Bioethicists set criteria for who can perform clinical ethics consults
Is it acceptable for someone with a masters degree in bioethics without a clinical background to perform ethics consults? What about a physician with an interest in ethics who has never done consults?
In order to resolve such questions about what level of education and experience is necessary for an individual to perform ethics consults, bioethicists at New York Presbyterian Hospital in New York City developed their own set of criteria.1
"We really wanted to get a handle on what we should be looking for to have the greatest success in recruiting people," says Cathleen A. Acres, RN, administrative director of the Division of Medical Ethics, lecturer in public health at Weill Cornell Medical College, and associate medical ethicist at New York Presbyterian Hospital/Weill Cornell Medical Center in New York City.
It's important that individual institutions recognize that ethics consultation is "a discreet practice discipline that requires a body of knowledge and clinical experience in order to effectively mediate and negotiate ethical issues in the hospital," says Acres.
Every institution is going to find their own "sweet spot" for the necessary qualifications, says Joseph J. Fins, MD, MACP, chief of the Division of Medical Ethics at Weill Cornell Medical College and director of medical ethics and attending physician at New York Presbyterian Hospital/Weill Cornell Medical Center.
Fins is also currently working on the The American Society for Bioethics and Humanities' Quality Attestation process to assess clinical ethics consultants at the national level.2
While it will be several years before there is a working model for quality attestation, "local and national efforts are not mutually exclusive," says Fins. "Until we have a national standard, local institutions will need to step up and begin to do this in a way that works with their local culture."
"It's kind of amazing — this has been a huge lacuna in the clinical space, and it has been very unregulated," says Fins.
As a result, people with the same problems could be treated differently at the same institution. "It's really important that institutions have a sense, as best they can, of the abilities and competency of the people who are doing ethics consults," says Fins.
Three levels of credentialing
Before the criteria were developed, there was no mechanism for the hospital to recognize Acres, a nurse who works for the medical college and not the hospital, as a professional performing medical ethics consults.
"That was our urgent issue, and we took this approach to address it," she says. Acres is not aware of any other institution that has developed similar credentialing criteria for ethics consults.
Part of the challenge was to develop criteria that the ethics programs at both New York Presbyterian — Columbia University Medical Center and New York Presbyterian — Weill Cornell Medical Center would agree to.
Acres and Fins developed a draft of the criteria for three levels of credentialing. The criteria specify the path for how one can progress from an assistant to associate to senior clinical ethicist.
They shared the draft criteria with two of their colleagues at New York Presbyterian Hospital — Columbia Presbyterian Medical Center. "The four of us then went back and forth to discuss the specific levels of expertise required," she says. "It was a very constructive process." The team also consulted with the chairs of pediatrics at both sites to be sure they were requiring enough experience for bioethicists to do pediatrics consults independently.
Next, the criteria had to be approved by senior administration. "From there, it went to the medical board of the institution for their approval, and we went forward," says Acres.
Model for other institutions
"We see this as a model for other institutions that can take this and tailor it to their particular needs," says Acres.
Although other institutions might vary the numbers of educational hours or consults performed, New York Presbyterian's criteria could help identify what experience is necessary for a potential ethics consultant.
"We have a very big institution with considerable expertise, so we were able to set the bar pretty high," she says. Other institutions may not be able to employ multiple clinical ethicists or provide supervision or mentoring, for instance.
The criteria recognize that clinical bioethics is a profession that people come to from many disciplines. "There are certainly physicians and nurses, as we are here, but there are also philosophers, social workers, chaplains, attorneys, and others who have training and expertise," says Acres.
A clinical license or clinical ethics fellowship training is a core qualification for non-clinicians. "Non-clinicians would have had to complete a master's or training program in clinical ethics that afforded them considerable clinical experience," says Acres.
Other institutions may take the approach of partnering a clinician with a bioethicist who has a PhD but no clinical background. "There are a lot of ways to get at this," says Acres. "This is the model we chose — that's not to say you couldn't have a wonderful program with another model."
- Acres CA, Prager K, Hardart GE, et al. Credentialing the clinical ethics consultant: An academic medical center affirms professionalism and practice. J Clin Ethics 2012;23(2):156-164.
- Kodish E, Fins JJ, Braddock C, et al. Quality attestation for clinical ethics consultants. Hastings Center Report 2013;43:26-36.
- Cathleen A. Acres, MA, RN, Administrative Director, Division of Medical Ethics, Weill Cornell Medical College, New York, NY. Phone: (212) 746-4246. E-mail: email@example.com.
- Joseph J. Fins, MD, MACP, Chief, Division of Medical Ethics, Weill Cornell Medical College/Director of Medical Ethics, New York Presbyterian Hospital/Weill Cornell Medical Center, New York, NY. Phone: (212) 746-4246. E-mail: firstname.lastname@example.org.