More than 300 ethicists now hold the American Society for Bioethics and Humanities (ASBH) Healthcare Ethics Consultant-Certified (HEC-C) credential. The authors of a recent analysis studied the program one year after its inception.1
“Many in the field have been working toward professionalization of clinical ethics for several years,” says lead author Claire Horner, JD, MA.
Various methods have been used to assess competence of ethicists. “One of the most notable efforts was the portfolio/attestation process,” recalls Horner, an assistant professor at the Baylor College of Medicine.
Participants submitted portfolios of their consultation work for evaluation by trained raters.2 More recently, ASBH developed a certification exam to evaluate the knowledge and skills of clinical ethics consultants.
“As members of an established clinical ethics program, we wanted to support this effort by taking the exam early on, and offering our honest feedback about the merits and shortcomings of this process,” Horner explains.
Since the certification is so new, it is unclear to what extent hospitals factor it into hiring decisions. “We hypothesize that hiring officers are going to assume this certification signifies a level of competence similar to licensure exam requirements of other healthcare workers, such as nurses or social workers,” Horner offers. Other recent developments:
• Some job postings now require ethicists to carry the HEC-C credential. “This could be dangerous, since this exam seems to establish a minimum threshold of ethics knowledge, which is not sufficient to certify that one is a competent ethics consultant,” Horner cautions.
The concern is hospitals are relying too heavily on the credential. “Hiring officers may assume the credential means the consultant is more highly qualified,” Horner observes.
In fact, there are many expert ethics consultants who have not taken the exam for various reasons. “The exam really establishes a minimum threshold of ethics knowledge,” Horner says. “It is not capable, in its current form, of commenting on the expertise or the clinical skills of the ethicist.”
For instance, communication skills, efficiency, and empathy are not evaluated. “The exam is a good first step,” Horner adds. “But it’s not yet ready to be used by institutions as a measure of a candidate’s ability to perform a high-quality ethics consultation.”
• The credential could pave the way to justify additional ethics resources. “Many clinical ethicists hope that the certification will be helpful to communicate the legitimacy of the field to administrators,” Horner says. This could result in more financial or personnel support for ethics.
• The credential has brought attention to the ethics field. “It has definitely shined a light on the conversation about professionalizing the field,” Horner offers.
The portfolio process was a pilot project aimed at testing feasibility. In contrast, the HEC-C exam has become an established program. “Regardless of the other ways the field of clinical ethics decides to evaluate and certify ethics consultants, the exam seems like it is here to stay,” Horner predicts. “We now have a solid base to build on.”
Previous approaches included requiring entry into the field through an accredited training program, an entrance exam, or allowing consultants to work in the field and submit evidence of their work for peer review. “All of the ideas put forth are different aspects of the kind of evaluation that is needed to assure that practicing clinical ethics consultants are proficient in their work,” Horner says.
It always was unclear which aspect of ethics evaluation should be developed first. “Now, we have our starting point,” Horner adds.
The authors studied and prepared for the HEC-C exam as a group. “We had similar reactions throughout the process of studying for and taking the exam,” says Sophia Fantus, PhD, an assistant professor at the University of Texas at Arlington School of Social Work. Mostly, the group questioned whether the exam, which consists of 110 multiple-choice questions, really painted an accurate picture of an ethicist’s expertise. It remains unclear how hospital administrators weigh the credential in hiring decisions.
Fantus obtained the certification in the second year of a clinical ethics fellowship, right before entering the job market. “During my interview process, there were some organizations who wanted and expected certification,” Fantus relates.
Others did not seem to place too high a value on it. As for ethicists, some find it valuable as a clear metric they can show to their administration. This is particularly helpful if leaders do not understand how the field of clinical ethics differs in training from other healthcare disciplines.
“Controversy over the credential within the profession is something we will have to consider moving forward, if we want to professionalize the field,” Fantus says.
The credential also does not reflect the amount of hands-on experience with difficult cases and conflict mediation skills. Offering more clinical ethics fellowships and expanding existing programs could fill this gap. “We see programs popping up across universities and hospital systems,” Fantus reports.
Not all have the necessary infrastructure or trained staff to be effective. For that, says Fantus, “you really need a strong interdisciplinary team with well-trained supervisors, and to work at a hospital that deals with a lot of rich and complex ethical dilemmas.”
- Horner C, Childress A, Fantus S, Malek J. What the HEC-C? An analysis of the Healthcare Ethics Consultant-Certified program: One year in. Am J Bioeth 2020;20:9-18.
- Pearlman RA, Foglia MB, Fox E, et al. Ethics consultation quality assessment tool: A novel method for assessing the quality of ethics case consultations based on written records. Am J Bioeth 2016;16:3-14.