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Abstract

Ethicist is a broad term that encompasses subcategories, including bioethicist and health-care ethicist. While anyone with expertise in descriptive or normative moral theory might refer to himself or herself as an “ethicist,” there is currently no recognized profession of ethicist. While bioethicists are employed in academia and industry, the broad category of “bioethicist” has not yet evolved into a bona ﬁde profession. This means that anyone can call himself or herself a bioethicist, a phenomenon that makes it difﬁcult to deﬁne the role boundaries of the bioethicist. The emerging profession of “health-care ethicist,” with a recently adopted code of ethics and evolving process for evaluating the competency of individuals who perform health-care ethics consultation, is the farthest along in deﬁning what constitutes a “professional ethicist.”

Introduction

The simplest answer to “what is an ethicist?” comes from the word’s sufﬁx, ist, which refers to a person who engages in a particular activity – in this case, ethics. Ethics refers to the discipline of delineating what constitutes right and wrong action (i.e., moral behavior) in a particular community or profession. But what does it mean to “engage in” ethics? Former columnist Randy Cohen wrote the New York Times Magazine column, The Ethicist, for several years. While dubbed the ethicist by his employer, solicited to resolve hundreds of moral dilemmas sent to him by readers, and looked upon by many as generally giving good moral advice, was Cohen an ethicist or a journalist? Or both?

These questions evoke the classic philosophical thought experiment asking whether a tree falling in a forest makes a sound if there is no one to hear it. That is, could we designate Cohen an ethicist based solely on his ethics knowledge and skills? Or does the title of ethicist require some societal recognition that ethics knowledge and skills are applied in some accountable way? To clarify, morality refers to an individual’s reasoning about right and wrong action based on his or her own core beliefs and values; ethics refers to reasoning at the level of a group or society, considering different conceptions of morality and how to resolve conﬂicts or uncertainty about what the right course of action should be across similar cases. One might consider whether Cohen’s writings actually helped resolve individuals’ moral conﬂicts (i.e., conﬂicting core values that cast uncertainty on the right decision to make or action to take in a particular situation). Or one might examine how others viewed Cohen: as a journalist? An entertainer? A wise counselor? Or truly as an ethicist? Does being an ethicist entail holding oneself accountable to professional standards and obligations? Or can the title be applied to anyone employing particular skills, knowledge, and character attributes to help resolve individual moral problems or to weigh in on how such problems or dilemmas should be resolved across individual cases?

Historical Use Of The Term Ethicist

Google’s Ngram Viewer allows one to timeline search the frequency of words and phrases found in over ﬁve million books digitized by Google. Ethicist ﬁrst appears in the Ngram Viewer in 1853. Sources where ethicists are cited originate from the ﬁelds of law (e.g., those such as jurists who recognize the precepts of justice as deﬁned by legislatures), religion (i.e., those promulgating moral duties and character attributes based on religious edicts), and normative philosophy (i.e., philosophers who promote a particular approach to leading the moral life), as well as others looked upon as experts about moral codes of behavior (referred to by such titles as the “social ethicist” or the “speculative ethicist”). Distinctions between these uses of ethicist are grounded in where the authority for others’ perceptions of the individual’s ability to speak to issues of morality resides: philosophical arguments?.. .the law?.. .God?… how the ethicist conducts his or her own moral life?

Conceptual Clarification

A conundrum in the use of the word ethicist comes from its meaning derived from authority others place on the individual perceived as possessing expert wisdom and judgment to assist in questions about either (1) how members of a particular community should lead a moral life or (2) how members of a particular profession should meet professional obligations. Purists might reason that the term ethicist implies an ethical person, that is, someone who practices “good ethics.” Indeed, words like ethics and ethicist convey that an individual possesses a degree of moral authority that many working in these ﬁelds caution could be vulnerable to abuses of power. An individual who is an expert on ethical theories or persuasive arguments regarding how to live a morally worthwhile life may or may not live up to his or her own theories or arguments in practice. Thus, the term ethicist refers more frequently to individuals whose profession primarily involves articulating theories or reasoning about what constitutes right and wrong action.

Two assumptions could be challenged here: (1) that the profession of ethicist exists and (2) that the use of the title ethicist is only valid when referring to a professional role. These two assumptions are related. Disproving the ﬁrst assumption effectively invalidates the second assumption. If ethicist is not a recognized profession, then anyone can designate himself, herself, or someone else as an ethicist, much as anyone can refer to himself or herself as a philosopher or a poet. It would be up to others to judge whether the individual lives up to the title. One might argue that for “lower stakes” practices, such as philosophizing or writing poetry, there are fewer motivating forces to professionalize the role. Likewise, for “higher stakes” practices such as health care or law, the need to professionalize emerges from concerns about ensuring the practitioner’s competence.

Is There A Profession Of Ethicist?

Individuals are considered members of a profession after a series of milestones are achieved. This includes the individuals collectively making some claim to their competence (i.e., gaining mastery of speciﬁc skills and knowledge that are inaccessible to untrained members of the community) and professing a commitment to the public to apply their expertise to achieve goals that are consistent with the core values of their profession, including abiding by a professional code of ethics (Kipnis 2009). In addition, professionals collectively must engender recognition and trust from members of the society their profession serves – a trust usually earned by the profession ensuring that its members are competent to practice. In turn, members of the community must value the expert services the professionals provide (Kipnis 2009). Thus, the ﬁnal steps of professionalization include practitioners receiving formal training and education from accredited programs to practice in their professional role, as well as certiﬁcation (and in some cases state licensure) attesting that they are qualiﬁed to practice (Kipnis 2009). A professional association usually guides this process.

While some philosophers might use the term ethicist to denote the category of philosophy in which they specialize, it is unlikely that a philosopher would use the term ethicist to describe his or her occupation. To date, the broad title of ethicist is not one embraced by individuals seeking professional status. However, one subset of ethicists has embarked on the path toward professionalization, namely, that of health-care ethicist, a subset of bioethicist.

Bioethicists, Health-Care Ethicists, And Steps Toward Professionalization

The more modern term bioethicist arose after bioethics as a term was introduced in 1971 by Van Rensselaer Potter and Andre Hellegers (Reich 1993). Potter, as cited by Reich, explained:

The goal of this discipline, as I see it, would be to help humankind toward a rational but cautious participation in the processes of biological and cultural evolution. .. . I chose “bio-” to represent biological knowledge, the science of living systems, and I chose “ethics” to represent knowledge of human value systems. (Reich 1993, p. S6)

Hellegers incorporated the term into the original title of The Kennedy Institute of Ethics at Georgetown University. Indeed, bioethics on Google’s Ngram Viewer shows a steady increase in use since 1971. The term bioethicist is broad in scope, subsumed under the broader category of ethicist. Individuals practicing bioethics include those who teach bioethics, who oversee the regulation of ethics in human and animal research, who conduct research and scholarship about bioethics topics (such as those outlined in The Hastings Center’s Bioethics Brieﬁng Book (n.d.)), and who provide bioethics-related services for health-care organizations, institutional review boards (IRBs), religious organizations, biotech companies, and public policy organizations, among others.

Beauchamp and Childress (1994) used the term biomedical ethics to narrow the scope of focus to health care. Some consider the terms biomedical ethics and medical ethics as too physician-centric and not reﬂective of the disciplinary diversity in the ﬁeld. Cummins (2002) viewed this disciplinary diversity in bioethics as emblematic of its identity – that is, a merging of various professions into a new professional entity. Health-care ethics has been adopted as the term to denote bioethics applied within health-care settings (American Society for Bioethics and Humanities 1998). But controversy remains as to what health-care ethicists do that is different from what other health professionals do. For example, social workers, chaplains, nurses, and physicians encounter ethical uncertainties and dilemmas in their daily practices. At what point does doing ethics constitute performing a separate professional role?

To be sure, not everyone “doing ethics” as part of another professional role self-identiﬁes as a bioethicist or as an ethicist. Similarly, not all individuals who provide bioethics services refer to themselves as ethicists or bioethicists. For example, academicians who teach bioethics often self-identify as professor, and health-care professionals who teach bioethics to students and trainees typically use the title of their primary professional discipline (e.g., nurse, physician, lawyer, social worker, chaplain). Similarly, an individual who oversees research integrity in an academic setting is more likely to refer to himself or herself as a “Research Integrity Ofﬁcer.” Those whose primary work involves research ethics oversight may use the title “Certiﬁed Institutional Review Board (IRB) Professional.” This likely relates to the newness of bioethics as a professional discipline and the evolving standards of practice in the ﬁeld. Yet, the subset of bioethicists who practice in health-care settings are increasingly using professional titles referring to their role as ethicist, such as health-care ethicist, health-care ethics consultant, clinical ethicist, and clinical ethics consultant. For simplicity, these will be referred to collectively as healthcare ethicist.

What Do Health-Care Ethicists Do?

An exploration of the full range of services provided by individuals who consider themselves health-care ethicists was conducted by a group of Canadians who, in 2009, formed the group, “Practicing Healthcare Ethicists Exploring Professionalization” (PHEEP). While initially collaborating with the Canadian Bioethics Society (CBS) under CBS’ Working Conditions for Bioethics Taskforce, PHEEP recently transformed into a voluntary professional association, the “Canadian Association of Practicing Healthcare Ethicists” (CAPHE). Several PHEEP charter members coauthored a publication identifying components of a “model role description” for health-care ethicists, which included the following common areas of responsibility of a healthcare ethicist:

Developing and managing an organization’s ethics program infrastructure
Providing organizational ethics leadership
Identifying ethical issues to be addressed
Providing ethics consultation
Developing and updating ethics-related policies
Providing ethics education to the staff and the community (both within and outside of ethics consultation)
Overseeing junior colleagues’ professional development
Conducting and disseminating ethics-related research (Chidwick et al. 2010)

These developments signal that the subset of bioethicists who consider themselves health-care ethicists are further along in the journey toward professionalization than bioethicists. This is largely grounded in a lack of consensus on the scope and standards of practice for bioethicists, compared to the growing consensus on the scope and standards of practice for health-care ethicists – particularly those who provide health-care ethics consultation.

Health-care ethics consultation comprises two general categories of knowledge and skills competencies: outcomes-related services and process-related services (Tarzian et al. in press). Outcomes-related services refer to the tangible results of the ethicist’s work in the form of an ethical analysis or justiﬁcation. For example, health-care ethics consultants typically provide a written ethical analysis supporting the decision(s) or action(s) recommended to address the ethical question, uncertainty, or conﬂict that prompted the request for ethics consultation. Process-related services refer to the manner in which health-care ethicists engage with parties involved in an ethics consultation to address ethical questions or concerns. For example, ethicists in health-care facilities often meet with patients, family members, and health-care professionals to gather information, elicit perspectives from all the involved parties, and facilitate effective communication among those affected by the decision or action in question. Fox, Myers, and Pearlman (2007) estimated that in 1998, approximately 29,000 individuals spent more than 314,000 hours in US hospitals providing more than 36,000 ethics consultations.

Skills and knowledge competencies required to provide effective ethics consultation services overlap with the skills and knowledge competencies of health-care professionals caring for patients in everyday clinical practice. In this regard, ethics consultation is no different from other health-care consultative services. An internal medicine physician has a certain degree of knowledge and skills to evaluate basic cardiac dysfunction, but lacks the advanced knowledge and skills required to provide cardiology consultations for patients with more complex cardiac problems. Similarly, the degree of knowledge and skills required to effectively provide palliative care consultations is no longer accessible to the average clinician. Thus, the role of the palliative care professional has emerged. While health-care professionals retain the ability to address basic ethical questions they encounter when delivering patient care, what sets ethics consultation apart from other services provided by health-care professionals is the application of a particular set of skills and knowledge competencies to address or help resolve a question primarily about ethics in health care, that is, what recommended actions are ethically justiﬁable when conﬂicting core values among stakeholders create uncertainty about the right course of action.

As stated earlier, individuals viewed as ethics experts need to exercise caution to avoid abuses of power when they provide ethics-related services. This is especially true in health-care settings. Because health-care ethicists are perceived as having more potential to directly inﬂuence life changing decisions made by patients and families receiving health-care services, more attention has been focused on their expertise to provide ethics consultation. This has quickened the progress toward professionalization of health-care ethics consultants, compared to others who claim to “do ethics” for a living.

Professionalizing The Role Of The Health-Care Ethicist

The American Society for Bioethics and Humanities (ASBH) initially began exploring professionalizing the broader ﬁeld of bioethics in 2005, when it formed the Advisory Committee on Ethics Standards (ACES). After conducting a survey of the ﬁeld, ACES recommended that ASBH begin the process of drafting the initial code of ethics for bioethicists. Baker (2005) published a proposed draft code of ethics that year, which was met with mixed reviews based on ambiguity surrounding what constituted a bioethicist. Anyone could call himself or herself a bioethicist. How would such a person’s competency be judged? To what is such a person held professionally accountable? Might such a person be used to “rubber stamp” practices as ethical that actually fall short of ethical ideals? Critics opined that bioethics lacked a core professional activity and that Baker had not made a case for bioethics warranting professional status.

While there lacked consensus about what constituted the professional domain of the bioethicist, a subset of bioethicists practicing in health-care organizations began responding to the growing concerns from both within and outside the ﬁeld that bioethicists lacked accountability to professional standards. ASBH responded by focusing efforts on the smaller subset of bioethicists – health-care ethicists – referred to as health-care ethics consultants (colloquially dubbed clinical ethics consultants). In 1998, ASBH published the report Core Competencies for Healthcare Ethics Consultation. This report focuses on one activity that health-care ethics consultants perform – health-care ethics consultation, which was deﬁned as “a service provided by an individual or a group to help patients, families, surrogates, health care providers, or other involved parties address uncertainty or conﬂict regarding value-laden issues that emerge in health care” (ASBH 1998, p. 3). Health-care ethics consultation is accomplished through the activity of “ethics facilitation,” a service that incorporates outcomes-related and process-related components as described above.

The ﬁrst edition of the report proposed the Core Competencies as “voluntary guidelines” rather than national standards. This was based on the lack of available outcomes data supporting the competencies identiﬁed, concerns about negative consequences from limiting the diversity of ethics consultants and approaches to ethics consultation, and worries that “professionalizing” the ﬁeld of health-care ethics consultation would displace health-care providers and patients as primary moral decision makers at the bedside (ASBH 1998). However, general acceptance of the ASBH’s Core Competencies in the ﬁeld over the following decade led to a reversal of this position in the second edition of the Core Competencies report (ASBH 2011).

In 2009, ASBH formed the Clinical Ethics Consultation Affairs (CECA) committee to advise the ASBH board about the components of professionalization for health-care ethics consultants and to develop a code of ethics for health-care ethics consultants. From 2009 to 2014, CECA drafted, circulated, modiﬁed, and ﬁnalized the ﬁrst code, entitled the “Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants.” The ASBH Board ofﬁcially endorsed this code of ethics in 2014.

Adoption of a code of ethics is a milestone in the ﬁeld of health-care ethics. Clark (2002) recognized both a normative and an aspirational aspect to a code of ethics (i.e., it both obligates practitioners to uphold standards established through professional consensus as well as motivates them to strive toward aspirational goals of service). Davis (2005) recognized at least six purposes served by a professional code of ethics: (1) it establishes standards of conduct that can change practice for the better; (2) it helps those new to the profession learn how to act; (3) it reminds those with experience what they might have forgotten; (4) it provides a framework for settling disputes; (5) it helps those outside the group (e.g., employers) understand what should reasonably be expected from those in the group; and (6) it justiﬁes discipline or legal liability. Latham (2005) was less optimistic, warning that lawyers and expert witnesses use codes as both “shield and sword,” to be referenced by compliance ofﬁcers, liability insurers, risk managers, and labor lawyers as much as (or perhaps more so) than by health-care ethics consultants themselves. Yet, this all points to an afﬁrmative answer to the question, does the profession of ethicist exist? Yes, in the form of the health-care ethicist, albeit in a nascent form. Health-care ethicists have served as expert witnesses in court trials. In addition, some health-care ethicists, using the International Classiﬁcation of Diseases (ICD)-10 taxonomy code for clinical ethicist, bill directly for their ethics consultation services in health-care settings.

While the code of ethics for health-care ethicists endorsed by ASBH focuses on the more narrow activity of health-care ethics consultation, those who drafted the code point out: “Despite the focus on ethics case consultation … these code responsibilities are considered translatable to the other ethics services that health care ethics consultants provide” (Tarzian et al. in press). Of note, the Canadian Bioethics Society’s Ad Hoc Working Group on Employment Standards for Bioethics produced a code of ethics (the “Draft Code of Ethics for Bioethics”) with a broader scope of application than ethics consultation alone (MacDonald n.d.). However, to date, the professional bioethics associations in Canada (i.e., PHEEP/CAPHE and CBS) have not endorsed this draft code of ethics.

Open questions remain about the scope of practice of health-care ethicists. Currently, the core document outlining the standards of practice (ASBH’s Core Competencies for Healthcare Ethics Consultation, 2011) allows for individuals with advanced knowledge and skills to practice alone (or as part of a team) and for individuals with basic knowledge and skills to pool their expertise to form an expert collective group. Are members with only basic knowledge and skills considered health-care ethicists? Are those who only devote a portion of their time to providing ethics-related services, often as an uncompensated volunteer, considered professionals in the ﬁeld? Are individuals who provide health-care ethics consultation without directly interacting with patients and families (e.g., academics weighing in on issues or cases without ever visiting the clinical setting) practicing as academicians, as bioethicists, or as health-care ethicists? These questions remain to be answered.

Dubler and colleagues (2009) identiﬁed a credentialing process to recognize health-care ethics consultants as qualiﬁed to perform ethics consultation and to document their consultations in the section of the patient’s medical record that is typically restricted to “credentialed health professionals.” In 2013, ASBH’s Quality Attestation Presidential Task Force (QAPTF) began developing a method to evaluate health-care ethics consultants as qualiﬁed to perform ethics consultations. They are currently piloting this method. This is an interim approach to a more formal certiﬁcation process. Other initiatives are being proposed to accredit programs that educate and train health-care ethicists. This inevitably raises concerns about administrative bureaucracy and cost burdens associated with professionalizing the role of the health-care ethicist. It is likely that these concerns will also inﬂuence how the broader ﬁeld of bioethics approaches (or eludes) steps toward professionalization.

Conclusion

The question of “what is an ethicist” was explored from the perspective of whether there is a recognized profession of ethicist. The answer to this question is yes, in the form of the health-care ethicist, which is a subset of bioethicist, which is a subset of the larger category – ethicist. That is, individuals using the title of health-care ethicist (and its synonyms, health-care ethics consultant, clinical ethicist, and clinical ethics consultant) are held accountable to practice according to established standards of competency and in accordance with their ﬁeld’s code of ethics. While many health-care ethicists perform the signature service of ethics consultation as “volunteer” work that is different from their primary professional work, there are a growing number of individuals working in health-care settings whose primary professional title is ethicist (or a variation of ethicist). While some components of professionalization for the health-care ethicist are lacking at the time of this writing (e.g., formal certiﬁcation and licensure of individuals and accreditation of programs that educate and train them), the subset of bioethicists who practice as health-care ethicists are well on their way to being recognized as professionals.

This assumes that the legitimacy of the title, ethicist, rests in its recognized status as a profession. The alternative is to allow the title to be used by anyone whom others recognize, by virtue of character attributes, behavior, knowledge, and skills, as expert in reasoning about right and wrong action. To wit, Randy Cohen’s column, The Ethicist, still runs in the New York Times Magazine, currently penned by Chuck Klosterman, a journalist and arts critic with no formal ethics education. Neither Klosterman nor his readers likely consider him an ethicist. Time will tell whether the title of ethicist in other domains will gain legitimacy.

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