A major obstacle to broad support of clinical ethics consultation is suspicion regarding the nature of the moral expertise it claims to offer. The suspicion seems to be confirmed when the field fails to make its moral expertise explicit. In this vacuum, critics suggest the following:Clinical ethics consultation's legitimacy depends on its ability to offer an expertise in moral matters.Expertise in moral matters is knowledge of a singular moral truth which applies to everyone.The claim that a clinical ethics consultant can (...) offer knowledge of a singular moral truth in virtue of her professional training is absurd, false, or gravely immoral.Therefore,The field is illegitimate. (shrink)

Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

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...

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)

Introduction to healthcare ethics committees / D. Micah Hester and Toby Schonfeld -- Brief introduction to ethics and ethical theory / D. Micah Hester and Toby Schonfeld -- Ethics committees and the law / Stephen Latham -- Cultural and ...

Failings in patient care and quality in NHS Trusts have become a recurring theme over the past few years. In this paper, we examine the Care Quality Commission’s Guidance about Compliance: Essential Standards of Quality and Safety and ask how NHS Trusts might be better supported in fulfilling the regulations specified therein. We argue that clinical ethics committees (CECs) have a role to play in this regard. We make this argument by attending to the many ethical elements that are highlighted (...) in the Commission’s Regulations and by providing practical examples of how CECs can (and in some case already do) provide ethics support to health professionals and trusts. Although CECs have been traditionally associated with case consultation, i.e., discrete problems caused by individual circumstances, in the previous 10 years the literature suggests that clinical ethics services have become more integrated into the life of the health care organization and are increasing construed as proactive agents of systematic change. We provide evidence from a recent survey of UK clinical ethics services that this trend is present in the UK. (shrink)

Background In 2001 a report on the provision of clinical ethics support in UK healthcare institutions identified 20 clinical ethics committees. Since then there has been no systematic evaluation or documentation of their work at a national level. Recent national surveys of clinical ethics services in other countries have identified wide variation in practice and scope of activities. Objective To describe the current provision of ethics support in the UK and its development since 2001. Method A postal/electronic questionnaire survey administered (...) to the chairs of all 82 clinical ethics services registered with the UK Clinical Ethics Network in July 2010. Results Response rate was 62% with the majority of responding services situated in acute trusts. All services included a clinical ethics committee with one service also having a clinical ethicist. Lay members were present in 72% of responding committees. Individual case consultation has increased since 2001 with 29% of chairs spending more than 50% of their time on this. Access to and involvement in the process of case consultation is less for patients and families than for clinical staff. There is wide variation in committee processes and levels of institutional support. Over half of the responding committees undertook some form of evaluation. Conclusion Clinical ethics services in the UK are increasing as is their involvement in case consultation. However, the significant variation in committee processes suggests that further qualitative research is needed to understand how these committees function and the role they play in their institution. (shrink)

The legitimacy of clinical ethics consultation is often implied to rest on the legitimacy of moral expertise. In turn, moral expertise seems subject to many serious critiques, the success of which implies that clinical ethics consultation is illegitimate. I explore a number of these critiques, and forward “ethics expertise,” as distinct from “moral expertise,” as a way of avoiding these critiques. I argue that “ethics expertise” succeeds in avoiding most of the critiques, captures what clinical ethics consultants might justifiably do, (...) and expresses a subject matter which can be taught and assessed. (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)

Background: Despite the expansion of ethics consultation services, questions remain about the aims of clinical ethics consultation, its methods and the expertise of those who provide such services.Objective: To describe physicians’ expectations regarding the training and skills necessary for ethics consultants to contribute effectively to the care of patients in intensive care unit .Design: Mailed survey.Participants: Physicians responsible for the care of at least 10 patients in ICU over a 6-month period at a 921-bed private teaching hospital with an established (...) ethics consultation service. 69 of 92 eligible physicians responded.Measurements: Importance of specialised knowledge and skills for ethics consultants contributing to the care of patients in ICU; need for advanced disciplinary training; expectations regarding formal-training programmes for ethics consultants.Results: Expertise in ethics was described most often as important for ethics consultants taking part in the care of patients in ICU, compared with expertise in law , religious traditions , medicine and conflict-mediation techniques . When asked about the formal training consultants should possess, however, physicians involved in the care of patients in ICU most often identified advanced medical training as important.Conclusions: Although many physicians caring for patients in ICU believe ethics consultants must possess non-medical expertise in ethics and law if they are to contribute effectively to patient care, these physicians place a very high value on medical training as well, suggesting a “medicine plus one” view of the training of an ideal ethics consultant. As ethics consultation services expand, clear expectations regarding the training of ethics consultants should be established. (shrink)

Of Goals and Goods and Floundering About: A Dissensus Report on Clinical Ethics Consultation Content Type Journal Article Pages 275-291 DOI 10.1007/s10730-009-9101-1 Authors Jeffrey P. Bishop, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Joseph B. Fanning, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite 400 Nashville Tennessee 37203 USA Mark J. Bliton, Vanderbilt University Center for Biomedical Ethics and Society 2525 West End Avenue, Suite (...) 400 Nashville Tennessee 37203 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 3. (shrink)

In the clinical setting, questions of medical ethics raise a host of perplexing problems, often complicated by conflicting perspectives and the need to make immediate decisions. In this volume, bioethicists and physicians provide a nuanced, in-depth approach to the difficult issues involved in bioethics consultation. Addressing the needs of researchers, clinicians, and other health professionals on the front lines of bioethics practice, the contributors focus primarily on practical concerns -- whether ethics consultation is best done by individuals, teams, or committees (...) how an ethics consult service should be structured the need for institutional support and techniques and programs for educating and training staff -- without neglecting more theoretical considerations, such as the importance of character or the viability of organizational ethics. (shrink)

This text provides a comprehensive and timely examination of the most pertinent factors affecting institutional ethics committees, for ethicists, trustees, administrators, physicians, clergy, nurses, social workers, attorneys and others with an interest in ethics committees.

Considerable debate has occurred about the proper role of philosophers when offering ethics consultations. Some argue that only physicians or clinical experienced personnel should offer ethics consultations in the clinical setting. Others argue still further that philosophers are ill-equipped to offer such advice, since to do so rests on no social warrant, and violates the abstract and neutral nature of the discipline itself.I argue that philosophers not only can offer such consultations but ought to. To be a bystander when one's (...) discipline does offer insights and methods of value discernment is pusillanimous. But this position requires a view of clinical medical ethics as one that arises out of the clinical practice of medicine, and not just from an application of general ethical principles to the practice of medicine. I conclude with some skills that trained philosophers can bring to the consultation service, and note that all consultations are in the form of recommendations that the patient, family, and physician are still free to accept or reject. Philosophers in the clinical setting do not make decisions. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (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)

Book reviewed in this article: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. By Albert R. Jonsen, Mark Siegler, and William J. Winslade.

A significant amount of discussion in the bioethics community has been devoted to the question of whether individuals performing ethics consultations in healthcare institutions have any special expertise. In addition, articles in the lay press have questioned the “added value” that bioethicists bring to ethical dilemmas. Those at the forefront of the bioethics community have argued repeatedly that those doing ethics consults cannot simply be well-intentioned individuals, that some training in bioethics, group process, and facilitation is necessary to competently execute (...) a consult. As one bioethicist commented:if you approach any endeavor as an amateur activity, you will get, in the end, an amateurish version of the activity. Without a sufficient commitment of personnel, time, support, and financial resources, a healthcare organization will get the ‘ethics’ program … it set out to create: an inept, unskilled, inefficient, and highly risky ‘program’ in healthcare ethics and bioethics. (shrink)

Clinical ethics consultation has become an important resource, but unlike other health care disciplines, it has no accreditation or accepted curriculum for training programs, no standards for practice, and no way to measure effectiveness. The Clinical Ethics Credentialing Project was launched to pilot‐test approaches to train, credential, privilege, and evaluate consultants.

While consensus exists among many practitioners of ethics consultation about the need for and identification of core competencies and standards, there has been virtually no attempt to determine how these competencies and standards are best taught and assessed. We believe that clinical ethics consultation has reached a state of sufficient maturity that expert practitioners can evaluate those who are new to the field. We will outline several steps that can facilitate the creation of a certification process for clinical ethics consultants, (...) assuring the competency and quality of consultation for the patients, families, and healthcare professionals who utilize ECSs. (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 this article I take up a central question posed by the article jointly authored with Bill Winslade in this issue of JCE: What should be the role of clinical ethics consultants (CECs) in (what we call) an unsettled case: that is, a situation in which the range of allowable choices, among which the parties to a bioethical disagreement must select, cannot be clearly or completely specified? I argue here that CECs should, in such cases, guide the parties by presenting (...) their own reasoned conclusions about what the scope of allowable choices should be taken to include. Since this position challenges the received view that CECs must not express their own moral positions or conclusions in their role as ethicists, I try to defend my view of the CEC’s role in unsettled cases against several objections. (shrink)

We describe the ethics consultation service (ECS) at the Cleveland Clinic and report on its activities over a 24-month period in which 478 consultations were performed. To our knowledge, this is the largest case series of ethics consultations reported to date. Established more than 25 years ago, the ECS at the Cleveland Clinic is staffed by multiple consultants with advanced training in bioethics. Several of these ethicists work closely with specialized clinical units and research departments, where they participate in multidisciplinary (...) meetings and provide specialized assistance. This combination of historical experience, large numbers of consultation requests, and specialized clinical ethicists suggests that the experience at the Cleveland Clinic may be helpful to ethicists and others who may be considering how to structure and sustain a vibrant ECS. Our results highlight the diversity of activities performed by a high-volume ECS at a tertiary care facility. Our hope in sharing the inner workings of the ECS at the Cleveland Clinic is to promote dialogue on common practices and approaches across medical institutions that support ethics consultation. (shrink)

The first clinical ethics committees in Norway were established in 1996. This started as an initiative from hospital clinicians, the Norwegian Medical Association, and health authorities and politicians. Norwegian hospitals are, by and large, publicly funded through taxation, and all inpatient treatment is free of charge. Today, all the 23 hospital trusts have established at least one committee. Center for Medical Ethics , University of Oslo, receives an annual amount of US$335,000 from the Ministry of Health and Care Services to (...) coordinate the committees and to facilitate competency building for committee members. (shrink)

In this article, the question is discussed if and how Healthcare Ethics Committees (HECs) should be regulated. The paper consists of two parts. First, authors from eight EC member countries describe the status quo in their respective countries, and give reasons as to the form of regulation they consider most adequate. In the second part, the country reports are analysed. It is suggested that regulation of HECs should be central and weak. Central regulation is argued to be apt to improve (...) HECs’ accountability, relevance and comparability. To facilitate biomedical citizenship and ethical reflection, regulation should at the same time be weak rather than strict. Independence of HECs to deliberate about ethical questions, and to give solicited and unsolicited advice, should be supported and only interfered with by way of exception. One exception is when circumstances become temporary adversarial to ethical deliberation in healthcare institutions. In view of European unification, steps should be taken to develop consistent policies for both Eastern and Western European countries. (shrink)

Clinical ethics support services are developing in Europe. They will be most useful if they are designed to match the ethical concerns of clinicians. We conducted a cross-sectional mailed survey on random samples of general physicians in Norway, Switzerland, Italy, and the UK, to assess their access to different types of ethics support services, and to describe what makes them more likely to have used available ethics support. Respondents reported access to formal ethics support services such as clinical ethics committees (...) (23%), consultation in individual cases (17.6%), and individual ethicists (8.8%), but also to other kinds of less formal ethics support (23.6%). Access to formal ethics support services was associated with work in urban hospitals. Informal ethics resources were more evenly distributed. Although most respondents (81%) reported that they would find help useful in facing ethical difficulties, they reported having used the available services infrequently (14%). Physicians with greater confidence in their knowledge of ethics (P = 0.001), or who had had ethics courses in medical school (P = 0.006), were more likely to have used available services. Access to help in facing ethical difficulties among general physicians in the surveyed countries is provided by a mix of official ethics support services and other resources. Developing ethics support services may benefit from integration of informal services. Development of ethics education in medical school curricula could lead to improved physicians sensititity to ethical difficulties and greater use of ethics support services. Such support services may also need to be more proactive in making their help available. (shrink)

Clinical ethics consultation has become an important resource, but unlike other health care disciplines, it has no accreditation or accepted curriculum for training programs, no standards for practice, and no way to measure effectiveness. The Clinical Ethics Credentialing Project was launched to pilot‐test approaches to train, credential, privilege, and evaluate consultants.

The Hannover qualifying programme ‘ethics consultation in hospitals’, conducted by a four-institution cooperation partnership, is an interdisciplinary, scientifically based programme for healthcare professionals interested in ethics consultation services and is widely acknowledged by hospital managements and healthcare professionals. It is unique concerning its content, scope and teaching format. With its basic and advanced modules it has provided training and education for 367 healthcare professionals with 570 participations since 2003 (until February 2010). One characteristic feature is its attractiveness for health professionals (...) from different backgrounds. Internationally, the Hannover programme is one of the few schedules with both academics and non-academics as target groups and a high participation rate of physicians. The concept of the Hannover programme is in great demand, and its schedule is continuously optimised through evaluation. The goals of enabling healthcare professionals from different professional backgrounds to define and reflect ethical problems, to facilitate and support the process of decision-making and to work out structures for their own institutions seem to have been achieved. However, in order to obtain effective and sustainable results, participation in the programme should be supplemented regularly by in-house training sessions or individual expert consultations. Future challenges include new thematic courses and providing a network for former participants, especially when they come from non-academic hospitals. The network is a reasonable platform to discuss participants' experiences, successes and pitfalls. A further task will be research on how the programme's concept can support the sustainability of ethics structures in the various institutions. (shrink)

In response to an article by Acres and colleagues, “Credentialing the Clinical Ethics Consultant: An Academic Medical Center Affirms Professionalism and Practice,” the authors urge continued action for the credentialing and certification of clinical ethics consultants. They also promote a vigorous and engaged model for ethics consultation.

In response to national trends calling for increasing accountability and an emerging dialogue within bioethics, we describe an effort to credential clinical ethicists at a major academic medical center. This effort is placed within the historical context of prior calls for credentialing and certification and efforts currently underway within organized bioethics to engage this issue. The specific details, and conceptual rationale, behind the New York-Presbyterian Hospital’s graduated credentialing plan are shared as is their evolution and ratification within the context of (...) institutional policy. While other programs will design their credentialing schema consistent with their local context and demographics, the description of one such effort is offered to be instructive to others who want to bring additional standardization to the assessment of the readiness and credentials of those who will engage in the practice of clinical ethics case consultation. (shrink)

The predominant historical narrative of bioethics describes how ethical expertise rescued medicine from growing dilemmas, and that these dilemmas were presumably best understood as ethical problems...

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...

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 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...

This article outlines one element of the work carried out by a group of Canadian ethicists [Practicing Healthcare Ethicists Exploring Professionalization (PHEEP)]—to begin the deliberative development of a set of practice standards for the Canadian context. To provide a backdrop, this article considers the nature and purpose of practice standards as they are used by regulated professions and how they relate to other practice-defining texts such as competencies, codes of ethics and statements of scope of practice. A comparative review of (...) current practice-defining documents developed within the field of healthcare ethics practice suggests that practice standards are not yet among them. A review of the practice standards and related texts articulated by various other professions, both regulated and not yet regulated, indicates that while these groups of documents serve to define and clarify various dimensions of practice in individual disciplines, there is no clear standardized approach to the terminology, structure and content across these documents. It is suggested that this variability presents a degree of flexibility that ought to allay many of the anxieties that have been expressed about practice standards in healthcare ethics: practitioners, PHEs, are at liberty to define their practice as they see fit, albeit within reasonable parameters if regulation is sought. A proposal for a draft structure and potential content for Canadian healthcare ethics practice standards is offered. (shrink)

The American Journal of Bioethics, Volume 12, Issue 8, Page 10-11, August 2012.

Clinical ethics committees (CECs) have been developing in many countries since the 1980s, more recently in the transitional countries in Eastern Europe. With their increasing profile they are now faced with a range of questions and challenges regarding their position within the health care organizations in which they are situated: Should CECs be independent bodies with a critical role towards institutional management, or should they be an integral part of the hospital organization? In this paper, we discuss the organizational context (...) in which CECs function in Europe focusing on five aspects. We conclude that in Europe clinical ethics committees need to maintain a critical independence while generating acceptance of the CEC and its potential benefit to both individuals and the organization. CECs, perhaps particularly in transitional countries, must counter the charge of “alibi ethics”. CECs must define their contribution to in-house quality management in their respective health care organization, clarifying how ethical reflection on various levels serves the hospital and patient care in general. This last challenge is made more difficult by lack of consensus about appropriate quality outcomes for CECs internationally. These are daunting challenges, but the fact that CECs continue to develop suggests that we should make the effort to overcome them. We believe there is a need for further research that specifically addresses some of the institutional challenges facing CECs. (shrink)

Why mediation? -- What makes bioethics mediation unique? -- Before you begin a bioethics mediation program -- The stages of bioethics mediation -- Techniques for mediating bioethics disputes -- How to write a bioethics mediation chart note -- Mediation with a competent patient : Mr. Samuels's case -- Mediation with a dysfunctional family : Mrs. Bates's case -- A complex mediation with a large and involved family : Mrs. Leonari's case -- Discharge planning for a dying patient : a role-play (...) -- An at-risk pregnancy : a role-play -- HIV and postsurgical complications in the ICU : a role-play -- Treating the dying adolescent : a role-play -- She didn't mean it : a role-play -- Don't tell mama : a role-play -- An at-risk pregnancy : a role-play transcript -- HIV and postsurgical complications in the ICU : a role-play transcript -- She didn't mean it: a role-play transcript -- Don't tell mama : a role-play transcript. (shrink)