20Q: ASHA Code of Ethics - What Do I Need to Know?

From the Desk of Ann Kummer

From the desk of Ann Kummer…

If you are a member of the American Speech, Language, and Hearing Association (ASHA) and hold a Certificate of Clinical Competence (CCC) in either audiology and/or speech-language pathology, you should know that out of the 30 required professional development hours needed during each 3-year maintenance interval, at least one hour must be in the area of ethics. So, why is training in ethics so important that ASHA requires it to be done during each interval period? It’s because this training serves to inform and guide ASHA professionals regarding ethical decision-making and professional conduct. Therefore, this training is vital to the maintenance of the highest ethical standards and integrity of our professions.

The tenets of ethical conduct are described in the ASHA Code of Ethics. This code (which includes Principles and Rules) “establishes expectations for our scientific and clinical practice" and is “intended to ensure the welfare of the consumer and to protect the reputation and integrity of the professions” (https://www.asha.org/code-of-ethics/).

Of course, most professionals aim to be ethical in all of their professional endeavors. However, there are some who will make an ethical mistake and others who will make an ethical “on purpose.” When there is a breach of ethics, complaints can be sent to the ASHA Board of Ethics for adjudication.   

Most members are not aware of the good work that the ASHA Board of Ethics does for our professions. Therefore, I asked my friend, Dr. Wayne Foster, to write this article on the role of this dedicated group of volunteers in mitigating ethical breaches.

By introduction, Wayne A. Foster, Ph.D., CCC-A/SLP is retired from the public schools in North Carolina and currently works with a private pediatric practice in Greensboro, NC. He is the audiologist and research coordinator for the practice. He is a Fellow of the American Speech, Language and Hearing Association and is an Honors recipient for the North Carolina Speech, Hearing, and Language Association. He is a current member of the ASHA Board of Ethics and chairs the Ethics Education Sub-Committee.

This article will provide some details on the function of the ASHA Board of Ethics and identify the essential elements of the ASHA Code of Ethics. Tips on how to integrate the Code into daily practice are included.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors

Contributing Editor

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: ASHA Code of Ethics - What Do I Need to Know?

Learning Outcomes

After this course, readers will be able to: 

• Describe the basic structure and function of the ASHA Board of Ethics 
• List and describe the Principles of the ASHA Code of Ethics
• Describe how select Rules of the Code of Ethics apply to the practice of audiology and speech-language pathology

Wayne A. Foster, PhD,
CCC-A/SLP

1. I have read and try to abide by the ASHA Code of Ethics. What is the composition of the ASHA Board of Ethics?

The ASHA Board of Ethics (BOE) is comprised of 17 members, including two public members and a minimum of six ASHA-certified audiologists and six ASHA-certified speech-language pathologists.  ASHA’s Senior Director of Ethics is also an ex-officio member of the BOE.

The BOE functions as a semi-autonomous body within the ASHA framework and meets at least three times per year to adjudicate complaints. Each member of the BOE serves a four-year term. In the fourth year of their term, members transition to the Ethics Education Subcommittee (EES) which is responsible for developing educational programs and materials on ethics. The four-year-terms are staggered to ensure continuity and maintain institutional knowledge from year to year.

2. Times change! How does the ASHA Code of Ethics stay up-to-date and reflective of the times?

The current Code of Ethics (the “Code”) was last updated in 2016. The EES is charged with systematically reviewing and updating the Code every (approximately) five years. In fact, an update is currently underway! A select panel of experts – all experienced ASHA certified members – was asked to participate in this review. It is anticipated that there will be a fully peer-reviewed, updated version of the Code in 2023.

Updating the Code is a complex project. Adding elements to the document to address every potential ethical dilemma is not practical and would, after several iterations, result in a lengthy and unwieldy document. The key is to make the Code general and flexible enough to address any potential ethical problem. Should there be specific sections addressing telepractice or social media, for example? The consensus is that specifically addressing every and any area is untenable. The goal is to strike the right balance and over the years ASHA review panels have done a remarkable job keeping the document relevant and appropriately concise.  The Code can be found at: https://www.asha.org/policy/ET2016-00342/

3. Is there an ASHA Ethics Police Force? I’m being facetious, but how does the BOE learn of potential violations?

The BOE typically has around a hundred pending complaints scheduled for adjudication each year. With almost 211,000 members of ASHA, this represents approximately .002 percent of its membership. Thus, there are always pending cases, but this number reflects potential violations by an exceedingly small percentage of ASHA membership.

That being said, the BOE does not actively search for individuals who may have violated the Code. There are three basic pathways for a complaint to reach the BOE. First, anyone may make a complaint against an ASHA member, applicant, or certificate holder. The BOE receives complaints from co-workers, parents, clients, owners of private practices, and a wide range of others. These complaints cannot be anonymous.

The second avenue is for the BOE to initiate a complaint after receiving notice of a disciplinary action from a state licensure or certification board.  Many state licensure boards report these violations directly to ASHA or publicly post them on their official website.  The BOE may also institute a complaint if it is notified that a member/applicant or certificate holder has been convicted of, or pled guilty or nolo contendere to, a crime.

Finally, under Principle IV, Rules S and T of the Code, applicants and certificate holders are required to self-report certain disciplinary actions and crimes to ASHA Standards and Ethics

4. I had forgotten about the self-reporting requirement. Can you say more about that?

Certainly. The final two rules in the Code describe the self-reporting process. Principle IV, Rule S states that “individuals who have been convicted; been found guilty; or entered a plea of guilty or nolo contendere to (1) any misdemeanor involving dishonest, physical harm – or the threat of physical harm – to the person or property of another, or (2) any felony” must self-report by notifying ASHA Standards and Ethics within 30 days of the conviction, plea or finding of guilt.  Additionally, such individual must include a copy of the court record or docket entry with the self-report.

Principle IV, Rule T states that “individuals who have been publicly sanctioned or denied license or a professional credential by any professional association, professional licensing authority or board, or other professional regulatory body” shall self-report to ASHA Standards and Ethics. This is also to be done within 30 days. Individuals should include a copy of the final order with the self-report.

5. Rules S and T of Principle IV suggest that an individual could be sanctioned by both the state licensure board, for example, and the ASHA BOE. Is that correct and is that fair?

When an individual obtains state licensure or certification, they are obligating themselves to the professional standards of that licensing or certifying body. ASHA members and certificate holders likewise obligate themselves to the professional standards of the Association, i.e., the standards identified in the Code.  Therefore, if a person is licensed and an ASHA member, applicant, or certificate holder, they have agreed to abide by two separate requirements - the laws of their state, as well as the Code. 

Individuals occasionally claim that this constitutes double jeopardy. That is not the case.  The individual has simply agreed to adhere to the separate rules of two unrelated entities.  Therefore, both bodies must review the matter and decide whether an individual has violated their applicable regulations/code.

There is an intersection between the Code and state licensure. This is presented in Principle IV, Rule R: “Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice, research ethics, and the responsible conduct of research.” This means that if an ASHA member, applicant, or certificate holder is found to have not complied with those laws they have, by definition, violated the Code. It would be very possible, if not likely, that they would incur a sanction by both bodies for the same conduct.

It should also be noted that it is possible to engage in a behavior that results in a violation and sanction by one but not the other body.

6. Can you give an example of that?

ASHA’s Code provisions are frequently different from the ethical rules set forth in state licensing regulations.  For instance, ASHA’s Code requires individuals to properly reference sources when using another person’s ideas, research, and other material. The State of Maryland does not have a similar provision in its regulations.  Therefore, if a person does not properly cite sources in an article they write, they could violate the Code, but may not violate Maryland law.

7. You have given examples of rules within the ASHA Code of Ethics. How is the Code organized? Can you make sense of the structure of the Code?

The Code is divided into three main sections. The Preamble provides a brief introduction and rationale for the Code. The Terminology section provides definitions for important terms utilized in the document. The remainder of the document is comprised of the four Principles and their associated Rules.

The Principles identify the four major areas of ethical responsibility. Under each Principle there are a series of rules that clarify and specify an individual’s responsibilities.

8. Would you summarize the four Principles?

Principle I has to do with an individual’s responsibility to the persons that they serve professionally. There are twenty rules under Principle I.  Principle II has to do with an individual’s responsibility to maintain the highest level of professional competence and performance. This principle has eight rules.

The third Principle focuses on an individual’s responsibility to the public when advocating for unmet communication and swallowing needs. There are seven rules under this Principle. An individual’s responsibility to uphold the dignity and autonomy of the profession is the subject of Principle IV. It is an individual’s ethical responsibility to maintain collaborative and harmonious inter- and intra-professional relationships and accept the profession’s self-imposed standards. There are twenty rules associated with Principle IV.

9. What is a good example of the relationship between a Principle and the associated rules?

Principle I, as noted previously, relates to an individual’s responsibility to the public. Here is the full wording of that principle: “Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or who are participants in research and scholarly activities, and they shall treat animals involved in research in a humane manner.”

This identifies the area of ethical responsibility. Let us look at a couple of the associated rules. Here is Rule A:

“Individuals shall not discriminate in the delivery of professional services or in the conduct of research and scholarly activities on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, or dialect.”

This adds a great deal of specificity and depth to the Principle. Here is Rule B:

“Individuals shall not misrepresent the credentials of aides, assistants, technicians, support personnel, students, research interns, Clinical Fellows, or any others under their supervision, and they shall inform those they serve professionally of the name, role, and professional credentials of persons providing the services.”

10. How is the determination made as to which Principle(s) and Rule(s) have been violated?

The individual or entity making a complaint against an ASHA member, applicant, or certificate holder is referred to as the “Complainant.” When a Complainant completes an ASHA Ethics Complaint Form, they describe the behavior that is believed to be in violation of the Code and provide supporting documentation. The Complainant will also identify the Principle(s) and Rule(s) that are thought to have been violated.

The person who is the subject of the complaint is referred to as the “Respondent.”  The Respondent will have an opportunity to respond to the allegations set forth in the complaint, and state why certain Code provisions have not been violated.

The case is then reviewed by a panel of BOE members at an “Initial Consideration Hearing”. The panel reviews and discusses relevant Code violations, and determines, based on the information provided by the Complainant and the Respondent, if any of these Code provisions were violated.    

11. Speaking of sanctions, what are the sanctions for a violation of the ASHA Code of Ethics?

There are four potential sanctions. The first is a “reprimand.” This is a formal but private sanction. A “censure” is a second type of sanction. It is a formal and public sanction. This (and the next two sanctions) are published in the ASHA Leader. The BOE may suspend an individual’s certification. “Suspension of Certification” is for a period determined by the BOE. The final sanction is “revocation.” Revocation may be permanent or for a period determined by the BOE. At the end of the revocation period, If any, an individual may petition the BOE for reinstatement.  Any petition must be approved by a two-thirds vote of the BOE.

12. What if I do not agree with the findings of the BOE? Is there an opportunity to appeal the finding?

There are three levels of adjudication available. There are significant differences between the three levels. After a complaint has been made, the BOE will schedule an Initial Consideration Hearing (ICH). Neither the Complainant nor Respondent are present at this hearing. At an ICH, the Board reviews all the materials that have been provided, including the complaint materials filed by the Complainant and the response by the Respondent. In their response, the Respondent may provide as much information as they choose to clarify and justify their position in their response.

The BOE takes as much time as necessary to assess the situation and decide carefully and fully. If the BOE decides to sanction the Respondent, the Respondent is informed of the determination and given thirty (30) days to request a Further Consideration Hearing (FCH). An FCH is fundamentally different from the ICH in two important ways. First, the Respondent is given the opportunity to provide a formal written defense or brief.  Second, an FCH is an in-person hearing. Therefore, the Respondent (and their attorney, if any) may be present. (This can be live or by remote video or audio link.)

If the Respondent does not accept the findings of the FCH, they may request an appeal.  If the appeal is granted, the case is referred to as an “Ethics Appeal Panel” (EAP) The EAP is made up of one current member of the ASHA Board of Directors, one former member of the BOE, and one current member of the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC). The EAP is charged with reviewing what took place during the ICH and FCH to determine if: (1) the BOE’s processes were properly followed; and (2) if the resulting decision was arbitrary, capricious, or without an evidentiary basis. If the EAP finds that the process was faithfully followed, the findings from the FCH stand. If not, the matter is remanded to the BOE, and another Further Consideration Hearing is held.

13. Can you describe how an FCH could have a different finding from the ICH? Is this a common occurrence?

Further Consideration Hearings are not uncommon; typically, there are two to four of these scheduled at each BOE meeting. Remember, the Respondent is given the option to provide additional information and attend the FCH in person (with or without an attorney). In some cases, Respondents do not provide sufficient information during the ICH for BOE members to fully understand what occurred. Admittedly, there are occasions when the BOE members suspect that some information is missing and that the “picture” of the situation is not complete. Since the BOE is not allowed to actively investigate a case, it must rely upon the information available and hope that the Respondent will request an FCH and clarify what happened when appropriate. It cannot be stressed enough that Respondents should take any complaint seriously and endeavor to supply all necessary information for a proper decision to be made.

There is no incentive for the BOE to come to any other determination than one that best represents the facts of the case. Sometimes it takes an in-person hearing for all necessary information to come to light. Therefore, it is not uncommon for the BOE to change its findings and sanctions after conducting an FCH.

14. How would you describe a BOE meeting? It seems like it could be quite dramatic, especially at an FCH?

This is a question that I am happy to answer. Members of the BOE, as well as the ASHA Standards and Ethics staff, take their responsibilities very seriously. All members sign confidentiality and conflict of interest agreements and are trained carefully on the adjudication process. The meetings are quite formal, and the rules of order are followed very carefully. You would, I am certain, be proud of the work of your fellow ASHA members serving on the BOE.

Each case is approached with the understanding that the Respondent is a peer with a lot riding on the outcome of the case. It is essential that the case information is carefully reviewed before the meeting and, again, at the meeting so that there is a full appreciation of the evidence, the timeline of events, and the comparison between the complaint material and the Respondent’s response to that complaint.  

There exist differences between an ICH and an FCH. The major difference is that during an FCH the Respondent is present and can be represented by legal counsel. At the initiation of the FCH meeting introductions are made and the Respondent is given the opportunity to make an opening statement. A lead member of the BOE is charged with presenting a series of questions to help clarify the details and nuances of the situation. These meetings are very proper but do allow for a great deal of give and take between the parties. Once the meeting is concluded the BOE members engage in a comprehensive discussion and make their determinations.

At every point along the adjudication pathway, a high degree of formality is maintained so that all the BOE policies and procedures are followed carefully, thoughtfully, and respectfully. Additionally, the BOE members are supported by ASHA’s Senior Director of Ethics, who is an attorney with twenty years of experience in certification disciplinary proceedings. ASHA’s Senior Director of Ethics is present at all ICH, FCH and Board Appeal sessions. While many cases are intense these cases are conducted with an amazing level of professionalism on the part of all involved.

15. Are there patterns in the types of (potential) violations handled by the BOE?

Each case really is different. However, there are some typical situations. In nearly every BOE meeting there are several cases where the respondent did not self-report a sanction issued by their state licensure/certification board (see Question 4). Probably the most common state-level violation is unlicensed practice. Principle IV, Rule R states that “Individuals shall comply with local, state, and federal laws and regulations applicable to professional practice...” Thus, if an individual practices without a license, even for a short period of time, then they have failed to comply with Rule R.

Unfortunately, another common problem has to do with fraudulent billing and documentation. For a variety of reasons some clinicians bill (and document) for services not rendered. Periodically this is simply fraud. However, in a great many cases, the clinician is experiencing a time of stress and makes poor decisions. It is, thankfully, relatively rare that fraudulent billing emanates from a well-organized, purposeful scheme. But it does occur.

16. Can you say a few words about ethics and social media?

Social media is a difficult topic to sum up in just a few words.  Ultimately social media is just a highly effective way to distribute information.  Accordingly, it can create a host of ethical issues, involving confidentiality, plagiarism, deceptive marketing, defamation, misrepresentation, and copyright infringement to name a few.  Instead of discussing all of these issues here, I would recommend reading a document produced by the BOE that provides guidance on the use of social media. The link to that document is: https://www.asha.org/Practice/ethics/Ethical-Use-of-Social-Media/

17. Are there other documents available to address specific areas of the Code such as the one cited in the previous question?

Yes. One of the charges of the EES is to generate “Issues in Ethics Statements (IES)” on important topics. There are more than 20 of these currently available on topics including client abandonment, confidentiality, and supervision. These are purposefully written to clarify the interpretation of the Code and provide information on how to avoid ethical dilemmas in each area in a format that is not complex, highly technical, or lengthy. The entire IES library can be found at: https://www.asha.org/practice/ethics/ethics_issues_index/

18. Can you clarify the American Speech, Hearing and Language Association (ASHA) rule on continuing education for ethics?

Thirty hours of continuing education are required to maintain ASHA certification during each three-year certification cycle. At least one of those hours must be in ethics. The ethics requirement became effective on January 1, 2020.

19. Do audiology and speech-language pathology assistants follow the Code of Ethics?

ASHA-certified audiology and speech-language pathology assistants must abide by the ASHA Code of Conduct. This Code went into effect on June 1, 2020.  It is organized much like the Code of Ethics with a Preamble, terminology section, and Principles (with the associated Rules). The Code of Conduct has three principles. The ASHA Code of Conduct can be found at: https://www.asha.org/policy/Assistants-Code-of-Conduct/

20. Is there a general piece of advice you would like to add to this discussion?

There is a line in the Preamble to the Code that resonates with me. It reflects the duality of having a professional code of ethics.  Here is the sentence: “The Code is partly obligatory and disciplinary and partly aspirational and descriptive in that it defines the professional’s role.”

Too often, I think, we focus on the first part of that sentence. There is a concern that we might do something wrong, inadvertently violate the Code, and “have the book thrown at us.” Perhaps it sounds odd to think of a code of ethics as being aspirational. Yet, if one has a clear understanding of the Principles, it is easy to recognize that the Code defines a thoughtful, mindful, organized, and safe professional approach. The Code does not place boundaries, highly regulate, or restrict innovation. It does, however, inform us on how to do those things the right way. Therefore, it is my recommendation that we refer to our Code on a regular basis and seek to integrate it into our professional life – aspirationally.

Acknowledgment: A special thank you to Katie Meyer, Esq., Senior Director of Ethics at the American Speech, Language and Hearing Association (ASHA) for her technical assistance in the writing of this article.