The Need for Accreditation Standards for Clinical Ethics Fellowship Programs

This editorial appears in the October 2025 issue of the American Journal of Bioethics

A half-century into its existence as a distinctive field of scholarship and practice, bioethics has arguably entered a phase in which it can be characterized as an “emerging moral tradition” and is at a point in its development where inadequacies are identified and remedies sought. Ellen Fox and Jason Wasserman’s (2025) study and the associated commentaries illuminate the inadequacies concomitant with the rapid growth over the past decade of clinical ethics fellowship programs (CEFPs) in the U.S. and Canada. This study provides evidence in support of an initiative by the Council On Program Accreditation for Clinical Ethicist Training (COPACET) to develop accreditation standards for CEFPs, the need for which is apparent given the divergences identified in this study not only between programs, but with professional standards such as those articulated by the Association of Bioethics Program Directors (ABPD). In addition to initial focus groups and reports to sponsoring organizations, the associated commentaries provide valuable stakeholder contributions to the COPACET standards development and should be considered part of the communities of interest feedback. In support of this initiative, we wish to emphasize the value of congruence with the ABPD standards for CEFPs. Further, we affirm the indispensability of providing interdisciplinary and interprofessional formation of clinical ethics fellows, which may lead to some programs serving distinct populations from others. Finally, we explore the somewhat vexed question of whether there are certain “personal qualities” clinical ethicists should possess that may be validly evaluated in admissions criteria.

Congruence with ABPD Standards

Fox and Wasserman note that “less than half of programs meet CEFP standards established by ABPD.” These standards, which were developed in 2017, are as follows:

1. All Fellows have a terminal degree in a field acknowledged as an accepted discipline that contributes to clinical ethics
2. All Fellows receive training or grounding in the American Society for Bioethics and Humanities (ASBH) Core Competencies for Healthcare Ethics Consultation, 2nd ed. (2011) sufficient to function as an individual or single or lead clinical ethics consultant independently.
3. The Fellowship Program is at least 11 months full‐time or the equivalent.
4. All Fellows receive direct supervision and mentorship for the duration of their training.
5. All Fellows serve as the lead consultant for at least 30 clinical ethics consultation cases.
6. All Fellows are periodically assessed and evaluated for meeting the skills and knowledge necessary to carry out consultations in accord with the ASBH core competencies
   
   

While these standards are not necessarily definitive—e.g., the ASBH Core Competencies is now in its 3^rd edition—nor binding as there is currently no accreditation requirement for CEFPs or licensure for clinical ethicists, the ABPD does represents the leadership of nearly 100 academic bioethics programs at medical centers and universities across North America and thus can be considered “authoritative” to a certain extent; additionally, the American Society for Bioethics and Humanities has implemented a certification process for clinical ethics consultation. The time is thus ripe for the development of accreditation standards for CEFPs that conform with the ABPD’s recommended standards and integrate cohesively with ASBH’s certification standards.

Two ways in which the majority of CEFPs fall short of these standards is the length of the fellowship (minimum 11 months) and the number of consultations for which the fellow serves as the lead consultant (at least 30). While there are undeniable practical benefits for both programs and fellows of a one-year program, the cost in breadth and depth of learning and experience compared to a two-year program prompts reflection, as Malek notes, not on “whether it is possible for an individual trainee to develop sufficient competency in clinical ethics consultation in less than two years (it certainly is), but whether it is possible for a program to consistently produce fellows who meet these standards within one year.” A longer fellowship period would also provide trainees with greater opportunity to serve as the lead consultant on cases. While the use of virtual technology and simulated-based education (SBE) or objective structured clinical exams (OSCEs) can provide trainees with greater experience and practice, they do not substitute for actually leading a consultation. It will be incumbent on programs to satisfactorily demonstrate how learners acquire the necessary competencies for accreditation within the time frame of the program. This may pose a significant challenge for shorter programs.

Further, fellows should not lead an in vivo consultation until late in their training, since a poorly handled consult could harm relationships between patients and families, within the health care team, or between the health care team and the ethics consultation service. We will return to this point later when discussing the evaluation of clinical ethics fellows in terms of “personal qualities.”

Interdisciplinary and Interprofessional Experience

The length of CEFPs also impacts trainees’ development with respect to exposure to other disciplinary methodologies and professional perspectives, as well as their cultivation as scholar-practitioners. As Fins notes, there is a significant lacuna in the formation of clinical ethics fellows with respect to research aiming “to ensure that the next generation of scholars is prepared to add to our fund of knowledge.” It not necessarily the case that every clinical ethics fellow has to engage in research, but at least some should be drawing upon their first-hand clinical experiences to inform normative ethical reflection among their peers; as Dudzinski aptly puts it, writing from the perspective of an employer of CEFP graduates, “ethical reflection is not the same as ethics consultation.”

This does not entail that all CEFPs must look the same or admit the same types of trainees. Different programs can have distinctive identities. For example, while arguably all programs should require some degree of scholarly research and consultation experience, one program could admit primarily those with a background in, say, philosophy, and thereby focus on giving them greater clinical experience—starting with a course on “medicine for ethicists”—and another program could be oriented toward clinicians and thus furnish them with courses in ethical theory, epistemology, and the philosophy of science. Different CEFPs could also focus on diverse topical areas such as pediatrics, end-of-life care, Catholic health care, or quality improvement. Another key area that Dudzinski identifies as a “critical need” in clinical ethics formation is organizational ethics, which is backed up by additional studies. Finally, as Goff et al. argue, CEFPs should “include structures that protect fellows’ well-being and prepare them for the emotionally challenging work of clinical ethics.”

“Personal Qualities” for Clinical Ethicists

A final set of concerns raised by commentators in this issue is the use of “personal qualities” in evaluations for admission, which 97.2% of CEFPs rated as “very” or “extremely” important. Qualities noted by respondents include interpersonal skills, cognitive skills, compassion, honesty, humility, maturity, ability to work independently, and passion for ethics. One concern is that evaluation of these qualities may involve “interpersonal bias” insofar as the qualities themselves may be “ill-defined and difficult to evaluate objectively”. Another is that the development of such qualities is typically not part of the formal training in philosophy or other humanities programs. The claim that humanities graduate programs lack opportunities for professional identity formation may be overstated. Master’s and doctoral programs in philosophy and the humanities often incorporate mentorship and formative experiences such as serving as a research or teaching assistant, teaching courses as the instructor of record, and pursuing independent or collaborative scholarship. These activities are part of a curriculum that shapes the habits, dispositions, and sense of professionalism expected of academic scholars. It is important that programs in clinical ethics intentionally create structured experiences and role-modeling to cultivate the professional qualities central to clinical ethics as a profession.

As there has not historically been the same emphasis on articulating a set of virtues for clinical ethicists as there has been for physicians, the emerging attention to professional identity formation for ethicists represents a relatively new and important development. We affirm that there are indispensable character traits that are crucial for clinical ethicists to function effectively in not only navigating the complex nature of bedside ethical dilemmas, but also managing interpersonal conflicts among family members, the health care team, hospital administrators, and other relevant parties. Such qualities include flexibility, adaptability, humility—which includes both awareness of one’s own values and influences, as well as the ability to understand those of others—and breadth of knowledge both interdisciplinarily and interprofessionally. We share the concern, however, that such qualities must be measurable to avoid bias and should be assessed through various modes of teaching and learning: case-based discussions, in vivo consultations, SBE, OSCEs, etc.

Conclusion

Fox and Wasserman’s study is a necessary first, but by no means last step in the ongoing critical self-reflection on the professionalization of clinical ethics in order to ensure both accountability and appropriate responses when ethicists are consulted. There are, of course, many questions left to be answered as COPACET develops accreditation standards for CEFPs. For example, how should health care institutions integrate fellows who have completed accredited training with practicing ethicists who may not have had the benefit of such programs? Initially, this could exacerbate the already tiered nature that exists among CEFPs, as well as equity and access issues for those seeking admission to accredited CEFPs. Further, there is an imperative to gather data from clinical ethics fellows themselves. With these questions and issues firmly in mind, we nevertheless commend the work of COPACET to develop an initial set of standards, in consultation with communities of interest and subject to continued scrutiny and revision, to improve the quality of clinical ethicists’ formation and the service they will provide for the benefit of patients, families, and health care institutions.

Jason T. Eberl is President of the Association of Bioethics Program Directors (ABPD), which is a sponsoring organization of COPACET.

Margie Hodges Shaw is a member of the Council On Program Accreditation for Clinical Ethicist Training (COPACET).