Ethics Q&A for School-Based Speech Language Pathology Practice

• Is it unethical for me to accept referrals for my part-time private practice for children who attend my school or district?
• My school system hires unqualified personnel as substitutes when I am ill or away from the job attending a professional meeting. Is this practice ethical?
• I sometimes disagree with parents about the amount of service their child needs. How can I avoid providing services that I feel are unwarranted?
• What are my ethical responsibilities related to providing culturally responsive services to  assess and treat children?
• What are my ethical responsibilities in mentoring clinical fellows?
• What are my ethical responsiblities in supervising student clinicians?
• What should I do if asked to "sign off" on Medicaid for speech-language pathologists whom I have not supervised?

General Ethics Questions

• Does ASHA have a process for reporting ethical violations?
• What is the ASHA Code of Ethics and why is it important for me to follow the code?
• Are there penalties for members who refuse to adhere to the Code, or is adherence optional?
• What ASHA documents provide guidance for ethical decision making?
• How do I know if I am facing an ethical dilemma?
• Where can I get guidance when I find myself in an ethical dilemma?
• How can I avoid ethical problems?

Is it unethical for me to accept referrals for my part-time private practice for children who attend my school or district?

A number of cases come before ASHA's Board of Ethics that center around real or potential conflict of interest. In its summary, the Board stated that practitioners who intend to accept cases for private practice from a place of primary employment should observe the following guidelines:

• Check first with local district and/or state education agency administrators’ guidelines or restrictions that may exist regarding this question.
• The persons served professionally must be fully informed of services available from the practitioner’s primary employment setting as well as those from the private practice or other practice environment and be given the freedom to choose whether and from whom they will obtain professional services.
• The costs associated with obtaining services from the practitioner’s primary employment setting versus those associated with the private practice must be made clear.
• Practitioners accepting cases in a private setting from their primary place of employment should inform the administrator of their primary employment setting of their intent.

For more information on this topic and a scenario taken from a school setting, please refer to Issues in Ethics: Obtaining Clients for Private Practice From Primary Place of Employment.

My school system hires unqualified personnel as substitutes when I am ill or away from the job attending a professional meeting. Is this practice ethical?

There are typically two levels of support personnel—aides and assistants. States may use different terminology to refer to these support personnel in speech-language pathology (e.g., communication aides, paraprofessionals, service extenders). Aides and assistants should not be used to substitute for a qualified professional. Based on the level of training, these support personnel may have different scopes of responsibility in the work setting. Aides, for example, typically have a narrower training base and a more limited scope of responsibilities than do speech-language pathology assistants. It is important to evaluate the role of a substitute. A substitute who is providing coverage for a day or two may play a different role (i.e., maintaining levels of student performance) than that of a long-term substitute hired to cover a leave of absence. It is important to discuss these situations with the supervisory staff to ensure that both the needs of the student and ethical issues are addressed.

It is also important to check state and local district regulations or policies regarding support personnel and missed sessions.

Under Principle I, Rule D of ASHA's Code of Ethics, it states: "Individuals shall not misrepresent the credentials of assistants, technicians, or support personnel and shall inform those they serve professionally of the name and professional credentials of persons providing services." Speech-language pathology aides or assistants are not considered qualified providers of speech-language services in the schools. See Additional Resources on Qualified Providers and Frequently Asked Questions About Speech-Language Pathology Assistants.

I sometimes disagree with parents about the amount of service their child needs. How can I avoid providing services that I feel are unwarranted?

Your decision should be guided by appropriate sections of ASHA's Code of Ethics, district policies, and state and federal regulation. Usually, when professional and parent or clients disagree, the conflict is related to one of the following: dismissal, frequency and intensity of treatment, type of treatment/therapeutic approach, eligibility for services, or specific assistive technology. It is often helpful to review the evidence used to make decisions with parents.

Illustrative examples of typical scenarios, including when parents refuse dismissal from services for their child, insist on more services than recommended for their child, or demand a treatment approach that has not been proven effective, can be found in the article "When Clinician and Parent Disagree" by Polly B. Pooser.

Additional information is in the article by Melanie Frazek, "Ethics vs. Legal Jurisdiction."

What are my ethical responsibilities related to providing culturally responsive services to assess and treat children?

Professionals must recognize that differences do not imply deficiencies or disorders. Culture and language may influence (a) the behaviors of individuals who are seeking health, habilitative, or rehabilitative care and (b) their attitudes toward speech, language, and hearing services and providers. Evaluations of students should be culturally responsive and appropriate based on the child’s heritage, language, and culture. You should not report test scores when using translated tests that have not been normed on the population representing the student, nor should you use tests containing biases that will negatively affect a child's performance and that may erroneously indicate the need for special education services. All individuals assessed and treated are members of a culture and speak one or more languages. We as clinicians need to consider the child’s context, including culture and language, as we assess and treat any child. See Issues in Ethics: Cultural and Linguistic Competence. For additional information, contact ASHA’s Office of Multicultural Affairs at multicultural@asha.org.

What are my ethical responsibilities in mentoring clinical fellows?

The CF mentor’s ASHA certification status must be current during the entire Clinical Fellowship experience in order for the Clinical Fellow to use those hours to apply for ASHA certification. Each CF mentor and Clinical Fellow is strongly encouraged to read ASHA’s Issues in Ethics: Responsibilities of Individuals Who Mentor Clinical Fellows in Speech-Language Pathology.

What are my ethical responsibilities  in supervising student clinicians?

ASHA-certified individuals who are engaged in supervision of student clinicians are bound to honor their responsibility to hold paramount the welfare of persons they serve professionally and to ensure that students under their supervision competently provide services. See Issues in Ethics: Supervision of Student Clinicians.

What should I do if asked to "sign off" on Medicaid for speech-language pathologists whom I have not supervised?

Speech-language pathologists must be very firm yet cautious when dealing with administrators who direct them to “sign off” for services not rendered or not supervised (when necessary). It is important to share with the administrators the consequences for violations of the rules and regulations set by Medicaid. Services and claims for services not adequately supervised could result in a school district having to repay Medicaid funds received for such services. In addition, fraudulent billing is a criminal activity that may be punishable by law, not only for the school district but also for the speech-language pathologist participating in the fraudulent billing. For additional information on this topic, visit the ASHA website, Medicaid Guidance for School-Based Speech-Language Pathology Services: Addressing the “Under the Direction of” Rule.

General Ethics Questions

Does ASHA have a process for reporting ethical violations?

Yes. Please review Filing a Complaint of Alleged Violation of the ASHA Code of Ethics or the Assistants Code of Conduct for instructions in completing and submitting a formal complaint with our Ethics office. Additionally, ASHA’s Statement of Practices and Procedures of the Board of Ethics explains how ethical complaints are processed and adjudicated. For more examples, please review the following two webpages:

• Everyday Ethics: Do I Need to Report This?
• Everyday Ethics: What Happens When Someone Files an Ethics Complaint?

For assistance, contact ethics@asha.org.

What is the ASHA Code of Ethics and why is it important for me to follow the code?

ASHA's Code of Ethics contains the rules or standards agreed upon by our membership that govern our conduct and activities. A code of ethics is a shared statement of values specific to a particular group. The importance of adherence to the Code of Ethics by ASHA members lies in the preservation of the highest standards of integrity and ethical principles. It is vital to ensure the responsible discharge of obligations by members of our profession working in all settings. For additional information, see ASHA’s Code of Ethics.

Are there penalties for members who refuse to adhere to the Code, or is adherence optional?

The Preamble of the Code of Ethics states that this document is intended to (a) ensure the welfare of the consumer served and (b) protect the integrity and reputation of the professions. It serves to reflect what we value as professionals and establishes expectations for our scientific and clinical practice based on principles of duty, accountability, fairness, and responsibility. ASHA members and certificate holders are required to abide by the Code's principles and rules, and the Association enforces that mandate by sanctioning those found in violation. Depending on the egregiousness of the misconduct, the sanctions that the Board of Ethics can impose range from a confidential Written Warning or Reprimand for lesser violations to the Revocation of ASHA membership and certification for a period of years, up to life, for violations of a serious nature.

What ASHA documents provide guidance for ethical decision making?

Start with the ASHA Code of Ethics. Ethics and Schools Practice as well as ASHA Ethics Resources provides ethical guidance and information.

How do I know if I am facing an ethical dilemma?

An ethical dilemma is defined as a situation that requires a choice between options that are or seem to be equally unfavorable or mutually exclusive. In its main sense, a dilemma refers to a situation in which the person must make a choice between alternative courses of action or argument.

For example, in schools, speech-language pathologists could be asked to provide services for children who no longer qualify for intervention to satisfy a parent's request or an employer’s demands. Adhering to the parent’s request or the employer's demand to provide unnecessary services could result in sanction for unethical conduct; however, not providing the services could result in employment discipline or termination.

Once you establish that an ethical dilemma exists, the questions that you must address are as follows:

• What possible courses of action are permissible, impermissible, or necessary?
• What are the effects (benefits and burdens) of each action?^[1]

[1] Chabon, S. S., & Morris, J. F. (2006). A consensus model for making ethical decisions in a less-than-ideal world. The ASHA Leader, 9(3),18-19.https://leader.pubs.asha.org/doi/10.1044/leader.MIW.09032004.18

Where can I get guidance when I find myself in an ethical dilemma?

The ASHA website can provide additional assistance. Check the Schools webpage for A 10-Step Process in Resolving Ethical Issues. ASHA's Ethics team is available for confidential consultation at ethics@asha.org.

How can I avoid ethical problems?

1. Advocate for best practices.
2. Use evidenced-based practices as the basis for decision making.
3. Know and understand the ASHA Code of Ethics and your employer's handbook and guidelines.
4. Connect the Code of Ethics with your program's mission statement, policies and procedures, and performance evaluations.
5. Acquaint supervisors, administrators, and colleagues with the Code of Ethics, Issues in Ethics Statements, and potential for ethical conflicts.
6. Discuss potential ethical issues before they become a problem.
7. Review federal, state, and local regulations and requirements.