Who can be a 'medical ethicist'? Absent formal definition, anybody
Bioethics field burgeoning even though bioethics not a recognized profession
If you serve on your hospital's ethics committee, does that make you a medical ethicist? If someone considers himself to be a bioethicist, is that a profession? Since there are no standardized degrees or credentialing in bioethics, how does a hospital administrator evaluate candidates when hiring an ethicist to direct an ethics committee or oversee research?
While codes of medical ethics have been around for more than 150 years in the United States, the field of bioethics as a profession and formal area of study is only about 30 years old. Tom Beauchamp and James Childress, of the Kennedy Institute for Ethics at Georgetown University, laid out the now widely prescribed cornerstones of bioethics — autonomy, nonmaleficence, beneficence, and justice — in their 1979 book Principles of Biomedical Ethics.
According to Craig M. Klugman, PhD, chair of the program in health care ethics at the University of Nevada, Reno, pioneers in the field of bioethics were people who practiced in other fields — theology, sociology, philosophy, law, or medicine — but shared an interest in common topics pertaining to their work.
"Most of these people never considered themselves 'ethicists' and most would never use that title," Klugman says. "Today, I think it takes more than simply saying you have an interest in these topics to be an ethicist."
Experts in bioethics (or medical ethics or health care ethics, depending on your choice of title) — along with and including educators, clergy, and health care providers — are engaged in a lively debate over how, and even whether, to standardize, define, and credential bioethicists; Klugman is preparing to publish a paper examining whether bioethics can even be considered a profession.
In a 2007 journal paper,1 a group led by Ellen Fox, MD, chief officer for the Veterans Health Affairs Center for Ethics in Health Care, pointed out that fewer than half of hospital medical ethics consultants have any formal training, and only one in 20 has a bioethics concentration or graduate degree.
Medical Ethics Advisor asked clinicians, a hospital chaplain, and ethics educators: "Who or what is a bioethicist/medical ethicist?" Their answers reflect the wide range of points at issue in this discussion.
Ethics director: Don't regulate out diversity
"I have to admit that I have little patience for this question [of who can or should call themselves] bioethicists," says Howard Brody, MD, PhD, director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston.
That's because one of the great strengths in the bioethics field is the diversity of academic backgrounds from which people come, he explains.
But, "having said that, I am sympathetic to the hospital administrator, for instance, who decides that she wants to hire an ethicist to help run the [institutional ethics committee] and to coordinate ethics education programs, and wants to be sure that they select a qualified and appropriate candidate, and has little time to consult widely with other ethicists to learn who is considered to be one of the tribe," Brody continues.
There's no way to evaluate such a candidate through a credentialing organization, because there is none.
"In some sense, the identity [of 'ethicist'] is self-chosen, since we do not have any standardized curriculums, degrees, or credentialing," Klugman points out.
Four organizations that eventually formed the American Society for Bioethics and Humanities (ASBH) published "Core Competencies in Health Care Ethics Consultation," a set of standards for ethics consultation released in 1998 currently under review and being updated by an ASBH task force.
Brody, a member of the task force, says while the ASBH core competencies are in need of updating, the basic approach is sound: That it is possible to identify knowledge and skills that an ethicist involved in hospital ethics consults should have, and people training in a variety of different academic disciplines could acquire that skill and knowledge and eventually be deemed an ethicist or ethics consultant.
Another area of bioethics as a practice that needs to be addressed is the ethics of ethics, Brody says.
"I also believe that there is a legitimate concern about the ethics of the ethicist, and that ethicists should be held responsible for adhering to a code of ethical conduct of some sort or other — which, in the past, we have been very slow to come to any sort of consensus about," he points out.
Education part, but not all, of ethicist's makeup
Though there are no standards or career maps leading to ethics as a career, Klugman says he believes an ethicist needs to have a terminal degree (PhD, MD, JD), and to have concentrated study in the core knowledge of bioethics. He lists court cases, general ethical moral theory, familiarity with the classic texts, and supervised clinical ethics experience among the elements of core knowledge.
"Bioethicists seem to self-specialize these days," says Klugman. "The first group includes PhD-trained individuals who seem to mostly do original research and teach students at various levels. The second group is clinicians [physicians and nurses] who seem to do most of the in-hospital consulting, residency, and clinical teaching."
Securing a position as a hospital ethicist without a clinical degree has become progressively more difficult, he adds.
But even with the training and specialization Klugman describes, "the reality is that a 'professional bioethicist' is anyone who calls themselves that," he says.
Echoing that thought is Arthur R. Derse, MD, JD, associate director of the Center for the Study of Bioethics at Medical College of Wisconsin. When asked who can call themselves bioethicists, he responded, "Currently, anybody who wants to. And that's a problem, since you don't know the person's education, training, or sponsors."
Even with an MD, JD, PhD, and specialized study of bioethics, there is no such credential or certification in the United States for "professional bioethicist."
"The issue of being a professional bioethicist is being argued in the bioethics literature because there is no firm idea," Klugman explains. "Some have argued that we need to create a code of ethics to help define the role, responsibility, and obligations. Others have suggested that as a field, we do not define this term in order to keep it diverse and open to people from many backgrounds."
There are those who endorse a testing system that would provide credentialing for those who want to be clinical ethicists, as opposed to research ethicists or ethics instructors; but so far, Klugman points out, those in the field of bioethics have not been able to agree even on whether to pursue professionalizing bioethics at all.
"In the end, I would be suspicious of anyone who called him- or herself a 'professional bioethicist,' since such a thing does not really exist," he suggests. "I think there are people who have terminal degrees, in-depth graduate training [or who are founders of the field and have been working and writing in it for decades], and clinical experience who are bioethicists. But whether that is a profession is doubtful.
"There are people in bioethics who teach, who do research, and who consult. But what is their profession? At this point, it is as a teacher, researcher, or clinical consultant."
Differentiate between 'ethicist,' 'bioethicist'
When talking about ethics in the health care arena, it's important to differentiate between bioethicists and "philosopher-ethicists," suggests J. Vincent Guss Jr., MDiv, a pastoral care and bioethics consultant in Alexandria, VA.
"A bioethicist is usually different from a philosopher-ethicist in that his or her primary function is to provide active clinical consultation in and for a health care program or institution," Guss explains.
While bioethicists also may be scholars, Guss contends that the more important factor be training in health care.
"I believe that a bioethicist should come from a discipline rooted in health care [medicine, nursing, pastoral care, social work, etc.], and if one is a philosopher, he or she needs to have practical, clinical, experiential training," he adds.
Guss suggests there is a large disparity between what health care organizations and bioethics practitioners themselves think constitutes a "bioethicist." While some base their standing as bioethicists on the fact that they have a PhD or other extensive postgraduate training, others practice bioethics consultation based on much more casual training (their own reading of the literature, "certification" seminars or workshops lasting a day or two or found on-line), or simply on their profession — a physician, nurse, health care attorney, or chaplain, for example, who has an active interest in bioethics.
Bioethics has "come to the fore" in health care, Guss says, as a means of providing a broader input beyond that of physicians, and to include nursing, clergy, chaplains, social work, the law, administration, the community, and patients and their families.
Ethics committee — No place for ethicists?
In discussions of bioethicists and their roles, it has been suggested by more than one writer that a hospital ethics committee is no place for a bioethicist. Guss says he's heard that comment made, and believes it stems from concerns that someone extensively trained in bioethics might hold a stronger position on the ethics committee than the clinicians, attorneys, community representatives, clergy, and other members of the committee.
"As long as the chair of the committee or the director of the program or the culture of the institution demand a truly multidisciplinary approach, and the professional ethicist understands that he contributes from his knowledge base and experience on an equal basis with all the disciplines, and that there is a true balance and openness in dialogue, the ethics committee or program can only benefit from having an ethicist on board," Guss says.
The presence of a bioethicist in any situation would hopefully encourage critical thinking, Klugman says.
"I like to think of us as protectors of the process of moral deliberation — in other words, providing a space and facilitation to make sure that moral deliberation can and does occur," he says. "I do not think that an ethics committee must have a 'professional bioethicist,' defined as someone whose primary job is dedicated to teaching, research, service, and clinical work in bioethical pursuits.
"But I believe that every ethics committee should have a professional bioethics consultant who can assist in training the committee, providing educational opportunities, assisting in deliberations, provide consulting services, and facilitate bioethical processes. Ideally, every hospital and medical center should have someone on staff (maybe even part-time) who is trained in the manners I have suggested; but at the very least, they should have a consultant on contract who can assist as needed."
What is not sufficient, Klugman says, is for an ethics committee to be satisfied that one or two members have taken a short course in bioethics "and then declare themselves to be bioethicists."
"That would be like me taking a two-week emergency medicine course and proclaiming myself a physician," he adds.
Reference
- Fox E, Myers S, Pearlman RA. Ethics consultation in United States hospitals: A national survey. Am J Bioethics 2007; 7:13.
Sources
For more information, contact:
- American Society for Bioethics and Humanities, 4700 W. Lake, Glenview, IL 60025. Phone: (847) 375-4745. Web site: www.asbh.org.
- Howard Brody, MD, PhD, director, Institute for the Medical Humanities; professor, family medicine; John P. McGovern Centennial Chair, University of Texas Medical Branch, Galveston. E-mail: [email protected].
- Arthur R. Derse, MD, JD, director for medical and legal affairs, and associate director, Center for the Study of Bioethics; director, medical humanities program; professor of bioethics and emergency medicine, Medical College of Wisconsin, Milwaukee. E-mail: [email protected].
- J. Vincent Guss Jr., MDiv, advocacy commissioner, Association of Professional Chaplains; pastoral care and bioethics consultant, Alexandria, VA. Phone: (703) 404-5215.
- Craig M. Klugman, PhD, associate professor of bioethics; chair, program in health care ethics, school of public health, University of Nevada, Reno. E-mail: [email protected].
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