By Stacey Kusterbeck
As the clinical ethics field continues to professionalize, some ethicists are seeking to differentiate themselves or advance their careers by obtaining additional education. “There are a variety of ways that ethics committee members and those designated to provide ethics consultations can enhance their skills and knowledge,” says Jeanne Kerwin, DMH, HEC-C, a clinical ethics and palliative care consultant at Atlantic Health System.
For years, there has been an ongoing debate over whether bioethics is a “field” or a “discipline.”1 “While there are strong opinions on this question, one thing is certain: Bioethics has become a profession,” says Lisa M. Lee, PhD, MA, MS, senior associate vice president for research and innovation at Virginia Tech and former executive director of the Presidential Commission for the Study of Bioethical Issues. There are available positions for bioethics faculty, medical ethicists, healthcare ethicists, research ethicists, and public health ethicists. “As these professional positions are filled, employers are assuming they are hiring a person with expertise in bioethics. Yet the field of bioethics has not yet decided what that expertise should look like. What should someone who calls themselves a bioethicist know and be able to do? What is the core knowledge that employers can count on?” asks Lee.
In Lee’s view, consistency in educational requirements and competencies across bioethics degree programs could establish clear answers to these questions. “That would go a long way in protecting our profession from the erroneous belief that bioethics is the opinion of a person who calls themselves a bioethicist,” says Lee.
In academic settings, there is an opportunity to expand on the ethics topics that currently are taught to prepare future ethicists for a broader role. “Additional knowledge and expertise could be added for specific subspecialties, such as research ethics or public health ethics,” suggests Lee. All bioethicists should be trained in the social and economic determinants of health, health policy advocacy, and the role of inclusivity and health justice in health outcomes, argue Lee and colleagues in a recent paper.2
For ethicists already in clinical settings, obtaining additional training can be valuable to their careers and their institutions. “Depending on the size, location, and complexity of a hospital system, a hospital bioethicist might be asked to provide bioethics expertise outside the typical healthcare ethics consultation,” says Lee. Ethicists might be asked to opine on issues of compliance or alleged discrimination, or to conduct research ethics training, for example. “Not all of these requests are aligned with healthcare ethics consultations. But with additional training, these activities could be complementary,” says Lee.
Ethicists can advance their education with these approaches:
Obtaining available training offered at their institutions. Providing education is part of the role of many hospital ethics committees. “Volunteer committee members who do not receive adequate training to participate in ethics work may ultimately feel that their time is not being utilized well, because they are unable to engage fully in the work. Paradoxically, spending additional time in training new members may increase their satisfaction with committee work,” says Jay Malone, MD, PhD, HEC-C, medical director of ethics at St. Louis Children’s Hospital. Some hospitals send ethics committee members to outside training programs. “Programs may be offered by hospital associations, medical societies, academic institutions, other medical centers, or national organizations that sponsor conferences dedicated to advanced learning about clinical ethics,” says Kerwin.
Enrolling in formal academic certificate programs offered by academic centers. “By obtaining a Certificate in Clinical Ethics from an academic institution, an individual may add to the weight of their credentials when applying for a paid position as a clinical ethicist,” says Kerwin. Some institutions rely on ethics committee members to assist with ethically complex cases. “Ideally, every healthcare ethics committee should have at least one certified and trained ethicist,” says Kerwin. Obtaining a certificate could open up additional opportunities at the institution for ethicists. “It could also open up opportunities to contribute to state and national groups that provide ethics guidance on tough questions about what we should do,” says Lee.
Obtaining a Healthcare Ethics Consultant-Certified (HEC-C) credential through the American Society of Bioethics and Humanities. “This certification is not required by hospitals for those who do ethics consults. But it has become the standard of excellence and expertise in ethics consultation proficiency in the U.S.,” says Kerwin.
Practicing ongoing self-reflection on their own practice. “Long after training is completed, a degree is earned, or a credential acquired, ethicists should continue to engage in clinical ethics consultations with a beginner’s mind — with the humility and curiosity and enthusiasm of a trainee,” urges Virginia L. Bartlett, PhD, assistant director at the Center for Healthcare Ethics at Cedars-Sinai Medical Center. Debriefing with colleagues and following up with participants after a consult can be a means of continuous training for ethicists. Some ethicists seek out specialized expertise in certain aspects of healthcare. “Expanding one’s skills with a certificate in research ethics, or even informal training related to other ethics specialties, could position a hospital bioethicist well for an expanding role,” says Lee.
Here are some subject areas in which ethicists could develop expertise:
Ethical issues involving medical aid in dying (MAID). “Any clinical ethicist who works in an institution that offers medical aid in dying should have a thorough understanding of the legal statutes that govern such practices,” says Kerwin.
Recently, a group of clinical ethicists were asked to provide recommendations to the Academy for Aid in Dying Medicine in response to questions posed by clinicians. At the institutional level, ethicists can evaluate ethical concerns that arise with MAID and participate in the development of policies regarding MAID. “MAID is a practice that is governed by law but also one that is highly emotionally charged and often controversial among many groups and individuals,” notes Kerwin.
Ethicists can ensure that no practices infringe on the rights and protections for patients eligible to engage in MAID. These rights include receiving full information on all available end-of-life options, for example.
Ethical issues related to special interest groups. As an ethicist working with the National Down Syndrome Society at the state and national levels, Kerwin has been asked to speak on numerous occasions about relevant ethical issues encountered by individuals with Down syndrome and those involved in their care.
Research ethics. “An ethicist with research ethics training would have a great deal to offer an IRB (Institutional Review Board),” asserts Lee. An ethics consultant can help to ensure that researchers respect patients’ autonomous choices, act in the patients’ best interest, and fairly and equitably select participants, says Kerwin.
Emergency medical services (EMS). “Ethical training for EMS providers is often inadequate in training programs, and paramedics have no access to clinical ethicists in the field,” says Kerwin.
Kerwin initially got involved with ethics as the director of a large EMS provider. Many scenarios in the pre-hospital environment raised difficult ethical questions. In one case, a 911 call came in for an infant in distress, and paramedics prepared to intubate. However, the parents explained that the infant had a known congenital defect that would eventually be fatal. The parents asked the paramedics not to intubate the infant’s airway to artificially prolong the life of the infant. Yet the paramedics had standing orders to intubate any patient with need for oxygenation. The paramedics had to do something immediately. “In this case, they applied their own value-based moral judgment and provided oxygen to the infant via a simple oxygen mask,” says Kerwin.
The parents accepted this non-invasive method of providing extra oxygen to the infant until they reached the hospital neonatologist, who knew the infant’s medical condition and understood the wishes of the parents. No harm was done through artificial means that would have been difficult to withdraw without further deliberations. The infant was kept comfortable with the non-invasive provision of extra oxygen during transport to the hospital. Critical end-of-life decisions then could be made by the parents and the attending physician.
“This case, and many others, was the impetus for my pursuit of ethics training, specifically as it applied to EMS providers,” says Kerwin. Kerwin found a Certificate program in Bioethics and Medical Humanities and went on to develop the first training program in ethics for EMS providers. “That set me on the path to a Doctorate in Medical Humanities, and eventually national certification as an HEC-C and a career in medical ethics far beyond EMS,” says Kerwin.
Kerwin has presented on ethics in EMS to paramedics and emergency medical technicians at Atlantic Health System and for the state of New Jersey through the Governor’s Council on EMS. “Having members of the hospital ethics team teach ethics to paramedics would require them to have some working knowledge of what goes on in the EMS world. I am sure there are some people with both fields of expertise, but it is not so common,” observes Kerwin.
Another approach is for the ethics committee to include a paramedic as a member to present EMS cases with ethical dilemmas. “It is a great education for the paramedic and also for the ethics committee, who are generally unfamiliar with ethical issues that occur for paramedics,” says Kerwin.
Pediatric ethics.“There’s a recognized paucity of pediatric ethicists,” says Brian S. Carter, MD, FAAP, chairman of the Department of Medical Humanities & Bioethics at the University of Missouri-Kansas City (UMKC) School of Medicine and interim director of Children’s Mercy Bioethics Center.
Lack of specialized pediatric expertise in the clinical ethics field is similar to the current situation in the palliative care field, observes Carter. Palliative care doctors graduating from palliative care fellowships typically have had little pediatric palliative care instruction. There is no current requirement by the American Academy of Hospice and Palliative Medicine for fellows to spend a specific amount of time doing pediatrics. “So, you can have a doctor who’s well-trained in adult palliative care, who works in a community hospital, and the only pediatric piece that’s in that hospital is a neonatal ICU (intensive care unit) because they have a busy obstetrics service. And if the palliative care doctor is called to the neonatal ICU, the doctor may be a fish out of water, not really understanding the nuances of neonatal pediatric palliative care,” Carter says.
The same can be said for bioethicists who are well-trained and quite capable of doing consults in the adult population. “But when the ethicist is called to take care of a child, a different approach is required,” says Carter. One important difference is that, in pediatric cases, there always is a third party involved in medical decision-making. “The parents are driving the decision-making, not from an approach of autonomy that would reflect their own wishes, but from parental authority that history, society, and the law has vested them with. There are limits to parental authority — principally, those are guided by not allowing harm or neglect. But if the parent doesn’t want a child to get a bone marrow transplant, and it’s medically indicated, what’s the doctor to do? Perhaps they call an ethics consult,” says Carter.
Ideally, the ethicist who responds has additional training in pediatric ethics. However, this is unlikely, given that there are few pediatric bioethics fellowship programs. “We’ve had one here for the last 10 years and have had great success in training fellows. Much like pediatrics palliative care has developed a recognized niche, we’ve done the same thing with pediatric bioethics,” Carter reports. All the fellows have found jobs in healthcare systems or as academicians, including a former chaplain who is now a full-time ethics consultant.
In addition to a one-year pediatric bioethics fellowship, Children’s Mercy-Kansas City offers a comprehensive Certificate in Pediatric Bioethics. The nine-month certificate program combines in-person and online education and has trained more than 350 people from 28 countries over 14 years.3 “We’ve had people with a master’s in bioethics take our course, and people who already have a PhD. The reason for that is, if you go to get a master’s in bioethics, over the course of one or two years of education, you’ll only have maybe one or two months of pediatric exposure. And that’s the same for essentially every adult certificate program and every master’s in bioethics program across the country,” says Carter.
References
1. Lee LM, McCarty FA. Emergence of a discipline? Growth in U.S. postsecondary bioethics degrees. Hastings Cent Rep. 2016;46(2):19-21. [Erratum in Hastings Cent Rep. 2016;46(3):47.]
2. Tuohy B, Lee LM, Strand N, et al. What does “bioethics” mean? Education, training, and shaping the future of our field. Am J Bioeth. 2024;24(9):35-38.
3. Plantz DM, Garrett JR, Carter B, et al. Engaging pediatric health professionals in interactive online ethics education. Hastings Cent Rep. 2014;44(6):15-20.
As the clinical ethics field continues to professionalize, some ethicists are seeking to differentiate themselves or advance their careers by obtaining additional education.
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