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07/07/2015

Clinical Ethics Consultant Professionalization: A Response to Dr. Shelton

In
his last AMBI blog
posted on June 18, 2015, Wayne N. Shelton,
PhD, MSW, discussed recent movement toward the professionalization of clinical
ethics consultants. He noted the adoption of a Code of Ethics for Health Care
Ethics Consultants by the American Society for Bioethics and Humanities (ASBH),
which has been praised as important milestone toward the professionalization of
clinical ethics consultants. Moreover, Dr. Shelton listed several challenges
that “professionals” who call themselves “clinical ethics consultants” currently
face, including: “[1]
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; [2]
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 [3], 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.” He concluded his
post with: “These challenges are indications that clinical ethics consultation
will not likely achieve professional status in the healthcare system in the
near future.” Of course, Dr. Shelton is correct in his analysis, but some might
see the challenges he listed as surmountable if those who practiced clinical
ethics consultation were to: (1) establish minimum uniform educational
standards for new clinical ethics consultants; (2) create national
certification and accreditation standards so employers would more fully
understand the nature and value of their work; and (3) provide consultants themselves
and other stakeholders unmistakable guidance on what clearly constitutes the
work of clinical ethics consultants. (This third point sounds very much like a
“scope of practice” definition found in state professional licensing statutes.)
However, it may take something much more for clinical ethics consultants to be
a separate professional category.

In making his case, Dr. Shelton might have used the emergence of the genetic counseling and clinical pharmacy professions as examples to illustrate his arguments. Genetic counseling is “the process by which the patients or relatives at risk of an inherited disorder are advised of the consequences and nature of the disorder, the probability of developing or transmitting it, and the options open to them in management and family planning. This complex process can be separated into
diagnostic (the actual estimation of risk) and supportive aspects.”
Clinical
pharmacy
(as contrasted with dispensing pharmacy) 
is “the branch of pharmacy where pharmacists provide patient care that optimizes the use of medication and promotes health, wellness, and disease prevention. Clinical pharmacists care for patients in all health care settings but the clinical pharmacy movement initially began inside hospitals and clinics. Clinical pharmacists often collaborate with physicians and other healthcare professionals.”

Both
genetic counseling and clinical pharmacy are evolving independent healing arts professions today. Genetic
counseling grew from a need recognized by medical geneticists relatively
separate from other health care arts professionals; clinical pharmacy arose from
within pharmacy itself as a branch of sub-specialty practitioners. For all
practical purposes, these two new professions now have well-recognized uniform
educational standards in their fields. Potential employers who advertise
specifically for credentialed genetic counselors or specialized clinical
pharmacists see both groups with unique skills and value. Regarding community-acknowledged
and clearly demarcated scopes of practice, genetic counselors are now licensed
in about 15 states, and clinical pharmacists are licensed as pharmacists – not clinical pharmacists – in all
American jurisdictions.

Curiously,
fledgling clinical ethics consultants, genetic counselors, and clinical
pharmacists all began their work at about the same time in the 1960s and 1970s.
It seems that genetic counseling and clinical pharmacy are succeeding in
establishing professional status more quickly than clinical ethics consultants.
The definition of profession offered
specifically for medical educators by Sylvia R. Cruess, MD, Sharon E. Johnston,
MA, LLM, and Richard L. Cruess, MD, might be useful in assessing the development
of these novel disciplines.
All three
“professions” clearly are: (1) “vocation[s] in which knowledge of some
department of science or learning or the practice of an art founded upon it is
used in the service of others”; (2) “its members are governed by codes of
ethics and profess a commitment to competence, integrity and morality, altruism,
and the promotion of public good within their domain”; and (3) they are
“[accountable] to those served and to society.” So then, what are the critical differences
in the emerging professionalization movements between clinical ethics
consultants and the genetic counselors and the clinical pharmacists? Perhaps
several: (1) Both genetic counselors and clinical pharmacists are grounded in
unique “mastery of a complex body of knowledge and skills” and clinical ethics
consultation is not; (2) both genetic counselors and clinical pharmacists are
seen as holding a social grant or social warrant (or “social contract”) for monopoly-like
“use of that unique knowledge base” and clinical ethics consultation does not;
and (3) both genetic counselors and clinical pharmacists enjoy “considerable
autonomy in practice and privilege of self-regulation” and again clinical
ethics consultation does not. In deference to 
Dr. Shelton’s views, it may be these three challenges – lack of a unique complex knowledge and skills base, lack of a social warrant, and lack of an ability to self-regulate – that will prove most difficult to clinical ethics consultation professionalization.

Maybe a better historical example of what might be happening in the attempt to separate clinical ethics consultation from its diverse roots might be that of pharmacy splitting off from medicine. Physicians were clearly seen as professionals in ancient times. The Code of Hammurabi (circa 2000 BC) drafted by the early Mesopotamians included provisions governing medical practitioners. The first apothecary in London opened in 1345 AD. Even as late as 1915, Abraham Flexner – the Father of American Medical Education – did not believe that pharmacy was a “profession” when he wrote: “Is pharmacy a profession? … The pharmacist compounds the physician’s prescription, for which task he requires a considerable degree of expertness, a knowledge of certain sciences – especially chemistry – and a high degree of caution, since either the slightest error on his part, or inability to detect an error on the part of the physician, whether due to ignorance or to carelessness, may have very serious consequences. Recurring to our criteria, I should say that pharmacy has definiteness of purpose, possesses a communicable technique, and derives at least part of its essential material from science. On the other hand, the activity is not predominantly intellectual in character and the responsibility is not original or primary. The physician thinks, decides, and orders; the pharmacist obeys – obeys, of course, with discretion, intelligence, and skill – yet in the end obeys and does not originate. Pharmacy, therefore, is an arm added to the medical profession, a special and distinctly higher form of handicraft, not a profession. Nor is this distinction merely a verbal quibble, for it has an important bearing on the solution of all educational questions pertaining to pharmacy.”

From this, one may reason that only after pharmacy developed its on unique knowledge and skills base, and social warrant, and ability to self-regulate – separate from medicine – did it truly achieve independent professional status.

For clinical ethicists to professionalize, that is, for consultants to be recognized as stand-alone healing arts practitioners, independent from other health professionals, such as, physicians, nurses, social workers, therapists, and genetic counselors and clinical pharmacists, something more than individual certification or training program accreditation will be necessary.

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.

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