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JCPSLP
Volume 17, Number 3 2015
Journal of Clinical Practice in Speech-Language Pathology
prescribed for the profession. The principles-based
approach is founded on the work of Beauchamp and
Childress (2001) and includes the four principles of
autonomy, beneficence, non-maleficence and justice. This
approach enables us to decipher what principles are most
relevant to the case and to weigh up the ability of different
proposed outcomes to fulfil these principles. This is
especially pertinent given the complexity of the given
hypothetical case.
In implementing the principles-based approach, we
must consider whether there is a problem that requires
action (SPA, 2014). In relation to our ethical dilemma,
we must decide whether to act in accordance with
client confidentiality or to disclose the incident. Would
it be possible to discuss the topic with the psychiatrist
without breaching Sharon’s confidence? There is also the
possible third option of encouraging Sharon to disclose the
information herself.
This decision is complicated by many principles
embedded within the scenario. Beauchamp’s (2007) four
principles can be applied to the case in order to align
our reasoning with the standards that we should strive to
implement as health professionals.
Autonomy
requires us to
respect the rights of our clients to make their own informed
decisions, to exercise free will and agency. According to
this principle, Sharon and Casper have the right to make
their own decision concerning whether or not to disclose
information. The principle of
beneficence
(to do good) is
relevant as the psychiatrist may not be able to provide
the most benefit to Casper without you disclosing the
incident so as to create a more complete image of Casper’s
behaviour.
Non-maleficence
is applicable in the sense that
medicating Casper, a possible consequence of revealing
the incident, may cause harm to him (as believed by
Sharon) and it may also cause harm to his family in the form
of legal costs and emotional upset and a sense of betrayal
towards you. Non-maleficence is also relevant as Casper
may continue to behave inappropriately towards, and cause
harm to others, including the young woman. Finally, the
fourth principle of
justice
, in terms of dealing with all clients
equally and fairly, is applicable as although Casper has a
cognitive impairment, he should receive the same rights to
intervention as other clients. The fact that he has not been
given the opportunity to voice his views on the events is a
barrier to meeting this principle.
In addition to these four principles, the Code of Ethics
(SPA, 2010) also encourages us to consider truth and
professional integrity. By application of the
truth
principle,
we are to provide accurate, honest information to people
we come into contact with. While we have not come
into direct contact with the psychiatrist, it is questionable
whether withholding information regarding the incident
is upholding this principle. With regard to
professional
integrity
, it is pertinent to consider whether we are working
within the legal guidelines of our profession concerning
confidentiality and the circumstances which permit the
breach of confidentiality.
The standards of practice outlined by the Code of
Ethics (SPA, 2010) necessitate that information about
our clients, or the confidences they share with us, must
not be disclosed “unless our clients consent to it, the law
requires us to disclose it; or there are compelling moral and
ethical reasons for us to disclose it” (p. 3). This directs us
to the
Privacy Act 1988
, where S16A states that the use
or disclosure of personal information is permissible when it
is unreasonable or impracticable to obtain the individual’s
consent to disclosure and it is believed necessary to lessen
exercise. The first was to create an authentic case for the
students based on my own specialist area of neurogenic
communication disorders, a UOS that students would
undertake in the following year. The second was as a
simulated client in their case history and ethical reasoning
task where I performed both the role of the mother and
debriefed with students about their own performance and
reasoning following the simulation. In constructing the case,
it was important that I balanced the opportunity to create a
case that illuminated important details about TBI and my
own neurogenic language disorders UOS with the goal of
the task – to provide a foundation for an interview and
ethical reasoning learning exercise.
In participating in the simulated interview, I was absorbed
in my role as mother of the young man with TBI, but I also
was still able to manipulate (sabotage) the interview to
challenge the students’ developing interview skills. The
atmosphere in the simulation was serious and tense, with an
authentic feeling to the interaction. There was palpable relief
in the room at the end of the interview when the students
reported on how difficult it was to balance listening to the
client and hearing and recording their story, while
simultaneously gathering pertinent information for their
assessment. Some students did manage to achieve this and
were also able to engage with me therapeutically to provide
education to me as a mother of a son with brain injury,
when I (deliberately) communicated a misunderstanding of
the nature of social communication disorders. The interview
debrief also enabled me to foreshadow aspects of my own
UOS the students would take the next year, and this was a
motivating factor in my participation in the simulation.
The hypothetical ethical dilemma
Casper is a 21-year-old man who was involved in a water
sports accident that resulted in a severe traumatic brain
injury. Casper was treated in a brain injury unit and has now
returned home. Casper’s mum, Sharon, has explained that
while functional, Casper is experiencing difficulty in some
areas of his day-to-day life. One issue in particular is his
lack of inhibition. This recently surfaced in an incident with
an old school friend. Casper behaved inappropriately
towards the young woman and she was left deeply upset
by his actions and wanting to lodge a complaint against
him. Sharon intervened and persuaded her not to follow
through with the complaint, believing that this would be the
only instance of such behaviour. Sharon has booked him in
to see a psychiatrist about his behaviour but does not want
to tell the psychiatrist about the incident for fear that he will
put Casper on medication that will make him sedated and
“zombie-like”. Sharon wants the SLP (you) to work with
Casper to explain appropriate behaviour. She tells you that
there is no need to tell anyone else about the incident.
There are a number of ethical issues presented by this
case and this is reflective of the complexity and multiple
layers of the caseload that SLPs may be exposed to
(McAllister, 2006). These include the issue of whether
or not the SLP should maintain the confidentiality of the
client’s mother. Should the speech pathologist break
the confidence of Casper’s mum and speak with the
psychiatrist or should she act as Sharon has asked her to?
This will form the basis of the current discussion.
Applying the principles-based
approach
The Code of Ethics (SPA, 2010) includes principles that
guide ethical decisions, thus use of the principles-based
approach will promote adherence to the requirements