JCPSLP Vol 17 Supplement 1 2015_lores

us daily into these grey, swampy areas. We need more than an ethical decision-making protocol to navigate our way through these swamps: we need to think and act ethically in proactive not reactive ways. Does our current code and decision-making protocol help us do this? Increasingly complex workplaces Economic rationalism has significantly changed our workplaces (Baum, 2002; Gardner, 2002). Many services for the public are now managed as businesses, which some will argue compromises client care. For example, the pressure to reduce length of stay in hospitals has had significant and often adverse effects on our clients who may be discharged with little if any rehabilitation of their ongoing communication needs. Further, as mentioned earlier, more clients now require our services and many of these clients present with increasingly complex needs. Services typically have responded to these pressures not by increasing staffing levels but by imposing stringent policies about client prioritisation, waiting lists, failure-to-attend, and number of sessions provided. Often such policies are in direct conflict with the principles of evidence-based practice for the management of communication and swallowing impairments. Such workplace pressures and policies bring us daily into dealing with conflict of ethical principles. How can we act with integrity and truthfulness in pursuit of beneficence and justice for a client who has experienced a CVA and according to the clinical pathway has had their quota of therapy and is about to be discharged, yet continues to have potentially treatable communication and swallowing impairments? How do we reconcile conflicting ethical principles and duties towards a preschooler with stuttering and his/her family, when our employer tells us that preschool-aged clients can have only six sessions of treatment per term, semester or year? The evidence base tells us that the mean treatment time for preschool-aged children who stutter is greater than this (Jones, Onslow, Harrison & Packman., 2001; Kingston, Huber, Onslow, Jones & Packman, 2003). These two scenarios exemplify other common scenarios where there may well be conflict in our duties to our clients and our duties to our employers, who expect us to implement their policies. Some speech pathologists resolve such situations by ignoring official policies, but this compromises their integrity. How can we fulfil our duties to our community, which, in an affluent social democracy, expects the best possible outcomes for all citizens? How many of us actively advocate for change, to improve services for clients and to enable ourselves to act ethically? Increasing litigation According to reports in the popular press, Australia has become one of the world’s most litigious societies. To the best of my knowledge, there have been no court cases resulting in successful prosecution of speech pathologists by clients in Australia. However, given the trends in our profession in the United States of America and in other allied health professions in Australia, speech pathologists may be at risk of legal action. The increasing complexity of client needs and workplace pressures discussed above, the pace of workplaces with intractable time pressures, together with better informed health care consumers are some of the factors driving increased litigation risks for health professionals. Applying an ethical decision-making protocol after an ethical dilemma has arisen will not protect

us from litigation. Nor will following the law necessarily protect us from ethics complaints. The interplay of ethical and legal conduct can be envisaged as follows:

unethical but legal

ethical and legal

unethical and illegal

ethical but illegal

We assume we readily will recognise illegal practice; can we readily recognise unethical practice? How attuned are we to practice that may be legal but not ethical, and conversely ethical but not legal? For example, reading the findings of the ASHA Ethics Board published in the ASHA Leader reveals cases where speech pathologists have been overly generous in interpreting treatment data as showing progress, so that clients can stay in treatment paid for by insurers. Some of these clinicians have attempted inadequately to reconcile conflicting ethical principles and duties to clients versus employers and insurers. We increasingly work in ethically and legally grey areas of practice. Increasing demands for evidence- based practice Workplace pressures and mandates do create ethical dilemmas for us as professionals beyond those involving face-to-face interactions with clients. In the section on duties to our employers, the Code of Ethics (Speech Pathology Australia, 2002) states that we “make sure that we follow best practice standards” (p. 5) and that “we strive to continually update and to extend our professional knowledge and skills;” (p.5). Not all speech pathologists are conversant with the principles of evidence-based practice or have the facilities to access literature and the skills to critically review literature to derive evidence for best practice. Budgets for professional development which might provide this upskilling and resources are severely constrained in many workplaces. As well as a duty to clients to be competent, we have a duty to our profession to not bring the profession into disrepute by offering ineffective assessments and treatments for clients. Given these ethical imperatives, whose responsibility is it to ensure we as individuals are knowledgeable and skilled to provide best practice and can fulfil concurrent and perhaps conflicting duties to ourselves, our clients and our employers regarding best practice? What should we do as an individual colleague or as a service manager when we aware that colleagues are not “fit for practice”, for whatever reason? How do we balance duties to clients, colleagues, employers and the profession by ensuring staff are competent? There may be workplace barriers and penalties embodied in public service acts for speaking out against our employers. What other solutions can we adopt? Working towards solutions for these problems requires acting ethically on several fronts as well as moral courage. So far in this paper, I have suggested that as a profession we may be narrowly focused on ethics as involving only client issues and too focused on the dilemmas of practice. Ethics in professional life involves more than just following ethical decision-making protocols. It also involves learning to make ongoing moral judgements. It involves not just making decisions about unusual ethics situations but thinking and acting ethically within the routine, ordinariness of professional life. Ethical practice is about pre-empting possible ethical issues as well as responding to those that have arisen.

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JCPSLP Volume 17, Supplement 1, 2015 – Ethical practice in speech pathology

Journal of Clinical Practice in Speech-Language Pathology