Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted (...) by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society (...) for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here. (shrink)

From the beginning, a code of ethics for bioethicists has been conceived of as part of a movement to professionalise the field. In advocating for such a code, Baker repeatedly identifies 'having a code of ethics' with 'professionalization'. The American Society of Bioethics and Humanities echoes this view in their code of ethics for healthcare ethics consultants 1 and the subsequent publication in the American Journal of Bioethics.2 Taking for granted that a code of ethics could be a valuable asset (...) for HCECs, this essay has two aims. First, there are good reasons to doubt that the label 'profession' has significant meaning for HCECs. Attempts to accurately conceive of a profession fall into two broad camps: substantive and formal. Substantive conceptions should be rejected. Specifically, substantive conceptions beg the question about what it means to be a profession, which produces devastating problems for practical application. Formal conceptions of profession avoid begging the question, but do so at the cost of identifying the responsibilities of a profession. Using the term 'professional responsibilities', then, requires additional explication and classifying HCECs as professionals requires the identification of their role-specific responsibilities.i Second, this essay will critique the ASBH code of ethics for HCECs as a first articulation of these responsibilities. As written, this code of ethics has limited value for HCECs because most of the responsibilities identified in this code do not identify HCEC-specific responsibilities. In closing, some important strategies to improve upon this initial attempt to define the responsibilities of HCECs are identified. (shrink)

In November 2018 the American Society for Bioethics and Humanities (ASBH) administered the first Healthcare Ethics Consultant Certification examination to 138 candidates, 136 of whom (98.5 percent) passed and were “certified” as “healthcare ethics consultants.” I believe this certification process is both premature and inadequate.Certification for ethics consultants is premature because, as Kornfeld and Prager state repeatedly in their article in this issue of The Journal of Clinical Ethics, “The Clinician as Clinical Ethics Consultant: An Empirical Method of Study,” (...) there is a lack of “empirical data on the nature of the problems that prompt ethics consultation requests and on the functions required to address them.” These authors proceed to provide a model for the kind of empirical data collection that is needed.Even more relevant, the ASBH model that certifies clinical ethics consultants is inadequate. First, it is inappropriate for a nonclinical organization such as the ASBH to claim the right to certify a clinical process, ethics consultation, involving patients and health professionals. Second, the current certification process requires only a written examination in contrast to the two-step quality attestation process proposed in 2013 by Eric Kodish, MD, and 11 other senior members of the ASBH, including its then president.Third and most importantly, the eligibility criteria for being certified to work on hospital units and to make clinical recommendations for patients and families are minimal and insufficient. The only stated requirements are a bachelor’s degree and 400 hours of healthcare ethics consulting experience. By contrast, practicing physicians and nurses train for many years to gain clinical experience that enables them to apply clinical ethical standards in the care and management of all inpatients and outpatients, not just the small percent for whom an ethics consultation is requested. (shrink)

There were several worrisome results in the long-awaited studies on clinical ethics consultation by Fox et al, but one of the most sobering was the self-assessments made by ECSs (Ethics Consult Ser...

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book (...) called A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work. (shrink)

A decade ago some members of the American Society for Bioethics and the Humanities (ASBH) concluded that the society's reluctance to develop a code of professional ethics, although a tolerable anom...

Over the past several years, the bioethics community has seen considerable attention being given in the bioethics literature and in various initiatives to the matter of standards and quality in hea...

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities has published core knowledge (...) competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models—both objective and written—must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization. (shrink)

Clinical ethics training programs are responsible for preparing their trainees to be competent ethics consultants worthy of the trust of patients, families, surrogates, and healthcare professionals. While the American Society for Bioethics and Humanities (ASBH) offers a certification examination for healthcare ethics consultants, no tools exist for the formal evaluation of ethics trainees to assess their progress toward competency. Medical specialties accredited by the Accreditation Council for Graduate Medical Education (ACGME) use milestones to report trainees’ progress along a continuum (...) of professional development as a means of “operationalizing and implementing” medical competencies. Utilizing the Core Competencies for Healthcare Ethics Consultation and the ACGME and American Board of Pediatrics’ (ABP) Pediatric Milestones Project, we developed milestones for 17 subcompetencies in clinical ethics consultation and academic bioethics. As the field of clinical ethics becomes more standardized, such tools will be needed to promote the development of robust training programs and to certify that their graduates are competent practitioners. (shrink)

_The Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants_ instructs clinical ethics consultants to preserve their professional integrity by “not engaging in activities that involve giving an ethical justification or stamp of approval to practices they believe are inconsistent with agreed-upon standards” (ASBH, 2014, p. 2). This instruction reflects a larger model of how to address value uncertainty and moral conflict in healthcare, and it brings up some intriguing and as yet unanswered questions—ones that the drafters of (...) the _Code_, and the profession more broadly, should seek to address in upcoming revisions. The objective of this article is to raise these questions as a way of urging greater clarification of the _Code’s_ overall approach to professional integrity, its meaning, and implications. (shrink)

The ASBH Core Competencies Update Task Force (Tarzian and ASBH Core Competencies Update Task Force 2013) provides useful information for individual consultants performing case consultations. A grow...

Since the inception of bioethics, some theorists have denied that clinical ethicists have ethics expertise, understood as the ability to give justified moral recommendations in patient cases. These denials have caused considerable alarm, leading some to argue that the entire discipline needs to be fundamentally reconsidered. Although this debate has been a source of academic attention for decades, these challenges to ethics expertise can now be either resolved by showing they are based on an untenable view of moral justification or (...) dissolved by showing they result from a rash of equivocations on key phrases such as what it means to give a “moral recommendation,” or “furnish answers” in an ethics consultation. Like the blind men and the elephant, what sounds like disagreement may only be theorists describing different aspects of the same facilitation approach to clinical ethics endorsed by the American Society for Bioethics and Humanities. While the question of whether ethicists have ethics expertise can be resolved or dissolved, theorists should refocus on how much (content-thick vs. content-thin) expertise ethicists have. Here, theorists need not commit themselves to a general view but can be content-thick on some issues and content-thin on others. (shrink)

Tarzian and ASBH Core Competencies Update Task Force (2013) say that making ethics consultation accountable means examining the abilities and qualifications of health care ethics consultants (HCECs...

We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most crucially, TIEC (like TIC) is systematically (...) sensitive to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners. (shrink)

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners’ opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of hospitals had very positive (...) perceptions of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. (shrink)

In an age of professionalization and specialization, the practice of clinical ethics is facing an identity crisis. Are clinical ethicists moral experts, ethics experts, or merely quasi-lawyers giving legal advice? Are they extensions of the hospital, always working to advance the hospital’s interests? Or is there another option? Since 1998, when the American Society for Bioethics and Humanities first issued its Core Competencies for Healthcare Ethics Consultation, there has been debate about the role of standardization and proceduralism in clinical ethics (...) consultation. Now, as ASBH continues to move forward with its credentialing program, proceduralism in clinical ethics must be critically examined. In this paper, I argue that the proceduralist approach to clinical ethics consultation, as espoused by the ASBH’s call for credentialing, creates a demeaning experience for all parties involved and precludes goods internal to the practice of clinical ethics consultation from being actualized. As a practice embedded in medicine and in institutions such as the hospital, clinical ethics consultation must define and examine its own goods in order to bring about more than a sterile, law-like solution to difficult moral quandaries, as these sterile solutions leave patients, families, and providers unsatisfied, abandoned, and disappointed. Thus, in an effort to push back against this proceduralism in clinical ethics consultation, I will offer a preliminary exploration of what these goods might be. (shrink)

Background Few studies have been conducted to assess the quality of orientation practices for ethics advisory committees that conduct ethics consultation. This survey study focused on several Harvard teaching hospitals, exploring orientation quality and committee members’ self-evaluation in the American Society of Bioethics and Humanities ethics consultation competencies. Methods We conducted a survey study that involved 116 members and 16 chairs of ethics advisory committees, respectively. Predictor variables included professional demographics, duration on committees and level of training. Outcome variables included (...) familiarity with and preparedness in the ASBH competencies and satisfaction with orientations. We hypothesised that responses would be associated with both the aforementioned predictors and whether or not participants had encountered the ASBH competencies in training. Results A majority of respondents found their orientation curricula to be helpful, although a significant portion of respondents did not receive any orientation or were unsatisfied with their orientation. Familiarity with ASBH competencies was a statistically significant predictor of respondents’ self-evaluation in particular categories. Standard educational materials were reported as offered during orientation, such as readings and case studies ; different medium resources were less evidenced such as videos on ethics consultation. Conclusions Institutions should re-evaluate orientation practices for ethics committee members that perform ethics consultation. Integrating ASBH competencies and useful methods into a resourceful pedagogy will help improve both member satisfaction with orientation and preparation in consultation. (shrink)

The American Society for Bioethics and the Humanities (ASBH) issued its Core Competencies for Health Care Ethics Consultation just as it is becoming ever clearer that secular ethics is intractably plural and without foundations in any reality that is not a social–historical construction (ASBH Core Competencies for Health Care Ethics Consultation , 2nd edn. American Society for Bioethics and Humanities, Glenview, IL, 2011 ). Core Competencies fails to recognize that the ethics of health care ethics consultants is not (...) ethics in the usual sense of a morally canonical ethics. Its ethics is the ethics established at law and in enforceable health care public policy in a particular jurisdiction. Its normativity is a legal normativity, so that the wrongness of violating this ethics is simply the legal penalties involved and the likelihood of their being imposed. That the ethics of ethics consultation is that ethics legally established accounts for the circumstance that the major role of hospital ethics consultants is as quasi-lawyers giving legal advice, aiding in risk management, and engaging in mediation. It also indicates why this collage of roles has succeeded so well. This article shows how moral philosophy as it was reborn in the 13th century West led to the ethics of modernity and then finally to the ethics of hospital ethics consultation. It provides a brief history of the emergence of an ethics that is after morality. Against this background, the significance of Core Competencies must be critically reconsidered. (shrink)

The Neuroethics Affinity Group of the American Society for Bioethics and Humanities met for the third time in October 2007 to review progress in the field of neuroethics and consider high-impact priorities for the future. Closely aligned with ASBH's own goals of recruiting junior scholars to bioethics and mentoring them to successful careers, the Neuroethics Affinity Group placed a call for new ideas to be presented at the Group meeting, specifically by junior attendees. One group responded with the idea (...) to probe a new direction for neuroethics focused on the neuroscience of gender differences. In the spirit of full disclosure, two of the authors are a student and fellow of the program I formerly directed at Stanford University. The third is junior faculty there. The intellectual ownership of the ideas in the report below, however, are entirely theirs. Like lit torches in a juggling act, there are many directions this project can go. The report is a snapshot of these authors' first iteration of the concept of women's neuroethics. Many thanks are extended to participants of the ASBH Neuroethics Affinity Group meeting whose enthusiasm and feedback was immensely helpful in shaping the concept and moving it ahead. - Judy Illes, Editor AJOB-Neuroscience. (shrink)

This issue of CQ was conceived in Salt Lake City, at the third annual meeting of the American Society of Bioethics and Humanities (ASBH). There, President-elect Laurie Zoloth delivered a stirring address, emphasizing the role of bioethics in responding to social deprivations and suggesting that ASBH on important issues where members share consensus. Not all the stirrings were pleasant. Debate erupted about the propriety of consensus statements, especially regarding possible deleterious effects on academic discourse, misappropriation of dues, and (...) the proliferation of quasi-political factions. The roots of this controversy extend deeply into the collective psyche of contemporary bioethics. (shrink)

Although bioethics societies are developing standards for clinical ethicists and a code of ethics, they have been castigated in this journal as “a moral, if not an ethics, disaster” for not having completed this task. Compared with the development of codes of ethics and educational standards in law and medicine, however, the pace of pro-fessionalization in bioethics appears appropriate. Assessed by this metric, none of the charges leveled against bioethics are justified. The specific charges leveled against the American Society for (...) Bioethics and Humanities and its Core Competencies report are analyzed and rejected as artifacts of an ahistoric conception of the stages by which organizations professionalize. For example, the charge that the ASBH should provide definitive criteria for what counts as “medical ethics consultation” antecedent to further progress towards professionalization is assessed by comparing it with the American Medical Association's decades-long struggle to define who can legitimately claim the title “medical doctor.” Historically, clarity about who is legitimately a doctor, a lawyer — or a “clinical ethicist”— is a byproduct of, and never antecedent to, the decades-long process by which a field professionalizes. The charges leveled against ASBH thus appear to be a function of impatient, ahistoric perfectionism. (shrink)

In this chapter, we explore the question of on what grounds reports of clinical ethics support in general, including especially clinical ethics consultation, can or should be evaluated when using a peer review system. It is our contention that to evaluate clinical ethics consultation within a peer review system aiming at transparency and fairness, a defined and shared criteria of evaluation, i.e. an evaluation standard is required. When evaluating a performed ethics consultation, we can roughly distinguish between an internal standard, (...) which refers to the conceptualization of clinical ethics consultation held by the respective consultant or by the assessed clinical ethics support service themselves, and external standards. Most important is the way how an external standard is being defined: Is it just the standard of another service or colleague? Or is it the result of a larger consensus-building process of a relevant body representing a larger group of colleagues, such as the ASBH? Or does it even rely on the “evidence” of related research? An external standard, however, may rest on criteria that are not – or not fully – accepted by the evaluated CESS or individual ethics consultant. Identifying the internal standard of an observed ethics consultant’s work may also be challenging. From the evaluator’s perspective the responsibility for making an internal standard known and unequivocal lies with the “author” of the material. The potential gap between internal and external standards marks a methodological difficulty that as such has to be addressed within peer review evaluation. (shrink)

Clinical ethics consultants (CECs) are not moral authorities. Standardization of CECs’ professional role does not confer upon them moral authority. Certification of particular CECs does not confer upon them moral authority (nor does it reflect such authority). Or, so we will argue. This article offers a distinctly Orthodox Christian response to those who claim that CECs—or any other academically trained bioethicist—retain moral authority (i.e., an authority to know and recommend the right course of action). This article proceeds in three parts. (...) First, we discuss recent movements toward the certification of CECs in the United States, focusing primarily on proposals and programs put forth by the American Society for Humanities and Bioethics (ASBH). Second, we outline two secular reasons to be concerned about the relevant trends toward certification. For one thing, certification is currently being advanced via political dominance, rather than gaining authority by reliance on rigorous philosophical argument or reason. For another, the trends operate on the assumption that there exists a secular, content-full, canonical, morality. There is no such morality. Next, we argue that Orthodox Christians should resist the current trends toward certification of CECs. Specifically, we unpack ways in which the ASBH’s certification program (and those like it) conflict with Orthodox claims about moral authority and the moral life more generally. We conclude that Orthodox Christians should resist the current certification trends. (shrink)

A proposal by the American Society for Bioethics and Humanities (ASBH) to identify individuals who are qualified to perform ethics consultations neglects case complexity in candidates’ portfolios. To protect patients and healthcare organizations, and to be fair to candidates, a minimum case complexity level must be clearly and publicly articulated. This proof-of-concept study supports the feasibility of assessing case complexity. Using text analytics, we developed a complexity scoring system, and retrospectively analyzed more than 500 ethics summaries of consults performed (...) at an academic medical center during 2013. We demonstrate its use with seven case summaries that range in complexity from uncomplicated to very complicated. We encourage the ASBH to require a minimum level of case complexity, and recommend that attestation portfolios include several cases of moderate complexity and at least one very complex case. (shrink)

As the field of clinical bioethics has moved from its pioneers, who turned their attention to ethics problems in clinical medicine and clinical and animal research, to today’s ubiquity of university degrees and fellowships in bioethics, there has been a steady drumbeat to professionalize the field. The problem has been that the necessary next steps—to specify the skills, knowledge, and personal and professional attributes of a clinical bioethicist, and to have a method to train and evaluate mastery of these standards—are (...) lacking.Ordinarily, the path to professionalism in medicine starts with the intellectual pioneers. Then come those who develop early experience in clinical settings. Then comes the specification of the skills, knowledge, and personal and professional attributes needed to perform the activities of the new specialty or subspecialty. And only then, after a method to train and evaluate levels of mastery from novice to advanced practitioner has been developed, comes credible credentialing and certification/licensing.Unfortunately, the field of clinical bioethics has skipped these steps. Rather, a credential, that is, the Healthcare Ethics Consultant (HEC) certification, was created by a small group within the bioethics professional association, the American Society of Bioethics and Humanities (ASBH), without community agreement or necessary input. Further, the testing of processes to train HECs and to evaluate their levels of mastery of competencies was prematurely forwarded as sufficient evidence of competence in clinical ethics. That is, the credential, offered by the ASBH for a fee, upon passing an exam based on how many hours one has been involved in clinical consultation, about which there is no field agreement on how such consultations ought to be conducted and for which only controversial standards have been set, is being touted as evidence of competence in clinical bioethics. In their article, “Competencies and Milestones for Bioethics Trainees,” Sawyer and colleagues identify the central weakness of these claims to professionalization and provide the field the first substantive assessment tool and method to train and evaluate competencies. The tool these authors present is the real next step forward for true professionalization of the field of clinical bioethics. (shrink)

Objective: To determine whether bioethicists are distributed along a rural-to-urban continuum in a way that reflects potential need of those resources as determined by the general population, hospital facilities and hospital beds.Methods: US members of a large, multidisciplinary professional society, the American Society of Bioethics and Humanities , the US population, hospital facilities and hospital beds were classified across a four-tier rural-to-urban continuum. The proportion of each group in rural settings was compared with that in urban settings, and odds ratios (...) were calculated with 95% confidence intervals.Results: Although 91% of ASBH members live or work in urban settings, only 66% of the US population did so. In contrast, 2% of ASBH members live or work in rural settings compared with 13% of the population. ASBH members were 10.7 times as likely to be represented in urban than in rural settings when compared with the general population, 25.6 times and 6.9 times as likely with regard to hospital facilities and hospital beds, respectively.Conclusions: Using various comparisons it was found that ASBH members are under-represented in rural as compared with urban settings. Although not all bioethicists are ASBH members, these findings suggest that the availability of professional bioethical resources may be inadequate in rural America. The disparities that were found may have considerable effect on ethics scholarship, research, ethical committees and education, and adds to the argument that rural American communities are under-served. (shrink)

The national standards for clinical ethics consultation set forth by the American Society for Bioethics and Humanities endorse an “ethics facilitation” approach, which characterizes the role of the ethicist as one skilled at facilitating consensus within the range of ethically acceptable options. To determine the range of ethically acceptable options, ASBH recommends the standard model of decision-making, which is grounded in the values of autonomy, beneficence, nonmaleficence, and justice. H. Tristram Engelhardt Jr. has sharply criticized the standard model for (...) presuming contentful moral claims in circumscribing the range of ethically acceptable options, which, he argues, cannot be rationally justified in a pluralistic context. Engelhardt’s solution is a secular clinical ethics based on a contentless principle of permission. The first part of this article lays out Engelhardt’s negative claim, that reason cannot establish contentful moral claims, and his positive claim, that secular clinical ethics ought to be based on a contentless principle of permission. The second part critiques these negative and positive claims. The purpose of this paper is to defend secular clinical ethics expertise—defined as the ability of ethicists to offer justified moral recommendations grounded in consensus positions endorsed by the American Society for Bioethics and Humanities—from the radical critiques of Engelhardt, who argues that no moral or metaphysical claims, and hence no bioethical consensus, can be rationally justified. Engelhardt’s critiques have caused some to worry that secular clinical ethics is in a state of theoretical crisis; this article concludes that Engelhardt’s view is an unstable basis for that worry. (shrink)

The model of clinical ethics consultation (CEC) defended in the ASBH Core Competencies report has gained significant traction among scholars and healthcare providers. On this model, the aim of CEC is to facilitate deliberative reflection and thereby resolve conflicts and clarify value uncertainty by invoking and pursuing a process of consensus building. It is central to the model that the facilitated consensus falls within a range of allowable options, defined by societal values: prevailing legal requirements, widely endorsed organizational policies, (...) and professional standards of practice and codes of conduct. Moreover, the model stipulates that ethics consultants must refrain from giving substantive recommendations regarding how parties to a moral disagreement in the clinic should evaluate their options. We argue that this model of CEC is incomplete, because it wrongly assumes that what counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible. We illustrate this problem with a recent case on which one of us consulted—a neonate born with trisomy 18 (T18). We try to show that law, policy, and standards of practice reveal no clear answer to the question posed by the case: namely, whether forgoing gastrostomy tube feedings for a baby with T18 is allowable. We suggest there may be other kinds of cases in which it may simply be unsettled whether a given choice falls within the set of allowable options within which consensus is to be facilitated. What should an ethicist do when confronting such unsettled cases? We agree with the facilitation model that an ethicist should remain neutral among the allowable options, when it is clear what the allowable options are. But, in unsettled cases, the role of a consultant should be expanded to include a process of moral inquiry into what the allowable options should be. We end by raising the issue of whether this means an ethicist should share his or her own conclusions or views about the allowability of a given clinical option. (shrink)

In their article “Structuring a Written Examination to Assess ASBH Health Care Ethics Consultation Core Competencies” (2014), White, Jankowski, and Shelton argue that a written examination to evalu...

The American Society for Bioethics and Humanities is now proposing a process whereby the role and authority of clinical ethics consultants can be legitimated. Without regulation and oversight, the field lacks validity and accountability. ASBH has sought to remedy the lack of uniform standards and accreditation by publishing Core Competencies in Health Care Ethics Consultation and an education guide, and now by proposing a “quality attestation process,” situated between national certification processes and local credentialing practices, to “attest to the (...) skills and ability of properly trained and competent clinical ethicists.” If the process is successful, a cadre of certified clinical ethics consultants will emerge. Before the dawn of this new era, it is worth pausing to consider the adequacy of the quality attestation process itself and how it will affect the current world of clinical ethics consultants. Ethics consultations are often done by a multidisciplinary team, and the consult note is a compilation or synthesis of the work of the team. If the evidence required to attest to one's quality as an ethics consultant is to bear on one's ability to work with a team and present an integrated consult note, then these notes are relevant. If, however, the evidence is to bear on the quality of one's own work, then the evidence is inconclusive at best, fraudulent at worst. The quality attestation process seems to be predicated on the individual ethics consultant model, which may not jibe with the realities of ethics consultation. There may be more than one way to demonstrate one's competence, and there may be more than one competency to demonstrate. (shrink)

In the process of professionalization, the American Society for Bioethics and Humanities (ASBH) has emphasized process and knowledge as core competencies for clinical ethics consultants; however, the credentialing program launched in 2018 fails to address both pillars. The inadequacy of this program recalls earlier critiques of the professionalization effort made by Giles R. Scofield and H. Tristram Engelhardt, Jr.. Both argue that ethics consultation is not a profession and the effort to professionalize is motivated by self-interest. One argument they (...) offer against professionalization is that ethics consultants lack normative expertise. Although the question of expertise cannot be resolved completely, the accusation of self-interest can be addressed. Underlying these critiques is a concern for hubris, which can be addressed in certification and the vetting of candidates. Drawing on the virtue ethics literature of Alasdair MacIntyre and Edmund D. Pellegrino, I argue that medicine is a moral community in which ethics consultants are moral agents with a duty to foster the virtue of humility (or what Pellegrino and Thomasma call self-effacement). The implications of this argument include a requirement for self-reflection in one’s role as a moral agent and reflection on one’s progress toward developing or deepening virtuous engagement with the moral community of medicine. I recommend that professionalization of clinical ethics consultants include a self-reflective narrative component in the initial certification and ongoing renewal of certification where clinical ethics consultants address the emotional dimensions of their work as well as their own moral development. Adopting a teleological view of ethics consultation and incorporating narratives that work toward that purpose will mitigate the self-interest and hubris of the professionalization project. (shrink)

In their systematic review of the work of the ASBH Core Competencies Update Task Force, Anita Tarzian and ASBH Core Competencies Update Task Force (2013) write, “The ethics facilitation approach do...

There is an increasing need for quality in ethics consultations, though there have been significant achievements in the United States and Europe. However, fundamental concerns that place the profession in jeopardy are discussed from the perspective of the U.S. in a manner that will be helpful for other countries. The descriptive component of the essay (the first two points) explains the achievements in ethics quality (illustrated by the IntegratedEthics program of the Veterans Health Administration) and the progress on standards and (...) competencies for ethics consultations (represented by the Core Competencies of the American Society for Bioethics and Humanities). Based on these achievements, the analytical component of the essay (the final three points) identifies and seeks to resolve three fundamental concerns (with increasing levels of importance) that compromise quality in ethics consultations: standards of quality; professionalism; and credentialing. The analysis argues for clearer standards of quality in ethics consultation and urges further professionalism by explaining the need for the following: interpreting the ASBH core competencies in a normative manner, developing a Code of Ethics, and clarifying the meaning of best practices. However, the most serious concern that threatens quality in ethics consultations is the lack of a credentialing process. This concern can be resolved effectively by developing an independent Ethics Consultation Accreditation Council to accredit and standardize graduate degree programs, fellowship experiences, and qualifying examinations. This credentialing process is indispensable if we are to strategically enhance quality in ethics consultations. (shrink)

In “Consensus, Clinical Decision Making, and Unsettled Cases,” David M. Adams and William J. Winslade make multiple references to both editions of the American Society of Bioethics and Humanities (ASBH) Core Competencies for Healthcare Ethics Consultation in their discussion of two assumptions that are supposed to be at the heart of the facilitated consensus model’s inability to handle unsettled cases; that is, that:1. Consultants “should maintain a kind of moral impartiality or neutrality throughout the process,” “explicitly condemn[ing] anything resembling (...) a substantive ‘ethics’ recommendation,” and2. “What counts as the proper set of allowable options among which the parties are to deliberate will itself always be clearly discernible.”Herein, I argue that neither of these assumptions is required by ASBH’s ethics facilitation approach. I then conclude by suggesting that, despite their fundamentally mistaken interpretation of the ASBH approach—perhaps even because of it—Adams and Winslade have made two important contributions to the ethics consultation literature. (shrink)

Several approaches to clinical ethics consultation (CEC) exist in medical practice and are widely discussed in the clinical ethics literature; different models of CECs are classified according to their methods, goals, and consultant’s attitude. Although the “facilitation” model has been endorsed by the American Society for Bioethics and Humanities (ASBH) and is described in an influential manual, alternative approaches, such as advocacy, moral expertise, mediation, and engagement are practiced and defended in the clinical ethics field. Our Clinical Ethics Center (...) in Paris was founded in 2002 in the wake of the Patients’ Rights Act, and to date it is the largest center that provides consultation services in France. In this article we shall describe and defend our own approach to clinical ethics consultation, which we call the “Commitment Model,” in comparison with other existing models. Indeed commitment implies, among other meanings, continuity through time, a series of coherent actions, and the realization of important social goals. By drawing on a recent consultation case, we shall describe the main steps of our consultation procedure: interviews with major stakeholders, including patients and proxies; case conferences; and follow up. We shall show why we have chosen the term “commitment” to represent our approach at three different but interrelated levels: commitment towards patients, within the case conference group, and towards society as a whole. (shrink)

Janet Malek (91–102, 2019) argues that a “clinical ethics consultant’s religious worldview has no place in developing ethical recommendations or communicating about them with patients, surrogates, and clinicians.” She offers five types of arguments in support of this thesis: arguments from consensus, clarity, availability, consistency, and autonomy. This essay shows that there are serious problems for each of Malek’s arguments. None of them is sufficient to motivate her thesis. Thus, if it is true that the religious worldview of clinical ethics (...) consultants should play no role whatsoever in their work as consultants, this claim will need to be defended on some other ground. (shrink)

For the past few years I've had the distinct privilege to edit the Hastings Center Report's Policy & Politics column. The column—as indicated by a little block of text at its end—was originally conceived as, and remains, a joint production of HCR and the American Society for Bioethics and Humanities. For me, as column editor, this means that I can accept contributions only from ASBH members. Luckily this presents me with an extremely large pool of talent from which to (...) draw! I am very proud of the fact that a large majority of contributors to the column in the last several years had never written in HCR before I invited them to contribute. But naturally, I don't know everyone, and I can't keep track of everything. I'd love to get even more unsolicited offers of P&P contributions than I already enjoy. (shrink)

The American Society for Bioethics and Humanities is to be congratulated on its updating of competency standards for ethics consultations (Tarzian and ASBH Core Competencies Update Task Force 2013)...

The push by some bioethicists to excise religion from the clinical ethics consultative process has received institutional support from the American Society for Bioethics and the Humanities. Their certification program, Healthcare Ethics Consultant-Certified, is intended to identify and assess “a national standard for the professional practice of clinical healthcare ethics consulting” devoid of religious content. As Christian ethicists who wish to preserve the morally evaluative nature of healthcare ethics, we must pause and theologically reflect on the meaning of such a (...) program. The five articles in this issue offer rich theological responses to the religion-free standardized methodology endorsed by the ASBH and reified in the HEC-C certification program. They offer a depth of theological reflection we see previously lacking in the literature, attending to the real possibilities of a “terraformed bioethics” effecting metaphysical harm, severing of clinical ethics from its sources, eliminating possibilities for conversion, and confusing the meaning of moral expertise. (shrink)

IntroductionDespite the need for trained physician ethicists, fellowships in clinical ethics are limited and primarily offered to thosewho have completed a graduate degree. The standardization of credentialing for clinical ethics consultants (CECs) and the restructuring of undergraduate medical education allow innovative models to train CECs that can provide an expanded opportunity for formal ethics training at an earlier stage.MethodsAt the University of Michigan Medical School we developed, implemented, and evaluated a pre-doctoral clinical ethics fellowship program from 2017 to 2019 for (...) senior medical students, designed to meet established competencies for CECs. Consultation notes from the beginning and end of the fellowship program were randomly selected for each fellow and independently rated by two faculty ethicists who used the validated Ethics Consultation Quality Assessment Tool (ECQAT).1 Inter rater reliability and trends in scores over time were calculated.ResultsThree students successfully completed the fellowship at the University of Michigan Medical School, conducted at least 50 formal ethics consultations, and spent approximately 40 hours a week on service for a minimum of six months. All students finished the fellowship with teaching and policy development experience, first-authored peer-reviewed manuscripts, and national presentations. The fellows demonstrated improvement in their ECQAT overall holistic rating score; all ended their fellowship with a holistic score of adequate or above. There was 92 percent agreement between raters withrespect to the acceptability of the fellows’ ethics consult notes. Two fellows have taken and passed the Healthcare Ethics Consultant-Certification (HEC-C) exam offered by the American Society for Bioethics and Humanities (ASBH).ConclusionsIntegration of a pre-doctoral fellowship model that meets professional certification standards for clinical ethics consultation creates an opportunity for medical students to become trained CECs early in their career. (shrink)

Objective: To survey members of the American Society for Bioethics and Humanities and of the Society for Medical Decision Making to elicit the similarities and differences in their reasoning about two clinical cases that involved ethical dilemmas.Cases: Case 1 was that of a patient refusing treatment that a surgeon thought would be beneficial. Case 2 dealt with end-of-life care. The argument was whether intensive treatment should be continued of an unconscious patient with multiorgan failure.Method: Four questions, with structured multiple alternatives, (...) were asked about each case: identified core problems, needed additional information, appropriate next steps and who the decision maker should be.Observations and results: Substantial similarities were noticed between the two groups in identifying the core problems, the information needed and the appropriate next steps. SMDM members gave more weight to outcomes and trade-offs and ASBH members had patient autonomy trump other considerations more strongly. In case 1, more than 60% of ASBH respondents identified the patient alone as the decision maker, whereas members of SMDM were almost evenly divided between having the patient as the solo decision maker or preferring a group of some sort as the decision maker, a significant difference . In case 2, both groups agreed that the question of discontinuing treatment should be discussed with the family and that the family alone should not be the decision maker.Conclusion: Despite distinctively different methods of case analysis and little communication between the two professional communities, many similarities were observed in the actual decisions they reached on the two clinical dilemmas. (shrink)