Multiple Professional Ethics Standards: A Challenge for Practitioners
Audiologists require the knowledge, desire, and discipline to identify potential ethical violations. Professional organizations and credentialing bodies in audiology typically require a commitment to follow their professional code(s) as a requirement for maintaining membership or a credential (Shinn, 2004). Some practitioners know about the ASHA Code of Ethics while others are familiar with their state board of examiners' code of conduct or ethics; it is important for all practitioners to be well versed with both sources of professional obligations.
Gaining and maintaining that knowledge takes a desire to learn and the discipline to follow through on ethical queries. Because ethics is so important in health care, most hospitals and health care organizations have created and published their own codes of ethics for their staff—another source of standards that practitioners cannot overlook (Kummer & Turner, 2011). Thus, most audiologists are subject simultaneously to multiple standards of professional conduct; standards that can and do overlap. Not surprisingly, professional ethics standards also tend to change over time. For instance, the Code of Ethics of ASHA was first issued in 1930, and it has been amended several times since then.
Uniformity among state board of examiners' codes of conduct and ASHA's Code of Ethics could ease practitioners' burden in becoming familiar with and staying abreast of multiple, overlapping professional obligations. Unfortunately, though increased uniformity is desirable, it is not the reality.
The dissimilarity among state codes is significant, even though most states with licensure laws have professional conduct standards based on ASHA's Code of Ethics. While some states initially adopted ASHA's Code of Ethics in whole or in large part, many deviated over time. That occurred presumably because of political or practical realities or failure to update state codes when ASHA updated its code. The end result for most practitioners is the challenging task of learning and applying multiple, sometimes inconsistent ethics rules, codes, and standards.
A survey of four randomly selected state boards of examiners' codes demonstrates the variation among the professional codes and conduct rules of state licensing boards that apply to speech-language pathologists and audiologists. In this article, I will compare and contrast the state conduct rules and codes in Delaware, Ohio, Maryland, and Mississippi and reference the current ASHA Code of Ethics (2010).
For the purposes of illustration, I will examine four common areas of ethical discourse in each code of ethics or conduct rules—
- independent professional judgment or prescription
- guarantee of results
- holding patients' welfare paramount
- use of every resource, including referral.
This article is only a brief snapshot of some provisions in these selected codes; it is not a substitute for reading the entire code for each state where one is licensed, in addition to reading the ASHA Code of Ethics.
Independent Professional Judgment and/or Prescription
ASHA Code of Ethics Principle IV Rule J: "Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription."
- Delaware Code of Ethics for Speech-Language Pathologists, Audiologists & Hearing Aid Dispensers: The code does not address independent professional judgment or prescription.
- Maryland Code of Ethics .04 Special Responsibilities F: "The licensee may not provide professional services without exercising independent professional judgment, regardless of referral source or prescription."
- Mississippi Rules for Professional Conduct 8.b: "Individuals must not provide clinical services by prescription of anyone who does not hold a license in speech-language pathology or audiology." (p. 17)
- Ohio Code of Ethics (B)(3)(d)(ii): "Licensees shall exhibit professional behavior in the delivery of services by…Accept[ing] for treatment, persons…Following the exercise of independent professional judgment, regardless of referral source or prescription."
So, no matter what the audiologist's circumstances, it is incumbent on the practitioner to determine when to accept limitations on professional responsibility. Unlike ASHA and three states above, Delaware does not currently address this specific topic in its code of ethics. No obvious conclusions can be drawn, however, by the absence of this provision but it is puzzling. Maryland's provision is most similar to ASHA's, but is less restrictive: The language uses "may" instead of the more legally compelling "shall."
Because of the varied and significant ethical dilemmas presented by prescription, the ASHA Board of Ethics (BOE) wrote an Issues in Ethics Statement about Prescription (2010) to provide additional analysis and focus. This ASHA BOE resource is instructive for all practitioners regardless of whether their state boards specifically address prescription.
Guarantee of Results
- ASHA Code of Ethics Principle I Rule J: "Individuals shall not guarantee the results of any treatment or procedure, directly or by implication; however, they may make a reasonable statement of prognosis."
- Delaware Code of Ethics 126.96.36.199: "Licensees shall make no guarantees of the results of any product or procedure but may make a reasonable statement of prognosis."
- Maryland Code of Ethics .02 Ethical Responsibilities C. (3): "The licensee may not guarantee the result of a speech-language or hearing consultation or therapeutic procedure. A guarantee of any sort expressed or implied, oral or written, is contrary to professional ethics."
- Mississippi Rules for Professional Conduct 6.b: "Individuals must not guarantee the results of any therapeutic procedures, directly or by implication. A reasonable statement of prognosis may be made, but caution must be exercised not to mislead persons served professionally to expect results that cannot be predicted from sound evidence."
- Ohio Code of Ethics (B)(3)(j): "Licensees shall exhibit professional behavior in the delivery of services by:...(j) Not guarantee the results of any speech or hearing consultative or therapeutic procedure.
- A guarantee of any sort, express or implied, oral or written, is contrary to professional ethics.
- A reasonable statement of prognosis is appropriate, but factors, hence, any warranty for services and outcomes is deceptive and unethical."
This provision is quite similar among all five sources. The more inclusive and arguably better drafted versions include broader language, such as "directly or by implication" or "expressed or implied, oral or written." Maryland's provision is most similar to ASHA's but appears to allow more discretion (i.e., uses "may" as opposed to "shall").
Holding Patients' Welfare Paramount
ASHA Code of Ethics Principle 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."
- Delaware Code of Ethics for Speech-Language Pathologists, Audiologists & Hearing Aid Dispensers: The code does not address, either specifically or in general, holding patient's welfare paramount.
- Maryland Code of Ethics .02 Ethical Responsibilities A: "The licensee shall consider paramount the welfare of individuals served professionally."
- Mississippi Rules for Professional Conduct 5.a: "Individuals shall hold paramount the welfare of persons served professionally."
- Ohio Code of Ethics "Preamble: Licensees shall hold tantamount the health and welfare of person(s) served."
This provision is quite similar among all five sources, with ASHA's being the most expansive (e.g., including participants and animals). Some of the other codes address scholarly activities elsewhere.
Use of Every Resource, Including Referral
- ASHA Code of Ethics Principle I Rule B: "Individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided."
- Delaware Code of Ethics 188.8.131.52: "Licensees shall use every resource, including referral, to provide quality service."
- Maryland Code of Ethics .02 Ethical Responsibilities D: "The licensee shall use every resource available, including referral to other specialists as needed, to effect maximal improvements in the individuals served."
- Mississippi Rules for Professional Conduct 5.b: "Individuals shall use every resource available, including referral to other specialists as needed, to provide the best service possible."
- Ohio Code of Ethics (B)(3): "Licensees shall exhibit professional behavior in the delivery of services by: ...(k) every resource available, including referrals to other specialists as needed, to effect maximum improvement in person(s) served. Licensees shall:
- Identify competent, dependable referral sources for person(s) served professionally.
- Include referrals to other audiologists and speech-language pathologists when the scope and nature of the indicated evaluation and/or treatment is beyond the training of the licensee...."
While the first four provisions are very similar, Ohio takes a different tack. Requiring licensees to identify competent, dependable referral sources may well lead to better protection of the public. The authors of Ohio's code appear to believe that the practitioner would be better informed about competent, dependable referral sources than would the individual patient.
So, as these examples show, the variations are not necessarily large or predictable and are unlikely to disappear. The challenge for practitioners is felt acutely when members or certificate holders inquire of ASHA for assistance in evaluating a potential or actual ethical dilemma that is associated with differing standards. ASHA's Code of Ethics can be easily located on its website. On the other hand, it is difficult at best to quickly locate online most state boards' codes of ethics or standards of conduct. Web addresses change periodically, and sites can go down, so even bookmarking is not always helpful. In the heat of the moment, the inquiring member or certificate holder can forget the requirement to comply with the mandates of both ASHA and the applicable state board(s) of examiners. If they have not previously appreciated this dual obligation, members or certificate holders may find the situation overwhelming.
Fortunately, with a little advance preparation, this situation can easily be overcome. Ideally, before faced with an ethical or a time sensitive issue, the practitioner can take the time to locate all of the codes of ethics and standards of conduct that apply to his or her professional conduct. If clarification is needed, the practitioner can contact the compliance or ethics officer at his or her place of work and get information on ASHA's Code of Ethics on the website, and locate the state board of examiners conduct rules.
There are a number of steps practitioners can take to prepare for ethics challenges.
- Determine what type of reference materials will work best for you (and your staff) should an ethics issue present itself.
- Save copies of each code or of conduct rules to your local computer drive or portable drive and/or print copies for future reference.
- Make a list of persons (with contact information) who can reliably be consulted for guidance on ethics issues; this will save time in the event a problem arises. Include compliance officers, ethics officers, supervisors, state board personnel, and ASHA's director of ethics.
Minimal advance preparation can relieve unnecessary stress and lead to better evaluation of the ethical implications of a factual scenario in professional practice.
Heather Bupp, Esq.
ASHA Director of Ethics
American Speech-Language-Hearing Association. (2010). Code of ethics. Available from www.asha.org/policy.
American Speech-Language-Hearing Association. (2012). Issues in ethics statements. Retrieved from www.asha.org/practice/ethics/ethics_issues_index/.
Chabon, S. S., & Ulrich, S. (2006, February 7). Uses and abuses of the ASHA code of ethics. The ASHA Leader.
Del. Reg., 3700 Bd. of Examiners of Speech/Language Pathologists, Audiologists & Hearing Aid Dispensers. (2005). 8 DE Reg. 1106 (2/1/05); 9 DE Reg. 1267 (2/1/06); 24 Del.C. §3715(a). Retrieved March 1, 2012, from http://regulations.delaware.gov/AdminCode/title24/3700.shtml.
Kummer, A. W., & Turner, J. (2011). Ethics in the practice of speech-language pathology in health care settings. Seminars in Speech and Language, 32, 330–337.
Md. Reg. 10.41.02 Code of Ethics [PDF]. (1974). Retrieved March 1, 2012, from www.dhmh.maryland.gov/boardsahs/Documents/COMAR_10.41.02_Ethics.pdf [PDF].
Miss. Regs. Governing Licensure of Speech-Language Pathologist and Audiologists. (1975). Miss. Code Ann. §73-38-13. Retrieved March 1, 2012, from http://msdh.ms.gov/msdhsite/_static/resources/571.pdf [PDF].
Ohio Admin. Code, Bd. of Speech Language Pathology and Audiology, Ch. 4753-9 Code of Ethics. (1973). Retrieved March 1, 2012, from http://codes.ohio.gov/oac/4753-9-01.
Shinn, R. (2004, March 16). Ethics and audiology. The ASHA Leader.