ethics

Sensible solutions or

a search for
the 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 fundamental inspiration of medical care as the will to create autonomy, the desire to give a person heightened control over his life (p.26). Mr Anderson is actively seeking intervention to increase his autonomy in communication. Since the motivation to create autonomy is fundamental, it follows that in areas of their lives where people have some autonomy it ought to be respected (Seedhouse & Lovett, 1992) and, as health professionals, we have some obligation to contribute actively to this desire. Respecting autonomy in healthcare has many prima facie implications such as telling the truth, respecting privacy, confidentiality and informed consent (Gillon, 1994). As Mr Anderson is the one seeking intervention, informed consent is assumed from the outset; indeed, as he is usually 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 of speech and language therapists and may expect direct rather than indirect approaches to his identified problems. Mr Anderson will need to be seen as competent, adequately informed and voluntary in his deliberations regarding this and any future therapy (Department of Health, 2002). 2. Red: duties of the health worker. Do most positive good, minimise harm. 3. Green: general nature of the outcome to be achieved. Most beneficial outcome for the patient. Beauchamp & Childress (1994) believe morality requires not only that we respect persons autonomy, but that we refrain from harming them and actively contribute to their welfare. The ideal is to provide net benefit to patients with minimal harm - beneficence in the context of non-malificence (Gillon, 1994; Beauchamp & Childress, 1994). Mr Anderson requests intervention to relieve distress, and increase his quality of life. Initial consultation and assessment deemed Mr Anderson as an appropriate candidate for a brief block of therapy, therefore we were in a unique position to do good for him personally. However,

if you want to have fair open and respectful relationships apply ethical decision making prioritise clients on the basis of need

Read this

Jois Stansfield

Pia Taylor

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, Pia Taylor and Jois Stansfield used an ethical framework to identify what the speech and language therapy role should be. To the golden rules 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 wedding, but this event is worrying him because of a combination of health and personal issues. He is also increasingly frustrated at his inability to communicate easily, especially with his grandchildren by telephone. His GP states that Mr Anderson has a social disability which he has so far appeared to manage in the manner best suited to his own perceived needs. He did however request help in this instance and, as this was so unusual, the GP agreed to a referral to speech and language therapy 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 for the health of a person, a clinician must draw on both clinical and ethical theory and use them in tandem (Seedhouse & Lovett, 1992), but this is not always as straightforward as it may at first appear. The four major principles of health care

ethics are beneficence (do the most positive good), non-malificence (do no harm), justice (fairness, or equity), and autonomy (enabling the individual to make decisions). These principles are not absolutes, but prima facie, indicating that the principle is binding unless overridden or outweighed by competing moral principles (Beauchamp & Childress, 1994). As a result, the principles need to be interpreted, rather than simply applied in our work. Canons or Codes of Ethics establish guidelines and standards for the ethical principles and practices of a group of professionals. In speech and language therapy, western professional bodies such as the Canadian Association of SpeechLanguage Pathologists and Audiologists (1992), Royal College of Speech and Language Therapists (1996), Speech Pathology Australia (2000) and the American SpeechLanguage Hearing Association (2001) may differ in the specificity of their values and rules, but they reflect very similar beliefs and philosophies regarding their particular standards of integrity. They espouse the four prima facie principles of autonomy, beneficence, nonmalificence and justice, either explicitly (Speech Pathology Australia) or implicitly (Royal College of Speech & Language Therapists) through their professional ethical codes. These codes are useful in providing guidance on how one can achieve fair, open and respectful relationships with those one serves, however, as Pannbacker et al (1996) recognise, they cannot give us solutions: we must in the end search for the answers on our own (p.ix). In Mr Andersons case, we applied The Ethical Grid (Seedhouse & Lovett, 1992) to help to clarify the decision making process. This Grid (see figure 2) is based on the idea that health professionals need to take into consideration various areas in decision making: health care principles (inner, blue level) the duties of the health worker (second, red level) the general nature of the outcome to be achieved (third, green level) pertinent practical features (outer, black level).

In any situation where the task is to work for the health of a person, a clinician must draw on both clinical and ethical theory and use them in tandem

A reminder
The Grid is essentially a reminder that there are at least four separate levels at which to think, and that within these levels there are several different ways of deciding on strategy. To address Mr Andersons communication needs, we focused on

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003

ethics

daft ideas:

Figure 1 Background (from discussion with Mr and Mrs Anderson)

Medical history: high blood pressure; series of heart attacks in 1972-5 and subsequently, most recent 1990. Controlled by drug therapy. Three possible transient ischaemic attacks in March 2002. Concomitant disabilities: severe headaches (helped in past by acupuncture); severe breathlessness (wife says exacerbated by even mild physical activity or doing too much); age related hearing impairment (hearing deteriorating, has tried NHS aids and recently spent 600 on private aids which he finds of limited value); wears dentures (ill-fitting despite a number of attempts to improve fit). Education: left school at 16 (unusual in his social group, where most left at 14). Employment: worked for an animal feed company all his working life except when drafted into army for National Service. Retired through ill health in 1975. Social: Mrs Anderson (74) is extremely involved in local church and other community social activities. Mr Anderson declines to join her on her frequent social outings, although will visit relatives for quiet lunches/teas. Never been a gregarious individual, but increasingly isolated by hearing loss and difficulty in accommodating multiple sources of noise. Family: At onset of health problems children were 10, 9, 2. Children now adults, scattered around UK. Family communication is by weekly phone calls and e-mail, rarely involving Mr Anderson who refuses to attempt to use e-mail. Mr Anderson is especially distressed at inability to communicate with grandchildren. Rarely writes letters although would always respond to letters from others. Regular visits from each of children and their families. Interests: Family; gardening; reading; stock-market especially as available via teletext. Reported communication difficulties: Mild comprehension difficulties especially in noisy surroundings; Articulation difficulties - as a result of ill-fitting dentures/hearing/transient ischaemic attacks/other? Cannot understand grandchildren (ages 18, 15 Scottish; 13, 10, 5 Welsh) on the phone. Reason for referral: Forthcoming golden wedding and the need to make a short speech. Personal distress.

answers
we were also aware that he suffers from concurrent disabilities including severe headaches, and breathlessness which is exacerbated by doing too much. In addition he has recently had queried (though unconfirmed) transient ischaemic attacks, which may be indicative of deteriorating health status. Intervention must aim to not aggravate such conditions. Hence, a principled decision had to be made by the speech and language therapist regarding the appropriateness and manner of delivery which did the most positive good, achieving the best personal outcome for Mr Anderson, whilst minimising harm, 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 moral obligation to act on the basis of fair adjudication between competing claims (p.xxv). At times a therapist may feel anxious or guilty because the resources are not available to carry out the intervention programme they see as best for the individual client. In Mr Andersons case, for example, we considered onward referral to a Hearing Therapist who may have been of considerable value in helping him compensate for his hearing loss. However, with only four hearing therapists in Scotland, this resource is very limited and Mr Anderson was unlikely to be a priority case. Similarly, we too had limited resources and were unable to see Mr Anderson as a priority, partly because of the Trusts guidelines on clients of this age and the apparent insignificance of his communication needs. Age alone is, however, insufficient ethical grounds for not offering intervention, indeed the NHS Research & Development Strategic Review (Department of Health, 1999) sees widespread ageism in society as a violation of the principle of justice. This Review suggests that professionals often make inappropriate assumptions that older people cannot benefit from health care or suffer too many side effects or complications. Equally, while in this case it was a management rather than a professional imperative which reduced our capacity to act, Mr Andersons difficulties were not insignificant to him, a fact emphasised by his GP in making clear how rare it was for Mr Anderson to seek help in any area of his health care. We fully accept the necessity to be able to consider individual need, regardless of artificial barriers. When priorities have to be decided in healthcare, we also agree with Seedhouse & Lovett (1992) that it is the most needy clients who should be helped first; it is that definition of need which gives rise to difficulties in interpretation.

Professional conduct
Having considered the four prima facie principles of healthcare through the Ethical Grid and related these to Mr Anderson, we also turned to the Royal College of Speech & Language Therapists Code of Ethics. Professional conduct guidance requires 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 principle of justice: Mr Andersons age alone should not mean he is less of a priority. We have a duty to respect the needs and opinions of the clients to whom a duty of care is owed (RCSLT, 1996, p.18). Mr Anderson is seeking therapy to relieve distress and, 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 the elderly population client group. These recommend an in-depth assessment of (his) communicative environment (as) necessary ...to identify any factors...which may be adversely affecting (his) communication skills (1996, p.115). It may be that advice on minimising background noise in Mr Andersons home in addition to assistive listening devices (Doyle, 1998) would be of value. Referral to other agencies/professionals may be considered particularly in relation to: vision, dentition, hearing (RCSLT, 1996, p.116). Referral to a hearing therapist has already been discussed as a possibility. Mr Andersons poor fitting dentures will require attention as they may be impeding adequate articulation. However, we are aware that his dentures are ill-fitting despite a number of attempts to improve fit and, if we are to respect his autonomy and he declines further dental intervention, therapy may instead have to be conducted around this. For adults such as Mr Anderson who fall into the deafness / hearing impairment client group, intervention may involve individual or group therapy aimed at improving communication (RCSLT, 1996, p.113). Specific therapy may require focus on communication skills and strategies,...speech intelligibility,...and other issues in relation to social skills (RCSLT, 1996, p.113). Mr Andersons acquired deafness means therapy needs to address adjustment to (his) new hearing status (RCSLT, 1996, p.113).

Figure 2 Ethical Grid

Series of suggestions
So, what did we do? Mr Anderson had two communication needs, one short-term and one requiring rather longer-term strategies. We were able to offer Mr Anderson two speech and language therapy sessions. The first, before the golden

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003

ethics

Figure 3 Therapy sessions

Communication need: immediate Forthcoming golden wedding and the need to make a short speech. Suggested solutions 1) Indicate to guests beforehand that there would be no speeches. 2) Pre-record a speech to be played by audio- or video tape at the ceremony. 3) Say only thank you for coming. 4) Ask another family member to speak. Communication need: longer term Personal distress: cannot understand family, especially grandchildren (ages 18, 15 Scottish; 13, 10, 5 Welsh) on the phone. 1) Identify causes of the problem. Easily identified accent, speed of childrens speech, inability to hear properly and hard to listen when they started to talk fast. Suggested that parents discuss this with children so they try to speak slowly and clearly when talking to grandpa. Limited success. Eventually also identified that they often called at the end of a day when Mr Anderson was tired and this increased the difficulties. Suggested Saturday and Sunday lunchtimes for regular weekly phone calls. Big improvement in understanding younger grandchildren. Older ones not keen to be committed to a regular time of day. Telephone was very old and had no modern facilities. Investigating buying a new phone which could accommodate new technology. Ongoing. 2) Develop strategies to maximise communication Older children were happy to address e-mail messages direct to Mr Anderson, which Mrs Anderson would print off and he would respond to by letter. This led to a major increase in correspondence. Encourage face to face orientation before commencing a conversation. Some success. Both Mr and Mrs Anderson are attempting to do this, though both find it difficult to maintain. Reducing noise sources. Limited success. Mr Anderson liked to watch teletext with the sound off the TV but Mrs Anderson wanted to listen to TV programmes. In the absence of a second TV in the house this continues to be a source of frustration for each. Try again to have dentures fitted correctly. Rejected. This has been a long running and painful problem and Mr Anderson did not consider it anything to do with the speech and language therapist. 3) Onward referral to hearing therapist or private speech and language therapist. Suggested, with the proviso that these individuals are rare in Scotland. Not accepted by Mr Anderson who considered it unnecessary at present. Outcome Rejected: They will think there is something wrong and worry about me. Rejected: What a daft idea, they will think I am dead! Accepted in conjunction with 4) below. Accepted after discussion with family and enthusiastic agreement by eldest grandson.

wedding celebration, explored the range of his communication difficulties and resulted in a series of suggestions for him to consider (figure 3). The second was a follow-up, at which Mr and Mrs Anderson both reported that his communication opportunities had expanded and improved. The short-term need was by far the easier to address. After a discussion in the speech and language therapy session, followed by a private family consultation, Mr Anderson decided to break with his original view of family tradition and ask his eldest grandson to speak at the Golden Wedding. This was successful on two counts. Firstly, as Mr Anderson reported at his appointment two weeks after the event: he spoke slowly and clearly, and for the first time in years I understood every word he said! And he was far better received that I would have been ... he had even done his homework and found and used some of my original speech notes from our wedding, which was a pretty good one, though I say so myself. Secondly, Mr Anderson had only needed to thank everyone for attending the event. For the longer-term a number of potential strategies were suggested, some of which were more successful than others. It is possible that Mr Anderson will ask for a further referral at some point in the future but, in the meantime, he was happy to accept or reject advice according to his current perceived needs. Mr Anderson reported that he felt that his autonomy had been respected, he had been able to make his own decisions, overall he had benefited from the

experience of speech and language therapy and he appreciated the fact that this had been possible despite the limited resource made available. An ethical framework can therefore help to address the communication needs of individuals by consideration of the four prima facie principles through a tool such as The Ethical Grid and also with more specific clinical guidelines such as those outlined in appropriate professional codes of ethics and good practice guidelines. It is not always a straightforward process to use an ethical framework to address the communication needs of clients. However, this appears to be the very nature of ethics itself. As Beauchamp & Childress (1994) state, we all recognise that morality would be a cold and uninspiring practice without various traits of character, emotional responses, and ideals that reach beyond principles and rules (p.462). Ethical decision making comes to life through its application. Pia Taylor is a speech pathology student at LaTrobe University who was an exchange student at Queen Margaret University College. Jois Stansfield is Head of Speech and Language Sciences at QMUC.

References
American Speech-Language-Hearing Association (2001) Code of Ethics. ASHA Leader 6 (23) 2-4. Beauchamp, T.M. & Childress, J.F (1994) Principles of Biomedical Ethics. Oxford: Oxford University Press. Canadian Association of Speech-Language Pathologists and Audiologists (1992) Canon of Ethics. Journal of Speech-Language Pathology and Audiology 16 (4) 257-258. Department of Health (1999) Topic Working Group Ageing and Age-Associated Disease and

Disability NHS R & D Strategic Review. www.doh.gov.uk/research/documents/rd3/ageing_final_report.pdf Retrieved April 11, 2002. Department of Health (2002) Consent - Reference Guide to Consent for Examination or Treatment. w w w. d o h . g o v. u k / c o n s e n t / r e f g u i d e . h t m . Retrieved April 11, 2002. Doyle, J. (1998) Practical Audiology for SpeechLanguage Therapists. London: Whurr Publishers Ltd. Gillon, R. (1994) Preface: Medical Ethics and the Four Principles in Gillon, R (Ed) (1994) Principles of Health Care Ethics. West Sussex: John Wiley & Sons pp. xxi-xxxi. Pannbacker, M., Middleton, G.F., & Vekovius, G.T. (1996) Ethical Practices in Speech-Language Pathology and Audiology: Case Studies. San Diego: Singular Publishing Group Inc. Royal College of Speech and Language Therapists (1996) Communicating Quality 2. London: RCSLT. Seedhouse, D & Lovett, L. (1992) Practical Medical Ethics. Chichester: John Wiley & Sons. Speech Pathology Australia (2000) Code of Ethics. www.speechpathologyaustralia.org.au/pages/cod e%20of%20ethics/codeofethics.html Retrieved April 11, 2002.

Reflections
Do I use clinical and ethical theory in tandem? Do I try to avoid making inappropriate assumptions about people? Do I respect reasons given by clients for accepting or rejecting my suggestions?

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2003