by Polly B. Pooser
(This article orginally appeared in the November 19, 2002 issue of The ASHA Leader.)
Uh-oh! You go along confidently making recommendations for treatment using your best (and so far unchallenged) clinical judgment. Then, unexpectedly, it happens! A parent disagrees with your recommendation. Do you cave in to the parent's demands and change your recommendation, thus preserving goodwill? Or, do you hold fast to your carefully thought-out plan, knowing that an uncomfortable situation will result and the conflict may affect your job security?
Your decision should be guided by appropriate sections of ASHA's Code of Ethics. Usually, when professional and parent or client disagree, the conflict is related to one of the following: dismissal, frequency and intensity of treatment, type of treatment/therapeutic approach, eligibility for services, or specific assistive technology.
Occasionally, when clinicians determine to dismiss a child from treatment, parents have difficulty "letting go," insisting that treatment continue. Principle I, Rule G of the Code of Ethics provides, "Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected" (emphasis added). Thus, where evidence exists demonstrating that the client has made maximum improvement and is not expected to improve further, then terminating services is correct. Perhaps a home program can be developed to wean the family from direct services.
Sometimes, parents are of the more-is-better mindset and wish for more sessions per week than the professional has recommended; or, the parents may ask for individual rather than group treatment. If the clinician reasonably believes the amount and type of treatment recommended is optimal for that client, then Principle I applies: "Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally." If the clinician feels additional treatment is necessary but cannot be provided, then Principle I, Rule B may be relevant: "Individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided." Additional services by another clinician/setting may be appropriate.
Perhaps one of the toughest dilemmas arises when parents demand a treatment approach that the professional feels has not been proven effective. Several new approaches (facilitated communication, sensory integration, some of the heavily advertised computer programs, etc.) have influenced parents seeking a "cure" for their children.
Again, Principle I, Rule G comes into play as clinicians are ethically bound to evaluate the effectiveness of treatments and determine the benefit of approaches. Principle III, which embodies responsibility to the public by promoting public understanding of the professions, may give guidance here also. By sharing research information (or lack of research) about new approaches, a parent may better understand why some treatments are preferable to others.
Related to this is when parents insist on a particular type of hearing aid, auditory trainer, or assistive device, for example, but the professional believes something else will better meet the needs of the client.
In many settings (e.g., schools, facilities billing third parties), eligibility for services is determined by someone other than the individual clinician. A parent may obtain an evaluation from a private clinic recommending treatment only to find the child is not eligible for treatment in the public school. Careful explanation of eligibility rules may help the parent understand. Principle III, Rule D states, "Individuals shall not misrepresent diagnostic information, services rendered, or products dispensed or engage in any scheme or artifice to defraud in connection with obtaining payment or reimbursement for such services or products." "Bending" eligibility rules in order to bill for services that are not covered is an ethical violation.
In summary, when clinicians and parents disagree, use research, clinical data, compromise, and your ethics to result in a favorable outcome for all involved.
Polly B. Pooser previously served as a member of the ASHA Board of Ethics.