American Medical News, an AMA publication, recently took a look at the state of ethics consult services in hospitals — and it found a lot of unease. Doctors are hesitant to call for ethics consults. Ethics consultants often lack the training and resources to effectively address situations. And among bioethicists, there’s uncertainty about whether ethics consults even help. From the article:

The use of ethics consultation services varies widely from hospital to hospital, but physician experts and ethicists agree that they frequently are underused. That leads, they say, to increased medical costs and ugly disputes among physicians, patients and families.

Physicians’ reluctance to seek aid when dilemmas arise is partly grounded in the notion that a call for help is equivalent to hauling in the “ethics police.” But the problem, experts say, goes far deeper.

Too often, ethics consultants lack the resources, training and mediation skills necessary to resolve disputes and address dilemmas in a timely and effective manner. In addition, the journal article pointed out that fewer than half of consultants have any formal training, and only one in 20 has a bioethics certification or graduate degree.

Moreover, the evidence that ethics consultation actually improves patient outcomes is thin. Many experts are at a loss on how even to go about measuring its impact.

“If ethics committees were a drug,” said Howard Brody, MD, PhD, director of the University of Texas Medical Branch’s Institute for Medical Humanities, “they would not be approved.”

The AMNews piece builds around the February 2007 AJOB cover article “Ethics Consultation in United States Hospitals: A National Survey” by Ellen Fox, Sarah Myers and Robert A. Pearlman. In that article, the authors reported that only 41 percent of ethics consultants had formal training. Ellen Fox, who’s director of the VA’s National Center for Ethics in Health Care, is now involved in an effort to standardize and measure the work of ethics consultants. From the AMNews piece:

… The VA began the initiative in May 2007. By September of this year, it will record electronically all consultations and their outcomes.

The VA has developed a 63-page primer and two-hour instructional video for its consultants. Ethics coaches will visit VA medical centers to train consultants on consistently following a step-by-step process when handling cases. They will be expected to evaluate their own performance and skills, and physicians and other health professionals will be surveyed for their feedback, said [Ellen Fox] …

“It is concerning to me that almost 20 years after the Joint Commission mandate, there still are not widely agreed-upon standards for quality,” she said. “That’s why in the VA we’ve issued these standards and will hold people accountable for meeting them.”

Dr. Fox, lead author of the study in The American Journal of Bioethics, said proof of ethics committees’ effectiveness is still largely anecdotal.

“The way to ensure that ethics consultation is utilized at an appropriate level is to ensure that the quality of ethics consultation is very high,” she said. “Our strategy is to prove the value of it on the ground.”

-Greg Dahlmann