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Quality in ethics consultations

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Abstract

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.

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Notes

  1. For a brief account of the emergence of healthcare ethics committees in general and healthcare ethics consultation services in particular, see, Cranford et al. (1984), Cranford et al (1989) and Fletcher et al (1989).

  2. See, Huxtable (2012), at 188.

  3. See, for example: Gefanus (2011), Hernandez et al. (2009), Pfäfflin et al. (2009), Hurst et al. (2007), Steinkamp et al. (2007).

  4. See, for example: Slowther et al. (2012), Caminiti et al. (2011), Førde and Pederson (2011), Dörries et al. (2010), Slowther (2008), Borovecki et al. (2005), Meulenbergs et al. (2005) and Glasa (2000).

  5. See, for example: Sokol (2012), Dörries et al. (2011), McLean (2007), Reiter-Theil (2009), Nietzke (2009); Pederson et al. (2010), Newson et al. (2009) and Fournier et al. (2009).

  6. See, for example, McClimans et al. (2012).

  7. In re Quinlan. Supreme Court of New Jersey. 355 A.2d 647 (N.J. 1976). Other landmark cases that occurred subsequently were: Joseph Saikewicz in 1977, Joseph Fox in 1980, Claire Conroy in 1985, Elizabeth Bouvia in 1986, Nancy Cruzan in 1990, and Helga Wanglie in 1991. See, Menikoff (2001).

  8. See, for example: Repenshek (2012); Opel et al. (2009).

  9. See American Society for Bioethics and Humanities (2011). All references are to the 2nd edition. The Core Competencies were originally developed by a Task Force on Standards for Bioethics Consultation of The Society for Health and Human Values/Society for Bioethics Consultation (SHHV-SBC). The final report led to the first edition of the Core Competencies approved by ASBH in 1998 (See, ASBH, Core Competencies, Appendix I). For an update on the recognition of these competencies as standards of quality, see, Tarzian (2013).

  10. Institute of Medicine, Committee on Quality of Health Care in America (2001), 232.

  11. Also see, Tarzian (2013), at 5; Aulisio (2011), Adams (2009). On the need for more than mere facilitation, such as ethics consultants expressing their reasoned perspectives, see, Adams (2011a, b).

  12. ASBH, Core Competencies, p. 8, section I.1 and p. 15 section II.1.2; also see p. 55, Appendix II, item 5. On mediation and conflict resolution processes, see, Dubler et al. (2004). On similarities between facilitation and mediation, see, Feister (2013); also see, Feister (2012).

  13. The Joint Commission (2011), ACC-38 on “Credentialed Practitioners.” Also see the many items on credentialing in the glossary and the index.

  14. See the VA’s website at: http://www.ethics.va.gov/integratedethics.

  15. Ellen Fox et al. (2010).

  16. Ellen Fox et al. “IntegratedEthics,” (2010). Also see the VA’s website at, http://www.ethics.va.gov/integratedethics/ELC.asp.

  17. Ellen Fox et al. “IntegratedEthics,” (2010). Also see the VA’s website at, http://www.ethics.va.gov/integratedethics/PEC.asp.

  18. Ellen Fox et al. “IntegratedEthics,” (2010). Also see the VA’s website at, http://www.ethics.va.gov/integratedethics/ECC.asp.

  19. For example: Geppert et al. (2012), Bruce et al. (2011), Nilson et al. (2008), Fox et al. (2007), Chwang et al. (2007), Swetz et al. (2007), DuVal et al. (2004), Schneiderman et al. (2003), McGee et al. (2001, 2002) and Hoffman et al. (2000).

  20. Also see, ASBH, Core Competencies, p. 55, Appendix II, item 9.

  21. Ellen Fox et al. “Integrated Ethics,” (2010); ASBH, Core Competencies, 54, Appendix II.

  22. Ellen Fox et al. “IntegratedEthics,” (2010); ASBH, Core Competencies, 54, Appendix II.

  23. ASBH, Core Competencies, p. 55, Appendix II, item 7.

  24. ASBH, Core Competencies, pp. 10–18, section II.1.2. Also see, for example: Bramstedt et al. (2009) and Orr et al. (2009).

  25. ASBH, Core Competencies, p. 54, Appendix II.

  26. See, for example, Altisent et al. (2013).

  27. For thorough explanations of the role of ethics committees and ethics consultants, see: Post et al (2007); Aulisio et al. (2003); Aulisio et al. (2000), Micah Hester et al. (2012). Also see: Carrese et al. (2012), Jonsen et al. (2006).

  28. ASBH, Core Competencies, pp. 19–21, section II.2.1.

  29. ASBH, Core Competencies, p. 55, Appendix II, item 8.

  30. ASBH, Core Competencies, pp. 22–24, section II.2.2.

  31. ASBH, Core Competencies, pp. 26–31, section II.2.3.

  32. ASBH, Core Competencies, p. 55, Appendix II, item 11.

  33. ASBH, Core Competencies, pp. 32–33, section II.2.4.

  34. ASBH, Core Competencies, p. 34, section II.3 (also see p. 18, section II.1.2), referring to the founder of quality measurement in healthcare, Donabedian (1980).

  35. ASBH, Core Competencies, pp. 34–36, section II.3.1, referring to the Ethics Consultation component of the VA’s IntegratedEthics approach.

  36. ASBH, Core Competencies, pp. 37–38, section II.3.1.2.

  37. ASBH, Core Competencies, pp. 39–42, section II.3.1.3.lacking.

  38. ASBH, Core Competencies, pp. 42–43, section II.3.2.

  39. ASBH, Core Competencies, pp. 43–44, section II.3.3.

  40. See, Cummins (2002).

  41. See, for example, Andereck et al. (2012).

  42. See, Gerard Magill et al. ASBH Task Force Report on Ethics Consultation Liability (80 pages), submitted to the ASBH Board on October 24, 2004. Members of the Task Force included: Gerard Magill, Jill Van Derven, JD, MPH; Arthur L. Caplan, PhD; Dean Cody, PhD, MALS; Diane Hoffmann, JD; Sandra Johnson, JD, LLM.; Jeffrey P. Kahn, PhD; Sheila A. M. McLean, PhD, LLD; Jerry A. Menikoff, MD, JD; Susan B. Rubin, PhD; Bethany J. Spielman, JD, PhD, MHA. The report appeared for some time on the ASBH website under the section for members only (www.asbh.org).

  43. ASBH website, section on Committees, at www.asbh.org.

  44. See, Baker (2009).

  45. ASBH website, section on Committees, at www.asbh.org.

  46. A code of ethics is being developed by the ASBH Clinical Ethics Consultation Affairs (CECA) Committee. The draft code includes these items: be competent; promote integrity; avoid or manage conflicts of interest; avoid or manage conflicts of obligation; maintain confidentiality; make responsible public statements; contribute to the field; promote just health care. See, http://www.asbh.org/about/content/asbh-ceca.html.

  47. See, for example a recent analysis from the Canadian perspective: Keel (2012).

  48. See, for example, Bogan et al. (1994); Boxwell (1994).

  49. See, for example, the Institute of Medicine, Crossing the Quality Chasm, 157–159.

  50. See, for example, Barry et al. (2002). Six Sigma is a systematic approach that seeks to improve quality by monitoring long-term performance in a quantitative manner (ibid. p. 13).

  51. Joint Commission, Comprehensive Accreditation Manual (CAM), PI-1. The Joint Commission further explains: “The best way to achieve better care is by first measuring the performance of processes that support care and then by using that data to make improvements” (CAM, PI-1), and that “the fundamental principles of performance improvement” are “collecting data, analyzing them, and taking action to improve” (CAM, PI-2).

  52. See, for example: McLaughlin et al. (2005); McLaughlin et al. (2012); Sollecito et al. (2013).

  53. See for example, Thomasma (1991), Self et al. (1993).

  54. See, for example: Belkin (2013), Engelhardt (2009, 2011), Bishop et al. (2009). For a response to critiques about ethics expertise, see, Rasmussen (2011).

  55. The point here is to distinguish facilitation expertise from ethical authority. See, for example, Adams (2013).

  56. See, Courtwright (2013).

  57. For example, Dubler et al. (2007).

  58. See the ASBH’s Clinical Ethics Consultation Affairs (CECA) Committee’s 2010 report to the ASBH Board of Directors, “Certification, Accreditation, and Credentialing of Clinical Ethics Consultants.” This report is on the ASBH website under the section on Committees, at www.asbh.org. Also see, Kipnis (2009).

  59. See for example: Acres et al. (2012), Schiedermayer et al. (2012), Smith et al. (2010). Also see the edition of HEC Forum 21:3 (2009) with these contributions: B. H. Childs, “Credentialing Clinical Ethics Consultants,” (231–40); A. J. Tarzian, “Credentials for Clinical Ethics Consultation,” (241–48); K. Kipnis, “The Certified Clinical Ethics Consultant,” (249–261); J. P., “Resolving the Vexing Question of Credentialing: Finding the Aristotelian Mean,” (263–273); Bishop et al “Of Goals and Goods and Floundering About: A Dissensus Report on Clinical Ethics Consultations,” (275–91).

  60. For a similar stance arguing that prioritizing accreditation over certification has the advantage of greater expedience, see, Silverman et al. (2013).

  61. This is one of the five recommendations of the ASBH’s Clinical Ethics Consultation Affairs (CECA) Committee’s 2010 report to the ASBH Board of Directors, “Certification, Accreditation, and Credentialing of Clinical Ethics Consultants” (p. 6). This report is on the ASBH website under the section on Committees, at www.asbh.org.

  62. See, for example, Silverman et al. (2013). The authors argue for “a council to establish standards to accredit educational programs (e.g., graduate, fellowship, or certificate programs) that use the ASBH Core Competencies” (ibid. 31).

  63. A similar proposal is presented by Hynds (2013). The author presents the ASBH Core Competencies as minimal standards arguing for “a system to accredit academic degrees and fellowships programs, promoting the expansion of clinical fellowship programs … and promoting the development of a professional entrance process” (ibid., 23).

  64. For a response to such concerns as being misplaced, see, Silverman et al. (2013).

  65. Dubler et al. (2009).

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    Gerard Magill

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Magill, G. Quality in ethics consultations. Med Health Care and Philos 16, 761–774 (2013). https://doi.org/10.1007/s11019-013-9489-x

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