Teaching Ethics in Speech-Language Pathology
Ethics is defined in Dictionary of the English Language (2001) as “a discipline dealing with good and evil and with moral duty and moral principles or practice. (1989) defined ethics as “moral principles or values that address whether actions, intentions, and goals are right or wrong”. These two definitions suggest that an individual’s moral values or principles influence his or her decision-making. (2001) further characterized ethics as the outer demonstration of morals, a collective system of principles, established accepted standards of conduct, and the value of behavioral influence on an individual or group.
(1988) noted health care managers often make decisions based on the premise “this is how we have always done things”. If true, one must question whether or not this attitude is reflected in how speech-language pathology (SLP) graduate students are taught to make ethical decisions.
Academia’s primary purpose is to prepare professionals for practice in “real world” settings. As such, there is a need to examine how SLP faculty teaches ethical decision-making. In particular, one might ask -- Is instruction with regard to ethical decision making limited to understanding a set of guidelines, or do faculty teach how to apply ethics to a decision making process?
(1994) dissertation was designed to explore what American Speech-Language-Hearing Association (ASHA) accredited programs were doing to provide ethics education for students-in-training. (1996) wrote a text devoted exclusively to ethics in SLP and audiology. In fact, an initial premise in the founding of the American Speech-Language-Hearing Association (ASHA) were the ethical concerns about the well-being of consumers (1989; 1994).
Nonetheless, as compared to other allied health disciplines, the profession of speech-language pathology appears to be in its infancy regarding a comprehensive education-based approach to ethics and related decision making protocols. Empirically-based ethics education is apparently lacking, and to strengthen the profession, speech-language pathologists should investigate additional instruction and education relating to ethics and the SLP.
The Need for an Organizational Ethics
The need to teach ethics can be traced back to the early Greeks (1994; 1901). The early Greeks were concerned with the basic meaning of life in regard to duty, conduct, and morals. The interest, and indeed demand for teaching ethics at a professional level was catapulted into America’s conscience during the 1970s, 1980s and 1990s (1994). Perhaps political, religious and business scandals raised concerns with the American public as to what does, or should constitute appropriate, moral and ethical behavior? Perhaps the American public currently demands accountability regardless of the profession or action, as a result of societal shift and the immediacy of the exchange of information resulting from modern media transmission?
Regardless, ethics and related concerns have become prominent in the clinical arena. SLP practitioners face ethical situations in which the idea of “self-serving” as opposed to the “well-being of consumer” must be addressed and competently managed.
Professional Ethics concerns one's conduct of behavior and practice when carrying out professional work. Such work may include consulting, researching, teaching and writing. The institutionalization of Codes of Conduct and Codes of Practice is common with many professional bodies for their members to observe. Any code may be considered to be a formalization of experience into a set of rules. A code is adopted by a community because its members accept the adherence to these rules, including the restrictions that apply.
It must be noted that there is a distinction between a profession such as Information Systems, and controlled professions such as Medicine and Law, where the loss of membership may also imply the loss of the right to practice. Apart from codes of ethics, professional ethics also concerns matters such as professional indemnity. Furthermore, as will readily be appreciated, no two codes of ethics are identical. They vary by cultural group, by profession and by discipline. The former of these three variations is one of the most interesting, as well as controversial, since it challenges the assumption that universal ethical principles exist. In some cultures, certain behaviors are certainly frowned upon, but in other cultures the opposite may be true.
Studies show that formal ethics programs are becoming increasingly common in U.S. organizations across the nonprofit, for-profit, and government sectors. Compared to the 1994 survey, the 2000 finds dramatic increases in the percentage of employees who report that their organizations have ethics programs. In the nonprofit sector specifically, the 2000 NBES finds that nearly 90 percent of employees say their organizations have written standards of ethical conduct. In addition, 65 percent say their organizations provide some form of training about these standards, and more than 40 percent say a dedicated telephone line or office is available for ethics advice. Not surprisingly, the percentages are consistently higher among larger nonprofits - those with more than 500 employees - as compared to smaller ones.
Essentially, ethics programs are meant to affect how people think about and address ethical issues that arise on the job. Gretchen Winter, vice president of business practices at Baxter International, puts it this way: By providing employees with ethics standards, training, and resources to get advice, organizations seek to create a work environment where (1) it’s okay for employees to acknowledge that they have an ethical dilemma, and (2) resources are readily available to guide employees in working through such dilemmas before making decisions.
The 2000 finds much that is encouraging for organizations that are putting their efforts into workplace ethics. For example, employees have high expectations for ethics within their organizations. More than nine in 10 respondents say that they “expect their organizations to do what is right, not just what is profitable.” This finding suggests that most employees are not so cynical about ethics at work. This should be encouraging news for all executives pursuing ethics initiatives. Most recognize that the long-term success of any program requires the active support of employees.
Findings from the also show that both formal ethics programs and informal ethics practices are related to key outcomes. Employees who work in organizations with ethics programs, who see their leaders and supervisors modeling ethical behavior, and who see values such as honesty, respect, and trust applied “frequently” at work generally report more positive experiences in the workplace.
Ethics are making a comeback. To begin with, more and more corporations and businessmen and woman are now realizing that ethics aren’t checked at the door when entering the workplace. Ethics have every bit as much a place in the public as they do the private. How is it there should be separate sets of ethics, depending upon whether it is your personal life or your work life? The answer is that there shouldn’t be a separate set and in light of recent events that we see on our television sets as of late, more and more companies are realizing this fact.
Some companies are incorporating ethics into their training. It is s subject that can go hand-in-hand with business and when employees and CEO’s alike understand what ethics are about, business can improve. Not only will the community take note of the ethical nature of a business but also so will customers.
(1996) maintained that if “self-serving” practices were allowed to exist, the effects on a profession would be detrimental. However, the Principle of Ethics IV of the ASHA Code of Ethics (2001) allows a practitioner to be autonomous and to independently use professional judgment. Therefore, these issues are worthy of further exploration. Ethics and related concerns within the healthcare professions will continue to evolve due to technological advances; tele-practice, the Internet and the essence of complex medical procedures which prolong life (2001; 2001; 1993). A challenge and an opportunity exists for professions and professionals to be cognizant of treatment outcomes and efficacy, with particular regard to ethical decision-making.
Ethical and Clinical Decision Making
(2001) and (1988) suggested an ethical decision is influenced by the values and beliefs of an individual professional; whereas a clinical decision is one that affects the welfare of the person served by that professional.
Physicians may experience conflict between different ethical principles, between ethical and legal or regulatory requirements, or between their own ethical convictions and the demands of patients, proxy decision makers, other health professionals, employers or other involved parties. Training in ethical analysis and decision making during undergraduate, postgraduate and continuing medical education is recommended for physicians to develop the knowledge, skills and attitudes needed to deal with these conflicts. Consultation with colleagues, licensing authorities, ethicists, ethics committees or others who have expertise in these matters is also recommended.
The consensus statement sees the teaching of medical ethics and law as contributing to the overall objective of medical education the creation of good medical practitioners who will enhance and promote the health and medical welfare of the people they serve in ways which fairly and justly respect their dignity, autonomy and rights. To achieve these goals medical students must be able to understand the ethical principles and values underpinning good medical practice be able to think critically about ethics, reflecting on their own beliefs and understanding and appreciating alternative, perhaps competing, approaches; and "be able to argue and counter argue in order to contribute to informed discussion and debate." Students must know the main professional and legal obligations of medical professionals, especially those specified by the General Medical Council, and be able constructively to participate in the ethical and legal reasoning needed in everyday practice.
Influences on ethical decision-making have been previously documented (1993;2001;1996; 1994; 1994). Influences include; humanitarian efforts, the need to be cost-effective, the ability to perform an array of tasks competently and efficiently, the need to meet consumer demands in an educated society, downsizing of staff which leads to restricted interactions with colleagues and supervisors, and the situations in which such decisions are made.
Using what she identified as Purtilo’s model, (2001) outlined a process for ethical decision-making. The process begins with data gathering, including; obtaining facts, specifying the context of interactions and identifying the source of the information. Once completed, the individual establishes the ethical problem (if any) and can then examine the “morally correct course of action, identify the primary decision maker, and take steps to maintain the integrity of the individual and the profession” (). The individual should evaluate the situation based on ethical theories and/or models and must consider the perspective used, as well as the areas of conflict and decide if a dilemma exists (). The individual explores all avenues of choice, recognition of options, immediate, and future consequences of those options and an ultimate choice of the “best” option emerges () and a decision is made. The individual should be able to act in a manner beneficial to the present situation, with a likely impact on decisions and situations in the future. Finally, the individual self-evaluates the action and the outcome to recognize what went well, what could have been done differently, and the influence on the outlook, perceptions, and careers of others . Bloom’s Taxonomy, as described by (2000), required an individual to progress through cognitive processes (knowledge, comprehension, application, analysis, synthesis, evaluation) to achieve an ethical outcome. In Horowitz’s final step an individual must conduct self-analysis, similar to the evaluation stage in . (2001) model loosely followed a total quality management process which included; brainstorming, gathering facts, planning, implementing the plan, collecting and evaluating data.
(1988) noted that legal decisions or ethical actions should be examined within an ethical and/or clinical decision making framework. proposed that individuals be taught ethical and legal principles by focusing on the content of ethics education in undergraduate and graduate course work and through continuing education. suggested education in ethics should be embedded instructionally into existing courses and delivered through methods such as case scenarios and discussions. If there is to be a comprehensive understanding of ethical decision-making, basic principles, concepts and theories of ethics must be addressed. Some principles of ethics for professionals have been previously presented in the literature (1994; 1995;2000; 1994; 1988) and have included discussions on; autonomy (the right to function as an independent decision maker), beneficence (concerned with benefit), fidelity (following the Code of Ethics), justice (the fairness with which one practices), nonmaleficence (attempts to avoid harm) and veracity (recognition of facts as well as the avoidance of misrepresentation of ones’ professional expertise and training) see , 2001; 1994.
(2001) presented the concepts of ethics as including equity (fairness, nondiscriminatory practice), veracity (dealing with facts), confidentiality (maintaining client’s privacy), paternalism (parent-child-like relationships), and informed consent (agreeing to a proposed method). Horowitz suggested exploration of these concepts should lead to consideration of “Meta-ethics” which focuses attention on deontological theories and teleological ethics. Deontological theories are concerned with how an individual’s “duties and rights influence that individual” and teleological ethics are “concerned with the consequences and the ultimate good”.
If an individual is to make ethical clinical decisions, that individual must understand the clinical process and there must be pre-existing knowledge about ethical theories and methods. (2001) proposed a plan that included an explanation of the need for ethics education; definitions, basic principles and concepts of ethics; types of ethics education; and steps to include in the decision-making process. Similar plans have been presented by others (1995; 2000; 1994;1988). If SLPs are going to explore the challenges faced in clinical decision-making, consideration has to be given to ways in which ones’ duties and values affect this process. In addition, consumer perceptions of ethical behavior may not match those of professionals.
If an ethical decision is in conflict with the viewpoint of a particular individual, he or she may consider that decision unethical. Individuals interpret actions according to their perceptions. For example, the ASHA Code of Ethics (2001) mandates that speech-language pathologists protect the welfare of individuals they serve. Herer (1989) agreed that quality care should be provided to benefit the client -- not the profession or the professional.
The Standards for Accreditation of Graduate Education Programs (1999) required inclusion of ethics instruction in speech-language pathology curricula, yet the specifics are left to individual training programs. Each ASHA accredited program determines the format in which ethics are taught, the number of hours, and whether instruction is embedded in other courses or offered as a formal academic course for academic credit. Strong support for teaching ethical decision-making processes comes from state regulatory agencies charged with monitoring ethical behavior among professionals ( 2001; 2001). Denton et al. noted, professionals must recognize the role of ethics education, legalities involved in professional practice and the need to continuously define ethical behavior due to societal changes as well as technological advances.
SLP has demonstrated a slower emergence in concentrated efforts to teach ethics (1993; 1994). It was not until 1988 that ASHA formed the Council on Professional Ethics (1989). Thus, as a profession, SLP is only in the early stages of discussing and understanding ethics education and the relationship to professional practice. Interested SLPs might note documentation regarding the importance of ethics education by related disciplines (1991; 2000; 1996; 1999). However, related disciplines do not yet have well-established instructional methods that could be used as a model (1995;1996; 1997;1999) for SLPs.
Many students enrolled in speech-language pathology training programs do not take formal courses in ethics. However, they are exposed to ethics education embedded in the curriculum (1994; 1994). (1993) used a questionnaire to survey SLP training programs in the United States to determine the format in which ethics education was provided. and her colleagues found the majority of responding programs used some form of embedded instruction such as discussions (77%), lectures (75%) and modeling of appropriate behavior (54%). The majority of responding programs (91%) did not offer a formal course in ethics and 85% of respondents spent no more than 20 hours teaching ethics. In medical schools, 28 hours of instruction in ethics is provided ( 2000). (1993) found that 91% of respondents stated training programs should offer ethics education.
(1994) analyzed data from 124 ASHA-accredited training programs to determine how ethics were being taught and to invite opinions as to what ethics should be taught. Ethics education was considered important by 97% of the respondents. (1994) found that 100% of the respondents reported their students were given information about the ASHA Code of Ethics. Young noted differences between how ethics should be taught and how ethics were taught. Regarding reimbursement, 93% agreed payment methods should be taught, while only 75% reported teaching such method. Regarding confidentiality, 92% agreed with its importance while only 53% provided instruction about confidentiality. When asked if students were given information about reporting questionable behavior by another professional, 96% agreed to its importance; however, only 73% taught students how to handle these types of situations, and 38% of respondents agreed ethical theories, models, and decision-making should be provided, yet only 23% reported actual instruction.
While there is a need to teach professional ethics in speech-language pathology, (1994) cautioned against teaching the principles only to students, new clinicians, or even established professionals. They supported the need for the profession to develop an overall understanding of ethics to support the premise that ethics are integral to practice. In spite of the long-standing premise that ethics are critical, the current status is that few formal courses in ethics are taught (1993,1994).
As the profession of SLP continues to change and expand, members must prepare to take the next step in ethics education. Professionals need to understand ethics, values, and their relationship to the decision-making process. Examination of moral values can assist with ethical decision-making and broaden the understanding of diversity. It should be recognized that “codes of ethics” only serve as guidelines for making decisions—clinically and ethically. Professional codes of ethics are policies set forth to govern professional conduct, they are not exhaustive or all-inclusive.
In the end, it’s all about what a person understands about ethics. Many university curriculums are now heavily applying the teaching of Ethics and for good reason. Young minds will take this information into the workforce and understand that ethics need to be applied there as well as in the private sector.
Corporations and professional organizations will be able to avoid embarrassing scandals that are presented all over national news hat are presented all over national news. Small business will be able to keep and attract more clients and customers. Negotiations between businesses could be accomplished with more consideration for the other company in mind, which would only help both. Above all, a high level of ethics in your business should be in place at least for the customers. If anything, it is the customer that should be considered the most when it comes to ethical business practices. In the long run, a company will reap great profits from a customer base that feels it is being treated fairly and truthfully.