Residency and fellowship programs are accredited through the Accreditation Council for Graduate Medical Education (ACGME), which sets requirements for the measurement of progress. “As part of that requirement, they have, over time, developed tools like milestones for programs to use,” says Douglas S. Diekema, MD, PHP.

Ethics programs, on the other hand, are comparatively new. “There is, at present, no central accrediting body to establish standards. Each individual ethics program more or less decides whether to evaluate fellows and how to do it,” says Diekema, director of education at the Treuman Katz Center for Pediatric Bioethics in Seattle.

The Pediatric Emergency Medicine Fellowship at the University of Washington and the Pediatric Residency Program at Seattle Children’s are accredited by the ACGME, which has published competencies and milestones that have been developed for each accredited residency. “The expectation is that each training program use these to map the progress of their residents and fellows as they move through the program,” says Diekema, who is affiliated with both programs.

In contrast, there are no competencies for bioethics training programs to track progress. Diekema and colleagues set out to develop milestones based on the American Society of Bioethics and Humanities Core Competencies for Healthcare Ethics Consultation, along with the Pediatrics Milestones Project, a joint venture by the ACGME and American Board of Pediatrics.1 “My primary purpose was to have an implementable standard that we could use locally in judging the progress of our fellows and the adequacy of their training,” Diekema says.

It turned out to be a bigger project than expected — and one that would benefit from multiple perspectives. The primary team included a prospective fellow, a fellow, and the bioethics program director. “We then sought input from all faculty in our own fellowship program,” Diekema explains. “We realized that there was value in sharing this work with others.”

The goal was to move toward a standard approach among training programs in bioethics. “As it currently stands, bioethics programs span a huge range in terms of training, experience, time commitment, and competency at completion,” Diekema reports.

Without some standardization, it is difficult for anyone seeking to hire someone into a bioethics job to know if the candidate has achieved an adequate level of competency in the field. In bioethics, hiring occurs in academic settings for jobs that include ethics consultation or research in ethics. It also occurs in hospital systems that are looking for a clinical ethicist. In either setting, says Diekema, “they have little to evaluate, other than looking at what kind of training in ethics someone has had and any publications” for which they might have written.

The newly developed standards give more information, according to Diekema, and can be adapted for specific needs. Programs may train students to be ethics consultants, academic bioethicists, or both. “Some of our milestones and competencies are more appropriate for one goal or the other,” Diekema notes.

The hope is that training programs will find a way to evaluate not only trainees’ progress, but also the adequacy of their programs in training people to work in the field of bioethics. “There’s been a lot of interest in professionalizing at least some aspect of bioethics,” Diekema says.

The problem is there is no agreed-upon standard for what kind of training someone working in bioethics requires. Nor is there a standard that must be met to market a program as a bioethics training program. “Our article was an attempt to provide one step toward the goal of setting minimal standards for training programs,” Diekema offers.

The hope is training programs will use some version of the milestones and competencies to evaluate fellows. “Eventually, there may be some attempt to have an accreditation process for fellowship programs,” Diekema says.

This would include a requirement for evaluation of the fellows and the program. “Until then, institutions hiring fellowship graduates face wide variation in terms of the skill and competencies coming out of fellowship programs around the country,” Diekema says.


  1. Sawyer KE, Dundas N, Snyder A, Diekema DS. Competencies and milestones for bioethics trainees: Beyond ASBH’s Healthcare Ethics Certification and Core Competencies. J Clin Ethics 2021;32:127-148.