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Sensible solutions or daft ideas: a search for answers.

Sensible solutions or daft ideas: a search for answers.

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Taylor P, Stansfield J (2003)
Ethical principles need to be interpreted rather than just applied in our work. When a 73 year old man uncharacteristically asked for assistance with his communication, in relation to giving a speech at his golden wedding, the authors used an ethical framework to identify what the speech and language therapy role should be. To the golden rule of ethics - beneficience, non-malificience, autonomy, justice - is added another: communication need. This article describes the four levels of approach and principles in relation to this case. The background, immediate and long-term communication needs, suggested solutions and outcomes of the intervention are discussed.
Taylor P, Stansfield J (2003)
Ethical principles need to be interpreted rather than just applied in our work. When a 73 year old man uncharacteristically asked for assistance with his communication, in relation to giving a speech at his golden wedding, the authors used an ethical framework to identify what the speech and language therapy role should be. To the golden rule of ethics - beneficience, non-malificience, autonomy, justice - is added another: communication need. This article describes the four levels of approach and principles in relation to this case. The background, immediate and long-term communication needs, suggested solutions and outcomes of the intervention are discussed.

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Published by: Speech & Language Therapy in Practice on Jul 04, 2013
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ethics
SPEECH & LANGUAGE THERAPY IN PRACTICE
SPRING 2003

Ethical principles need to beinterpreted rather than justapplied in our work. When a 73year old man uncharacteristicallyasked for assistance with hiscommunication,
Pia Taylor 
and
 Jois Stansfield 
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
au fait 
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).
A reminder
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
M
 
In anysituationwhere the taskis to work forthe health of aperson, aclinician mustdraw on bothclinical andethical theoryand use themin tandem
Sensible solutions or
a search for
if you want tohave fair open and respectfulrelationshipsapply ethical decision makingprioritise clients on the basisof need
Read this
 Jois Stansfield Pia Taylor 
 
SPEECH & LANGUAGE THERAPY IN PRACTICE
SPRING 2003

ethics
we were also aware that he suffers from concur-rent disabilities including severe headaches, andbreathlessness which is exacerbated by “doingtoo much”. In addition he has recently hadqueried (though unconfirmed) transientischaemic attacks, which may be indicative ofdeteriorating health status. Intervention mustaim to not aggravate such conditions. Hence, aprincipled decision had to be made by the speechand language therapist regarding the appropri-ateness and manner of delivery which did themost positive good, achieving the best personaloutcome for Mr Anderson, whilst minimisingharm, as seen in the Ethical Grid.
4. Black: practical issues. Resources available
.
Gillon (1994) claims that “equality is at the heart of justice” (p.xxv) and may be summarised as “the moralobligation to act on the basis of fair adjudicationbetween competing claims” (p.xxv). At times atherapist may feel anxious or guilty because theresources are not available to carry out the interven-tion programme they see as ‘best’ for the individualclient. In Mr Anderson’s case, for example, weconsidered onward referral to a Hearing Therapistwho may have been of considerable value in helpinghim compensate for his hearing loss. However,with only four hearing therapists in Scotland, thisresource is very limited and Mr Anderson wasunlikely to be a priority case. Similarly, we too hadlimited resources and were unable to see MrAnderson as a priority, partly because of the Trust’sguidelines on clients of this age and the apparentinsignificance of his communication needs.Age alone is, however, insufficient ethicalgrounds for not offering intervention, indeed theNHS Research & Development Strategic Review(Department of Health, 1999) sees widespreadageism in society as a violation of the principle of justice. This Review suggests that professionalsoften make inappropriate assumptions that olderpeople cannot benefit from health care or suffertoo many side effects or complications. Equally,while in this case it was a management ratherthan a professional imperative which reduced ourcapacity to act, Mr Anderson’s difficulties werenot insignificant to him, a fact emphasised by hisGP in making clear how rare it was for MrAnderson to seek help in any area of his healthcare. We fully accept the necessity to be able toconsider individual need, regardless of artificialbarriers. When priorities have to be decided inhealthcare, we also agree with Seedhouse &Lovett (1992) that it is the most needy clients whoshould be helped first; it is that definition of needwhich gives rise to difficulties in interpretation.Figure 1 Background (from discussion with Mr andMrs Anderson)
Medical history: high blood pressure; series ofheart attacks in 1972-5 and subsequently, mostrecent 1990. Controlled by drug therapy. Threepossible transient ischaemic attacks in March 2002.Concomitant disabilities:severe headaches(helped in past by acupuncture); severe breath-lessness (wife says exacerbated by even mildphysical activity or “doing too much”); agerelated hearing impairment (hearing deteriorating,has tried NHS aids and recently spent £600 onprivate aids which he finds of limited value);wears dentures (ill-fitting despite a number ofattempts to improve fit).Education:left school at 16 (unusual in his socialgroup, where most left at 14).Employment:worked for an animal feed companyall his working life except when drafted intoarmy for National Service. Retired through illhealth in 1975.Social: Mrs Anderson (74) is extremely involvedin local church and other community socialactivities. Mr Anderson declines to join her onher frequent social outings, although will visitrelatives for quiet lunches/teas. Never been agregarious individual, but increasingly isolatedby hearing loss and difficulty in accommodatingmultiple sources of noise.Family: At onset of health problems childrenwere 10, 9, 2. Children now adults, scatteredaround UK. Family communication is by weeklyphone calls and e-mail, rarely involving MrAnderson who refuses to attempt to use e-mail.Mr Anderson is especially distressed at inabilityto communicate with grandchildren. Rarelywrites letters although would always respondto letters from others. Regular visits from eachof children and their families.Interests:Family; gardening; reading; stock-marketespecially as available via teletext.Reported communication difficulties:Mild comprehension difficulties especially innoisy surroundings;Articulation difficulties - as a result of ill-fittingdentures/hearing/transient ischaemicattacks/other?Cannot understand grandchildren (ages 18, 15Scottish; 13, 10, 5 Welsh) on the phone.Reason for referral:Forthcoming golden wedding and the need tomake a short speech.Personal distress.
Figure 2 Ethical Grid
daft ideas:
answers
Professional conduct
Having considered the four prima facie principlesof healthcare through the Ethical Grid and relat-ed these to Mr Anderson, we also turned to theRoyal College of Speech & Language Therapists’Code of Ethics. Professional conduct guidancerequires speech and language therapists to“refrain from discrimination on the basis of race,religion, gender or any other consideration”(1996, p.18). This emphasises again the principleof justice: Mr Anderson’s age alone should notmean he is less of a priority. We have a duty to“respect the needs and opinions of the clients towhom a duty of care is owed” (RCSLT, 1996, p.18).Mr Anderson is seeking therapy to relieve distressand, if he is an appropriate candidate for therapy,this need ought to be respected and acted upon.We also looked at the Royal College of Speech &Language Therapists’ guidelines on working with theelderly population client group. These recommendan“in-depth assessment of (his) communicative envi-ronment (as) necessary ...to identify any fac-tors...which may be adversely affecting (his) com-munication skills” (1996, p.115). It may be thatadvice on minimising background noise in MrAnderson’s home in addition to assistive listeningdevices (Doyle, 1998) would be of value. “Referralto other agencies/professionals may be consideredparticularly in relation to: vision, dentition, hearing”(RCSLT, 1996, p.116). Referral to a hearingtherapisthas already been discussed as a possibility. MrAnderson’s poor fitting dentures will requireattention as they may be impeding adequatearticulation. However, we are aware that his den-tures are ill-fitting despite a number of attempts toimprove fit and, if we are to respect his autonomyand he declines further dental intervention, thera-py may instead have to be conducted around this.For adults such as Mr Anderson who fall into thedeafness / hearing impairment client group, inter-vention “may involve individual or group therapyaimed at improving communication” (RCSLT, 1996,p.113). Specific therapy may require “focus on com-munication skills and strategies,...speech intelligi-bility,...and other issues in relation to social skills”(RCSLT, 1996, p.113). Mr Anderson’s acquired deaf-ness means therapy needs to address “adjustmentto (his) new hearing status” (RCSLT, 1996, p.113).
Series of suggestions
So, what did we do? Mr Anderson had two com-munication needs, one short-term and one requir-ing rather longer-term strategies. We were ableto offer Mr Anderson two speech and languagetherapy sessions. The first, before the golden

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