ASBH task force develops revision to the core competencies

Final draft to be based on survey results

The American Society for Bioethics and Humanities voted in 2006 to create a task force to revise the core competencies expected for those who perform ethics consults and for ethics consult services. Nearly four years later, the Core Competencies Task Force — after much debate — issued a revision in November 2009, and task force members are currently reviewing the feedback received from members on the revision.

But some disagreement remains, according to the head of the task force, Anita J. Tarzian, PhD, RN, an ethics and research consultant in Baltimore. Tarzian is also program coordinator of the Maryland Health Care Ethics Committee Network at the University of Maryland School of Law, and adjunct faculty member of the University of Maryland School of Nursing.

"There's controversy in the field about whether we should go the route of professionalizing, with a code of ethics, and in addition to the core competencies, [have] some way of accrediting or credentialing people," Tarzian tells Medical Ethics Advisor. "There are other people who say [that] most of the people who do this are volunteers, and they do other things in hospitals and health care facilities — and that they should just be at least minimally competent.

"It's a tall order for the document to address those types of people, in addition to the fact that there's still that allowance for the non-professional ethicists, who are doing it as part of other duties to kind of share the burden of the competencies in a team," she says.

Tarzian notes that this differs from the first set of core competencies, approved by the ASBH nearly 10 years ago.

In that first edition of the document, "there was actually a position taken that they didn't want to recommend pursuing any kind of credentialing in people, because they thought that would go down the road of professionalizing and displace the ones who are involved in this kind of work and this kind of decision making — and then push forward a certain type of professional, let's say, who might not have a clinical background but gets a PhD in ethics, and then you squelch diversity," she says.

The current revision, which has yet to be finalized, is important because "it is more pervasive that you have ethics consult services and ethics committees in hospitals, and some state laws are relying on these groups to help avoid having to go to court for certain decisions. There's more concern being raised that people aren't fully qualified," Tarzian says.

And currently, there's no real way for these individuals, who perform ethics consults, to be vetted, she says.

However, once the core competencies document is finalized — probably by June — the document would be the first step toward an accrediting or credentialing process, Tarzian says.

Standing committee formed, also

In addition to the core competencies task force, a standing committee was formed to look into whether or not the ASBH should offer something akin to board certification or other accreditation for ethics consultants.

"They are exploring other models that are similar, like chaplaincy certification. It's a similar concept of a lot of the affective skills needed. You can't just give them a multiple choice test. You have to be careful about your own bias . . . so there's [also] a lot of similarities with hospice and palliative medicine for a model, because [ethics consultation] requires communications skills," Tarzian explains. "And they do other measures that are like proxy measures; for example, they have to have taken care of a certain number of patients who are dying, a certain number of practical hours, a letter attesting to their work and character. So, is that the way to go?"

The standing committee is expected to have its report ready by the next ASBH annual conference in October.

"There, we're looking at the goal of having a really exhaustive report that says, "These are all the ways we think you could do this; this is how much it would cost; this is an estimate of how many people might be interested in doing this. You know, how much revenue would you generate, would you farm it out to another organization, would the ASBH do it, and then come out with a recommendation of what we think the first steps should be," she says. "Not actually doing it, but coming out with a comprehensive report that would then give a recommendation on next steps."

Tia Powell, MD, director of the Montefiore-Einstein Center for Bioethics in Bronx, New York, said of the revision effort: "I would say that the original core competencies report was a very important document; it was a great step forward and a real innovation. Similarly, I think this update fills a real need. I do think clinical ethics consultation has gone on for too long with insufficiently articulated standards, and that it's impossible to define what, in clinical ethics consultation, is excellence, or even what minimal competency is in clinical ethics consultation, without a step forward liked the revised core competencies report."

Powell, a physician, tells MEA that she approaches ethics from a clinical point of view.

"Either for that reason or for others, I really feel that if you interact with patients, you need to be accountable for your work with patients," Powell says. "When someone goes to do an EKG or to draw blood, they have to document that they've been through a training program, they're supervised, and their work is reviewed for quality. I think that the same standards should apply to clinical ethics consultants."

Some highlights on what's new

The core competencies revision document recommends against relying on any one kind of model for ethics consults, advising instead that the type of model used should be adapted for the particular situation being evaluated, which is a different view from that of the original core competencies document, which was developed more than 10 years ago. There are three standard models for ethics consultation: individual consultant, the ethics consult team, or the entire ethics committee itself.

"There are some people who feel pretty strongly [that one model is superior to another]," Tarzian says, although she says there is "still a range of practice out there."

"So, we understand that say, people in a rural setting that have to do a lot of telecommuting for providing resources, or long-term care facilities that function differently, might come up with a different way of addressing ethics consultation requests. But we're saying in general, all other things being equal, the type of [ethics] question drives whether you use one person, the team, or the whole [ethics] committee."

Powell tends to agree with the report's suggestion that ethics consult services not rely on one particular model for the service.

"I agree with the report that the needs of the patient and the clinical context is needed to determine what model you use. I would say, though, that I think an excellent ethics consultation service needs to be able to work in each of these models, so that they can meet the needs of their patients," Powell explains.

Tarzian does not find it unusual that there are differences of opinion on certain recommendations in the document.

"Whenever you get ethicists together, you get differences of opinion. And our goal is to try and represent diversity where there is diversity, but to try to come to some consensus on basic standards," Tarzian says. "So, basically there will be variations, and it's up to the individual [institution]. I think what we try to say is: 'At a minimum, you should have established what your policy is at your institution and then be consistent with your policy."

Case vs. non-case consultations

Another topic where there was a difference of opinion was the revised core competencies document making a distinction between "case" and "non-case" consultations, Tarzian notes.

A case consultation is one where there is an active patient case under consideration; non-case covers "every other type of question that comes to a consultant," such as organizational ethics policy, she says.

"We talked and talked and talked about alternative ways of naming that, but the bottom line was, the situation, or the one [where] ethics consultants can do the most damage is where there's an active patient involved. And people go in and they can, at best, do a lot of good to resolve conflict and enlighten people and provide clarification of values and other things, but there's a lot of harm that can be done, if you don't know what you're doing," Tarzian explains.

"So, the thinking was: You kind of have to know the same knowledge base for both types of questions that come to an ethics consult service, but that there will be different procedural standards in place if there's an active patient involved," she says. "So, for example, you [would] want to see the patient. If you're making an opinion and sharing recommendations about what happens to an actual patient, you want to make sure that you see the patient, then you talk to other people involved in the case, that you document your recommendation and your ethical analysis — so there are certain things that should happen."

The document also specifically defines ethics consultation as "response to a request from someone — just like you would with medical consults," Tarzian says.

Also, anybody with standing in a case should be able to request an ethics consult, whether that's a patient or a family member or a member of the health care team. Tarzian, for example, believes that once a patient consult is requested, the attending physician should always be notified that a consult is set to occur. However, this was another point of disagreement among certain ASBH members.

One realization the committee members had while conducting their research and developing the core competencies was that not everyone who conducts an ethics consultation writes this in the medical chart — something most committee members thought was an understood standard, Tarzian says.

Another area of contention was whether or not ethics consult services should be required to evaluate their institution's consult services.

And while Tarzian believes that internal debate is "good," she still maintains that ethics consult services "could benefit from more systematic procedures to ensure quality. So, this whole movement toward quality improvement is based on being able to show what you're doing . . . I mean, who can be in a health care facility and say, 'I'm not obligated to show the value of what I'm doing'? It seems out of touch with reality."

[Editor's note: For the complete revised Core Competencies document, please visit the American Society of Bioethics and Humanties web site at www.asbh.org.]

Sources

Tia Powell, MD, Director, Montefiore-Einstein Center for Bioethics, Bronx, NY. E-mail: bioethics@montefiore.org.

Anita J. Tarzian, PhD, RN, Ethics & Research Consultant; Program Coordinator, Maryland Health Care Ethics Committee Network, University of Maryland School of Law; Adjunct Faculty, University of Maryland School of Nursing. E-mail: atarzian@law.umaryland.edu.