ACQ Vol 11 No 1 2009

MULTICULTURALISM AND DYSPHAGIA

pathologists and their professional associations with arguments against resource allocation and prioritisation which exclude children and people with disabilities from speech pathology services. It is clear that resources for health care need to undergo an allocation process; however, how such decisions are made is an ethical matter. If we want our clients to have access to a “decent minimum” (Beauchamp & Childress, 2009, p. 260) of health care, then the principles of “equal share” and “need” can be drawn upon. Allocating resources on the basis of an equal share for all belies the reality that some people have more health care needs than others. It may also result in virtually nobody getting effective care, “the jam being spread so thinly it can no longer be tasted” (Sim, 1997, p. 127). The alternative of providing different levels of health care accord­ ing to need presents some challenges as well. A disproportionate amount of service may be needed to achieve gains, for example, for those whom we label “disadvantaged”. On the other hand, a small amount of service may be all that is required to achieve significant outcomes for some people in so-called low priority categories. Body and McAllister (in press) consider the ethics of health economics and provide some discussion of factors to be considered in making resource allocations across health services and within speech pathology services themselves. One of the outcomes of reducing services available in the public sector has been the growth of private practice. While recognising the many benefits of this trend to both clients and the profession, workshop participants expressed concern about standards in private practice, especially with regards to knowledge of the evidence base and maintenance of fitness for practice. It is worth noting that a majority of inquiries about possible ethics complaints received at National Office of Speech Pathology Australia pertain to service provision within private practice. Staying on top of the growing evidence base for our practice and maintaining fitness for practice are concerns for the whole profession, not just private practice. Earlier in this paper we raised the issue of responsibility for CPD, which becomes particularly important as consumer expectations and knowledge of our evidence base increase with rising Internet access and information literacy of the community. In this context, and also that of changing scope of practice, ensuring fitness for practice of new graduates, clinicians changing work sectors (e.g., from health to disability, from education to health), and rural and remote practitioners becomes a major ethical obligation for employers, individuals and the professional association. Ensuring the competence and standards of practice for allied health assistants and other support workers will also become a major ethical issue as reshaping of the workforce occurs and delegation of some speech pathology tasks becomes more common. The ethical issues involved in delegation should not be allowed to mask what Threats, writing in Body and McAllister (in press), refers to as “protectionism”, however. In the absence of evidence that speech pathologists deliver superior treatment to that provided by assistants under their super­ vision, Threats argues that there are ethical considerations (as well as economic considerations) in allowing the extension of speech pathology services using assistants and volunteers to reach a greater number of people than the speech pathology workforce alone could deliver. While fiscal constraints, workforce concerns, population trends and consumer preferences are driving shifts in resource allocations and modes of service delivery, increasing litigation is also driving management policies. As organisations seek to limit risk and litigation, some practitioners in the workshop reported incursions on clients’ autonomy and quality of life.

2008). Such conflicts highlight the needs for continued work on expanding our evidence base and for advocacy at individual and professional levels. McLeod, writing in Body and McAllister (in press), suggests that reference to the United Nations Convention on the Rights of the Child (1989) and Rights of Persons with Disabilities (2006) may provide speech Access to professional development resources and opportunities restricted by employers (e.g., backfill time not available to go to CPD; firewalls prevent access to Internet at work) Table 1. Emerging ethical concerns for Australian speech pathologists Medical focus on saving lives versus quality of life Resource allocation and prioritisation issues Tension between service policies and values of profession Restricting rights of others by focusing on particular service areas Narrowing of services to some groups (e.g., fluency, voice) Families forced to seek private therapy due to decreased service in public sector Prioritisation – clinician choice versus service direction Clients with speech and language alone – low priority compared with clients with behaviour problems for “early intervention” Uneven decision making – acute versus disability Tightening of eligibility for service related to age How you engage with clients – limitations of service available Individual/one-size-fits-all decisions Push for discharge versus completion of episode of care Time limits imposed not evidence-based practice Services to clients of non-English speaking backgrounds especially in remote areas Occupational Health and Safety (OH&S) risk manage­ ment for organisation overrides client quality of life Changing scope of practice Consultancy role for speech pathologists Expansion of roles in workplace in areas of care planning, advocacy Use of allied health assistants/support workers Training needs Clarification of roles Accountability to whom? ward? team? Safety and risk Discipline specific versus multi-disciplinary student placements Managing expectations of clients Private practice standards Accreditation issues Evidence based practice What evidence? New/old evidence? Hard to “manage” the evidence Lack of evidence Are we ethically bound to research areas with poor/ little evidence? Fitness for practice Problems with access to continuing professional development (CPD) Supervision re “standards” for rural and remote speech pathologists

S p eech P athology A ustralia

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