Individuals who conduct ethics consults may have undergone limited or inconsistent training — or none at all.
“It really depends on if the institution uses volunteer committee members or if they have professionally trained ethics consultants,” says Melissa M. Bottrell, MPH, PhD, CEO of Ethics Quality Consulting in Berkeley, CA.
Some ethics programs rely on the American Society for Bioethics & Humanities (ASBH)’s Improving Competencies in Clinical Ethics Consultation: An Education Guide. The guide provides “an amazing resource for training ethics consultants,” according to Bottrell. Ethicists can create a comprehensive, case-based series of training sessions covering a core content area (e.g., shared decision-making or end-of-life decisions).
Recently, Bottrell developed training slides based on the ASBH resources for a small facility. Even if institutions do not have a professionally trained ethicist on the ethics committee, it is possible to build a good educational session this way.
“With the staff ethics person working with maybe someone in their education department, they could build a very nice training that could be housed on an internal website to use in onboarding new committee members,” Bottrell suggests.
Hospital administrators vary in their awareness of the need for training for ethics consultants. “They want to believe the committee is doing good work. But as ethics committees often don’t capture metrics to measure their work product quality, it’s hard for administrators to question the training quality,” Bottrell explains.
Many hospital leaders do not think much about it, unless an ethics consult does not appear to add value to a challenging situation, from the perspective of staff who requested the consult, patients, or family members. “That can arise if the committee does not appropriately use analytic standards, doesn’t have a broad enough representation to assure that a range of perspectives are heard, or has poor documentation of the analysis process and decision-making process and recommendations,” Bottrell says.
“Some institutions have developed their own internal checklists or feedback process, which are more informal methods,” says Katherine Wasson, PhD, MPH, HEC-C, director of the Bioethics and Professionalism Honors Program at Loyola University Chicago.
As the field of clinical ethics developed, training mainly consisted of shadowing another consultant. “The fellowship model has become the gold standard of training,” Wasson says.
After obtaining an academic or clinical degree, individuals spend one or two years learning the skills to conduct ethics consults, but such programs are limited in number. At Loyola, the Assessing Clinical Ethics Skills (ACES) program is used to train healthcare professionals who conduct ethics consults and sit on ethics committees. In 2014, ethicists created the ACES tool based on the ASBH national competency standards and the Veterans Affairs Ethics Consultation Service Proficiency Assessment Tool (a self-assessment instrument also based on ASBH standards).
“We now use the ACES tool to train students, with three levels of courses involving ethics consultation simulation and trained raters,” Wasson says.
Ethics consultants come from a variety of backgrounds, including philosophy, theology, law, medicine, nursing, and social work. ASBH has instituted a certification process for ethics consultants, which requires 400 hours of relevant experience in the past four years, a bachelor’s degree, and passing a written exam. However, criteria for certification do not include an assessment of the individual’s skills in a consultation. “The ACES tool offers a consistent framework through which to assess these skills,” says Wasson.
Wasson has led an effort to develop a website for users in the field to learn how to apply the ACES tool to an ethics consultation. (Learn more here.) Four video case examples provide instruction on how to use the ACES tool to rate the clinical ethicists in the video. Users receive written and video feedback on how their responses match those of expert raters. The ACES tool details the components needed to conduct a competent ethics consult for people learning about consultations and those already performing this work. Trained raters provide individualized feedback to each student, and rate components of the ethics consult as “done,” “not done,” or “done incorrectly.”
For instance, a trainee might elicit the values and expectations of the medical team, but failed to do so for the patient (or surrogate decision-maker). This part of the consult would be rated as “done incorrectly,” because it was partly completed, but not sufficiently. Likewise, a trainee might not identify the full range of ethically acceptable options in a case. In that instance, the rater would help the trainee identify additional options.
“Part of the reason an ethics consultation has been called is to provide a different framing or perspective on the case and the disagreement or conflict,” Wasson notes.
The ethics consultant must help parse these issues and clarify them for all parties. Sometimes, learners need help to step back and analyze the options, and then explain why these would be ethically appropriate, or not.
Hospital administrators vary in their awareness of the need for training for ethics consultants. They want to believe the committee is doing good work. But as ethics committees often do not capture metrics to measure their work product quality, it is hard for leaders to question the training quality.
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