This article was downloaded by: [North Dakota State University] On: 04 March 2015, At: 06:27 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
The Birth of Clinical Ethics Consultation as a Profession Jeffrey P. Spike
a
a
University of Texas , Houston Published online: 14 Jan 2014.
Click for updates To cite this article: Jeffrey P. Spike (2014) The Birth of Clinical Ethics Consultation as a Profession, The American Journal of Bioethics, 14:1, 20-22, DOI: 10.1080/15265161.2014.863109 To link to this article: http://dx.doi.org/10.1080/15265161.2014.863109
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
The Birth of Clinical Ethics Consultation as a Profession
Downloaded by [North Dakota State University] at 06:27 04 March 2015
Jeffrey P. Spike, University of Texas, Houston The year 2013 may someday be seen as the year a new profession was born. Clinical ethics consultation has been practiced in different ways for roughly 30 years, originally initiated by a group of hospital chaplains in pastoral care such as George Kanotti, Joy Skeel, John Fletcher, and Stuart Sprague. They were all members of a group known as the SBC, Society for Bioethics Consultation. While modern bioethics had already been a subject of important publications for a decade, these were the pioneers who brought it to the bedside, and gradually came to change its name to clinical ethics to clarify its focus on patient care. Perhaps unfortunately for the field, SBC joined with two other organizations out of financial need, forming the American Society of Bioethics and Humanities (ASBH). While it was a valuable, diverse, and stimulating organization, suddenly the ethics consultants were a minority within their primary national organization. When they were joined by theoretical bioethicists in academic settings, and humanists of many disciplines (history, literature, religion, and anthropology, to name but a few), any suggestion of licensing sounded unnecessary to some, and threatening to others. Why should individuals teaching literature and medicine, or film and bioethics, have to take any exam after finishing a PhD in their field? What sense does it make for them to have to adhere to a code of ethics that implies a fiduciary duty to patients? They teach students, not patients. The practice of clinical ethics consultation continued to grow, even though its efforts to set standards or define standard operating procedures were being stymied. But gradually it became clear to academic bioethicists and humanists that only clinical ethicists needed to set professional standards, and that their doing so would not impose any duty upon scholars in purely academic positions. The rules for academics would continue to be set by the promotion and tenure committee, and would continue to be protected by the laws governing academic freedom. Only those who see patients must take on the additional training requirements, and adhere to the additional professional responsibilities of clinical ethics—training and responsibilities much like those of others in the clinical world, including hospital chaplains and doctors in new fields such as palliative care (Spike 2012). Over these past 30 years many different styles of clinical ethics practices developed; some withered, while others flourished. It is now possible to assemble a group of 100 paid practitioners, full-time or part-time, and find a remarkable (though not universal) consensus. For example, few would now argue with the claim that an ethics con-
sultant should always see a patient before expressing any opinions about a case. And few would argue that a consultation should generate a consult note in the chart, like any other consultation—both to provide documentation that it occurred, and to guarantee communication of its results equally to all members of the care team (Dubler et al. 2009; ASBH 2011). For at least a decade many consultants have wished to see standards set for the process of a consultation and for the education of a consultant. But during this past year, 2013, three major developments have been achieved. Each had been sought by many, but resisted by others. That all three are on the brink of coming to fruition simultaneously is a signal that the time has come, barriers have fallen, and important first steps toward professionalization are about to be taken. I will mention each one briefly, then address some of the details about one of them that Bruce White and colleagues (White, Jankowski, and Shelton 2014) raise. The first important step toward professionalization is from the American Society of Bioethics and Humanities (ASBH). The ASBH formed a standing committee on Clinical Ethics Consultation Affairs (CECA) and gave it the task of drafting a code of ethics. (Disclosure: I am a member of CECA.) This code of ethics has been written, has been revised in response to comments from consultants (including nonmembers of ASBH), and has been sent (as of the time of writing this article) to the ASBH Board for approval. Barring any changes, it should be official before the end of 2013. It is available for anyone to see on the ASBH website. As with any code of ethics, it is to be seen as a living document; in other words, there will inevitably be some changes (updates, improvements) made every few years. But what is important for now is that the first code of ethics for clinical ethicists will soon be official. The second and third steps toward professionalization are processes to set some minimal level of competency, both of the skills and knowledge of ethics consultants, and of any programs that purport to train them. Again, the first sets of standards may be too low, or need further adjustment. But as with the code of ethics, at least the resistance to setting some standards seems to have been removed. Two organizations have accepted taking on this responsibility, ASBH for finding a way to assess the competence of individual ethics consultants, and the Association of Bioethics Program Directors (ABPD) for accreditation of training programs. Each has stated that it hopes to have a trial system in place by the end of 2013 or in the spring of 2014; while
Address correspondence to Jeffrey P. Spike, University of Texas, Houston, McGovern Center, 6431 Fannin, Houston, TX 77030, USA. E-mail: [email protected]
20 ajob
January, Volume 14, Number 1, 2014
Downloaded by [North Dakota State University] at 06:27 04 March 2015
Examination for ASBH Ethics Knowledge Competencies
many problems will be exposed in the process, at least there is now an acceptance that we ought to begin the process, and then refine it as problems are discovered. Accreditation of training programs has always seemed to this author to be a far easier task (Spike 2009). After years of discussing the topic with others in the field, it is common to find agreement that a well-trained ethics consultant needs to have many skills, as well as knowledge derived from many academic disciplines (e.g., law and medicine as well as philosophy). No matter what training a person brings to ethics consultation, many of these will be lacking—this is an inevitable consequence of clinical ethics being an inherently interdisciplinary field. No MD program in the country, no JD, and no philosophy PhD teaches all the requisite knowledge bases, let alone all the complex interpersonal skills. Most active ethics consultants would agree that it would take at least a full year of full-time work (or perhaps 2–3 years of part-time work) to gain all the knowledge and skills (Kodish et al. 2013). The ABPD has chosen to take two smaller steps to achieve this goal, to separately accredit programs that teach the requisite knowledge base and programs that teach the requisite skills base. This can be an important first step, as long as the Bioethics Program Directors can agree that clinical ethics requires some training in health law and in clinical, empirical, and scientific knowledge (such as familiarity with the risk of infections at the surgical site and of aspiration pneumonia with feeding tubes), as well as in bioethics knowledge. There are dozens of bioethics master’s degree programs, and one hopes that some will acknowledge that they are excellent programs in bioethics that just don’t have the resources to stretch into these other subjects; it should also be recognized that some of the best bioethics programs in the world simply don’t want to include what they might see as these more plebian topics in their coursework. The goal to identify accredited programs is by no means normative, to say the clinical ethics training programs are better; it is simply to help those people who do want to work in hospitals seeing patients to find the programs most likely to help them fill in their knowledge gaps. The ABPD also plans to accredit training programs that teach clinical ethics skills. These are more likely to be medical school or hospital-based programs, with either simulation labs and standardized patients, or very active consult services. There are now a number of hospitals with an ethics consultation service (ECS) that performs 200 or more consults per year. A 1-year fellowship in any one of these ECS would clearly be extraordinarily beneficial for anyone entering the field. Someday it may make more sense to have a single accreditation, limited to programs that offer both the knowledge base and the skills base. But for now there may be too few programs that can meet both sets of requirements, and many more that can only offer one; the important achievement here is the acknowledgment that both are necessary. This is one of the important differences between bioethics and clinical ethics, and clearly offering accreditation in both
January, Volume 14, Number 1, 2014
is an acknowledgment of the importance of each (and that they must be kept distinct, and one cannot substitute one for the other). Since it is the program directors who are offering to oversee the process, the success will hinge on their ability to remain objective, and admit that some good bioethics programs do not qualify for accreditation as adequate programs in either knowledge or skills for training future clinical ethics consultants. The third step toward professionalization is the hardest, to find a way to assess the knowledge and skills of individual consultants. This is the thorny topic that White and colleagues address. With unlimited resources, clinical ethics could have a 1-day exam that would effectively assess the knowledge and skills of applicants. To sit for the exam one might require a terminal degree in any related field, and either 1 year of on the job training or a 1-year fellowship, for example. But as White and colleagues point out, there will be some difficulties with writing the exam, not insurmountable, but very nearly so. Writing valid multiple-choice questions is more difficult than many realize. Every time one hears someone protest that one cannot test X (ethics, critical thinking, philosophy, etc.) with a multiple-choice question, one can charitably understand that protest to mean “it is very difficult to test X with a multiple-choice question.” A team of three or four experts assigned to write good questions may well find that it takes 4 hours to write four questions. But it can be done. Another problem, and a very important one, is that an ethics consultant must be familiar with national and state health law. National health law is easily testable, but sparse. Most health law is not national or constitutional law. Does one require residents of California to be familiar with New York law, and vice versa? And what about those other 48 states, including such populous states as Texas and Florida, or such important states in the history of health law as Massachusetts? It is important and highly relevant that while there is a national exam for medical practice, there are different bar exams for the practice of law in each state. If the mere mention of variations among the five states just mentioned does not suffice to convince readers of the difficulties, then here are three important topics in clinical ethics where there are important differences in what would be “the correct answer” according to state: the confidentiality of HIV tests and of the disclosure of HIV status to sexual partners; the duty to warn patients of imminent risk as occurred in the Tarasoff case; and the rights of teenagers to make decisions regarding contraception, or abortion, or (even) life-sustaining treatment. In these cases, some states make disclosure mandatory, while many make it elective or discretionary but not required. And these differences are, if anything, becoming greater as the political divide of “North” versus “South,” or “red” versus “blue” continues to widen. There are other, similar topics: who (if anyone) can make a surrogate decision for a patient with no family or friends (“the unbefriended”), or when (if ever) one can stop lifesustaining treatment that is deemed “futile” or “nonbeneficial.” No matter an ethicist’s personal views, she must know
ajob 21
Downloaded by [North Dakota State University] at 06:27 04 March 2015
The American Journal of Bioethics
the law of the state where she practices. State variations will make it difficult to craft a national exam. The simplest solution for this problem would be 2 hours of multiple-choice exam questions, and at least 1 hour with two or three free-response (essay) questions. Evaluators would have to familiarize themselves with these variations so as to assess the answers appropriately. The most important thing would be that by the end of the examinations, there would have been a sample of a few questions on each of the 20 or so topic areas that are most commonly encountered in clinical ethics consultation. (An initial list of 13 such topics is contained in the ASBH “Education Guide” [ASBH 2009].) The panel of evaluators will have to decide well in advance, so people can prepare, whether consultants’ answers would need to cover laws in multiple states. For example, a question might ask them to compare and contrast the law in their own state to laws in other states that differ significantly; if so, then trainees anywhere would need to learn at least some laws in other states. This is often done to some degree already, so the exam would only help to clarify the degree this is needed, and let training programs better understand what is expected of them. White and colleagues provide some good examples of both multiple-choice questions and free response (essay) questions for a credentialing exam in clinical ethics knowledge. Besides knowledge, there will need to be a way to test skills such as interviewing, running family meetings, breaking bad news, analyzing complex and sometimes contradictory information (both personal information about the patient, and medical information from different consultants to a case), dealing with angry family members, dealing with interprofessional conflict on the team, and (of course) writing good, clear consult notes. Most of these skills would probably be best tested in an oral exam, and (ideally) there would also be objectively structured clinical examinations (OSCEs) with standardized patients. While White and colleagues focus on testing of core knowledge, we must remain cognizant that eventually we need to assess the core skills of potential ethics consultants as well (Smith et al. 2010). These elements would require at least a fourth hour of testing, and significant time and expense to develop. The “Quality Attestation” (“QA”) project currently being initiated by ASBH is another path to assess both knowledge and skills. It is most likely the first phase of a process, and may well lead to the acceptance of a national exam such as White and colleagues anticipate. The “QA” project anticipates the submission of a portfolio, with sample cases and letters of support, but no examination. As with the accreditation of programs, it is a valuable first step, and most important for the simple acknowledgment that it is time to begin setting standards and moving toward the eventual goal of professionalization. Its success though will be de-
22 ajob
termined by who are the examiners chosen to review the portfolios and interview the applicants, and whether they are able and willing to set a high standard—in other words, if they will be willing to reject some of the initial group of applicants who might be well-respected bioethics colleagues who simply have failed to recognize the additional knowledge and skills required to do ethics consultations at the bedside. The conclusion for bioethics centers that wish to become clinical ethics training programs might be that many of them will need to affiliate with academic medical centers to provide the training needed to prepare for these tests. But that is a good thing, as the trainees ought to be getting experience at the bedside if they are going to be ethics consultants. This is an essential differentiating factor between bioethics and clinical ethics consultation, and it is now time for people in both fields to better understand their differences as well as their commonalities. Echoing the title of Albert Jonsen’s book The Birth of Bioethics, 2013 marked an important year of labor, and we are now, at the end of 2013, witnessing the birth of clinical ethics consultation as a profession. This next year, 2014, will likely tell us if we will have a vigorous newborn, or whether continued resistance has led to further developmental delay.
REFERENCES American Society of Bioethics and Humanities. 2009. Improving competencies in clinical ethics consultation: An education guide. Glenville, IL: American Society for Bioethics and Humanities. American Society of Bioethics and Humanities. 2011. Core competencies for health care ethics consultation, 2nd ed. Glenville, IL: American Society for Bioethics and Humanities. Dubler, N. N., M. Webber, and D. Swiderski, with the National Working Group for the Clinical Ethics Credentialing Project. 2009. Charting the future: Credentialing, privileging, quality, and evaluation in clinical ethics consultation. Hastings Center Report 39(6): 23–33 Kodish, E., and J. J. Fins, with the ASBH Quality Attestation Presidential Task Force. 2013. Quality attestation for clinical ethics consultants. Hastings Center Report 43(5): 26–36. Smith, M. L, R. R. Sharp, K. Weise, and E. Kodish. 2010. Toward competency-based certification of clinical ethics consultants: A four-step process. Journal of Clinical Ethics 21(1): 14–22. Spike, J. P. 2009. Resolving the vexing question of credentialing: Finding the Aristotelian mean. HEC Forum October: 263–273 Spike, J. P. 2012. Do clinical ethics consultants have a fiduciary responsibility to the patient? American Journal of Bioethics 12(8): 13–15. White, B. D., J. B. Jankowski, and W. N. Shelton. 2014. Structuring a written examination to assess ASBH health care ethics consultation core knowledge competencies. American Journal of Bioethics 14(1): 5–17.
January, Volume 14, Number 1, 2014
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
The Birth of Clinical Ethics Consultation as a Profession Jeffrey P. Spike
a
a
University of Texas , Houston Published online: 14 Jan 2014.
Click for updates To cite this article: Jeffrey P. Spike (2014) The Birth of Clinical Ethics Consultation as a Profession, The American Journal of Bioethics, 14:1, 20-22, DOI: 10.1080/15265161.2014.863109 To link to this article: http://dx.doi.org/10.1080/15265161.2014.863109
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
The Birth of Clinical Ethics Consultation as a Profession
Downloaded by [North Dakota State University] at 06:27 04 March 2015
Jeffrey P. Spike, University of Texas, Houston The year 2013 may someday be seen as the year a new profession was born. Clinical ethics consultation has been practiced in different ways for roughly 30 years, originally initiated by a group of hospital chaplains in pastoral care such as George Kanotti, Joy Skeel, John Fletcher, and Stuart Sprague. They were all members of a group known as the SBC, Society for Bioethics Consultation. While modern bioethics had already been a subject of important publications for a decade, these were the pioneers who brought it to the bedside, and gradually came to change its name to clinical ethics to clarify its focus on patient care. Perhaps unfortunately for the field, SBC joined with two other organizations out of financial need, forming the American Society of Bioethics and Humanities (ASBH). While it was a valuable, diverse, and stimulating organization, suddenly the ethics consultants were a minority within their primary national organization. When they were joined by theoretical bioethicists in academic settings, and humanists of many disciplines (history, literature, religion, and anthropology, to name but a few), any suggestion of licensing sounded unnecessary to some, and threatening to others. Why should individuals teaching literature and medicine, or film and bioethics, have to take any exam after finishing a PhD in their field? What sense does it make for them to have to adhere to a code of ethics that implies a fiduciary duty to patients? They teach students, not patients. The practice of clinical ethics consultation continued to grow, even though its efforts to set standards or define standard operating procedures were being stymied. But gradually it became clear to academic bioethicists and humanists that only clinical ethicists needed to set professional standards, and that their doing so would not impose any duty upon scholars in purely academic positions. The rules for academics would continue to be set by the promotion and tenure committee, and would continue to be protected by the laws governing academic freedom. Only those who see patients must take on the additional training requirements, and adhere to the additional professional responsibilities of clinical ethics—training and responsibilities much like those of others in the clinical world, including hospital chaplains and doctors in new fields such as palliative care (Spike 2012). Over these past 30 years many different styles of clinical ethics practices developed; some withered, while others flourished. It is now possible to assemble a group of 100 paid practitioners, full-time or part-time, and find a remarkable (though not universal) consensus. For example, few would now argue with the claim that an ethics con-
sultant should always see a patient before expressing any opinions about a case. And few would argue that a consultation should generate a consult note in the chart, like any other consultation—both to provide documentation that it occurred, and to guarantee communication of its results equally to all members of the care team (Dubler et al. 2009; ASBH 2011). For at least a decade many consultants have wished to see standards set for the process of a consultation and for the education of a consultant. But during this past year, 2013, three major developments have been achieved. Each had been sought by many, but resisted by others. That all three are on the brink of coming to fruition simultaneously is a signal that the time has come, barriers have fallen, and important first steps toward professionalization are about to be taken. I will mention each one briefly, then address some of the details about one of them that Bruce White and colleagues (White, Jankowski, and Shelton 2014) raise. The first important step toward professionalization is from the American Society of Bioethics and Humanities (ASBH). The ASBH formed a standing committee on Clinical Ethics Consultation Affairs (CECA) and gave it the task of drafting a code of ethics. (Disclosure: I am a member of CECA.) This code of ethics has been written, has been revised in response to comments from consultants (including nonmembers of ASBH), and has been sent (as of the time of writing this article) to the ASBH Board for approval. Barring any changes, it should be official before the end of 2013. It is available for anyone to see on the ASBH website. As with any code of ethics, it is to be seen as a living document; in other words, there will inevitably be some changes (updates, improvements) made every few years. But what is important for now is that the first code of ethics for clinical ethicists will soon be official. The second and third steps toward professionalization are processes to set some minimal level of competency, both of the skills and knowledge of ethics consultants, and of any programs that purport to train them. Again, the first sets of standards may be too low, or need further adjustment. But as with the code of ethics, at least the resistance to setting some standards seems to have been removed. Two organizations have accepted taking on this responsibility, ASBH for finding a way to assess the competence of individual ethics consultants, and the Association of Bioethics Program Directors (ABPD) for accreditation of training programs. Each has stated that it hopes to have a trial system in place by the end of 2013 or in the spring of 2014; while
Address correspondence to Jeffrey P. Spike, University of Texas, Houston, McGovern Center, 6431 Fannin, Houston, TX 77030, USA. E-mail: [email protected]
20 ajob
January, Volume 14, Number 1, 2014
Downloaded by [North Dakota State University] at 06:27 04 March 2015
Examination for ASBH Ethics Knowledge Competencies
many problems will be exposed in the process, at least there is now an acceptance that we ought to begin the process, and then refine it as problems are discovered. Accreditation of training programs has always seemed to this author to be a far easier task (Spike 2009). After years of discussing the topic with others in the field, it is common to find agreement that a well-trained ethics consultant needs to have many skills, as well as knowledge derived from many academic disciplines (e.g., law and medicine as well as philosophy). No matter what training a person brings to ethics consultation, many of these will be lacking—this is an inevitable consequence of clinical ethics being an inherently interdisciplinary field. No MD program in the country, no JD, and no philosophy PhD teaches all the requisite knowledge bases, let alone all the complex interpersonal skills. Most active ethics consultants would agree that it would take at least a full year of full-time work (or perhaps 2–3 years of part-time work) to gain all the knowledge and skills (Kodish et al. 2013). The ABPD has chosen to take two smaller steps to achieve this goal, to separately accredit programs that teach the requisite knowledge base and programs that teach the requisite skills base. This can be an important first step, as long as the Bioethics Program Directors can agree that clinical ethics requires some training in health law and in clinical, empirical, and scientific knowledge (such as familiarity with the risk of infections at the surgical site and of aspiration pneumonia with feeding tubes), as well as in bioethics knowledge. There are dozens of bioethics master’s degree programs, and one hopes that some will acknowledge that they are excellent programs in bioethics that just don’t have the resources to stretch into these other subjects; it should also be recognized that some of the best bioethics programs in the world simply don’t want to include what they might see as these more plebian topics in their coursework. The goal to identify accredited programs is by no means normative, to say the clinical ethics training programs are better; it is simply to help those people who do want to work in hospitals seeing patients to find the programs most likely to help them fill in their knowledge gaps. The ABPD also plans to accredit training programs that teach clinical ethics skills. These are more likely to be medical school or hospital-based programs, with either simulation labs and standardized patients, or very active consult services. There are now a number of hospitals with an ethics consultation service (ECS) that performs 200 or more consults per year. A 1-year fellowship in any one of these ECS would clearly be extraordinarily beneficial for anyone entering the field. Someday it may make more sense to have a single accreditation, limited to programs that offer both the knowledge base and the skills base. But for now there may be too few programs that can meet both sets of requirements, and many more that can only offer one; the important achievement here is the acknowledgment that both are necessary. This is one of the important differences between bioethics and clinical ethics, and clearly offering accreditation in both
January, Volume 14, Number 1, 2014
is an acknowledgment of the importance of each (and that they must be kept distinct, and one cannot substitute one for the other). Since it is the program directors who are offering to oversee the process, the success will hinge on their ability to remain objective, and admit that some good bioethics programs do not qualify for accreditation as adequate programs in either knowledge or skills for training future clinical ethics consultants. The third step toward professionalization is the hardest, to find a way to assess the knowledge and skills of individual consultants. This is the thorny topic that White and colleagues address. With unlimited resources, clinical ethics could have a 1-day exam that would effectively assess the knowledge and skills of applicants. To sit for the exam one might require a terminal degree in any related field, and either 1 year of on the job training or a 1-year fellowship, for example. But as White and colleagues point out, there will be some difficulties with writing the exam, not insurmountable, but very nearly so. Writing valid multiple-choice questions is more difficult than many realize. Every time one hears someone protest that one cannot test X (ethics, critical thinking, philosophy, etc.) with a multiple-choice question, one can charitably understand that protest to mean “it is very difficult to test X with a multiple-choice question.” A team of three or four experts assigned to write good questions may well find that it takes 4 hours to write four questions. But it can be done. Another problem, and a very important one, is that an ethics consultant must be familiar with national and state health law. National health law is easily testable, but sparse. Most health law is not national or constitutional law. Does one require residents of California to be familiar with New York law, and vice versa? And what about those other 48 states, including such populous states as Texas and Florida, or such important states in the history of health law as Massachusetts? It is important and highly relevant that while there is a national exam for medical practice, there are different bar exams for the practice of law in each state. If the mere mention of variations among the five states just mentioned does not suffice to convince readers of the difficulties, then here are three important topics in clinical ethics where there are important differences in what would be “the correct answer” according to state: the confidentiality of HIV tests and of the disclosure of HIV status to sexual partners; the duty to warn patients of imminent risk as occurred in the Tarasoff case; and the rights of teenagers to make decisions regarding contraception, or abortion, or (even) life-sustaining treatment. In these cases, some states make disclosure mandatory, while many make it elective or discretionary but not required. And these differences are, if anything, becoming greater as the political divide of “North” versus “South,” or “red” versus “blue” continues to widen. There are other, similar topics: who (if anyone) can make a surrogate decision for a patient with no family or friends (“the unbefriended”), or when (if ever) one can stop lifesustaining treatment that is deemed “futile” or “nonbeneficial.” No matter an ethicist’s personal views, she must know
ajob 21
Downloaded by [North Dakota State University] at 06:27 04 March 2015
The American Journal of Bioethics
the law of the state where she practices. State variations will make it difficult to craft a national exam. The simplest solution for this problem would be 2 hours of multiple-choice exam questions, and at least 1 hour with two or three free-response (essay) questions. Evaluators would have to familiarize themselves with these variations so as to assess the answers appropriately. The most important thing would be that by the end of the examinations, there would have been a sample of a few questions on each of the 20 or so topic areas that are most commonly encountered in clinical ethics consultation. (An initial list of 13 such topics is contained in the ASBH “Education Guide” [ASBH 2009].) The panel of evaluators will have to decide well in advance, so people can prepare, whether consultants’ answers would need to cover laws in multiple states. For example, a question might ask them to compare and contrast the law in their own state to laws in other states that differ significantly; if so, then trainees anywhere would need to learn at least some laws in other states. This is often done to some degree already, so the exam would only help to clarify the degree this is needed, and let training programs better understand what is expected of them. White and colleagues provide some good examples of both multiple-choice questions and free response (essay) questions for a credentialing exam in clinical ethics knowledge. Besides knowledge, there will need to be a way to test skills such as interviewing, running family meetings, breaking bad news, analyzing complex and sometimes contradictory information (both personal information about the patient, and medical information from different consultants to a case), dealing with angry family members, dealing with interprofessional conflict on the team, and (of course) writing good, clear consult notes. Most of these skills would probably be best tested in an oral exam, and (ideally) there would also be objectively structured clinical examinations (OSCEs) with standardized patients. While White and colleagues focus on testing of core knowledge, we must remain cognizant that eventually we need to assess the core skills of potential ethics consultants as well (Smith et al. 2010). These elements would require at least a fourth hour of testing, and significant time and expense to develop. The “Quality Attestation” (“QA”) project currently being initiated by ASBH is another path to assess both knowledge and skills. It is most likely the first phase of a process, and may well lead to the acceptance of a national exam such as White and colleagues anticipate. The “QA” project anticipates the submission of a portfolio, with sample cases and letters of support, but no examination. As with the accreditation of programs, it is a valuable first step, and most important for the simple acknowledgment that it is time to begin setting standards and moving toward the eventual goal of professionalization. Its success though will be de-
22 ajob
termined by who are the examiners chosen to review the portfolios and interview the applicants, and whether they are able and willing to set a high standard—in other words, if they will be willing to reject some of the initial group of applicants who might be well-respected bioethics colleagues who simply have failed to recognize the additional knowledge and skills required to do ethics consultations at the bedside. The conclusion for bioethics centers that wish to become clinical ethics training programs might be that many of them will need to affiliate with academic medical centers to provide the training needed to prepare for these tests. But that is a good thing, as the trainees ought to be getting experience at the bedside if they are going to be ethics consultants. This is an essential differentiating factor between bioethics and clinical ethics consultation, and it is now time for people in both fields to better understand their differences as well as their commonalities. Echoing the title of Albert Jonsen’s book The Birth of Bioethics, 2013 marked an important year of labor, and we are now, at the end of 2013, witnessing the birth of clinical ethics consultation as a profession. This next year, 2014, will likely tell us if we will have a vigorous newborn, or whether continued resistance has led to further developmental delay.
REFERENCES American Society of Bioethics and Humanities. 2009. Improving competencies in clinical ethics consultation: An education guide. Glenville, IL: American Society for Bioethics and Humanities. American Society of Bioethics and Humanities. 2011. Core competencies for health care ethics consultation, 2nd ed. Glenville, IL: American Society for Bioethics and Humanities. Dubler, N. N., M. Webber, and D. Swiderski, with the National Working Group for the Clinical Ethics Credentialing Project. 2009. Charting the future: Credentialing, privileging, quality, and evaluation in clinical ethics consultation. Hastings Center Report 39(6): 23–33 Kodish, E., and J. J. Fins, with the ASBH Quality Attestation Presidential Task Force. 2013. Quality attestation for clinical ethics consultants. Hastings Center Report 43(5): 26–36. Smith, M. L, R. R. Sharp, K. Weise, and E. Kodish. 2010. Toward competency-based certification of clinical ethics consultants: A four-step process. Journal of Clinical Ethics 21(1): 14–22. Spike, J. P. 2009. Resolving the vexing question of credentialing: Finding the Aristotelian mean. HEC Forum October: 263–273 Spike, J. P. 2012. Do clinical ethics consultants have a fiduciary responsibility to the patient? American Journal of Bioethics 12(8): 13–15. White, B. D., J. B. Jankowski, and W. N. Shelton. 2014. Structuring a written examination to assess ASBH health care ethics consultation core knowledge competencies. American Journal of Bioethics 14(1): 5–17.
January, Volume 14, Number 1, 2014
