Core competencies for ethics consultations

The goal is to have all voices heard

Decision making in health care ethics consultation cases often involves difficult, complex issues and mediating differences of opinion.

So, too, does deciding the standards for those who perform ethics consultation, as well as how an ethics consultation should be completed, including questions such as who has access, how to document, and what constitutes a "good" ethics consultation.

Those are among the questions being considered in the process initially begun as an effort to update the Core Competencies for ethics consultants from the American Society for Bioethics and Humanities (ASBH) in Glenview, IL.

Anita J. Tarzian, PhD, RN, an ethics and research consultant in Baltimore, with affiliations with both the University of Maryland School of Law and the University of Maryland School of Nursing, is heading the ASBH task force on this effort, which began two years ago, when, as secretary of the organization, she noted that the document outlining the Core Competencies was completed in 1998. Thinking that much has changed in the field, she decided — "naively," she now jokes — that an update was necessary.

"In that document, the '98 version, the task force took a stand on endorsing a model for ethics consultation – what they call not a pure facilitation model, but the facilitation model — that was the role of the ethics consultant," she says.

In other words, it was not the role of the ethics team to tell the patient or family or clinicians what the right answer was, but "to just get all the stakeholders together and to make sure that all voices are heard, and to facilitate that fact-finding and coming to some conclusions about what would be an ethically justifiable action to take."

But, with that model, "there's been some controversy over that," and, Tarzian says, as well as "some misinterpretation."

It's due to the variety of opinions expressed that the initiative to update the Core Competencies is behind schedule. But being behind schedule is not necessarily a bad thing in this case.

"It would be important to have the right process, and you would come to some consensus in the field in order to not be guilty of what we're saying you shouldn't do in an ethics consult and say, 'We're going to say this is the right way,' and not listen to alternative views," Tarzian says.

It was her expectation at the outset of this process that the task force could complete a comprehensive document to include not only the core competencies for individual consultants, but also to the standards for an ethics committee.

That probably isn't going to happen this time.

"I'm starting to realize that — again, anything in the field of bioethics . . . by definition involves lots of different opinions," she says.

Ellen Fox, MD, chief ethics in health care officer, Department of Veterans Affairs National Center for Ethics in Health Care in Washington, DC, who also serves on the task force, agreed that this document may not be as comprehensive as task force members originally had hoped.

"It remains to be seen exactly where the final draft will end up, but I don't think that this particular effort will solve the problem of a lack of standards for how to do ethics consultation," Fox says.

Fox contends that the problem with ethics consultation in the United States is a "lack of standards."

"For almost everything we do in a health care organization, we have specific quality standards for how those things are done," Fox says. "And in the area of ethics consultation, there's no clearly recognized national standards for how to do ethics consultation.

"The closest thing" to a set of guidelines and standards is the ASBH's 1998 document, she says.

Fox et al. completed a study published in The American Journal of Bioethics in 2007 that found that there was wide variability in ethics consultation services.1

"Well, there was a complete lack of knowledge about what was going on in U.S. hospitals with regard to ethics consultation, so . . . the purpose of the study was to help fill that gap," Fox says.

Debate centers around models

Tarzian indicates that the debate centers around how the facilitation model is described in the original core competencies document, and how it is interpreted.

She provides an example of the complexities involved: what if an individual completed a living will that indicated they did not want to be kept alive under certain circumstances, and that will was questioned, with others saying, perhaps, that the individual still could be kept alive by a ventilator, despite the fact this would be counter to what that individual declared in a living will.

Some would say that an ethics consultant or ethics committee "shouldn't facilitate a resolution that runs counter to that standard."

"There are some people who think facilitation is sort of a way of saying you're completely neutral, and that you're going in, and you're just sort of facilitating communication and not providing input — and not drawing a line and saying, 'Actually, that's not an acceptable outcome or response."

Others "really denounce this whole recommendation model," or the model of the professional ethicist, who has specific training in ethics study or a degree in philosophy, or closely relate discipline, who may be a consultant or on staff as an ethicist at an institution, unlike many who are clinicians who serve voluntarily on ethics committees within their institutions.

"That comes from the sort of paternalistic history of people that got involved in ethics being [in] the 'I'll tell you what the right answer is' mode," Tarzian says. "It was in the physician model, with physicians not wanting to be told what to do, and there was this sense of 'We know what the right answer is, and we're going to enlighten people.'"

Another debate taking place centers around some people who feel that there is no one right way to do ethics consultation, and one model will not fit the bill for every hospital.

For example, the VA system has standardized its approach systemwide to ethics consultation for all its facilities across the country.

And Fox says the VA has seen "tremendous interest" in those standards from many health care organizations.

While there's still no consensus, many agree that the role of ethics committees will continue to evolve. And there's been a great deal of attention "drawn to the fact, for example, that the field doesn't have a credentialing process."

Such a credentialing process may be yet to come.

In the meantime, Fox says, "I think in the natural evolution of a field, there's progress toward increased specificity in terms of standards, and I think we're on the cusp of seeing a standardized approach — not just by individual health care institutions, but across the field nationally and internationally."

Sources

For more information, contact:

  • Ellen Fox, MD, Chief Ethics in Health Care Officer, Center for Ethics in Health Care, Department of Veterans Affairs, Washington, DC.
  • Anita Tarzian, PhD, RN, Ethics & Research Consultant, Baltimore. Committee Network, University of Maryland School of Law, Associate Faculty, University of Maryland School of Nursing.