A Possible Solution, But Not the Last Word

In 1998 the authors of Core Competencies for Health Care Ethics Consultation declined to endorse certification of individuals or groups who do ethics consultation, judging it was, "at best, premature." The "professionalization" of clinical ethics consultants has long been a subject of heated debate, with questions raised about accreditation of training programs, licensure and certification of practitioners, identification of competency standards, and development of a code of ethics. Many remain concerned about the quality of clinical ethics consultations because the level of knowledge, skill, and training seems to vary widely among practitioners.

In this issue, Nancy Dubler and colleagues report on consensus recommendations from a "national working group" convened to critique the products and processes of the Clinical Ethics Credentialing Project, whose goal is to create a model for credentialing and privileging clinical ethics consultants. In its statement, the group identified five characteristics, three components, and nine standards for clinical ethics consultation services and consultants. Two of the standards directly address consultants' credentialing and privileging.

The CECP represents one possible solution to assuring quality in clinical ethics consultation. At the local level, the institution or hospital would grant "privileges" to qualified, credentialed ethics consultants, just as it does to clinical practitioners. These individuals would then be permitted to provide ethics consultation at the institution and to place notes in patients' medical records. A significant issue is what credentials are considered adequate for consultants who wish to apply for privileging. The CECP working group and faculty recommends completion of a substantial, formal program in bioethics and clinical ethics, a supervised apprenticeship, and satisfactory written evaluations from teachers or mentors.

Although the model CECP promotes contains positive elements, what qualifies as a "substantial, formal program" is unclear, especially given the absence of any existing accreditation process for training programs. A simpler proposal would be to assess candidate practitioners for competencies related to particular knowledge, skills, experiences, and attributes. Candidates demonstrating these competencies upon examination would be credentialed and could apply for institutional privileges. This model bypasses any requirement to participate in a training program or apprenticeship. What path a candidate used to acquire the required competencies would be irrelevant. Demonstrating them is all that would matter.

The CECP places significant emphasis on writing detailed ethics consultation notes, which can then be used as a basis and proxy for consultants' demonstration of competencies, as a method for quality improvement through later assessment with a structured tool, and as mechanisms for the ethics education of the health care personnel who read them. In support of educational outreach, CECP faculty developed a "library" of boilerplate paragraphs analyzing ethical issues that can be integrated into chart notes when relevant.

This reliance on chart notes seems misplaced both from theoretical and practical perspectives. Certainly, charting during and after an ethics consultation is important, with the chart note incorporating recommendations and brief ethical analysis. Significant, too, are the potential educational role of ethics consultation and often-neglected quality improvement efforts. However, using patients' medical records as a means to accomplish the multiple ends of both ethics consultation services and consultants (demonstrating competencies, quality improvement, and education of personnel) is inappropriate given that the primary purpose of the medical record is communication and coordination among clinical personnel in the service of the patient. From a practical point of view, whether busy clinicians managing patients with complex medical conditions and suffering from information overload will attentively read multipage ethics chart notes seems doubtful. Consultation report forms that record robust information about process and interventions, including copies of chart notes, could just as effectively contribute to retrospective assessments of competencies and quality. The educational goal of ethics consultation should not be abandoned or ignored, but it is more likely to be achieved during thoughtful conversations with those involved in consultation than through extensive chart notes.

The recommendations of the CECP working group and faculty are an important contribution to the ongoing discussion about clinical ethics consultation. But its specific model and proposal need modification to work in the institutions that most need them.