Issues in Ethics: Cultural and Linguistic Competence
About This Document
Published 2013. This Issues in Ethics statement is a revision of Cultural Competence (2004). The Board of Ethics reviews Issues in Ethics statements periodically to ensure that they meet the needs of the professions and are consistent with ASHA policies.
Issues in Ethics Statements: Definition
From time to time, the Board of Ethics determines that members and certificate holders can benefit from additional analysis and instruction concerning a specific issue of ethical conduct. Issues in Ethics statements are intended to heighten sensitivity and increase awareness. They are illustrative of the Code of Ethics and intended to promote thoughtful consideration of ethical issues. They may assist members and certificate holders in engaging in self-guided ethical decision-making. These statements do not absolutely prohibit or require specified activity. The facts and circumstances surrounding a matter of concern will determine whether the activity is ethical.
This Issues in Ethics statement is developed to provide guidance to ASHA members and certificate holders so that they may provide ethically appropriate services to all populations, while recognizing their own cultural/linguistic background or life experience and that of their client/patient/student. Culture can encompass a variety of factors including race, ethnicity, religious beliefs, age, national origin, gender, gender identity/gender expression, sexual orientation, socioeconomic levels, and disabilities. Linguistic diversity can accompany cultural diversity.
As the 21st century has moved forward, the ethnic, cultural, and linguistic makeup of the United States has been changing steadily. The different traditions, beliefs, and values present in the United States have created one of the most diverse societies in history. Speech-language pathologists, audiologists, and speech, language, and hearing scientists practicing in the 21st century must recognize the similarities among culturally diverse populations while respecting and acknowledging the important differences that make people distinct and that can affect service delivery, research, and professional/supervisory relationships.
What Is Cultural and Linguistic Competence?
Culture and linguistics refer to integrated patterns of human behavior that include language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or other groups (e.g., gender, gender identity/gender expression, age, national origin, sexual orientation, disability). Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.
Why Is Cultural and Linguistic Competence Important?
The professional must recognize that differences do not imply deficiencies or disorders. Culture and language may influence the behaviors of individuals who are seeking health, habilitative, or rehabilitative care and their attitudes toward speech, language, and hearing services and providers. Similarly, the delivery of services is impacted by the values and experiences of the provider. Competent care is providing service that is respectful of, and responsive to, an individual's values, preferences, and language. Care should not vary in quality based on ethnicity, age, socioeconomic status, or other factors.
In addition, federal and state regulations and programs, such as Medicaid, Medicare, and IDEA, require that providers render culturally and linguistically appropriate services. These programs are in accordance with broader legislation, Title VI, Executive Order 13166, and National Standards on Culturally and Linguistically Appropriate Services (CLAS). Audiologists, speech-language pathologists, and speech, language, and hearing scientists have legal and ethical responsibilities to provide services and conduct research that is culturally and linguistically appropriate.
How Does the Code of Ethics Speak to Cultural and Linguistic Competence?
The Code of Ethics speaks directly to the need for culturally and linguistically competent services and research.
Principle of Ethics I: Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner.
Rule A, Individuals shall provide all services competently.
Rule B. Individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided.
The implication of Rule B is that if a professional feels unprepared to serve an individual with cultural and linguistic differences, the option of an appropriate referral should be utilized.
Rule C. Individuals shall not discriminate in the delivery of professional services or the conduct of research and scholarly activities on the basis of race or ethnicity, gender, gender identity/gender expression, age, religion, national origin, sexual orientation, or disability.
Rule E: Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, and judgment that are within the scope of their profession to assistants, technicians, support personnel, or any nonprofessionals over whom they have supervisory responsibility.
Rule E prohibits delegation of tasks that are beyond the competence of the designee and requires that adequate supervision be provided by the professional. The implications are widespread when cultural or linguistic differences exist between the service provider and the client or research participant, especially when the use of bilingual assistants, aides, transliterators, and interpreters are required. While providing services to linguistically diverse individuals may require the assistance of trained interpreters or other bilingual professionals, it is the responsibility of the professional to understand the influence of issues related to cultural and linguistic diversity (e.g., second language acquisition, dialectal differences, bilingualism). Ultimately, the professional is responsible for the appropriate diagnosis and treatment/management of communication disorders, as well as swallowing and balance disorders.
Principle of Ethics II: Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.
Rule B: Individuals shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their level of education, training, and experience.
Rule B should not be construed as a reason not to provide services to individuals with different cultural and linguistic backgrounds. Professionals should consider other options, such as additional training, making a referral, and using an interpreter to ensure appropriate services.
Rule C: Individuals shall engage in lifelong learning to maintain and enhance professional competence and performance.
Rule C reminds professionals of the importance of lifelong learning to develop the knowledge and skills required to provide culturally and linguistically appropriate services.
Principle of Ethics IV: Individuals shall honor their responsibilities to the professions and their relationships with colleagues, students, and members of other professions and disciplines.
Rule K: Individuals shall not discriminate in their relationships with colleagues, students, and members of other professions and disciplines on the basis of race or ethnicity, gender, gender identity/gender expression, age, religion, national origin, sexual orientation, or disability.
Rule K underscores that discrimination in any professional arena and against any individual for any reason, whether subtle or overt, ultimately dishonors the professions and harms all those within the practice.
There are far-reaching implications for the principles and rules cited above. The clinician, educator, supervisor, and researcher must be mindful of the impact of cultural and linguistic diversity in interactions with clients, families, students, and colleagues. Regardless of personal culture, practice setting, or caseload demographics, professionals must strive for culturally and linguistically appropriate service delivery. This will impact all aspects of professional practice including assessment procedures, diagnostic criteria, treatment plans, treatment discharge decisions, and research.
The beliefs and values unique to that individual service provider-client encounter must be understood, protected, and respected. Providers must enter into the relationship with awareness, knowledge, and skills about their own culture and cultural biases, strengths, and limitations. Care must be taken to avoid making assumptions about individuals that could lead to misdiagnosis or improper treatment of the individual. To best address the unique, individual characteristics and cultural background of individuals and their families, providers should be prepared to be open and flexible in the selection, administration, and interpretation of diagnostic and/or treatment regimens.
Certain materials and activities may be inappropriate and even offensive to some individuals. Families may choose complementary and alternative medicine, traditional healing practices, and different communication styles, as opposed to mainstream diagnostic and therapeutic approaches. This applies to the treatment of communication disorders, as well as swallowing and balance disorders.
When a professional is not proficient in the language used by the client and family, a suitable interpreter should be used. The use of interpreters and others who are proficient in the language of the persons served does not negate the ultimate responsibility of the professional in diagnosing and/or treating the individual. Speech-language pathologists or audiologists who present themselves as bilingual for the purposes of providing clinical services must be able to speak their primary language and to speak (or sign) at least one other language with native or near-native proficiency in lexicon (vocabulary), semantics (meaning), phonology (pronunciation), morphology/syntax (grammar), and pragmatics (uses) during clinical management or conduct of research. In addition, bilingual clinicians must understand issues related to cultural and linguistic diversity, such as, second language acquisition, dialectal differences, and bilingualism.
Cultural and linguistic competence is as important to successful provision of services as are scientific, technical, and clinical knowledge and skills. The Code of Ethics requires the provision of competent services to all populations and recognition of the cultural/linguistic or life experiences of both professionals and those they serve. Caution must be taken not to attribute stereotypical characteristics to individuals. Speech, language, and hearing research and services should be respectful of and responsive to the needs of culturally and linguistically diverse populations. Members and certificate holders should explore resources available from ASHA, other professionals, and other sources in order to continually enhance their cultural and linguistic competence.