ACQ Vol 12 No 3 2010

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ACQ Volume 12, Number 3 2010 127
Ethical conversations
Deborah Hersh
(top), Suze
Leitão (centre)
and Melanie
Breese
Sometimes, I think we assume that “implied consent” is the
same thing as “informed consent”.
Deborah
Speech pathologists know about the importance of
presenting oral and written information in accessible ways,
using alternative and augmentative communication, involving
family members appropriately, adapting the environment
effectively to promote communication and checking for
feedback that information has been understood. In addition,
ethical principles can help guide the process such as
through respecting autonomy, veracity or telling the truth,
and beneficence or doing the best one can to bring benefit
to the client. However, it is also worth stating the obvious
– that the quality of the relationship and the level of trust
between clinician and client have a contribution to making
information accessible. Obtaining informed consent for
treatment is not just giving information but involves sharing
information, something which is more effective when two
people understand each other well. Perhaps it is also worth
adding that if the speech pathologist is viewed as accessible
(easy to talk to, someone who really listens, someone who is
available to answer questions and provide reassurance), then
it is more likely that the information provided will be
accessible too.
Suze
I agree. On a number of occasions, family members have
talked to me about their experiences with other therapists.
Sometimes, they have not really felt comfortable with what
was going on in therapy for their loved one, and have not
really understood the reasons behind it. However, this has
been difficult for them to tackle because of the assumption
that the therapist is the expert and must know what he or
she is doing. One of the suggestions I talk through with them
is to try to make an appointment to sit and talk through the
therapy process with the speech pathologist, and ask
questions about the goals, the reasons underlying the
approach, and the process itself. It seems as though in
these cases, the clinician has not been viewed as
“accessible”.
Melanie, in your clinical practice, how do you deal with
consent for treatment in people with dementia and cognitive
damage who have already been judged as “lacking in
competence”?
Suze
When most clinicians reflect on the topic of informed
consent, they tend to think about it in the research context.
The topic of this issue of ACQ – Communicatively Accessible
Healthcare Environments – made me reflect on the role that
informed consent plays in making healthcare environments
accessible for our clients. It reminded me that informed
consent is also critically important in making decisions, for
example, about treatment.
Deborah
Informed consent for treatment is “not a discreet event but a
process of information exchange and autonomous decision
making” (Berglund, 2004, p. 79). It involves sharing and
understanding the details, including benefits and risks, and
choices about treatment, making a voluntary, competent
decision, and being able to express that decision. However,
we know as speech pathologists that it is precisely a
difficulty with elements of that process which often prompts
a person to seek our services in the first place. Informed
consent for treatment can be a difficult area when judging
whether someone has decision-making capacity, whether to
rely on a family member as a proxy or to refer for
guardianship. For those with capacity but with
communication disorder, speech pathologists may need to
be creative about how to make information truly accessible.
So when we think about informed consent for treatment,
it is useful to look beyond the classic choice between
two medical procedures or signing on the dotted line of a
consent form (important as those may be) to also consider
how we might enable our clients to be more fully informed
and involved in negotiations about intervention. Body
and McAllister (2009) point out that access to meaningful
information is important for health, and reduces client and
carer stress. The timing, format, and manner of delivery are
all important. Information may need to be shared regularly
and reviewed over time.
Suze
Yes, there is a responsibility for us, as speech pathologists,
to make sure our healthcare environments and the
assessments and interventions we offer within them, are as
accessible as possible. We need to ensure we present
information in a clear and concise manner. We have to
remember that our clients, and their families, may not being
making a fully informed decision about the therapy process.
Communicatively
accessible healthcare
environments
Ethics and informed consent
Deborah Hersh and Melanie Breese talk to Suze Leitão