Discussion

LSHSS
Clinical Forum
Ethical Issues in Providing Services in
Schools to Children With Swallowing
and Feeding Disorders
Nancy P. Huffman
Churchville, NY
DeAnne W. Owre
Woonsocket School System, Woonsocket, RI
I ndividuals across the life span with swallowing
and feeding disorders (dysphagia) receive treatment
and management services from speech-language
pathologists (SLPs). The 1999 American Speech-Language-Hearing
Association (ASHA) Omnibus Survey reported that more than 50%
of SLPs were involved in the clinical management of dysphagia
(ASHA, 1999). Persons with dysphagia receive treatment in a
variety of settings. Treatment occurs at home via home health care,
at early intervention program sites, hospitals, residential facilities,
nursing homes, daycare centers and nursery schools, facilities and
worksites for individuals with developmental disabilities, rehabilitation facilities, clinics, agencies, and private practices. As part
of their workload, SLPs in school-based settings routinely provide
services to students who were born prematurely or who have
neurologic conditions, craniofacial anomalies, complex medical
conditions, head injury, or other serious chronic illnesses and injuries. Many of these students1 require dysphagia treatment and
management. On the 2006 ASHA Schools Survey (ASHA, 2006a),
10% of respondents reported that they regularly serve students
with dysphagia and that the average number served in the caseload
was four students.
Regarding schools in relation to other, primarily medical,
settings, Logemann and O’Toole (2000) observed,
Differences between professionals working in each setting are decreasing
for two reasons. First, more sick children are expected by their third-party
payers to receive their dysphagia management in the schools and,
second, schools are billing third parties for the kinds of speech and
swallowing treatment being provided in the educational setting.
Although, obviously, there are continuing differences between the
various work settings, in the area of dysphagia, many commonalities
exist between the medical and school settings. ( p. 79)
This article will review and explore ethical issues in dysphagia
treatment that confront the SLP, including practice and ethical
considerations in the context of the school setting.
ABSTRACT: Purpose: This article is a commentary and discussion
of ethical issues in dysphagia services as related to school-based
practice in speech-language pathology.
Method: A review of the literature on ethical issues in the
provision of speech-language pathology services to individuals
with dysphagia was conducted, with particular emphasis on
students receiving school-based services.
Results: Issues in dysphagia management that were identified
in the literature review are discussed from the perspective of
biomedical ethics, professional ethics, and professional practice
issues pertinent to the school setting.
Conclusion: Considerations, suggestions, and resources for
ethically responsive action on the part of the school-based
speech-language pathologist are provided.
KEY WORDS: ethics, dysphagia, schools, competence
1
Given the focus of this article on school-based practice, the term “student” is used
when referring to infants, toddlers, children, and youth receiving services via
school-based programs.
LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 39 • 167–176 • April 2008 * American Speech-Language-Hearing Association
0161-1461/08/3902-0167
167
ETHICS AND DYSPHAGIA: LITERATURE REVIEW
AND DISCUSSION
Basic Concepts: Biomedical and Professional Ethics
An understanding of basic ethical concepts of self-determination,
beneficence, nonmaleficence, and justice (Beauchamp & Childress,
2001; Horner, 2003; Strand, 1995) is necessary for the provision
of ethically responsible service to all persons who are served by
SLPs. Self-determination or autonomy refers to the professional’s
responsibility to respect the right of the individual to make care
decisions for him- or herself. Beneficence refers to the professional’s responsibility to act for the benefit or good of the client.
Nonmaleficence refers to the professional’s responsibility to avoid
unnecessary harm to the client. Justice refers to the professional’s
responsibility to act fairly, to distribute resources fairly, and to
see that the client receives the service that he or she deserves.
Horner provided a tutorial on values, morality, philosophy, ethics,
and law and their relationship to one another in guiding courses
of action relative to these concepts. Consequently, in the provision
of care to persons with dysphagia, SLPs must strive to (a) respect
the wishes of their clients or their surrogate decision makers (e.g.,
desire for oral feeding/desire for tube feeding); (b) do good or do
the “right thing” (e.g., provide for appropriate intake of nutrition);
(c) prevent harm (e.g., reduce negative, even life-threatening,
consequences associated with eating/feeding); and (d) do this by
fairly allocating resources, both human and financial.
Much of the speech-language pathology literature on ethical
decision making in dysphagia explores in depth the concepts of selfdetermination, beneficence, nonmaleficence, and justice in various situations (Flather-Morgan, 1994; Goldsmith, 1999; Groher,
1990, 1994; Landes, 1999; Lazarus, 1996; Lefton-Greif, 2001;
Lefton-Greif & Arvedson, 1997; Pittenger, 1997; Rubin, Wilson,
Fischer, & Vaughn, 1992; Segal & Smith, 1995; Serradura-Russell,
1992; Sharp & Genesen, 1996; Shelley, 1995; Strand, 1995, 2003).
In providing dysphagia services, SLPs must deal with medical
realities, the client’s personal preferences, and considerations for
quality of life. This must all be done within a larger context of
considerations including family preferences, care team preferences,
caregiver preferences, legal/regulatory rules, costs, and adherence
to professional ethical obligations. Decision-making models for
dysphagia services (as well as other life-impacting medically complex conditions) attempt to balance the basic tenets of autonomy,
beneficence, nonmaleficence, and justice given the client’s circumstance (Beauchamp & Childress; 2001; Flather-Morgan, 1994;
Lefton-Greif, 2001; Lefton-Greif & Arvedson, 1997; Sharp &
Genesen, 1996; Strand, 1995, 2003).
Professional ethics are promulgated in codes of ethics such as
the Code of Ethics of the American Speech-Language-Hearing
Association (ASHA, 2003a). Professional codes involve rules or
standards that have been agreed on by the members of the organization or profession and that govern the conduct and activities
of its members.
The ASHA Code of Ethics (ASHA, 2003a) consists of four
principles of ethics that constitute the moral basis for the code.
These four principles deal with responsibilities to persons served
professionally, responsibility for one’s professional competence,
responsibility to the public, and responsibilities involving inter- and
intraprofessional relationships. Each principle has its associated
rules of ethics that further elaborate on acceptable or unacceptable
conduct.
Professional ethics and biomedical ethics are indeed intertwined.
As students with medically compromising issues (such as dysphagia)
continue to enter school caseloads, SLPs in schools will find
themselves involved in discussions not only within the framework
of professional ethics but also, and to a greater extent than previously, within the framework of biomedical ethics. That is, balancing doing what is of benefit to the student (beneficence) with
doing no harm (nonmaleficence); considering the wishes of a parent
or a surrogate acting on behalf of the student who legally, and/or
because of age, or because of the degree of disability, is unable to
express wishes or participate in decisions (client autonomy in selfdetermination); or determining type, intensity, and frequency of
services given the school district’s resources (justice).
Arvedson (2000), Brady (1998a), Lefton-Greif and Arvedson
(1997), and Lefton-Greif (2001) focused on pediatric populations.
Informed decision making brings its own set of issues in pediatric
populations where parents act on behalf of their child. For example, questions may arise as to whether in acting “on behalf of their
child” a parent is acting “in the child’s best interest.” Treatment
planning also brings its own set of considerations. For example,
in the pediatric population, children are developing and changing.
Their medical and communicative status must be monitored as a
function of growth and development or lack thereof. As children
change or present with additional challenges, modifications in
treatment may need to occur or new technology may need to be
introduced. Issues between caregivers and care providers on how
to proceed may arise and need to be resolved. Service delivery in
natural environments (home, daycare centers, preschools, schools)
has its set of considerations. For example, issues may have to be
resolved regarding safety, availability of emergency help, transition
from one setting to another, or consistency of techniques between
settings (e.g., home and school) and caregivers.
Riquelme (2004) explored dysphagia services with regard to
the SLP’s cultural competence. He wrote that decisions are influenced by client/family dietary rules and conventions, concepts
of wellness, concepts of time, feelings about types of medical
intervention, access to medical care, family rules for decision
making, beliefs about medicine, and the primary treatment provider used by the family. All have potential issues of ethical
significance in dysphagia treatment. Sensitivity and respect for
what the client brings to the situation is critical. ASHA’s Issues
in Ethics statement—Cultural Competence (ASHA, 2005a)—
provides an expanded discussion of cultural competence, ethics,
and the need for the practitioner to recognize one’s own cultural and
life experience as well as that of the client in planning and
delivering ethically responsible services.
Case Scenarios
Ethical issues, dilemmas, and debates usually arise because of
circumstances and relationships surrounding the people involved,
such as issues of attitude, competence, education, and expectations.
Ethical issues also arise out of circumstances involving workplace
systems, workplace operating procedures, legal mandates, regulatory
requirements, reimbursement streams, employer expectations, and
site-specific planning and preparedness or lack thereof. When
considering ethical issues in providing services to individuals with
dysphagia, instructive guidance comes through the presentation of
168 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 39 • 167–176 • April 2008
case studies. By reviewing and analyzing case scenarios, it becomes
clear that there may not be a “single” or “right” or “wrong” answer to
the ethical questions posed; rather, there may be several ethically
responsive alternatives to handling a situation. As Groher stated,
“each individual presents with a unique set of medical circumstances
and a unique set of beliefs as they relate to their medical care” (1994,
p. 11). Groher continued by pointing out that the complexity of
interactions between the persons involved (i.e., client, physician,
parent, family members, professionals, other team members) rarely
results in the same decision when identical dysphagia scenarios are
presented (1994). Several case studies are available (Brady, 1996a,
1996b, 1997a, 1997b, 1998b, 1999, 2000, 2001; Goldsmith, 1999;
Lefton-Greif, 2001; Lefton-Greif & Arvedson, 1997; Pittenger,
1997; Sharp & Genesen, 1996; Strand, 1995). Table 1 depicts a
representative example of topics of ethical interest in dysphagia that
are covered in these case scenarios.
One case study (Brady, 2001) will be elaborated on primarily
because it takes place in a school setting. It is demonstrative of
the dynamic between parent, teacher, SLP, and physician. This scenario is illustrative of ethical issues related to autonomy, in terms
of respecting the wishes of the child’s parent/decision maker;
beneficence, in terms of the SLP’s need to promote what is believed
to be good for the child; and nonmaleficence, in terms of the SLP’s
concern that oral feeding may cause harm. In Brady’s opinion, the
scenario represents “one of the most challenging ethical dilemmas
speech-language pathologists face—when the expressed preference
of a parent for their child is in direct opposition to what is (at least
initially) seen to be the most ‘beneficent’ plan of care” ( p. 20).
To summarize, a parent obtained a prescription from the physician ordering oral feeding for her daughter who was receiving
tube-fed nutrition, hydration, and medications. The prescription was
sent to the child’s teacher, who showed it to the SLP. It was the
opinion of the SLP that it would be against professional standard
to allow the child to eat orally. Further, the SLP questioned what
she perceived to be the mother’s and physician’s limited understanding of what was in the child’s best interest. Brady makes a
number of key points. First, this scenario (parent–SLP–school–
physician disagreement) is not an unfamiliar experience for schoolbased SLPs. Rather, what may be unfamiliar is the urgency and
nature of concern for potentially medically compromising, lifethreatening outcomes. Second, a typical approach to ethical
questions is to seek an answer that promotes a single course of
action that is the “right” way to go. Brady points out that in the
framework of clinical ethics, the emphasis is on “developing
practical solutions that comprise a range of options” ( p. 18) given
each individual case and its facts and context. In this scenario,
Brady suggests that the first line of consideration be recognizing
that the “team” extends beyond the school walls and that the team
must be operating with the same set of facts. Thus, all interested
parties need to be identified, involved, and communicating regularly. Third, Brady reminds the reader that adults who have
identified a proxy have likely had discussions with that proxy
whereby instruction has been given about wishes. Children, on
the other hand, may not have the capability to express wishes or
make self-determining decisions. Thus, when dealing with the
parent/proxy decision maker as in this scenario, it is helpful for
the team to identify and discuss together the concerns that might
have motivated the request for oral feeding. Presumably, parents
act in the child’s best interest. Consider that in this scenario, the
parent has not requested that the feeding tube be removed. The
parent is not ignoring the child’s needs. Rather, the request may be
coming from a quality-of-life perspective viewing feeding as a
social activity integral to the parent–child relationship.
Where issues of disagreement, safety, doing harm versus doing
good, and urgency exist, as in this case, team leadership, communication, negotiation, and consideration of an array of possible
alternatives are key. An ethically responsive plan that emerged in
this instance was a carefully considered and monitored time-limited
Table 1. Topics of ethical interest in dysphagia from case studies.
Topic Citation(s) of case scenario(s)
Removal of feeding tube; demand of family for oral feeding Brady (2000, 2001), Lefton-Greif (2001)
Introduction of feeding tube Brady (1996a), Lefton-Greif & Arvedson, (1997, Case 2),
Sharp & Genesen (1996, Cases 1, 2, 3), Strand (1995, Cases 3, 4, 5)
Family insisting on intense therapy (frequency and duration) from
SLP; family insisting for more care than would have been
recommended
Brady (2000)
Team member disagreement/conflict; SLP disagreeing
with colleagues; conflict in opinion and professional judgment
Brady (1998a, 1999, 2001), Lefton-Greif & Arvedson (1997, Case 1)
Disagreement between team and client/family Brady (2001), Pittenger (1997)
& refusal of team recommendations
& unilateral decision of team parent and physician
Sensitivity to cultural factors Lefton-Greif & Arvedson (1997, Case 2)
Patient preference; decision-making capacity; surrogate decision maker Brady (1996a, 1996b, 1999, 2001), Goldsmith (1999),
Sharp & Genesen (1996, Cases 1, 2, 3), Strand (1995, Cases 1, 4, 5)
Informed consent Brady (1996a, 1996b)
Caregiver not able to carry through with recommendations and strategies Brady (1997a)
Oral diet under certain conditions Brady (1997b, 1998a)
Staff members handling meal supervision Brady (1997b, 1998a)
Paternalism and patient family interest Brady (2000)
Clinician values in conflict with parent choices Brady (1998b)
Quality-of-life concerns Sharp & Genesen (1996, Case 2)
Huffman & Owre: Ethical Issues in Providing Services in Schools 169
trial with defined and detailed conditions, roles, and observations.
Following the time-limited trial, a jointly developed plan of action emerged.
The ethical issues raised in this and the other scenarios listed
in Table 1 are particularly instructive to school-based SLPs because the ethical questions and dilemmas raised transcend a variety
of worksites, including a skilled nursing facility, a rehabilitation
hospital, a public school, and a private residential school. The issues
around team conflict, caregivers’ management of clients, parent/
surrogate decision makers, special diets, defined conditions for
certain eating activities, family demands for treatment beyond what
would have been recommended, and educating less informed colleagues are quite within the realm of experience of school-based SLPs.
In discussions of basic concepts in ethics and through presentations of case studies, authors identify key questions to ask
and propose models to use in order to make decisions that are
ethically responsible for dysphagia services. Consistent across all
decision-making frameworks is the importance of (a) gathering the
facts, (b) carefully outlining the ethical concerns, (c) listing the
alternatives and the pros and cons of potential outcomes for each
alternative, (d) arriving at an ethically responsible course(s) of
action acknowledging that there may be no single answer, and
(e) reflection and analysis (Goldsmith, 1999; Landes, 1999; LeftonGreif, 2001; Lefton-Greif & Arvedson, 1997; Pittenger, 1997;
Rubin et al., 1992; Segal & Smith, 1995; Serradura-Russell,
1992; Sharp & Genesen, 1996; Strand, 1995).
From a professional ethics point of view, Huffman (2001) and
Chabon and Morris (2004) offered strategies for analyzing ethical
problems that can be applied to issues surrounding dysphagia. In
an ASHA publication, Ethics and IDEA (2003b), ethical decisionmaking strategies are presented through the study of vignettes
drawn from issues related to the Individuals With Disabilities
Education Act (IDEA, 1990). The focus is on ethically responsive
conduct in the context of regulatory rules, including team functioning, outside referral, and employer demands.
Ethics and School-Based Dysphagia Services
The importance of the educational preparation and competency
of the school-based SLP in the area of dysphagia is emphasized
by Power-deFur (2000). In reviewing state requirements for
certification/licensure in speech-language pathology, Power-deFur
found mention of competency in dysphagia to be “rare” ( p. 77).
One exception was the state of Virginia, where candidates for
education (i.e., teacher certification) licensure were expected to
demonstrate “understanding of the knowledge, skills and processes of the evaluation and treatment of disorders of the oral
and pharyngeal mechanisms as they relate to communication,
including but not limited to dysphagia” (p. 77).
Power-deFur (2000) directs attention to the ASHA Code of
Ethics and the ASHA-certified SLP’s affirmative obligation to
“engage in only those aspects of the professions that are within
the scope of their competence, considering their level of education,
training and experience” and “to continue their professional development throughout their careers” (ASHA, 2003b, p. 14). In the area
of dysphagia, continuing education goes beyond self-study and
should include observation of experienced clinicians and opportunities for supervised clinical experiences. In discussing the need for
school-based SLPs to pursue continuing education to develop and
maintain expertise in dysphagia, Power-deFur makes a potent point:
Failing to attain this competency [in dysphagia] results in three outcomes:
(a) failure to provide dysphagia services to the student by any school
personnel, (b) provision of dysphagia services to the student by other
health-related school personnel who may not have the knowledge and
skills to assess or treat dysphagia (e.g. the occupational therapist, the
school nurse) or school personnel with limited awareness or knowledge
of dysphagia (e.g. the teacher, school paraprofessionals), or (c) provision
of services by a speech-language pathologist who is inadequately
prepared. ( p. 78)
Power-deFur suggests that each school district have at least one SLP
who has received the necessary continuing education to provide
appropriate services to students with swallowing and feeding
disorders.
O’Toole’s discussion (2000), although more focused on handling dysphagia services from a regulatory process point of view
under IDEA, does touch on ethical, liability, and risk management
considerations as they relate to practice under IDEA. He primarily
addresses the need for practitioners to obtain education and training beyond that necessary for ASHA clinical certification standards
that were in effect at that time.2
Owre (2001) cited concerns related to the education and clinical
training of SLPs; the range of dysphagia expertise found in school
systems; the appropriateness of various service delivery models;
attitudes among SLPs as to whether or not dysphagia intervention
belongs in the school setting; employer demands to become familiar
with dysphagia intervention as part of third-party reimbursement
programs; and the lack of understanding among school district
administrators, parents, and school staff regarding the role of the
SLP in managing swallowing and feeding disorders.
Arvedson and Homer (2006) emphasized the need for a schoolbased dysphagia team, suggesting that “no one discipline can,
nor should, manage children with issues surrounding their feeding
and swallowing” (p. 8). It is critical that school-based teams and
medically based teams communicate regularly so that “all health,
developmental, and feeding issues are handled in ways that maximize each student’s safety for oral [or tube] feeding and to facilitate
the ability to participate fully in the academic process” ( p. 8).
Owre (2006a, 2006b) reported on the results of an informal
questionnaire for school-based SLPs providing dysphagia services.
The questionnaire was developed by a committee established in
2005 to coordinate the efforts of ASHA Special Interest Divisions 13 (Swallowing and Swallowing Disorders) and 16 (SchoolBased Issues) on dysphagia management in school settings. It
was disseminated to 7,781 affiliates of the two divisions via their
respective newsletters, Perspectives. There were 187 respondents.
Owre (2006a, p. 16) summarized,
Concern about liability issues was prominent in the concerns of SLPs, as
was lack of experience/expertise and proving “educational relevance”.
Probably the strongest reaction from respondents was the expressed need
for more courses and training in dysphagia management in colleges/
universities. Additional needs included development of an ASHA
position statement and guidelines for dysphagia management in schools,
the development of basic competencies and the need for more information
on the topic via professional development offerings. ( p. 17)3
2
Effective January 2005, ASHA certification requirements specify demonstration
of knowledge and skills in swallowing processes; swallowing disorders; and their
prevention, assessment, and intervention (ASHA, 2006b).
3
The 2005 (ASHA Dysphagia in Schools Coordinating Committee members were
Joan Sheppard (Chair), Sheryl Amaral, Joan Arvedson, Emily Homer, DeAnne
Wellman Owre, Celia Hooper (ASHA Vice President for Professional Practices in
Speech-Language Pathology and monitoring Vice President), and Janet Brown (ASHA
Director of Health Care Services in Speech-Language Pathology, Ex Officio).
170 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 39 • 167–176 • April 2008
The questionnaire asked school-based SLPs to indicate how they
were involved in the delivery of dysphagia services. A broad range
of activities was identified. The 10 most frequently reported areas
(Owre, 2006a, p.16) for SLP involvement were as follows:
1. Evaluating and providing of “hands on” therapy (e.g. oral
motor exercises, swallowing techniques) – 42%
2. Providing in-service to school staff regarding dysphagia and
safe feeding – 39%
3. Obtaining medical information from the child’s physician – 37%
4. Identifying and referring to medical personnel (e.g. medically-based SLP) as indicated – 35%
5. Collaborating with other professionals (e.g. OT, PT and/or
nurse) in the dysphagia management process – 30%
6. Managing dysphagia interventions independently – 26%
7. Coordinating with medical SLP and school team (including
family members) to evaluate and establish intervention plan
in the school setting (SLP writes school plan) – 26%
8. Obtaining medical clearance from a physician for dysphagia
intervention – 25%
9. Establishing accommodations and precautions only and
ensuring follow-through as a consultant – 25%
10. Implementing established district-wide dysphagia program
and procedures – 14%
SLPS were also asked to identify dysphagia management barriers in school settings. In order of priority (Owre, 2006a, p. 17),
they were:
a. liability issues
b. own lack of experience/expertise in dysphagia
c. restrictions of a school setting versus a medical setting
Regarding future involvement of ASHA and Divisions 13 and
16 in addressing issues identified, the questionnaire asked SLPs
to prioritize the kinds of support needed for the acquisition of
knowledge, expertise, and competence in dysphagia management
in schools. Respondents gave highest priority (Owre, 2006a, p. 17)
to the following:
a. Promotion of more courses, offerings and training in schoolbased dysphagia management at the university/college level,
b. Development of guidelines and position statement for
dysphagia management in schools,
c. Development of recommended basic competencies for the
SLP providing dysphagia management in schools,
d. Provision of information via The ASHA Leader, ASHA
Division Perspectives, Web forums, etc.
Given the wide range of areas of SLP involvement in the delivery of dysphagia services in the school setting, and the barriers
identified by school-based SLPs currently providing services to
students with dysphagia, the questionnaire results offer rather clear
direction with regard to next steps for the profession based on
the expressed needs of SLPs.4
DISCUSSION AND CONSIDERATIONS FOR
ETHICALLY RESPONSIVE PLANNING FOR
THE PROVISION OF SERVICES IN SCHOOL
SETTINGS TO STUDENTS WITH DYSPHAGIA
SLPs involved with school-based dysphagia services should be
familiar with ASHA’s Scope of Practice in Speech-Language
Pathology (2001b), Preferred Practice Patterns for the Profession
of Speech-Language Pathology (2004c), and Code of Ethics
(2003a). ASHA’s Scope of Practice in Speech-Language Pathology
defines areas of professional practice for, and services rendered by,
ASHA-certified SLPs. It is a statement to various “publics” (e.g.,
other professionals, consumers, regulators, educators, health care
personnel), and a reminder to SLP practitioners themselves, of what
SLPs are competent to do based on their education, training, and
experience. ASHA’s Preferred Practice Patterns for the Profession
of Speech-Language Pathology defines activities (such as #40
Swallowing and Feeding Assessment—Children, or #41 Swallowing and Feeding Intervention—Children) that fall within the
SLP scope of practice and current practice patterns that would “apply across all settings in which the procedure is performed” ( p. iii).
The setting in which SLPs work does not “define” scope of practice. In other words, there is not a “scope of practice” for schools or
hospitals or other practice settings. The setting in which SLPs work,
however, often influences how services in the professional scope
of practice are carried out. To illustrate, ASHA’s Guidelines for the
Roles and Responsibilities of the School-Based Speech-Language Pathologist (2000b), while consistent with ASHA’s scope of practice and preferred practice patterns, addresses issues, practices, and
roles that are specific to school-based SLPs; and, pertinent for this
discussion, addresses swallowing intervention in the school setting.
The ASHA Code of Ethics (2003a) undergirds professional
practice. It embraces the profession’s values and defines ethical
commitments for ASHA members, whether certified or not; ASHA
nonmembers who hold the certificate of clinical competence (CCC);
applicants for ASHA membership or certification; or clinical
fellows seeking to fulfill standards for ASHA certification.
Education and Competence
Attention to competence is a valid ethical concern in any setting
when a client presents with a disorder with which the SLP has had
little or no experience. School-based SLPs are asking for more
academic and clinical preparation as well as the development of
guidelines and competencies for the provision of school-based
management of dysphagia (Owre, 2006b). Current ASHA standards
for the CCC require demonstration of knowledge in the area of
swallowing, including supervised practicum with client populations
with various types and severities of communication and/or related
disorders (ASHA, 2006b). Those SLPs who were certified before
the implementation of current standards may have had limited,
perhaps no, preservice education and training. Current certification
standards, however, also require all holders of the CCC-SLP to
demonstrate continued professional development for maintenance
of certification. Thus, even though certified, a need exists for SLPs
to seek continuing education in dysphagia.
The ASHA Code of Ethics (2003a) repeatedly speaks to
competence on the part of the clinical service provider as well as
supervisors of staff who are SLPs:
4
The results of this questionnaire were the impetus for ASHA to form a Working Group
on Dysphagia in Schools charged with developing a new guidelines document,
Guidelines for Speech-Language Pathologists Providing Dysphagia Services in
Schools (ASHA, 2007).
Huffman & Owre: Ethical Issues in Providing Services in Schools 171
& “Individuals shall provide all services competently.”
(Principle I, Rule A)
& “Individuals shall engage in only those aspects of the
professions that are within the scope of their competence,
considering their level of education, training, and experience.”
( Principle II, Rule B)
& “Individuals shall not require or permit their professional staff
to provide services or conduct research activities that exceed
the staff member’s competence, level of education, training,
and experience.” ( Principle II, Rule C)
& “Individuals shall continue their professional development
throughout their careers.” ( Principle II, Rule C)
SLP responsibilities and roles in all settings must be responsive
to progress in medicine and technology and impact on diagnosis
and treatment. Consideration of one’s knowledge and skills and
acknowledging what one knows and does not know are critically
important for the SLP in today’s everchanging and challenging
clinical environment. This acknowledgment and associated selfreflection serve as a basis for an SLP’s professional development to
fulfill the ethical obligations of holding client welfare paramount
and continuing professional development throughout one’s career
(ASHA, 2003a). Thus, in the context of this discussion, an ethically
responsive SLP would design and execute a continuing competency
plan to develop and/or hone knowledge and skills in dysphagia
diagnosis, management, and treatment. There are continuing education opportunities and venues in this regard including academic
coursework, formal continuing education workshops, independent study, self-study, mentorships, journal study groups, clinical
exchanges, and teleseminars.
On a different note, it would be profoundly disturbing if a
practitioner were to cite lack of competence as an excuse or a screen
to hide behind in order to avoid any involvement or responsibility in
handling an unfamiliar or challenging case. The ASHA Code of
Ethics is instructive here as well:
& “Individuals shall use every resource, including referral
(emphasis added) when appropriate, to ensure that
high-quality service is provided.” (Principle I, Rule B)
& “Individuals shall not discriminate in the delivery of
professional services or the conduct of research and
scholarly activities on the basis of age, religion, national
origin, sexual orientation, or disability (emphasis added).”
(Principle I, Rule C)
ASHA’s Code of Ethics (2003a) focuses on the ethical responsibilities of individuals. However, as an employer of SLPs, a school
district also has a strong, educationally relevant, and ethical incentive to provide professional development in dysphagia. From
a pragmatic perspective, schools have an obligation to ensure that
children are safe while at school, which includes ensuring a safe
eating environment. During the course of the day, nutritious meals
(breakfast, school lunch) are available to all students. Snacks are
very much a part of the typical school day as well. For all students,
social communication skills development is connected to social
activities that involve meals and snacks in school. Schools are
already accommodating students who have food allergies, special
diet requirements, or frequency of eating requirements. Of course,
health services are considered a related service under IDEA, and
certain health and related services are reimbursable under public
and private health insurance.
By supporting and providing opportunities for continuing
education for SLPs and other key personnel, school districts are
more likely to recognize that eating and taking nourishment is a
major life function that is impaired by dysphagia and requires
accommodation during the school day. Districts are more likely
to have increased awareness of issues faced by students with
dysphagia and how their alertness, well-being, potential for learning,
and participation in the academic process is facilitated by appropriate
services. Thus, guided by the tenets of self-determination, beneficence, nonmaleficence, and justice, school districts are more likely
to develop a dysphagia management program that meets professional standards of care, satisfies legal and regulatory requirements,
involves risk management planning, and addresses the safety of
students with dysphagia.
Working on Multidisciplinary Teams
and Scope of Practice
School-based dysphagia management and treatment programs
require a team of players from within and beyond the school walls
(Arvedson & Homer, 2006). It is the team that makes decisions
balancing self-determination, beneficence, nonmaleficence, and
justice. Teamwork calls for a level of interdependence based on
the skills and knowledge that each member brings to the table.
Teamwork also calls for respect of the scope of practice and expertise of each member. Teams may include parents, nurses, dieticians,
paraprofessionals, physicians, SLPs, SLP consultants, occupational therapists, physical therapists, building principals, higher
level administrators, regular and special education teachers, transportation providers, cafeteria workers, and social workers. The
list changes as the student’s needs change.
In the quest to act on the given principles of self-determination,
beneficence, nonmaleficence, and justice, teams are faced with
challenges such as those associated with scope of practice, shared
roles, levels of expertise, cultural competence, strong opinions,
attitudes, and expectations. A skilled team leader with excellent
communication skills will promote collaboration and cooperation
among team members, resulting in utilization of the “best from
each” given their expertise and scopes of practice.
Dysphagia is part of the speech-language pathology scope of
practice (ASHA, 2001b). Therefore, in school districts around the
country, SLPs are seen as a primary provider and often the point
person in the management of dysphagia services (Arvedson &
Homer, 2006; Owre, 2006a, 2006b). Although this may be true,
scope of practice issues do arise. ASHA’s position statement and
technical report, Speech-Language Pathologists Training and
Supervising Other Professionals in the Delivery of Services to
Individuals With Swallowing and Feeding Disorders (2004e,
2004f ), reinforces the importance of multidisciplinary teams and
addresses SLPs’ scope of practice: “This statement recognizes
the importance of other professionals working with SLPs on a
multidisciplinary and interdisciplinary team to address all the needs
of the client/patient in swallowing and feeding; however the role
of the SLP is not replaceable by members of other professions”
(2004e, p. 1). These documents (2004e, 2004f ) are cautionary
about teaching and training others to perform an activity that is
clearly within the speech-language pathology scope of practice.
Speech-language pathologists (SLPs) are primary providers of
evaluation and treatment for swallowing and feeding disorders.IIt is
172 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 39 • 167–176 • April 2008
the position of the American Speech-Language-Hearing Association
that speech-language pathologists (SLPs) should not train, via
professional education courses or on-the-job training, or provide
direct clinical supervision to individuals or groups of individuals
from other professions in the delivery of evaluation and treatment for
infants, children, and adults with swallowing and feeding disorders.
(ASHA, 2004e, p. 1)
This is consistent with Principle II, Rule D of the ASHA Code
of Ethics:
Individuals shall delegate the provision of clinical services only to:
(1) persons who hold the appropriate Certificate of Clinical Competence;
(2) persons in the education or certification process who are appropriately
supervised by an individual who holds the appropriate Certificate of Clinical
Competence; or (3) assistants, technicians, or support personnel who are
adequately supervised by an individual who holds the appropriate
Certificate of Clinical Competence. (ASHA, 2003a)
However, the position statement (ASHA, 2004e) also indicates
what SLPs can do both ethically and professionally. For example,
SLPs can share information for “purposes such as teaching another
professional to screen for potential dysphagia” (ASHA, 2004e, p. 1)
or recognize signs of dysphagia in order to refer a student for evaluation by an SLP. SLPs can share information for “advancing the
scientific knowledge base across professions” (2004e, p. 1) so others
will have increased understanding of the disorder and how it is
treated. SLPs can “inservice other professionals and nonprofessionals
about the role and activities of SLPs in evaluating and treating swallowing disorders” (2004e, p. 1). SLPs can and should train family
members, caregivers, paraprofessionals, and others to use patientspecific techniques that have been developed as a result of the SLP’s
evaluation and treatment planning to help the individual with
dysphagia carry over skills outside the treatment session.
Existing Models
Concern regarding the restrictions of a school setting versus
a medical setting has been identified as a barrier to dysphagia
management in schools (Owre, 2006a, 2006b). Fortunately, there
are school-based dysphagia management programs in place that
can be replicated. The following program elements should be
considered and defined when developing a dysphagia management
program: team composition, protocols for referral, evaluation, planning, medical support, consultations, student feeding/swallowing
plans, diet prescription documentation, responsibilities of persons
involved with the student, handling emergencies, education, and
in-service training (Arvedson & Homer, 2006; Homer, 2003; Homer
& Arvedson, 2006; Homer, Bickerton, Hill, Parham, & Taylor,
2000). Overall, programs require extensive planning and support
by the school district administration in view of its overarching
responsibility relative to self-determination, beneficence, nonmaleficence, and justice. District allocation of resources such as
legal counsel is integral to program planning, procedure development,
and assurance of adherence to procedures (Arvedson & Homer 2006;
Homer & Arvedson 2006). Programs give attention to addressing
and monitoring accountability standards, risk management, and
liability in order to protect the student, the employee, and the district.
Existing dysphagia management programs have also been
presented and described as part of continuing education offerings
such as ASHA convention short courses (Arvedson, Homer, Owre,
& Amaral, 2005) and teleseminars (Homer & Arvedson, 2006).
Kurjan (2000) and Arvedson et al. (2005) provide accounts of SLP
leadership in a school district’s planning and service provision.
Finally, there are several ASHA policy documents that are
instructive (some to a greater extent than others) to the management
and treatment of dysphagia in school settings and the establishment
of school-based programs for dysphagia management (ASHA,
2000a, 2000b, 2001a, 2002a, 2002b, 2002c, 2002d, 2004a, 2004b,
2004d, 2004e, 2004f, 2005b, 2005c). Two documents are of
particular interest: Guidelines for Speech-Language Pathologists
Providing Dysphagia Services in Schools (ASHA, 2007) and
Guidelines for the Roles and Responsibilities of the School-Based
Speech-Language Pathologist (2000b). The ASHA Web site (http://
www.asha.org/members/slp/clinical/dysphagia) offers extensive
resources under topics such as pediatric dysphagia and dysphagia
practice issues, discussion via ASHA members’ forums, consumer
information, professional development products, technical assistance packets, special interest division articles (Division 13 and
Division 16 sites), The ASHA Leader articles, ASHA journal
articles, and Access Schools.
CLINICAL IMPLICATIONS
Considering this discussion on ethics issues associated with the
provision of services in school settings to students with dysphagia,
Tables 2 and 3 provide examples of ethically responsive actions
and ethically questionable actions/potentially unethical actions by
school-based SLPs. Table 2 focuses on SLPs who are knowledgeable and skilled in dysphagia. Table 3 focuses on SLPs who do not
have knowledge and skills in the area of dysphagia.
The evaluation, treatment, and management of dysphagia is a
challenging area of speech-language pathology practice regardless
of work setting. Even though schools are educating students with
medical issues that must be dealt with on a daily basis, schools are
educational institutions, not medical sites. They are under the aegis
of education administrators, boards of education, and state departments of instruction. Related service providers typically see
themselves as part of the educational institution, not the medical
setting, where the priority is on medical services and where medical
support is readily accessible.
When dealing with medically fragile students, school districts
and staff are thrust into handling the life-threatening issues that these
students face. School districts today are providing education and
related services to students with many kinds of disabilities, including
serious medical conditions. The nature of services has evolved to
the point where it is not uncommon in today’s school environment to
see a one-on-one paraprofessional or full-time nurse assigned to a
particular student; medical plans and do-not-resuscitate orders as part
of a student’s health plan; or student service teams extending far
beyond the schoolhouse walls and consisting of a variety of players
such as dieticians, physicians, and consultants.
Not all school districts employ certified SLPs, and even
where they do, not all certified SLPs are competent in dysphagia.
Nonetheless, the SLP does have professional and ethical responsibility to ensure that students receive appropriate services while
in school. A professional activity is not deemed to be “ethical” or
“unethical” based on the setting in which it is delivered. Rather,
ethical principles, including those associated with biomedical ethics
Huffman & Owre: Ethical Issues in Providing Services in Schools 173
Table 2. Suggestions for ethically responsive actions or options available to the school-based speech-language pathologist (SLP) who is knowledgeable
in the area of dysphagia management and treatment.
When the SLP has knowledge and skills in the area of dysphagiaI
ASHA Code of Ethics principle(s)
and rule(s) relative to this action
Examples of ethically responsive actions
& Be proactive and take a leadership role in your school district to develop a
plan for managing dysphagia.
ASHA Code of Ethics, Principle I, Rules A, B
& Help administrators understand the nature of dysphagia and the gravity of potential
problems associated with swallowing and feeding disorders.
ASHA Code of Ethics, Principle I, Rules A, B
& Work to create a district dysphagia team. ASHA Code of Ethics, Principle I, Rules A, B
& Work with school administrators to advocate for workload accommodations
when managing students with swallowing and feeding disorders.
ASHA Code of Ethics, Principle I, Rules A, B
& Facilitate the training of SLPs in the district who may not be competent in dysphagia. ASHA Code of Ethics, Principle I, Rules A, B
& Work with the dysphagia team to develop procedures (e.g., referral, evaluation,
setting up special diets, and handling emergency situations).
ASHA Code of Ethics, Principle I, Rules A, B;
Principle IV, Rule G.
& Develop appropriate forms and checklists for procedures, releases or other activities. ASHA Code of Ethics, Principle I, Rules A, B
& Provide in-service to school staff about dysphagia (what it is, risk for,
signs and symptoms, complications of, the need for a safe eating environment).
ASHA Code of Ethics, Principle I, Rules A, B
& Work with the dysphagia team in developing and executing the treatment plan; train
in-school caregivers.
ASHA Code of Ethics, Principle I, Rules A, B;
Principle IV, Rule G.
& Engage in continuing education. ASHA Code of Ethics, Principle II, Rule C
& Engage in interdisciplinary consultation; facilitate and be involved in monitoring/observing
various procedures.
ASHA Code of Ethics, Principle I, Rules A, B
& Consider the basic ethical principles of self-determination, beneficence, nonmaleficence,
and justice in making decisions regarding the student.
ASHA Code of Ethics, Principle of Ethics I
& Address issues with administrators that may preclude your involvement in a dysphagia
management program so alternatives can be explored.
ASHA Code of Ethics, Principle of Ethics I;
Principle I, Rule A; Principle II, Rule B
Examples of ethically questionable/ potentially unethical actions
& Act “solo” without regard for team planning and expertise of team members. ASHA Code of Ethics, Principle of Ethics I;
Principle I, Rule B
& Refuse to be involved (client abandonment). ASHA Code of Ethics, Principle of Ethics I
& Train/teach other professionals to do what is in the SLP scope of practice (evaluation,
developing feeding/eating treatment plans, supervising dysphagia treatment).
ASHA Code of Ethics, Principle II Rule C
Table 3. Ethically responsive actions or options available to the school-based SLP who is not knowledgeable in the area of dysphagia management
and treatment.
When the SLP does not have knowledge and skills in the area of dysphagiaI
ASHA Code of Ethics Principle(s)
and Rule(s) relative to this action
Examples of ethically responsive actions
& Give advance warning to your district of areas of practice where you have limited
or no knowledge and competency. Explore strategies for acquisition of competency.
ASHA Code of Ethics, Principle II. Rules B, C
& Work with the district to arrange for a consultant SLP who is experienced in dysphagia
to be involved. Continue to be involved on the student’s team and in team planning.
ASHA Code of Ethics, Principle I, Rule B
& Advocate for the establishment of a dysphagia management program and be involved
in its planning. Use available resources to determine what questions to ask and what
needs to be addressed.
ASHA Code of Ethics, Principle I, Rule B
& Facilitate and advocate for in-service of school staff. ASHA Code of Ethics, Principle I, Rule B
& Research and study available resources, such as ASHA position statements relating
to dysphagia, case scenarios, preferred practice patterns, and SLP scope of practice.
ASHA Code of Ethics, Principle I, Rule B
& Engage in continuing education. ASHA Code of Ethics, Principle II, Rule C
& Acquire and/or enhance clinical skills. ASHA Code of Ethics, Principle II, Rule C
Examples of ethically questionable/potentially unethical actions
& Conduct evaluation and treatment without the requisite knowledge and skill. ASHA Code of Ethics, Principle I, Rule A;
Principle II, Rule B
& Avoid any involvement. ASHA Code of Ethics, Principle I, Rules B, C
& Refuse to use resources available such as outside consultants. ASHA Code of Ethics, Principle I, Rule B
& Refuse to participate on the school team. ASHA Code of Ethics, Principle I, Rule B
& Refuse to engage in professional development to improve skills. ASHA Code of Ethics, Principle II, Rule C
& Refuse to refer. ASHA Code of Ethics, Principle I, Rule B
174 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 39 • 167–176 • April 2008
and professional ethics, must be considered and applied in the
practice of speech-language pathology wherever it takes place. By
virtue of current certification standards (ASHA, 2006b), scope of
practice (ASHA, 2001b), and affirmative ethical obligations (ASHA,
2003a), the SLP is frequently the leader that the school district relies
on to develop and oversee safe eating programs for students with
dysphagia. Therefore, it is incumbent on the SLP to promulgate, by
advocacy and example, ethically responsible practices.
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Received March 1, 2006
Revision received October 30, 2006
Accepted April 2, 2007
DOI: 10.1044/0161-1461(2008/017)
Contact author: Nancy P. Huffman, 590 Stearns Road, Churchville,
NY 14428. E-mail: [email protected].
176 LANGUAGE, SPEECH, AND HEARING SERVICES IN SCHOOLS • Vol. 39 • 167–176 • April 2008