Ethical Consent Considerations

Published in the May 2025 issue of the ISHA Voice.

By Lea Rose Markham, co-chair of the Medical Practice Issues Committee           

Ethical practice is fundamental to high-quality healthcare, and procedures, such as Flexible Endoscopic Evaluation of Swallowing (FEES), are no exception. Consent is a critical aspect of informed patient care—not a one-time formality, but an ongoing process of communication grounded in patient autonomy, shared decision-making, and trust. In all exams, especially FEES, which may be considered more "invasive", speech-language pathologists have a heightened responsibility to protect vulnerable populations, including children, individuals with communication disorders, individuals with cognitive impairments, and those with intellectual disabilities (Checklin, 2022). Extra care is often necessary to ensure that consent is both informed and voluntary.

Consent can take many forms—verbal, written, implied, informed—but regardless of type, it must meet ethical and legal standards as defined by institutional, state, and national policy. Informed consent involves explaining the procedure, outlining risks and benefits, discussing alternatives, and confirming that the decision is made without coercion. Some researchers have called for written informed consent for FEES due to potential risks (Nacci, 2008). Hospitals in select areas in the United States appear to vary in their policies, often relying on a mix of verbal and written approaches, though there are not any formal guidelines. Neither the American Speech-Language-Hearing Association nor the Illinois Practice Act for SLPs offers clear guidance on what type of consent is required. Aligning clinical practice with these frameworks—and considering guidance from the Centers for Medicare & Medicaid Services—can help ensure clinicians maintain high standards of care, especially when performing procedures that can significantly impact patient outcomes. 

Challenges arise when patients have compromised decisional capacity, which is common in many SLP practice settings. When capacity is unclear, a physician must assess the patient’s ability to understand, appreciate, and reason through medical decisions (Bari, 2024). Engaging a surrogate decision-maker may be required when a patient is deemed to not have decisional capacity. Close coordination among SLPs, physicians, and families is essential to navigate these situations ethically and efficiently.

Consent processes must also account for language barriers, health literacy, and family dynamics. In acute care, where patients may urgently require oral medications for seizures or hydration post-surgery, consent cannot be overlooked. Urgency of care must still be balanced with the obligation to inform and involve the patient or their legal representative. Clinicians should be prepared to document consent appropriately, consult with medical providers who are determining capacity, and at minimum assist medical teams, patients and families through the decision-making process. Recognizing that decisional capacity can fluctuate—particularly in medically complex patients—underscores the need to continually reassess and respect patient preferences.

In practice, clinicians must ask not only whether consent has been obtained, but how and from whom. For patients lacking capacity, substituted or advanced consent—typically involving a family member or legal guardian—may be required. It is not always clear who, SLP alone or in conjunction with a physician, holds responsibility for obtaining consent. This reinforces the importance of clarity and collaboration within an institution and interdisciplinary discussion amongst SLPs in various levels of care. Some may say that the clinician’s duty extends beyond technical explanation to ensuring that patients or surrogates understand the full implications of the procedure. Others may state that the patient's physician must also take responsibility in the consent process for FEES. A commitment to determining if consent is required and pursuing proper consent procedures are followed by ethical codes and institutional policy. This works to protect both patient rights and clinical integrity.

Ethical consent practices reflect a deep commitment to quality patient-centered care (Bernat, 2021). In treating consent as an evolving dialogue rather than a transactional event, clinicians can build stronger therapeutic relationships, empower patients in their own care, improve interdisciplinary collaboration, and uphold the dignity of individuals across all ages and abilities. In the realm of FEES, these principles are not just ideals, they should be considered essential standards of practice.

References

Bari, B. A., & Beach, S. R. (2024). Evaluating capacity: Appelbaum’s framework interpreted diagrammatically. Journal of the Academy of Consultation-Liaison Psychiatry. https://pmc.ncbi.nlm.nih.gov/articles/PMC10922513/

Bernat, J. L., & McQuillen, M. P. (2021, April). On shared decision-making and informed consent. Neurology. Clinical practice. https://pmc.ncbi.nlm.nih.gov/articles/PMC8032407/

Checklin, M., Dahl, T. Tomolo, G., (2022). Feasibility and safety of fiberoptic endoscopic evaluation of swallowing in people with disorder of consciousness: A systematic review. Dysphagia. https://pubmed.ncbi.nlm.nih.gov/34142244/

Nacci, A., Ursino, F., La Vela, R., Matteucci, F., Mallardi, V., & Fattori, B. Fiberoptic endoscopic evaluation of swallowing (FEES): proposal for informed consent. (2008, August, 28). Official Journal of the Italian Hospital Otology Association. 206-211. https://pmc.ncbi.nlm.nih.gov/articles/PMC2644994/