Issues in Ethics: Ethics and Delivery of Care in Public Health and Safety Emergencies
About This Document
Published 2020. This Issues in Ethics statement is new and 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.
Issues in Ethics Statements: Definition
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) and the Assistants Code of Conduct (2020) 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.
Public Health and Safety Emergency–Related Definitions
A state of emergency is a situation in which a government (e.g., local, state, and/or national) is empowered to enact policies beyond those routinely within their purview to protect the health and safety of its citizens. A state of emergency may be declared as a result of an epidemic, a pandemic, a natural disaster (e.g., flood, tornado, earthquake, hurricane, tsunami, etc.), civil unrest, or an act of (bio)terrorism.
A public health emergency is an urgent need for health care services to respond to a disaster, to a significant outbreak of an infectious disease, to a (bio)terrorist attack, or to some other catastrophic occurrence.
A pandemic is “an epidemic that has spread over several countries or continents, usually affecting a large number of people.” (Centers for Disease Control and Prevention [CDC])
A natural disaster is defined as including “all types of severe weather, which have the potential to pose a significant threat to human health and safety, property, critical infrastructure, and homeland security. Natural disasters occur both seasonally and without warning, subjecting the nation to frequent periods of insecurity, disruption, and economic loss. Examples of natural disasters include winter storms, floods, tornadoes, hurricanes, wildfires, earthquakes, volcanic eruptions, etc.” (U.S. Department of Homeland Security [DHS])
A (bio)terrorism attack is “the intentional release of viruses, bacteria, or other germs that can sicken or kill people, livestock, or crops.” (CDC)
Introduction
ASHA-certified audiologists and speech language pathologists (SLPs), as well as ASHA-certified assistants, have an ethical responsibility to perform professional services with skill and safety. This is generally possible when there is predictability and stability in our daily routines. But when uncertainty arises, we may be unprepared for its impact on our professional lives. The COVID-19 global pandemic heightened our awareness of the magnitude of disruption that can be caused in our professional work. Public health and safety emergencies may foster ethical dilemmas, requiring clinicians to balance responsibilities to clients/patients/students and their families, to themselves, and to their own families.
According to the Federal Emergency Management Agency (FEMA), the “President [of the United States] can declare an emergency for any occasion or instance when the President determines federal assistance is needed. Emergency declarations supplement State and local...efforts in providing emergency services, such as the protection of lives, property, public health, and safety, or to lessen or avert the threat of a catastrophe in any part of the United States.” Declaration of a public health emergency by governors permits state governments to request waivers of some requirements by Medicare, Medicaid, and perhaps private health insurance companies to allow beneficiaries to more easily access critical health care. Events that trigger states of emergency—whether or not they impact audiologists and SLPs in their professional lives—are often traumatic events in the personal lives of clinicians, their clients and patients, and the families of both.
The ASHA Code of Ethics (2016) (hereafter, “Code of Ethics”) and the Assistants Code of Conduct (2020) (hereafter, “Code of Conduct”) provide guidance across many areas of practice and research, including areas related to localized or widespread public emergencies, including pandemics, natural disasters, and (bio)terrorist attacks. The following interpretative guidance has been compiled to assist with ethical dilemmas that arise during public health and/or safety emergencies.
Principle of Ethics I of the Code of Ethics and Principle of Conduct I of the Code of Conduct state that ASHA-certified individuals “shall honor their responsibility to hold paramount the welfare of persons they serve professionally.” This core principle should inform and guide practitioners in their approach to any declared public health or safety emergency.
This document addresses potential ethical issues that audiologists, SLPs, and assistants may face during a pandemic, a natural disaster, or an act of (bio)terrorism. This document also provides ethical guidance regarding ways you might face those challenges and addresses the implicit ethical need under the Codes for clinicians and assistants to keep themselves safe and care for their own health while also caring for their clients/patients/students.
Guidance
Protecting the Welfare of Clients and Practitioners
Principle of Ethics I of the Code of Ethics provides that practitioners have the ethical obligation to “hold paramount the welfare of persons they serve professionally.” From the COVID-19 pandemic we learned the counterpart proposition that is implicit and embedded in Principle of Ethics I: Clinicians also have an ethical obligation to protect themselves. Practitioners cannot “honor their responsibility” for the welfare of their clients/patients/students and their families if they themselves become ill. Clinicians protecting themselves from exposure to dangers equates to clinicians protecting their clients and colleagues from inadvertent danger when carrying out their work responsibilities.
Nor can practitioners deliver clinical services competently under Principle of Ethics I, Rule A, if they are felled by a pandemic, unable to continue to provide services in a building damaged by a hurricane, or exposed to the fallout from a (bio)terrorist attack.
One of the most distressing experiences of audiologists and SLPs during the COVID-19 pandemic was the supply chain disruption related to personal protective equipment (PPE) (i.e., masks, gloves, gowns, face shields, etc.) and cleaning supplies. Practitioners suddenly had to evaluate inventory and accessibility of PPE and quickly realized that they were not prepared for an emergency of such magnitude. Clinicians should think about their environment of care (school, hospital, home health, etc.), considering alternatives for safe service delivery and ensuring that they have the necessary infection control supplies available—to the extent feasible—during emergency events.
Although the declaration of a public health emergency may release resources, national reserves of health care supplies and equipment, and other disaster relief services, there may be delays in the delivery of such supplies. Moreover, if resources are limited, there may be a prioritization of those health care practitioners who are in immediate need (e.g., doctors, nurses, surgeons, etc.)—and that may not include our professions, at least not initially.
Ethical violations in this scenario might include requiring employees to perform indirect patient care activities, such as working in close quarters with other clinicians or team members to prepare therapy material “resource kits” for clients, without providing those employees with proper PPE or sanitizing supplies. In such circumstances, clinicians should follow Principle of Ethics IV, Rule M—and assistants should follow Principle of Conduct III, Fundamental H—and “work collaboratively to resolve the situation.” Most likely, guidance from federal, state, and/or local agencies will be available during a declared emergency so clinicians and the public may stay informed of current safety requirements. In addition, such information might be helpful in working toward a collaborative resolution with a colleague, supervisor, or employer.
SLPs who did not have PPE during the initial phase of the pandemic reported supervising from outside hospital rooms while nurses wearing PPE inside the rooms performed swallowing procedures. That collaboration enabled (a) the procedures to be performed by a qualified health care provider, (b) the patient to be evaluated and diagnosed by an SLP (which is in their scope of practice), and (c) the SLP to develop an appropriate treatment plan—all during which the patient, nurse, and SLP were protected. Employing practitioners or supervisors who are ASHA members and/or ASHA certified have the ethical responsibility to not “knowingly allow anyone under their supervision to engage in any practice that violates the Code of Ethics” (Principle of Ethics IV, Rule I). They might violate the Code of Ethics if they compel clinicians, assistants, or students to deliver professional services without the necessary infection control supplies or risk-reduction procedures.
Certified administrators and supervisors also have the ethical duty to “not require or permit their professional staff to provide services or conduct clinical activities that compromise the staff member’s independent and objective professional judgment” (Principle of Ethics II, Rule F). Such “independent and objective judgment” of practitioners may include their determination that they need to wear PPE in delivering particular services, performing necessary procedures, or working in specific settings.
Although certified assistants must engage only in activities that have been delegated by their supervising audiologist or SLP (Principle of Conduct I, Fundamental A), they must also take care not to work beyond their training and experience (Principle of Conduct I, Fundamental B). An ASHA-certified supervisor may not “delegate tasks that require the unique skills, knowledge, judgment, or credentials that are within the scope of their profession to...assistants...over whom they have supervisory responsibility” (Principle of Ethics I, Rule F). Even when an ASHA-certified supervisor delegates tasks for which a certified assistant is adequately prepared and trained, “responsibility for the welfare of those being served” remains with the certified supervisor (Principle of Ethics I, Rule E).
Avoiding Client Abandonment
Principle of Ethics I, Rule T of the Code of Ethics states, “Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services.” The Issues in Ethics Statement, Client Abandonment, further provides, “Clinical relationships may be interrupted if an organization decides to close a program or when natural disasters occur. It is expected that even in these types of situations, practitioners would hold paramount the welfare of the clients they serve; however, no clinician is ever ethically required to work without pay or to place themselves in physical danger in order to offer client care.” Just as practitioners must provide reasonable notice to their clients and supervisor(s) if they are ending a client relationship, so too must certified assistants provide reasonable notice to their supervising audiologist or SLP if “they can no longer provide clinical services” (Principle of Conduct I, Fundamental I).
The declaration of a public health or safety emergency may result in local, state, or national officials (a) issuing “stay-at-home” orders or curfews and/or (b) closing schools, businesses, and facilities with little or no time to prepare clients/patients/students for service delivery alternatives. There may also be little to no information about the expected duration of the emergency conditions. Clinicians will want to have a plan already in place to stay in contact with their clients/patients/students. Such a plan may include creating confidential, up-to-date client contact lists (mobile phone numbers, email and home addresses, etc.) and—to the extent possible and appropriate—making resources available for remote services and/or short-term self-directed therapies or exercises.
Practitioners are not ethically required to work in conditions that place them in physical danger. The critical issue is what constitutes “physical danger” and if that differs depending on circumstances (e.g., high-risk patient, an unstable natural environment post-earthquake, etc.). Clinicians who provide services without proper risk reduction processes or supplies such as PPE—even if employers demand that they do so—might violate Principle of Ethics IV, Rule R if (a) emergency laws or regulations have been enacted requiring providers’ use PPE or (b) other mandatory precautions have been ordered to reduce public risk. Likewise, certified assistants must “comply with local, state, and federal laws and regulations applicable to their practice” (Principle of Conduct III, Fundamental N).
In addition, practitioners and/or assistants who are being pressured by employers or supervisors to provide services without proper protections may find it useful to refer to and understand the “recognized hazards” from which they need to be protected by employers under the Occupational Safety and Health Act guidelines, state department of health and safety regulations, and/or facility, employee, and/or state health department rules.
During emergencies, some service locations (e.g., skilled nursing facilities, residential schools, correctional facilities, etc.) may restrict visitors, which sometimes include some types of health care providers, to reduce the likelihood of outsiders transmitting dangers to residents. Principle of Ethics IV, Rule A indicates that, “Individuals shall work collaboratively, when appropriate, with members of one’s own profession and/or members of other professions to deliver the highest quality of care.” It may be possible to partner with care providers who are authorized to be at the facility; they may be able to help you check on your clients/patients or set up an electronic device that you can access remotely in order to evaluate your clients’/patients’ health status.
Providing Services Competently
During the COVID-19 pandemic, seemingly overnight, many clinicians had to find and/or learn new ways to deliver care. Principle of Ethics I, Rule A of the Code of Ethics requires that audiologists and SLPs “provide all clinical services and scientific activities competently.” During a declared public emergency, this may mean that providers adopt alternative delivery methods to be effective, such as using telepractice or other technologies and/or modifying materials. However, significant disruptions to telecommunication infrastructure may be triggered by major disasters, such as the 1995 Oklahoma City bombing and the September 11 terrorist attacks. During some emergency situations, communications and Internet bandwidth may be diverted exclusively for use by first responders, and natural disasters may disrupt electrical power supplies for extended periods of time. It will be important to have a backup plan for contacting clients/patients/students and perhaps providing professional services in a less technology-dependent format.
Clinicians have the ethical obligation to (a) “evaluate the effectiveness of services provided, technology employed, and products dispensed” when adopting telepractice or other service delivery modes (Principle of Ethics I, Rule K) and (b) ensure that whatever technology they use to provide service is “in proper working order and is properly calibrated” (Principle of Ethics II, Rule H). Clinicians also need to make certain that informed consent forms include an agreement to provide services using those alternative delivery systems and/or technologies (Principle of Ethics I, Rule H).
Under the direction of their supervising audiologist or SLP, certified assistants “shall make use of technology and instrumentation consistent with accepted professional guidelines in their areas of practice” (Principle of Conduct I, Fundamental K).
In anticipation of future emergencies, practitioners may want to “enhance and refine their professional competence and expertise” by keeping current on (a) new service delivery methods and related technologies, (b) state regulations and billing restrictions related to telepractice, and (c) software programs or backup plans to bill, file, and pay staff if your place of employment closes or if roads are not navigable (Principle of Ethics II, Rule D).
Scope of Practice: Deployment and Supervision
Local, state, and national declarations of emergencies should be reviewed carefully; confirm the authority delegated to health care providers to deploy practitioners as needed to ensure the provision of essential services.
During some public emergencies, clinicians may be deployed by their employer (usually hospitals) to meet other disaster service needs, performing tasks that are in critical demand but that are not clearly delineated as being within the scope of audiology or speech-language pathology practice. Principle of Ethics II, Rule A states that “Individuals who hold the Certificate of Clinical Competence (CCC) 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.” Keep in mind that this rule is specific to “aspects of the professions,” meaning audiology and speech-language pathology. For example, it might violate the Code of Ethics if an ASHA-certified SLP with no training or experience in aphasia is asked to perform aphasia-related care. However, in a declared emergency, Principle of Ethics II, Rule A would not apply to an audiologist or SLP who is deployed to perform critically needed general relief tasks that are not delineated in their professions’ scope of practice nor within other professions’ scopes of practice.
An example of an appropriate deployment during a declared emergency may be a hospital temporarily reassigning an audiologist who holds the CCC to a patient intake area to collect and document patient vital signs. An example of an inappropriate deployment during emergency conditions is a hospital directing an audiologist who holds the CCC to provide a skilled service typically done by another professional within their scope of practice but not within the ASHA Scope of Practice in Audiology—especially if that certified individual doesn’t have the expertise required to provide that service and there is an expectation of diagnosis and treatment (e.g., dispensing medication or setting a broken bone).
Similarly, Principle of Conduct I, Fundamental B states that certified assistants must “engage in only those work areas that are within the scope of their competence, considering their certification status, education, training, and expertise.” Certified assistants may be deployed in a declared public emergency to perform general relief tasks that are critically needed but are not related to hearing or speech services or do not fall within the scope of practice of another profession.
Audiologists and SLPs also need to be aware that state occupational licensing laws limit duties to their scope of competence. Practitioners should check with their state boards about the general tasks they are being asked to undertake, such as replacing used masks or shelving clean linens in stock rooms, to find out whether these tasks would be acceptable within their scope of practice, even if not specifically enumerated. If clinicians violate state law, they may also violate Principle of Ethics IV, Rule R: “Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice...” Likewise, assistants may violate Principle of Conduct III, Fundamental N for failing to “comply with local, state, and federal laws and regulations applicable to their practice.”
Exercising Independent, Evidence-Based Professional Judgment
Principle of Ethics I, Rule M provides, “Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served.” By their very nature, public health and/or safety emergencies involve rapidly changing and perhaps even conflicting information. Clinicians should establish and maintain communication with (a) their employer, (b) any employees, assistants, or student clinicians they supervise, and (c) patients and the families they serve, with the understanding that information and regulations may shift quickly during a declared emergency and may require changes to service delivery protocols. Temporary government regulations may be put into place and/or existing policies expanded with the common goal being the health and safety of clients/patients/students and their families as well as practitioners and their families. However, even during a public emergency when situation status and scientific evidence may change almost daily, certified individuals retain their ethical responsibility to use independent and evidence-based judgment that relies on on the most current scientific evidence available from official government agencies to determine how to appropriately adapt their delivery of services (Principle of Ethics I, Rule M).
Furthermore, Principle of Ethics IV, Rule B states, “Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative mandate, referral source, or prescription prevents keeping the welfare of persons served paramount.” During the COVID-19 pandemic, some employers, agencies, and school districts issued across-the-board mandates to use telepractice or change session parameters from individual to group sessions. However, some clinicians, relying on their professional, scientifically based independent judgment, determined that such modifications were not appropriate to meet the treatment needs of particular clients/patients/students. As previously stated, certified individuals should work collaboratively to resolve these issues of professional judgment. Although certified assistants are not independent practitioners (Code of Conduct Preamble), they are also encouraged to seek advice or consultation for ethical dilemmas with their supervising audiologist or SLP.
Maintaining Patient Confidentiality
Even during emergencies, when health and safety regulations may be updated and/or changed frequently and offices may be closed or difficult to reach, clinicians have the continued responsibility to safeguard patient health information.
Patient confidentiality is one of the cornerstones of the provider–patient relationship (Code of Ethics Principle I, Rules O and P, and Code of Conduct Principle of Conduct I, Fundamental E). To meet ethical challenges involving patient confidentiality and privacy during public emergencies, practitioners should be aware of legal and regulatory privacy requirements for health care providers and their clients, service delivery telepractice rules, and appropriate informed consent forms that notify clients/parents/students and their families of the potential risks to confidentiality posed by technology. Practitioners should also stay informed about the products of telepractice platform vendors and the development of privacy security patches and other adaptations.
Providing Referrals and Promoting Interprofessional Collaboration
Principle of Ethics I, Rule B states that practitioners “shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.” Similarly, Principle of Conduct III, Fundamental A provides that “assistants shall work collaboratively with audiologists and speech-language pathologists and/or members of other professions to deliver the highest quality of care.”
Depending on the nature of a health-related public emergency, some clinicians and/or assistants may find that they themselves are at high risk if they become ill with the health condition forming the basis of the emergency. There will likely be guidance from government agencies, such as the Centers for Disease Control and Prevention (CDC) and state health departments, about temporary exclusions from providing direct patient care services for health care workers who fall into categories related to age, pregnancy status, and/or pre-existing health condition(s).
High-risk clinicians may want to speak with their supervisors to explore potential options, such as exchanging assignments with other providers (who are not at risk) in their practice or finding independent contractors (who are not at risk) to minimize the disruption to professional services while at the same time minimizing their own risk. Even so, Principle of Ethics I, Rule E provides for delegation of “tasks related to the provision of clinical services to aides, assistants, technicians, support personnel, or any other persons only if those persons are adequately prepared and are appropriately supervised” [emphasis added]. During public health emergencies, certified assistants may want to help by assuming additional responsibilities to lessen the risk of exposure of their supervisors who are in a high-risk category. Such generous offers are tempting; however, supervisors and certified assistants must remember that assistants should “engage in only those work areas that are within the scope of their competence” (Principle of Conduct I, Fundamental B).
If, as a practitioner, you should choose to refer a potentially infected client to another provider (Principle of Ethics I, Rule B) because you are at high risk and the other provider is presumed to be at lower risk and/or their office is set up to better protect practitioners from exposure, your ethical obligation of interprofessional collaboration includes disclosing any potential risks that may be posed by the client, such as the client’s known or potential health status.
Summary
ASHA-certified individuals are obligated to adhere to the Code of Ethics or Code of Conduct, as applicable, in addition to other rules, laws, and regulations governing the professions and, to some degree, assistants. Public health and/or safety emergencies are fluid, and circumstances may shift as the situation unfolds. Nevertheless, the Code of Ethics remains in place during declared public emergencies. Often, some creativity and flexibility are required to apply ethical requirements while you work during a localized or widespread public emergency to protect your clients, their families, and yourself. Consider the guidance above as you face such challenges in your practices.
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