Check the ETHICS Box

Barbara Jacobson, Ph.D. CCC-SLP

Associate Professor

Vanderbilt Bill Wilkerson Center

Vanderbilt University Medical Center

Disclosures

Financial

Salary from Vanderbilt University Medical

Center

Non-financial

None

Outline

Values, morals, laws, and ethics

Medical ethics

ASHA’s Code of Ethics (2016)

The Board of Ethics and the adjudication process

Frameworks for ethical decision making

Social media, civility & ethics

Resources

Scenarios

The Landscape

Values

Morals

Laws

Medical ethics

Professional ethics

Does this action or

behavior violate our

values, our morals, our

laws or our ethical

principles?

Values

Beliefs that are typically formed in the

context of community – family and those

with whom we share common interests and

goals.

Resourcefulness, honesty, and respect are

examples of values.

May change over time as a person moves

through personal, educational, and

professional milestones.

Values influence our behavior and may not

have an inherently ‘good’ or ‘bad’ quality

as we consider them.

Vanderbilt Credo

We provide excellence in healthcare, research and

education.

We treat others as we wish to be treated.

We continuously evaluate and improve our performance.

Morals

Derive from values and comprise a belief

system that guides behavior in various

contexts and situations.

Morality is often judged by others or

communities and is the outward

expression of values.

Laws

Determined by legislative bodies at the

local, state, and federal level and apply

to criminal, civil, and administrative

violations.

An action can be illegal but not immoral,

although many laws and statutes

regulate moral behavior.

There is a penalty for violating a law but

may be none for being immoral or

having ‘bad’ values.

Ethical Principles

Ethics is a system of principles that sets

forth what behavior is good, just, equal,

and truthful, among other attributes.

(Bupp, 2012).

Medical Ethics

The Four Topics (Jonsen, et al.,

2015)

Medical Indications

Preferences of Patients

Quality of Life

Contextual Features

Medical Indications

Medical problem?

GOC?

Treatment not indicated?

Treatment outcomes?

Preferences of Patients

Informed consent?

Capable & competent?

Patient preferences?

Present and/or prior?

Surrogates?

Patient compliance?

Quality of Life

Return to normal life?

Physicial, mental, social deficits?

Can others judge QOL?

Health provider biases?

Contextual Features

COIs in clinical treatment?

Family members’ input?

Financial factors?

Allocations of resources?

Religious factors?

Legal factors?

Public health/safety?

HELP!!!

Many of us don’t have access to an ethics ‘hotline’ to

help us navigate the thorny issues related to ethical

dilemmas as they occur in our daily practice.

We have to rely on the codified principles of our

association to begin our journey.

What is a Code of Ethics?

A formalization of experience into a set of rules which are adopted by a community because its members accept the adherence to the rules, including the restrictions that apply.

(http://www.is.cityu.edu.hk/research/resources/isworld/ethics/)

Some reflections on ethics….

Sometimes ethical behavior is not the difference in right and wrong. It is the difference in right and more right.

Stuart Finder

(Former Director of Medical and Research Ethics, Vanderbilt University, lecture to DHSS-Professional Issues)

Some reflections on ethics….

Always stay on the high road.You’ll find there is way less trafficup there.

Arlene Carney

(Personal communication)

What does a Code of Ethics

enable us to do?

State the ideals and responsibilities of the

profession

Exert a regulatory effect, protecting both

clients and professionals

Improve the profile of the profession

Motivate and inspire practitioners by

defining their reason for being

Provide guidance on acceptable conduct

Raise awareness and consciousness of issues

Improve quality and consistency

(http://www.is.cityu.edu.hk/research/resources/isworld/ethics/)

Principles/Values identified in Codes of

other professions

APA

Beneficence and Non-maleficence

Fidelity and Responsibility

Integrity

Justice

Respect for People’s Rights and Dignity (Autonomy)

(http://www.apa.org/ethics/code2002.html#principle_d)

…and from the AMA

Competence

Compassion

Respect

Professionalism

Honesty

Responsibility

Privacy

Commitment

Appropriate patient

care

Improvement of the

community

Betterment of public

good

Support access to care

(http://www.ama-assn.org/ama/pub/category/2512.html)

…and from the APTA Principle 1: Physical therapists shall respect the inherent

dignity and rights of all individuals.

Principle 2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients and clients.

Principle 3: Physical therapists shall be accountable for making sound professional judgments.

Principle 4: Physical therapists shall demonstrate integrity in their relationships with patients and clients, families, colleagues, students, research participants, other health care providers, employers, payers, and the public.

Principle 5: Physical therapists shall fulfill their legal and professional obligations.

Principle 6: Physical therapists shall enhance their expertise through the lifelong acquisition and refinement of knowledge, skills, abilities, and professional behaviors.

Principle 7: Physical therapists shall promote organizational behaviors and business practices that benefit patients and clients and society.”

(http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/CodeofEthics.pdf)

Most Codes are Based On:

Freedom of action and choice (autonomy)

Justice and fairness (justice)

Doing good for others (beneficence)

Preventing or avoiding harm (nonmaleficence)

Fidelity and loyalty (fidelity)

(Bupp, H. (2012). 9 Upsetting Dilemmas. The ASHA Leader, 17 (14), 10-14.)

What a Code of Ethics is not:

Feelings/Intuition

Religion or set of religious principles

Legal precept

A set of cultural norms

Science

(http://www.scu.edu/ethics/practicing/decision/framework.html)

2016 ASHA Code of Ethics

(3.1.16)

Preamble was updated

New terminology section

15 new rules added

2 Code Principles revised

New COE will be developed this year

New & Revised Rules

Research conduct

Evidence-based & independent clinical judgment

Client abandonment

Impaired practitioner

Workplace service delivery coercion

Use of technology

Self-disclosure, financial disclosure, honesty in

reporting

Intraprofessional and interprofessional collaboration

New & Revised Rules (cont.)

Reporting members of other professions

Compliance with local, state, and federal laws and

regulations

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.

Principle I

Focuses on welfare of persons served in

clinical and research settings and

humane treatment of animals

20 rules regarding specific

behaviors/activities such as providing

clinical services competently;

discriminating against populations in

service delivery or research; delegating

tasks to other personnel or students;

obtaining informed consent, among

others

Principle of Ethics II

Individuals shall honor their

responsibility to achieve and

maintain the highest level of

professional competence and

performance.

Principle II

Focuses on the achievement and

maintenance of the highest levels of

competence in the professions

8 rules regarding specific

behaviors/activities such as complying

with local, state, and federal regulations

in clinical service provision and research;

continuing to engage in learning;

maintaining technology, among others

Principle of Ethics III

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.

Principle III

Focuses on responsibilities to the public in

advocacy and communication about

the professions

7 rules regarding specific

behaviors/activities such as accurately

representing credentials; avoiding

conflicts of interest; avoiding fraud in

clinical service provision and research,

among others.

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 professions'

self-imposed standards.

Principle IV

Focuses on responsibilities to the professions, including interprofessional and intraprofessional relationships and the standards of the professions.

10 rules regarding specific behaviors/activities such as working collaboratively; avoiding dishonesty, deceit, or negligence; avoiding plagiarism or failure to credit others’ ideas or contributions; self-reporting criminal activity or sanctions from other credentialing bodies, among others.

Most Common Types of Inquiries or Complaints

Documentation Lapses

Sign-off on the work of students or

assistants who have not been supervised

by the signatory

Lack of time for documentation

Failure to keep adequate records

Evaluation and treatment

Time

(Bupp, H. (2012). 9 Upsetting Dilemmas, The

ASHA Leader, 17 (14), pp.10-14)

.

Most Common Types of Inquiries or Complaints

Employer Demands

Increasing caseloads

Higher productivity requirements

Rejection of professional judgments

regarding need/type of treatment

Use and Supervision of Support Personnel

Also involves state guidelines

BOE has no jurisdiction over the support

person, only the supervising member

Most Common Types of Inquiries or Complaints

Clinical Fellowship Mentoring/Student

Supervision

CFs who don’t feel they are getting

sufficient guidance from the supervisor

CFs and students who do not respond

appropriately to supervisory input

Client Abandonment

Professionals change jobs abruptly

Adequate notice is essential

Have transition plans for clients

Most Common Types of Inquiries or Complaints

Reimbursement for Services

Intent, fraud, misrepresentation

Reputation and livelihood may be placed

“on the line” for what is judged to be the

“greater good”

Business Competition

Marketing, bidding on contracts, and

business competition may be necessary

Welfare of patients must still be

paramount

May not be detrimental to the professions

Most Common Types of Inquiries or Complaints

Impaired Practitioners

Untreated or undiagnosed mental illness

(other health-related issues)

Issues of substance abuse

Liability to clients and colleagues that

increases with time and opportunity

Should not be taken on by one person –

use the institution and other resources

Affirmative Disclosures

Employers, licensure boards and other

regulators require disclosure about

previous sanctions and findings

Professionals must be honest and disclose

fully

The Code of Ethics applies

to……

A member of the American Speech-Language-Hearing Association holding the Certificate of Clinical Competence (CCC)

A member of the Association not holding the Certificate of Clinical Competence (CCC)

A nonmember of the Association holding the Certificate of Clinical Competence (CCC)

An applicant for certification, or for membership and certification

(Preamble, Code of Ethics, 2016)

BOE Members

Public members

SLPs

AuDs

Practitioners, academics, administrators

Variety of settings – representing the membership

Typically, the Office of Ethics receives 3,000

inquiries/complaints each year

Complaint Process

Mail formal letter to ASHA’s Office of Ethics (no

anonymous complaints unless there is a formal record)

Include detailed description of the concern

Citation of specific aspects of the Code of Ethics that

were violated

Determination of whether this is something under the

jurisdiction of the BOE

No further communication until adjudication

Possible Outcomes

Sanctions include:

a reprimand (private)

censure (a public reprimand)

withholding, suspending, or revoking membership and/or

certification for a period of years, up to life

Publication in ASHA Leader Online

Full description in online version

Rationale: Received a felony conviction in the U.S. District

Court for the Eastern District of Virginia, Richmond

Division, of one count of theft of public money, for

accepting disability benefits while failing to report her

income. Failed to respond to correspondence from ASHA

Ethics regarding the complaint of alleged violation.

Code (2010r): IV, IV-A, IV-C, IV-N

Sanction: Withholding of membership and certification for 24 months, effective Aug. 17, 2018

Rationale: Engaged in an inappropriate relationship with

the parent of a child on her speech-language pathology

caseload, resulting in a public sanction by the Ohio

Board of Speech-Language Pathology and Audiology;

and failed to self-report the public sanction from the

board to ASHA Standards and Ethics.

Code (2016): III, III-B, IV, IV-D, IV-R, IV-T

Sanction: Censure, effective Sept. 4, 2018.

Rationale: Failed to use appropriate behavioral

management strategies as evidenced by repeatedly

striking, with her belt, a young sibling of a pediatric client

in the presence of the family.

Violations: I, II, IV, IV-A, IV-E.

Sanction: Revocation of membership and certification for 36 months, effective April 4, 2016.

Rationale: Billed for speech-language pathology services

not rendered on multiple occasions; admitted that

health-related conditions adversely affected her ability to

provide services; and falsified client records and

employer timesheets.

Code (2016): I, I-O, I-R, III, III-D, IV, IV-D

Sanction: Censure, effective Aug. 15, 2019.

Frameworks

for Ethical

Decision

Making

Markkula Center for Applied

Ethics (Santa Clara University,

2009)

Ethics Quick Calibration Test

(EQCT; Seymour, 1994)

Consensus Model for Ethical

Decision Making (Chabon &

Morris, 2004)

Social Media, Civility & Ethics

1.6 billion people worldwide are ‘daily

active users’ of Facebook.

30% of users are ages 25 to 34 years.

200 audiology and speech-language

pathology pages and forums on

Facebook that are both public and

private.

Twitter has 330 million monthly active

users.

40% of those monthly users access

Twitter daily.

500 million users worldwide access

Instagram stories daily

ASHA members

2017 - ASHA surveyed audiologists and

speech-language pathologists about

their use of social media.

Overall, 77% of clinicians used

Facebook and 37% used Instagram.

In another ASHA survey, over 50% of

members reported incivility on

professional social media sites and over

35% had similar unpleasant experiences

on personal social media.

Social media & ethics

Principle I, Rules O and P refer to the importance

of protecting patient, client and student

confidentiality in various environments.

Disclosing information that can be traced

back to a specific individual in a social media

post is an ethics violation (as well as a HIPAA

or FERPA violation).

Principles I, III, and IV address mispresenting the

skills and services by members that can occur on

social media platforms as advertising.

Claiming unsubstantiated outcomes for a

product or treatment technique can potentially violate Principle 1, Rule J as well as

Principle IV, Rule C

Specific resources

https://www.asha.org/about/civility/

ASHA Civility Digital Toolkit

https://blog.asha.org/2019/04/19/ashas-

4-tenets-of-civility-a-guide-to-public-

discussions/

https://www.asha.org/Practice/ethics/Et

hical-Use-of-Social-Media/

https://leader.pubs.asha.org/doi/10.1044

/leader.GS.17022012.np

When you’re faced with an

ethical dilemma..

Identify the problem as you see it.

Gather relevant data from federal, state, local regulations, practice documents, Code of Ethics

Is this a

regulatory issue

ethics issue

workplace issue?

Compare the issue to a specific rule in ASHA's Code of Ethics.

Identify who has the power and control in the situation.

Identify what is in your control and what is not.

Identify your resources.

Make a list of possible actions and their positive

and negative consequences.

Design a plan that you can defend professionally

and ethically and that meets the requirements of

the regulations.

Take action and evaluate your plan as you

proceed. Determine next steps.

(Ethics and IDEA: A Guide for Speech-Language Pathologists and Audiologists Who Provide Services Under IDEA, ASHA, 2003)

Risk Management -

Prevention

Open communication with clients, students, patients,

their families/caregivers

Utilize informed consent when necessary

Review Codes of Ethics (state, national)

Incorporate ethics CEs into your CEUs

Mandated for certification, starting in 2020

Regularly do a ‘gut check’ about ongoing practices

Ethics practices journal club

“How is my client’s/patient’s/student’s welfare

impacted.”

Always do what is right. That will satisfy most people

and astonish the rest.

Mark Twain

Resources

http://www.asha.org/Code-of-Ethics/

http://www.asha.org/Practice/ethics/Sp

eech-Language-

Pathology-Assistants/

http://www.asha.org/practice/ethics/

From Practice Management tab

Several ASHA Leader articles written by

Heather Bupp, former

Director of Ethics, ASHA

ethics@asha.org

Ethics Education

Issues in Ethics Statements

Ethical Use of Social Media

Ethical Disclosure, Misrepresentation, and Conflict of

Interest

Required Ethical Reporting in the Professions

Ethics Live Event Replays

ASHA Ethics Products

Ethics-Related Articles and Other Information

Issues in Ethics Statements

http://www.asha.org/about/ethics/ethics_issues_index.ht

m

Includes guidance on competition, confidentiality,

conflicts of professional interest, cultural competence,

fees for service provided by students and CFs,

protection of human subjects, etc.

Frameworks for Ethical

Decision Making

Chabon, S.S., & Morris, J.F. [2004, February 17]. A

consensus model for making ethical decisions in a less-

than-ideal world. The ASHA Leader, 17.

Markkula Center. (2009) Framework for Ethical

Decision Making. Santa Clara University.

Seymour, C. (1994) – Ethics Calibration Quick Test. In F.

Silverman (Ed.), Professional issues in speech-language

pathology and audiology. Boston: Allyn & Bacon.

Medical Ethics

Kummer, A.W., Turner, J. (2011) Ethics in the practice of

speech-language pathology in health care settings.

Semin Speech Lang, 32, 330-337.

Jonsen, A.R., Siegler, M., Winslade, W.J. (2015) Clinical

ethics: A practical approach to ethical decisions in

clinical medicine. 8th ed. New York: McGraw-Hill.

The Hastings Center

https://www.thehastingscenter.org/

Scenarios