Posted on June 17, 2015 at 10:06 PM
Let me say emphatically at the outset of this blog, as someone who has been a clinical ethics consultant for over 20 years, I am quite sure that clinical ethics consultations overall improve the quality of patient care and currently are an important, even essential, part of the providing excellent patient care in hospitals. Contemporary medicine is filled with value laden questions and issues that often can be effectively addressed by someone with expertise and training in clinical ethics. Having said this, I am still somewhat skeptical about clinical ethics consultation becoming a professional area of healthcare that parallels other professional areas like medicine, nursing, and social work. I think there are some special considerations about the field of clinical ethics consultation that makes its future status as a professional activity uncertain.
First of all it is well-known that CEC’s come from a variety of backgrounds and training—from philosophers to physicians to social workers to nurses and lawyers and on and on. People enter the field of clinical ethics consultations from very different disciplinary backgrounds and seemingly learn a common vocabulary and methodology of clinical ethics and a basic familiarity with and ability to function in the clinical setting. They learn this vocabulary in very different ways—some informally, some through short 1-2 week long intensives, some with certificate programs, some with master’s degrees, and some with 1-2 year long fellowships. No other area of healthcare work admits of such diversity. Though this is a positive feature in some ways by providing diverse perspectives in understanding value dilemmas, it creates a challenge of considerable controversy when we try to define the kind of educational training a future CEC should have. At the moment there seem to be many pathways into the field and no clear answer has emerged.
At the same time, I must admit as the number of master’s and fellowship programs have proliferated in the past decade or so and more graduates come out of these programs with PhD’s, MD’s, and JD’s, a new generation of CEC’s are entering the field. It is possible that over the course of the next several decades there will naturally emerge a standard for what is expected in educational training. If this does happen my intuition is that it will include, as I have written elsewhere, a terminal professional degree, and master’s in bioethics or clinical ethics, and a fellowship in clinical ethics in which the trainee learns to do consultation under supervision. This would be a viable basis for professionalization. But we are nowhere near it today and if it is to happen, my guess is it will be a decade or more.
Another factor that limits the professionalization of clinical ethics consultation is the lack of a national organization that can control standards and licensing requirements. This is not meant to be critical of the American Society of Bioethics and Humanities (ASBH). Rather it reflects the fact that many CEC’s do not belong to the CEC and many healthcare organizations do not follow the lead of the ASBH. Leaders in the ASBH are by and large academic bioethicists like myself, while so many of the individuals doing clinical ethics consultations are not. Although the ASBH has made enormous progress in developing the Core Competencies in clinical ethics, a document which expertly lays out the essential competencies necessary to do clinical ethics consultation, responsibility and authority for who gets to be a CEC and perform clinical ethics consultation is all at the local level. My sense is that ASBH leaders in the field of clinical ethics consultation are more concerned about standards and professionalization than local administrative leaders in hospitals around the country. The concerns of local leaders are more about meeting JHACO standards and appointing individuals to perform clinical ethics consultations they can trust and fit into the local culture. Moreover, moving to the professionalization of clinical ethics consultation would likely mean hospitals would be required to hire CEC’s with more advanced education and training which would mean higher costs, which it is not likely most hospitals would agree to. Clinical ethics consultation, though highly regarded for good reason by ASBH members like myself, is not a widely regarded service that payers in the healthcare system are prepared to acknowledge and pay a premium for.
The final factor that I think makes professionalization problematic in clinical ethics consultation is in my view the most serious. Most professional areas of healthcare deal with problems that lend themselves to conceptual and scientific definition, which can be addressed by a body of knowledge and agreed upon methodology. Though there are genuine ethical dilemmas that do lend themselves to be addressed in this manner, it is often not the case in clinical ethics consultations. Many of the problems referred to clinical ethics consultation are not ethical issues so much as they are problems in communication and a reflection of dysfunction and problems in the institution and healthcare system; moreover, many of the problems reflect the needs and interests of physicians and nurses, like their hypersensitive concerns about following procedural guidelines such as those for withdrawing or withholding treatment for a developmentally disabled patient, how to assess capacity, and be in compliance with DRN policy. These are not ethical problems per se and bioethics and clinical ethics education and training may do little to help learners address such problems. CECs learn to navigate such non-ethical issues on the job within one’s local culture.
It is also the case that many, perhaps most, of the genuine ethical dilemmas that arise in cases in any given hospital may not involve calling for a clinical ethics consultation. It is far from clear that serious ethical dilemmas are clearly recognized as definable problems by many practicing physicians requiring the expertise of a clinical ethics consultant. In fact I am sure in my own hospital that our ethics consultation gets called only a fraction of the cases with serious ethical problems, and the cases we do get called on by no means are the most serious ethical cases. These patterns of how problems in clinical ethics consultation are often nebulously defined and reflect larger system’s issues and concerns about caregiver liability issues make it difficult to define clinical ethics consultation as a well-defined professional activity.
I have alluded to the challenges of how to make sense of the diverse educational backgrounds and training of those who perform clinical ethics consultations and how far to push such requirements; the lack of a national body to set requirements that leaves local hospital leaders with little incentive to pay for highly qualified CECs and view this as a sound investment; and finally, most seriously, the way in which many problems in patient care are misidentified as clinical ethical problems while other serious clinical ethical problems may be entirely overlooked or if recognized, not viewed as requiring the expertise of a CEC. The very nature of CEC problems, including legitimate value dilemmas, are such that problem solving can be idiosyncratically local, e.g. depending on how policies on DRN and capacity assessment are interpreted, and less a function of commonly shared knowledge and methods by a group of commonly trained professionals. These challenges are indications that clinical ethics consultation will not likely achieve professional status in the healthcare system in the near future.
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.