JCPSLP Vol 17 Supplement 1 2015_lores

By far the largest category of concerns were those related to resource allocation. These categories are discussed below. Discussion The emerging ethical issues identified in the workshop align well to the trends presented in the first part of this paper, particularising these to our professional practice, as well as raising some new concerns. Of interest in the discussions at this workshop was the focus on ethical issues at the systemic level rather than at the individual client–practitioner level. Inevitably, system level pressures will impact on services to clients but the discussion in the workshop was 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 management 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 • 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)

primarily around the larger contexts in which ethical practice must be ensured. Speech pathologists at the workshop spoke of the ethics of a medical emphasis on “saving lives at all costs”, especially when the costs to quality of life are high. As a result, allied health professionals increasingly work with clients with complex disabilities who have care needs across the lifespan. This in turn impacts on resource allocation and prioritisation of services, which are already under strain with population ageing, fiscal constraints and a shrinking health care workforce. Workshop participants identified several worrying trends in resource allocation and prioritisation, including the cutting of services to some client groups (e.g., those with fluency or voice disorders, children with speech and/or language impairments in the absence of concurrent behavioural problems) and some age groups. For example, in some states without school-based therapy services, school-aged children are not a high priority at health services. Further, service management policies sometimes limit the number of occasions of service to clients in ways which are not consistent with evidence-based practice or which may lead to discharge before an episode of care has achieved the established goals. As a result, practitioners often experience tension and conflict between the values of the profession and the values underpinning management policies (Cross, Leitão & McAllister, 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 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 according 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.

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

Journal of Clinical Practice in Speech-Language Pathology