EXECUTIVE SUMMARY

The American Society for Bioethics and Humanities (ASBH) is considering developing a national standard for assessment of individuals who perform clinical ethics consultations.

  • Some ethicists believe a national standard is necessary for clinical ethicists to be taken seriously in a healthcare climate increasingly focused on outcomes and evidence-based standards.
  • ASBH recently surveyed practicing ethics consultants across the country to assess their interest in a certification program, and define the knowledge and skills they use in their practice.
  • The results will help the ASBH board of directors determine whether to move forward with a national certification program.

Evaluation of individuals who perform healthcare ethics consultations (HCECs) varies widely. In some cases, it doesn’t occur at all.

“We would never tolerate that for any other clinical intervention, be it bypass surgery or primary care,” says Joseph J. Fins, MD, MACP, chief of the division of medical ethics at Weill Cornell Medical College in New York City.

Ethics consults often involve some of the most important decisions in the hospital, notes Fins. Ethicists routinely help to resolve issues such as whether life-sustaining therapies will be continued or withdrawn, or whether a patient’s religious beliefs are respected or not in the context of a medical need, for instance.

“We need to assure the American public that people who are doing ethics consults are capable of doing so,” says Fins. “It’s pivotal to the legitimacy of what we do.”

The American Society for Bioethics and Humanities (ASBH) recently surveyed practicing ethics consultants across the country to assess their interest in a possible certification program. The survey will also define the knowledge and skills that they use in their practice.

Current ASBH president Amy M. Haddad, PhD, expects the study’s findings to be considered at the board’s spring 2017 meeting.

“If the market research proves that a voluntary certification program is sustainable, the information we have gathered about knowledge and skills will form the foundation of a credible, defensible certification program to improve the quality of HCEC services,” reports Haddad, director of the Center for Health Policy and Ethics and Dr. C.C. and Mabel L. Criss endowed chair in the health sciences at Creighton University in Omaha, NE.

The ASBH survey included questions on ethicists’ background, work setting, and the core skills they rely on during consults, such as assessment, analysis, and moral reasoning. “A rating scale allowed respondents to express their judgment of the significance of each area as it applies to their current role in HCEC,” Haddad explains.

During his tenure as ASBH president, Fins convened a task force that took the first steps to assess the competence of clinical ethics consultants.1 “It’s untenable that clinical ethical consultation is not the object of some type of assessment and certification process,” Fins states. “It’s a patient safety issue.”

A recent study demonstrated that using portfolios as an evaluation tool for quality of clinical ethical consultation is a feasible approach.2

“We were able to demonstrate that we could assess the complex process of ethics consultation, with concurrence between reviewers,” says Fins. “That was a tremendous step forward in a rather nebulous area of assessment.”

The researchers view their findings as important progress toward an eventual certification process for clinical ethics consultants. “Conceptually, we proved it was doable. The next challenge will be implementation,” says Fins.

Fins believes a national standard is necessary for clinical ethicists to be taken seriously in a healthcare climate increasingly focused on outcomes and evidence-based standards.

“If we don’t seize the moment, it might jeopardize the field,” Fins says. “A standard is needed so people with similar kinds of dilemmas and problems are treated in a consistent fashion, as we would expect for any other clinical activity.”

Fins notes that important medical/legal decisions in the hospital setting are often handled by ethics committees.

“We have authority in hospitals, that in a sense, courts have ceded to us going back to Quinlan,” Fins says. “If we do not have a process that can withstand rigorous scrutiny, others will begin to question the legitimacy of the activity.”

How a certification process would be funded, and whether individuals who perform ethics consults would be willing to pay for certification, are important questions. “Establishing a national standard is not only a methodological problem to solve — it’s also a political and financial challenge,” says Fins.

To explore these issues, ASBH is currently conducting market research to assess the fiscal sustainability of a voluntary certification program. “The steps currently underway are designed to meet industry standards for legal defensibility and credibility,” Haddad explains. Criteria for accreditation, as established by organizations such as the National Commission for Certifying Agencies, must also be met.

Alexander A. Kon, MD, FAAP, FCCM, president-elect of ASBH, says that in order to obtain robust data, ASBH sent surveys to all known and potential healthcare ethics consultants throughout the U.S. “Based on the findings of this project, the ASBH board of directors will consider whether to move forward with a national certification program,” says Kon, clinical professor of pediatrics at University of California, San Diego School of Medicine.

The market research portion of the project is designed to assess interest among those currently providing HCEC services throughout the United States in obtaining national HCEC certification. This will provide data regarding feasibility and sustainability of national certification.

“The role delineation portion of the survey will provide a snapshot of what current healthcare ethics consultants do on a day-to-day basis,” explains Kon. This will shed light on what knowledge and skills consultants use in practice — necessary information for development of professional certification examinations.

“Therefore, this information is imperative if national certification in HCEC is to meet standards set by organizations that certify such professional certification programs,” says Kon.

Exciting Time for Ethics

Lack of standards for what qualifies an individual to provide ethics consults results in “tremendous variability in terms of quality of such services,” says Kon.

Hospitals may simply relegate this important task to individuals who are willing to take on the role, but lack the necessary expertise. “Assigning this task to individuals who lack appropriate education and training can — and often does — lead to substandard decision-making, and therefore, suboptimal patient care,” says Kon.

Creating standards for education and training, coupled with a national certification program, “has the potential to dramatically improve patient care,” says Kon. It also promises increased respect and credibility for the field. “As seen in other fields in healthcare — medicine, nursing, social work, chaplaincy, and pharmacy — as standards are promulgated, and professionals seek state or national certification, the quality of care improves,” says Kon.

With standards in place, adds Kon, “it is likely that facilities will be more willing to provide adequate funding for HCEC services, which is sorely needed.”

Haddad is enthusiastic about the future. “This is an exciting time for the field of clinical ethics consultation,” she says.

REFERENCES

  1. Kodish E, Fins JJ, Braddock C, et al. Quality attestation for clinical ethics consultants. Hastings Cent Rep 2013; 43(5): 26–36.
  2. Fins JJ, Kodish E, Cohn F, et al. A pilot evaluation of portfolios for quality attestation of clinical ethics consultants. Am J Bioeth 2016; 16(3):15-24.

SOURCES

  • Joseph J. Fins, MD, MACP, E. William Davis, Jr., MD Professor of Medical Ethics and Chief, Division of Medical Ethics, Weill Cornell Medical College/Director of Medical Ethics, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York City. Phone: (212) 746-4246. Fax: (212) 746-8738. Email: jjfins@med.cornell.edu.
  • Amy M. Haddad, PhD, Director, Center for Health Policy and Ethics/Dr. C.C. and Mabel L. Criss Endowed Chair in the Health Sciences, Creighton University, Omaha, NE. Phone: (402) 280-2164. Fax: (402) 280-5735. Email: ahaddad@creighton.edu.
  • Alexander A. Kon, MD, FAAP, FCCM, Clinical Professor of Pediatrics, University of California, San Diego School of Medicine. Email: kon.sandiego@gmail.com.