Ethics consultations come under increasing scrutiny
National group reviews formal credentialing
Ethics committees and consultation teams have always emphasized that they are not decision makers. Yet the recommendations they make, and the direction they offer to family members and staff often have a direct impact on patient care. Indeed, increasingly in the last several years ethics committee meetings/consultations have been called into question in court cases. Now some bioethics professionals say it is time for some serious self-evaluation.
"The reality of clinical ethics consultation is part of what drives the need for a thorough consideration of whether some sort of standards need to be set both for ethics consultation itself and for the education and training of those who will function as ethicists in clinical settings," says Stuart Youngner, MD, professor of medicine, psychiatry, and biomedical ethics at Case Western Reserve School of Medicine in Cleveland, and president of the Society for Bioethics Consultation (SBC).
SBC and a group of other professional organizations have developed a task force that has met three times in the past year to consider the role or functions of a health care ethics consultant or consult team, and whether standards, credentialing, and guidelines should be developed.
The task force will issue a white paper at the end of this year based on the consensus of its members, says Mark Aulisio, PhD, research associate at the Center for Medical Ethics at the University of Pittsburgh Medical Center and executive director of the task force.
"One of our first jobs was to look at the kind of issues brought to ethics consultation and what policies these groups are developing," says Aulisio. "Our ongoing goal is to decide what ethics consultation is and what its goals should be."
Aulisio stresses that members have agreed that the scope of discussion involves ethics consultation and policy development, but not ethics education. The group decided that while one of the effects of good ethics consultation may be that those involved become more knowledgeable and educated, ethics consultation itself should not be extended to cover the broad range of other ethics services such as continuing medical education.
At its initial meeting, the task force sought to develop an understanding of what models for ethics credentialing currently exist, how the Joint Commission on Accreditation of Healthcare Organization in Oakbrook Terrace, IL. views evaluation and guidelines, and how other evolving professions have struggled with and arrived at standards that become widely accepted by practitioners.
Two existing models served as examples: a Canadian project developed in 1994 involving professional certification and a Virginia program based at the University of Virginia in Charlottesville that has evolved into a 61¼2-day training program since its inception in 1990.
Keep credentialing process open
Any process for professional standards and credentialing must be open and participatory, says Francoise Baylis, MD, head of the Social Sciences and Humanities Research Council Strategic Network in Canada. The network project involved participation of many bioethics professionals throughout Canada and was the result of a mandate by the research council, an official government body. The government funded the work in 1991 to look at the problem of "the charlatan in ethics consultation."
The Canadian group developed and widely disseminated a survey to everyone involved in clinical ethics consultation. This included anyone involved in clinical ethics issues in clinical cases or research, ethics committees, research ethics boards, institutional review boards, and policy formation committees in health care institutions.
The network project resulted in a published report that includes requirements on certification for professionals, a profile of a good bioethicist, and education and training for anyone involved in ethics consultation.1
The Virginia program evolved as an outreach and training program held twice each year as a response to a failure of ethics groups to thrive, says John C. Fletcher, PhD, director of the program and of the Center for Biomedical Ethics at the University of Virginia Health Sciences Center.
The condition of many groups engaged in ethics consultation is marginal, fragile, and unsupported," says Fletcher. Those in the health care setting who need the ethics consultation the most fail to use the group as a resource and many health care professionals on these committees are untrained for their tasks, he contends.
Fletcher maintains that ultimately a thriving ethics consultation team or ethics committee should be sufficiently trained and supported to continue its ethics consultative role and to take on education, policy making, and research roles. It should conduct research aimed at prevention of the ethical problems that tend to dominate their particular group agenda, he argues.
The need for education and training for professionals in bioethics consultation is critical, says Fletcher. This training must also be available to resource persons for ethics committees, clinicians, and others who desire to devote part of their careers to clinical ethics.
Voluntary or obligatory
Another aspect of ethics consultation discussed by the multidisciplinary task force is a review of research into effective ethics consultation and a determination of the proper scope of ethics consultation. Should it be a requirement in certain circumstances? Should ethics consultants or teams involve themselves in a particular case, regardless of whether they are asked?
The task force suggested the following wording as an overreaching goal or purpose of ethics consultation: "To improve the provision of health care and its outcome through the identification, analysis, and resolution of ethical issues as they emerge in particular clinical cases or in the full range of patient oriented policy questions."
Aulisio strongly emphasizes that the task force is in an information gathering stage and has not made any definitive conclusions or recommendations. The group is open to comments from members of ethics consult teams, ethics committees, and other groups that may be affected by the implementation of a professional standards initiative. Aulisio says the task force would like input from health care ethics programs that have implemented their own education and training requirements.
[Editor’s note: Further information on the workings of the task force is available on the Medical College of Wisconsin and the Society for Health and Human Values web sites (see list of web sites, p. 46). This information includes minutes of meetings and a list of the multidisciplinary group’s members. You can also contact Mark Aulisio, PhD, research associate, University of Pittsburgh Center for Medical Ethics, 3708 Fifth Avenue, Medical Arts Bldg., Suite 300, Pittsburgh, PA 15213. Telephone: (412) 647-5789. Fax: (412) 647-5877. E-mail: [email protected]]
Reference
1. Baylis F. The Healthcare Ethics Consultant. Humana Press, Totowa, NJ 1994.
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