Fine-Tuning the Future
- Fine-Tuning the Future
- To the Editor
In “Charting the Future: Credentialing, Privileging, Quality, and Evaluation in Clinical Ethics Consultation” (Nov–Dec 2009), Nancy Dubler and colleagues aptly and accurately indict clinical ethics consultants, or CECs, for failing to develop standards of practice, standards for education, and standards for accrediting clinical ethics educational programs. Acting to fill this void, in eleven substance-packed pages they spell out standards for clinical ethics consultation, propose institutional and peer oversight of consultations, suggest criteria for ensuring CECs’ qualifications and competency, detail standards for evaluating CEC education, and outline a plan for credentialing and privileging CECs.
Their report—a product of the Clinical Ethics Credentialing Project—is good on many points and so likely to improve the level of clinical ethics consultation that it almost seems impolitic to criticize the details. As with most policy recommendations, however, there is always room for improvement. One item that appears to have been overlooked is the role that the clinical ethicists’ professional society, the American Society for Bioethics and Humanities, might play in developing fieldwide standards. Dubler and colleagues cite the achievements of hospital chaplains and palliative care specialists in achieving training standards for their fields, yet these fields set standards by working with their professional societies. It seems odd and potentially self-defeating to offer a proposal for developing fieldwide standards and credentialing procedures without involving the field’s professional society.
My primary concern, though, is the narrowness of CEC education envisioned in the report. While noting that “CEC services may do other things to promote an institutional environment that supports ethical discourse on many levels,” the CECP report “focus[es] on CEC activities involving individual patient cases.” Setting aside the point that “supporting ethical discourse” is an odd and somewhat disparaging characterization of CECs’ important role as ethics educators, policy advisors, and researchers, CECs are also involved in “the clarification of institutional ethics policies” and other issues beyond disagreements over patient care, as Dubler and colleagues themselves remark. A 2006 survey of ASBH members shows that most have multiple tasks: six in ten are engaged in clinical ethics consultation, and almost all are involved in education and research or scholarship. Yet the section of the report addressing the competencies to be taught in clinical ethics education programs ignores these other things that CECs do. Since we know that institutions expect CECs to serve as ethics educators, policy analysts on ethics issues, and researchers, it seems shortsighted to develop standards for education that fail to evaluate programs on their ability to educate CECs to perform these tasks competently.
Moreover, as the report properly notes, successful clinical ethics consultation often involves discussion of the “history of bioethics.” Yet the criteria proposed for evaluating CEC education programs omits standards for teaching the history of bioethics and—perhaps more to the point—for teaching the history of clinical ethics. Modern [End Page 6] clinical ethics was conceived and developed along with the modern clinic in eighteenth-century charity hospitals. Its development is documented in the writings of John Gregory, who insinuated “sympathy” into the physician-patient relationship; of Thomas Percival, who coined the expression “medical ethics”; and of Florence Nightingale, whose principle, “a hospital should do the sick no harm,” is still foundational to organization ethics in health care. Every accredited CEC education program should teach this history.
The perfect, as Voltaire insightfully remarked, is the enemy of the good. Although the CECP proposal would benefit from a more collaborative strategy for attaining fieldwide standards and credentialing and a broader vision of CEC education, it is without doubt the most thoughtful proposal for advancing the field currently in play. Everyone in the field should support its objectives, even as they strive to improve its details.
Robert Baker
Union Graduate College-
Mount Sinai School of Medicine
Bioethics Program
Mount Sinai School of Medicine
Bioethics Program
- To the Editor
Dubler and colleagues contribute helpfully to the debate on “professionalizing” the role of the clinical ethics consultant, although they don’t commit to it. Nonetheless, their credentialing project sets out the argument for ensuring competence in practitioners; lists...
