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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Clinical Ethics Consultation: Accountability or Shared Responsibility? Lisa Anderson-Shaw
a
a
University of Illinois Medical Center Published online: 08 May 2014.
Click for updates To cite this article: Lisa Anderson-Shaw (2014) Clinical Ethics Consultation: Accountability or Shared Responsibility?, The American Journal of Bioethics, 14:6, 42-43, DOI: 10.1080/15265161.2014.900149 To link to this article: http://dx.doi.org/10.1080/15265161.2014.900149
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 14(6): 42–53, 2014 c Taylor & Francis Group, LLC Copyright ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.900149
Open Peer Commentaries
Clinical Ethics Consultation: Accountability or Shared Responsibility? Downloaded by [University of Western Ontario] at 23:50 06 February 2015
Lisa Anderson-Shaw, University of Illinois Medical Center The concept of “accountability” is often used to describe a professional relationship that involves a question, an action, and an outcome. Thus, “accountability” “is associated with the process of being called ‘to account’ to some authority for one’s actions” (Mulgan 2000). In such an exchange, there is social interaction between two entities—one who seeks answers and the other who responds and accepts any sanction implied with the right of authority accorded their answer or advice (Mulgan 2000). This definition of accountability is very basic and in no way implies the complex social meanings common in today’s individual and political environments. However this view of accountability is at the heart of those professions for which licensure, certifications, and advanced training are expected. Such professions include but are not limited to nursing, law, medicine, and the various allied health fields. In addition, most professions have codes of ethics as well as practice guidelines with a formal authority to provide services independently according to their scope of professional practice. There is “an assurance of competence” that is critical to maintain trust in the practice of a profession (Cruess, Johnston, and Cruess 2004). Weise and Daly, in their article “Exploring Accountability of Clinical Ethics Consultants: Practice and Training Implications” (2014), discuss the concept of accountability with relationship to the clinical ethics consultant. This article is a very novel theoretical discussion as to the degree and scope of accountability a clinical ethics consultant related to “aspects of patient care and outcome” (34) may possess, depending on the consultant’s professional and educational background. The authors note that clinical ethics consultants “represent a multidisciplinary group of scholars and practitioners with varied training backgrounds, who are integrated into a medical environment to assist in the provision of ethically supportable care,” (34) which I have found to be true in my many years of experience in health care and ethics consultation. They define accountability in a similar way as noted, a “personal, internalized acceptance of responsibility for one’s action and for the consequences of
one’s actions, as well as transparent willingness to share this reasonability with colleagues” (34). In addition, they offer three forms of ethics consultant accountability, which guides their role within consultative activity: restricted accountability (acceptable to defer to medical team), balanced accountability (evaluates opposing views, but works collaboratively), and unbounded accountability (single-minded pursuit of the consultant’s identified optimal outcome). These are not supported by any qualitative research and would be interesting to study further. However, I would suggest the three forms of ethics consultant accountability are better described as forms of shared responsibility—the ethics consultant as participant in the care team activities, rather than a form of professional accountability related to specific consultation outcomes. This ultimately brings up the question of professional accountability and professionalization, including the future of bioethics as a profession. “Debate over professionalizing ethics consultation has been simmering for more than 20 years, but in recent years the emphasis seems to have shifted away from the question of whether to move toward professionalization to the question of how” (Fox 2014, 1). I would propose a more clearly articulated concept, not as Weise and Daly do (restricted, unbound, balanced) in relationship to that which directs the consultant’s behavior, but rather, a professional accountability that comes with a professional license or certification associated with public awareness and acceptance as one who has authority for actions and outcomes (e.g., RN, MD, JD). As such, I do not mean that those without such license/certification would/could not be competent ethics consultants. I would only argue that perhaps the term better served for the Weise and Daly idea would be, as they state, “shared responsibility” as participants in the care team activities, rather than personal accountability for specific consultation outcomes. The nonclinician disciplines providing clinical ethics consultation and education often include and are not limited to sociology, philosophy, theology, anthropology, and literature. Though familiar with the culture of their own
Address correspondence to Lisa Anderson-Shaw, DrPH, MA, MSN, University of Illinois Medical Center, Administration, 1740 W. Taylor Street, m/c 693, Chicago, IL 60612, USA. E-mail: [email protected]
42 ajob
Downloaded by [University of Western Ontario] at 23:50 06 February 2015
Accountability of Clinical Ethics Consultants
discipline, the nonclinician ethics consultants may not be familiar with the culture of health care institutions and direct patient/family/provider interactions. This health care culture may include review and documentation in the medical record, medical/clinical terminology, clinical personnel responsibility (i.e., chain of command when seeking patient information), direct communication with patients/family members and various clinical staff, awareness of multiple clinicians and services involved in the care of a particular patient, and policy information. With experience, however, one can learn much of the environmental and institutional culture in order to navigate ethics consultation activity. The consult outcome action accountability may be viewed very differently between nonclinician ethics consultants and clinical ethics consultants. Clinical training within the health professions (including health law) includes discussing various care options and informed consent issues, along with the authority to execute chosen options and be accountable for the outcomes related to the chosen options. The clinician who has advanced training in medical ethics consultation may feel more professional accountability for consult outcomes due to that person’s clinical training, and it would be very difficult to disassociate the clinical authority as a clinician from that person’s role in ethics consultation discussion and activities, even if direct patient orders are not part of the clinician as ethics consultant’s role. The authors provide an “accountability continuum,” which describes five roles that an ethics consultant may provide, as well as giving a description of each role within the three levels of accountability (Weise and Davis 2014, Table 1). This continuum is much like the communication facilitator as described in the 1998 Casarett, Daskal, and Lantos article that speaks to the role of a clinical ethicist as a kind of mediator in the discourse of patient care. Casarett and colleagues describe one model of ethics consultation as “an outsider whose contribution (and authority) depends
on a ‘critical distance’ from clinicians . . . the ethics consultant’s role is to facilitate communication, to clarify the moral positions of others, and to arrange a safe moral space within which differences can be aired, understood, and resolved” (6) Communication and consensus building would be the role of the ethics consultant. There is value in having a “critical distance,” as noted. My work as a clinical ethics consultant is strengthened by the fact that I am an outsider (not part of the clinical team) and as such I bring a form of objectivity that can only be had by an outsider. I am also a clinician and that allows me a sense of accountability that also comes with my clinical profession. I think all clinical ethics consultants possess a sense of personal accountability for their work. The ethics consultant role as described by Weise and Daly has more to do with a sense of “shared responsibility” as participants in the care team activities than with a professional accountability for specific consult outcomes.
REFERENCES Casarett, D., F. Daskal, and J. Lantos. 1998. The authority of the clinical ethicist. Hasting Center Report 28(6): 6–11. Cruess, S., S. Johnston, and R. Cruess. 2004. Profession: A working definition for medical educators. Teaching and Learning in Medicine 16(1): 74–76. Fox, E. 2014. Developing a certifying examination for health care ethics consultants: Bioethicist need help. American Journal of Bioethics 14(1): 1–4. Mulgan, R. 2000. “Accountability”: An ever-expanding concept? Public Administration 78(3): 555–573. Weise, K. L., and B. J. Daly. 2014. Exploring accountability of clinical ethics consultants: Practice and training implications. American Journal of Bioethics 14(6): 34–41.
On Internal Accountability in Clinical Ethics Consultation Lisa M. Rasmussen, University of North Carolina Charlotte Before we commit significant resources of time and energy to clinical ethics consultation (CEC) certification, education, and the like, one of the questions we ought to be able to answer is how to hold consultants accountable, since accountability is a hallmark of professionalism. Assuming the juggernaut of quality assurance cannot be withstood
(though against some of its facets we should make the attempt), how we choose to measure success in clinical ethics consultation will significantly constrain the future options and directions of the field. As Campbell’s Law1 reminds us, what we measure affects what we do, often in unintended and even perverse ways. If we do not make such choices
1. “The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor” (Campbell 1976, 49). Address correspondence to Lisa M. Rasmussen, University of North Carolina Charlotte, Department of Philosophy, 9201 University City Blvd., Charlotte, NC 28233, USA. E-mail: [email protected]
June, Volume 14, Number 6, 2014
ajob 43
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Clinical Ethics Consultation: Accountability or Shared Responsibility? Lisa Anderson-Shaw
a
a
University of Illinois Medical Center Published online: 08 May 2014.
Click for updates To cite this article: Lisa Anderson-Shaw (2014) Clinical Ethics Consultation: Accountability or Shared Responsibility?, The American Journal of Bioethics, 14:6, 42-43, DOI: 10.1080/15265161.2014.900149 To link to this article: http://dx.doi.org/10.1080/15265161.2014.900149
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 14(6): 42–53, 2014 c Taylor & Francis Group, LLC Copyright ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.900149
Open Peer Commentaries
Clinical Ethics Consultation: Accountability or Shared Responsibility? Downloaded by [University of Western Ontario] at 23:50 06 February 2015
Lisa Anderson-Shaw, University of Illinois Medical Center The concept of “accountability” is often used to describe a professional relationship that involves a question, an action, and an outcome. Thus, “accountability” “is associated with the process of being called ‘to account’ to some authority for one’s actions” (Mulgan 2000). In such an exchange, there is social interaction between two entities—one who seeks answers and the other who responds and accepts any sanction implied with the right of authority accorded their answer or advice (Mulgan 2000). This definition of accountability is very basic and in no way implies the complex social meanings common in today’s individual and political environments. However this view of accountability is at the heart of those professions for which licensure, certifications, and advanced training are expected. Such professions include but are not limited to nursing, law, medicine, and the various allied health fields. In addition, most professions have codes of ethics as well as practice guidelines with a formal authority to provide services independently according to their scope of professional practice. There is “an assurance of competence” that is critical to maintain trust in the practice of a profession (Cruess, Johnston, and Cruess 2004). Weise and Daly, in their article “Exploring Accountability of Clinical Ethics Consultants: Practice and Training Implications” (2014), discuss the concept of accountability with relationship to the clinical ethics consultant. This article is a very novel theoretical discussion as to the degree and scope of accountability a clinical ethics consultant related to “aspects of patient care and outcome” (34) may possess, depending on the consultant’s professional and educational background. The authors note that clinical ethics consultants “represent a multidisciplinary group of scholars and practitioners with varied training backgrounds, who are integrated into a medical environment to assist in the provision of ethically supportable care,” (34) which I have found to be true in my many years of experience in health care and ethics consultation. They define accountability in a similar way as noted, a “personal, internalized acceptance of responsibility for one’s action and for the consequences of
one’s actions, as well as transparent willingness to share this reasonability with colleagues” (34). In addition, they offer three forms of ethics consultant accountability, which guides their role within consultative activity: restricted accountability (acceptable to defer to medical team), balanced accountability (evaluates opposing views, but works collaboratively), and unbounded accountability (single-minded pursuit of the consultant’s identified optimal outcome). These are not supported by any qualitative research and would be interesting to study further. However, I would suggest the three forms of ethics consultant accountability are better described as forms of shared responsibility—the ethics consultant as participant in the care team activities, rather than a form of professional accountability related to specific consultation outcomes. This ultimately brings up the question of professional accountability and professionalization, including the future of bioethics as a profession. “Debate over professionalizing ethics consultation has been simmering for more than 20 years, but in recent years the emphasis seems to have shifted away from the question of whether to move toward professionalization to the question of how” (Fox 2014, 1). I would propose a more clearly articulated concept, not as Weise and Daly do (restricted, unbound, balanced) in relationship to that which directs the consultant’s behavior, but rather, a professional accountability that comes with a professional license or certification associated with public awareness and acceptance as one who has authority for actions and outcomes (e.g., RN, MD, JD). As such, I do not mean that those without such license/certification would/could not be competent ethics consultants. I would only argue that perhaps the term better served for the Weise and Daly idea would be, as they state, “shared responsibility” as participants in the care team activities, rather than personal accountability for specific consultation outcomes. The nonclinician disciplines providing clinical ethics consultation and education often include and are not limited to sociology, philosophy, theology, anthropology, and literature. Though familiar with the culture of their own
Address correspondence to Lisa Anderson-Shaw, DrPH, MA, MSN, University of Illinois Medical Center, Administration, 1740 W. Taylor Street, m/c 693, Chicago, IL 60612, USA. E-mail: [email protected]
42 ajob
Downloaded by [University of Western Ontario] at 23:50 06 February 2015
Accountability of Clinical Ethics Consultants
discipline, the nonclinician ethics consultants may not be familiar with the culture of health care institutions and direct patient/family/provider interactions. This health care culture may include review and documentation in the medical record, medical/clinical terminology, clinical personnel responsibility (i.e., chain of command when seeking patient information), direct communication with patients/family members and various clinical staff, awareness of multiple clinicians and services involved in the care of a particular patient, and policy information. With experience, however, one can learn much of the environmental and institutional culture in order to navigate ethics consultation activity. The consult outcome action accountability may be viewed very differently between nonclinician ethics consultants and clinical ethics consultants. Clinical training within the health professions (including health law) includes discussing various care options and informed consent issues, along with the authority to execute chosen options and be accountable for the outcomes related to the chosen options. The clinician who has advanced training in medical ethics consultation may feel more professional accountability for consult outcomes due to that person’s clinical training, and it would be very difficult to disassociate the clinical authority as a clinician from that person’s role in ethics consultation discussion and activities, even if direct patient orders are not part of the clinician as ethics consultant’s role. The authors provide an “accountability continuum,” which describes five roles that an ethics consultant may provide, as well as giving a description of each role within the three levels of accountability (Weise and Davis 2014, Table 1). This continuum is much like the communication facilitator as described in the 1998 Casarett, Daskal, and Lantos article that speaks to the role of a clinical ethicist as a kind of mediator in the discourse of patient care. Casarett and colleagues describe one model of ethics consultation as “an outsider whose contribution (and authority) depends
on a ‘critical distance’ from clinicians . . . the ethics consultant’s role is to facilitate communication, to clarify the moral positions of others, and to arrange a safe moral space within which differences can be aired, understood, and resolved” (6) Communication and consensus building would be the role of the ethics consultant. There is value in having a “critical distance,” as noted. My work as a clinical ethics consultant is strengthened by the fact that I am an outsider (not part of the clinical team) and as such I bring a form of objectivity that can only be had by an outsider. I am also a clinician and that allows me a sense of accountability that also comes with my clinical profession. I think all clinical ethics consultants possess a sense of personal accountability for their work. The ethics consultant role as described by Weise and Daly has more to do with a sense of “shared responsibility” as participants in the care team activities than with a professional accountability for specific consult outcomes.
REFERENCES Casarett, D., F. Daskal, and J. Lantos. 1998. The authority of the clinical ethicist. Hasting Center Report 28(6): 6–11. Cruess, S., S. Johnston, and R. Cruess. 2004. Profession: A working definition for medical educators. Teaching and Learning in Medicine 16(1): 74–76. Fox, E. 2014. Developing a certifying examination for health care ethics consultants: Bioethicist need help. American Journal of Bioethics 14(1): 1–4. Mulgan, R. 2000. “Accountability”: An ever-expanding concept? Public Administration 78(3): 555–573. Weise, K. L., and B. J. Daly. 2014. Exploring accountability of clinical ethics consultants: Practice and training implications. American Journal of Bioethics 14(6): 34–41.
On Internal Accountability in Clinical Ethics Consultation Lisa M. Rasmussen, University of North Carolina Charlotte Before we commit significant resources of time and energy to clinical ethics consultation (CEC) certification, education, and the like, one of the questions we ought to be able to answer is how to hold consultants accountable, since accountability is a hallmark of professionalism. Assuming the juggernaut of quality assurance cannot be withstood
(though against some of its facets we should make the attempt), how we choose to measure success in clinical ethics consultation will significantly constrain the future options and directions of the field. As Campbell’s Law1 reminds us, what we measure affects what we do, often in unintended and even perverse ways. If we do not make such choices
1. “The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor” (Campbell 1976, 49). Address correspondence to Lisa M. Rasmussen, University of North Carolina Charlotte, Department of Philosophy, 9201 University City Blvd., Charlotte, NC 28233, USA. E-mail: [email protected]
June, Volume 14, Number 6, 2014
ajob 43
