Standards will keep lone ranger’ consultants from saving the day
Draft standards recommend core competency, accountability
You’re bombarded daily with new policies, procedures, and regulations from virtually every corner of the health care industry. So why would you as an ethicist want yet another set of standards to comply with? The reason is to keep the lone ranger’ ethics consultants from riding into town to save the day only to find that they have virtually no clinical background to help solve a problem, say ethicists who attended a standing-room only session where the draft standards were presented.
The standards were presented at the joint meeting of the American Association of Bioethics in Minneapolis, the Cleveland-based Society for Bioethics Consultation, and the McLean, VA-based Society for Health and Human Values, held in November in Baltimore. (For more on the task force, see Medical Ethics Advisor, November 1997, p. 137.)
The 21-member task force comprised members of the Society for Bio-ethics Consultation and the Society for Health and Human Values. Although the standards are not considered documents from the two organizations, they will likely be endorsed before a new organization is formed. The organizations voted in Baltimore to merge with the American Association of Bioethics to form the American Society for Bioethics and Humanities.
It is unclear whether that new organization will endorse the task force’s recommended standards, notes 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. The impact of the standards, however, could be far-reaching indeed. The final version of the standards will be submitted to the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, and the American Medical Association in Chicago. In fact, each organization had a representative on the task force. The standards likely could become a model for the Joint Commission to propose to health facilities as a means of complying with its ethics standards, says Aulisio.
Much of the anxiety from ethicists centered on whether the task force’s recommendations would be mandatory. As it turns out, those fears were unfounded. In fact, the task force’s 18-month effort endorses voluntary use of the standards.
"When the task force was determining whether to recommend an accreditation, education, or voluntary model of standards, we thought it would be the most controversial, but it turned out to be the area of least debate. We unanimously voted to make the standards voluntary," says Robert M. Arnold, MD, co-director of the task force and associate professor in the Division of Internal Medicine at the University of Pittsburgh Medical Center.
Reasons for voluntary standards
Reasons cited for endorsing a voluntary model for using the standards include the following:
• Voluntary guidelines have a modesty appropriate to the complexity of the issues before the task force.
• They are sensitive to the current theoretical, political, and practical difficulties in this area.
• They also are sensitive to the wide diversity of institutional settings within which consultation takes place (for example, the needs of large teaching hospitals differ tremendously from those of long-term care facilities).
• Voluntary guidelines, while remaining tentative, can encourage gradual change and stimulate public discussion.
• Whether voluntary guidelines are adopted depends, at least in part, on their own merit.
• Voluntary guidelines also are sensitive to the current lack of opportunity for education in bioethics in many regions.
• The alternative models (certification, accredi-tation, and education) have several serious drawbacks that led the task force to reject them.
Discussion among ethicists now focuses on refining and revising them during a four-month period. A follow-up meeting is scheduled for late February 1998. A final recommendation will be issued at that time. (For more on issues concerning the standards, see story, p. 145.)
"Providers conducting ethics consultations should evaluate their work, especially in the institutional setting, and the standards address those issues," says David Ozar, PhD, director of the Center for Ethics Across the University at Loyola University in Chicago. An additional section Ozar was glad to see included was the abuse of power and conflict of interest.
Core competencies outlined
The most discussion and revision at the task force’s presentation of the draft involved recommended attributes in three core areas of ethics consultation: skills, knowledge, and character traits.
"If a consultation is done by an individual, that individual should have all the skills we recommend [in the draft]. In the area of knowledge, we’ve recommended advanced and basic levels of expertise in certain areas, but individuals within the group could bring the required skills to the table as collective whole," explains Arnold. (For task force skills recommendations, see p. 144.)
In the area of character, the task force suggests traits that individuals should possess, minimum items taught in clinical ethics consultation education programs, and procedures to help foster good character among ethicists in health care institutions. (For a list of knowledge areas and skill levels, see box, at left.)
While task force members suggest that ethicists or members of ethics committees are of no higher character than other health professionals, they do suggest that consultants or members possess certain traits, including patience, fairness, tolerance, compassion, rationalism, honesty, forthrightness, integrity, courage, and prudence.
The task force also recommends minimum elements of education programs to teach and model good character. Programs to educate persons for clinical ethics consultation, according to the standard, should at least:
• take character seriously in selecting consultants;
• encourage reflection about character and its development;
• use faculty or mentors who model good character in consultations and who are willing to reflect with students on what constituted past successful or unsuccessful consultations;
• hold consultants accountable for their behavior.
Additionally, the standards suggest that health care institutions should foster an environment where good character in ethics consultation can flourish. Recommendations to help promote such an atmosphere include:
• supporting a clear process by which consultants are educated, trained, and appointed;
• separating clinical ethics consultation from personnel oversight, so clinicians see ethics consultation as a welcome resource for difficult problems in patient care rather than a disciplinary action;
• enabling all staff, patients, and family to call for an ethics consultation and protecting from intimidation those who call for consultation;
• instructing attorneys who serve on ethics consultation teams or committees to promote the patient’s interests and not simply represent the health care facility’s interests;
• minimizing the use of clinicians with direct supervisory responsibility over a clinical issue from serving as the primary ethics consultants on that issue;
• respecting the independence of ethics committee policy initiatives and ethics consultation.
The task force, Arnold stresses, used several assumptions in developing the standards. "First, the ethics field has always been interdisciplinary and should remain so," he says. "Second, there should be some form of accountability for ethics consultations. Lastly, we want this to be an open process and welcome suggestions and comments from everyone involved in ethics consultation."
Overall, ethicists express a feeling that the standards will assist in proving to colleagues and administration that members of this specialty view their profession in high regard.
"The health care institution will benefit from the standards as well because their ethicists will continually increase their skills through behavioral-based training," notes Arnold.
[Editor’s note: Comments and suggestions for task force members of the Standards for Bioethics Consulta-tion can be e-mailed to: [email protected]. To view the draft document in entirety, visit the Internet Web site: http://www.mcw.edu/bioethics.]
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