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Abstract

Clinical ethics accreditation deals with the accreditation of training programs and of individual professionals who provide ethics consultation services. The purpose of ethics consultation is to adopt an ethics facilitation approach that fosters consensus around the most ethical treatment in a situation of ambiguity, dilemma, or dispute. A reliable model for accreditation integrates formal degree education with clinical residency, each followed by examinations. This model emphasizes professional practice standards that integrate knowledge and skills, with the former preceding the latter. This model suggests that it would be odd to certify individuals based on fellowship experiences in ethics consultations prior to completing the requisite knowledge standard. The goal of clinical ethics accreditation is to establish best practices based on empirical data to ensure the highest quality in ethics consultation services around the world.

Introduction

Clinical ethics accreditation is an emerging topic that deals with the accreditation of training programs and of individual professionals who provide clinical ethics consultation services. Although ethics consultations can be requested in all aspects of healthcare delivery, most often they deal with clinical dilemmas at the end-of-life care where patients, surrogates, families, and clinicians disagree about withholding or withdrawing end life-sustaining treatments.

The role of the ethics consultation service is to align the patient’s goals with the goals of medicine in a way that presents realistic alternatives. To ensure that ethics consultations occur in a professional manner they are accountable both to professional peers and to society. Hence ethics consultations must be guided by evidence-based data to be justiﬁable before professional peers. Also, they must adopt professional standards of practice to foster the trust of society. The combination of empirical-based evidence and professional standards of practice are at the core of clinical ethics accreditation.

Background

In healthcare around the world, clinical ethics professionals increasingly seek accreditation in terms of both their formal education and their clinical residencies. In this essay, clinical ethics accreditation integrates two features: successful completion of an education program in an accredited school and successful completion of an extended period of residency in clinical settings to integrate intellectual training with clinical expertise. Both components, education and residencies, are followed by qualifying examinations to demonstrate proﬁciency for clinical practice. Evidence-based methods and professional standards of practice require this integration of education and training.

The combination of degree education and residency training can be described as the accreditation requirement to provide ethics consultation services in healthcare. Yet, surprisingly, this accreditation requirement is just beginning to receive extensive attention. This need for an accreditation requirement has come to the fore recently because clinical ethics consultation services typically deal with end-of-life dilemmas, such as artiﬁcial nutrition and hydration. The need for accreditation is emerging now because the ﬁeld of ethics consultation has taken decades to develop and become widespread in healthcare globally.

This analysis discusses the urgent need for implementing an accreditation requirement for clinical ethics consultation services in the hope that it can be applied and integrated in varying health systems in different cultures and nations across the world. To begin it can be helpful to understand what ethics consultation involves to determine the key elements that need to be considered for clinical ethics accreditation.

Ethics Consultation

Clinical ethics consultations do not compromise the responsibility of the attending physician to make clinical decisions about patient care. There has been extensive discussion about ethics consultations as part of the role of ethics committees more broadly (Hester et al. 2012; Post et al. 2007). Ethics committees have a variety of names in different nations, but generally the role is to serve as a committee of interdisciplinary professionals in a healthcare facility to address ethics issues that arise. This is a very distinct role from research ethics committees that focus upon research protocols. Ethics consultations adopt an ethics facilitation approach that fosters consensus around the most ethical treatment in a situation of ambiguity, dilemma, or dispute (Aulisio et al. 2003; Jonsen et al. 2006). In this sense, ethics consultations focus upon enhancing quality in patient care (Magill 2013 – some of the concepts from this publication have been incorporated and developed for this contribution). However, while ethics consultation can appear similar to patient advocacy it is very different from it professionally (Rasmussen 2012). A closer look at what ethics consultation means helps to clarify what clinical ethics accreditation might require.

Ordinarily, clinical ethics consultation is a service provided by an individual professional or by a team of professionals seeking in a collaborative manner with patients, surrogates, and their families to resolve or mediate uncertainties or conﬂicts that reﬂect different values or understandings about patient preferences (ASBH 2011). An example might be that a patient has suffered multisystem failure, is unconscious and on a ventilator, and is close to death. The patient may not have provided instructions about end-of-life preferences with regard to treatment alternatives but did appoint the only two children as surrogates to deal with these sorts of dilemmas.

The siblings disagree about what to do: to initiate every possible intervention to keep the parent alive or to withdraw life-sustaining measures and provide comfort care only to let the parent die. The opposing arguments of the siblings reﬂect their own religious preferences one has strong religious faith and wants every intervention in order to let God perform a miracle to bring back the parent; the other does not have religious faith and seeks a good death for the parent including palliative sedation to death based on a perceived right to die. The conﬂict here clearly reﬂects value-laden concerns. Often, an experienced physician is able to work through this sort of conﬂict. However, if the conﬂict prevails the physician or the siblings can request an ethics consultation to facilitate resolution or provide mediation.

When a case like this occurs, the role of the ethics consultation is one of ethics facilitation that can requires mediation. The purpose is not to resolve the dilemma in an authoritarian manner – such as by saying, “we have investigated the situation and our decision is this or that.” Rather, the ethics facilitation approach seeks to identify the underlying values and speciﬁc goals of the patient or the patient’s surrogate(s) and align them in a realistic manner with the goals of treatment. This process of ethics facilitation must be informed by the situation of the patient in order to clarify the speciﬁc value conﬂict or uncertainty and to seek a resolution based on ethics principles (ASBH 2011).

In ethics consultations, the main ethics principles that have to be engaged are autonomy, beneficence, nonmaleﬁcence, and justice (Beauchamp and Childress 2013). The principle of autonomy focuses upon respect for the patient’s dignity. This can occur by honoring the consent of the patient to treatment. This can also occur by honoring the preference of the patient to forgo life-sustaining interventions – those preferences are routinely stated in advance directives or by appointing a surrogate for healthcare decision-making about treatments if the patient becomes incompetent. The principle of beneﬁcence focuses upon whether there is a substantive probability that a treatment would provide a beneﬁt for the patient, and if there is not such a beneﬁt, the treatment would be deemed to be futile and hence not obligatory. The principle of nonmaleﬁcence focuses upon not causing harm to the patient, such as can occur when futile treatments are continued, potentially causing pain or discomfort to the patient and delaying palliative or comfort care measures. The principle of justice focuses upon the costs that a patient’s treatment accrues to healthcare in particular and to society in general. Decisions about futility are different from issues about rationing – futility deals with treatments that have no beneﬁt, focusing upon an individual patient; whereas rationing deals with treatments that have a beneﬁt, focusing on policy. However, treatment decisions have signiﬁcant stewardship implications (e.g., ﬁnances, costs, expenditures) for healthcare delivery and ﬁnancing. Hence, they have a legitimate place from the perspective of justice and the common good in evaluating treatment alternatives.

The ethics facilitation approach is crucial for the accreditation for clinical ethics consultations, including achieving appropriate closure at the end of the process (Feister 2015). For the approach to be effective, ethics consultants (whether acting individually or as a team) need to be properly trained in relevant professional practice standards that guide accreditation processes.

Professional Standards Of Practice

In the clinical arena, professional standards of practice set the bar for the delivery of quality in healthcare. Similarly, for ethics consultations, professional practice standards intersect with discussions about quality and professional accountability (Weise and Daly 2014). Standards highlight the variety of competencies that are needed for effective ethics consultations. These standards are typically reﬂected in professional codes, such as in the newly established Code of Ethics for health care ethics consultants (Tarzian et al. 2015). In turn, this relation between quality, standards, and competencies shapes the landscape for clinical ethics accreditation. A consideration of these standards can help to guide the discussion of accreditation. The standards refer to the knowledge standard and the skills standard. The American Society for Bioethics and Humanities (ASBH) in the U.S.A has delineated an updated account of these standards as being required for ethics consultations (ASBH 2011; Tarzian et al. 2013). The ASBH also provides an education guide to accompany these standards (ASBH 2015) and has initiated an accreditation process (called “Quality Attestation”) for individual ethics consultants focusing upon these standards (Kodish et al. 2013).

Knowledge Standard

Professional practice standards require a signiﬁcant level of knowledge about clinical ethics consultations. Broadly speaking, the following tapestry of knowledge provides a practical approach that could be readily adopted in any country that seeks to integrate ethics consultation services into healthcare. Hence, a brief summary of this knowledge can be useful.

The knowledge standard requires a sound comprehension of general theory and routine concepts in bioethics. On the one hand, understanding ethics theory provides a general framework for engaging practical issues that arise. This broad comprehension of ethics theory includes several components, as follows: secular theories in ethics such as deontology, consequentialism, communitarianism, etc.; religious theories in ethics such as natural law and virtue ethics; the distinction and relation between principle-based reasoning and case-based reasoning (casuistry); and justice theories, especially distributive justice as it relates to healthcare.

On the other hand, understanding routine concepts in bioethics provides the professional categories that are required to engage practical issues in a sophisticated manner. This grasp of routine concepts includes both general and speciﬁc issues. General topics include the following: practical rights of patients in the healthcare scenario in which they ﬁnd themselves – the articulation of these patient rights will vary from country to country, such as the right of access to healthcare, disability rights, conﬁdentiality and privacy rights, and the right to refuse treatment; the right to informed consent and its relation to competency and surrogate decision-making with regard to substituted judgment and best interests, such as for mentally disabled adults, unconscious patients in end-of-life care, or children and adolescents before they become competent; the meaning and implications of the patient-professional relationship in different cultures; and the principle of double effect that clariﬁes when unintended side effects are legitimate.

Also, there is a variety of speciﬁc topics. Issues at the beginning of life include the following:

reproductive technology and surrogate parenthood, abortion and maternal-fetal conﬂict, in utero surgery and critically ill newborn; genetic testing and counseling, and the right that family members may have to genetic information of parents and siblings. Issues at the end of life include these: advance directives and surrogacy, do-not-resuscitate orders, withholding or withdrawing life-sustaining treatment including medically assisted nutrition and hydration, the meaning of medical futility, and assisted suicide and euthanasia. Issues related to organ donation (procurement and transplantation) include these topics: the debate over donation after cardiac death, the distribution and allocation of organs and tissues, the discussion of compensation vs. sale of organs and tissues to increase their availability, the debate on the so-called organ trade, and consideration around opt-in and opt-out transplantation policies. Issues related to medical research including the following: the meaning of terms like equipoise and therapeutic misconception, the difference between a patient and a research subject, the role on institutional review boards, the different phases of clinical trials, and the debate about shared beneﬁt for vulnerable populations where research is undertaken. Issues related to social policy include these topics: the right to healthcare that varies in different countries, the obligation to care for vulnerable populations, the debate over rationing of healthcare resources, and the debate over vaccinations and quarantine to contain outbreaks of disease. Finally, issues related to professional responsibility include these topics: the patient-physician relationship, the duty to care, conscientious objection, conﬂicts of interest and conﬂicts of commitment, and professional codes of ethics; and cultural and religious issues that relate to diversity but cause biases with regard to gender, race and ethnicity, and disability.

The knowledge standard also requires an understanding of the health system that pertains in the country where the clinical ethics consultation services are provided. There are several related elements: knowledge of the speciﬁc health system and health policy in different nations and the particular organization in which ethics consultations occur, including awareness of the local patient and staff populations, knowledge of the clinical context and relevant health law, and knowledge of relevant professional codes. A brief word about each can be enlightening.

Health systems vary across the world; hence knowledge of what is pertinent for ethics services is important. This means being aware of national health systems and health policy as well as being familiar with how healthcare organizations operate in these varying contexts. In addition to being familiar with the relevant health system and health policy in each nation, there also needs to be a working knowledge of local healthcare institutions including their institutional policies. This means being familiar with the purpose and structure of the institution, its medical records system that ethics consultation services may need to access, how to read the patient’s medical record or chart, the institution’s range of services and resources, and how the ethics consultation service ﬁts into and interacts with the organizational structure such as with social work, risk management, legal counsel, palliative care services, and chaplaincy, if those services exist. Knowledge of the local healthcare institution should include knowledge of the local patient and staff populations, such as the religious or cultural milieu that can inﬂuence not only perceptions about gender, race and ethnicity, and disability but also interpretations of faith and values.

Naturally, this knowledge involves being familiar with the clinical context in which the healthcare institution operates. Knowledge of the clinical context includes an understanding not only of basic anatomy that is routinely needed for diagnosis, prognosis, and treatment but also of how disease progresses and the processes that clinical professionals adopt to manage illness. This necessitates familiarity with the role of healthcare professionals and the technology they use across the range of services in healthcare, from primary care to emergency care, intensive care, long-term care, and palliative and hospice care. In addition, there should be familiarity with the process of healthcare decision-making between patients, families, and professionals, including how different notions of health, disease, and illness inﬂuence decision-making. Knowledge of the clinical context must be related with knowledge of relevant health law. An ethics consultation service should never provide legal advice – that is for lawyers. Nonetheless, ethics consultation services need to be able to interpret the implications of health law. Hence, there needs to be familiarity with relevant health law in general, and especially laws and regulations governing these issues: end-of-life topics including consent and competency, advance directives, surrogate decision-making, guardianship, minors, and reporting requirements for abuse (child, spouse, elder) and communicable diseases.

Furthermore, the local institution’s policies often need to be examined or reviewed by ethics consultation services; hence, familiarity with them is crucial, such as regarding informed consent, conﬁdentiality and privacy, conﬂicts of interest, professional impairment, conscientious objection, advance directives and surrogate decision-making, medical futility, withholding or withdrawing life-sustaining treatment, do-not-resuscitate orders, pain management and palliative services, determination of death criteria, organ donation and procurement, etc. Finally, the knowledge standard requires familiarity with professional codes of ethics and conduct and relevant guidelines of accrediting organizations – eventually including institutions for clinical ethics accreditation if they are developed in the country or region where ethics consultation services occur.

In addition to the knowledge standard that is crucial for professional practice and clinical ethics accreditation, there is a fairly sophisticated skills standard that needs to be achieved.

Skills Standard

This standard presents the ethical analysis skills that constitute the fulcrum of sound ethics consultation. The requirement of ethical analysis skills emphasizes the capacity to identify value uncertainty or conﬂict that characterizes the need for ethics consultation services. This skill involves an analytical capacity in ethics to guide an ethics consultation. One way of enacting this skill is to adopt a matrix that integrates data and deliberation with decisions and the direction or outcome that results from the decision. The ﬁrst two features (data and deliberation) can be construed as undertaking a root cause analysis of the conﬂict that elicits the ethics consultation. The latter two features (decision and direction) can be construed as pursuing a proportional resolution of the conﬂict. The matrix is delineated in this diagram.

To begin the ethics analysis, gathering relevant data requires an astute distinction between the ethical components and other aspects (e.g., clinical, institutional, legal). This feature entails a clariﬁcation of the beliefs and values of those involved and their accompanying assumptions including those of the consultation staff (e.g., regarding quality of life). The data feature emphasizes the participants and the information that are involved. The participants refer to the relevant persons who are involved, clarifying why they are involved and how they are affected, including the competing interests at stake. The relevant information includes the medical and legal as well as the personal and societal issues that cause disagreement or conﬂict and might contribute to a solution.

Next, deliberation requires a consideration of relevant standards to identify realistic and justiﬁable alternatives. This feature requires research of the relevant scholarly literature and health law to enlighten the conﬂict so that a range of acceptable alternatives can be identiﬁed, weighing the evidence against each in a balanced manner. The deliberation feature emphasizes the standards and alternatives that should be considered. The standards refer to the ethical principles, doctrines, codes, regulations, and values, and how they might conﬂict with one another. The alternatives refer to practical actions, policies, or alternatives that merge the ideal goal with reasonable compromise without sacriﬁcing basic values. Together, the features of data and deliberation constitute a root cause analysis in the sense of ethically analyzing the conﬂict and its causes in order to clarify possible resolutions. The next two features identify the analytical components of a proportional resolution to the conﬂict that caused the ethics consultation to arise.

On the one hand, a decision is made, balancing the data in a deliberate manner to select the best alternative available that elicits consensus. This feature requires open communication and effective collaboration with those involved to facilitate a consensus decision. The decision feature involves prudence and virtue. Here prudence requires combining necessity with minimal compromise of principles. To achieve a goal around which there is consensus, a speciﬁc intervention should be necessary (assuming it is effective) but minimally compromise the relevant principles and values that are at stake in the conﬂict. By making a prudent decision, virtue is highlighted. Here virtue refers to the personal traits that both enable and are fostered by the decision as a proportionate intervention to resolve a conﬂict.

On the other hand, a direction is determined by the decision that reﬂects the outcome of the ethics consultation. The so-called direction feature involves quality and stewardship. Here quality indicates the caliber of the ethics consultation as resolving the conﬂict in a satisfactory manner for everyone involved – the need for appropriate closure has become a crucial component of a sound ethics consultation process. This involves bringing closure to the case by summarizing the results and recommendations, clarifying the responsibilities of those who have to implement the outcome, documenting the consultation appropriately, and providing assessment and feedback mechanisms for ongoing improvement and accountability.

By focusing upon the quality of the ethics consultation, stewardship is emphasized. Here stewardship refers to fostering professional standards of practice in ethics consultation in a manner that generates best practices.

These ethical analysis skills need to be accompanied by other skills to ensure the ethics consultation functions properly. These other skills include process skills, interpersonal skills, and assessment skills for quality improvement. These are more general skills that are applied to ethics consultation, and while necessary they are not unique to this enterprise.

Conclusion

Clinical ethics accreditation of programs and of individuals must include the knowledge standard and the skills standard, completing a degree program to master the knowledge standard and a fellowship residency to master the skills standard. Just as the knowledge standard typically ends with examinations, similarly there should be a ﬁnal examination for the fellowship skills standard (Fox 2014; White et al. 2014). These are needed to establish sound professional practice standards for clinical ethics accreditation. However, they also need to be in the correct order. The knowledge standard should precede the skills standard. It would seem odd to certify individuals for residency experience prior to completing the knowledge standard (Magill 2013). Models need to be created for the accreditation of programs around both the knowledge standard and the skills standard to achieve appropriate quality in ethics consultations (Feister 2014; Kodish et al. 2013; Magill 2013). The goal of clinical ethics accreditation is to establish best practices based on empirical data to ensure the highest quality of patient care in ethics consultation services around the world.

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