Sorting Through the Gray Consider the “ifs” and “whens” of several scenarios to identify real trouble spots. Features
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Features  |   July 01, 2016
Sorting Through the Gray
Author Notes
  • Glenn Waguespack, MS, CCC-A, is in private practice in Shreveport, Louisiana. He is chair of the Louisiana license board and serves on the ASHA Board of Ethics. He served as president of the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology, chair of the ASHA Continuing Education Board and the ASHA Council on Academic Accreditation in Audiology and Speech-Language Pathology, and audiology vice chair of the ASHA Council for Clinical Certification in Audiology and Speech-Language Pathology. audmath1@aol.com
    Glenn Waguespack, MS, CCC-A, is in private practice in Shreveport, Louisiana. He is chair of the Louisiana license board and serves on the ASHA Board of Ethics. He served as president of the National Council of State Boards of Examiners for Speech-Language Pathology and Audiology, chair of the ASHA Continuing Education Board and the ASHA Council on Academic Accreditation in Audiology and Speech-Language Pathology, and audiology vice chair of the ASHA Council for Clinical Certification in Audiology and Speech-Language Pathology. audmath1@aol.com×
Article Information
Professional Issues & Training / ASHA News & Member Stories / Attention, Memory & Executive Functions / Features
Features   |   July 01, 2016
Sorting Through the Gray
The ASHA Leader, July 2016, Vol. 21, 44-51. doi:10.1044/leader.FTR1.21072016.44
The ASHA Leader, July 2016, Vol. 21, 44-51. doi:10.1044/leader.FTR1.21072016.44
All health care providers face ethical dilemmas, and audiologists are no exception. What makes such dilemmas tricky to handle is that right versus wrong can be separated by many areas of gray.
To help future professionals navigate such uncertainty, audiology training programs provide ethics education that often includes references to the ASHA Code of Ethics and a requirement that students develop their own scenarios to illustrate specific principles and rules. Despite all this emphasis on ethics, some practitioners continue to be accused of behaving unethically or violating ethical principles—either by their state licensure board, ASHA or both.
Why? Again, much of the problem relates to the fact that ethical decision-making is not typically clear-cut. Most agree that billing fraud, for example, constitutes a violation of ethical principles, and those who bill fraudulently are frequently sanctioned. But other potential ethics violations are subject to varying interpretations by other practitioners. What may be viewed as an ethics violation by one practitioner may be viewed as an acceptable standard of care by another.
To illustrate such perceptual differences—and to bring attention to the March 2016 revision of the ASHA Code of Ethics—the ASHA Board of Ethics presented hypothetical ethical dilemmas to audiences at the 2014 and 2015 ASHA conventions. The scenarios represented ethical dilemmas in both audiology and speech-language pathology. (However, for this article, all scenarios are modified to illustrate audiology issues.) Although some scenarios presented at the conventions represented a clear violation of the ASHA Code of Ethics, others required more thought and did not result in consensus that there was a violation.
Interestingly, although the sessions focused on applying the ASHA Code of Ethics, audience members often applied other principles and rules to the situations. Here, we present examples of the scenarios and the attendee responses to each one. (Note that the scenarios were based on the 2010 Code of Ethics and have been modified to reference the revised 2016 code.) The varied responses clearly illustrate many gray areas of ethical decision making.

Ethical decision-making is not typically clear-cut. Most agree that billing fraud, for example, constitutes a violation of ethical principles. But other potential ethics violations are subject to varying interpretations.

Scenario 1: Conflict of interest
An audiologist, Sarah, is offered an all-expense-paid, five-day trip to Hawaii by a hearing aid manufacturer for a course on technology and programming new hearing aid products. The schedule is set so that all sessions (lectures and hands-on labs) are conducted in the morning, with the afternoon open for sightseeing or whatever activities the audiologist chooses.
A complaint has been filed with the ASHA Board of Ethics, alleging that Sarah violated Principle III, Rule B: Individuals shall avoid engaging in conflicts of interest whereby personal, financial, or other considerations have the potential to influence or compromise professional judgment and objectivity.
These are three possible decisions:
  • Sarah has not violated this section of the Code of Ethics.

  • Sarah is in violation of this section of the Code of Ethics.

  • There is insufficient information provided to determine if a violation has occurred.

In their discussion, attendees at the 2015 ASHA Convention unanimously agreed that no conflict of interest had occurred, as there were no minimum purchases or other incentives linked to the trip. The trip was determined to be educational in nature with its primary goal to present new advances in technology and strategies for programming.
Consider the situation with a slightly different slant: An audiologist, Sarah, is offered an all-expense-paid, five-day trip to Hawaii by a hearing aid manufacturer for a course on technology and programming new hearing aid products. The schedule is set so that all sessions (lectures and hands-on labs) are conducted in the morning, with the afternoon open for sightseeing or whatever activities the audiologist chooses. Sarah, however, must sell a specified number of hearing aids in the next six months to qualify for the trip.
A complaint has been filed with the ASHA Board of Ethics, alleging that Sarah has violated Principle III, Rule B: Individuals shall avoid engaging in conflicts of interest whereby personal, financial, or other considerations have the potential to influence or compromise professional judgment and objectivity.
There are three possible decisions:
  • Sarah has not violated this section of the Code of Ethics.

  • Sarah may be in violation of this section of the Code of Ethics.

  • There is insufficient information provided to determine if a violation has occurred.

In their discussion, attendees considered this scenario to be different from the first in that the trip was based on the sale of a certain number of hearing aids within a specified period of time. It was the audience’s opinion that this situation had the appearance of impropriety because the professional judgment of the audiologist could be compromised by the apparent conditions attached to the trip.

The scenarios highlight the role of perception and past ethical experiences in the decision-making process.

Scenario 2: Practicing while impaired
Jason is a first-year audiologist who provides audiological services to inpatients and outpatients at a local medical center. Jason’s immediate superior has noticed that Jason frequently returns from lunch with the smell of alcohol on his breath and is often late for work.
Concerned that Jason may have a drinking problem, the supervisor files a complaint with the ASHA Board of Ethics, alleging that Jason has violated Principle I, Rule R: Individuals whose professional practice is adversely affected by substance abuse, addiction, or other health-related conditions are impaired practitioners and shall seek professional assistance and where appropriate, withdraw from the affected areas of practice.
There are three possible decisions:
  • Jason has not violated this section of the Code of Ethics.

  • Jason may be in violation of Principle I, Rule R.

  • There is insufficient information provided to determine if a violation has occurred.

In this situation, the fact that Jason is frequently late for work and the fact that the supervisor often smells alcohol on Jason’s breath after lunch are not sufficient to allege that a violation of the Code of Ethics has occurred. No evidence has been presented that relates to competence or harm to the patient, and no principle or rules of ethics directly address the allegations of the supervisor.
Consider the situation with additional information: Jason is a first-year audiologist who provides audiological services to inpatients and outpatients at a local medical center. Jason’s immediate superior/supervisor has noticed that Jason frequently returns from lunch with the smell of alcohol on his breath and is often late for work. His appearance has become somewhat unkempt, and he noticeably slurs his speech when counseling patients. In addition, he does not enter evaluation results into the electronic medical records database in a timely manner, resulting in loss of billing revenue for the medical center.
Concerned that Jason may have a drinking problem and is engaging in behavior that may be harmful to the patients, the supervisor files a complaint with the ASHA Board of Ethics, alleging that Jason has violated Principle I, Rule Q: Individuals shall maintain timely records and accurately record and bill for services provided and products dispensed and shall not misrepresent services provided, products dispensed, or research and scholarly activities conducted, as well as Principle I, Rule R: Individuals whose professional practice is adversely affected by substance abuse, addiction, or other health-related conditions are impaired practitioners and shall seek professional assistance and where appropriate, withdraw from the affected areas of practice.
There are three possible decisions:
  • Jason has not violated the referenced sections of the Code of Ethics.

  • Jason may be in violation of one or more of the referenced sections of the Code of Ethics.

  • There is insufficient information provided to determine if a violation has occurred.

Depending on the documentation submitted with the alleged complaint, it is possible that Jason is not only practicing while impaired, but is also exhibiting issues with record-keeping and billing. Although there may be other violations of the revised Code of Ethics, the violations regarding substance abuse and record-keeping remain at the forefront of the allegations.
This scenario addresses only the potential violations of the audiologist and does not speak to the culpability of the supervisor and the supervisor’s actions. The supervisor could be held responsible for compromising patient care because he allowed Jason to continue to see patients. Additionally, there is no evidence that the supervisor attempted to resolve the problems with Jason and his possible impaired practice. This scenario represents multiple layers of violations in that both supervisor and supervisee could be in violation of the Code of Ethics. Although the supervisor in question filed the complaint with the Board of Ethics, his actions warrant a complaint filed against him.

Practitioners are encouraged to examine standards of care to ensure that their practice is ethically sound.

Scenario 3: Patient abandonment
Clint is the only audiologist working in a rural speech-language-hearing center with three speech-language pathologists. He is offered a position in an urban medical center and gives his employer four weeks’ notice when he tenders his resignation. At the end of the four weeks, the rural facility has not been able to replace Clint, and Clint stands to lose the medical center position if he does not begin work there within the designated time period.
Concerned that she has been unable to employ another audiologist and concerned that Clint is leaving his patients with no access to audiological services, the director of the center files a complaint with the ASHA Board of Ethics, alleging a violation of Principle I, Rule T: Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services.
There are three possible decisions:
  • Clint may be in violation of the Code of Ethics, as his leaving can be construed as patient abandonment.

  • Clint is not in violation of Principle I, Rule T.

  • There is insufficient evidence to render a decision regarding this allegation.

In their discussion, participants agreed that Clint should not be responsible for securing his replacement, and he was commended for providing four weeks’ notice in this situation. However, it was suggested that he could have provided a list of referrals to his patients, although the nearest audiologist was 50 miles away. Online resources were also suggested as a resolution for the situation. Patient abandonment was not considered an appropriate violation, given the amount of notice provided to the center.
Consider the issue of patient abandonment with a slightly different scenario: Clint is the only audiologist working in a rural speech-language-hearing center with three SLPs. His relationship with the owner is tenuous, and he does not think he is being properly paid for his audiological services. One afternoon he is scheduled to see four hearing-aid patients for follow-up. Following another argument with the director at their Friday morning staff meeting, he decides to resign immediately and not return after lunch.
Concerned because she has no other audiologist to conduct the afternoon evaluations, the director files a complaint with the ASHA Board of Ethics, alleging a violation of Principle I, Rule T: Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services.
There are three possible decisions:
  • Clint is not in violation of Principle I, Rule T.

  • Clint may be in violation of Principle I, Rule T, as his resignation with no notice could be construed as patient abandonment.

  • There is insufficient evidence to determine if a violation of the ASHA Code of Ethics has occurred.

The fact that hearing-aid patients were scheduled that afternoon—and that Clint resigned from the center without notice—may certainly constitute patient abandonment. It was noted that no audiologists were in the area, and Clint did not make referrals or suggest alternatives for the hearing-aid patients scheduled that afternoon or any other patients scheduled thereafter.
These three scenarios depicting conflict of interest, impaired practitioners and patient abandonment are all issues addressed in the revised ASHA Code of Ethics. Although other principles and rules could be referenced for each of the scenarios presented, the scenarios described illustrate the process of ethical decision-making.
At the same time, the scenarios highlight the role of perception and past ethical experiences in the process, as well as the manner in which different professionals interpret the information presented. Ethical decision-making is subject to interpretation, discussion and evaluation, and practitioners are encouraged to examine standards of care to ensure that their practice is ethically sound.
Ethics Terms Explained

The ASHA Code of Ethics and other information on the ASHA website define a number of terms, including:

  • Conflict of interest: An opposition between the private interests and the official or professional responsibilities of a person in a position of trust, power and/or authority.

  • Diminished decision-making ability: Any condition that renders a person unable to form the specific intent necessary to determine a reasonable course of action.

  • Fraud: Any act, expression, omission or concealment—the intent of which is either actual or constructive—calculated to deceive others to their disadvantage.

  • Impaired practitioner: An individual whose professional practice is adversely affected by addiction, substance abuse or health-related and/or mental health-related conditions.

  • Kickback: Anything of value presented to a practitioner or supplier that may induce that entity to refer health services back to the source of remuneration.

  • Negligence: Breaching of a duty owed to another, which occurs because of a failure to conform to a requirement, and this failure has caused harm to another individual, which led to damages to this person(s); failure to exercise the care toward others that a reasonable or prudent person would take in the circumstances, or taking actions that such a reasonable person would not.

  • Self-referral: Referral by a physician to an entity with which the physician or a member of the physician’s family has a financial relationship. The relationship is such that the physician would earn a financial return based on the success of, for example, a speech and hearing clinic in which the physician invested.

Find yourself witness to or involved in an ethical conundrum? In addition to the Code of Ethics, ASHA has a number of resources to guide decision-making:

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July 2016
Volume 21, Issue 7