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JCPSLP
Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology
Journal of Clinical Practice in Speech-Language Pathology
us from litigation. Nor will following the law necessarily
protect us from ethics complaints. The interplay of ethical
and legal conduct can be envisaged as follows:
We assume we readily will recognise illegal practice;
can we readily recognise unethical practice? How attuned
are we to practice that may be legal but not ethical, and
conversely ethical but not legal? For example, reading the
findings of the ASHA Ethics Board published in the ASHA
Leader reveals cases where speech pathologists have
been overly generous in interpreting treatment data as
showing progress, so that clients can stay in treatment paid
for by insurers. Some of these clinicians have attempted
inadequately to reconcile conflicting ethical principles
and duties to clients versus employers and insurers. We
increasingly work in ethically and legally grey areas of
practice.
Increasing demands for evidence-
based practice
Workplace pressures and mandates do create ethical
dilemmas for us as professionals beyond those involving
face-to-face interactions with clients. In the section on
duties to our employers, the Code of Ethics (Speech
Pathology Australia, 2002) states that we “make sure that
we follow best practice standards” (p. 5) and that “we strive
to continually update and to extend our professional
knowledge and skills;” (p.5). Not all speech pathologists are
conversant with the principles of evidence-based practice
or have the facilities to access literature and the skills to
critically review literature to derive evidence for best
practice. Budgets for professional development which
might provide this upskilling and resources are severely
constrained in many workplaces. As well as a duty to
clients to be competent, we have a duty to our profession
to not bring the profession into disrepute by offering
ineffective assessments and treatments for clients. Given
these ethical imperatives, whose responsibility is it to
ensure we as individuals are knowledgeable and skilled to
provide best practice and can fulfil concurrent and perhaps
conflicting duties to ourselves, our clients and our
employers regarding best practice? What should we do as
an individual colleague or as a service manager when we
aware that colleagues are not “fit for practice”, for whatever
reason? How do we balance duties to clients, colleagues,
employers and the profession by ensuring staff are
competent? There may be workplace barriers and penalties
embodied in public service acts for speaking out against
our employers. What other solutions can we adopt?
Working towards solutions for these problems requires
acting ethically on several fronts as well as moral courage.
So far in this paper, I have suggested that as a profession
we may be narrowly focused on ethics as involving only
client issues and too focused on the dilemmas of practice.
Ethics in professional life involves more than just following
ethical decision-making protocols. It also involves learning
to make ongoing moral judgements. It involves not just
making decisions about unusual ethics situations but
thinking and acting ethically within the routine, ordinariness
of professional life. Ethical practice is about pre-empting
possible ethical issues as well as responding to those that
have arisen.
us daily into these grey, swampy areas. We need more than
an ethical decision-making protocol to navigate our way
through these swamps: we need to think and act ethically
in proactive not reactive ways. Does our current code and
decision-making protocol help us do this?
Increasingly complex workplaces
Economic rationalism has significantly changed our
workplaces (Baum, 2002; Gardner, 2002). Many services
for the public are now managed as businesses, which
some will argue compromises client care. For example, the
pressure to reduce length of stay in hospitals has had
significant and often adverse effects on our clients who may
be discharged with little if any rehabilitation of their ongoing
communication needs. Further, as mentioned earlier, more
clients now require our services and many of these clients
present with increasingly complex needs. Services typically
have responded to these pressures not by increasing
staffing levels but by imposing stringent policies about client
prioritisation, waiting lists, failure-to-attend, and number of
sessions provided. Often such policies are in direct conflict
with the principles of evidence-based practice for the
management of communication and swallowing
impairments.
Such workplace pressures and policies bring us
daily into dealing with conflict of ethical principles. How
can we act with integrity and truthfulness in pursuit of
beneficence and justice for a client who has experienced
a CVA and according to the clinical pathway has had
their quota of therapy and is about to be discharged, yet
continues to have potentially treatable communication and
swallowing impairments? How do we reconcile conflicting
ethical principles and duties towards a preschooler with
stuttering and his/her family, when our employer tells us
that preschool-aged clients can have only six sessions of
treatment per term, semester or year? The evidence base
tells us that the mean treatment time for preschool-aged
children who stutter is greater than this (Jones, Onslow,
Harrison & Packman., 2001; Kingston, Huber, Onslow,
Jones & Packman, 2003). These two scenarios exemplify
other common scenarios where there may well be conflict
in our duties to our clients and our duties to our employers,
who expect us to implement their policies. Some speech
pathologists resolve such situations by ignoring official
policies, but this compromises their integrity. How can
we fulfil our duties to our community, which, in an affluent
social democracy, expects the best possible outcomes for
all citizens? How many of us actively advocate for change,
to improve services for clients and to enable ourselves to
act ethically?
Increasing litigation
According to reports in the popular press, Australia has
become one of the world’s most litigious societies. To the
best of my knowledge, there have been no court cases
resulting in successful prosecution of speech pathologists
by clients in Australia. However, given the trends in our
profession in the United States of America and in other
allied health professions in Australia, speech pathologists
may be at risk of legal action. The increasing complexity of
client needs and workplace pressures discussed above, the
pace of workplaces with intractable time pressures,
together with better informed health care consumers are
some of the factors driving increased litigation risks for
health professionals. Applying an ethical decision-making
protocol after an ethical dilemma has arisen will not protect
unethical but legal
ethical and legal
unethical and illegal
ethical but illegal