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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
On Internal Accountability in Clinical Ethics Consultation a
Lisa M. Rasmussen a
University of North Carolina Charlotte Published online: 08 May 2014.
Click for updates To cite this article: Lisa M. Rasmussen (2014) On Internal Accountability in Clinical Ethics Consultation, The American Journal of Bioethics, 14:6, 43-45, DOI: 10.1080/15265161.2014.903644 To link to this article: http://dx.doi.org/10.1080/15265161.2014.903644
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
Downloaded by [Michigan State University] at 04:30 25 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
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The American Journal of Bioethics
deliberately at the outset, we should not be surprised if we arrive where we never meant to go. Because it is difficult to establish appropriate training and evaluation standards for clinical ethics consultation in the absence of a discussion—and decision—regarding the concrete aims of the activity,2 I am convinced that accountability should be among the first, rather than the last, of the topics considered en route to professionalization.3 As a result, I welcome Weise and Daly’s (2014) consideration of one possible nexus of accountability, “the degree and scope of accountability of the clinical ethics consultant for aspects of patient care and outcome” (34).4 They interpret accountability for patient care as “the personal, internalized acceptance of responsibility for outcomes, as well as transparent willingness to share this responsibility with colleagues” (34), and suggest that the right model for this is “balanced accountability.” This means neither restricting one’s accountability too much, nor interpreting it too liberally, instead appropriately acknowledging one’s part in the whole. A prima facie appeal of this approach is that it focuses on patient care within the context of a health care team some of whose members may disagree with a CEC’s recommendation. Premature deference to other members (“restricted accountability”) poses one unacceptable extreme, while solipsistic insistence on the righteousness of one’s opinion (“unbounded accountability”) poses another; in between is the appropriate “balanced accountability.” Anyone who practices clinical ethics consultation will recognize the dangers in consultants who normally practice at these poles—the terms “show dogs” and “ethics police” accurately capture consultants of either extreme. It is hard to argue against a moderate path in most things. However, the question regarding accountability in clinical ethics consultation is not whether or not either extreme of personal responsibility is always the right approach, but rather whether it ever is, and if so, when, and why. The higher the stakes, and the more problematic the views of the rest of the team, the more justified a CEC might be in stridently objecting to a planned course of action. As many consultants can attest, considering when to push one’s colleagues on a point of disagreement puts one on uncertain normative terrain. So to agree with and adopt Weise and Daly’s suggestions for the cultivation of a particular internal state is not yet to find a helpful place to settle disputes or aim one’s practice. It cannot serve as an assessment tool for practitioners. But isn’t that what “accountability” means? If it does not mean what can be assessed, what is its function? In the suggested accountability point of patient care outcomes and the model used to interpret it, Weise and 2. As I have argued elsewhere (Rasmussen 2013), the specification of tasks such as ensuring that “ethically appropriate” recommendations are made is unhelpful in the absence of what makes a recommendation ethically appropriate. 3. See Rasmussen (2013) for a fuller discussion of this topic. 4. They do not suggest that this is the only aspect of a CEC’s accountability. Because CECs have obligations to other parties (the health care team, the institution, etc.), a full analysis of CEC accountability will have to address other areas as well.
44 ajob
Daly present a different notion of accountability than what might ordinarily come to mind. “Accountability” typically cohabits with “quality assurance measures,” “performance reviews,” “best practice,” and other corporate terms of art. Interpreted in that way, accountability in clinical ethics consultation would stipulate benchmarks: performance goals to be attained, minimal expected standards, number of initiatives initiated, and so on. A very real and recognized danger in linking clinical ethics consultation to patient care outcomes is unintended consequences—for example, that the practice might immediately be identified as a cost containment activity. After all, CECs have been shown to reduce (expensive) intensive care unit (ICU) stays.5 Instead, Weise and Daly’s model offers a guide for the perplexed: It recommends a mind set (and training in it) to clinical ethics consultants, rather than describing a performance target. In its construal of accountability as an internalized sense of responsibility that should avoid extremes, this model suggests something like a virtue ethics. On one hand, this is an example of how we can talk about accountability without immediately beginning to track and tally consultants’ daily activities. Moreover, it comfortingly evokes the traditional notion of an “internal morality of medicine.” But that harkening reveals a weakness of any use of the model that does more than recommend the cultivation of an internal state. This is not a data point that could be deployed for quality assurance measures, which I think is the source of much of the push for professionalization, standardization, and accountability in clinical ethics consultation. The one exception to this claim, as the authors conclude by recommending, is that it might become part of a standardized training for consultants: “We believe that it is critical that training programs recognize and explicitly address a goal of enabling consultants to accept a balanced accountability as an element of a consultant’s professional identity” (40). As they observe, it is important to recognize that a consultant’s home discipline will affect the extent to which he or she is already habituated to do that.6 So, for example, those without clinical experience should spend some time training in that context, while others may need training in stepping back from customary roles as “captains of the ship.” It seems wise to consider how a consultant’s willingness to shoulder some responsibility for the subjects of consultation should factor into the practice and training for it. But it is not clear how far we can go with this. Insofar as this “balanced accountability” is strictly internal, it has no 5. See Heilieser, Meltzer, and Siegler (2000) for statistics on this point, and Rasmussen (2006) for a consideration of the dangers of co-optation in clinical ethics consultation. 6. “To the extent that a profession’s code of ethics represents the core values taught and reinforced in basic education and clinical training, this suggests that ethics consultants who have a primary clinical discipline (e.g., medicine, nursing, etc.), may perceive a different degree or kind of accountability for what happens to the patient” (Weise and Daly 2014, 36). (This fact ought to be taken into consideration for any contemplated “deliverables” in clinical ethics consultation as well.)
June, Volume 14, Number 6, 2014
Downloaded by [Michigan State University] at 04:30 25 February 2015
Accountability of Clinical Ethics Consultants
teeth—apart from internal ones, that is, teeth that depend on the consultant’s own views about his or her culpability.7 And teeth are often the aim of considerations of accountability. Moreover, some of the ways in which this balanced approach are interpreted will vary significantly—for example, when Weise and Daly suggest that an ideal model for balanced internalized accountability includes learning to be “respectful of decision hierarchies,” how strongly should this be interpreted? What is to me appropriate respect for hierarchy may come off to others as show-dog shirking of responsibility (if I’m too respectful) or ethics-police intrusion (if I’m not respectful enough)—and how can we get anywhere with evaluating consultants when my internal state can’t be directly accessed? This model interprets accountability for patient care and outcome as “a personal, internalized acceptance of responsibility for one’s actions and for the consequences of one’s actions.” But if there should be accountability for patient care outcomes in clinical ethics consultation, why limit it
to an internal acceptance of responsibility? If it is important, it may be worth a careful articulation of what that looks like on the outside, so that we have a way of recognizing whether or not a consultant took the responsibility seriously enough. Even there, I wonder what adopting this model might change in the day-to-day evaluation of a consultant.
REFERENCES Campbell, D. T. 1976. Assessing the impact of planned social change. The Public Affairs Center, Dartmouth College, Hanover, NH. Available at: https://www.globalhivmeinfo.org/ CapacityBuilding/Occasional%20Papers/08%20Assessing%20the %20Impact%20of%20Planned%20Social%20Change.pdf Heilicser, B., D. Meltzer, and M. Siegler. 2000. The effect of clinical medical ethics consultation on healthcare costs. Journal of Clinical Ethics 11: 31–38. Rasmussen, L. M. 2006. Sinister innovations: Beware the co-optation of clinical ethics consultation. Journal of Value Inquiry 40: 235–242.
7. This should not be underestimated; after all, each of us has to live with the consequences of our choices. But if this is what an internal balanced accountability amounts to, it is more about self-help for the worried consultant than it is about professionalization.
Rasmussen, L. M. 2013. The chiaroscuro of accountability in the core competencies for healthcare ethics consultation (2nd ed.). Journal of Clinical Ethics 24(1): 32–40. 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.
Incorporating Balanced Accountability in a Clinical Ethics Fellowship Program Kevin M. Dirksen, UCLA Health, Ethics Center As the emerging profession of clinical ethics continues to reflect on important questions such as attestation, certification, and accreditation (Magill 2013), Weise and Daly (2014) provide the opportunity to consider the degree to which clinical ethics consultants should accept accountability for the advice rendered in an ethics consult. This topic has broad application throughout the discipline toward continuing to promote practice standards (Reel 2012) such as the American Society for Bioethics & Humanities Core Competencies for Healthcare Ethics Consultation (American Society for Bioethics & Humanities Core Competencies Update Task Force 2011). In addition, this discourse is also relevant for those who direct energies toward training future clinical ethics consultants. Specifically, I aim to look at how the teaching of balanced accountability might be integrated in a clinical ethics fellowship program.
In addition to promoting what they term “balanced accountability,” Weise and Daly (2014) argue that a consultant’s professional identity other than ethicist—such as nurse, lawyer, physician, and so on—informs how a clinical ethics consultant might view his or her accountability for the advice rendered in an ethics consult. They show how relevant professional guidance such as codes of ethics for medicine and nursing speak to this question and suggest that a physician or a nurse may already have strong professional guidance in this area, though a lawyer’s professional guidance may be less applicable since the client and not the patient is the primary focus (Weise and Daly 2014). I suggest that a common distinction be borrowed in terms of the clinician (e.g., physician, nurse) on the one hand, and the nonclinician (e.g., philosopher, theologian, lawyer, etc.) on the other, in order to consider how fellowship education
Address correspondence to Kevin M. Dirksen, UCLA Health, Ethics Center, 10833 LeConte Avenue, Los Angeles, CA 90095-1730, USA. E-mail: [email protected]
June, Volume 14, Number 6, 2014
ajob 45
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
On Internal Accountability in Clinical Ethics Consultation a
Lisa M. Rasmussen a
University of North Carolina Charlotte Published online: 08 May 2014.
Click for updates To cite this article: Lisa M. Rasmussen (2014) On Internal Accountability in Clinical Ethics Consultation, The American Journal of Bioethics, 14:6, 43-45, DOI: 10.1080/15265161.2014.903644 To link to this article: http://dx.doi.org/10.1080/15265161.2014.903644
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
Downloaded by [Michigan State University] at 04:30 25 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
Downloaded by [Michigan State University] at 04:30 25 February 2015
The American Journal of Bioethics
deliberately at the outset, we should not be surprised if we arrive where we never meant to go. Because it is difficult to establish appropriate training and evaluation standards for clinical ethics consultation in the absence of a discussion—and decision—regarding the concrete aims of the activity,2 I am convinced that accountability should be among the first, rather than the last, of the topics considered en route to professionalization.3 As a result, I welcome Weise and Daly’s (2014) consideration of one possible nexus of accountability, “the degree and scope of accountability of the clinical ethics consultant for aspects of patient care and outcome” (34).4 They interpret accountability for patient care as “the personal, internalized acceptance of responsibility for outcomes, as well as transparent willingness to share this responsibility with colleagues” (34), and suggest that the right model for this is “balanced accountability.” This means neither restricting one’s accountability too much, nor interpreting it too liberally, instead appropriately acknowledging one’s part in the whole. A prima facie appeal of this approach is that it focuses on patient care within the context of a health care team some of whose members may disagree with a CEC’s recommendation. Premature deference to other members (“restricted accountability”) poses one unacceptable extreme, while solipsistic insistence on the righteousness of one’s opinion (“unbounded accountability”) poses another; in between is the appropriate “balanced accountability.” Anyone who practices clinical ethics consultation will recognize the dangers in consultants who normally practice at these poles—the terms “show dogs” and “ethics police” accurately capture consultants of either extreme. It is hard to argue against a moderate path in most things. However, the question regarding accountability in clinical ethics consultation is not whether or not either extreme of personal responsibility is always the right approach, but rather whether it ever is, and if so, when, and why. The higher the stakes, and the more problematic the views of the rest of the team, the more justified a CEC might be in stridently objecting to a planned course of action. As many consultants can attest, considering when to push one’s colleagues on a point of disagreement puts one on uncertain normative terrain. So to agree with and adopt Weise and Daly’s suggestions for the cultivation of a particular internal state is not yet to find a helpful place to settle disputes or aim one’s practice. It cannot serve as an assessment tool for practitioners. But isn’t that what “accountability” means? If it does not mean what can be assessed, what is its function? In the suggested accountability point of patient care outcomes and the model used to interpret it, Weise and 2. As I have argued elsewhere (Rasmussen 2013), the specification of tasks such as ensuring that “ethically appropriate” recommendations are made is unhelpful in the absence of what makes a recommendation ethically appropriate. 3. See Rasmussen (2013) for a fuller discussion of this topic. 4. They do not suggest that this is the only aspect of a CEC’s accountability. Because CECs have obligations to other parties (the health care team, the institution, etc.), a full analysis of CEC accountability will have to address other areas as well.
44 ajob
Daly present a different notion of accountability than what might ordinarily come to mind. “Accountability” typically cohabits with “quality assurance measures,” “performance reviews,” “best practice,” and other corporate terms of art. Interpreted in that way, accountability in clinical ethics consultation would stipulate benchmarks: performance goals to be attained, minimal expected standards, number of initiatives initiated, and so on. A very real and recognized danger in linking clinical ethics consultation to patient care outcomes is unintended consequences—for example, that the practice might immediately be identified as a cost containment activity. After all, CECs have been shown to reduce (expensive) intensive care unit (ICU) stays.5 Instead, Weise and Daly’s model offers a guide for the perplexed: It recommends a mind set (and training in it) to clinical ethics consultants, rather than describing a performance target. In its construal of accountability as an internalized sense of responsibility that should avoid extremes, this model suggests something like a virtue ethics. On one hand, this is an example of how we can talk about accountability without immediately beginning to track and tally consultants’ daily activities. Moreover, it comfortingly evokes the traditional notion of an “internal morality of medicine.” But that harkening reveals a weakness of any use of the model that does more than recommend the cultivation of an internal state. This is not a data point that could be deployed for quality assurance measures, which I think is the source of much of the push for professionalization, standardization, and accountability in clinical ethics consultation. The one exception to this claim, as the authors conclude by recommending, is that it might become part of a standardized training for consultants: “We believe that it is critical that training programs recognize and explicitly address a goal of enabling consultants to accept a balanced accountability as an element of a consultant’s professional identity” (40). As they observe, it is important to recognize that a consultant’s home discipline will affect the extent to which he or she is already habituated to do that.6 So, for example, those without clinical experience should spend some time training in that context, while others may need training in stepping back from customary roles as “captains of the ship.” It seems wise to consider how a consultant’s willingness to shoulder some responsibility for the subjects of consultation should factor into the practice and training for it. But it is not clear how far we can go with this. Insofar as this “balanced accountability” is strictly internal, it has no 5. See Heilieser, Meltzer, and Siegler (2000) for statistics on this point, and Rasmussen (2006) for a consideration of the dangers of co-optation in clinical ethics consultation. 6. “To the extent that a profession’s code of ethics represents the core values taught and reinforced in basic education and clinical training, this suggests that ethics consultants who have a primary clinical discipline (e.g., medicine, nursing, etc.), may perceive a different degree or kind of accountability for what happens to the patient” (Weise and Daly 2014, 36). (This fact ought to be taken into consideration for any contemplated “deliverables” in clinical ethics consultation as well.)
June, Volume 14, Number 6, 2014
Downloaded by [Michigan State University] at 04:30 25 February 2015
Accountability of Clinical Ethics Consultants
teeth—apart from internal ones, that is, teeth that depend on the consultant’s own views about his or her culpability.7 And teeth are often the aim of considerations of accountability. Moreover, some of the ways in which this balanced approach are interpreted will vary significantly—for example, when Weise and Daly suggest that an ideal model for balanced internalized accountability includes learning to be “respectful of decision hierarchies,” how strongly should this be interpreted? What is to me appropriate respect for hierarchy may come off to others as show-dog shirking of responsibility (if I’m too respectful) or ethics-police intrusion (if I’m not respectful enough)—and how can we get anywhere with evaluating consultants when my internal state can’t be directly accessed? This model interprets accountability for patient care and outcome as “a personal, internalized acceptance of responsibility for one’s actions and for the consequences of one’s actions.” But if there should be accountability for patient care outcomes in clinical ethics consultation, why limit it
to an internal acceptance of responsibility? If it is important, it may be worth a careful articulation of what that looks like on the outside, so that we have a way of recognizing whether or not a consultant took the responsibility seriously enough. Even there, I wonder what adopting this model might change in the day-to-day evaluation of a consultant.
REFERENCES Campbell, D. T. 1976. Assessing the impact of planned social change. The Public Affairs Center, Dartmouth College, Hanover, NH. Available at: https://www.globalhivmeinfo.org/ CapacityBuilding/Occasional%20Papers/08%20Assessing%20the %20Impact%20of%20Planned%20Social%20Change.pdf Heilicser, B., D. Meltzer, and M. Siegler. 2000. The effect of clinical medical ethics consultation on healthcare costs. Journal of Clinical Ethics 11: 31–38. Rasmussen, L. M. 2006. Sinister innovations: Beware the co-optation of clinical ethics consultation. Journal of Value Inquiry 40: 235–242.
7. This should not be underestimated; after all, each of us has to live with the consequences of our choices. But if this is what an internal balanced accountability amounts to, it is more about self-help for the worried consultant than it is about professionalization.
Rasmussen, L. M. 2013. The chiaroscuro of accountability in the core competencies for healthcare ethics consultation (2nd ed.). Journal of Clinical Ethics 24(1): 32–40. 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.
Incorporating Balanced Accountability in a Clinical Ethics Fellowship Program Kevin M. Dirksen, UCLA Health, Ethics Center As the emerging profession of clinical ethics continues to reflect on important questions such as attestation, certification, and accreditation (Magill 2013), Weise and Daly (2014) provide the opportunity to consider the degree to which clinical ethics consultants should accept accountability for the advice rendered in an ethics consult. This topic has broad application throughout the discipline toward continuing to promote practice standards (Reel 2012) such as the American Society for Bioethics & Humanities Core Competencies for Healthcare Ethics Consultation (American Society for Bioethics & Humanities Core Competencies Update Task Force 2011). In addition, this discourse is also relevant for those who direct energies toward training future clinical ethics consultants. Specifically, I aim to look at how the teaching of balanced accountability might be integrated in a clinical ethics fellowship program.
In addition to promoting what they term “balanced accountability,” Weise and Daly (2014) argue that a consultant’s professional identity other than ethicist—such as nurse, lawyer, physician, and so on—informs how a clinical ethics consultant might view his or her accountability for the advice rendered in an ethics consult. They show how relevant professional guidance such as codes of ethics for medicine and nursing speak to this question and suggest that a physician or a nurse may already have strong professional guidance in this area, though a lawyer’s professional guidance may be less applicable since the client and not the patient is the primary focus (Weise and Daly 2014). I suggest that a common distinction be borrowed in terms of the clinician (e.g., physician, nurse) on the one hand, and the nonclinician (e.g., philosopher, theologian, lawyer, etc.) on the other, in order to consider how fellowship education
Address correspondence to Kevin M. Dirksen, UCLA Health, Ethics Center, 10833 LeConte Avenue, Los Angeles, CA 90095-1730, USA. E-mail: [email protected]
June, Volume 14, Number 6, 2014
ajob 45
