Small and large hospitals vary widely in terms of ethics consultation volume, and the gap is widening, according to the authors of a recent study.1 “When ethics consultation practitioners compare their own practices to other hospitals, it’s important to compare apples to apples,” says Ellen Fox, MD, HEC-C, the study’s lead author and president of Fox Ethics Consulting.

In a study conducted in 2000, a group of researchers led by Fox surveyed 600 hospitals about ethics consultation practices.2 “That study was described as a ‘wake-up call’ by leading bioethicists who were alarmed by its results,” Fox recalls.

Back then, Fox and colleagues learned the median number of consults performed annually was only three. Just 5% of ethics consult practitioners had completed a graduate degree program or fellowship in bioethics. Only 28% of ethics consult services included a formal evaluation process that involved the collection and analysis of data. That 2000 study has been widely read and cited in the ethics field. “But a lot has changed in the last two decades. There was a need for up-to-date information,” Fox notes.

Recently, Fox led a follow-up survey, also of 600 hospitals. The new study mirrored the methods of the 2000 survey, but was much broader in scope. Researchers wanted to learn more about the determinants of ethics consult volume and to what extent consultation practices adhere to established standards. The investigators also wanted to hear ethics practitioners share opinions related to training and how consultations might have improved since 2000.

Fox and colleagues are publishing the findings from this study in a series of seven articles, one devoted to each of seven research questions. The first is about how ethics consult practices have changed over time. “We included some of the questions from the previous survey, which allowed us to draw direct comparisons between the two data sets,” Fox says. Some key findings:

There was a dramatic increase in the number of consults, but only in large hospitals. “The number of case consultations increased dramatically in hospitals with 400 or more beds, but did not change in small hospitals, which make up the majority of hospitals in this country,” Fox reports.

Compared to 2000, the estimated number of consults performed in U.S. hospitals annually increased by 94%, from 35,000 to 68,000. However, the median number of consults per hospital remained unchanged, at only three.

Most large hospitals said they needed more financial support for ethics consultations. In the 2000 study, 83% of hospitals found financial support sufficient. In the new study, only 56.5% of hospitals did. Again, this varied depending on the hospital’s size. Financial support was perceived to be sufficient in most small hospitals and non-teaching hospitals. In most large hospitals and major teaching hospitals, it was thought to be insufficient.

“In a lot of small hospitals, ethics consultation services receive no funding, but this is not seen as a problem. The level of activity is low, so the idea of a specific budget line for ethics doesn’t make sense to people,” Fox says.

In contrast, in large hospitals, “it may be that workload is increasing faster than financial support,” Fox adds.

There was no change in the average percentage of ethics consultation practitioners (8%) who completed an advanced degree or fellowship program in bioethics. “People might find this surprising, given that there has been a strong movement toward professionalizing ethics consultation,” Fox says.

However, those efforts have been driven largely by academic bioethicists. That possibly resulted in a major impact on large hospitals and major teaching hospitals, but a limited impact on hospitals with few ties to academic medicine.

“Changes that occur in academic medical centers may not have much of an effect on averages, since these hospitals make up only about 5% of all U.S. hospitals,” Fox says.3 When considering all hospitals, says Fox, “the changes that occur in the academic medical centers are not going to have a huge impact on the overall numbers.”

Apples-to-apples comparisons are useful for benchmarking or determining if a hospital is out of step with comparable hospitals. For example, the data show a major teaching hospital that performs only 10 ethics consults a year, or that uses the full committee model for most of its consults, is an outlier among its peers. That way, hospital’s ethics consult service can use the data to determine what, if anything, it should be doing differently.

“These data might also be useful to hospital leadership when they are deciding what sort of resources to devote to ethics consultation,” Fox says.


  1. Fox E, Danis M, Tarzian AJ, Duke CC. Ethics consultation in U.S. hospitals: A national follow-up study. Am J Bioeth 2021:1-14.
  2. Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: A national survey. Am J Bioeth 2007;7:13-25.
  3. Advisory Board. Why some universities are bidding adieu to academic medical centers. Daily Briefing. April 24, 2015.