Is individual qualified to perform clinical ethics consults? National standard is coming
"Monumental step forward" for bioethics
An American Society for Bioethics and Humanities (ASBH) task force is currently developing a two-step quality attestation process that will result in a national standard to assess clinical ethics consultants. This will identify individuals who are qualified to perform this important role.1
"We are still early on, and the process will take years to evolve. But the key thing is to keep things moving forward so as not to lose momentum and interest," reports Joseph Fins, MD, MACP, immediate past president of ASBH. Clinical ethics consultations should not be taking place without any oversight or standards, he underscores. "People should be competent and capable of doing what they do, and we should have a process for regulating that,"says Fins, the E. William Davis, Jr., MD, professor of medical ethics, professor of medicine, and chief of the Division of Medical Ethics at Weill Cornell Medical College in New York City. Fins is also director of medical ethics and attending physician at New York Presbyterian Hospital/Weill Cornell Medical Center.
The current process is a pilot designed to determine what eligibility and the final process will look like, says Felicia Cohn, PhD, president of ASBH and bioethics director for Kaiser Permanente Orange County (CA).
"The task force has developed a blueprint. This is likely to evolve as we learn more throughout the pilot," she says. "We have started with a focus on a two-step process, including a portfolio and an oral examination, but our assessment may suggest different or better mechanisms."
With funding from the Macy and Greenwall Foundation, the task force, led by Fins and Eric Kodish, MD, professor and chairman of the Cleveland Clinic Foundation’s Department of Bioethics, has outlined the process and is developing metrics to evaluate and score items submitted by individuals. The applicant’s educational background, case writeups, letters of recommendation, and a philosophy of consultation will determine whether an individual is eligible to take an oral examination.
"In the absence of accredited programs and a training pathway that would be uniform for everybody, we have to go through the process of determining the eligibility criteria," explains Fins. While individuals who attend medical schools and residency programs are able to take board certification examinations to establish their competency, no such process currently exists for those who perform clinical ethics consultations.
The process is slow and deliberate, says Fins, and "is really a proxy for board eligibility that one would normally have by going through an accredited program. But since we don’t have accreditation for programs yet, that additional task has to be determined on an individual basis."
Approaches to credentialing of ethics consultants vary widely at hospitals, and many lack established ethics programs. "The vast majority of people practicing clinical ethics are not regulated, so we don’t really know the quality of the job," says Fins. "It’s especially hard when there is only one person doing it."
If a patient has the same circumstance, makes the same request, and is located in the same state with the same laws as another patient, he or she might still get a different outcome from an ethics consultation.
"That variation should be troubling. People who are similarly situated should be treated the same," says Fins. "There should be standards that are upheld."
If a patient is going to have a ventilator withdrawn, for instance, it should be handled the same way at all hospitals within the same legal jurisdiction, argues Fins.
"The idiosyncrasies of the practitioners or the consultant or the hospital shouldn’t determine what happens," says Fins. "Rather, there should be a standard approach to these problems." The approach should be based on the ASBH core competencies, he adds, which reflect a national consensus on clinical ethics practice.
"ASBH is the professional home for many individuals who engage in clinical ethics, many of whom have been working toward developing consensus regarding the need for this process for a long time," says Cohn.
In addition to the goal of assuring competence of clinical ethicists, says Cohn, other goals are enhancing the professionalism of the field and improving patient care.
"Developing a reliable, credible, and professional process for a multidisciplinary field will take time," adds Cohn. "We wish to balance the need to get this done with the need to get this done well."
Bioethicists’ possible expanded role
One concern in the bioethics community is that the examination won’t adequately consider the day-to-day experiences of those working in the field, such as the ability to run meetings with the patient’s family and come to a consensus with providers. A written exam might not capture the ability of an individual to talk to a family refusing a treatment based on a religious objection, for instance.
"It’s like taking a written exam for surgery but never having operated," says Fins. "We are aware of that, and we are working to capture a wider range of experience in the instrument."
Fins says that in his opinion, a national standard for credentialing of individuals who perform ethics consults will help legitimize the specialty. "We’re at a stage where we have reached a consensus for the first time in our history — perhaps a fragile consensus, but a consensus nonetheless — that this is something we should do, and we have outlined a blueprint for this," says Fins. "That’s a monumental step forward."
Fins believes that ultimately, the national standard could facilitate the ability of ethicists to meet broader societal needs. "We’ve got monumental changes in health care. There are disruptions in patients’ experience," he says, such as family doctors no longer managing hospitalized patients. "Having ethicists in hospitals as stewards of fairness and equity and access, is something that is a new role."
Fins would like to see The Joint Commission require credentialing of individuals who perform ethics consults in hospitals. "An accreditation standard would convert this specialty into actual consultative work, versus what is still, in many places, a volunteer experience," he explains.
Ethicists can then be more involved in guiding the restructuring of the health care system, says Fins, "because they’ll have a front row seat — and a sanctioned front row seat."
- Kodish E, Fins JJ, Braddock C, et al. Quality attestation for clinical ethics consultants. Hastings Center Report 2013;43(5): 26-36.
- Felicia Cohn, PhD, Bioethics Director, Kaiser Permanente Orange County. Phone: (714) 644-6353. E-mail: Felicia.G.Cohn@kp.org.
- Joseph J. Fins, MD, MACP, the E. William Davis, Jr., MD, Professor of Medical Ethics, Weill Cornell Medical College, New York, NY. Phone: (212) 746-4246. E-mail: firstname.lastname@example.org.