Published 2017. This Issues in Ethics statement is a revision of Prescription (originally published in 2001, and revised in 2010 and 2015). 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.
Principle of Ethics IV, Rule B of the of the Code 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."
The challenges associated with clinical practice today may pressure practitioners to provide and bill for services that are in conflict with their professional judgment. A relevant issue is the definition of the word prescription and its implication for certificate holders who are engaged in clinical practice. The term prescription is most commonly used in medical settings, and it refers to a written statement by a physician directing that professional services be offered to meet the needs of the individual client.
Prescription is often used solely as a request for the initiation or continuation of audiology and/or speech-language pathology services. When that is the case, prescription may be regarded as synonymous with referral, and it is a useful instrument in the total treatment program for a client.
In addition, a written request for services from a physician may be required if the audiologist or speech-language pathologist intends to seek reimbursement for clinical services from third-party payers such as Medicare, Medicaid, or private insurance companies. The Board does not consider certificate holders to be in violation of the Code for accepting a prescription referral that represents only a request for initiation or continuation of audiology or speech-language services.
On occasion, however, the language of a prescription unduly restricts audiologists or speech-language pathologists in exercising their professional responsibility to develop and/or implement appropriate clinical services because the prescription specifies the content, frequency, or duration of services to be provided. Health maintenance organizations (HMOs), Medicare, Medicaid, private insurance companies, and Individualized Education Programs (IEPs) developed for students with disabilities under the Individuals with Disabilities Education Act (IDEA) may prescribe services, protocols, and procedures which they then authorize and/or approve for reimbursement. These entities may also require updates and the issuance of new “prescriptions” for the continuation of services. Within these regulatory entities there are mechanisms in place. Audiologists or speech-language pathologists can challenge or appeal these mechanisms, or they can seek modification of requirements for these mechanisms. In the event that audiologists or speech-language pathologists are pressured by any source to provide services that are against their best professional knowledge and judgment (e.g., provide services with inappropriate frequency or intensity or when no benefit can be expected), they have the responsibility to challenge such pressure or prescription. Indeed, if a certificate holder did not challenge prescriptive mandates where the welfare of the person served is at risk, the certificate holder could be held in violation of the Code.
The support for independent clinical judgment is specifically stated in Principle of Ethics I, Rule M: "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." Implications for patient benefit are addressed by Principle of Ethics I, Rule K, which states, "Individuals who hold the Certificate of Clinical Competence shall evaluate the effectiveness of services provided, technology employed, and products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected."
Audiologists or speech-language pathologists often work in concert with other human services professionals, and the issue of restriction of professional responsibilities may be difficult to interpret in circumstances of interprofessional collaborative effort. Examples of such might include serving on an IDEA-defined planning team in the schools to develop an IEP, serving on an IDEA-defined early intervention multidisciplinary team to develop an Individualized Family Service Plan (IFSP), or serving on a multidisciplinary team in medical or rehabilitative agencies. In these clinical service decision-making models, team members may convey interpretations of their individual test data to a single professional on the team, who then synthesizes the information and conveys the findings and interpretations of the audiologist or speech-language pathologist to the client. Not only is this an efficient procedure, but, more important, it may be in the best interests of the client to have test results from one discipline interpreted in the context of test findings from other professions. Principle of Ethics I, Rule B supports this clinical service model, stating, "Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided."
As to such coordinated efforts, audiologists or speech-language pathologists should be cautioned that they continue to have a responsibility, recognized under the laws of many states, to correctly and completely communicate to the client their findings and recommendations for treatment, including the risks associated with any treatment plan. If the audiologist or speech-language pathologist is not the person communicating the findings and recommendations directly to the client, then that audiologist or speech-language pathologist remains responsible for ensuring that the findings and recommendations are communicated to the client and relayed correctly and completely by a competent professional.
In all circumstances, it is incumbent on the audiologist or speech-language pathologist to determine when to accept limitations on professional responsibility, but still serve the client's needs. Principle of Ethics III reinforces this concept: "Individuals shall honor their responsibility to the public when advocating for the unmet communication and swallowing needs of the public and shall provide accurate information involving any aspect of the professions."
As long as the audiologist or speech-language pathologist maintains independence of judgment and preserves the professional prerogatives to plan and provide audiology or speech-language pathology services that are in the best interests of the individual client, and accepts responsibility for the plan and services so provided, there is no violation of the Code.