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A framework for ethical practice in Speech and Language Therapy

Adopted by the General Assembly of CPLOL in Turin, October 2009

Introduction

CPLOL considers that the objective of Speech and Language Therapy (SLT) practice in Europe is to contribute to the wellbeing of all individuals who access these services, in accordance with the European Convention of Human Rights. Various terms are used in different countries in Europe, but here we have used the term “patients” to include all those individuals with communication disorders, to whom the SLT is providing professional services. The ethical framework described below is intended to provide a basis for the development and updating of detailed national ethical codes and guidance.

Ethical codes for Speech and Language Therapists across Europe will contain variations which reflect the specific conditions of practice within each country. However, we consider that there are basic principles which will be valid in any setting, and which will be relevant to the production of more detailed local guidance. Within each country the ethical code will take account of the national law, the regulations applying to health services and health professionals, and the way clinical practice is organised. Codes will also differ in whether they are stated as commands, as prohibitions, as general principles or a combination of these. Here we are stating the basic ethical principles we should refer to, the main ethical duties arising out of them, and the main areas where there are specific difficulties to consider within Speech and Language Therapy practice.

Ethical principles and duties

The bio-ethical approach to healthcare ethics can be described through a set of ethical principles, which can form the basis of decision-making, and which can be developed into more detailed codes reflecting the specific concerns of speech and language therapy practice. These principles are:

To have respect for the autonomy and dignity of individuals

To act in such a way as to bring benefits to individuals and to improve their quality of life

To avoid doing anything which will do harm to individuals

To act in an equitable and just way towards individuals and society.

These principles are the basis of the common ethical duties towards patients, relating to

obtaining informed consent from the patient

maintaining confidentiality

communicating effectively

giving well-founded and honest professional opinion and advice,

acting within the limits of one’s knowledge and skills

acting in the best interests of patients

respecting the social, cultural and moral norms of the local communities

maintaining good records which are accurate, objective and comprehensive

acting on the basis of scientific evidence and the professional consensus

maintaining and developing one’s skills throughout one’s career

effectively supervising therapy tasks that have been delegated to others

working within a multidisciplinary framework and collaborating with other professionals.

These principles are also the basis for a duty to the profession, since our behaviour and conduct affect the ability of the profession as a whole to carry out its work for the benefit of the patient. This is reflected in requirements about

personal behaviour in clinical practice and outside it

maintaining the reputation of the profession

avoiding any action which might undermine the profession as a whole or any member of it.

CPLOL recognises that these principles may be in conflict in some situations, and that Speech and Language Therapists have to consider the interaction of different duties relating to an individual patient in deciding how to act.

This may be manifested in

the clash between confidentiality and the possible need to act to protect a child or vulnerable adult;

a case where a patient and their parents/carers have differing views about whether therapy is needed – and the nature of that therapy;

situations where the clinical judgment of an SLT about the needs of an individual patient is in conflict with the overall policy of a service in allocating resources.

No set of rules will resolve such problems, and the individual Speech and Language Therapist must decide which principle is the over-riding one in the situation. Individuals need to recognise the ethical considerations that are implicit in all clinical decision-making and should aim to make explicit reference to these common values that are shared and practised by SLTs throughout Europe.

Specific challenges for the SLT profession

The “duty of care” of each Speech and Language Therapist towards their patients is to be 'accountable' for their clinical decision-making, but they cannot be held 'responsible' for the ultimate outcome of any healthcare intervention, as that may be beyond the control of the professional for many reasons.

CPLOL considers that there are particular ethical problems in working in partnership with patients who have communication disabilities, and with their families and other carers.

This will affect

explaining the results of the assessment

decision-making concerning therapy and intervention

obtaining informed consent from the patient.

Ethical principles must be applied with extra care, and with due account taken of the effect of communication difficulties on patients. Clinical decisions and interventions must be based on an understanding of the cognitive and psychological factors which may go along with a communication disorder. Since communication disorders affect the patient in their whole environment, decisions about a patient’s care must be based on all the factors which affect the patient in that environment. It is recognised that there are specific ethical problems and challenges in providing SLT services to patients and to populations where there are diverse mother tongues and heritage languages, by therapists who have different language backgrounds. In addition, SLTs must consider the mental capacity of the individuals with whom they are working and their ability to give informed consent. This issue may be addressed by legislation in some member Countries. Although this has a legal context, the starting point of assuming capacity unless otherwise demonstrated has its roots in ethical principles and is fundamental to ensuring that these individuals are treated in an ethical manner. The principle responsibility for the SLT may be to ensure that others are aware of the differences between cognition deficits, language and communication difficulties and mental capacity. It should also be noted that a judgement of mental capacity may only be made in relation to a specified circumstance and is not fixed. Any decision made on behalf on someone who is deemed to lack capacity to decide for themselves must be defendable in line with the principle of ‘best interests’ for that individual.

It should additionally be noted that to a significant extent, SLTs are required to contribute towards ethical decision-making within the context of a multi-disciplinary team rather than as an autonomous practitioner. As such, the SLT needs to acknowledge the ethical standards of other professionals and the subsequent decisions should expressly account for the potential harms and benefits of the impact of the holistic case management. The “duty of care” of each Speech and Language Therapist towards their patients is to be 'accountable' for their clinical decision-making, but they cannot be held 'responsible' for the ultimate outcome of any healthcare intervention, as that may be beyond the control of the professional for many reasons.

Some speech and language therapists are involved in procedures where there is a specific risk of harm to the patient, either from invasive physical procedures, or from the use of less well-known therapeutic or psychological techniques.

These will require

specific consent

specific extra training and competencies (if not covered within initial education),

appropriate partnerships with other professions to ensure that risks are minimised and harm to the patient is avoided.

These situations will be covered by specific practice standards and procedures, relevant to the clinical setting.

Conclusion

Ethical practice is an essential and very challenging aspect of our professional role and SLTs should recognise the ethical dimensions of all their clinical decision-making. It is intended that this framework will provide guidance on how to approach ethical practice for individual SLTs and for SLT organisations. This guidance also embodies CPLOL’s joint commitment to ethical practice across Europe.

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