Issues in Ethics: Prescription
About This Document
Published 2025. This Issues in Ethics statement is a revision of Prescription, which was originally published in 2001 and was last revised in 2017. It has been updated to make any references to the Code of Ethics consistent with the Code of Ethics (2023) (hereinafter, the "Code of Ethics"). The Board of Ethics (hereinafter, the "BOE") reviews Issues in Ethics statements periodically to ensure that they reflect current practices and the current Code of Ethics.
Issues in Ethics Statements: Definition
From time to time, the BOE determines that members and certificate holders can benefit from additional analysis and instruction concerning a specific issue of ethical conduct. Issues in Ethics statements are intended to heighten sensitivity and increase awareness. They are illustrative of the Code of Ethics and are intended to promote thoughtful consideration of ethical issues. They may assist members and certificate holders in engaging in self-guided, ethical decision making. These statements do not absolutely prohibit or require specified activity. The facts and circumstances surrounding a matter of concern will determine whether the activity is ethical.
Introduction
Principle IV, Rule B of the of the Code of Ethics states, "Individuals shall exercise independent professional judgment in recommending and providing professional services when an administrative directive, referral source, or prescription prevents them from keeping the welfare of persons served paramount." Because of the challenges associated with clinical practice today, practitioners sometimes feel pressure to provide and bill for services that are in conflict with their professional judgement. As discussed below, when faced with these situations, it is important for the practitioner to work collaboratively while maintaining their independent judgment and acting in the best interests of the client/patient.
The terms referral, medical order (or "order"), and prescription are used in medical settings and refer to a written statement (electronic or paper) by a physician that directs an offering of professional services to a client/patient. These terms are sysnonymous, are often used as a request for the initiation or continuation of audiology and/or speech-language pathology services, and are useful instruments in the total treatment program for a client/patient.
In addition, a written request for services from a physician may be required if the audiologist or speech-language pathologist (SLP) intends to seek reimbursement for clinical services from third-party payers such as Medicare, Medicaid, or private insurance companies.
On occasion, however, the language of a referral, order, or prescription unduly restricts audiologists or SLPs in exercising their professional responsibility to develop and/or implement appropriate clinical services because the prescription specifies the content, frequency, or duration of services to be provided. Health maintenance organizations (HMOs), Medicare, Medicaid, private insurance companies, and individualized education programs (IEPs) developed for students with disabilities under the Individuals with Disabilities Education Act (IDEA) may prescribe services, protocols, and procedures which they then authorize and/or approve for reimbursement. These entities may also require updates and the issuance of a new referral, order, or prescription for the continuation of services.
Within these regulatory entities, standard protocols and mechanisms are in place. Audiologists and SLPs can challenge or appeal these mechanisms, or they can seek modification of requirements for these mechanisms. In the event that audiologists or SLPs are pressured by any source—through a referral, an order, or a prescription—to provide services that are against their best professional knowledge and judgment (e.g., provide services with inappropriate frequency or intensity or when no benefit can be expected), then they have the responsibility to challenge the referral, order, or prescription. Indeed, if a certificate holder did not challenge prescriptive mandates where the welfare of the person served is at risk, the certificate holder could be held in violation of the Code of Ethics.
The support for independent clinical judgment is specifically stated in Principle I, Rule L: "Individuals who hold the Certificate of Clinical Competence shall use independent and evidence-based clinical judgment, keeping paramount the best interests of those being served."
Implications for patient benefit are addressed by Principle I, Rule K, which states, "Individuals who hold the Certificate of Clinical Competence shall evaluate the effectiveness of services provided, technology employed, and products dispensed, and they shall provide services or dispense products only when benefit can reasonably be expected."
Discussion
After receiving a referral, order, or prescription from a client/patient, audiologists and SLPs often work in concert with other health services professionals, and the issue of restriction of professional responsibilities may be difficult to interpret in circumstances of interprofessional collaborative effort. Examples of such responsibilities might include serving on an IDEA-defined planning team in the schools to develop an IEP, serving on an IDEA-defined early intervention multidisciplinary team to develop an individualized family service plan (IFSP), or serving on a multidisciplinary team in medical or rehabilitative agencies.
In these clinical service decision-making models, team members may convey interpretations of their individual test data to a single professional on the team, who then synthesizes the information and conveys the findings and interpretations of the audiologist or SLP to the client/patient. Not only is this an efficient procedure, but—more important—it may be in the client's best interests to have test results from one discipline interpreted in the context of test findings from other professions. Principle I, Rule B supports this clinical service model, stating, "Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided."
As to such coordinated efforts, audiologists and SLPs should be cautioned that they continue to have a responsibility— recognized under the laws of many states—to correctly and completely communicate to the client/patient their findings and recommendations for treatment, including the risks associated with any treatment plan. If the audiologist or SLP is not the person communicating the findings and recommendations directly to the client/patient, then that audiologist or SLP remains responsible for ensuring that a competent professional communicates the findings and recommendations to the client/patient correctly and completely.
In all circumstances, it is incumbent on the audiologist or SLP to determine when to accept limitations on professional responsibility, but still serve the client's/patient's needs. Principle III reinforces this concept, stating: "In their professional role, individuals shall act with honesty and integrity when engaging with the public and shall provide accurate information involving any aspect of the professions."
As long as the audiologist or SLP maintains independence of judgment and preserves the professional prerogatives to plan and provide audiology or speech-language pathology services that are in the best interests of the individual client/patient—and they accept responsibility for the plan and services so provided—there is no violation of the Code of Ethics.
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