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Semin Speech Lang 2020; 41(03): 209-211
DOI: 10.1055/s-0040-1710325
Preface
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Moral and Ethical Considerations…

Kevin P. Kearns
1   Communication Disorders and Sciences, SUNY Fredonia, Fredonia, New York
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Publication History

Publication Date:
25 June 2020 (online)

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Speech-language pathology students are taught about disorders and techniques needed to care for individuals with communication impairments. They are also exposed to the moral and ethical responsibilities inherent in clinical practice, and they learn the tenets of the American Speech-Language-Hearing Association's Code of Ethics.[1] Far too often, however, there is a paucity of applied ethical training or mentoring during required clinical practicums.

I vividly recall gut wrenching, morally challenging clinical cases from decades ago. One involved a young woman who had suffered a severe traumatic brain injury. Her husband, a lawyer at the medical center where she was admitted for care, had learned that she was pregnant at the time of her car accident. He wanted to know very soon after her trauma if she would sufficiently recover her cognitive abilities and decision-making capacity to be able to decide if she wanted to keep and raise the unborn child. Another case involved a man with young children who was diagnosed with advanced laryngeal cancer and was adamant that he would not agree to life-saving surgery.

This issue of Seminars in Speech and Language outlines the basis for making difficult moral and ethical clinical decisions. The articles provide clinical vignettes, based on decades of clinical experience, that demonstrate applied ethical decision making. Horner[2] sets the stage for the ethical care of individuals with neurologically based communication disorders through her discussion of the moral features of the therapeutic relationship. She carefully defines relational ethics and applies the concepts of dignity, trust, autonomy, vulnerability, and resilience to the therapeutic relationship. The application of these principles is deftly illustrated in a clinical example that demonstrates how therapeutic relationships empower persons with aphasia with enhanced dignity, agency, and optimism.

Kagan et al[3] present powerful case illustrations that demonstrate communication support strategies used by speech-language pathologists in capacity evaluations for persons with aphasia. The dire consequences of making erroneous assumptions about competence or failing to provide adequate support for communication when aphasia masks cognitive ability are presented. Their work emphasizes the moral imperative to provide guidance and communication support throughout the process of evaluating capacity and highlights the need to educate those involved in assessing decision-making capacity of persons with aphasia.

Individuals with right hemisphere cognitive-communication deficits present unique challenges for clinicians. When patients' verbal skills surpass their underlying cognitive ability, clinicians and rehabilitation teams must carefully assess their capacity to make informed decisions, that is, not only to understand information and weigh alternatives but also to appreciate the consequences of their choices. Cherney et al[4] address the ethical principle of respect for autonomy which involves respecting others' decisions and their actions. Two case studies are used to demonstrate the delicate balance between respecting patients' autonomy and acting in their best interests (beneficence). A model developed by Jonsen and colleagues[5] is adapted to demonstrate how to balance patients' medical indications, preferences, quality of life, and other contextual features when making ethical clinical decisions.

Group therapy for adults with communication impairments presents novel clinical and ethical challenges. Guided by the principles of the ASHA Code of Ethics, Elman[6] discusses ethical responsibilities involved in group therapy. She uses clinical case examples to demonstrate why clinicians should acquire specialized clinical competence to meet the challenges of group intervention, should be judicious in referring clients to other professionals, should maintain patient confidentiality, should use evidence to support the need for intervention, and should treat patients in a group setting only when there is a reasonable expectation of treatment gain. Elman's article makes a compelling case that specific training to address the needs of individuals in group settings should be provided during graduate education of speech-language pathologists.

Principles of ethical clinical care for individuals with primary progressive aphasia (PPA) are discussed by Tippett and Hillis.[7] The challenges of managing progressive neurological disorders are elegantly discussed. Cases are presented for the principal PPA variants (logopenic, nonfluent agrammatic, and semantic) to illustrate how patients manifest self-determination in the course of making decisions about important life events such as housing, driving, and finances. The authors demonstrate that multifaceted approaches, including patient and family education and implementation of safeguards, are required to manage the ethical and practical challenges that arise when helping individuals with PPA preserve their autonomy.

With regard to ethical issues in dysphagia management, Leslie and Lisiecka[8] stress the sociocultural influences of eating and the need to consider social influences on dysphagia clinical decisions. They propose a humanistic rather than purely physiologic approach to patient management, thereby setting the stage for incorporating principles of ethics into clinical practice. Clinical vignettes demonstrate how ethics principles influence and help reconcile competing ethical considerations. In one example, a patient's right to refuse a treatment recommendation for a modified diet (respect for patient autonomy) has to be reconciled with the clinician's desire to recommend what she believes to be in the patient's best interests (beneficence). The authors stress the need to use evidence-based practices and to carefully document patient's informed consent.

The final article in this series presents a balanced and useful distinction between professional ethics and corporate compliance in healthcare organizations. Rao[9] describes and demonstrates the gamut of corporate compliance and professional ethics issues related to cultural competence, employer demands, and conflict of interest. The author reminds us that medical ethics and professional codes of ethics are generally governed by the principles of beneficence (doing good for others), respect for patient autonomy (respecting patient choices and decisions), nonmaleficence (avoiding actions that are harmful to others), and justice (fair access to healthcare). By contrast, healthcare compliance programs target the prevention of activities that are unlawful and contrary to ethical and business practices. In part because fraud and abuse have resulted in losses of billions of dollars each year, healthcare organizations have implemented extensive formal compliance programs to ensure adherence to corporate ethics and regulatory compliance. Examples of unethical therapist and corporate behaviors demonstrate the devastating consequences of illegal and unethical practices.

The articles in this issue highlight the importance of incorporating ethical principles and practices into patient care. One common thread that weaves this text together is the idea that the moral basis for the healthcare professions (and institutions) arises from the therapeutic relationship, that is, ethics is relational, and does not arise merely out of unilateral concerns about patient “rights” and professional “duties.” A related thread is that, despite our clinical expertise, we are bound by an implicit ethical contract to respect the opinions, desires, and decisions of our patients. Finally, it is clear from the illustrative cases in this issue that ethical clinical behavior requires a balanced, collaborative perspective about what is best for our patients. Although there are no hard and fast rules to guide us, the principles articulated in the medical ethics literature and the ASHA Code of Ethics provide the foundation for ethical, patient-centered care.