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Question: I’m a private-practice, ASHA-certified speech-language pathologist who is three months pregnant. I have been treating a child in her home, but I want to discontinue services to the child because no one in the family has been vaccinated for the measles. Can I do so or would it be considered client abandonment?

More than 1,150 measles cases occurred in more than 30 states in the U.S. in 2019, and most of those cases involved unvaccinated people, according to the U.S. Centers for Disease Control and Prevention (CDC). Measles is highly contagious and there is no cure. Measles in pregnant women may have serious consequences, including low-birth weight and miscarriage, reports the American College of Obstetricians and Gynecologists (ACOG).

Your query triggers several ethical considerations specific to the circumstances of your situation.

As always, the welfare of your client is paramount. However, the ethical analysis in this situation doesn’t stop there.

Could it be considered client abandonment?

Discussion about vaccines can generate controversy given the strongly-held beliefs triggered by the topic. We are analyzing the specific facts and circumstances of your situation only: The below analysis should not be construed as general guidance, because different facts may lead to different analysis under the Code of Ethics.

First and foremost, as a CCC-SLP you must abide by the ASHA Code of Ethics. Accordingly, you have an ethical obligation not to abandon a client; but this obligation isn’t absolute. ASHA’s Issues in Ethics statement on client abandonment states, “no clinician is ever ethically required to work . . . in physical danger in order to offer client care.”

The risk of you being exposed to measles while pregnant and providing services to a nonvaccinated child in her home could be viewed as posing such a “physical danger,” and so your withdrawal from treating this client in the home probably would not be considered client abandonment by the Board of Ethics (Code of Ethics Principle I, Rule T). However, our ethical exploration continues about ways that may exist to maintain the relationship with your client.

If your state provides for telepractice, perhaps you could establish a remote treatment plan that would enable you to continue working with your client and her family. Alternatively, maybe you could provide the family with home exercises to undertake to bridge the gap of in-person treatment during your pregnancy. If neither of those options is viable for some reason, then you should work with your employer and/or colleagues to find another SLP with the skills to provide similar services, but for whom potential exposure to measles poses less of a medical risk—during the hiatus of your pregnancy.

Is it considered religious discrimination?

It depends. Your ethical responsibility to clients involves not discriminating because of their religious beliefs. Your decision to stop treatment might potentially trigger a Board of Ethics complaint from the child’s family based on religious discrimination, if the family belongs to a religious group expressly prohibiting medical intervention, such as vaccines. Check whether your state public health law—including recently passed legislation—allows religious, philosophical, or “personal belief” exemptions to measles vaccinations. If you follow your employer’s health and safety policies and/or state health laws, there’s much less concern that your reason for ceasing treatment of the family might be perceived as religious discrimination (Code of Ethics Principle I, Rule C). In addition, some children are “medically fragile,” usually because of a weakened immune system, and so with a doctor’s note are often exempt from state vaccination laws.

Protect your health and safety

If you are working in a setting other than your own private practice, your employer and/or your collective-bargaining agreement might include a policy to protect staff health and safety, including infection control. If not, consider doing the following:

Work to develop health and safety policies to facilitate the provision of quality professional service in your workplace. (See ASHA guidance on quality indicators for professional service programs in audiology and speech-language pathology.)

Contact your state department of health—most provide guidance for private and public settings on children’s vaccinations against certain infectious diseases.

Check for applicable regulations under your state occupational licensing law for audiologists and SLPs, as well as the state’s occupational health and safety code.

Other professions face similar ethical dilemmas. Ethical guidance in 2019 from two other health-related professions—pediatricians and dentists—concluded that, while the decision should never be made lightly, declining to treat families who refuse vaccinations is “not per se unethical, so long as necessary precautions are taken as may be dictated in your state, and patient abandonment does not occur.”

Donna R. Euben, Esq., is ASHA director of ethics. deuben@asha.org.

Legal Disclaimer: The information provided in this posting is for informational and educational purposes only. Nothing in this document should be construed as legal advice, and your use of the legal information provided is not a substitute for legal advice. ASHA has no knowledge of the specific or unique circumstances under which such information may be used by you. Your use of this posting specifically or ASHA’s website generally does not create an attorney–client relationship between you and ASHA, or between you and any of ASHA’s employees or representatives. Each state has its own laws and they can vary widely, so you should obtain advice from any attorney regarding answers about your state laws.

