a peer reviewed article on special education professional ethical principles

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Ethical Principles and Practice Standards

Special Education Professional Ethical Principles

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Professional special educators are guided by the Council for Exceptional Children (CEC) professional ethical principles, practice standards, and professional policies in ways that respect the diverse characteristics and needs of individuals with exceptionalities and their families. They are committed to upholding and advancing the following principles:

• Maintaining challenging expectations for individuals with exceptionalities to develop the highest possible learning outcomes and quality of life potential in ways that respect their dignity, culture, language, and background.
• Maintaining a high level of professional competence and integrity and exercising professional judgment to benefit individuals with exceptionalities and their families.
• Promoting meaningful and inclusive participation of individuals with exceptionalities in their schools and communities.
• Practicing collegially with others who are providing services to individuals with exceptionalities.
• Developing relationships with families based on mutual respect and actively involving families and individuals with exceptionalities in educational decision making.
• Using evidence, instructional data, research, and professional knowledge to inform practice.
• Protecting and supporting the physical and psychological safety of individuals with exceptionalities.
• Neither engaging in nor tolerating any practice that harms individuals with exceptionalities.
• Practicing within the professional ethics, standards, and policies of CEC; upholding laws, regulations, and policies that influence professional practice; and advocating improvements in the laws, regulations, and policies.
• Advocating for professional conditions and resources that will improve learning outcomes of individuals with exceptionalities.
• Engaging in the improvement of the profession through active participation in professional organizations.
• Participating in the growth and dissemination of professional knowledge and skills.

Translations

CEC Ethics in Arabic CEC Ethics in English CEC Ethics in Greek CEC Ethics in Korean CEC Ethics in Russian CEC Ethics in Spanish CEC Ethics in Traditional Chinese

Translations coordinated by Alice Farling on behalf of DISES.

Special Education Standards for Professional Practice

• Systematically individualize instructional variables to maximize the learning outcomes of individuals with exceptionalities.
• Identify and use evidence-based practices that are appropriate to their professional preparation and are most effective in meeting the individual needs of individuals with exceptionalities.
• Use periodic assessments to accurately measure the learning progress of individuals with exceptionalities, and individualize instruction variables in response to assessment results.
• Create safe, effective, and culturally responsive learning environments which contribute to fulfillment of needs, stimulation of learning, and realization of positive self-concepts.
• Participate in the selection and use of effective and culturally responsive instructional materials, equipment, supplies, and other resources appropriate to their professional roles.
• Use culturally and linguistically appropriate assessment procedures that accurately measure what is intended to be measured, and do not discriminate against individuals with exceptional or culturally diverse learning needs.
• Only use behavior change practices that are evidence-based, appropriate to their preparation, and which respect the culture, dignity, and basic human rights of individuals with exceptionalities.
• Support the use of positive behavior supports and conform to local policies relating to the application of disciplinary methods and behavior change procedures, except when the policies require their participation in corporal punishment.
• Refrain from using aversive techniques unless the target of the behavior change is vital, repeated trials of more positive and less restrictive methods have failed, and only after appropriate consultation with parents and appropriate agency officials.
• Do not engage in the corporal punishment of individuals with exceptionalities.
• Report instances of unprofessional or unethical practice to the appropriate supervisor.
• Recommend special education services necessary for an individual with an exceptional learning need to receive an appropriate education.
• Represent themselves in an accurate, ethical, and legal manner with regard to their own knowledge and expertise when seeking employment.
• Ensure that persons who practice or represent themselves as special education teachers, administrators, and providers of related services are qualified by professional credential.
• Practice within their professional knowledge and skills and seek appropriate external support and consultation whenever needed.
• Provide notice consistent with local education agency policies and contracts when intending to leave employment.
• Adhere to the contracts and terms of appointment, or provide the appropriate supervisor notice of professionally untenable conditions and intent to terminate such employment, if necessary.
• Advocate for appropriate and supportive teaching and learning conditions.
• Advocate for sufficient personnel resources so that unavailability of substitute teachers or support personnel, including paraeducators, does not result in the denial of special education services.
• Seek professional assistance in instances where personal problems interfere with job performance.
• Ensure that public statements made by professionals as individuals are not construed to represent official policy statements of an agency.
• Objectively document and report inadequacies in resources to their supervisors and/or administrators and suggest appropriate corrective action(s).
• Respond objectively and non-discriminatively when evaluating applicants for employment including grievance procedures.
• Resolve professional problems within the workplace using established procedures.
• Seek clear written communication of their duties and responsibilities, including those that are prescribed as conditions of employment.
• Expect that responsibilities will be communicated to and respected by colleagues, and work to ensure this understanding and respect.
• Promote educational quality and actively participate in the planning, policy development, management, and evaluation of special education programs and the general education program.
• Expect adequate supervision of and support for special education professionals and programs provided by qualified special education professionals.
• Expect clear lines of responsibility and accountability in the administration and supervision of special education professionals
• Maintain a personalized professional development plan designed to advance their knowledge and skills, including cultural competence, systematically in order to maintain a high level of competence.
• Maintain current knowledge of procedures, policies, and laws relevant to practice.
• Engage in the objective and systematic evaluation of themselves, colleagues, services, and programs for the purpose of continuous improvement of professional performance.
• Advocate that the employing agency provide adequate resources for effective school-wide professional development as well as individual professional development plans.
• Participate in systematic supervised field experiences for candidates in preparation programs.
• Participate as mentors to other special educators, as appropriate.
• Recognize and respect the skill and expertise of professional colleagues from other disciplines as well as from colleagues in their own disciplines.
• Strive to develop positive and respectful attitudes among professional colleagues and the public toward persons with exceptional learning needs.
• Collaborate with colleagues from other agencies to improve services and outcomes for individuals with exceptionalities.
• Collaborate with both general and special education professional colleagues as well as other personnel serving individuals with exceptionalities to improve outcomes for individuals with exceptionalities.
• Intervene professionally when a colleague’s behavior is illegal, unethical, or detrimental to individuals with exceptionalities.
• Do not engage in conflicts of interest.
• Assure that special education paraeducators have appropriate training for the tasks they are assigned.
• Assign only tasks for which paraeducators have been appropriately prepared.
• Provide ongoing information to paraeducators regarding their performance of assigned tasks.
• Provide timely, supportive, and collegial communications to paraeducators regarding tasks and expectations.
• Intervene professionally when a paraeducator’s behavior is illegal, unethical, or detrimental to individuals with exceptionalities.
• Use culturally appropriate communication with parents and families that is respectful and accurately understood.
• Actively seek and use the knowledge of parents and individuals with exceptionalities when planning, conducting, and evaluating special education services and empower them as partners in the educational process.
• Maintain communications among parents and professionals with appropriate respect for privacy, confidentiality, and cultural diversity.
• Promote opportunities for parent education using accurate, culturally appropriate information and professional methods.
• Inform parents of relevant educational rights and safeguards.
• Recognize and practice in ways that demonstrate respect for the cultural diversity within the school and community.
• Respect professional relationships with students and parents, neither seeking any personal advantage, nor engaging in inappropriate relationships.
• Do not knowingly use research in ways that mislead others.
• Actively support and engage in research intended to improve the learning outcomes of persons with exceptional learning needs.
• Protect the rights and welfare of participants in research.
• Interpret and publish research results with accuracy.
• Monitor unintended consequences of research projects involving individuals with exceptionalities, and discontinue activities which may cause harm in excess of approved levels.
• Advocate for sufficient resources to support long term research agendas to improve the practice of special education and the learning outcomes of individuals with exceptionalities.
• Maintain accurate student records and assure that appropriate confidentiality standards are in place and enforced.
• Follow appropriate procedural safeguards and assist the school in providing due process.
• Provide accurate student and program data to administrators, colleagues, and parents, based on efficient and objective record keeping practices.
• Maintain confidentiality of information except when information is released under specific conditions of written consent that meet confidentiality requirements.
• Engage in appropriate planning for the transition sequences of individuals with exceptionalities.
• Perform assigned specific non-educational support tasks, such as administering medication, only in accordance with local policies and when written instructions are on file, legal/policy information is provided, and the professional liability for assuming the task is disclosed.
• Advocate that special education professionals not be expected to accept non-educational support tasks routinely.

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All members of The National Association of Special Education Teachers , through an agreement with the American Academy of Special Education Professionals , will now have free access to an online peer reviewed research journal in special education, the Journal of the American Academy of Special Education Professionals ( JAASEP ).

The Journal of the American Academy of Special Education Professionals ( JAASEP ) is an online peer-reviewed journal committed to advancing the professional development of special education professionals through research, policy, and practice.  JAASEP is a multi-faceted electronic journal that seeks new contributions based on original work of practitioners and researchers with specific focus on or implications for the field of special education.

The content of  JAASEP  is likely to be of interest to college or university faculty, school administrators, educational evaluators, psychologists, special education teachers, psychiatrists, medical doctors, directors of special education services, directors of early intervention agencies, infant-toddler service coordinators, transition service coordinators, speech and language pathologists, occupational and physical therapists, educational lawyers, and all other practitioners and professionals in the field of special education.

We hope that you take the time to read the professional literature provided. As always, if you have any questions or comments, please contact us at: [email protected]

JAASEP WINTER 2024 - CLICK HERE

JAASEP Editorial Board of Reviewers

An Overview of the Challenges and Resources Special Education Professionals Reported During the Early COVID-19 Pandemic

Ai kamei, kathryn lubniewski, stacy lauderdale littin, carol mcarthur-amedeo, mary haspel, & wendy harriott, an exploration of pre-service teachers’ attitudes toward including students with autism spectrum disorder (asd) in general education, mary. a. houser, tara s. guerriero, & trevor o’brien, supporting student engagement through the use of various discussion formats in a graduate teacher education course, marla j. lohmann, & kathleen a. boothe, ramping up 504 professional development for all types of educators: going beyond section 504 being a special education responsibility, shawna p. ortogero,  vera glushenko, joan umiokalani jensen, victoria timmerman, & tierney o. barcarse, parent perspectives of transition planning for english learners with disabilities, yi-chen wu, martha thurlow & david johnson, when parents of children with severe autism become their teachers: unique cases from the covid-19 pandemic, sydney bueno, uzeyir ogurlu, lisa bardon, & nikki logan, a rural community's role and process to secure work experiences for youth with disabilities, building communities of practice: initial perceptions of an interdisciplinary preparation program for special education teachers and social workers, robbie j. marsh, heather, baltodano-van ness, & monica brown, parent perceptions of interactions with professionals that improve individualized education program development, kristopher hawk yeager, malarie e. deardorff, belkis choiseul-praslin, wendy r. mitchell, courtney tennell, & brooki beasley, a comparison of teaching efficacy between paraprofessionals and special education teachers working with special education students, cristhian c. altamirano, & dake zhang .

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2020 - click here, what parents tell their post-secondary students with intellectual and developmental disabilities about money, joanne caniglia, yvonne michali, michelle meadows, & davison mupinga, the perceived effectiveness of using mindfulness as a strategy for special educators in coping with the stress of their work environment  , lisa ciraldo, the influence of introductory coursework on preservice teachers’ sense of self-efficacy towards teaching in an inclusive classroom, moriah smothers, tori colson, nina yssel, & linda taylor, insights gained from special education pre-service teachers interviewing paraprofessionals, rob schulze, experiences of special educators in creating opportunities for students to practice self-determination, kaitlyn m. millen, lori y. peterson, jason robinson, & timothy m. luff, examining the effectiveness of fidgets on attention of elementary students with adhd, leslie a. mathews, kimberly j. osmani, & james e. martin, autism spectrum disorder: a cross-cultural variability in personal identity, dr. aftab khan & dr. michel ferrari, the development of aissend: an observation tool to assess inclusive practices  , randa g. keeley, rebecca alvarado-alcantar, & david w. keeley, exploring factors related to burnout among special education teachers in specialized schools, dr. oksana huk & dr. brian cesario, services for young children with disabilities in romania in the post-communist era, luminita hartle, amanda quesenberry, & sharon doubet, progress in education for students with intellectual disabilities in saudi arabia: evaluating status, khalid h. alshamri, jaasep spring/summer 2020 - click here, effects of mass trials versus distributed trials during a shared story reading for students with moderate to severe disabilities, mona nasir-tucktuck, joshua n. baker, cori more, k. ryan wennerlind, and stephanie devine, a pilot study of a self-determination curriculum on secondary students  , brent a. askvig, melissa naslund, evan d. borisinkoff, and rebecca daigneault, student voices: a qualitative self-awareness study of college students with disabilities, chen-ya juan, penny l. cantley, james martin, and brad mays, effects of physical activity on executive function of children with adhd, jeffery l. hart and david phillips, inclusive book club: perspectives of undergraduate participants, shawnna helf, and debra leach, constructivism, zone of proximal development and target in a multi-dimensional classroom, bradley johnson, ph.d., playgrounds for “all” children, sharon e. rouse, rose b. jones and david w. walker, challenges to collaboration, inclusion and best practices within the special education community, cecilia scott-croff, use of visual performance feedback to increase teacher use of behavior-specific praise among high school students with severe disabilities, michelle l. simmons, robin h. lock, janna brendle, and laurie a. sharp, empowering refugee families of students with disabilities, sadia warsi, and karen fitzgerald, individual education plan considerations for online learning: accommodations, carolyn l. berenson, jaasep winter 2020 - click here, transition programs for individuals with disabilities: a post-secondary college experience leading to greater independence in life and work, karen h. feathers and deborah e. schadler, use of shaping to overcome the fear of entering a restroom: a case study of a preschooler with autism, suja m. george, and tamara soemali, the effects of cra/csa explicit instruction for students with and without disabilities taught in an inclusive setting, vanessa hinton, anna gibbs, and toni franklin, cultural issues: treating & diagnosing adhd, noe ramos, and john lowdermilk, the impact of social communication on employment success for adolescents with asd, beth clavenna-deane, mary pearson, and blake hansen, hopes and hurdles: parents’ perceptions and experiences with transition planning for students with intellectual disabilities, jason robinson, and tracy gershwin mueller, how early experiences in cognitive development improve working memory and processing speed skills of children, heather dube, and sarah sarette, instruction in co-taught secondary classrooms: an exploratory case study in algebra 1, margaret p. weiss and wendy rodgers, the effects of relationship history on student responding in an academic setting, regan weston, tonya davis, and abby hodges, a brief primer of three major counseling theories for use by school-based personnel, samuel f. whitley, jaasep fall 2019 - click here, a systematic review of video modeling interventions to improve the independent living skills of students with autism spectrum disorder and intellectual disability, kaylee s. wynkoop, daniel r. wissinger, and matthew van horn, what challenges do special education teacher educators encounter while preparing novice special education teachers, laurie a. sharp & frank goode, services and supports for individuals with autism spectrum disorders in the kingdom of saudi arabia, siddiq ahmed, morgan chitiyo, and mohamad al-jaffal, how parents of students with pandas or pans perceive the educational process, patricia rice doran and elizabeth o’hanlon, the changing role of the itinerant teacher of the deaf: a snapshot of current teacher perceptions, holly f. pedersen and karen l. anderson, augmentative and alternative communication in classrooms: special education teacher competences, rashed a. aldabas, overcoming adapted physical education barriers through collaboration among special educators and administrators, scott w.t. mcnamara, lisa silliman-french, valda morgan, and tammy l. stephens-pisecco, perceived effectiveness of classroom management interventions with attention deficit/hyperactivity disorder, darlene desbrow, theory to practice: implementation achievements and challenges of response to intervention in a rural district, brenda l. barrio, kira j. carbonneau, marcus poppen, darcy miller, michael dunn, and yun-ju hsiao, general educator perceptions of school support in teaching students with an iep, faith kenny, jaasep spring-summer 2019 - click here, use of projective techniques in emotional disturbance evaluations, ryan a. allen, timothy hanchon, & bradley bornancin, developing culturally responsive transition plans using the indicator 13 checklist, meungguk park, morgan chitiyo, changdeog huh, and waganesh zeleke, an assessment of perceived antecedents to attitudes of college students towards children with autism, anthony m. denkyirah, yaw nyadu offei & emmanuel k. acheampong, exploring the effects of the autismate application on a 12 year-old boy with asd: a case study, natalie g. wall, julie ivey, and karen frederick, addressing the need for progress in special education:  understanding endrew f. and the role of special educators, laura kern, heather peshak george, lauren l. evanovich, and stephanie martinez, creating self-efficacious special educators through mentoring during teacher preparation, mary m. lombardo-graves, challenging behavior in students with an intellectual disability: promoting understanding and compassionate educational practice, evelyn bilias-lolis and alyson m. martin, exploring preservice teachers' perceptions of preparedness to teach students with disabilities, linda m. reeves, rebecca m. giles, and todd johnson, but… how helpful is that  parents’ views on the helpfulness of selected resources when making educational decisions for their young children with disabilities, maría isolina ruiz, linda flynn-wilson, lauren giovingo, and philip g. wilson, an investigation of co-teaching to improve academic achievement of students with disabilities: a meta-analysis, mickey losinski, sara sanders, robin parks-ennis, nicole wiseman, jessica nelson, and antonis katsiyannis, evaluation of the rhythmic arts project, a multi-modal rhythm-based perception and action intervention, in a school-based setting in children with autism spectrum disorders, beth a. smith, eddie tuduri, emily mostovoy, denise pannell, and chris landon, jaasep winter 2019 - click here, responding to the endrew’s decision: measuring meaningful educational benefit, deborah w. hartman, social skills for students with moderate to severe disabilities: can community based instruction help, carissa hernandez, m.a. & saili s. kulkarni, ph.d., mobile hearing screening in a rural community school in ghana, an investigation of special education preservice teachers' perspectives and practices of steam education, ashley gess, ph.d.  & nai-cheng kuo, ph.d., increasing teachers' use of behavior-specific praise with the teacher vs. student game, renée e. lastrapes, ph.d. , jennifer n. fritz, ph.d. & robert c. hasson, ed.d., building independence through self-prompting with technology, dana r. reinecke, ph.d., bcba-d, meeting the needs of students with disabilities: characteristics of universal design of instruction in odds-beating middle schools, heather kurto, m.s. ed., kristen c. wilcox, ph.d. & kristie asaro-saddler, ph.d., social skill and self-advocacy goals: an iep study, gregory w. smith, ph.d., k. alisa lowrey, ph.d. & david walker, ed.d., perspectives on current practices and barriers to training for paraeducators of students with autism in inclusive settings, emily eyrolles sobeck, ph. d & rachel robertson, ph.d., bcba-d, poverty and learning: the effects of poverty in the classroom, dr. jessie s. thacker-king, download winter 2019 issue of jaasep - download page, fall 2018 jaasep - click here, understanding the removal of classroom auditory distractors: an interactive design, gregory w. smith, ph.d., audra i. classen, ph.d., paul j. riccomini, ph.d., & robyn r. brewer, graduate student (bcba program), communication in support of students with disabilities attending career technical education, christine powell, ed.d., strategies for supporting students diagnosed with autism spectrum disorders in stem education, amelia k. moody, ph.d., dennis s. kubasko, ph.d. and allison r. walker, ph.d., gifting the ungifted: disproportionality of minority students in gifted education, nicholas catania, m.ed., prompting with wearable technology to increase teaching behaviors of a preservice special education teacher, andrew m. markelz m.ed., jonte c. taylor ph.d., mary catherine scheeler ph.d., paul j. riccomini ph.d., & david b. mcnaughton ph.d., “how am i doing” teaching children with emotional-behavioral disorders to self-manage their behaviors, lael tensfeldt, m.a., amory verroulx, m.a., bcba & jennifer n. mahdavi, ph.d, bcba-d., developing peer mediated interventions for secondary students with emotional and behavioral disorders, danielle feeney, m.ed., fostering reading motivation in self-contained classrooms for students with emotional and behavioral disorders, heidi r. cornell, ph.d., exceptional gifted in west virginia: reflections of a teacher of the exceptional gifted on the state program, dr. patricia coon, the effect of a skills-based behavioral program on raising the self-concept of individuals with mild intellectual disability in uae, dr. ousha almheiri, democratic citizenship education and inclusion: preparing preservice teachers for inclusive social studies, dennis j. urban, jr., spring/summer 2018 jaasep - click here, social skills and students with moderate to severe disabilities: can community based instruction help, carissa hernandez, ma and saili s. kulkarni, ph.d., supporting students with disabilities during group activities: five tools every inclusive mathematics educator needs, benjamin s. riden ph.d., andrew m. markelz ph.d. and m. kathleen heid ph.d., using an alternating treatment design in a co-taught classroom to measure student on-task behavior, randa g. keeley, ph.d., a whole language reading intervention: a case study, matthew glavach, ph.d. and warren pribyl, m.a., common purpose, uncommon results: a literacy collaboration for a preschooler with down syndrome, chelsea t. morris, m.ed. and rachel j. chidester, m.s., educational policy: instruction and assessment, christina m. sorrentino, increasing use of research-based practices: action research report on a college-school partnership to support instruction aligned to middle school common core math standards for students with significant disabilities, katherine trela, ph.d., wendy gladstone-brown, ed.d., norah merritt, ph.d. and leah raftis, ed.d., the impact of assistive technology on autism spectrum disorder: a systematic review, angela bollin, bs tr, ctrs, julia vandermolen, ph.d and taylor bierwagen, effects of video modeling and video modeling plus prompting and reinforcement on the daily living skills of a student with autism, kaylee s. wynkoop. ph.d., rachel e. robertson, ph.d., bcba-d and emily e. sobeck, ph.d., winter 2018 jaasep - click here, supervisory teacher coaching in k-12 classrooms, millicent carmouche and jelisa thompson, factors that may hinder the implementation of the school-wide positive behavior intervention support model, jonathan chitiyo and michael e. may, matching students to augmentative and alternative communication: a single case study, sarah dimeo, mary frances baxter, susan zapf, jane pemberton, and husny amerih, academic experiences of students who are deaf at the university of education, winneba, ghana, alexander m. oppong, joyce adu, daniel fobi, and emmanuel k. acheampong, the effect of video modeling on preschoolers’ learning who are diagnosed with autism spectrum disorder: a meta-analysis, sanpalei nylla lyngdoh, m.a. and konabe bene, ph.d., autism support teachers’ attitudes about inclusion for children with autism, twila lukowiak, ed.d., james ghareeb, b.s., sarah wadi, b.s., samantha stanis, b.s. & jack walter, disabilities and social engagement: inclusive classroom preparation for pre-service art teachers, alyssia ruggiero, student engagement in an online special education-general education graduate program, laron scott and priyadarshini pattath, mindfulness meditation with high school students who receive special education services: research recommendations from a pilot study, ernest solar, ph.d., fall 2017 jaasep - click here, implementation of a post-secondary inclusive recreation program, chris brown, ph.d., john david johnson, ph.d. & ibrahim z. elsawy, ph.d., strengthening social and emotional intelligences through writing, jeanne hager burth, ed.d. & michelle mcconnell, b.s., let’s get parents ready for their initial iep meeting, helen hammond & lawrence ingalls, preparing preservice teachers for inclusive classrooms: a state-wide survey of teacher education faculty, lucinda anne lang, ph.d. & sherry mee bell, ph.d., are we practicing what we are preaching an evaluation of self-determination instructional components in ieps at a midwestern high school, nancy lopez, ed.d. & julia b. stoner, ed.d., ccc-slp, stretch (students ready to make change): making a difference in the lives of students, effects of activity schedules on challenging behavior for children with autism, dr. rachel scalzo, dr. tonya n. davis, regan weston, elizabeth dukes, dana leeper, nandar min, allen mom, jessica stone & alex weber, alternative approaches to iep conflict: a review of the literature, laura sinkonis, m.ed., evaluating the validity and reliability of a student self-advocacy teacher rating scale, christopher m. walick, ph.d., spring/summer 2017 jaasep - click here, the history of behavioral treatments in autism: from the punitive to the positive, jennifer l. suppo, ed.d., how early experiences in a kindergarten classroom shape the development of self-regulation skills of children, eloisa darcy, ed. d., sarah sarette, ed. d., anna boghigian and marley martin, mothers’ perspectives and experiences of speech generating devices, yeunjoo lee, ph.d. and luis a. vega, ph.d., teachers' pedagogical competence in adapting curricula for children with learning difficulties (ld) in primary schools in ghana, abdul-razak kuyini alhassan and chigorom okechukwu abosi, parents are the experts: understanding parent knowledge and the strategies they use to foster collaboration with special education teams, colby kervick, ed. d, examination of social story format on frequency of undesired behaviors, robyn thompson, ph.d., and susan s. johnston, ph.d., preparing early childhood educators for blending practices in inclusive classrooms, mary donegan-ritter, ph. d. and frank kohler, ph. d., pre-service teachers assisting the transition of the student with autism from school to adulthood, jeanne hager burth, ed.d., pre-service teacher self-efficacy for teaching students with disabilities: what knowledge matters, brooke browarnik, sherry mee bell, r. steve mccallum, kelly smyth and melissa martin, variables affecting the amputees' reactions artificial limbs in the kingdom of jordan, mezyed al-adwan, yahya najjar, maha hdaib and monadel al-khateeb, winter 2017 jaasep - click here, how expert special educators effectively negotiate their job demands, shawna p. ortogero, ph.d., rhonda s. black, ed.d.  and bryan g. cook, ph.d., inclusive concurrent enrollment: a promising postsecondary transition practice for building self-determination among students with intellectual disability, amy l. cook, ph.d., felicia l. wilczenski, ed.d. and laura vanderberg, ph.d., improving outcomes for students with disabilities: identifying characteristics of successful districts, melissa devries, m.ed. and oran tkatchov, m.ed., a comparative study of teachers’ pedagogical competencies in supporting children with learning difficulties in primary schools in ghana and brunei darussalam, okechukwu abosi, ph.d, and abdul razak kuyini alhassan, ph.d., a case study of factors that influenced the attrition or retention of two first-year special education teachers, marquis c. grant, ed.d., significant outcomes in case law in the united states: autism and idea in 2013, transition issues and changes in diagnostic evaluation criteria, doris adams hill, ph.d. and jonte taylor, ph.d., effectiveness of pearson’s successmaker mathematics for students with disabilities, steven k. mckissick, teachers’ methodologies and sources of information on hiv/aids for students with visual impairments in selected residential and integrated schools in ghana, samuel k. hayford and frederick ocansey, managing asthma in elementary and middle schools: adherence to federal laws and national guidelines, ethan j. schilling, ph.d., stacey neuharth-pritchett, ph.d., yvette q. getch, ph.d. and a michele lease, ph.d., use of social narratives as an evidence-based practice to support employment of young adults with asd: practitioner’s guide, jamie thomas, m.s. and susan nix, m.ed., fall 2016 jaasep - click here, examining the attitudes of secondary general education and special education teachers toward inclusion of children with autism in general education classrooms, morghan e. bosch, ed.d., action research report: using objects to increase reading comprehension in students with significant cognitive disabilities, sheila bravo, the redundancy effect on retention and transfer for individuals with high symptoms of adhd, victoria brown, david lewis and mario toussaint, guidelines for the administration of educational programs for students who are deaf/hard of hearing, visually impaired, or deafblind, susan bruce, kay ferrell and john l. luckner, teaching reading comprehension to students with autism spectrum disorders in social studies classrooms: middle school teacher perceptions, lisa burke, wu-ying hsieh, norma lopez-reyna and kathryn servilio, general education and special education teachers’ attitudes towards inclusion, david a. hernandez, susan hueck and carmen charley, steps to becoming independent: toilet training challenges facing children with autism spectrum disorder, andrea belyea, herbert neely and julie p. jones, leadership style of head teachers of basic special schools as correlates of retention of special needs educators in southern ghana, felix kwame kumedzro, nelly otube, chomba wamunyi and mary runo, revisiting the regular education initiative: multi-tiered systems of support can strengthen the connection between general and special education, debra leach and shawnna helf, effects of inclusion classrooms on academic achievement of students with learning disabilities and students in general education, sharon ware, spring/summer 2016 jaasep - click here, the implications of a system-wide positive behavioral intervention initiative: from design to successful implementation, vance l. austin, micheline s. malow, nikki l. josephs and andrew j. ecker, creating an environment for pre-service teachers to work with learners with special needs, are we ready to have teachers with learning disabilities a study of school principals' observations, heidi flavian, ph.d., follow-up study to family members’ reactions to the initial special education meeting, dr. lawrence ingalls, dr. helen hammond, mr. carlos paez and mr. ivan rodriguez, perceptions of parents of children with autism spectrum disorders towards their partnerships with teachers, yun-ju hsiao, ph.d., brain gym: pseudoscientific practice, kevin kroeze, bae, keith j. hyatt, ed.d., and m. chuck lambert, ph.d., housing and independent living for individuals with intellectual and developmental disabilities, debra leach, ed.d., using the “asked” model to contrive motivations and teach individuals with asd to ask wh-questions in natural settings, cheryl ostryn, ph.d., bcba-d, lba, an analysis of factors influencing low enrolment and retention of girls with disabilities in integrated primary schools in embu county, kenya, njeru idah muthoni, dr. nelly otube and dr. samson rosana ondigi, employing case study methodology in special educational settings, angelise m. rouse, ph.d., retraction statement, jaasep winter 2016 - click here, the effects of special education training on educator efficacy in classroom management and inclusive strategy use for students with autism in inclusion classes, lynn d. parsons, ph.d., heather miller, ph.d. and aaron r. deris, ph.d., the effectiveness of using a social story intervention to improve social interaction skills of students with autism, mohammed al zyoudi, oshua al murhairi, enas olimat and abedsalm al zyoudi, preventing and responding to student escalation: combining de-escalation strategies and function-based support, chelsea martel and brian cavanaugh, ed.d., teaching sam to read: an integrated team approach with one child with asd, gail coulter, ph.d. and roger sasnett, ph.d., high stakes testing in the 21st century: implications for students in special education, lola gordon, ed.s., identifying and correcting barriers to successful inclusive practices: a literature review, marquis c. grant, m.ed., ed.d. and kimberly michelle jones-goods, mps, ph.d., cameras in self-contained classrooms: legal, professional and student implications, ashlee ivie, effects of an intervention on math achievement for students with learning disabilities, vivian d. kitchens, ph.d., aaron r. deris, ph.d. and marilyn k. simon, ph.d, crossing borders and building bridges: a video ethnography of special education in nuevo progresso, mexico, john lowdermilk, ph.d., mrs. julie pecina, cheryl fielding, ph.d. and mrs. lisa beccera, evaluating and using literature including people with disabilities in all classrooms, mary ellen oslick, ph.d. and mary pearson, ph.d., a pilot examination of the adapted protocol for classroom pivotal response teaching, aubyn c. stahmer, ph.d., jessica suhrheinrich, ph.d. and san diego state university, principals and teachers’ attitudes towards inclusion in israel, dr. itay hess, dr. sara zamir and ben- gurion, fall 2015 jaasep - click here, elements of good teaching and good teachers: a theoretical framework and effective strategies for special educators, vance l. austin, ph.d, what factors contribute to self-efficacy, hildy straus, ph.d., rhonda bondie, ph.d., co-teaching and collaboration: preservice teachers’ knowledge, attitudes, and perceived sense of efficacy in teaching students with disabilities, tamara m. bowlin, ph.d., sherry mee bell, ph.d., mari beth coleman, ph.d. & david f. cihak, ph.d., creating a common table: using peer mediated intervention to promote social communication skills with at-risk and autism spectrum disorder populations, dr. lesley craig-unkefer & dr. jennifer loncola walberg, home-school collaboration for students with asds: parents’ perspectives, mary a. houser, ed.d., charlotte l. fontenot, ed.d., & john spoede, ph.d., validating an observation protocol to measure special education teacher effectiveness, dr. evelyn s. johnson & dr. carrie l. semmelroth, teaching play skills through the use of assistive technology and instructional strategies: a national survey, susan s. johnston, ph.d. & robyn m. thompson, m.s., student outcomes in a blended preschool program, sybil a. keesbury, ed.d., a meta-analytic review of tactile-cued self-monitoring interventions used by students in educational settings, dr. dennis mcdougall & dr. cecily ornelles, teachers’ knowledge of special education policies and practices, pamela sanders, ph.d., spring/summer 2015 jaasep - click here, table of contents, learning disabilities today: an examination of effective and not-so-effective interventions, vance l. austin, teaching algebraic equations to middle school students with intellectual disabilities, joshua n. baker, christopher j. rivera, joseph john morgan & noelle reese, students with disabilities in the polish educational system after the political changes (2007-2012), danuta apanel, fape and lre in online learning: special education directors’ perspectives, diana greer, ph.d., danna harvey, m.s., paula burdette, ph.d. & james basham, ph.d., a preliminary investigation of the benefits of computer-aided instruction in reading decoding for students with autism spectrum disorder and other developmental disabilities, doris adams hill, phd, bcba-d& margaret m. flores, phd, bcba-d, perspective taking through film: educating pre-service and in-service teachers about autism, jacqueline p. kelleher, comparing student and teacher perceptions of the importance of social skills in a self-contained setting, joseph john morgan ph.d., nicole dobbins, ph.d., yun-ju hsiao, ph.d., nancy brown, m.ed. & kyle higgins, ph.d., inclusive education practice in southwestern nigeria: a situational analysis, samuel olufemi adeniyi, ph.d. & akinkunmi oluwadamilare adeyemi, parent perspectives on home-based intervention for young children with developmental disabilities: the parent-implemented communication strategies (pics) project in illinois, usa, hedda meadan, ph.d., bcba-d, julia b. stoner, ed.d., ccc-slp & maureen e. angell, ph.d., the digital divide and inequities for students with disabilities: needed….a bridge over troubled waters, patricia a. tyson, winter 2015 jaasep - click here, effects of the picture exchange communication system (pecs) on maladaptive behavior in children with autism spectrum disorders (asd): a review of the literature, dana battaglia and mary e. mcdonald, comparing measure of academic progress (map) and piers-harris 2 scores of students with emotional and behavioral disorders, terrence rainer chisolm, perceptions of disability and special education services: the perspectives of korean-american parents of children with disabilities, nari choi and raymond ostendorf, instructional constraints faced by learners with muscular dystrophy: a case of joytown special primary school, thika, kenya, annrose wanjiku wang’ang’a, franciscah irangi wamocho and paul kioy, the perspectives of k-12 stakeholders involved in early implementation of response to intervention (rti), nai-cheng kuo, ph.d., the role of peer guided play for children with autism spectrum disorder, amy m. papacek, ph.d., improving science scores of middle school students with learning disabilities through engineering problem solving activities, leyf peirce starling, ya-yu lo and christopher j. rivera, service delivery for high school students with high incidence disabilities: issues and challenge, edward schultz, cynthia simpson, jane c. owen and christina janise mcintyre, teaching children with autism to ask questions, katie e. squires and alyssa bickel, the principals' impact on the implementation of inclusion, carmelita thompson, fostering special education certification through professional development, learning communities and mentorship, mitzi p. trahan, dianne f. olivier and donna e. wadsworth, fall 2014 jaasep - click here, speech-language services in public schools: how policy ambiguity regarding eligibility criteria impacts speech-language pathologists in a litigious and resource constrained environment, lesley sylvan, ed.d, ccc-slp, are parents really partners in their child’s education, clarissa e. rosas, ph.d. and kathleen g. winterman, ed.d, vocational rehabilitation counselors’ perceived influences on the secondary transition planning process and postsecondary outcomes of students with disabilities, vickie miller-warren, ed.d., gender differences in emotional or behavioral problems in elementary school students, amanda malfitano, african american parental beliefs about resiliency:  a delphi study, vita jones, ph. d., kyle higgins, ph.d., randall boone, ph.d., susan p. miller, ph.d., & nancy sileo, ed.d., blending common core standards and functional skills in thematic units for students with significant intellectual disabilities, karena cooper-duffy and glenda hyer, effects of peer tutoring and academic self-monitoring on the mathematics vocabulary performance of secondary students with emotional or behavioral disorders, brittany l. hott, anya evmenova and frederick j. brigham, teaching multiplication with regrouping using the concrete-representational-abstract sequence and the strategic instruction model, margaret m. flores and toni m. franklin, student and teacher perceptions of the five co-teaching models: a pilot study, randa g. burks-keeley, m.a. and monica r. brown, ph.d., students with disabilities’ perspectives of stem content and careers, kimberly e bryant davis, a researcher’s story of assessing motor skills of children with autism spectrum disorder, casey m. breslin and alice m. buchanan, the impact of video modeling on improving social skills in children with autism, dr mohammed alzyoudi, professor  abedalziz. sartawi and dr. osha almuhiri, spring-summer 2014 jaasep - click here, using e-readers to improve reading for students with mild disabilities, amy camardese, m. eileen morelli, yehuda peled and maile kirkpatrick, importance of quality of life issues: a pilot comparison of teachers and parents of children with autism spectrum disorders, julie ivey-hatz and karen frederick, effects of early childhood education on children with hearing impairments in special schools in kiambu, murang’a and nyeri counties, kenya, chege loise w, franciscah  i. wamocho and john aluko orodho, bringing aba into early childhood routines to meet the needs of young children with asd, perceptions of pre-service teachers as they relate to professional practice, emily williams, elissa poel, miguel licona, elsa arroyos and alma meraz-rodriguez, effectiveness of transitional and follow-up programmes to community integration of young adults with intellectual disabilities (yawid) in kiambu county, kenya, margaret w. makanya, mary runo and violet wawire, family communication: strategies for building effective partnerships and working relationships, emily r. shamash and alyson m. martin, adhd in preschool:  approaches and teacher training, ajay singh and jane squires, practitioners' perceptions of their knowledge, skills and competencies in online teaching of students with and without disabilities, diana l. greer, sean j. smith and james d. basham, effects of environmental and instructional factors on student motivation and self-directed learning, anne d. burkhalter, denise a. rich-gross, ph.d., winter 2014 jaasep - click here, preservice teachers’ attitudes toward inclusive education policy in the united states, paul m. ajuwon, ph.d., effie laman, ed.d., & john c. earle, ph.d., autism spectrum disorders and implications for teachers, crystal echaniz, m.a. &  kathleen a. cronin, ph.d., stop the blame game: teachers and parents working together to improve outcomes for students with behavior disorders, melissa davis, positive and negative aspects of inclusion services, christye hayes, m.ed., ed.s., teacher perceptions of response to intervention implementation, j. kevin jenkins, ed.d  &  dia sekayi, ph.d, supporting preschool children with autism spectrum disorders (asd) and their families, dr. jin-ah kim, dr. nancy cavaretta & krystle fertig, ma, adolescence: a period of transition, leena jo landmark  &  trina geye, students with attention deficit hyperactivity disorder participating in recess, matthew d. lucas, ed.d, michael  j. justice & kelly m. rosko, issues and concerns of assessment for english language learners with learning disabilities, blanca pichardo, maximizing the potential of our youth with intellectual disabilities: rethinking functional curriculum, trust and communication: perspectives of mothers of children with disabilities on the role and importance of communication in trusting relationships with teachers, julia b. stoner ed.d., ccc-slp  &  maureen e. angell, ph.d., fall 2013 jaasep - click here, responses to positive versus negative interventions to disruptive classroom behavior in a student with attention deficit hyperactivity disorder (adhd), renee b. brown, a comparison of two curricular models of professional development to increase teacher repertoires for instructing students with autism, information needs and information seeking behavior of teachers of special education in shillong, india, bikika laloo and jocica l. buhril, helping preservice special educators scaffold the reflection process, elissa wolfe poel, monica r. brown, luis-vicente reyes, and cristóbal rodríguez, preparing preservice teachers to address bullying through cartoon lessons, audrey c. rule, stephanie r. logan, and frank w. kohler, special educator evaluation: cautions, concerns and considerations, carrie semmelroth, evelyn johnson, and keith allred, working together for learning together: supporting students and teachers with collaborative instruction, cynthia t. shamberger and marilyn friend, general education teachers’ knowledge of and attitudes toward students with attention deficit/hyperactivity disorders: are they still being overlooked and underserved, roben wallace taylor and ravic p. ringlaben, should i stay or should i go revisiting influencing factors of sped teacher attrition & retention: a review of the literature, raschelle theoharis and michael fitzpatrick, spring-summer 2013 jaasep - click here, using a four-point scaled writing rubric: improving the quantity and the quality of the writing in a first grade specialized 8:1:1 classroom, lynn carlson, effective inclusion strategies for professionals working with students with disabilities, kathleen a. hogan, marla lohmann, and rose champion, professional development to support students with disabilities in multi-tier classrooms:  a case study, brooke blanks, integrated education in contemporary poland, the effects of self-graphing on oral reading fluency for a student with e/bd within an alternative education school, sara c. mcdaniel, kristine jolivette and robin parks ennis, applied behavior analysis: current myths in public education, cheryl fielding, john lowdermilk, lauren l. lanier, abigail g. fannin, jennifer l. schkade, chad a. rose, and cynthia g. simpson, application of the rti model in learning disability diagnosis: perceptions of current practices by new jersey special education administrators, pamela e. lowry, an exploratory study of successful paperwork management techniques for novice special education teachers, richard l. mehrenberg, factors influencing teacher behavior with students with diverse learning and behavioral needs, edward k. schultz and cynthia g. simpson, educational outcomes for students with special needs: the impact of support and resources on teachers’ perceptions, traci y. sharpe, winter 2013 jaasep - click here, identifying and integrating relevant educational/instructional technology (e/it) for culturally and linguistically diverse (cld) students with disabilities in urban environments, implementing and monitoring the response to intervention process: the special educator perspective, leigh k. gates,  john c. fischetti, and amelia moody, nature and causes of locomotor disabilities in india, santoshi halder and arindam talukdar, the over identification of minority males in middle school special education programs: examining the rti modely, nicole anderson-irish, literacy based behavioral interventions and video self-modeling with students with autism spectrum disorder (asd), debra leach and jennifer rodecki, m.ed., students with speech impairments participating in recess, matthew d. lucas and carolyn r. watson, writing ieps for the audience of teachers, parents, and students: the case for the communicative individual education program, richard j. lucido, comparison of gifted and advanced students on motivation toward science learning and attitude toward science, mustafa serdar köksal, exploring the experiences of special educators following the joplin tornado, allyson palmer, addressing the shortage of speech-language pathologists in school settings, katie squires, fall 2012 jaasep - click here, factors that affect the success of students with emotional and behavioral disorders in inclusive placements, naomi arseneau m.s. ed, theoretical frameworks for math fact fluency, katherine arnold, liberty university, fape model of exceptional student education leadership, dr. russell g. dubberly, working towards math facts mastery, anne durham, district-wide pbis team questions related to using the pbis framework to transition students with challenging behaviors from an alternative school to a neighborhood school, kristine jolivette, nicole c. swoszowski, nikki l. josephs, sara c. mcdaniel, & robin parks ennis, students with obsessive compulsive disorder participating in recess, matthew d. lucas, ed.d. c.a.p.e. & amanda l. sturgis, current issues in teaching bilingual children with autism spectrum disorder, amelia m. medina and judy t. salamon, an evaluation of inclusive education of students with visual impairment in schools and university in beira, mozambique, lawrence nhemachena, samuel kusangaya, & isaiah gwitira, transition knowledge of high school special education teachers in a midwestern school district, christine peper, & kristen mcmaster, the competency based community assessment: a five step process, laura a. roberts, ph.d., & orv c. karan, ph.d., download this issue of jaasep - ( aasep members login to access download ), spring/summer 2012, resilience theory: risk and protective factors for novice special education teachers, thomas l. benjamin & rhonda s. black, the ability-achievement model versus the response to intervention model:  which model is more accurate in the assessment of diagnosing students with learning disabilities, debra camp-mccoy, a program evaluation of an inclusive model for training pre-service general education teachers to work with students with special needs, joanna e. cannon, nicole c. swoszowski, peggy gallagher & susan r. easterbrooks, evaluation of push-in/integrated therapy in a collaborative preschool for children with special needs, stephen j. hernandez, students with multiple sclerosis participating in recess, matthew d. lucas, ed.d. c.a.p.e. & jamie brentlinger, perspectives of parents who have a child diagnosed with an autism spectrum disorder, lori a. kalash, ed.d. & myrna r. olson, ed.d., high fructose corn syrup, mercury, and autism - is there a link, heather a. opalinski, the use of a functional behavioral assessment-based self management intervention for students with emotional/behavioral disorders, saleem `a. rasheed, ph. d., cecil fore, iii, ph.d., arthur jones, ed. s. & latisha smith, ph.d., teaching common core math practices to students with disabilities, michelle stephan & jennifer smith, involuntary teacher transfer in special education: concepts and strategies for teachers facing new assignments, jan stivers, sharon f. cramer & kate riordan, how one teacher, two students with visual impairments, and a three-year r & d project could change how all students learn science, vicki urquhart, download this issue of jaasep  ( naset members - login access this issue), winter 2012, consulting to support emotional behavioral disordered students: implementing a behavioral school-based approach, faith andreasen, finding opportunity in co-teacher personality conflicts, kara boyer & cory mcmillen, meeting the needs of special education students in inclusion classrooms, cathy ledoux, shanna l. graves & winona burt, community-based instruction (cbi) as a component of a successful transition plan for students with intellectual disabilities, dr. russell dubberly, postsecondary education experience for students with developmental disabilities: a look into perceptions of parents of senior high transition students on a small university campus, neil friesland & brad king, autistic spectrum disorder and assistive technology: action research case study of reading supports, james e. gentry & pam lindsey, a qualitative study of special education certification methods and how they affect teacher efficacy, the classroom infrastructure and the early learner: reducing aggression during transition times, caroline guardino & elizabeth kirby fullerton, development of web quest lesson enhancing thai reading skills for students with down syndrome at lower elementary, nantawan kaewchote & maturos chongchaikit, should children with auditory processing disorders receive services in schools, jay r. lucker, the use of a rubric as a tool to guide pre-service teachers in the development of ieps, clarissa e. rosas & kathleen g. winterman, quality care for down syndrome and dementia, amanda tedder, does repeated reading improve reading fluency and comprehension for struggling adolescent readers, kristine lynn still & christine a. flynt, the psychological, behavioral, and educational impact of immigration: helping recent immigrant students to succeed in north american schools, thomas mcintyre, ellis i.barowsky & virginia tong, high anxiety: addressing family issues in the transition of students with disabilities from middle grades to high school, nancy brigham & cynthia m. aguilar, identifying and helping struggling readers, antonio hairston, research in reading interventions for students with emotional and behavioral disorders, thienhuong hoang & michael oshiro, personal epistemology and self-efficacy in the special education teacher, bradley w. johnson, cooking for independence: middle school students gain skills while cooking, gloria mixon, a student’s guide to navigating the irb: how to successfully navigate a potentially overwhelming process, corinne m. murphy & claire verden, teacher candidates’ knowledge of special education law, pamela sanders, m.ed., a veteran special education teacher and a general education social studies teacher model co-teaching: the copd model, karen a. thomas-brown & peggy sepetys, how do job related field experiences affect job readiness in secondary transition students, michelle uetz, using music to increase math skill retention, catherine yoho, spring/summer 2011, table of contents - spring/summer 2011, attitudes among vietnamese educators towards students with disabilities and their implications relative to inclusive practices: the findings of a preliminary investigation vance l. austin, an exploration of instructional support use in a secondary science classroom, doris kennedy tyler, students with sickle cell anemia participating in recess, matthew d. lucas, who does the alternate assessment really assess, debra bruster, exploring transition education and community-based instruction for high school students with disabilities: a practice in taiwan, cheng-chen pan, correlates of attitudes toward academic and physical inclusive practices for students with disabilities and selected leadership behaviors among middle school principals in north carolina, mary a. houser, virginia dickens & terence hicks.

Study of Thai Language Oral Reading Problems for Students with Down Syndrome: Grade Range 1

Podcasting and Digital Video in the Classroom: A Call for Research

John H. Newman

Students with Fetal Alcohol Syndrome Participating in Recess

Rebecca Scheel & Matthew D. Lucas

Differentiating for Struggling Readers and Writers: Improving Motivation and Metacognition through Multisensory Methods & Explicit Strategy Instruction

Jennifer Walet

Extracurricular Activities and 504 Plans

George Wilkerson

Using an Accountability Tool to Improve the Quality of Outcomes on Individual Family Service Plans

Kristen M. Votava, Carol Johnson , & Kari Chiasson

Spring/summer  2011 jaasep - click here, winter  2011 jaasep - click here, effective teacher behaviors evident in successful teachers of students with emotional and behavioral disorders vance l. austin, ellis i. barowsky, micheline s. malow, & diane w. gómez, students with mild mental retardation participating in recess matthew d. lucas, teaching artists: serving special education students in local schools roberta levitt & louisa kramer-vida, a multi-faceted approach to successful transition for students with intellectual disabilities russell g. dubberly, high school teacher perceptions of the student assistance team process jeff stoehr & jody isernhagen, a review of research on the educational benefits of the inclusive model of education for special education students sherry l. hicks-monroe, the millennial generation special education teacher: promise or problem rich mehrenberg, one-to-one in the inclusive classroom: the perspectives of paraeducators who support adolescents with autism spectrum disorder christopher healy, the role of self-efficacy on job readiness s and career choice among people with intellectual disability in singapore jen-yi li & li li goh, download this issue of jaasep, fall  2010 jaasep - click here, identifying and working with elementary asperger’s students in rural america barton allen, vito loiacono & james s. vacca, rise to the challenge: examining the relationship of swimming & autism spectrum disorders elizabeth p. kuhfuss & matthew d. lucas, preservice general education teachers’ attitudes and knowledge of special education patricia mahar, katherine terras, kari chiasson, lynne chalmers, & tricia lee, multiple-choice tests with correction allowed in autism: an excel applet elisabetta monari martinez, the use of assistive technology for people with special needs in the uae abdurrahman ghaleb almekhalfi & sana tibi, punishment strategies: first choice or last resort twila lukowiak & jennifer bridges, picture exchange communication system for individuals with autism spectrum disorder lauren e. andersen, special education is broken lacie rader, locus of control, interest in schooling and science achievement of some deaf and typical secondary school students in nigeria r. ademola olatoye & e. mosunmola aanu, m.ed., educational solutions for children with cerebral palsy lynn driver, donna riccio omichinski, nicole miller, danielle sandella, & seth warschausky, teachers’ perceptions on special education preparation: a descriptive study clarissa e. rosas & kathleen g. winterman, comparison of metacognitive strategies used by individuals with adhd in online instruction victoria brown, download this issue of jaasep  (loggin required), spring/summer  2010 jaasep - click here.

The Relationship Between Self-Esteem and Academic Achievment of Girls with Hearing Impairments in Secondary Schools for the Deaf in Kenya Beatrice Bunyasi Awori, John K. Mugo, John A. Orodho & G. K. Karugu

Special Education and at-Risk Kindergarteners as Authors Louisa Kramer-Vida, Roberta Levitt & Susan P. Kelly

Sensory Integration Used with Children with Asperger’s Syndrome Analisa L. Smith

Use of Art/Art Work and Cognitive Skill for the Rehabilitation of Special Children of 4-9 Years of Age Zubair Hina

Social Issues Surrounding the Adolescent with Asperger Syndrome: Perceptions of Parents and Teachers Karen Hurlbutt & Elaine LaPlante

St udents with Autism Participating in Recess Matthew D. Lucas & Kourtney M. Nichols

A Comparison Between Collaborative and Authoritative Leadership Styles of Special Education Administrators Natasha W. Veale

The Effect of Embossed Picture Technique on Reading Performance of Learners with Hearing Impairments: A Case of Kambui School for the Deaf Sella Munyendo & Franciscah  Irangi Wamocho

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WINTER  2010 JAASEP - CLICK HERE

Training and Support for Parents of Children with Emotional and Behavioral Disorders

Twila Lukowiak

Recess for Students with Visual Impairments Matthew Lucas

Positive Behavioral Strategies for Students with EBD and Needed Supports for Teachers and Paraprofessionals Twila Lukowiak

Planning a Good School Experience for Children with Autism: A Family’s Story Ling-Ling Tsao & Dena Krueger

A Preliminary Study on Sight Word Flash Card Drill: Does it Impact Reading Fluency? Sharla N. Fasko & Daniel Fasko, Jr .

An Introduction to Literary Quaranic Stylistics Dr. Lubna Almenoar

Learning to Critique Disability Children’s Literature Available to Teacher Candidates in Their Local Communities Alicja Rieger

Assessing and Teaching Reading to Pupils with Reading Disabilities in Nyeri and Nairobi Districts-Kenya: The Teachers’ Opinion Mary Runo, Geoffrey Kargu & John K. Mugo

Response to Intervention and Identifying Reading Disability Thienhuong Hoang

The Importance of Identifying and Studying the Reasons Why Special Education Students Drop Out of High School Richard Wieringo

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The Relationship Between Childhood Traumatic Experiences and Gang-Involved Delinquent Behavior in Adolescent Boys Nichole L. Adams, Sergei V. Tsytsarev, and Paul J. Meller

What Do Brothers and Sisters Think? An Investigation of Expectations of Siblings with Autism Spectrum Disorders Julie K. Ivey and Lucy Barnard-Brak

Investigating Secondary Special Educator’s Perception of Interagency Collaboration Jen Yi Li and Hsintai Lin

Resistance to Change: Overcoming Institutional and Individual Limitations for Improving Student Behavior Through PLCs John W. Maag

Preparing Students with Moderate/Severe Disabilities for Employment Peter Dragula

Academic Interventions Implemented to Teach Students with Emotional Disturbance Twila Lukowiak

From LD to Degree- Effective techniques for the Student with a Learning Disability Joshua A. Del Viscovo

Author Guid elines for Submission to JAASEP

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A Comparison of the Effects of Tactile and Auditory Stimulation and Choice on the Problem Solving of Students with Attention Problems Stacey Emmert, Suneeta Kercood and Janice A. Grskovic

Significance of Multiple Intelligence Among Children with Special Needs S.Saradha priyadarshini

Foster Youth Who Have Succeeded in Higher Education: Common Themes Thomas Lovitt and John Emerson

A Mother’s Story about Raising Children with Disabilities Sadia Warsi

Due Process: A Primer for Special Education Teachers Roberta Wiener

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JAASEP - Fall 2008 - Login Required

Social Skills Training: Evaluating its Effectiveness for Students with Learning Disabilities, Emotional, and Behavioral Disorders Gregory Campbell

Assessment Beyond IQ Donna Riccio Omichinski, Marie Van Tubbergen, & Seth Warschausky

A Qualitative Study of Students with Behavioral Problems Participating in Service-Learning Michael P. O’Connor

Incorporating Research Based Strategies to Empower Educational Staff in Supporting Students with EBD Cathy A. Bradley, Courtney Degler, Larry Zamora & Michael Fitzpatrick

Steps for Special Education Teachers to Take to Appropriately Service Students Who Practice Islam Matthew D. Lucas

Inclusive Education Lukischa Lambert

Perceptual Differences in Quality Standards Among Teachers and Related Service Personnel Who Work with Students with Emotional/Behavioral Disorders Maria L. Manning, Lyndal M. Bullock and Robert A. Gable

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Instructional Tactics That Facilitate Inclusion William N. Bender, Richard T. Boon & Joe Ann Hinrichs

Master's Level Teacher Preparation for Educating Immigrant Students with Special Needs in US Schools John J. Hoover, Ph.D., Judy Smith-Davis, Ph.D., Leonard Baca, Ed.D., & Emily Wexler Love, Doctoral Candidate

Special Education Editorial: Autism Should Be a Singular Discipline for Undergraduate Study Sara E. Nixon

No Child Left Behind: Implications for Special Education Students and Students with Limited English Proficiency Dr. Mark E. Jewell

Cultural Identity and Special Education Teachers Loretta Salas, Ed.D., & Eric J. López, Ph.D.

Special Education Debate

Natalie Bogg & Vernette Hansen

The Impact of Assistive Technology on Vocabulary Acquistion of a Middle School Student with Learning Disabilities and Limited English Proficiency James E. Gentry, Ed.D. & Pam Lindsey, Ph.D.

Seven Winnings to Inclusion Patricia Mahar, Ph.D

An Investigation of Agency and Marginality in Special Education Robert C. McOuat

“A League of Our Own”-The Implementation of the Vocabulary Football League Karen Talalas and Bill Gallache

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Table of contents.

Evaluating Childhood Bipolar Disorder: A Survey of School Psychologists Knowledge and Practices Linda A. Mayo and Joseph A. Mayo

Using the Choice-making Skills of Students with Disabilities for Educational Planning Marie Van Tubbergen, Donna Omichinski, and Seth Warschausky

Effects of Animal-Assisted Therapy on a Student with an Emotional/Behavioral Disorder Val Rae M. Boe

Self-Determination Skills in Postsecondary Students with Learning Disabilities Saleem A. Rasheed

Integrating Service-Learning in Teacher Education to Raise Disability Awareness Lynn DeCapua

Future Action Research  - The Relationship of the General and Special Education Teachers in the Inclusive Setting James D. Oliver III

Essay - Strategies for Differentiated Instruction Rachael Cook

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Faculty Epistemological Beliefs as a Mediator to Attitudes Toward Persons with Disabilities Lucy Barnard, Tara Stevens, Kamau O. Siwatu, & William Y. Lan

Relationship Between Service Coordinator Practices and Early Intervention Services Mary Beth Bruder and Carl J. Dunst

Individualized Interventions: When Teachers Resist Sharla N. Fasko

No Child Left Behind’s Implementation in Urban School Settings: Implications for Serving Students with Emotional and Behavior Disorders Michael Fitzpatrick and Earle Knowlton

The Impact of High-Stakes Testing for Individuals with Disabilities: A Review Synthesis Richard Boon, Debbie Voltz, Carl Lawson, Sr.,and Michael Baskette

Special Education Professionals and Assistive Technology: Requirements for Preparation in a Digital Age George R. Peterson-Karlan, Jack J. Hourcade, Howard P. Parette, and Brian W. Wojcik

Book Review - The Short Bus: A Journey Beyond Normal Richard L. Mehrenberg

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A Meta-analytic Review: Teachers’ Attitudes Toward Students with Disabilities Thienhuong Hoang and Mark Dalimonte

Recruitment and Retention of Assessment Personnel Cynthia G. Simpson, Sharon A. Lynch, and Vicky G. Spencer

Paving the Way for Women with Asperger Syndrome Karen Hurlbutt

No Child Left Behind and Paraprofessionals: Are They Perceived To Be Highly Qualified? Heather G. Nelson, Betty Y. Ashbaker, Shannon Coetzee, and Jill Morgan

Using a Checkbook Management System to Decrease the Inappropriate Speaking-Out Behaviors of a 14-Year-Old Special Education Student Martha Smith-Fontenot and Wendy Lowe Siegel

The Section 504 Process in Middle School: Perspectives of Parents, Teachers and Section 504 Coordinators Kari Chiasson and Myrna R. Olson

Winter 2007 JAASEP - Login Required

Widely Used Disciplinary Options for Aggressive Kids: Are the Current Approaches Effective? Tracy Blankenship and William N. Bender

The Effects of Functional Communication Training on the Appropriate Behavior of a Student with Emotional and Behavioral Disorders Kristine Jolivette, Janine P. Stichter, David E. Houchins, and Christina Kennedy

School-Age Homeless Children: Crucial Transporters of Literacy Activities in the Shelter Sadia Warsi

Transition Planning: Improved Methods to Promote Student Success from High School to the Workforce Christopher Martin, Richard T. Boon, and Cordy Love

A Comparison of Inclusive versus Resource Classroom Placement for Black Students with Mild Disabilities at the Secondary Level: Is There a Need for Separation? Earle Graham, Carl Lawson, Saleem `A. Rasheed,  and Deborah Voltz

Adventure Based Learning Experience (ABLE) Robert M. White

FALL 2006 JAASEP - LOGIN to Access Articles

The Emperor Has No Clothes! Unanswered Questions and Concerns on the Response To Intervention Procedure Michael R. Baskette, Lisa Ulmer, and William N. Bender 

Creating a Motivating Classroom: What Really Motivates Students to Achieve in Secondary Content-Area Classrooms? Richard T. Boon, Vicky G. Spencer, & Tara Jeffs

Does Inclusion Work?  Teacher Verification of Proof of Impact Sherwin D. Holmes, Joyce W. Barclay, Bonnie Dupuis, Valerie K. Lewis, Morgan Platt, and Steven H. Shaha

A Glimpse into the Lives of Mothers and their Children in a Homeless Shelter: What has Changed Over the Decades? Sadia Warsi

Using Conceptual Models of Teaching to Incorporate a Dog into a Self-Contained Classroom for Students with Severe Emotional or Behavioral Disorders: A Research-Based Intervention Katherine L. Anderson and Myrna R. Olson

Improving the Spelling Performance of Students Who Are Deaf and Exhibit Characteristics Consistent with Learning Disabilities Monica Soukup

Teaching Homeless Students or Others about Homelessness:  Juvenile Literature Can Help Marissa Johnstun, Mary Anne Prater, Tina Taylor Dyches

Summer 2006 JAASEP - Login Required to Access Articles

The Perspectives and Assumptions of Pupil Appraisal Professionals in the Identification Process for Students with Behavioral Concerns Janice Rutledge Janz and Mary M. Banbury

Educational Implications for Children in Homeless Shelters and Beyond: Implications for All Educators and Child Advocates Sadia Warsi and Dorota Celinska

Research on Self-Management Techniques Used by Students with Disabilities in General Education Settings: A Promise Fulfilled? Dennis McDougall, Jim Skouge, Anthony Farrell and Kathy Hoff

Does Inclusion Help Students: Perspectives from Regular Education and Students with Disabilities Bonnie Dupuis, Joyce W. Barclay, Sherwin D. Holmes, Morgan Platt, Steven H. Shaha, and Valerie K. Lewis

What Does Health Have to Do with Transition? Everything! Ceci Shapland

Teaching Children With Autistic Spectrum Disorder: A Preschool Teacher Survey To Determine Best Practice Approach Joanne Grossi-Kliss,OTR/L

International Perspectives on Attention-Deficit/Hyperactivity Disorder: A Comparison of Teachers in the United States and Sweden Steven Carlson, William Frankenberger, Kristina M. Hall, Sara J. Totten, and Katarina House

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• v.30(1); 2021 Feb

Principles of Clinical Ethics and Their Application to Practice

An overview of ethics and clinical ethics is presented in this review. The 4 main ethical principles, that is beneficence, nonmaleficence, autonomy, and justice, are defined and explained. Informed consent, truth-telling, and confidentiality spring from the principle of autonomy, and each of them is discussed. In patient care situations, not infrequently, there are conflicts between ethical principles (especially between beneficence and autonomy). A four-pronged systematic approach to ethical problem-solving and several illustrative cases of conflicts are presented. Comments following the cases highlight the ethical principles involved and clarify the resolution of these conflicts. A model for patient care, with caring as its central element, that integrates ethical aspects (intertwined with professionalism) with clinical and technical expertise desired of a physician is illustrated.

Highlights of the Study

• Main principles of ethics, that is beneficence, nonmaleficence, autonomy, and justice, are discussed.
• Autonomy is the basis for informed consent, truth-telling, and confidentiality.
• A model to resolve conflicts when ethical principles collide is presented.
• Cases that highlight ethical issues and their resolution are presented.
• A patient care model that integrates ethics, professionalism, and cognitive and technical expertise is shown.

Introduction

A defining responsibility of a practicing physician is to make decisions on patient care in different settings. These decisions involve more than selecting the appropriate treatment or intervention.

Ethics is an inherent and inseparable part of clinical medicine [ 1 ] as the physician has an ethical obligation (i) to benefit the patient, (ii) to avoid or minimize harm, and to (iii) respect the values and preferences of the patient. Are physicians equipped to fulfill this ethical obligation and can their ethical skills be improved? A goal-oriented educational program [ 2 ] (Table ​ (Table1) 1 ) has been shown to improve learner awareness, attitudes, knowledge, moral reasoning, and confidence [ 3 , 4 ].

Goals of ethics education

Ethics, Morality, and Professional Standards

Ethics is a broad term that covers the study of the nature of morals and the specific moral choices to be made. Normative ethics attempts to answer the question, “Which general moral norms for the guidance and evaluation of conduct should we accept, and why?” [ 5 ]. Some moral norms for right conduct are common to human kind as they transcend cultures, regions, religions, and other group identities and constitute common morality (e.g., not to kill, or harm, or cause suffering to others, not to steal, not to punish the innocent, to be truthful, to obey the law, to nurture the young and dependent, to help the suffering, and rescue those in danger). Particular morality refers to norms that bind groups because of their culture, religion, profession and include responsibilities, ideals, professional standards, and so on. A pertinent example of particular morality is the physician's “accepted role” to provide competent and trustworthy service to their patients. To reduce the vagueness of “accepted role,” physician organizations (local, state, and national) have codified their standards. However, complying with these standards, it should be understood, may not always fulfill the moral norms as the codes have “often appeared to protect the profession's interests more than to offer a broad and impartial moral viewpoint or to address issues of importance to patients and society” [ 6 ].

Bioethics and Clinical (Medical) Ethics

A number of deplorable abuses of human subjects in research, medical interventions without informed consent, experimentation in concentration camps in World War II, along with salutary advances in medicine and medical technology and societal changes, led to the rapid evolution of bioethics from one concerned about professional conduct and codes to its present status with an extensive scope that includes research ethics, public health ethics, organizational ethics, and clinical ethics.

Hereafter, the abbreviated term, ethics, will be used as I discuss the principles of clinical ethics and their application to clinical practice.

The Fundamental Principles of Ethics

Beneficence, nonmaleficence, autonomy, and justice constitute the 4 principles of ethics. The first 2 can be traced back to the time of Hippocrates “to help and do no harm,” while the latter 2 evolved later. Thus, in Percival's book on ethics in early 1800s, the importance of keeping the patient's best interest as a goal is stressed, while autonomy and justice were not discussed. However, with the passage of time, both autonomy and justice gained acceptance as important principles of ethics. In modern times, Beauchamp and Childress' book on Principles of Biomedical Ethics is a classic for its exposition of these 4 principles [ 5 ] and their application, while also discussing alternative approaches.

Beneficence

The principle of beneficence is the obligation of physician to act for the benefit of the patient and supports a number of moral rules to protect and defend the right of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger. It is worth emphasizing that, in distinction to nonmaleficence, the language here is one of positive requirements. The principle calls for not just avoiding harm, but also to benefit patients and to promote their welfare. While physicians' beneficence conforms to moral rules, and is altruistic, it is also true that in many instances it can be considered a payback for the debt to society for education (often subsidized by governments), ranks and privileges, and to the patients themselves (learning and research).

Nonmaleficence

Nonmaleficence is the obligation of a physician not to harm the patient. This simply stated principle supports several moral rules − do not kill, do not cause pain or suffering, do not incapacitate, do not cause offense, and do not deprive others of the goods of life. The practical application of nonmaleficence is for the physician to weigh the benefits against burdens of all interventions and treatments, to eschew those that are inappropriately burdensome, and to choose the best course of action for the patient. This is particularly important and pertinent in difficult end-of-life care decisions on withholding and withdrawing life-sustaining treatment, medically administered nutrition and hydration, and in pain and other symptom control. A physician's obligation and intention to relieve the suffering (e.g., refractory pain or dyspnea) of a patient by the use of appropriate drugs including opioids override the foreseen but unintended harmful effects or outcome (doctrine of double effect) [ 7 , 8 ].

The philosophical underpinning for autonomy, as interpreted by philosophers Immanuel Kant (1724–1804) and John Stuart Mill (1806–1873), and accepted as an ethical principle, is that all persons have intrinsic and unconditional worth, and therefore, should have the power to make rational decisions and moral choices, and each should be allowed to exercise his or her capacity for self-determination [ 9 ]. This ethical principle was affirmed in a court decision by Justice Cardozo in 1914 with the epigrammatic dictum, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body” [ 10 ].

Autonomy, as is true for all 4 principles, needs to be weighed against competing moral principles, and in some instances may be overridden; an obvious example would be if the autonomous action of a patient causes harm to another person(s). The principle of autonomy does not extend to persons who lack the capacity (competence) to act autonomously; examples include infants and children and incompetence due to developmental, mental or physical disorder. Health-care institutions and state governments in the US have policies and procedures to assess incompetence. However, a rigid distinction between incapacity to make health-care decisions (assessed by health professionals) and incompetence (determined by court of law) is not of practical use, as a clinician's determination of a patient's lack of decision-making capacity based on physical or mental disorder has the same practical consequences as a legal determination of incompetence [ 11 ].

Detractors of the principle of autonomy question the focus on the individual and propose a broader concept of relational autonomy (shaped by social relationships and complex determinants such as gender, ethnicity and culture) [ 12 ]. Even in an advanced western country such as United States, the culture being inhomogeneous, some minority populations hold views different from that of the majority white population in need for full disclosure, and in decisions about life support (preferring a family-centered approach) [ 13 ].

Resistance to the principle of patient autonomy and its derivatives (informed consent, truth-telling) in non-western cultures is not unexpected. In countries with ancient civilizations, rooted beliefs and traditions, the practice of paternalism ( this term will be used in this article, as it is well-entrenched in ethics literature, although parentalism is the proper term ) by physicians emanates mostly from beneficence. However, culture (a composite of the customary beliefs, social forms, and material traits of a racial, religious or social group) is not static and autonomous, and changes with other trends over passing years. It is presumptuous to assume that the patterns and roles in physician-patient relationships that have been in place for a half a century and more still hold true. Therefore, a critical examination of paternalistic medical practice is needed for reasons that include technological and economic progress, improved educational and socioeconomic status of the populace, globalization, and societal movement towards emphasis on the patient as an individual, than as a member of a group. This needed examination can be accomplished by research that includes well-structured surveys on demographics, patient preferences on informed consent, truth-telling, and role in decision-making.

Respecting the principle of autonomy obliges the physician to disclose medical information and treatment options that are necessary for the patient to exercise self-determination and supports informed consent, truth-telling, and confidentiality.

Informed Consent

The requirements of an informed consent for a medical or surgical procedure, or for research, are that the patient or subject (i) must be competent to understand and decide, (ii) receives a full disclosure, (iii) comprehends the disclosure, (iv) acts voluntarily, and (v) consents to the proposed action.

The universal applicability of these requirements, rooted and developed in western culture, has met with some resistance and a suggestion to craft a set of requirements that accommodate the cultural mores of other countries [ 14 ]. In response and in vigorous defense of the 5 requirements of informed consent, Angell wrote, “There must be a core of human rights that we would wish to see honored universally, despite variations in their superficial aspects …The forces of local custom or local law cannot justify abuses of certain fundamental rights, and the right of self-determination on which the doctrine of informed consent is based, is one of them” [ 15 ].

As competence is the first of the requirements for informed consent, one should know how to detect incompetence. Standards (used singly or in combination) that are generally accepted for determining incompetence are based on the patient's inability to state a preference or choice, inability to understand one's situation and its consequences, and inability to reason through a consequential life decision [ 16 ].

In a previously autonomous, but presently incompetent patient, his/her previously expressed preferences (i.e., prior autonomous judgments) are to be respected [ 17 ]. Incompetent (non-autonomous) patients and previously competent (autonomous), but presently incompetent patients would need a surrogate decision-maker. In a non-autonomous patient, the surrogate can use either a substituted judgment standard (i.e., what the patient would wish in this circumstance and not what the surrogate would wish), or a best interests standard (i.e., what would bring the highest net benefit to the patient by weighing risks and benefits). Snyder and Sulmasy [ 18 ], in their thoughtful article, provide a practical and useful option when the surrogate is uncertain of the patient's preference(s), or when patient's preferences have not kept abreast of scientific advances. They suggest the surrogate use “substituted interests,” that is, the patient's authentic values and interests, to base the decision.

Truth-Telling

Truth-telling is a vital component in a physician-patient relationship; without this component, the physician loses the trust of the patient. An autonomous patient has not only the right to know (disclosure) of his/her diagnosis and prognosis, but also has the option to forgo this disclosure. However, the physician must know which of these 2 options the patient prefers.

In the United States, full disclosure to the patient, however grave the disease is, is the norm now, but was not so in the past. Significant resistance to full disclosure was highly prevalent in the US, but a marked shift has occurred in physicians' attitudes on this. In 1961, 88% of physicians surveyed indicated their preference to avoid disclosing a diagnosis [ 19 ]; in 1979, however, 98% of surveyed physicians favored it [ 20 ]. This marked shift is attributable to many factors that include − with no order of importance implied − educational and socioeconomic progress, increased accountability to society, and awareness of previous clinical and research transgressions by the profession.

Importantly, surveys in the US show that patients with cancer and other diseases wish to have been fully informed of their diagnoses and prognoses. Providing full information, with tact and sensitivity, to patients who want to know should be the standard. The sad consequences of not telling the truth regarding a cancer include depriving the patient of an opportunity for completion of important life-tasks: giving advice to, and taking leave of loved ones, putting financial affairs in order, including division of assets, reconciling with estranged family members and friends, attaining spiritual order by reflection, prayer, rituals, and religious sacraments [ 21 , 22 ].

In contrast to the US, full disclosure to the patient is highly variable in other countries [ 23 ]. A continuing pattern in non-western societies is for the physician to disclose the information to the family and not to the patient. The likely reasons for resistance of physicians to convey bad news are concern that it may cause anxiety and loss of hope, some uncertainty on the outcome, or belief that the patient would not be able to understand the information or may not want to know. However, this does not have to be a binary choice, as careful understanding of the principle of autonomy reveals that autonomous choice is a right of a patient, and the patient, in exercising this right, may authorize a family member or members to make decisions for him/her.

Confidentiality

Physicians are obligated not to disclose confidential information given by a patient to another party without the patient's authorization. An obvious exception (with implied patient authorization) is the sharing necessary of medical information for the care of the patient from the primary physician to consultants and other health-care teams. In the present-day modern hospitals with multiple points of tests and consultants, and the use of electronic medical records, there has been an erosion of confidentiality. However, individual physicians must exercise discipline in not discussing patient specifics with their family members or in social gatherings [ 24 ] and social media. There are some noteworthy exceptions to patient confidentiality. These include, among others, legally required reporting of gunshot wounds and sexually transmitted diseases and exceptional situations that may cause major harm to another (e.g., epidemics of infectious diseases, partner notification in HIV disease, relative notification of certain genetic risks, etc.).

Justice is generally interpreted as fair, equitable, and appropriate treatment of persons. Of the several categories of justice, the one that is most pertinent to clinical ethics is distributive justice . Distributive justice refers to the fair, equitable, and appropriate distribution of health-care resources determined by justified norms that structure the terms of social cooperation [ 25 ]. How can this be accomplished? There are different valid principles of distributive justice. These are distribution to each person (i) an equal share, (ii) according to need, (iii) according to effort, (iv) according to contribution, (v) according to merit, and (vi) according to free-market exchanges. Each principle is not exclusive, and can be, and are often combined in application. It is easy to see the difficulty in choosing, balancing, and refining these principles to form a coherent and workable solution to distribute medical resources.

Although this weighty health-care policy discussion exceeds the scope of this review, a few examples on issues of distributive justice encountered in hospital and office practice need to be mentioned. These include allotment of scarce resources (equipment, tests, medications, organ transplants), care of uninsured patients, and allotment of time for outpatient visits (equal time for every patient? based on need or complexity? based on social and or economic status?). Difficult as it may be, and despite the many constraining forces, physicians must accept the requirement of fairness contained in this principle [ 26 ]. Fairness to the patient assumes a role of primary importance when there are conflicts of interests. A flagrant example of violation of this principle would be when a particular option of treatment is chosen over others, or an expensive drug is chosen over an equally effective but less expensive one because it benefits the physician, financially, or otherwise.

Conflicts between Principles

Each one of the 4 principles of ethics is to be taken as a prima facie obligation that must be fulfilled, unless it conflicts, in a specific instance, with another principle. When faced with such a conflict, the physician has to determine the actual obligation to the patient by examining the respective weights of the competing prima facie obligations based on both content and context. Consider an example of a conflict that has an easy resolution: a patient in shock treated with urgent fluid-resuscitation and the placement of an indwelling intravenous catheter caused pain and swelling. Here the principle of beneficence overrides that of nonmaleficence. Many of the conflicts that physicians face, however, are much more complex and difficult. Consider a competent patient's refusal of a potentially life-saving intervention (e.g., instituting mechanical ventilation) or request for a potentially life-ending action (e.g., withdrawing mechanical ventilation). Nowhere in the arena of ethical decision-making is conflict as pronounced as when the principles of beneficence and autonomy collide.

Beneficence has enjoyed a historical role in the traditional practice of medicine. However, giving it primacy over patient autonomy is paternalism that makes a physician-patient relationship analogous to that of a father/mother to a child. A father/mother may refuse a child's wishes, may influence a child by a variety of ways − nondisclosure, manipulation, deception, coercion etc., consistent with his/her thinking of what is best for the child. Paternalism can be further divided into soft and hard .

In soft paternalism, the physician acts on grounds of beneficence (and, at times, nonmaleficence) when the patient is nonautonomous or substantially nonautonomous (e.g., cognitive dysfunction due to severe illness, depression, or drug addiction) [ 27 ]. Soft paternalism is complicated because of the difficulty in determining whether the patient was nonautonomous at the time of decision-making but is ethically defensible as long as the action is in concordance with what the physician believes to be the patient's values. Hard paternalism is action by a physician, intended to benefit a patient, but contrary to the voluntary decision of an autonomous patient who is fully informed and competent, and is ethically indefensible.

On the other end of the scale of hard paternalism is consumerism, a rare and extreme form of patient autonomy, that holds the view that the physician's role is limited to providing all the medical information and the available choices for interventions and treatments while the fully informed patient selects from the available choices. In this model, the physician's role is constrained, and does not permit the full use of his/her knowledge and skills to benefit the patient, and is tantamount to a form of patient abandonment and therefore is ethically indefensible.

Faced with the contrasting paradigms of beneficence and respect for autonomy and the need to reconcile these to find a common ground, Pellegrino and Thomasma [ 28 ] argue that beneficence can be inclusive of patient autonomy as “the best interests of the patients are intimately linked with their preferences” from which “are derived our primary duties to them.”

One of the basic and not infrequent reasons for disagreement between physician and patient on treatment issues is their divergent views on goals of treatment. As goals change in the course of disease (e.g., a chronic neurologic condition worsens to the point of needing ventilator support, or a cancer that has become refractory to treatment), it is imperative that the physician communicates with the patient in clear and straightforward language, without the use of medical jargon, and with the aim of defining the goal(s) of treatment under the changed circumstance. In doing so, the physician should be cognizant of patient factors that compromise decisional capacity, such as anxiety, fear, pain, lack of trust, and different beliefs and values that impair effective communication [ 29 ].

The foregoing theoretical discussion on principles of ethics has practical application in clinical practice in all settings. In the resource book for clinicians, Jonsen et al. [ 30 ] have elucidated a logical and well accepted model (Table ​ (Table2), 2 ), along the lines of the systematic format that practicing physicians have been taught and have practiced for a long time (Chief Complaint, History of Present Illness, Past History, pertinent Family and Social History, Review of Systems, Physical Examination and Laboratory and Imaging studies). This practical approach to problem-solving in ethics involves:

• Clinical assessment (identifying medical problems, treatment options, goals of care)
• Patient (finding and clarifying patient preferences on treatment options and goals of care)
• Quality of life (QOL) (effects of medical problems, interventions and treatments on patient's QOL with awareness of individual biases on what constitutes an acceptable QOL)
• Context (many factors that include family, cultural, spiritual, religious, economic and legal).

Application of principles of ethics in patient care

Using this model, the physician can identify the principles that are in conflict, ascertain by weighing and balancing what should prevail, and when in doubt, turn to ethics literature and expert opinion.

Illustrative Cases

There is a wide gamut of clinical patient encounters with ethical issues, and some, especially those involving end-of-life care decisions, are complex. A few cases (Case 1 is modified from resource book [ 30 ]) are presented below as they highlight the importance of understanding and weighing the ethical principles involved to arrive at an ethically right solution. Case 6 was added during the revision phase of this article as it coincided with the outbreak of Coronavirus Infectious Disease-2019 (COVID-19) that became a pandemic rendering a discussion of its ethical challenges necessary and important.

A 20-year old college student living in the college hostel is brought by a friend to the Emergency Department (ED) because of unrelenting headache and fever. He appeared drowsy but was responsive and had fever (40°C), and neck rigidity on examination. Lumbar puncture was done, and spinal fluid appeared cloudy and showed increased white cells; Gram stain showed Gram-positive diplococci. Based on the diagnosis of bacterial meningitis, appropriate antibiotics were begun, and hospitalization was instituted. Although initial consent for diagnosis was implicit, and consent for lumbar puncture was explicit, at this point, the patient refuses treatment without giving any reason, and insists to return to his hostel. Even after explanation by the physician as to the seriousness of his diagnosis, and the absolute need for prompt treatment (i.e., danger to life without treatment), the patient is adamant in his refusal.

Comment . Because of this refusal, the medical indications and patient preferences (see Table ​ Table2) 2 ) are at odds. Is it ethically right to treat against his will a patient who is making a choice that has dire consequences (disability, death) who gives no reason for this decision, and in whom a clear determination of mental incapacity cannot be made (although altered mental status may be presumed)? Here the principle of beneficence and principle of autonomy are in conflict. The weighing of factors: (1) patient may not be making a reasoned decision in his best interest because of temporary mental incapacity; and (2) the severity of life-threatening illness and the urgency to treat to save his life supports the decision in favor of beneficence (i.e., to treat).

A 56-year old male lawyer and current cigarette smoker with a pack-a-day habit for more than 30 years, is found to have a solitary right upper lobe pulmonary mass 5 cm in size on a chest radiograph done as part of an insurance application. The mass has no calcification, and there are no other pulmonary abnormalities. He has no symptoms, and his examination is normal. Tuberculosis skin test is negative, and he has no history of travel to an endemic area of fungal infection. As lung cancer is the most probable and significant diagnosis to consider, and early surgical resection provides the best prospects for cure, the physician, in consultation with the thoracic surgeon, recommends bronchoscopic biopsy and subsequent resection. The patient understands the treatment plan, and the significance of not delaying the treatment. However, he refuses, and states that he does not think he has cancer; and is fearful that the surgery would kill him. Even after further explanations on the low mortality of surgery and the importance of removing the mass before it spreads, he continues to refuse treatment.

Comment . Even though the physician's prescribed treatment, that is, removal of the mass that is probably cancer, affords the best chance of cure, and delay in its removal increases its chance of metastases and reaching an incurable stage − the choice by this well informed and mentally competent patient should be respected. Here, autonomy prevails over beneficence. The physician, however, may not abandon the patient and is obligated to offer continued outpatient visits with advice against making decision based on fear, examinations, periodic tests, and encouragement to seek a second opinion.

A 71-year-old man with very severe chronic obstructive pulmonary disease (COPD) is admitted to the intensive care unit (ICU) with pneumonia, sepsis, and respiratory failure. He is intubated and mechanically ventilated. For the past 2 years, he has been on continuous oxygen treatment and was short of breath on minimal exertion. In the past 1 year, he had 2 admissions to the ICU; on both occasions he required intubation and mechanical ventilation. Presently, even with multiple antibiotics, intravenous fluid hydration, and vasopressors, his systolic blood pressure remains below 60 mm Hg, and with high flow oxygen supplementation, his oxygen saturation stays below 80%; his arterial blood pH is 7.0. His liver enzymes are elevated. He is anuric, and over next 8 h his creatinine has risen to 5 mg/dL and continues to rise. He has drifted into a comatose state. The intensivist suggests discontinuation of vasopressors and mechanical ventilation as their continued use is futile. The patient has no advance care directives or a designated health-care proxy.

Comment . The term “futility” is open to different definitions [ 31 ] and is often controversial, and therefore, some experts suggest the alternate term, “clinically non-beneficial interventions” [ 32 ]. However, in this case the term futility is appropriate to indicate that there is evidence of physiological futility (multisystem organ failure in the setting of preexisting end stage COPD, and medical interventions would not reverse the decline). It is appropriate then to discuss the patient's condition with his family with the goal of discontinuing life-sustaining interventions. These discussions should be done with sensitivity, compassion and empathy. Palliative care should be provided to alleviate his symptoms and to support the family until his death and beyond in their bereavement.

A 67-year old widow, an immigrant from southern India, is living with her son and his family in Wisconsin, USA. She was experiencing nausea, lack of appetite and weight loss for a few months. During the past week, she also had dark yellow urine, and yellow coloration of her skin. She has basic knowledge of English. She was brought to a multi-specialty teaching hospital by her son, who informed the doctor that his mother has “jaundice,” and instructed that, if any serious life-threatening disease was found, not to inform her. He asked that all information should come to him, and if there is any cancer not to treat it, since she is older and frail. Investigations in the hospital reveals that she has pancreatic cancer, and chemotherapy, while not likely to cure, would prolong her life.

Comment . In some ancient cultures, authority is given to members of the family (especially senior men) to make decisions that involve other members on marriage, job, and health care. The woman in this case is a dependent of her son, and given this cultural perspective, the son can rightfully claim to have the authority to make health-care decisions for her. Thus, the physician is faced with multiple tasks that may not be consonant. To respect cultural values [ 33 ], to directly learn the patient's preferences, to comply with the American norm of full disclosure to the patient, and to refuse the son's demands.

The principle of autonomy provides the patient the option to delegate decision-making authority to another person. Therefore, the appropriate course would be to take the tactful approach of directly informing the patient (with a translator if needed), that the diagnosed disease would require decisions for appropriate treatment. The physician should ascertain whether she would prefer to make these decisions herself, or whether she would prefer all information to be given to her son, and all decisions to be made by him.

A 45-year-old woman had laparotomy and cholecystectomy for abdominal pain and multiple gall stones. Three weeks after discharge from the hospital, she returned with fever, abdominal pain, and tenderness. She was given antibiotics, and as her fever continued, laparotomy and exploration were undertaken; a sponge left behind during the recent cholecystectomy was found. It was removed, the area cleansed, and incision closed. Antibiotics were continued, and she recovered without further incident and was discharged. Should the surgeon inform the patient of his error?

Comment . Truth-telling, a part of patient autonomy is very much applicable in this situation and disclosure to patient is required [ 34 , 35 , 36 ]. The mistake caused harm to the patient (morbidity and readmission, and a second surgery and monetary loss). Although the end result remedied the harm, the surgeon is obligated to inform the patient of the error and its consequences and offer an apology. Such errors are always reported to the Operating Room Committees and Surgical Quality Improvement Committees of US Hospitals. Hospital-based risk reduction mechanisms (e.g., Risk Management Department) present in most US hospitals would investigate the incident and come up with specific recommendations to mitigate the error and eliminate them in the future. Many institutions usually make financial settlements to obviate liability litigation (fees and hospital charges waived, and/or monetary compensation made to the patient). Elsewhere, if such mechanisms do not exist, it should be reported to the hospital. Acknowledgment from the hospital, apologies from the institution and compensation for the patient are called for. Whether in US or elsewhere, a malpractice suit is very possible in this situation, but a climate of honesty substantially reduces the threat of legal claims as most patients trust their physicians and are not vindictive.

The following scenario is at a city hospital during the peak of the COVID-19 pandemic: A 74-year-old woman, residing in an assisted living facility, is brought to the ED with shortness of breath and malaise. Over the past 4 days she had been experiencing dry cough, lack of appetite, and tiredness; 2 days earlier, she stopped eating and started having a low-grade fever. A test for COVID-19 undertaken by the assisted living facility was returned positive on the morning of the ED visit.

She, a retired nurse, is a widow; both of her grown children live out-of-state. She has had hypertension for many years, controlled with daily medications. Following 2 strokes, she was moved to an assisted living facility 3 years ago. She recovered most of her functions after the strokes and required help only for bathing and dressing. She is able to answer questions appropriately but haltingly, because of respiratory distress. She has tachypnea (34/min), tachycardia (120/min), temperature of 101°F, BP 100/60 and 90% O 2 saturation (on supplemental O 2 of 4 L/min). She has dry mouth and tongue and rhonchi on lung auscultation. Her respiratory rate is increasing on observation and she is visibly tiring.

Another patient is now brought in by ambulance; this is a 22-year-old man living in an apartment and has had symptoms of “flu” for a week. Because of the pandemic, he was observing the recommended self-distancing, and had no known exposure to coronavirus. He used saline gargles, acetaminophen, and cough syrup to alleviate his sore throat, cough, and fever. In the past 2 days, his symptoms worsened, and he drove himself to a virus testing station and got tested for COVID-19; he was told that he would be notified of the results. He returned to his apartment and after a sleepless night with fever, sweats, and persistent cough, he woke up and felt drained of all strength. The test result confirmed COVID-19. He then called for an ambulance.

He has been previously healthy. He is a non-smoker and uses alcohol rarely. He is a second-year medical student. He is single, and his parents and sibling live hundreds of miles away.

On examination, he has marked tachypnea (>40/min), shallow breathing, heart rate of 128/min, temperature of 103°F and O 2 saturation of 88 on pulse oximetry. He appears drowsy and is slow to respond to questions. He is propped up to a sitting position as it is uncomfortable for him to be supine. Accessory muscles of neck and intercostals are contracting with each breath, and on auscultation, he has basilar crackles and scattered rhonchi. His O 2 saturation drops to 85 and he is in respiratory distress despite nebulized bronchodilator treatment.

Both of these patients are in respiratory failure, clinically and confirmed by arterial blood gases, and are in urgent need of intubation and mechanical ventilation. However, only one ventilator is available; who gets it?

Comment . The decision to allocate a scarce and potentially life-saving equipment (ventilator) is very difficult as it directly addresses the question “Who shall live when not everyone can live? [ 5 ]. This decision cannot be emotion-driven or arbitrary; nor should it be based on a person's wealth or social standing. Priorities need to be established ethically and must be applied consistently in the same institution and ideally throughout the state and the country. The general social norm to treat all equally or to treat on a first come, first saved basis is not the appropriate choice here. There is a consensus among clinical ethics scholars, that in this situation, maximizing benefits is the dominant value in making a decision [ 37 ]. Maximizing benefits can be viewed in 2 different ways; in lives saved or in life-years saved; they differ in that the first is non-utilitarian while the second is utilitarian. A subordinate consideration is giving priority to patients who have a better chance of survival and a reasonable life expectancy. The other 2 considerations are promoting and rewarding instrumental value (benefit to others) and the acuity of illness. Health-care workers (physicians, nurses, therapists etc.) and research participants have instrumental value as their work benefits others; among them those actively contributing are of more value than those who have made their contributions. The need to prioritize the sickest and the youngest is also a recognized value when these are aligned with the dominant value of maximizing benefits. In the context of COVID-19 pandemic, Emanuel et al. [ 37 ] weighed and analyzed these values and offered some recommendations. Some ethics scholars opine that in times of a pandemic, the burden of making a decision as to who gets a ventilator and who does not (often a life or death choice) should not be on the front-line physicians, as it may cause a severe and life-long emotional toll on them [ 35 , 36 ]. The toll can be severe for nurses and other front-line health-care providers as well. As a safeguard, they propose that the decision should rest on a select committee that excludes doctors, nurses and others who are caring for the patient(s) under consideration [ 38 ].

Both patients described in the case summaries have comparable acuity of illness and both are in need of mechanical ventilator support. However, in the dominant value of maximizing benefits the two patients differ; in terms of life-years saved, the second patient (22-year-old man) is ahead as his life expectancy is longer. Additionally, he is more likely than the older woman, to survive mechanical ventilation, infection, and possible complications. Another supporting factor in favor of the second patient is his potential instrumental value (benefit to others) as a future physician.

Unlike the other illustrative cases, the scenario of these 2 cases, does not lend itself to a peaceful and fully satisfactory resolution. The fairness of allocating a scarce and potentially life-saving resource based on maximizing benefits and preference to instrumental value (benefit to others) is open to question. The American College of Physicians has stated that allocation decisions during resource scarcity should be made “based on patient need, prognosis (determined by objective scientific measure and informed clinical judgment) and effectiveness (i.e., likelihood that the therapy will help the patient to recover), … to maximize the number of patients who will recover” [ 39 ].

This review has covered basics of ethics founded on morality and ethical principles with illustrative examples. In the following segment, professionalism is defined, its alignment with ethics depicted, and virtues desired of a physician (inclusive term for medical doctor regardless of type of practice) are elucidated. It concludes with my vision of an integrated model for patient care.

The core of professionalism is a therapeutic relationship built on competent and compassionate care by a physician that meets the expectation and benefits a patient. In this relationship, which is rooted in the ethical principles of beneficence and nonmaleficence, the physician fulfills the elements shown in Table ​ Table3. 3 . Professionalism “demands placing the interest of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health” [ 26 , 40 ].

Physicians obligations

Drawing on several decades of experience in teaching and mentoring, I envisage physicians with qualities of both “heart” and “head.” Ethical and humanistic values shape the former, while knowledge (e.g., by study, research, practice) and technical skills (e.g., medical and surgical procedures) form the latter. Figure ​ Figure1 1 is a representation of this model. Morality that forms the base of the model and ethical principles that rest on it were previously explained. Virtues are linked, some more tightly than others, to the principles of ethics. Compassion, a prelude to caring, presupposes sympathy, is expressed in beneficence. Discernment is especially valuable in decision-making when principles of ethics collide. Trustworthiness leads to trust, and is a needed virtue when patients, at their most vulnerable time, place themselves in the hands of physicians. Integrity involves the coherent integration of emotions, knowledge and aspirations while maintaining moral values. Physicians need both professional integrity and personal integrity, as the former may not cover all scenarios (e.g., prescribing ineffective drugs or expensive drugs when effective inexpensive drugs are available, performing invasive treatments or experimental research modalities without fully informed consent, any situation where personal monetary gain is placed over patient's welfare). Conscientiousness is required to determine what is right by critical reflection on good versus bad, better versus good, logical versus emotional, and right versus wrong.

Integrated model of patient care.

In my conceptualized model of patient care (Fig. ​ (Fig.1), 1 ), medical knowledge, skills to apply that knowledge, technical skills, practice-based learning, and communication skills are partnered with ethical principles and professional virtues. The virtues of compassion, discernment, trustworthiness, integrity, and conscientiousness are the necessary building blocks for the virtue of caring. Caring is the defining virtue for all health-care professions. In all interactions with patients, besides the technical expertise of a physician, the human element of caring (one human to another) is needed. In different situations, caring can be expressed verbally and non-verbally (e.g., the manner of communication with both physician and patient closely seated, and with unhurried, softly spoken words); a gentle touch especially when conveying “bad news”; a firmer touch or grip to convey reassurance to a patient facing a difficult treatment choice; to hold the hand of a patient dying alone). Thus, “caring” is in the center of the depicted integrated model, and as Peabody succinctly expressed it nearly a hundred years ago, “The secret of the care of the patient is caring for the patient” [ 41 ].

Conflict of Interest Statement

The author declares that he has no conflicts of interest.

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