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JCPSLP
Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology
Journal of Clinical Practice in Speech-Language Pathology
Makaton signing that way. This will require her to be very
committed to the task. A class aide would take much
pressure off the teachers, but Bev still needs to go through
the process of applying, and it may take time.
Autonomy:
Mandy has reservations about Makaton and
aided language which will impact on her attitude to learning
and implementing the communication strategies. Bev
needs to counsel Mandy to help her understand the
evidence that aided language and Makaton key word
signing facilitate oral language. However, if Mandy is not
convinced by Bev’s information, it is her right to refuse to
use aided language. This would be very difficult for Bev,
who knows how important this is for the development of
communication.
Professional integrity:
Bev is not a Makaton trainer, but
could show Mandy some signs and refer her to the
Makaton DVD. She could show Mandy and the teachers
how to encourage Jenny to sign using the “hand-over-
hand” technique (http://en.wikipedia.org/wiki/Tactile_
signing). She could also assist Mandy by informing her
about the Adapted Learning website (Adaptedlearning.
com), a website set up by Boardmaker™ for parents to
share picture based resources. She could inform Mandy
about Boardmaker™ and try to encourage the local library
to purchase it. She realises the need to respond to the
many opportunity barriers, but does not have sufficient
hours to do so as effectively as she would like. She knows
that unless Mandy and Jenny’s teachers are motivated,
Jenny’s progress in learning Makaton will be slower than it
should be.
Case scenario: Rachel
Background
Rachel is a 21-year-old woman with traumatic brain injury
due to a hit-and-run car accident. While she is able to walk,
her fine motor skills have not improved as well as the health
professionals expected. Her parents and some family
members can understand her dysarthric speech, but she is
not understood by people who do not know her. She has a
Lightwriter™ but due to a tremor in her better hand, her
access is slow. She also has some problems with her
memory.
Rachel’s court case is scheduled for one month’s time.
She is determined to give evidence in court, but is very
anxious that she will not be understood, that she will be
slow when using her Lightwriter™, and that her evidence
will not be taken at full value. When giving evidence, Rachel
will need a communication assistant/facilitator to assist in
the interpretation of her speech or to convey the messages
composed on the Lightwriter™. At their last speech
pathology session funded by the Transport Accident
Commission (TAC; http://www.tac.vic.gov.au/jsp/corporate/
homepage/home.jsp?gclid=CJHqsuyswJ0CFc0vpAodgB
RssA), Rachel’s speech pathologist, Susie, suggested that
she have a word-based communication board made up,
with sentences and phrases in case she becomes fatigued
during the long hearing. It may also help her remember
some important points she wishes to make. Rachel wants
her speech pathologist to support her in court, but Susie
has not been funded by TAC for this purpose.
Rachel’s family has heard that Communication Rights
Australia
1
(CRA) have a communication support worker
service
2
which is equivalent to a sign language interpreter
service for the deaf. On making enquiries, they have been
informed that they only have a small pool of communication
speech, but vocalises and will sometimes take her mum to
something she wants and point to it. The visiting early
intervention speech pathologist, Bev, has assessed Jenny
and provided a comprehensive report, recommending that
Jenny should use Makaton key word signing plus picture-
based communication aids. Jenny was very responsive
when Bev used basic gestures to ask Jenny to bring a ball.
Bev also recommended that Jenny attend the local
preschool where teachers have agreed to accept her but
have expressed a need for information and support as they
have never had a child with disability at the preschool
before. They have also expressed the need for a teacher’s
aide. Bev feels that, with time, Jenny could learn to use a
basic speech-generating device to make simple choices,
like choosing a song at school, or to help her to actively
participate at circle time (e.g., have animal sounds recorded
on the device so she can “sing” “Old MacDonald had a
farm”).
Jenny’s mum, Mandy, works part-time and is
overwhelmed by the need to learn Makaton and become
the agent for developing all the aided language resources
Jenny needs in order to learn to communicate effectively.
Mandy is also concerned that if she introduces other ways
of communicating, Jenny will never learn to speak. Bev
can only offer her services monthly according to the service
model of her organisation because of the demand for
speech pathology services in her region.
Ethical dilemmas
Beneficence / non-maleficence:
Bev has a good
understanding of what Jenny needs and the critical
importance of introducing communication strategies
immediately. She has the skills to offer the support needed,
but does not know how she will do all this within a monthly
visit of 2 hours. If Bev does not provide support both to
mum and the teachers there is the potential for maleficence
in that negative attitudes will develop towards the
communication intervention and towards Jenny, placing
strain on the system. Bev is very aware that Mandy is
already feeling stressed by all the intervention Jenny will
need. Bev realises that her hours with the family would be
most beneficial if directed to developing Mandy’s skills and
confidence in facilitating Jenny’s communication and to
working with the teachers, rather than working directly with
Jenny.
Truth:
There is evidence of the importance of early
intervention for AAC in establishing patterns for active
communication, for cognitive development, and for social
participation. Visual aids provide an immediate form of
communication, but have to be designed, produced, and
introduced in all communication environments. Makaton
key word signing is an unaided strategy and Jenny has
responded well to gesture, so there is good likelihood that
Jenny will take to Makaton. It is also very effective in
conveying meaning, but the system must be learnt by
Mandy and Jenny’s brother as well as the teachers. Bev
also sees the potential for a basic electronic communication
aid which she will need to apply for, and which again will
require training and monitoring.
Justice:
Bev needs many more funded hours for an
effective AAC intervention. In addition to applying for the
communication device, she needs to motivate and lobby for
a class aide for Jenny. Travelling to a centre where a
Makaton course may be held is not an option for Mandy,
but it is possible for her to purchase a DVD and learn