Theresa H. Rodgers, MA, CCC-SLP, BCS-CL, Licensed SLP, EdS (LD)
“Ethical dilemmas are a common and difficult part of the practice of speech-language pathology and audiology.” These words by Noma Anderson and Shelly Chabon at the 2007 ASHA Schools Conference may not seem at first glance to be earth-shattering. However, they illustrate two important facts that are particularly relevant in today’s practice environment. First – we encounter ethical quandaries on a regular basis. It is critical that we not only acknowledge this fact, but that we are well-equipped to resolve these dilemmas. Secondly – the resolution of ethical dilemmas is challenging, involving us in situations in which options, sometimes with countervailing considerations and even zero risk, must be weighed.
The American Speech-Language-Hearing Association conducts a health care survey as well as a schools survey in alternating years. Contained within the survey results is information about the frequency with which respondents encounter ethical challenges due to employer pressure. In the 2021 health care survey, more than half (58%) of respondents indicated that they had not felt pressured by their employers or supervisors to engage in any of the six activities delineated. SLPs employed in Skilled Nursing Facilities (SNF) were most likely to have been pressured on four of the activities: to provide inappropriate frequency or intensity of services (11% overall, SNF 19%) ; to discharge inappropriately (e.g., early or delayed) (10% overall, SNF 22%); to provide evaluation and treatment that were not clinically appropriate (10% overall, SNF 21%); to provide group therapy when individual therapy was appropriate (7% overall, SNF 19%). The percentage of respondents who indicated they felt pressured to alter documentation for reimbursement was 3%, a decrease from 4% in 2019. Pressure to provide services for which SLPs had inadequate training and/or experience was the sixth activity included in the survey with 7% of the respondents indicating they had experienced such influence from an employer or supervisor.
Let’s examine the results of the 2020 schools survey by comparing the responses of educational audiologists and those of speech-language pathologists to the question “Which of the following ethical issues have you faced during the last 3 years?”
There is another significant survey result that should be noted. The 2018 schools survey asked for the first time whether school-based SLPs felt “pressured by an employer, administrator, or supervisor to provide or deny a service, report scores, etc., that would be in violation of the ASHA Code of Ethics.” Thirteen percent responded YES!
The inclusion of culture as a key consideration in ethical decision-making is essential. Values, beliefs, how information is processed and interpreted, as well as preferences manifested in behavior may frequently be associated with and influenced by culture. Studies have shown that culture dictates how problem-solving occurs because of the influence on how people “think, communicate, and behave” (Oliveira, 2007, pg. 15). Cultural competence then is essential in order to understand underlying assumptions, and recognize cultural differences and their potential effects on the ethical dilemma at hand.
Additionally, we need to focus on the broader topics of cultural sensitivity and cultural humility. In a 2020 ASHA Leader article by Dr. Kyomi Gregory entitled “Moving Forward as a Profession in a Time of Uncertainty”, the need to continually develop cultural competence along with cultural humility is identified. Depending on a number of factors including when we received training, our experiences, and other considerations, we may have assumed or been taught that cultural competence is a static skill, a finite proficiency that is mastered at a moment in time. However, cultural competence is a dynamic, complex, and ongoing process requiring self-awareness as well as cultural humility. These are integral to ethical practice.
The Consensus Model for ethical decision-making is frequently applied in the field of speech-language pathology. Chabon and Morris developed a process which incorporates several factors, and ensures that the influence of culture and diverse values are considered in deriving appropriate resolution of the issue. In considering the Consensus Model, it is important to be cognizant of the fact that consensus “is not 100% unanimity, nor is it a compromise” (Chabon and Morris, 2004). The first consideration relative to this model is answering the question, “Am I facing an ethical dilemma?” If personal and professional integrity are being challenged, the answer will likely be “yes”. The SLP must determine the relevant facts and identify the key people involved. Based on that information, the dilemma must be stated clearly followed by analysis of possible courses of action (which may be obligatory, impermissible, or permissible) and the conflicts that may arise from each of those courses of action. Next a proposed course of action is determined along with evaluation of the following factors: ethical principles, code(s) of ethics, cultural heritage/values, social roles, self-interests, and applicable laws. Lastly, the practitioner must decide if the proposed course of action leads to consensus. If the answer is affirmative, the practitioner may proceed. Otherwise, the deliberation should be repeated beginning with analysis of possible courses of action and the conflicts that may arise, with subsequent steps in the process implemented until consensus is reached.
The need to adhere to overlapping practice standards imposed by multiple jurisdictions must be taken into account. Consider that speech-language pathology licensure laws exist in all fifty states and the District of Columbia. These statutes regulate the practice of the profession in the respective jurisdictions including the requirements for licensure, scope of practice, exemptions, administrative provisions, and grounds for and types of disciplinary action. The rules and regulations further implement the enabling statute and will typically include a Code of Ethics. Unless a specific exemption is included in the licensure law, all SLPs in the state must hold a license in order to practice. Note that it is not uncommon for the school-based setting to be exempt; however, if an SLP who works in the schools holds a license, the individual must comply with all mandates of the practice act and rules and regulations including the Code of Ethics.
ASHA represents speech-language pathologists, audiologists, speech, language and hearing scientists, speech-language pathology and audiology support personnel, and students. The ASHA Code of Ethics (2016) is applicable to an individual who holds the Certificate of Clinical Competence (CCC) and/or is a member of ASHA, or is an applicant for certification, or for certification and membership. These individuals then are subject to the jurisdiction of the Board of Ethics (BOE). ASHA members who are providing clinical services must hold the appropriate CCC.
Given the licensure law in each state, many ASHA members, then, are subject to the jurisdiction of both the state licensure board and the ASHA Board of Ethics. However, that jurisdiction is separate and independent as are varying Codes of Ethics/Professional Conduct Standards/Codes of Conduct for each entity. The content of a state licensure board’s Code of Ethics may closely mirror the ASHA Code of Ethics or may be quite different in scope. The complaint and adjudication process of a state regulatory body is specified by the enabling statute and Administrative Procedure Act and include a description of the investigative and subpoena powers of the licensing board or designee. It is important to note that the ASHA BOE does not have investigatory nor subpoena power, and the complaint materials are critical to the adjudication process.
Utilization of social media is one of the topics that can present challenges for SLPs. The Pew Research Center reports that 72% of American adults use social media with YouTube and Facebook being the most widely used platforms. Social media, while having numerous positive aspects, can present ethical dilemmas for speech-language pathologists including situations that result from lack of knowledge about legal and other issues. Copyright infringement may not be uppermost in our thinking if we copy graphics, text, etc., about a professional topic without assigning credit (and permission to do so may also be required). There is also a tendency on the part of some to think that because information is readily available, be it on social media or the internet, it can be copied and reused by an individual as though it’s their own work. The mindset seems to be “it’s there and I have access to it so I can take it”. Not so. Regrettably, plagiarism is real in the world of speech-language pathology and the need to attribute work to the author(s) is not always recognized. Principle IV , Rule J of the ASHA Code of Ethics states, “Individuals shall assign credit only to those who have contributed to a publication, presentation, process, or product.” When proper attribution is not provided, the presenter or author is falsely presenting ideas and information as their own. (It is somewhat ironic that this author has witnessed lack of attribution by presenters on the topic of ethics.)
Breach of confidentiality is another potential danger in the use of social media. It does not take utilization of a patient/client/student’s name for the breach to occur. Acknowledgement of the professional relationship between the SLP and a client or a client’s family is not uncommon. Friending a client or client’s family on Facebook, for example, presents a slippery slope. Does the client/client’s family recognize the broad reach of the social media platform, the digital footprint, and was this an explicit provision to which they provided informed consent?
Defamation is another critical consideration. The incivility and vitriol that are present on social media are shocking. Yet are the posts actually unethical? Inappropriate does not necessarily translate to unethical. A disparaging remark about another professional may not in and of itself result in an ethics violation. However, depending on the statement, there could be a violation of Principle IV, Rule C of the ASHA Code of Ethics which states “Individuals' statements to colleagues about professional services, research results, and products shall adhere to prevailing professional standards and shall contain no misrepresentations.” Additionally, if the statement (printed or verbal) violates a state’s defamation law, there would be violation of Principle IV, Rule R: Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research.
In addition to social media utilization, there are numerous issues presenting ethical challenges for SLPs – supervision, coding, billing, and reimbursement, telepractice, and conflict of interest to name a few. With the exception of evidence-based practice, there is probably no other issue in the field of speech-language pathology that transcends all professionals, practice settings, and types of clients, aside from the topic of ethics. Ethical principles, codes of ethics, and ethical decision-making processes are pervasive to our work. It is imperative then that we are well-equipped to not only recognize ethical dilemmas, but that we have the knowledge and expertise to resolve them confidently.
References
American Speech-Language-Hearing Association. (2021). ASHA 2021 SLP Health Care Survey: Practice issues. www.asha.org.
American Speech-Language-Hearing Association. (2020). Practices and procedures of the Board of Ethics [Ethics]. Available from www.asha.org/policy.
American Speech-Language-Hearing Association. (2020). 2020 Schools Survey report: SLP workforce and work conditions. www.asha.org/Research/memberdata/Schools-Survey/.
American Speech-Language-Hearing Association. (2018). 2018 Schools Survey report: SLP workforce and work conditions. www.asha.org/research/memberdata/schoolssurvey/.
American Speech-Language-Hearing Association. (2016). Code of Ethics [Ethics]. Available from www.asha.org/policy.
Anderson, N. & Chabon, S. (2007). Providing ethically responsible services to children from culturally and linguistically diverse backgrounds. Seminar presented at ASHA Schools Conference, Pittsburgh, Pennsylvania.
Chabon, S. & Morris, J. (2004). A consensus model for making ethical decisions in a less-than-ideal world. The ASHA Leader, 9(3), 18-19. doi/10.1044/leader.MIW.09032004.18
Chabon, S. & Rodgers, T. (2012, May). Resolving evolving ethical dilemmas. Presentation at the Spring Conference of the Council of State Association Presidents, Anchorage, AK.
Euben, D. & Rodgers, T. (2019). Navigating ethical dilemmas faced by SLPs practicing in schools. Seminar presented at ASHA Connect, Chicago, Illinois.
Gregory, K. (2020). Moving forward as a profession in a time of uncertainty. ASHA Leader, 25(6), 8-9. https://leader.pubs.asha.org/do/10.1044/leader.FMP.25082020.8/full/.
Oliveira, A. (2007). A discussion of rational and psychological decision-making theories and models: The search for a cultural-ethical decision-making model. Electronic Journal of Business Ethics and Organization Studies, 12(2), 12-17. https://jyx.jyu.fi/bitstream/handle/123456789/25397/1/ejbo_vol12_no2_pages_12-17.pdf
Pew Research Center. (2021, April). Social media fact sheet. Demographics of Social Media Users and Adoption in the United States | Pew Research Center
Rodgers, T. & Waguespack, G. (Eds). (2021). Licensure and regulation in audiology and speech-language pathology: A reference manual by NCSB. National Council of State Boards of Examiners for Speech-Language Pathology and Audiology.
