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. In view of the current and projected make-up of our society, as well as the demographics of the current ASHA membership, this includes all providers of clinical and educational services in speech-language pathology and/or audiology. Principle of Ethics I, Rule C speaks directly to the issue of clinical and research activities by prohibiting discrimination “in the delivery of professional services or the conduct of research and scholarly activities on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or disability.” Other sections of the Code provide additional guidance regarding professional interactions with individuals from diverse backgrounds.
The overarching directive of Principle of Ethics I is to hold the welfare of those whom we serve paramount. Rules A and B of this Principle direct members and certificate holders to “provide all services competently” and to “use every resource, including referral when appropriate, to ensure that high quality service is provided.” Principle of Ethics II, Rule B, cautions that individuals should engage in practices only within the scope of their competence. Competence issues are more complex when there are cultural and/or linguistic differences between the clinician and client that affect professional service provision. There must be knowledge of the disorder and appropriate diagnostic and treatment processes and procedures.
In addition, beliefs and values unique to that individual clinician-client encounter must be understood, protected, and respected. Care must be taken not to make assumptions about individuals based upon their particular culture, ethnicity, language, or life experiences that could lead to misdiagnosis or improper treatment of the client/patient. Providers must enter into the relationship with awareness, knowledge, and skills about their own culture and cultural biases. To best address the unique, individual characteristics and cultural background of clients and their families, providers should be prepared to be open and flexible in the selection, administration, and interpretation of diagnostic and/or treatment regimens. When cultural or linguistic differences may negatively influence outcomes, referral to, or collaboration with, others with the needed knowledge, skill, and/or experience is indicated.
Principle of Ethics II, Rule C, states that “individuals shall continue their professional development throughout their careers.” Thus, this ethical principle reminds clinicians of the importance of lifelong learning to develop the knowledge and skills required to provide culturally and linguistically appropriate services. Principle of Ethics II, Rule B, should not be construed as a reason not to provide the services.
Principle of Ethics I, Rule E, prohibits delegation of tasks that are beyond the competence of the designee and requires that adequate supervision be provided by the certified individual. The implications of this rule are widespread where cultural or linguistic differences exist between the clinician and the client, especially when the use of bilingual assistants, aides, and interpreters are required. The issue becomes particularly complex if the certified individual does not speak the language being used and the assistant/aide/interpreter is not appropriately trained, as the quality of service and supervision can be compromised. This does not negate, however, the responsibility of the certified individual to understand issues related to cultural and linguistic diversity (e.g., second language acquisition, dialectal differences, bilingualism). Ultimately, the certified individual is responsible for the diagnosis of the speech, language, hearing, swallowing, and/or balance disorders and appropriate treatment/management.
Principle of Ethics IV, Rule H, provides guidance in our interactions with colleagues and students, prohibiting discrimination against these individuals on the basis of race or ethnicity, gender, age, religion, national origin, sexual orientation, or disability. Whether subtle or overt, discrimination in any professional arena and against any individuals with whom we interact for any reason ultimately dishonors the professions and harms all those within the practice.
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There are far reaching applications for the principles and rules cited above. The clinician, educator, supervisor, and researcher must be mindful of the impact of cultural and/or linguistic diversity in interactions with clients, families, students, and colleagues. Certain materials 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. The clinician must have the cultural competence to accommodate these needs and choices, or at a minimum know when and where to seek assistance. The clinician must be aware that “differences” do not imply “deficiencies.” When a clinician 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 client and family does not negate the ultimate responsibility of the clinician in diagnosing and/or treating the client/patient. Additionally, the clinician must remember that bilingual skill (understanding and speaking the language) does not equate to bicultural skill (understanding and respecting the culture)—both are necessary for culturally competent service delivery. Ethical considerations mandate cultural competence in activities such as hiring practices, teaching, evaluation, and supervision of staff and students.
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