Improving the quality of clinical ethics consultants

Clinical ethicists play a vital role in hospitals and other health care systems by helping to resolve ethical conflicts that arise between patients, families, and clinicians about end-of-life care and other important medical decisions. To improve the quality of clinical ethics consultants, the American Society for Bioethics and Humanities (ASBH) has proposed a method for assessing them. An article in the Hastings Center Report describes the process and explains its importance.

Questionable credentials and unacceptable variations in practice patterns "may be placing patients at risk," write the authors, who make up a task force of ASBH, the main professional society for bioethicists and scholars in the medical humanities as well as for clinical ethics consultants practicing in the United States. There is no entrance examination and no prescribed educational requirement that qualifies someone to conduct clinical ethics consultations, and the practice is, the authors explain, "largely outside the scope of regulation and oversight." As a result, there has been a growing consensus in favor of creating a standardized system for assessing the knowledge, skills, and practice of clinical ethicists.

The method developed by the task force for evaluating the quality of clinical ethics consultants is a two-step process. The first step requires a candidate to submit a portfolio for review by the ASBH. The portfolio should include the individual's curriculum vitae or resume and a summary of his or her education and training related to ethics consultation, as well as a summary of the individual's philosophy of clinical ethics, letters of evaluation, and discussions of cases.

The authors explain that the portfolio is intended to show whether "a candidate has achieved a level of general competence as a clinical ethics consultant in a variety of clinical settings, regarding a wide range of ethical issues, and in a collaborative manner; to document that a candidate has a sufficient level of ability to function independently in CEC; and to provide evidence from a candidate that he or she is able to engage in what has been described as an 'entrustable' professional activity."

A candidate whose portfolio passes this step then moves on to the oral examination, which is partly based on the portfolio's contents.

The article was written by the ASBH Quality Attestation Presidential Task Force assembled by the society's president, Joseph J. Fins, MD, MACP, who is also the chief of the Division of Medical Ethics at Weill Cornell Medical College, as well as a member of The Hastings Center's board of directors and a Hastings Center Fellow. Eric Kodish, MD, who is director of the Cleveland Clinic's Center for Ethics, Humanities, and Spiritual Care and a Hastings Center Fellow, and Fins are the primary authors of the article.

"Although CEC [clinical ethics consultation] is not clinical practice in the conventional sense, its analytic and deliberative process can affect decisions about care and influence patient case management," the article states. "[C]linical ethics consultants have access to families and the medical record, and they are often called upon to mediate conflict and provide assistance at times of great stress and emotional need. They must be trained to avoid the risk of imposing their values and judgments."

The development of the quality attestation process represents an evolution in reflections on and critiques of the field by ASBH and others concerned with clinical ethics. ASBH's 1998 publication Core Competencies for Health Care Ethics Consultation, which provides an overview of the knowledge base and skills essential to clinical ethics consultation, is the foundation for the quality attestation process.

In addition to Kodish and Fins, the Quality Attestation Presidential Task Force members are Clarence Braddock III, MD, MPH, of the Center for Medical Education Research and Innovation, the Center for Medical Ethics, and the Division of General Internal Medicine, Department of Medicine, Stanford School of Medicine; Felicia Cohn, PhD, of Kaiser Permanente Orange County and the American Society for Bioethics and Humanities; Nancy Neveloff Dubler, LLB, of The Albert Einstein College of Medicine, the New York City Health and Hospitals Corporation, and the NYU Langone Medical Center; Marion Danis, MD, with the Section on Ethics and Health Policy, Department of Bioethics, NIH Clinical Center, National Institutes of Health; Arthur R. Derse, MD, JD, of the Center for Bioethics and Medical Humanities, Institute for Health and Society, Medical College of Wisconsin; Robert A. Pearlman, MD, MPH, with the National Center for Ethics in Health Care, United States Department of Veteran Affairs, and the University of Washington; Martin Smith, STD, of the Center for Ethics, Humanities and Spiritual Care, Department of Bioethics, Cleveland Clinic; Anita Tarzian, PhD, RN, of Family and Community Health, University of Maryland School of Nursing, and the Maryland Health Care Ethics Committee Network, University of Maryland School of Law; Stuart Youngner, MD, of the Department of Bioethics, Case Western Reserve University; and Mark G. Kuczewski, PhD, with the Neiswanger Institute for Bioethics and Health Policy, Health Sciences Division, Loyola University Chicago, and American Society for Bioethics and Humanities.

For more information, please contact Susan Gilbert, public affairs and communications manager, gilberts@thehastingscenter.org; 845-424-4040 x 244.