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07/06/2018

Certifying Clinical Ethics: Fracturing Bioethics

by Craig Klugman, Ph.D.

After an effort of nearly a decade, bioethics is taking a big step toward professionalization. Under the American Society for Bioethics & Humanities, the Healthcare Ethics Consultant Certification Commission has launched a health care ethics consultant certification program (HEC-C). According to the Commission website, “the HEC-C credential endorses your knowledge of key concepts in healthcare ethics and affirms your expertise, competence, and skillset.” The process includes reviewing one’s skills in assessment, analysis, consulting process, evaluation and quality improvement, moral reasoning, general health care ethics issues and concepts, as well as knowledge of health care systems, clinical context, local health care organization policies, and health law.

Certification is supposed to be a panacea to a longstanding question of “what makes someone a clinical bioethicist (health care ethicist)?”[1]The program addresses a concern which is that anyone can call themselves a “clinical ethicist” since there has not been any credentialing, licensing, certification, or accreditation of individuals or education programs. Certification can help ensure that a person meets minimum standards of practice. This program is also supposed to raise our worth in the clinic by providing a credential which can be verified by a hospital or health care organization, and which would give us some street cred.

Art by Craig Klugman

The many commissions and committees that have worked on this process should be thanked and commended for this work. That said, I do not agree with everything about this result and remain concerned about how its adoption may effect our field.

First, I have to ask if this project can succeed. Consider other recent experiments in this vein. While a faculty member at a public health program, I followed the National Board of Public Health Examiners develop and then administer the first national certification exam (in 2008) forpublic health. Those who pass the exam are “Certified in Public Health.” In order to sit for the exam, one has to have earned an MPH from an accredited public health school or program, or hold a bachelor’s degree and have five years of public health work experience. The exam costs $385 (discounts are available). Of course, you will first want to read a study guide (available in prices ranging from $40 to $3,100). A commentary in the Journal of Public Health Management and Practice reportsthat as of May 2018, over 6,000 people have taken the exam, and 10 programs require the exam for graduation. However, the article offers no sources for this information.

In regards to bioethics, what is the incentive to undergo this certification? Some public health programs require their exam for degree completion and bioethics could do the same for masters and PhD programs—thus creating a de facto qualifying exam and standardized curriculum for bioethics students. The 400 hour requirement means that degree programs would need to increase their clinical experiences, or may be a barrier to adopting this process as a form of qualifying step, the process that has brought the most people to the public health exam. As a field, we have not been able to agree upon a set of core readings (beyond some “classic texts”), nevermind an entire curriculum that would be covered everywhere. Does certification necessitate standardizing what we teach?  Will bioethics programs begin advertising that they prepare their students to undergo certification review? Will students believe that having a certification means that one will get a job in clinical ethics, a belief held by many students enrolled in bioethics masters programs even if not true. Should a student with a bachelors only (the current requirement to sit for the certification) be held to the same requirements as someone with a masters or a doctorate? Will students who wish to do clinical ethics flee their bioethics masters programs because they aren’t necessary for the certification program?

A certification only means something if employers require it for employment and are willing to pay people for it. Public health is a much larger, wealthier, and more organized field than bioethics and has met very limited success in its certifying exam efforts. In looking through current public health job ads, I could not find one that required the exam for employment (even on the American Public Health Association’s career center website). To be successful, certification needs to be a requirement for the job, and that requires getting hospitals and health care institutions on board. Credentialing a physician at these organizations costs a great deal of money and often requires dedicated staff. This makes sense because the health care staff performs life and death procedures on patients and because the hospital can charge insurers, the government, and individuals for the actions of these providers. The same cannot be said for clinical ethics. There is no ICD code for ethics consultation. Clinical ethicists make recommendations, not prescriptions, and do not have their own patients—we have cases to which we are invited. For most institutions, ethics costs them money—money that they may save in lawsuits that never happened or fines from violations that were avoided. Thus to get the hospitals to require the certification will require setting up payment mechanisms for clinical ethics consultants to make the expense and process of verifying certification worthwhile.
Second, certification may diminish the “big umbrella” of bioethics and the interdisciplinary conversation that has been a hallmark of the field. By building walls to keep out those who “do clinical bioethics” without having an “accepted” background or training, we threaten to keep out (and even kick out) people who have a great deal to offer but may no longer fit a narrowing definition of a “clinical ethicist.” Clinical bioethics is a set of job tasks filled by people from a variety of backgrounds whether in medicine, nursing, philosophy, religion, social work, literature, communications, law, social sciences, psychology, and more. With a standard, a certain set of skills and knowledge is privileged against others meaning that the umbrella of bioethics becomes a lot smaller.

A third consideration revolves around how one does bioethics. There are many different methods to doing consults: the VA has CASES, Loyola Chicago offers ACES, Nancy Dubler at Columbia developed bioethics mediation, and the ASBH had the facilitation method. All of these have elements in common: receiving a consult request, gathering information, talking to relevant parties, facilitating conversations, making recommendations, and following up. But they also have unique aspects. For example, mediation tries to emphasize being nondirective and the VA approach tries to be proactive. The systems have developed to meet different institutions, populations, and geographic needs. Does a certification necessitate choosing the one, “right” way to do consults?

This leads to my fourth concern which is that the cost and the effort for this certification means that clinical ethics will become a subspecialty of medicine. In the last 15 years, there has been a trend toward clinical bioethics positions requesting one be a “physician-ethicist” who will have both clinical and ethics duties (i.e. be able to bring in money to the institution to support their work). There are schools of thought in bioethics that hold that only clinicians can do clinical ethics—that others lack the medical knowledge to truly understand and engage. I have also encountered schools of thought that hold only non-clinicians can truly do this work because clinical ethics requires a different perspective, different set of tools, and a different relationship to patients. In several recent conversations, junior faculty in bioethics have come to me saying they have been told outright: The future of bioethics is as a medical subspecialty. Funding systems in medicine, changing job requirements, and credentialing certainly point in this direction. I believe that bioethics and clinical ethics would be poorer if this shift happened.

I do wonder whether this program tolls the bell toward the end of a professional identity as a bioethicistversus as aclinical research ethicist, neuroethicist, genethecist, pediatric ethicist,and clinical ethicist. Government and foundation research funding has led to a partition of bioethics into several specialties and this certification certainly lends a push in that direction. Proof of this fragmentation comes from the biography of a person running for ASBH office where the candidate said, now that there is clinical ethics certification, they would like to see clinical research ethics certification. Are we doomed to a pantheon of subspecialized certifications in bioethics? Is the age of the generalist over?

Continuing to develop bioethics and its subspecialties like clinical ethics is important. As these four points demonstrate, though, part of the concern is the many unanswered questions and ways that clinical ethics practice and education will have to change. Some of this will be good and some of this may not be. I lament the loss of the generalist bioethicist identity that this move may foretell and I worry that many good people could be left out of doing clinical ethics who would have had entry in the past.


 [1]For the purposes of this essay, health care ethics consultant, clinical bioethicist, clinical ethicist, and health care ethicist are used interchangeably.

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