Healthcare ethics consultation has been developed, practiced, and analyzed internationally. However, only a few professional standards have evolved globally in this field that would be comparable to standards in other areas of healthcare. This article cannot compensate for this situation. It contributes to the ongoing debate on professionalization by presenting experiences with ethics consultation in Austria, though. After exploring its contexts and providing an overview of one of its primary ethics programs, the article (...) analyzes the underlying assumptions of “ethics consultation” as an essential effort on the path to professionalize ethics consultation. (shrink)

Healthcare ethics consultation is therefore one of the most consequential, institutionally accepted, and widespread forms of public philosophy in the United States. In this chapter, the authors begin with an overview of the development of healthcare ethics and its emergence as a concrete practice embedded in healthcare settings. They then describe the core ethical principles that inform the everyday practice of ethics consultations and the generally accepted steps involved in conducting a consultation. (...) The authors discuss the role of clinical ethicists in medical education and policy development. Finally, they conclude with some remarks on the distinctive contributions made by those with philosophical training to these endeavors and the importance of continued engagement by philosophers in this important public work. (shrink)

Volume 20, Issue 3, March 2020, Page 19-21.

Volume 20, Issue 3, March 2020, Page 1-5.

Shocking. There seems no other response to the Fox findings. The bioethics community has been working for decades to improve the quality of, and access to, competent healthcare ethics consultation....

This paper addresses the need for, and ultimately proposes, an educational framework to develop competencies in attending to ethical issues in mental health and substance use health (MHSUH) in healthcare ethics consultation (HCEC). Given the prevalence and stigma associated with MHSUH, it is crucial for healthcare ethicists to approach such matters skillfully. A literature review was conducted in the areas of bioethics, health professions education, and stigma studies, followed by quality improvement interviews with content experts to (...) gather feedback on the framework’s strengths, limitations, and anticipated utility. The proposed framework describes three key concepts: first, integrating self-reflexive practices into formal, informal, and hidden curricula; second, embedding structural humility into teaching methods and contexts of learning; and third, striking a balance between critical consciousness and compassion in dialogue. The proposed educational framework has the potential to help HCEC learners enhance their understanding and awareness of ethical issues related to structural stigma and MHSUH. Moreover, context-specific learning, particularly in MHSUH, can play a significant role in promoting competency-building among healthcare ethicists, allowing them to address issues of social justice effectively in their practice. Further dialogue is encouraged within the healthcare ethics community to further develop the concepts described in this framework. (shrink)

Tertiary healthcare ethics (HCE) consultation occurs when an HCE consultant at a healthcare facility requests guidance from one or more senior HCE consultants who are not members of that facility’s HCE consultation service. Tertiary HCE consultants provide advanced HCE guidance and/or mentoring to facility (secondary) HCE consultants, mirroring healthcare consultation in clinical practice. In this article, we describe advantages and challenges of providing tertiary HCE consultation through a hub-and-spoke model administered by a (...) national integrated HCE service. (shrink)

Ellen Fox and collaborators have produced the most detailed description of healthcare ethics practices in the United States available. Some findings are shocking for anyone committed to promoting q...

BackgroundNo standard method exists to assess how many consults a healthcare ethics consultation (HCEC) service should perform. To address this, we developed a method to estimate the volume of HCEC services based on a mixed-methods approach that included a systematic review and survey data on the volume of consult services requested.MethodsOur investigation included a systematic review of studies that reported the volume of HCEC services that were requested from 2000 to 2017, institutional surveys, and statistical analyses that (...) estimated the volume of HCEC services that were adjusted to the size of the hospitals in the survey and to population acuity.ResultsWe contacted the authors of 19 studies that met our inclusion criteria; 17 authors responded to the institutional survey and five provided annualized data points. We found that standard methods of reporting the volume of HCEC services led to inaccuracies in estimating the growth of HCEC services over time. To rectify this, we proposed two means to estimate volume based on either the service goals of HCEC services or hospital size and acuity.DiscussionThe statistical limitations of our study highlight the need to standardize the sharing and reporting of data in clinical ethics. Future work should further standardize methods of HCEC quality assessment using measures similar to those we describe. (shrink)

Bioethics has received important criticisms for its perceived privileging of biomedical authority with longstanding calls for greater recognition of the social, political, economic, historical, and...

In November 2018, the practice of health care ethics consultation crossed a major threshold when 138 candidates took the inaugural Healthcare Ethics Consultant Certification Examination. This accomplishment, long in the making, has had and continues to have both advocates and critics. The Healthcare Ethics Consultant Certification Commission, a functionally autonomous body created and funded by the American Society for Bioethics and Humanities, was charged with overseeing creation of the certification process, developing the exam, and (...) formulating certification standards and policies to assess candidates’ qualifications. In this essay, as members of the commission, we describe the process of developing, administering, and scoring the certification examination as well as the historical context and the outlook for certification. By detailing the decisions and actions of the commission, we aim to provide a transparent account of the commission's efforts to develop a psychometrically sound, reliable, and secure examination through a deliberative, fair, and data‐driven process. (shrink)

Clinical ethics training programs are responsible for preparing their trainees to be competent ethics consultants worthy of the trust of patients, families, surrogates, and healthcare professionals. While the American Society for Bioethics and Humanities (ASBH) offers a certification examination for healthcare ethics consultants, no tools exist for the formal evaluation of ethics trainees to assess their progress toward competency. Medical specialties accredited by the Accreditation Council for Graduate Medical Education (ACGME) use milestones to report (...) trainees’ progress along a continuum of professional development as a means of “operationalizing and implementing” medical competencies. Utilizing the Core Competencies for Healthcare Ethics Consultation and the ACGME and American Board of Pediatrics’ (ABP) Pediatric Milestones Project, we developed milestones for 17 subcompetencies in clinical ethics consultation and academic bioethics. As the field of clinical ethics becomes more standardized, such tools will be needed to promote the development of robust training programs and to certify that their graduates are competent practitioners. (shrink)

Volume 20, Issue 3, March 2020, Page 24-27.

Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.

From the beginning, a code of ethics for bioethicists has been conceived of as part of a movement to professionalise the field. In advocating for such a code, Baker repeatedly identifies ‘having a code of ethics’ with ‘professionalization’. The American Society of Bioethics and Humanities (ASBH) echoes this view in their code of ethics for healthcare ethics consultants (HCECs)1 and the subsequent publication in the American Journal of Bioethics.2 Taking for granted that a code of (...) ethics could be a valuable asset for HCECs, this essay has two aims. First, there are good reasons to doubt that the label ‘profession’ has significant meaning for HCECs. Attempts to accurately conceive of a profession fall into two broad camps: substantive and formal. Substantive conceptions should be rejected. Specifically, substantive conceptions beg the question about what it means to be a profession, which produces devastating problems for practical application. Formal conceptions of profession (eg, Davis’ conception3) avoid begging the question, but do so at the cost of identifying the responsibilities of a profession. Using the term ‘professional responsibilities’, then, requires additional explication and classifying HCECs as professionals requires the identification of their role-specific responsibilities.i Second, this essay will critique the ASBH code of ethics for HCECs as a first articulation of these responsibilities. As written, this code of ethics has limited value for HCECs because most of the responsibilities identified in this code do not identify HCEC-specific responsibilities. In closing, some important strategies to improve upon this initial attempt to define the responsibilities of HCECs are identified. For at least the last decade, Baker has encouraged bioethicists to adopt a code of ethics. Throughout this effort, Baker intertwines having a code of ethics with becoming a profession: ‘Is it time for bioethics to assert its integrity by developing …. (shrink)

Efforts to professionalize the field of bioethics have led to the development of the Healthcare Ethics Consultant-Certified (HEC-C) Program intended to credential practicing healthcare ethics consultants (HCECs). Our team of professional ethicists participated in the inaugural process to support the professionalization efforts and inform our views on the value of this credential from the perspective of ethics consultants. In this paper, we explore the history that has led to this certification process, and evaluate the ability (...) of the HEC-C Program to meet the goals it has set forth for HCECs. We describe the benefits and weaknesses of the program and offer constructive feedback on how the process might be strengthened, as well as share our team’s experience in preparing for the exam. (shrink)

In the article “An Argument for Standardized Ethical Directives for Secular Healthcare Services,” Abram L. Brummett and Jamie C. Watson argue that, parallel to the directives of the Roman Catholic Church, secular healthcare ethics consultants (HECs) need substantive standardized ethical guidelines (what they call SEGs) that would constitute a best practice across all HECs in the U.S. Brummett and Watson believe that the absence of such directives constitutes an important deficit in clinical ethics consultation (CEC) (...) that needs to be rectified in order for consultation to achieve the professionalism and universality necessary for legitimacy. This is a bold argument worthy of consideration, perhaps most because it challenges the field to engage in a self-assessment about its current and future directions against the backdrop of both the concerning data on national CEC and the current intense values polarization in the U.S. As part of assessment, I will argue in this essay that such a consensus document is not only impossible in our current national climate, but undesirable given the way that it would impose lib- Values Imposition and Ethical Pluralism: An Argument Against Standardized Ethical Directives for Healthcare Ethics Consultants Autumn Fiester eral clinical ethics values on an extremely values-pluralistic populace and exacerbate the deep divisions that many of us fear could be our national undoing. (shrink)

“Chiaroscuro” is a art technique that makes use of light and shade to suggest depth and solidity on a flat surface. I argue that the standards regarding accountability in the second edition of the Core Competencies for Healthcare Ethics Consultation , are chiaroscuro, because, despite the offered lists of competencies, it is very difficult to imagine how consultants might be held accountable to such standards. It is not clear to which of the many suggested standards a consultant (...) should be held accountable, and even if one stipulates that only the tabulated competencies are meant as standards, the vague wording makes it hard to know how a consultant might fail to meet the standards or perform excellently. In addition, because terms such as “ethics” and “ethical” are not defined in the document, we are left with no way to determine whether consultants have made appropriate recommendations. The document is useful as a point of discussion, but not yet ready to serve as a tool for holding practitioners accountable. (shrink)

Conflict resolution is a core component of healthcare ethics consultation (HEC) and proficiency in this skill set is recognized by the national bioethics organization and its HEC certification process. Difficult interpersonal interactions between the clinical team and patients or their families are often inexorably connected to the normative disputes that are the catalyst for the consult. Ethics consultants are often required to navigate challenging dynamics that have become entrenched and work with patient-provider or family-provider relationships that (...) have already broken down. The first step in conflict resolution is diagnosing the source of the conflict. Because so many interpersonal and normative conflicts rest on misunderstanding and mischaracterization, the diagnosis of the problem requires untangling the actual positions and perspectives of the conflicting parties from the fallacious assumptions made about the parties’ respective positions and views. Developed in management science, the Ladder of Inference (LOI) is a diagnostic tool for assisting stakeholders in re-examining the process they used to form beliefs about others involved in the conflict. The LOI is a device that detects errors in reasoning, including implicit racial bias, that lead to false judgments and counterproductive responses to those judgments. The LOI is an instrument that can be used by ethics consultants to help resolve contentious bedside conflicts, but the LOI can also be employed as a teaching tool used by healthcare ethics consultants in training the clinical staff in how to avoid such conflicts in the first place. (shrink)

In the process of professionalization, the American Society for Bioethics and Humanities (ASBH) has emphasized process and knowledge as core competencies for clinical ethics consultants; however, the credentialing program launched in 2018 fails to address both pillars. The inadequacy of this program recalls earlier critiques of the professionalization effort made by Giles R. Scofield and H. Tristram Engelhardt, Jr.. Both argue that ethics consultation is not a profession and the effort to professionalize is motivated by self-interest. One (...) argument they offer against professionalization is that ethics consultants lack normative expertise. Although the question of expertise cannot be resolved completely, the accusation of self-interest can be addressed. Underlying these critiques is a concern for hubris, which can be addressed in certification and the vetting of candidates. Drawing on the virtue ethics literature of Alasdair MacIntyre and Edmund D. Pellegrino, I argue that medicine is a moral community in which ethics consultants are moral agents with a duty to foster the virtue of humility (or what Pellegrino and Thomasma call self-effacement). The implications of this argument include a requirement for self-reflection in one’s role as a moral agent and reflection on one’s progress toward developing or deepening virtuous engagement with the moral community of medicine. I recommend that professionalization of clinical ethics consultants include a self-reflective narrative component in the initial certification and ongoing renewal of certification where clinical ethics consultants address the emotional dimensions of their work as well as their own moral development. Adopting a teleological view of ethics consultation and incorporating narratives that work toward that purpose will mitigate the self-interest and hubris of the professionalization project. (shrink)

Events in the US in 2020 have laid bare the reality that racism and its effects continue to take a heavy toll on the lives of Black Americans. The three articles in this issue of AJOB each provide...

As part of a project to examine health care ethics consultation in Canada, we surveyed individuals who were considered by themselves or others to play a significant role in health care ethics consultation. Since one goal of the project was to examine the education and abilities necessary for consultants, we sought to determine the qualifications and skills currently possessed by persons considered to be ethics consultants. For the purposes of the questionnaire, health care ethics (...) consultation was defined broadly to include consultation on ethical issues in clinical care or in clinical research, ethics consultation to Clinical Ethics Committees, Research Ethics Committees, and policy formulation committees in health care institutions; clinical ethics work was defined more broadly still to include, in addition to the above, ethics education, administration, research and writing on bioethics other than the above, and public speaking.Three hundred and fifty questionnaires were sent to individuals and institutions across Canada that were thought to have some involvement in health care ethics consultation. Two hundred and fifty-three questionnaires were returned for a response rate of 72%. This report presents initial findings of the study and attempts to provide a comprehensive overview of the current state of ethics consultation within Canada. The survey examines demographics, educational background, time spent on ethics, institutional affiliations, approaches to the role of consultation, research related issues, and attitudes toward certification. (shrink)

A decade ago some members of the American Society for Bioethics and the Humanities (ASBH) concluded that the society's reluctance to develop a code of professional ethics, although a tolerable anom...

For over three decades, clinical ethicists in the United States have recorded their consulting activities to supplement documentation in the medical record, often using locally developed instrument...

Background: Ethics consultation is the traditional way of resolving challenging ethical questions raised about patient care in the United States. Little research has been published on the resolution process used during ethics consultations and on how this experience affects healthcare professionals who participate in them. Objectives: The purpose of this qualitative research was to uncover the basic process that occurs in consultation services through study of the perceptions of healthcare professionals. Design and Method: The (...) researchers in this study used a constructivist grounded theory approach that represents how one group of professionals experienced ethics consultations in their hospital in the United States. Results: The results were sufficient to develop an initial theory that has been named after the core concept: Moving It Along. Three process stages emerged from data interpretation: moral questioning, seeing the big picture, and coming together. It is hoped that this initial work stimulates additional research in describing and understanding the complex social process that occurs for healthcare professionals as they address the difficult moral issues that arise in clinical practice. (shrink)

Healthcare ethics consultants in the Veterans Health Administration (VHA) document consults in an enterprise-wide web-based database entitled IEWeb, serving as a system of record for healthcare ethics documentation at 1300 VA facilities. The need arose to evolve the database from an ethics process training resource into a more streamlined documentation repository that captures essential consult elements. A VHA National Center for Ethics in Health Care (NCEHC) Improvement Team convened for three tasks: (1) Specify and (...) prioritize IEWeb changes (occurred via six focus groups composed of “new user” and “super user” cohorts with analysis of existing documentation patterns); (2) Pilot the changes regionally (via regional communication, training, and reviews of pre-post use patterns); and (3) Measure the impact of national change implementation on user perspectives (via pre-and post-change implementation polls). Focus groups identified six implementable priority areas for ethics consult documentation improvement, including the development of a usable consult summary note for ready conversion from IEWeb fields into the electronic health record. Post-IEWeb updates showed an increased number of consults documented, a reduction in “time to consult documentation closure” by a mean of 4.5 days, and a clinically-meaningful improvement in the quality of documentation (78% of ethics questions scored “above-bar” on the validation tool pre- vs. 89% scored “above-bar” post-IEWeb changes, n = 140). According to national survey findings, the number of consultants documenting “all” consults in IEWeb increased, satisfaction increased, and perception of documentation difficulty decreased. IEWeb simplification enabled ethics consultants to re-focus their documentation completion efforts by decreasing perception of documentation burden while improving documentation frequency and quality in a clinically-meaningful way. (shrink)

Volume 20, Issue 6, June 2020, Page 73-75.

Clinical Ethics Consultations (CECs) are used by healthcare systems to offer healthcare practitioners a structured level of support to approach ethical questions. The objective of this study was to detail the elements of surveyed CECs and offer guidance in the approach to future ethics consultations at a regional healthcare system. This cohort study has a qualitative and quantitative retrospective approach, surveying ethics consultations through the dates of 4/27/22 to 4/26/24. A documentary sheet was created, (...) and information was entered via online data-gathering forms. The cases are from a range of specialties within a regional healthcare system servicing Minnesota, Wisconsin, and North Dakota. 103 CECs were performed within the study period across the regional healthcare system. Consultations were identified through retrospective review of the internal CEC database, and patient information was collected through the medical record. Decision-making was often performed by a substitute decision-maker (N = 54), occurring in 70.1% of cases with known decision makers. CECs were documented in an ethics-specific note in the patient medical record in 37 of 82 (45.1%) documented patient cases. It was common for physicians to mention the ethics consultation in their patient notes, occuring in 51 of 82 (62.2%) of documented patient cases. Age was recorded in 92.0% (N = 91) of unique patient cases; the median age was 62 years. Ethical questions concerning end-of-life care were the most common cause for consultation (N = 35, 34%), and CECs were most commonly requested in general medicine or hospitalist departments (N = 38, 45.2%). Most consultations resulted in resolution at time of initial consultation with the ethics call team. Recommendations for increased frequency and timing of policy review are given based on the results of the data presented. Using interpretation of the CECs in this study, we offer recommendations towards the use and documentation of ethics consultations in the era of open notes, open the door towards areas of future research, and ultimately promote use of CECs for more favorable patient outcomes. (shrink)

Volume 20, Issue 3, March 2020, Page 27-29.

While valuable work has been done addressing clinical ethics within established healthcare systems, we anticipate that the projected growth in acquisitions of community hospitals and facilities by large tertiary hospitals will impact the field of clinical ethics and the day-to-day responsibilities of clinical ethicists in ways that have yet to be explored. Toward the goal of providing clinical ethicists guidance on a range of issues that they may encounter in the systematization process, we discuss key considerations and (...) potential challenges in implementing system-wide ethics consultation services. Specifically, we identify four models for organizing, developing, and enhancing ethics consultation activities within a system created through acquisitions: train-the-trainer, local capacity-building, circuit-riding, and consolidated accountability. We note each model’s benefits and challenges. To our knowledge, this is the first paper to consider the broader landscape of issues affected by consolidation. We anticipate that clinical ethicists, volunteer consultants, and hospital administrators will benefit from our recommendations. (shrink)

Since 1989, clinical ethics consultation in form of hospital ethics committees was established in most of the transition countries of Central and Eastern Europe. Up to now, the similarities and differences between HECs in Central and Eastern Europe and their counterparts in the U.S. and Western Europe have not been determined. Through search in literature databases, we have identified studies that document the implementation of clinical ethics consultation in Central and Eastern Europe. These studies have (...) been analyzed under the following aspects: mode of establishment of HECs, character of consultation they provide, and their composition. The results show that HECs in the transition countries of Central and Eastern Europe differ from their western-European or U.S. counterparts with regard to these three aspects. HECs were established because of centrally imposed legal regulations. Little initiatives in this area were taken by medical professionals interested in resolving emerging ethical issues. HECs in the transition countries concentrate mostly on review of research protocols or resolution of administrative conflicts in healthcare institutions. Moreover, integration of non-professional third parties in the workings of HECs is often neglected. We argue that these differences can be attributed to the historical background and the role of medicine in these countries under the communist regime. Political and organizational structures of healthcare as well as education of healthcare staff during this period influenced current functioning of clinical ethics consultation in the transition countries. (shrink)

Throughout the 20th century, many doctors did not view pain management as an important aspect of their practice. Because pain cannot be objectively measured by the doctor, many doctors found it dif...

BackgroundClinical ethics consultations can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. (...) ObjectiveThe primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality, process factors, and clinical factors. The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

Bioethics, Volume 36, Issue 3, Page 313-317, March 2022.

Systematic study of the intersection of ethics consultation services and solid organ transplants and recipients can identify and illustrate ethical issues that arise in the clinical care of these patients, including challenges beyond resource allocation. This was a single-centre, retrospective cohort study of all adult ethics consultations between January 1, 2007, and December 31, 2017, at a large academic medical centre in the north-eastern United States. Of the 880 ethics consultations, sixty (6.8 per cent ) involved (...) solid organ transplant, thirty-nine (65.0 per cent) for candidates and twenty-one (35.0 per cent ) for recipients. Ethics consultations were requested for 4.3 per cent of heart, 4.9 per cent of lung, 0.3 per cent of liver, and 0.3 per cent of kidney transplant recipients over the study period. Nurses were more likely to request ethics consultations for recipients than physicians (80.0 per cent vs 20.0 per cent, p = 0.006). The most common reason for consultation among transplant candidates was discussion about intensity of treatment or goals of care after the patient was not or was no longer a transplant candidate. The most common reason for ethics consultation among transplant recipients was disagreement between transplant providers and patients/families/non-transplant healthcare professionals over the appropriate intensity of treatment for recipients. Very few consultations involved questions about appropriate resource allocation. Ethics consultants involved in these cases most often navigated communication challenges between transplant and non-transplant healthcare professionals and patients and families. (shrink)

In this study, Canadian healthcare ethics consultants describe their use of ethics decision-making frameworks. Our research finds that ethics consultants in Canada use multi-purpose ethics decision-making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such (...) frameworks. Some of the ethics consultants we interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision-making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants. (shrink)

The annual volume of ethics consultations (ECs) has been a topic of interest in the bioethics literature, in part because of its presumed relationship to quality. To better understand factors associated with EC volume, we used multiple linear regression to model the number of case consultations performed in the last year based on a national survey. We found that hospital bed size, academic affiliation, and urban/rural location were all associated with EC volume, but were not the primary drivers. Instead, (...) these variables affected EC volume through three other variables, all of which relate to ethics staffing: the percentage of case consultations performed by a single individual; whether the survey respondent’s main role at the hospital contained the word “ethics”; and especially, the number of full-time ethics program staff. We conclude that EC is an example of supply-sensitive care, and further research is needed to determine the optimal level of EC activity. (shrink)

While there is no denying the relevance of ethical knowledge and analytical and cognitive skills in ethics consultation, such knowledge and skills can be overemphasized. They can be effectively put into practice only by an ethics consultant, who has a broad range of other skills, including interpretive and communicative capacities as well as the capacity effectively to address the psychosocial needs of patients, family members, and healthcare professionals in the context of an ethics consultation (...) case. In this paper, I discuss how emotion can play an important interpretive role in clinical ethics consultation and why attention to the role of defense mechanisms can be helpful. I concentrate on defense mechanisms, arguing first, that the presence of these mechanisms is understandable given the emotional stresses and communicative occlusions that occur between the families of patients and critical care professionals in the circumstances of critical care; second, that identifying these mechanisms is essential for interpreting and managing how these factors influence the way that the “facts” of the case are understood by family members; and, third, that effectively addressing these mechanisms is an important component for effectively doing ethics consultation. Recognizing defense mechanisms, understanding how and why they operate, and knowing how to deal with these defense mechanisms when they pose problems for communication or decision making are thus essential prerequisites for effective ethics consultation, especially in critical care. (shrink)

While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim (...) to fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters. (shrink)

To design effective strategies to improve ethics consultation (EC) practices, it is important to understand the views of ethics practitioners. Previous U.S. studies of ethics practitioners have overrepresented the views of academic bioethicists. To help inform EC improvement efforts, we surveyed a random stratified sample of U.S. hospitals, examining ethics practitioners’ opinions on EC in general, on their own EC service, on strategies to improve EC, and on ASBH practice standards. Respondents across all categories of (...) hospitals had very positive perceptions of their own ethics consultation service (ECS) and few concerns about quality. Our findings suggest that the ethics-related needs of small, rural, non-teaching hospitals may be very different from those of academic medical centers, and therefore, different approaches to addressing ethical issues might be warranted. (shrink)

Clinical ethics consultation service remains undeveloped in developing countries. It is recognised that its introduction poses challenges. Malaysia, a multicultural society with diverse religions, values and perceptions further complicate the introduction of formal clinical ethics consultation service. Clinicians attending a national congress workshop completed a Strengths–Weaknesses–Opportunities–Threats analysis. The aim was to gain insight into clinician’s expectations and promote initiatives leading to the introduction of clinical ethics consultation service. Clinicians agree that clinical ethics (...) class='Hi'>consultation service can improve quality of care, reduce healthcare costs and advocate for patients and providers. The analysis highlighted constraints in sufficient critical mass of relevant expertise and restricted opportunities for training. The opportunities lie in education, curriculum development and availability of dedicated proponents. Cultural barriers, limited resources, lack of awareness, differenc... (shrink)

Clinical Ethics Consultations are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs’ perceived availability, use of CECs, and perceived usefulness of such support. (...) Physicians in our study generally encounter hard ethics cases, even—surprisingly—those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful—even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system. (shrink)

BackgroundTo help inform the development of more accessible, acceptable, and effective ethics consultation (EC) training programs, we conducted an EC training needs assessment, exploring ethics practitioners’ opinions on: the relative importance of various EC practitioner competencies; the potential market for EC training (that is, how many individuals would benefit and how much individuals and hospitals would be willing to pay); and the preferred content, format, and characteristics of EC training.MethodsAs part of a multipart study, we surveyed “best (...) informants” who self-identified as the person most actively involved in EC or healthcare ethics in a random sample of 600 U.S. general hospitals, stratified for bed size.ResultsThe competency that was ranked most important for a lead or solo ethics consultant was knowledge of ethics, while common sense was ranked least important. The median estimated number of individuals at each hospital who would benefit from EC training was six at the basic level, three at the advanced level, and two for EC management training. In 19.1 percent of hospitals, respondents thought their hospital would not be willing to pay anything for EC training within the next two years. Respondents thought potential trainees would be likely to participate in EC training on multiple different topics. Opinions varied widely on preferred formats. Most respondents thought it very important to be able to interact with instructors and with other trainees, practice EC skills, receive a certificate for completing EC training, and complete EC training during work hours.ConclusionsThese findings provide U.S. population data that may be useful to healthcare educators and bioethics leaders in their efforts to develop EC training programs and products that match trainees’ preferences and needs. (shrink)

The increasing age of the patient population around the globe and in the United States has resulted in a growing number of patients with dementia. In this manuscript, we examined the role of the ethics consultation service in patients who have dementia and associated cognitive and neuropsychiatric sequelae. We addressed a particularly challenging case presenting with behavioral and psychological symptoms of dementia. We discussed the ethical questions and challenges considered by the ethics consultation service and compared (...) these with current suggestions and expectations from the research literature regarding the role of ethics consultation service in dementia management. We demonstrated two potentially useful approaches of clinical ethical analysis, the principalist theorem and Jonsen's four quadrants approach. While the number of consults in patients with behavioral and psychological symptoms of dementia is likely to increase in clinical ethics, the role of the ethics consultation service in this cohort of patients still remains to be determined. There are significant gaps in understanding of the ethics consultation service role in dementia management, and much work remains to be undertaken on the part of regulatory and healthcare systems in clarifying their roles, expectations, and competencies. (shrink)

Recent global events demonstrate that analytical frameworks to aid professionals in healthcare ethics must consider the pervasive role of social structures in the emergence of bioethical issues. To address this, the authors propose a new sociologically informed approach to healthcare ethics that they term “social bioethics.” Their approach is animated by the interpretive social sciences to highlight how social structures operate vis-à-vis the everyday practices and moral reasoning of individuals, a phenomenon known as social discourse. As (...) an exemplar, the authors use social bioethics to reframe common ethical issues in psychiatric services and discuss potential implications. Lastly, the authors discuss how social bioethics illuminates the ways healthcare ethics consultants in both policy and clinical decision-making participate in and shape broader social, political, and economic systems, which then cyclically informs the design and delivery of healthcare. (shrink)

Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination (...) within clinical ethics consultations. Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice. (shrink)

There is an increasing need for quality in ethics consultations, though there have been significant achievements in the United States and Europe. However, fundamental concerns that place the profession in jeopardy are discussed from the perspective of the U.S. in a manner that will be helpful for other countries. The descriptive component of the essay (the first two points) explains the achievements in ethics quality (illustrated by the IntegratedEthics program of the Veterans Health Administration) and the progress on (...) standards and competencies for ethics consultations (represented by the Core Competencies of the American Society for Bioethics and Humanities). Based on these achievements, the analytical component of the essay (the final three points) identifies and seeks to resolve three fundamental concerns (with increasing levels of importance) that compromise quality in ethics consultations: standards of quality; professionalism; and credentialing. The analysis argues for clearer standards of quality in ethics consultation and urges further professionalism by explaining the need for the following: interpreting the ASBH core competencies in a normative manner, developing a Code of Ethics, and clarifying the meaning of best practices. However, the most serious concern that threatens quality in ethics consultations is the lack of a credentialing process. This concern can be resolved effectively by developing an independent Ethics Consultation Accreditation Council to accredit and standardize graduate degree programs, fellowship experiences, and qualifying examinations. This credentialing process is indispensable if we are to strategically enhance quality in ethics consultations. (shrink)