Published 2017. This Issues in Ethics statement is a revision of Cultural and Linguistic Competence (2013), which revised Cultural Competence (2004). It has been updated to make any references to the Code of Ethics consistent with the Code of Ethics (2016). 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.
From time to time, the Board of Ethics (hereinafter, the "Board") 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 (2016) (hereinafter, the "Code") and are 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 and cultural diversity can incorporate a variety of factors, including but not limited to age, disability, ethnicity, gender identity (encompasses gender expression), national origin (encompasses related aspects e.g., ancestry, culture, language, dialect, citizenship, and immigration status), race, religion, sex, sexual orientation, and veteran status. 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. Audiologists, speech-language pathologists, 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.
The terms 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 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.
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. Providing 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 the Individuals with Disabilities Education Act (IDEA), require that providers render culturally and linguistically appropriate services. These programs are in accordance with broader legislation such as 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.
The Code speaks directly to the need for culturally and linguistically competent services and research. The following excerpts from the Code address this need.
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 clinical services and scientific activities competently.
Rule B. Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.
The implication of Rule B is that if a professional feels unprepared to serve an individual on the basis of cultural and linguistic differences, then the option of an appropriate referral should be utilized.
Rule C. Individuals shall not discriminate in the delivery of professional services or in the conduct of research and scholarly activities on the basis of race, ethnicity, sex, , gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, or dialect.
Rule F. Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, judgment, or credentials that are within the scope of their profession to aides, assistants, technicians, support personnel, or any nonprofessionals over whom they have supervisory responsibility.
Rule C prohibits discrimination across the full range of dimensions of diversity. Assuming no legal exemptions, all affiliated individuals, programs, organizations, and institutions are expected to comply with all applicable laws, regulations, and executive orders, in addition to the Code.
Rule F 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 is required. Although 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 of 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 A. Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.
Rule A should not be construed as justification for denying services on the basis of an individual's cultural and linguistic background. Professionals should consider other options, such as additional training, making a referral, and using an interpreter to ensure appropriate services.
Rule D. Individuals shall enhance and refine their professional competence and expertise through engagement in lifelong learning applicable to their professional activities and skills.
Rule D 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 uphold the dignity and autonomy of the professions, maintain collaborative and harmonious interprofessional and intraprofessional relationships, and accept the profession’s self-imposed standards.
Rule L. Individuals shall not discriminate in their relationships with colleagues, assistants, students, support personnel, and members of other professions and disciplines on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, dialect, or socioeconomic status.
Rule L 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 clinical and research interactions must be understood, protected, and respected. Professionals 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, improper treatment of the individual, or research bias. To best address the unique, individual characteristics and cultural background of individuals and their families, professionals should be prepared to be open and flexible in the selection, administration, and interpretation of diagnostic and/or treatment regimens and research decisions.
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, family, or research subject, 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 or conducting research. Audiologists and speech-language pathologists who present themselves as bilingual for the purposes of providing clinical services must be able to speak the primary language of the client, family, or research subject 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 the successful provision of services as are scientific, technical, and clinical knowledge and skills. The Code requires the provision of competent services to all populations and the recognition of the cultural and linguistic experiences, or life experiences, of both the professional 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.