Setting the Stage: The Role of Ethics at Work

The practice of speech-language pathology represents a dynamic combination of service, education, and research. There are currently 127,390[1] certified speech-language pathologists (SLPs) in the ASHA. Most (53%) of these individuals work in the schools, ∼24% work in health care facilities, and ∼19% work in private practice.[1] The number of different employment and practice opportunities—from work contexts to the diversity of the populations served—sets this profession apart from others and is at the same time what makes it such a challenging and rewarding career choice. Work settings vary in the nature, frequency and costs of services, the types of disorders treated, and the cultural and linguistic backgrounds of those served. All of these areas can, and often do, generate questions with ethical implications.

As SLPs, we continuously encounter situations that require making ethical choices. How we respond to these quandaries reflects our values, describes our obligations and responsibilities, and, ultimately, defines who we are as professionals. Several models and frameworks to approaching ethical decision making are provided to assist readers in developing a systematic, ethical position in their specific work environments. These models include those of Seedhouse[2] (see Watson et al), Fitzpatrick et al[3] (see Chabon et al), Chabon and Morris[4] (see Denton), Maguire,[5] and Lonergan[6] (see Payne). These organizational frameworks are grounded in ethical principles, which are reflected in the ASHA Code of Ethics.[7] When we earn the certificate of clinical competence in speech-language pathology, we agree to practice by the principles set forth in the ASHA Code of Ethics. It is important to remember that these guidelines are ever-present; exist to benefit our growth in all situations, not just when ethical dilemmas arise; and prompt us to be mindful of the consequences of our actions. In this edition of Seminars, authors examine the ethical challenges associated with service provision across several pediatric settings, review the principles of the Code of Ethics from several perspectives, and apply examples of ethical questions faced by SLPs within the everyday practice of our profession. Although cases are used as examples throughout these articles, the questions that emerge are not specific to a particular individual but rather demonstrate how the general principles of ethics and professionalism may be applied in new situations.

Respect for the client's autonomy is one such principle. Autonomy refers to an understanding that the client “has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act.”[8] As discussed in the following articles, respect for client autonomy is observed in many ways within the practice of speech-language pathology: use of informed consent for clinical and research practices (ASHA Code of Ethics Principle I, Rules H and P); collaboration with clients and families in assessment and intervention planning with the intent of providing benefit (Principle I, Rules H and I); and respect for each individual's cultural and linguistic background (Principle I, Rules B and C; Principle II, Rules B and C; Principle IV, Rule K).[7]

Another key principle inherent in our practice across work environments is the use of empirical evidence and individual client data in clinical decision making. The ASHA Code of Ethics Principle I,[7] Rule A, states that “individuals shall provide all services competently.” In addition, Principle I, Rule I states that “individuals shall evaluate the effectiveness of services rendered and of products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected.” These rules, taken in conjunction with Principle I, Rule B, which states that “individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided,” offer a solid foundation for ethical use of data in clinical decision making.

These principles and others are examined further within the first four articles in this issue, which address ethical decision making from a historical and social perspective as related to evidence-based practice, professional relationships, advocacy, and research across multiple work settings. The last four articles focus on the ethical challenges within specific pediatric settings, including schools, multidisciplinary clinical settings, hospitals, and private practices.

In the first article, Payne introduces the historical development and transformation of the social ethics of disability by detailing the influence of culture, religion, law, politics, economics, and science in ethical decision making. She asserts that, regardless of work setting, SLPs can play a key role in promoting the rights of people with disabilities through advocacy.

Next, Moss focuses on the responsible conduct and consumption of research and reminds us of the value of research in clinical work, the ethical principles and practices to be followed, and the special and unique obligations of scientists completing clinical research involving children. She recounts some of the risks intrinsic to research with children and provides some considerations in preparing for, executing, and participating in ethical research endeavors.

Chabon, Morris, and Lemoncello review the ethical principles of beneficence, nonmaleficence, justice, and autonomy. They present a definition of professionalism and articulate the ethical obligations inherent in this title and infused in the ASHA Code of Ethics. The authors assert that decisions that are evidence-based must begin with and be explored within an ethical context.

Denton's article follows with a description of some of the common and the unique work-related ethical challenges. He emphasizes the importance of the structure of the employer relationship and the benefit of ethics education in the workplace.

Watson, Byrd, and Moore next address some of the ethical complications encountered when working with children who stutter in the schools. This article includes three cases to illustrate how Seedhouse's Ethics Grid[2] can be used to assist SLPs in examining and evaluating treatment options.

Kummer and Turner continue with a discussion of medical ethics and issues specific to the practice of speech-language pathology within a medical setting. They examine common ethical questions within this work environment and encourage consultation with the facility's bioethical committee for support in ethical decision making.

Larsen and McMillin describe clinician-researcher partnerships within a multidisciplinary clinical setting as well as the potential dilemmas, and the many benefits that result from recruitment of research participants within this setting. They identify and describe the role of therapeutic misconception and clinician-client vulnerability in interpreting and applying ethical guidelines. Larsen and McMillin also share a policy for recruiting research participants created for and used by their own multidisciplinary agency.

In the final article, Jakubowitz captures the benefits and risks of private practice and considers some of the ethical questions that emerge when establishing and running a business. Case studies are used to discuss ethical issues related to marketing and advertising, finances and personal management, privacy and confidentiality, service delivery and clinical responsibilities, and documentation.

Ethical decision making is, from start to finish, a complex task. Decisions are based on numerous factors related to both the client and the clinician. One variable not previously explored, nor fully understood, is the influence of work setting. This issue considers some of the ethical questions encountered across work environments, raises further inquiries, and provides guidance for reaching reasoned, defensible, and socially just resolutions.

REFERENCES

• 1 American Speech-Language-Hearing-Association .Highlights and Trends: ASHA Counts for Year End 2010. Available at: http://www.asha.org/uploadedFiles/2010-Member-Counts.pdf Accessed November 17, 2011
• 2 Seedhouse D. Ethics: The Heart of Health Care. Chichester, West Sussex, United Kingdom: Wiley-Blackwell; 2009
• 3 Fitzpatrick J L, Sanders J R, Worthen B R. Program Evaluation: Alternative Approaches and Practical Guidelines. 3rd ed. Boston: Pearson Education, Inc.; 2004
• 4 Chabon S, Morris J. A consensus model for making ethical decisions in a less-than-ideal world.  The ASHA Leader. 2004;  9 18-19
• 5 Maguire D. Ethics: How to Do It: Death by Choice. Garden City, NY: Image Books; 1984
• 6 Lonergan B. Insight: A Study of Human Understanding. Collected Works of Bernard Lonergan. Vol. 3. Toronto, Ontario, Canada: University of Toronto Press; 1997
• 7 American Speech-Language Hearing Association .Code of Ethics [Ethics]. 2010. Available at: http://www.asha.org/docs/html/ET2010-00309.html Accessed November 17, 2011
• 8 University of Washington School of Medicine .Ethics in medicine: Principles of bioethics. 2008. Available at: http://depts.washington.edu/bioethx/tools/princpl.html Accessed November 17, 2011