in
guiding action to resolve the issues involved.
Limitations of our current
biomedically oriented ethical
principles
Most codes of ethics in the health professions are derived
from a biomedical paradigm of practice (Beauchamp &
Childress, 1994). However, speech pathologists, like many
allied health professionals, work across biomedical, social
and educational models of practice. We are engaged in
sustained relationships with our clients, and as a result have
an ongoing duty of care. We are concerned with quality of
life issues, not just issues of “saving of life”. Noddings
(1984) has written extensively about an “ethic of care”. How
can we as speech pathologists integrate and foreground
this ethical principle of care into our existing principles?
How might this ethic of care be expressed in our daily
work? In addition, the relational nature of our work and the
use of self-astherapeutic agent mean decision-making is
not “clinical” or “black and white”. Instead as Schön (1987)
suggests, professional practice deals in the “grey areas”
and “the swampy lowlands” of professional practice. To act
ethically in contemporary speech pathology practice forces
of ethics. By not attempting the impossible task of
prescribing and delimiting what is ethical behaviour and
proscribing unethical behaviour, the code has the potential
to encourage speech pathologists to think ethically and
integrate ethical principles into their diverse, complex and
rapidly changing daily work practices. However, my
discussions as a mentor with speech pathologists about
ethical matters suggests that this diffusion into everyday
thinking and practice is not easily or routinely occurring for
all clinicians. Ethics is more than following ethical decision-
making protocols. As Midgely (1993, p. 25) noted:
judging is not simply accepting one or two ready
made alternatives as the right one. It cannot be done
by tossing up. It is seeing reason to think and act
in a particular way. It is a comprehensive function,
involving our whole nature, by which we direct
ourselves and find our way through a whole forest
of possibilities … We are always moving into new
territories. All the same, some explicit maps and some
general guidelines for explorers do exist and can be
referred to. There is constant use of rationality; the
area is cognitive; we can know things. We are not just
guessing or gambling.
In pursuing our ideals as a profession for ethical conduct
of members, we need to do more than focus just on
ethical dilemmas. In the absence of research into ethics
in our profession we can extrapolate from other health
professions (such as occupational therapy), which share
similar underpinning values about client relationships, to
guide considerations of an expanded view of what it means
to think and act ethically. Wright-St Clair and Seedhouse
(2004, p. 18) argue that:
By their very nature, professional codes of ethics
contribute a shift in emphasis from morality being
considered as integral to relating in the everyday
practice world towards being something that directs
decisions about how to act, particularly in ethically
challenging situations.
They suggest that the commonplace nature of morality
consigns it to routine, habitual ways of acting in the world
and that these ways are rarely subjected to scrutiny. They
suggest that it is only when something unusual happens,
such as the presentation of an ethical dilemma, that the
way we think and act with regard to ethics is considered.
I ask speech pathologists to consider whether this
“fascination in extraordinary events” (Wright-St Clair &
Seedhouse, 2004, p. 19) in the form of ethical dilemmas,
rather than the moral practice of everyday work, also
occurs in speech pathology. I question whether the focus
of the Ethics Education Package on a decision-making
protocol to resolve ethical dilemmas inadvertently reinforces
this notion that ethics comes into play only when we are
faced with unusual, rather than daily situations.
Moving beyond a focus on dilemmas, I also suggest
that as a profession we may be too focused on our ethical
duties to clients, to the neglect of meeting our ethical duties
towards community, employer, profession and colleagues.
There may be many good reasons for this and I want to
move on now to a consideration of some of the pressures
which obscure awareness of the broad ethical context in
which we operate.
Pressures on ethical thinking
and action
Since the founding of health care professions and the
promulgation of the Hippocratic Oath for doctors in