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Communicating Ethics

Communicating Ethics

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‘First do no harm’ is a well-known phrase, but it is only one of many guiding ethical principles we need to juggle as healthcare professionals.
With the help of a hypothetical client with profound cognitive and physical disabilities, Jois Stansfield and Jane Handley explore how an ethical framework can help speech and language therapists and students negotiate a path to what feels like the ‘right’
outcome for a given situation at a given time.
‘First do no harm’ is a well-known phrase, but it is only one of many guiding ethical principles we need to juggle as healthcare professionals.
With the help of a hypothetical client with profound cognitive and physical disabilities, Jois Stansfield and Jane Handley explore how an ethical framework can help speech and language therapists and students negotiate a path to what feels like the ‘right’
outcome for a given situation at a given time.

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Published by: Speech & Language Therapy in Practice on Jul 10, 2013
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ETHICS
SPEECH & LANGUAGE THERAPY IN PRACTICE
WINTER 2010
E4
Communicating ethics
‘First do no harm’ is a well-known phrase, but it is only one o manyguiding ethical principles we need to juggle as healthcare pro-essionals. With the help o a hypothetical client with prooundcognitive and physical disabilities,Jois StansfeldandJane Handley  explore how an ethical ramework can help speech and languagetherapists and students negotiate a path to what eels like the ‘right’outcome or a given situation at a given time.
READ THIS IF YOUWANT TOIDENTIFY YOUROPTIONS• UNDERSTANDDIFFERINGPRIORITIESIMPROVE YOURDECISION-MAKING
1. A tutor’s tale –Jois Stansfeld
Speech and language therapy stu-dents are routinely conronted withpractical clinical issues during theirpre-registration education. In someclinical areas, the ‘right’ actionsappear to be obvious to students:or example, in many aspects o dysphagia management, the needto ensure nutrition and hydrationcan lead inevitably to the technicalinterventions necessary to maintainlie. On other occasions students(and therapists) report eeling guiltybecause they sense they have notdone everything they believe theycould, but are not able easily to articu-late the reasons or this, or to identiyany ways in which they could havechanged their decisions or actions.Final year speech and languagetherapy students at ManchesterMetropolitan University ollow a case-based approach to ethical reasoning. They collaborate in workshops,identiying ethical issues involved ina range o hypothetical cases, andcomplete a piece o coursework basedon one o these cases. Students arepresented with a number o dierentethical decision-making tools. Onewhich they have consistently oundto be valuable is the Seedhousegrid (Seedhouse, 2007). It enablesstudents (and others) to identiyelements o a case at dierent levelso decision making, and to judge themost important considerations with agiven client at a given time.Seedhouse has also developedan online approach to ethicaldecision-making, ‘Values Exchange’(Seedhouse, 2005; www.values-exchange.com). It is an apparentlysimple, but challenging, methodo enabling us all to make initialdecisions, see others’ ideas andreconsider our own views, withimmediate eedback. It incorporatesboth grids and a ‘rings o uncertainty’element. This enables us to respondwithout eeling that we should bemaking defnitive judgements untilwe have considered not only thecase, but also others’ responses to it.It is possible to use cases posted onthe open web site, or set up ‘closedcases’ or specifc audiences. ‘Bryan’(fgure 1) is the frst ManchesterMetropolitan University speechand language therapy case to bepresented in this ormat.
2. A student’s journey –Jane Handley
As a speech and language therapystudent I requently fnd mysel acedwith dicult decisions that requirenot only sound clinical judgementbut also clear ethical reasoning. Suchdecisions are oten dicult to resolvebecause they present ethical dilem-mas which cannot be reasoned outwith logic alone. To achieve the bestpossible outcome, it seems that amoral judgement is also required.In these situations, fnding a waythrough to the best outcome has, attimes, proved extremely challenging.ISSN 2045-6174 (online)Figure 1 Bryan (hypothetical client)
You have been asked to provide asecond opinion or the parents o a veyear old boy, Bryan, who has prooundphysical and cognitive disabilities.He lives at home and attends a specialeducational placement. He has respitecare one week in our at a local specialunit.At home Bryan is ed by mouth. Hisswallow is impaired and great care isneeded over the quantity and textureo ood given. There is also someoesophageal dysphagia (refux).Bryan’s parents are unhappy witheeding in school, where they believehe is receiving inadequate nutritionas a result o the amount o timeallocated. They are also highly criticalo the respite provision.The respite unit will only acceptBryan on condition that eeding issupplemented by nasogastric tube.The parents eel they were pressuredinto signing an agreement or this,otherwise respite care would havebeen denied.
JoisJane
 
SPEECH & LANGUAGE THERAPY IN PRACTICE
WINTER 2010
E5
ETHICS The series o workshops on ethicalreasoning in our fnal year hasprovided a useul ramework orworking through ethical dilemmasin practice. By sharing this processin relation to Bryan’s case (fgure 1,p.E5), I hope to make other studentsand therapists aware o tools that canhelp us approach ethical reasoningmore confdently.An important ethical issue in thiscase is the clear discrepancy betweenwhat Bryan’s parents consider to bein the best interests o their child,and the service provided by theproessionals managing the case.Bryan’s parents believe he canand should continue to be ed orallywithout supplemented eeding, andthat the necessary resources shouldbe provided to enable him to do thissaely and to thrive. Based on theinormation provided, I hypothesisedthat their motivation in seeking asecond opinion is to gather evidenceand support to help them fght or this.Using the Seedhouse Ethical Grid(Seedhouse, 2007) (fgure 2) as a basisor my ethical decision-making, thefrst consideration in this case is myown competency as a clinician. Am Isuciently skilled to take on the case?According to the Royal College o Speech & Language Therapists’ codeo ethics (RCSLT, 2006), membersmust “act within the limits o personalknowledge, skills and experience”(p.10). At graduate level, a clinicianonly has basic skills in dysphagiamanagement (RCSLT, 2006). Thereorei I do not have sucient skills,knowledge or experience it is myduty to decline this case. However, i I have worked in the feld and haveappropriate expertise, I can go on toconsider other ethical issues beoremaking a decision.It is possible that the parents wantme to comment on issues that alloutside the remit o speech andlanguage therapy. It is important tomake explicit to them rom the outsetthe boundaries o my proessionalcompetence. They may, or example,wish to discuss the issue o non-oraleeding, but I would need to makeclear to them that in this respectI can only comment on the saetyand eciency o Bryan’s oral intake(RCSLT, 2005) (
Tell the truth
).
Needs beore wants
Another important consideration isthe conict between the principleso 
serving needs rst 
and
respectingautonomy 
. We are required to act inthe best interests o our clients andthereore ethically we should servethe needs o the client beore thewants (Stansfeld & Hobden, 1999). Itis important to clariy here that theclient is Bryan and not his parents,which brings us to the issue o inormed consent. In the UK, “consentor assessment and intervention o children under the age o 16 willnormally be sought rom the parent / guardian” (RCSLT, 2006, p.19).Although children under the age o 16 can give this consent in certaincircumstances, given Bryan’s ageand proound cognitive impairment,his parents are responsible orconsenting to any decisions madeby the healthcare team. Accordingto Richards (2003), “Legally adequateinormed consent requires thatdecisions are inormed, competentand voluntary” (p.378). Bryan’sparents say they elt pressured intosigning the agreement or nasogastrictube eeding, and thereore thevalidity o their inormed consent maybe questionable (
Wishes of others
;
Respect autonomy 
).From the parents’ perspective,they may have elt excluded romthe decision-making process andmay thereore want me to act asan advocate to give voice to their
Keep promisesMinimise harmDomostpositivegoodMostbenefcialoutcomeoronesel  TellthetruthMostbenefcialoutcomeorsocietyMost benefcial outcomeor the patientMost benefcial outcomeor a particular groupResources availableEectiveness andeciency o actionWisheso others Thelaw Therisk Codeso practiceDisputed acts The degree o certaintyo the evidence on whichaction is takenRespect personsequallyServeneeds frstCreateautonomyRespectautonomy
Figure 2 Seedhouse Ethical Grid (Seedhouse, 2007, reproduced by kind permission)
An important ethicalissue ... is the cleardiscrepancy betweenwhat Bryan’s parentsconsider to be in thebest interests o theirchild, and the serviceprovided by the pro-essionals managingthe case.

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