Clinical Ethics Consultant Research Articles

Understanding Clinical Ethics Consultation: What Stories Reveal.

This commentary reflects on twelve stories of participants in clinical ethics consultations from the perspective of family members, some of whom are ethics consultants, and healthcare professionals. Together they reveal expectations of ethics consultations and suggest descriptions of the service. Some common themes emerge, including the role of the clinical ethics consultant in navigating complex situations, assuring all stake-holder voices are heard, attending to moral distress, addressing issues that seem beyond medical practice, and being accessible. They are almost uniformly positive about the experience, with criticism primarily about lack of access to the service.

Development and evaluation of remote supervision in clinical ethics consultation training

During clinical ethics consultation training, hands-on practice after acquiring the necessary knowledge under an experienced clinical ethics consultant's supervision is an effective method of obtaining technical and practical skills. However, in regions where clinical ethics consultation is still nascent, few experienced clinical ethics consultants exist. The number of clinical ethics consultation cases is small, making on-the-job training significantly difficult. To address this problem, this study developed a remote supervision program using e-mail and ZOOM and evaluated its effectiveness using Kirkpatrick's learning effectiveness model. The findings confirmed the good learning effects of both programs. In particular, ZOOM's learning effectiveness was greater than e-mail's in Level 2 learning effects. Nevertheless, remote supervision may be an effective method when in-person training is difficult, such as in countries with developing clinical ethics consultations or during the outbreak of infection.

Addressing Racism in the Healthcare Encounter: The Role of Clinical Ethics Consultants

Clinical ethicists move in different environments and interface with a variety of stakeholders, and are therefore uniquely positioned to answer the call for equity and anti-racism. We describe why a clinical ethicist should contribute to anti-racism efforts and describe general approaches for addressing racism across institutional contexts, including: (1) addressing racism as bedside clinical ethics consultant, (2) addressing wider lens of anti-racism work across multiple ethics consults over time, and (3) addressing racism at the organizational level.

Policing the Sublime: The Metaphysical Harms of Irreligious Clinical Ethics

Abstract Janet Malek has recently argued that the religious worldview of the clinical ethics consultant should play no normative role in clinical ethics consultation. What are the theological implications of a normatively secular clinical ethics? I argue that Malek’s proposal constitutes an irreligious clinical ethics, which commits multiple metaphysical harms. First, I summarize Malek’s key claims for a secular clinical ethics. Second, I explicate both John Milbank’s notion of ontological violence and Timothy Murphy’s irreligious bioethics to show how they apply to Malek’s secular clinical ethics, resulting in an irreligious clinical ethics. Third, I then show how an irreligious clinical ethics commits metaphysical harms to patients, clinical ethics consultants, and the institution of clinical ethics consultation. I conclude that Malek’s proposal for an irreligious clinical ethics must be rejected to maintain the metaphysical integrity of clinical ethics consultants, patients, and the institution of clinical ethics consultation.

Clinical Ethics Consultation and the Reframing of Risk.

As a clinical ethics consultant, I've received numerous consultation requests from health-care providers that reflect the tension at the heart of the concept of dignity of risk, often presented in this form: "The patient wants to [do something that we think is unsafe]. How can we change their mind or stop them?" These consultation requests are almost always framed within a medicalized conception of risk: each is presented as a medical provider's concern that a patient's behavior or choice will lead to a specific physiological harm that the medical team wishes to avoid. However, this medicalized perspective neglects the subjective nature of self-determined choices and ignores important aspects of how patients integrate their disability or illness into a broader narrative of how their preferences and actions fit within their self-understanding. In this article, I offer ways to reframe provider perspectives as an attempt to foster an empathetic understanding of "risky" patient preferences at the physiological, environmental, and psychosocial levels.

Responding Well to Spiritual Worldviews: A Taxonomy for Clinical Ethicists.

Every clinical ethics consultant, no matter their own spirituality, will meet patients, families, and healthcare professionals whose spiritualities anchor their moral worldviews. How might ethicists respond to those who rely on spirituality when making medical decisions? And further, should ethicists incorporate their own spiritual commitments into their clinical analyses and recommendations? These questions prompt reflection on foundational issues in the philosophy of medicine, political and moral theory, and methods of proper clinical ethics consultation. Rather than attempting to offer definitive answers to these questions, this essay prompts readers to consider their own answers to these questions. Specifically, it offers a taxonomic analysis of six (6) distinct responses: assessment, delegation, examination, translation, incorporation, and assertion. Furthermore, this essay describes the role of the ethicist's own spiritual commitments during the responses. Each section also names several strengths and weaknesses that ethicists ought to consider when evaluating the purpose and scope of each response. This paper prompts readers to consider circumstances under which they might promote, critique, or incorporate spiritual worldviews-their own and those of their patients-when offering clinical analyses and recommendations.

Clinical Ethics Consultations during the COVID-19 Pandemic Surge at a New York City Medical Center

The COVID-19 pandemic swept through New York City swiftly and with devastating effect. The crisis put enormous pressure on all hospital services, including the clinical ethics consultation team. This report describes the recent experience of the ethics consultants and Columbia University Irving Medical Center during the COVID-19 surge and compares the case load and characteristics to the corresponding period in 2019. By reporting this experience, we hope to supplement the growing body of COVID-19 scientific literature and provide details of the human toll the virus took on our hospitals and communities. We also aim to highlight the role of the clinical ethics consultant as well as areas of policy and law that may need to be addressed in order to be better prepared for a future public health crisis.

Phases of a Pandemic Surge: The Experience of an Ethics Service in New York City during COVID-19

When the COVID-19 surge hit New York City hospitals, the Division of Medical Ethics at Weill Cornell Medical College, and our affiliated ethics consultation services, faced waves of ethical issues sweeping forward with intensity and urgency. In this article, we describe our experience over an eight-week period (16 March through 10 May 2020), and describe three types of services: clinical ethics consultation (CEC); service practice communications/interventions (SPCI); and organizational ethics advisement (OEA). We tell this narrative through the prism of time, describing the evolution of ethical issues and trends as the pandemic unfolded. We delineate three phases: anticipation and preparation, crisis management, and reflection and adjustment. The first phase focused predominantly on ways to address impending resource shortages and to plan for remote ethics consultation, and CECs focused on code status discussions with surrogates. The second phase was characterized by the dramatic convergence of a rapid increase in the number of critically ill patients, a growing scarcity of resources, and the reassignment/redeployment of staff outside their specialty areas. The third phase was characterized by the recognition that while the worst of the crisis was waning, its medium- and long-term consequences continued to pose immense challenges. We note that there were times during the crisis that serving in the role of clinical ethics consultant created a sense of dis-ease as novel as the coronavirus itself. In retrospect we learned that our activities far exceeded the familiar terrain of clinical ethics consultation and extended into other spheres of organizational life in novel ways that were unanticipated before this pandemic. To that end, we defined and categorized a middle level of ethics consultation, which we have termed service practice communication intervention (SPCI). This is an underappreciated dimension of the work that ethics consult services are capable of in times of crisis. We believe that the pandemic has revealed the many enduring ways that ethics consultation services can more robustly contribute to the ethical life of their institutions moving forward.

Roles of the Ethics Consultant: A Response to Vaughan and Colleagues and DeRenzo

We respond to commentaries on our article, "The Clinician as Clinical Ethics Consultant: An Empirical Method of Study," that appeared in the summer 2019 issue of The Journal of Clinical Ethics.

The Quasi-religious Nature of Clinical Ethics Consultation.

What is the proper role of a clinical ethics consultant's (CEC) religious beliefs in forming recommendations for clinical ethics consultation? Where Janet Malek has argued that religious belief should have no influence on the formation of a CEC's recommendations, Clint Parker has argued a CEC should freely appeal to all their background beliefs, including religious beliefs, in formulating their recommendations. In this paper, I critique both their views by arguing the position envisioned by Malek puts the CEC too far from religion and the position envisioned by Parker puts the CEC too close. For a CEC to give recommendations about what is morally prohibited, permissible, or obligatory in the clinic, I propose a view of the CEC that is neither religious nor non-religious but quasi-religious. I argue that a quasi-religious approach avoids the problems of both religious and non-religious views while preserving their benefits. Additionally, a quasi-religious view resists the marginalization of "religious" traditions that occurs when secular ethicists come to think of their approach as somehow distinctly non-religious.

How Should Ethics Consultants Weigh the Law (and other Authoritative Directives)?

In the continuing debate about the role of the Clinical Ethics Consultant in performing clinical ethics consultations, it is often assumed that consultants should operate within ethical and legal standards. Recent scholarship has focused primarily on clarifying the consultant's role with respect to the ethical standards that serve as parameters of consulting. In the following, however, I wish to address the question of how the ethics consultant should weigh legal standards and, more broadly, how consultants might weigh authoritative directives, whether legal, institutional, or professional, against other normative considerations. I argue that consultants should reject the view that authoritative directives carry exclusionary reason for actions and, further, ethicists should interpret directives as lacking any moral weight qua authoritative directive. I then identify both implications and limitations of this view with respect to the evolving role of the ethics consultant in an institutional setting, and in doing so propose the kinds of considerations the ethicist should weigh when presented with an authoritative directive.

The Place for Religious Content in Clinical Ethics Consultations: A Reply to Janet Malek.

JanetMalek (HEC Forum 31(2):91-102, 2019) argues that a "clinical ethics consultant's religious worldview has no place in developing ethical recommendations or communicating about them with patients, surrogates, and clinicians." She offers five types of arguments in support of this thesis: arguments from (i) consensus, (ii) clarity, (iii) availability, (iv) consistency, and (v) autonomy. This essay shows that there are serious problems for each of Malek's arguments. None of them is sufficient to motivate her thesis (nor are they jointly sufficient). Thus, if it is true that the religious worldview of clinical ethics consultants (CECs) should play no role whatsoever in their work as consultants, this claim will need to be defended on some other ground.

Pediatric Ethics Consultation: Practical Considerations for the Clinical Ethics Consultant

Clinical ethics consultants face a wide range of ethical dilemmas that require broad knowledge and skills. Although there is considerable overlap with the approach to adult consultation, ethics consultants must be aware of differences when they work with infant, pediatric, and adolescent cases. This article addresses unique considerations in the pediatric setting, reviews foundational theories on parental authority, suggests practical approaches to pediatric consultation, and outlines current available resources for clinical ethics consultants who wish to deepen their skills in this area.

The Clinician as Clinical Ethics Consultant: An Empirical Method of Study

Some 30 years ago the role of the clinical ethics consultant (CEC) was formalized. At the time, the perception of the role differed between two groups serving in that capacity, clinicians and nonclinicians. Differences in their roles reflected their training and experience. These divergent views were resolved semantically by designating the role of the CEC as "ethics facilitation." In practice the different perspectives have remained. However, the subsequent published literature on clinical ethics consultation has not adequately reflected the activity of the clinician as a CEC. There have been recurring unanswered calls for the acquisition of empirical data on the nature of the problems that prompt ethics consultation requests and the functions required to address them. The authors introduce a template that provides a means to acquire such data for clinician ethicists. A similar instrument could be constructed to reflect the role of the nonclinician ethicist serving in that capacity.

The ASBH Approach to Certify Clinical Ethics Consultants Is Both Premature and Inadequate

In November 2018 the American Society for Bioethics and Humanities (ASBH) administered the first Healthcare Ethics Consultant Certification examination to 138 candidates, 136 of whom (98.5 percent) passed and were "certified" as "healthcare ethics consultants." I believe this certification process is both premature and inadequate. Certification for ethics consultants is premature because, as Kornfeld and Prager state repeatedly in their article in this issue of The Journal of Clinical Ethics, "The Clinician as Clinical Ethics Consultant: An Empirical Method of Study," there is a lack of "empirical data on the nature of the problems that prompt ethics consultation requests and on the functions required to address them." These authors proceed to provide a model for the kind of empirical data collection that is needed. Even more relevant, the ASBH model that certifies clinical ethics consultants is inadequate. First, it is inappropriate for a nonclinical organization such as the ASBH to claim the right to certify a clinical process, ethics consultation, involving patients and health professionals. Second, the current certification process requires only a written examination in contrast to the two-step quality attestation process proposed in 2013 by Eric Kodish, MD, and 11 other senior members of the ASBH, including its then president. Third and most importantly, the eligibility criteria for being certified to work on hospital units and to make clinical recommendations for patients and families are minimal and insufficient. The only stated requirements are a bachelor's degree and 400 hours of healthcare ethics consulting experience. By contrast, practicing physicians and nurses train for many years to gain clinical experience that enables them to apply clinical ethical standards in the care and management of all inpatients and outpatients, not just the small percent for whom an ethics consultation is requested.

Roles of the Clinical Ethics Consultant: A Response to Kornfeld and Prager

We believe that clinical ethics consultants (CECs) should offer advice, options, and recommendations to attending physicians and their teams. In their article in this issue of The Journal of Clinical Ethics, however, Kornfeld and Prager give CECs a somewhat different role. The CEC they describe may at times be more aptly understood as a medical interventionist who appropriates the roles of the attending physician and the medical team than as a traditional CEC. In these remarks, we distinguish the role of the CEC from that of the physician, in contrast to some of these authors' recommendations, which confuse the two roles.

Moving Towards a New Hospital Model of Clinical Ethics

The role of clinical ethics consultant in hospitals was created about 30 years ago. Since that time, two very different models for clinical ethics consultation, and who should perform it, have arisen: clinician ethicists and nonclinician ethicists, or bioethicists. Neither model provides everything that hospitals might need, and both include perspectives that are not ideal for hospital practice. It's time for a new model, one designed specifically to meet the needs of hospital patients, one we might call the hospital model of clinical ethics (HMCE).

Religion, Authenticity, and Clinical Ethics Consultation.

A clinical ethics consultant (CEC) may, at times, be called upon to make independent substantive moral judgments and then offer justifications for those judgments. A CEC does not act unprofessionally by utilizing background beliefs that are religious in nature to justify those judgments. It is important, however, for a CEC to make such judgments authentically and, when asked, to offer up one's reasons for why one believes the judgment is true in a transparent fashion.

The Appropriate Role of a Clinical Ethics Consultant's Religious Worldview in Consultative Work: Nearly None.

Ethical reasoning is an integral part of the work of a clinical ethics consultant (CEC). Ethical reasoning has a close relationship with an individual's beliefs and values, which, for religious adherents, are likely to be tightly connected with their spiritual perspectives. As a result, for individuals who identify with a religious tradition, the process of thinking through ethical questions is likely to be influenced by their religious worldview. The connection between ethical reasoning and one's spiritual perspective raises questions about the role that CECs' personal religious worldviews should play in their professional lives and their consultative work. This paper offers numerous arguments critiquing the inclusion of a consultant's own spiritual perspective in her work and has identified only limited circumstances under which such inclusion might be permissible. In particular, these arguments lead to the conclusion that a CEC's personal beliefs should never influence her ethical analysis or development of a recommendation. Further, religious appeals should not be used in communication during decision-making conversations other than to describe the patient or surrogate's stated perspective. There may be limited cases in which a CEC may share her spiritual worldview with a patient with the intent of building a collaborative relationship, but such situations should be approached with extreme caution.

Certification and evaluation of the clinical ethics consultant. A proposal for Italy.

Clinical ethics, as a sub-discipline of bioethics, is subject to growing professionalization in North America, Europe and elsewhere. Since the goal of clinical ethics is the identification, analysis and resolution of ethical dilemmas and conflicts in health care settings, specific competencies for practitioners and criteria to evaluate them are strongly needed. Regarding clinical ethics consultation (CEC) many efforts have been made by American clinical ethicists and scholars to delineate the core knowledge and skills to perform it, to settle specific professional responsibilities and tasks and to identify the fundamental training and quality requirements that candidates and actual professionals should satisfy in order to serve as ethics consultants. Starting from the analysis of two meaningful international experiences, the one American and the other German, the paper discusses the process of certification of the clinical ethics consultant and encourages its implementation in the Italian context trying to outline a model which is suited to it.