SPEECH & LANGUAGE THERAPY IN PRACTICE
Ethical principles need to beinterpreted rather than justapplied in our work. When a 73year old man uncharacteristicallyasked for assistance with hiscommunication,
used an ethicalframework to identify what thespeech and language therapyrole should be. To the goldenrules of ethics - beneficence,non-malificence, autonomy, justice - they now add another:communication need.
r Anderson is an independent,73 year old man (see figure 1).He is close to his golden wed-ding, but this event is worry-ing him because of a combi-nation of health and personalissues. He is also increasinglyfrustrated at his inability to communicate easily, espe-cially with his grandchildren by telephone.His GP states that Mr Anderson has a social dis-ability which he has so far appeared to manage inthe manner best suited to his own perceivedneeds. He did however request help in thisinstance and, as this was so unusual, the GPagreed to a referral to speech and language thera-py to develop strategies to overcome his difficulties.We used an ethical framework to identify what -if any - role we would have to play.In any situation where the task is to work forthe health of a person, a clinician must draw onboth clinical and ethical theory and use them intandem (Seedhouse & Lovett, 1992), but this isnot always as straightforward as it may at firstappear. The four major principles of health carethe following levels and boxes:1.Blue: create autonomy, respect autonomy;2.Red: do most positive good, minimise harm;3.Green: most beneficial outcome for the patient;4.Black: resources available.
1. Blue: health care principles. Create autonomy;respect autonomy.
Seedhouse & Lovett (1992) see the fundamentalinspiration of medical care as the will to createautonomy, “the desire to give a person height-ened control over his life” (p.26). Mr Anderson isactively seeking intervention to increasehis autonomy in communication. Since themotivationto create autonomy is funda-mental, it follows that in areas of theirlives where people have some autonomyit ought to be respected (Seedhouse &Lovett, 1992) and, as health professionals,we have some obligation to contributeactively to this desire.Respecting autonomy in healthcare hasmany prima facie implications such astelling the truth, respecting privacy, confi-dentiality and informed consent (Gillon,1994). As Mr Anderson is the one seekingintervention, informed consent isassumed from the outset; indeed, as he isusually self-sufficient and independent,his GP saw this as an unusual situation,demanding a referral. Mr Anderson may not,however, be entirely
with the work ofspeech and language therapists and may expectdirect rather than indirect approaches to his iden-tified problems. Mr Anderson will need to beseen as competent, adequately informed and vol-untary in his deliberations regarding this and anyfuture therapy (Department of Health, 2002).
2. Red: duties of the health worker. Do most positivegood, minimise harm.3. Green: general nature of the outcome to beachieved. Most beneficial outcome for the patient.
Beauchamp & Childress (1994) believe moralityrequires not only that we respect persons’ auton-omy, but that we refrain from harming them andactively contribute to their welfare. The ideal is toprovide net benefit to patients with minimalharm - beneficence in the context of non-malifi-cence (Gillon, 1994; Beauchamp & Childress,1994). Mr Anderson requests intervention torelieve distress, and increase his quality of life.Initial consultation and assessment deemed MrAnderson as an appropriate candidate for a briefblock of therapy, therefore we were in a uniqueposition to ‘do good’ for him personally. However,ethics are beneficence (do the most positivegood), non-malificence (do no harm), justice (fair-ness, or equity), and autonomy (enabling the indi-vidual to make decisions). These principles are notabsolutes, but prima facie, indicating that theprinciple is binding unless overridden or out-weighed by competing moral principles(Beauchamp & Childress, 1994). As a result, theprinciples need to be interpreted, rather than sim-ply applied in our work.Canons or Codes of Ethics establish guidelinesand standards for the ethical principles and prac-tices of a group of professionals. Inspeech and language therapy, west-ern professional bodies such as theCanadian Association of Speech-Language Pathologists andAudiologists (1992), Royal College ofSpeech and Language Therapists(1996), Speech Pathology Australia(2000) and the American Speech-Language Hearing Association (2001)may differ in the specificity of their val-ues and rules, but they reflect very sim-ilar beliefs and philosophies regardingtheir particular standards of integrity.They espouse the four prima facie prin-ciplesof autonomy, beneficence, non-malificence and justice, either explicit-ly (Speech Pathology Australia) orimplicitly (Royal College of Speech & LanguageTherapists) through their professional ethicalcodes. These codes are useful in providing guid-ance on how one can achieve fair, open andrespectful relationships with those one serves,however, as Pannbacker et al (1996) recognise,they cannot give us solutions: “we must in theend search for the answers on our own” (p.ix).In Mr Anderson’s case, we applied The EthicalGrid (Seedhouse & Lovett, 1992) to help to clarifythe decision making process. This Grid (see figure2) is based on the idea that health professionalsneed to take into consideration various areas indecision making:•health care principles (inner, blue level)•the duties of the health worker (second, red level)•the general nature of the outcome to beachieved (third, green level)•pertinent practical features (outer, black level).
The Grid is essentially a reminder that there are atleast four separate levels at which to think, andthat within these levels there are several differentways of deciding on strategy. To address MrAnderson’s communication needs, we focused on