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February 20, 2014 | Posted By Wayne Shelton, PhD

Over the past few decades, clinical ethics consultations have become an important component in providing quality care in cases where there are value conflicts that must be resolved before viable goals of healthcare can be accomplished. With the development of this service and its acceptance as a necessary part of patient care, questions arise as to how and when will clinical ethics consultation be recognized as a specialized professional service comparable to medicine, nursing, social work and pastoral care? For physicians, nurses, social workers, and chaplains there are well-established pathways for practitioners to take in each of these areas in order to be recognized as fully qualified professionals. There is no such pathway to date for those individuals who provide clinical ethics consultations. For those of us who have been involved in this area it is interesting to reflect upon the vast improvements made in providing clinical ethics consultations and whether the field is ready for professionalization.

I recall my early years of training in medical ethics as a graduate student in philosophy at the University of Tennessee. As part of the requirements for the PhD in philosophy with a concentration in medical ethics, students had to spend 3 months at the Health Science Center in Memphis where we participated in intensive internship in medical ethics. At that time I was fortunate to have one of the early pioneers in medical ethics as a mentor, Professor David Thomasma, who was beginning to do clinical ethics consultations. During the 1970’s philosophers and others in fields pertaining to ethics were being invited to enter the medical setting to help physicians and nurses grapple with some of the ethical dilemmas that were becoming more evident with the increasing use of dialysis machines and mechanical life supports. There seemed to be an assumption, perhaps naïve in retrospect, that philosophers like professor Thomasma and others had some special understanding of ethical issues that would shed light on the emerging medical ethical dilemmas and therefore would be in a position to give helpful advice.

It is obvious to me now as I look back on those years that philosophical ethics had not yet been exposed to the messy world of practitioners and real life ethical problems. We forget the lingering influence of logical positivism and emotivism on philosophical ethics and how unprepared philosophers were to participate in the practical world of professional practitioners. Much of what we did in those days was analysis of language and ethical claims and working out the implications of various ethical theories. Some of that was and remains very relevant today. But in order to give practical medical ethical advice, one must become immersed in the details of medical practice and become acculturated to the world of medicine.  Those early pioneers like Professor Thomasma were getting their bearings in the clinical setting by forging relationships of trust and bridges of communication. Most of what happened then was informal discussion and meetings between those of us who thought of ourselves as medical ethicists and the medical care team. But as I recall, no full, systematic review of cases and clear recommendations about what course of action enabled physician’s to fulfill their ethical obligations in individual cases went into the patient’s chart. Medical ethicists were not ready to assume that role because they had not both earned their bone fides as clinical team members. To do so would take time and the result would be that philosophical ethics was as deeply impacted, perhaps more so, than medical decision-making. This integration of philosophical ethics and medicine would provide the basis of the growth of the field that we have come to call clinical ethics and become the knowledge base of much of what clinical ethics consultants are expected to master.

By the early 1990’s much of the field of clinical ethics had been established and clinical ethics consultations had become a widely accepted service in medicine.  But it was also clear that the training of clinical ethics consultants had developed considerably. During 1993-94 I was a fellow at the MacLean Center at the University of Chicago where the fellows staffed the ethics consultation service at the University of Chicago Hospitals. By then there was a well-established format in which consultations were written and entered into the charts. Ethics consultants were coming into the clinical units, speaking with the care team but also with patients and their families, and sometimes attending family meetings. Within a period of 15 years or so, the role of clinical ethics consultants had become relatively clear and competencies were beginning to be taught to trainees at least in a few programs.

It is significant that during the early 1990’s the Joint Commission (JAHCO) issued standards that required hospitals to have a mechanism in place for resolving ethical disputes that arose in the course of patient care. This spurred a considerable interest in clinical ethics and more healthcare professionals were expressing an interest in working on ethics committees and performing clinical ethics consultations. Thus questions arose about the qualifications to do clinical ethics consultations.  What were the qualifications and who possesses them? This led the American Society for Bioethics and Humanities (ASBH) to publish a landmark document called the “Core Competencies” which was compiled by a group of national experts. For the first time, there were presumed professional standards for the field of clinical ethics consultations but it is noteworthy that these standards were viewed as guidelines and could not be made mandatory. The possibility of certifying clinical ethics consultants was rejected for such reasons as the risk of elevating consultants to authorities, the lack of accurate measurement tools, and the political task of overseeing the process. The field was diverse and no one practicing clinical ethics consultations wanted to be left out, regardless of their lack of formal training.

But questions and concerns about qualifications continued and grew more intense during the first decade of 2000. A national survey in 2007 showed what many assumed to be true: ethics consultants came from many different professional backgrounds and most had no formal training. Some critics alleged that the lack of proper training of clinical ethics consultants was “…a quietly growing scandal.” After all the cases that ethics consultants were being called upon to give advice involved some of the most complex and difficult end of life cases where families and patients were most vulnerable. Therefore, it stands to reason that ethics consultants who enter into those situations have the necessary competencies to provide state of the art ethics consultations. Sadly, though the field is still struggling to find ways to ensure that those who perform ethics consultations are fully qualified, it seems evident that many ethics consultants still do not have sufficient training.

Within the past few years there has been considerable discussion about the elements of certification of ethics consultants, though it is clear that the ASBH is not ready to begin a process of certification of ethics consultants. Yet, most people in the field agree that a written exam, case portfolio, demonstration of applied skills and an oral exam are some of the likely components of certification. Moreover, there has been considerable discussion of how the field might accredit training programs for ethics consultants, much like all training programs for other health care professionals are accredited. As a first effort in the direction of certification the ASBH initiated a pilot process called Quality Attestation in which a randomly selected cohort would provide evidence of their qualifications by having at least a master’s degree in a relevant field, presenting a portfolio that includes a CV, summary of experience, 3 letters of evaluation, 6 case discussions of consultations performed, and an oral exam. Though this is a modest first step, it is significant that movement is occurring toward providing the basis for ethics consultants being viewed as professionals like all other health care workers.

Because the field developed so informally with individuals with diverse backgrounds performing consultations, the process of professionalization is highly political and controversial. But the process continues and those who wish to become clinical ethics consultants would do well to have a terminal professional degree such at an MD, PhD or JD and a master’s in bioethics and a fellowship progress where they perform consultations under supervision. Such qualifications will likely be an expectation in future decades. By that time, there will hopefully be more commonality in the competencies in those who perform ethics consultations and thus a firmer basis for having a well-defined process in which individuals can show they are professionally qualified to do ethics consultations.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

1 comments | Topics: Clinical Ethics, Consultation, Credentialing

Comments

James Finnerty, M.D, M.A

James Finnerty, M.D, M.A wrote on 03/10/14 8:53 PM

Hi Wayne, You bring back many memories as to how we handled ethics consults and selecting consultants at the University of Virginia in the 90s. John Fletcher was the director of the Ethics Program and he more or less evaluated your performance and when he felt you had attained a certain degree of competency (acquiring a Masters in Ethics helped) he would appoint you to the consult service. We met every week on Monday and reviewed, as a group under Dr. Fletcher's supervision, the consults from the previous week. I guess this was some effort at uniformity and consistency.

Jim Finnerty

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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