Freedom of action and choice. Justice and fairness. Doing good for others. Preventing or avoiding harm. Fidelity and loyalty.
These five moral principles underlie the ethical guidelines of many health care organizations (Kitchener, 1984), including ASHA. The core principles of the ASHA Code of Ethics, as stated in the preamble, focus in particular on honoring professional boundaries with—and responsibilities to—communications sciences and disorders (CSD) clients, colleagues, support personnel, students, and the public (ASHA, 2010a). These principles include:
- Responsibilities to persons served professionally.
- Responsibilities for one's professional competence.
- Responsibilities to the public.
- Responsibilities involving inter- and intraprofessional relationships.
But what happens when somebody believes a CSD professional has violated one of these principles? Or if a CSD professional thinks he or she is being asked to do something unethical? ASHA routes the inquiry or complaint to its Ethics Office, where it is determined whether ASHA's Board of Ethics has jurisdiction over the potential complaint and whether the matter is appropriate to be heard and decided by the board.
About half the inquiries require ethics guidance to address a potential code violation. Callers seeking redress regarding past conduct are directed to the online Ethics Complaint Filing Instructions and Form [PDF] to file a written ethics complaint. Once the complaint is received, the complainant is notified that it has been accepted and will be scheduled for an initial consideration hearing by the board. The board holds the complaint filing in strict confidence, in accordance with its policy (ASHA, 2012).
The board recognizes that each case must be judged on an individual basis. If, upon its final decision (after any appeals), the board publicly sanctions a member—with censure or with suspension, revocation, or withholding of membership and/or certification—the public sanction is first shared with the complainant and respondent. Then the sanction is published in The ASHA Leader and shared with state licensure boards with which the member is affiliated. If the board finds insufficient evidence to justify a violation, or if it decides on a private sanction of reprimand, no publication occurs (ASHA, 2012).
The settings of ethical lapses vary. The bulk of ethics inquiries and complaint filings involve professionals working in school settings, which isn't surprising because slightly more than half of ASHA members work in school settings. Next are health care settings, where all too often members report being required to add patients to their caseloads when no treatment benefit can reasonably be expected. Private practice settings come in third, not surprising given that a smaller number of members—just under a fifth of them, according to ASHA's 2011 member survey [PDF]—work full- or part-time in private practice. Following are the nine most common types of ethical inquiries and complaints ASHA receives.
1. Documentation Lapses
The Ethics Office frequently gets calls and e-mails about potential documentation-related abuses. For instance, members call about discomfort with a supervisor's request that they "sign off" on documentation for patients they did not evaluate or treat. The same is true of requests to sign off on student- or assistant-provided treatment that they did not supervise. Also common are disagreements about time needed to complete documentation properly. Respondents often say they need extensions to finish it accurately and completely. Even more often, though, members express concerns about issues related to altering or supplementing patient or treatment paperwork.
The amount of patient-, billing-, and treatment-related information today's clinicians need to gather, distribute, and save has ballooned. ASHA knows about this increasing paperwork burden, and is working to address it by exploring methods to reduce or streamline required treatment and billing paperwork.
2. Employer Demands
Increasing caseloads, tighter time limits, higher production quotas, and rejection of a professional's independent judgment top the list of demands by supervisors and directors. These demands can sometimes tempt members to act unethically. Unfortunately, members who find themselves in this position often feel they must prepare for termination and seek other employment—or risk being sanctioned by ASHA's Board of Ethics or a state licensure board. But this outcome doesn't necessarily have to be the case, because ASHA offers ethics resources members can use to educate their employers in such situations. Ethics Office staff are available to help members advocate for ethical and best practices while, if possible, meeting their employer's demands.
3. Use and Supervision of Support Personnel
Support personnel and assistants are invaluable to SLPs and audiologists, but their responsibilities and supervision can pose ethical conundra. Because of differing state requirements and various job titles, the Ethics Office receives numerous ethical inquiries about roles and responsibilities of support personnel. But the Board of Ethics does not have jurisdiction over an assistant practicing alone. The board's jurisdiction is limited to a member, certified member, or applicant (ASHA, 2008). In general, however, there is no ethical use of assistants in any setting without adequate direction and supervision by an ASHA certified professional (ASHA, 2004).
4. Clinical Fellowship Mentoring/Student Supervision
Staff in the Ethics Office speak regularly with clinical fellows who are disappointed by the failure of their mentors to supervise them or to demonstrate appropriate ethical behavior. We also speak with numerous mentors and supervisors who describe students and fellows with careless attitudes toward delivering treatment and professional services. The Board of Ethics has two "Issues in Ethics" statements to help address ethics concerns related to supervision and mentoring of clinical fellows (ASHA, 2007) and student clinicians (ASHA, 2010d).
The good news is that the ASHA Board of Directors is aware of these supervision issues. Recently, it appointed an ad hoc committee to study ways to assist members with supervision and mentoring and address the challenges to providing good supervision. This work will benefit students, clinical fellows, mentors, ASHA members, and the Board of Ethics. Recently, the Board of Ethics has seen a significant rise in complaints involving ethical disputes with clinical fellows, disputes that often could have been avoided with adherence to proper supervision.
5. Client Abandonment
ASHA members must, at all times, maintain their focus on the welfare of the client, even when, as clinicians, they decide to end their relationships with employers or patients. Given the current shortage of CSD professionals, however, departures may leave clients without appropriate care. Adequate notice is necessary to prevent treatment disruptions, but even when given adequate notice, employers may be tempted to pressure or threaten departing clinicians to stay or give unreasonable amounts of notice. The Board of Ethics "Issues in Ethics" statement on client abandonment (ASHA, 2010b) offers specific guidance to remain ethical while in transition. Prior to departing, a professional must make effective efforts to provide for the patient's continuing care. The more seamless the transition for the patient, the better.
6. Reimbursement for Services
Although inquiries and complaints about reimbursement come from different settings and deal with different types of reimbursement, the ethical issues behind the complaints are always the same: intent, fraud, and misrepresentation. In this area, members sometimes place their reputations and livelihoods on the line for the greater good. In the "Issues in Ethics" statement on representation of services for insurance reimbursement, funding, or private payment (ASHA, 2010c), the Board of Ethics sets out six particular behaviors that often result in ethics challenges or charges:
- Misrepresenting information to obtain reimbursement or funding, regardless of the motivation of the provider.
- Providing service when there is no reasonable expectation of significant communication or swallowing benefit for the person served.
- Scheduling services more frequently or for longer than is reasonably necessary.
- Requiring staff to provide more hours of care than can be justified.
- Supervision of students or other service providers in a fee-for-service environment.
- Providing professional courtesies or complimentary care for referrals or otherwise discounting care not based on documented need.
7. Business Competition
Running a private practice in speech-language pathology or audiology is competitive, even though demand for services remains high. Private practitioners must market their services, bid on contracts, and compete for business in different settings. Although competition is healthy, it must hold the welfare of clients paramount and be undertaken in a way that is not detrimental to the professions. The "Issues in Ethics" statement on competition in professional practice (ASHA, 2011) addresses ways to compete ethically in the marketplace. The statement makes a CSD professional's responsibility to the public clear: "services must be designed to serve the public by providing accurate information in all aspects" of the professions, from advertising to prognosis.
8. Impaired Practitioners
Recognizing and dealing with impaired practitioners, professionals, and clinical fellows is ugly but important. Impairments range from untreated or undiagnosed mental health issues to substance abuse of all types. The issues may be as much legal as they are ethical. National mental health statistics and surveys of ASHA members indicate that there may be a number of professionals who are challenged by mental illness, substance abuse, or both. Impaired professionals pose a liability to clients and colleagues that increases with time and opportunity, so addressing their impairment is imperative.
Because the circumstances surrounding an impaired professional are complex, this type of ethical dilemma should not be taken on by one person. The supervisor, director, owner, lawyer, employee assistance program counselor, ethics officer, and/or compliance officer should be consulted to draw up a plan that encompasses all needed aspects to manage both the impaired professional as well as his or her caseload and/or students.
9. Affirmative Disclosures
University programs and licensure boards increasingly require applicants to reveal past criminal or professional discipline history, and applicants for ASHA certification, reinstatement, and recertification must do the same. This requirement generates many inquiries from applicants regarding what or how much to reveal. For more information on certification disclosures, see the frequently asked questions for audiology and speech-language pathology. Likewise, most licensure boards share professional discipline records of reciprocal members or applicants with the Ethics Office. Some state licensure boards also require licensees who are disciplined by a state board to self-report this professional discipline to ASHA's Ethics Office within a month of receiving it. This requirement has led to several Board of Ethics-initiated ethics complaints against ASHA members. For instance, if a member's license was revoked by the state licensing board as a result of the member being convicted of a felony by a court, the Board of Ethics would likely initiate a complaint against that member and possibly sanction the member with revocation of ASHA certification and membership for many years.
All ASHA members have either had coursework, continuing education, or both in ethics. Thus, it should come as no surprise that Principle I, Rule A, states, "Individuals shall provide all services competently." This rule means services can be provided competently only if they're provided ethically. Common sense would dictate the same. Seeking ethics guidance from a trusted colleague or the ASHA Ethics Office is an easy, smart way to determine what you don't know but need to know about ethics.
To help educate members, the ASHA Board of Directors recently created the Ethics Education Subcommittee of the Board of Ethics. Under the direction of Chair Fred Britten, this year the group immediately embarked on several education activities, including presentations for state associations, conferences, and ASHA's annual Convention. In addition, Ethics Education (second edition), an essential manual for any ethics education activities, will be updated by the subcommittee for the 2010 ASHA Code of Ethics, and will be available for purchase in 2013. (Ethics Education, Item #0112930, the original edition, is still available; it is based, however, on the 2003 ASHA Code of Ethics.)
The new subcommittee will also update and add to the 18 Board of Ethics "Issues in Ethics" statements. Possible new topics include professional documentation, telepractice, the impaired practitioner, and the changing business landscape for dispensing audiologists. If you have a suggestion for an "Issues in Ethics" topic, e-mail firstname.lastname@example.org.
Ultimately, regardless of topic or circumstance, acting and practicing ethically requires being proactive and vigilant. When thinking through an ethical dilemma, CSD professionals—like the Board of Ethics in deliberating on an ethics complaint—need to gather all facts and consider the circumstances: practice setting, patient's age, disorder type, billing options, and state or licensing issues.
With so many factors and players to consider, the ethical thinking process can be sticky and difficult. When weighing one's professional obligations, there is rarely a "zero-risk" option. Even doing nothing may pose risks ethically. When in doubt of the best path to take, seek ethics guidance before taking action or making a decision.