Requirements, Standards Vary for Clinical Ethics Fellowship Programs

By Stacey Kusterbeck

Clinical ethics fellowships in the United States and Canada vary in some important ways, a recent study found.¹ “Programs have largely developed independently in the absence of any established standards. But as clinical ethics matures as a field, it is important for programs to share best practices and become more standardized,” asserts Ellen Fox, MD, HEC-C, the study’s lead author and president of Fox Ethics Consulting.

Fox and Jason Adam Wasserman, PhD, HEC-C, surveyed directors at all the 36 clinical ethics fellowship programs in the United States and Canada. “Before we conducted this study, very little was known about the current state of fellowship programs. No one even knew how many programs there were. Now we have a lot of information about these programs and their commonalities and differences,” says Fox. Some key findings:

• Most (88.8%) of programs required applicants to have an advanced degree or rarely accepted applicants without one.
• 91.7% of programs did not restrict applicants to a specific background (such as philosophy or medicine).
• 88.9% of programs compensated clinical ethics fellows.
• Salaries of clinical ethics fellows ranged widely (from $0 to $95,000).
• Fellowships varied widely in the number of fellows trained in the previous three years (ranging from one to 111). “Personally, I was surprised to discover that so many programs train only one fellow per year,” says Fox.
• Programs varied widely in the number of consultations performed by each clinical ethics fellow (ranging from zero to 450).
• Programs that did not pay fellows and larger programs were more likely to have lower expectations and lower admission standards.
• Fellowships varied in terms of pre-admission requirements, months required to complete the program, and training hours per week.

Although the study does not identify individual programs, understanding how programs differ could help applicants identify the right questions to ask and to select the program that best fits their preferences and needs. For example, some programs are more stringent than others. “Some applicants may be seeking a rigorous training program that will fully prepare them to enter the career market as a full-time clinical ethicist. Others may be looking for a training experience that is less intensive and requires less of a time commitment,” observes Fox.

Most program directors said that a lack of agreed-upon standards and national accreditation process were “moderate” or “major” problems for the bioethics field.² “People largely knew that fellowship programs varied pretty widely on a number of characteristics. But to see how different they can be on several factors that are associated with rigor and quality highlights the need for establishing at least some kind of baseline set of standards,” says Wasserman, a clinical ethicist at Corewell Health William Beaumont University Hospital and founding director of the Center for Moral Values in Health and Medicine at Oakland University William Beaumont School of Medicine.

Now that there are data demonstrating the program’s variation, it could be a turning point for the field of clinical bioethics. “Every profession wrestles with the tensions that come with standardization and formalization,” says Wasserman.

The study’s findings will inform the work of the Council on Program Accreditation for Clinical Ethicist Training (COPACET), a new non-profit organization that will develop accreditation standards for clinical ethics fellowships.³ Accreditation ensures that all graduates, regardless of where they were trained, meet the same high standards and are competent to practice. “The goal of standardization should not be to preserve the status quo but to ‘lift all boats.’ That’s what we hope to achieve through COPACET,” says Fox, chair of the steering committee for COPACET.

The Association of Bioethics Program Directors (ABPD) recommends that all fellows serve as the lead consultant for at least 30 clinical ethics consultation cases.⁴ Less than half of the fellowship programs met this standard. “Clearly, experience with ethics consultations is an important part of fellowship training. But there is nothing magic about the number 30. It is actually not at all clear how many consults are needed to gain proficiency as a clinical ethicist. This is one of many questions that COPACET will grapple with as it develops accreditation standards for clinical ethics fellowships,” says Fox. The first meeting of COPACET’s Board of Directors is scheduled for January 2025.

For applicants, the absence of accreditation for clinical ethics fellowship programs means there are inconsistent standards. Applicants might wrongly assume that all programs have identical goals and identical practices to meet those goals. “While there is overlap, different programs have different emphases. The applicant has to do their own research, compare, contrast, and evaluate,” advises Trevor M. Bibler, PhD, director of clinics ethics consultation services at Houston Methodist Hospital and associate professor at Baylor College of Medicine.

For some applicants, a fellowship is a mid-career opportunity to better understand ethics issues in medicine. “They may be seen as especially dedicated to their craft, creating the possibility of collaboration and new kinds of institutional responsibility,” says Bibler. Bibler says that anyone considering a clinical ethics fellowship should ask these questions:

• How is the mentoring structure set up? Applicants should look for a mentoring relationship that helps them transition from a novice to a competent professional.⁵ As for whether a program’s mentoring approach is sufficient, “it really just depends on the fellow’s goals and the competencies of the faculty in charge of the fellowship program,” says Bibler.
• What are the graduation requirements? Some programs require that the fellow sees a certain number of consultations before graduating; some have scholarship or research requirements. Others require that the trainee is there for a certain amount of time before being considered a graduate of the program.
• How does the program ensure that the applicant has a good chance of making progress and meeting their goals? “I am a proponent of structure, conversation, and evaluation. And we take an incremental approach to incorporating our fellows into consultation work. I know of training programs that say, on day 1, ‘Have at it. Go talk to the patient.’ That would not work for me as a learner or me as a director,” says Bibler.
• How much is the program willing to adapt to the interests and career plans of the fellow? Some fellow might desire a job as a staff ethicist at a hospital, because they enjoy doing consults and teaching healthcare professionals. Others plan on returning to their existing role and incorporating what they learned during their training. “Others, like me when I was a fellow, are aiming for a job in academic medicine, allowing them to do clinical work, but also setting aside time for research. Programs have different emphases, so applicants should be aware,” says Bibler.
• What are the graduates of the program doing now? “If applicants want a pathway to academic medicine, they should look for a program whose graduates have gone into that field,” says Bibler.

REFERENCES

1. Fox E, Wasserman JA. Clinical ethics fellowship programs in the U.S. and Canada: A descriptive study of program characteristics and practices. Am J Bioeth. 2024; Aug 20:1-16. doi: 10.1080/15265161.2024.2388723. [Online ahead of print].
2. Fox E, Wasserman JA. Clinical ethics fellowship programs in the United States and Canada: Program directors’ opinions about accreditation and funding. AJOB Empir Bioeth. 2024; Aug 27:1-9. doi: 10.1080/23294515.2024.2388516. [Online ahead of print].
3. COPACET Steering Committee. Frequently asked questions about accreditation, CAAHEP, and COPACET. Last reviewed Aug. 22, 2024. https://img1.wsimg.com/blobby/go/6dce0c97-7268-4346-91e9-256548bec413/downloads/COPACET%20FAQs%20August%2022%202024.pdf?ver=1724372958294
4. The Association Bioethics Program Directors. Clinical ethics fellowship program standards. https://www.bioethicsdirectors.net/wp-content/uploads/2017/11/Clinical-Ethics-Fellowship-Program-Standards.pdf
5. Bibler TM, Nelson RH, Moore B, et al. Building effective mentoring relationships during clinical ethics fellowships: Pedagogy, programs, and people. HEC Forum. 2024;36(1):1-29.