The American Society for Bioethics and Humanities’ Core Competencies for Healthcare Ethics Consultation was meant to address persistent concerns about training clinical ethics consultants.1 “But there is still work to do to standardize training programs across the country,” says Seema K. Shah, JD, founder’s board professor of medical ethics in the department of pediatrics at Northwestern University.
Shah says shadowing experienced ethics consultants and participating in debriefings after consults with other members of the ethics team are top priorities for ethics training.
Training to adequately prepare someone to perform ethics consults “depends on how the consults are run,” says Rosamond Rhodes, PhD, director of bioethics education at Icahn School of Medicine at Mount Sinai in New York City. Where a team of people are consulting together, at least one person should have undergone significant training and experience in medical ethics, “but the other members of the team can have their medical experience as a basis,” Rhodes says.
If an individual is consulting alone, that person will need significant and focused training in ethics. “A degree in philosophy is not sufficient. A certificate program or week-long course in bioethics is not sufficient,” Rhodes stresses. “Just being able to recite the four principles of bioethics is certainly inadequate.”
Rhodes is associate director of Clarkson University’s bioethics program. There, in addition to theoretical courses, clinical ethics trainees complete two semester-long courses in case analysis and learn a methodology for approaching clinical ethics dilemmas. Trainees learn to elicit factual information about the case, and how to go about analyzing the ethical issues.
“What we use for teaching is a structured methodology for how to go through a clinical ethics consultation,” Rhodes says.
First, trainees must know how to identify the ethics question that is at issue. “That is really hard for a lot of people,” Rhodes acknowledges. “The clinical ethics question should involve the word ‘should.’ Because we are talking about ethics, it’s not how many or when; it’s ‘What should we do?’”
Ethics consults are called because two different values are in conflict, and clinicians are looking for direction on what to do. “You need to be able to use the factual information to support reasons for going one way or another,” Rhodes says.
That involves an in-depth conversation, typically 30 minutes to an hour. “Like anything else, the more you do it, the better you get,” Rhodes says.
To prepare trainees to handle actual ethics consults, the program provides a week of intensive training focused on about 20 real cases. Several involve role-playing, with actors playing the part of patients, family members, and clinicians. “I believe this level of intensive, skill-based training is unique to our program,” Rhodes offers.
Classmates observe one another. Experts in ethics and communication skills critique what they see. “Even though we have increased the case analysis training as much as the schedule allows, our trainees always want more and more experience,” Rhodes says. These are some of the case scenarios used to prepare trainees:
• Decisional capacity. The ethicist does not have legal authority to assess someone’s capacity, but has to recognize the need to involve someone who does. “You might need to get the psychiatrist on staff to make a determination, either globally or for a specific decision,” Rhodes observes.
Depending on state law, any licensed physician or several clinicians who have interacted with the patient might be able to make the determination on capacity. “A patient may be somewhat impaired, but still have the capacity to make the specific decision that’s in front of them,” Rhodes notes. “Sometimes, it’s the surrogate who lacks capacity.”
• No capacity, no surrogates. With “unbefriended” patients, “you need a good idea of their prognosis and condition, and the legal constraints on the kind of decisions you can make on their behalf,” Rhodes says.
• Surrogate requests the clinical team believes are inappropriate. The ethicist has to evaluate the surrogate’s concern for the patient. “You don’t have to think that the patient’s life is the only thing that matters, but you do have to have a reasonable concern for the patient’s well-being,” Rhodes explains.
The central concern for ethicists is whether the surrogate’s decision is reasonable. A decision to not give pain medication to a terminally ill patient who clearly is suffering greatly is not reasonable. “We are not accepting that decision. It is inhumane,” Rhodes says.
• Refusal of treatment. The ethicist needs to be able to assess when clinicians are entitled to impose treatment over the patient’s objection, and when they are not. “It takes a lot of understanding of what you’re entitled to force on somebody,” Rhodes notes.
Refusals can range from something relatively inconsequential to a condition that is highly treatable but will otherwise result in death. An extreme example would be a patient with strangulated hernia who will die without surgery, but most likely will see a full recovery with surgery. The ethical question is: Is the team justified in imposing treatment over the patient’s objection because the patient will otherwise die?
“You have to have the authority to explain to the team why what the patient is saying is not a good enough reason. You need a lot of background information to be able to do that. It’s rather a daunting task,” Rhodes admits.
Some patients refuse dialysis, even though it would allow them to continue living many years. In other consults, the ethics question is whether it is OK to impose artificial feeding, or what to do if patients want to leave the hospital against medical advice.
“The consult should involve people with the needed expertise, and a lot of social work intervention, to arrange a safe discharge,” Rhodes says.
In all these “refusal” cases, the ethicist must consider: How great is the benefit? How likely is the benefit with treatment? How great is the harm without treatment? How likely is the harm? “You have to be able to synthesize all this with your reasons, and explain it to the team that wants your input,” Rhodes says.
• Multiple surrogates with different opinions. Rhodes says it is useful to ask a small group to meet with all the surrogates. At first, ethicists talk about the patient, rather than the decision at hand. Next, ethicists ask each surrogate if the patient ever talked about medical decision-making.
“This can take hours. But usually by the end of the conversations, there is a resolution without anybody pushing things,” Rhodes says.
• A conflict between the surrogate and the clinical team. Some surrogates really care about the patient and want something that is in the patient’s interest, but the doctor thinks something else is appropriate. “Sometimes, you might have to adjudicate between the doctor and the surrogate,” Rhodes says.
The clinician’s core beliefs may need to be challenged. Clinicians might think they would never want to live in the same condition as their patient, and that they would find it unacceptable and deplorable. The patient cannot communicate, and the family wants life to continue.
“This is a place where the decision isn’t made by the clinician’s values and goals, but by societal limits on what’s acceptable,” Rhodes explains.
• Futility and withdrawal of life-sustaining interventions (e.g., turning off pacemakers). The ethical question might be framed in terms of prolonging life, or in terms of ending life. The ethicist might have to convey to the clinical team that in this particular case, it is simply not their call.
“Ethicists may need to say, ‘This is a legitimate place for the family to make a decision,’ and talk about how far we have to go to accommodate the family,” Rhodes suggests. Even after intensive training, it is questionable that trainees truly have learned enough to handle all the conversations and judgments involved in varied and complex cases. “We try hard in our program. To me, it doesn’t feel like it’s enough, but it’s probably as far as we can go in training,” Rhodes adds.
- Tarzian AJ, ASBH Core Competencies Update Task Force. Health care ethics consultation: An update on core competencies and emerging standards from the American Society for Bioethics and Humanities’ core competencies update task force. Am J Bioeth 2013;13:3-13.