In a 2017–18 national survey, my colleagues and I found that 86% of U.S. general hospitals and nearly 98% of those with 500 beds or more had an ethics consultation service. The people who staff these services help patients, families, and clinicians work through difficult questions, such as whether to continue life-sustaining treatment when people disagree about what a patient would have wanted.
Ethics consultation is performed by people in substantially different roles, including as voluntary members of consultation teams, as solo or lead consultants, and as professional clinical ethicists. Despite these differences, the field offers only one nationally accredited certification program, and its credential does not distinguish among the different levels of competency their work requires. To address this problem, I have made public a proposal for a three-tier credentialing system that would make those distinctions explicit.
The stakes are high. In a case consultation, consultants often meet directly with the patient and family, offer advice and practical assistance to everyone involved, and document the consultation in the patient’s medical record, where the consultant’s recommendations can directly influence the patient’s care.
Yet unlike virtually everyone else in a hospital who is authorized to visit patients, give advice, and write in charts, a person performing ethics consultation is not required to have any particular training or hold any credential or license. A hospital may therefore authorize someone to perform this consequential work without any standardized way to determine whether the person possesses the knowledge and skills the role requires.
In 2018, the field took an important step toward addressing this problem by launching Healthcare Ethics Consultant-Certified (HEC-C), which gave hospitals a way to identify people who had met a national standard for ethics consultation. That was a genuine accomplishment.
But an important problem remained: HEC-C does not differentiate among the substantially different roles in which healthcare ethics consultation is performed.
For many people, ethics consultation is a side activity performed in addition to their primary professional role as a physician, nurse, chaplain, social worker, or other healthcare professional. Most consultants participate as members of teams, often under someone more experienced, and most are not hired specifically to perform ethics consultation and are not specifically compensated for this work.
There is a smaller group of ethics consultants that has the advanced knowledge, skills, and experience needed to perform consultations independently or lead consultation teams. These individuals may be accountable for the consultation as a whole and may also supervise other consultants or manage the consultation service.
A still smaller group consists of professional clinical ethicists, for whom clinical ethics is a principal professional identity and focus of paid professional work. Their role requires advanced consultation competency together with broader competencies in education, program leadership, policy, organizational ethics, quality improvement, and institutional advising.
These are distinct roles requiring different types and levels of competency, responsibility, and accountability.
What one credential can mean
Consider three hypothetical practitioners. Assume that each has met the HEC-C program’s eligibility requirements, including 400 hours of qualifying experience within the previous four years, and passed its examination; each therefore holds the HEC-C credential.
- The first is a social worker who serves on a twenty-member hospital ethics committee whose members take turns staffing the consultation service. She has no formal academic training in ethics. When a consultation request comes to her, she works alongside other committee members under the supervision of a trained ethicist.
- The second is a physician whose position designates ten percent of his time for ethics work. He leads a team in performing ethics consultations and helps train new consultants. His formal training in ethics consultation consisted of a two-day seminar, but he has developed expertise in ethics consultation through years of experience.
- The third is a PhD philosopher employed full-time as a clinical ethicist at an academic medical center. She oversees a busy consultation service, trains and supervises consultants, leads hospital-wide initiatives to improve ethical practices, evaluates the ethics program, and advises executives on ethical issues.
If all three practitioners sought a nationally accredited credential in clinical ethics, HEC-C would be their only option. They could therefore end up holding the same credential despite their substantially different roles. Using the same credential across these different roles creates confusion about the level of competency it represents.
The name of the HEC-C credential can add to the confusion. The HEC-C program’s website describes the credential as affirming “basic competence” in healthcare ethics consultation, but its name contains no qualifier identifying it as a basic credential. The designation “certified healthcare ethics consultant” can easily be misunderstood as indicating qualification to perform consultation independently—or as certification for an occupation rather than for a particular activity.
The hiring problem
This ambiguity becomes especially consequential when a hospital hires for a paid clinical ethics position. Imagine if certified nursing assistants, licensed practical nurses, registered nurses, and advanced practice registered nurses all held the same undifferentiated nursing credential. A hiring manager would know that each had met a standard but not what type or level of competency the credential represented. Hospitals face a similar problem when they rely on HEC-C to judge whether a candidate is prepared for a specific role.
A manager may reasonably assume that a “certified healthcare ethics consultant” is qualified to work independently or fill a clinical ethicist position. Even a manager who understands what HEC-C certifies may have no external, standardized benchmark for judging whether a candidate has the knowledge and skills the position requires. The manager may have to infer candidates’ capabilities from résumés, references, and personal networks, which can be hard to verify and compare.
A three-tier solution
What would a credentialing system that reflects these different roles look like?
In “Rethinking Competence in Clinical Ethics: A Proposal for a Three-Tier Credentialing Ecosystem,” I have proposed a three-tier credentialing ecosystem. Tier 1 would recognize competency for supervised, team-based, or otherwise limited participation in ethics consultation. Tier 2 would recognize advanced competency for independent and lead-consultant roles. Tier 3 would recognize competency for the broader paid professional role of the clinical ethicist.
The hypothetical social worker’s supervised role illustrates Tier 1, the physician’s lead-consultant role illustrates Tier 2, and the clinical ethicist’s broader professional role illustrates Tier 3. A hospital hiring a clinical ethicist could therefore look for a credential designed for that role.
A tiered system would not eliminate the need for hospitals to evaluate individual candidates. But it would give employers, colleagues, patients, and families clearer information about the type and level of competency a credential represents.
Ethics consultation has become a standard part of American healthcare, but the credentialing system supporting it remains incomplete. I hope readers will engage critically with this proposal and help determine what would be needed to make a three-tier system workable. The ultimate beneficiaries of getting this right will be the patients, families, and clinicians whom clinical ethics exists to serve.
Ellen Fox, MD, HEC-C, is President of Fox Ethics Consulting.
Image Credit: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.