JCPSLP Vol 17 No 3 2015

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

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

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JCPSLP Volume 17, Number 3 2015

Journal of Clinical Practice in Speech-Language Pathology