This post is presented in conjunction with the March 2020 issue of the American Journal of Bioethics. You can read the full article and commentaries here.
by Denise M. Dudzinski
In “What the HEC-C? An Analysis of the Healthcare Ethics Consultant-Certified (HEC-C) Program: One Year In,” Horner et al. provide an overview of the new HEC-C examination and note many opportunities for improvement. Their contributions, and those of the Open Peer Comment (OPC) authors, will help the HEC Certification Commission improve the certification process.
Horner and the authors of the OPC’s are grappling with the question, “what is the HEC-C exam trying to achieve?” Their answers determine whether they believe the American Society for Bioethics & Humanity’s (ASBH’s) nascent exam has potential. Horner et al. believe the HEC-C’s “goal [of HEC-C] is modest: to set an entry-level foundation for minimum experience, knowledge, and skill for clinical ethics consultation as a first step toward greater standardization and evaluation in the field.” Most OPC authors agree that qualifying for and passing an exam does not adequately attest to the full spectrum of an ethics consultant’s competencies. For example, a multiple-choice exam cannot effectively assess interpersonal, conflict resolution, and facilitation skills. Those skills must be evaluated by peers, colleagues, and ethics service chiefs. In fact, I do not know anyone who thinks successful completion of 400 hours of diverse HEC activities and one exam is sufficient. I agree with Horner et al. (2020, 14) that “the HEC-C exam should not [emphasis added] be seen as an indication that a candidate has achieved a high level of proficiency in clinical ethics consultation.” Ultimately, the exam is one small part of the broader goal to ensure HECs are well qualified. It is the first step.
The goal of certification is “to balance the goals of standardization while preserving the interdisciplinary nature of the field”. This is a supremely difficult goal to achieve. Acknowledging the limitations of an exam format, ASBH and the Commission had to decide whether early certification would be inclusive or exclusive? They chose inclusive.
Horner and most of the OPC authors wish they had been a little more exclusive. Starting with an exam nods to the multidisciplinary nature of our work and signals that professionalization is coming, even if we have not fully arrived. It gives HECs without the necessary education an opportunity to acquire it. In addition, those of us designing educational programs are prompted to find more egalitarian, inclusive, and less expensive educational pathways, like online clinical ethics training programs. Today’s certification requirements are liberal. They will not remain so.
Horner et al. detail a key opportunity for improvement, “The wide range of possible activities that count as [the required 400 hours of] experience mean that candidates who sit on an active ethics committee, engage in educational activities, and develop policy, but who have never once engaged in a clinical ethics consultation, may have sufficient hours to sit for the exam… This raises additional questions about the meaning of certification…” Agreed. Healthcare ethics consultation certainly includes these activities, yet it is clinical, bedside experience that distinguishes a clinical ethics consultant from an ethicist of another stripe. So, one refinement might be to require a certain number of hours of bedside or direct clinical experience so that all 400 hours cannot be policy writing, committee work, and educational activities.
To be effective and helpful, HECs need to be clinicians themselves or deeply entrenched in the clinical world. Without extensive clinical experience, HEC’s fail to understand the professional context and unspoken values that inform clinical praxis. So, it is apt to liken HEC certification to other types of healthcare certification and licensure. Surgeons Shuman and Vercler would model HEC-C on surgical training and the bar for certification would be high, based on trainer observation and assessment. “Clinical ethics consultation has established itself as an essential part of contemporary healthcare and should hold itself to the same high standard as other clinical endeavors”.
Similarly, Kon likens the HEC-C to the hospice and palliative medicine certification program, created through cooperation between multiple medical specialties, in which qualifications became more stringent over more than a decade and now include completion of an accredited fellowship program. “(T)he practice of allowing a broad range of individuals with highly variable education, training, and experience and then gradually requiring a more prescribed training program is common among certification programs”. This is the approach envisioned for HEC-C, under leaders such as Kon, who championed certification in his role as past president of ASBH.
A number of authors, including Horner et al., Shuman and Vercler, Mitchell and Teti, and Jankowski et al. think accreditation of formal teaching programs may be a better way to ensure quality ethics consultations. Several authors, like Mabel and Horner et al., recommend basic and advanced certifications. Jankowski advocates for requiring “supervised practice”. In contrast, Aultman and Pathmathasan want to encourage disciplinary diversity and inclusion in clinical ethics, focusing primarily on work setting diversity. They note the difficulty in some settings of acquiring the necessary hours of experience over four years. Some authors think we should go back to a portfolio-type process like the one piloted in 2013 by ASBH’s Quality Attestation Presidential Task Force, which included evaluations from peers and supervisors. This approach can assess better interpersonal and process skills foundational to ethics consultation.
May, the self-described curmudgeon, conjures past debates about professionalization, quality attestation, and credentialing. He critiques the certification project as “the attempt to ‘test competence’ over content for which sufficient consensus has not yet been established,” noting that some consultation methods like mediation, may be favored in the exam over alternative but equally accepted methods. He has a point, but we’ve grappled with this for many years and we may never achieve sufficient consensus, given our disciplinary diversity. I say, begin then refine and improve.
Wasson thinks interpersonal skills assessment is lacking in a multiple-choice exam and recommends the Assessing Clinical Ethics Skills (ACES) tool which includes evaluation by a trained rater and a simulated ethics consultation with standardized patients. Stolper et al. recommend the Moral Case Deliberation (MCD) model that encourages a dialogical process emphasizing “learning by doing” and ongoing assessment. They note that even in this rich, hands-on approach, they face challenges differentiating good-enough from not good-enough consultants.
Qualified HECs must demonstrate acumen in ethical deliberation, something that, strangely, often gets short shrift in clinical ethics education and assessment of consultants. Brummet seems to agree, concluding, “despite ongoing debate over whether clinical ethicists have ethics expertise, the HEC-C exam presumes they do. The process of credentialing secular clinical ethicists is, and ought to be, in part, a credentialing of ethics expertise”.
Scofield, drawing on Horner et al.’s critique, scrutinizes the HEC Certification Commission’s marketing materials. On the one hand, the credential is “a credible endorsement of a candidate’s core knowledge and skills in clinical healthcare ethics consulting”. Elsewhere it states that HEC-C certification attests exemplary “commitment to the highest level of care and service” (ASBH HEC-C Benefits). The contradiction warrants attention. After all, neither formal ethics education, attestation of high-quality consultation service, or mentoring is required to sit for the exam. “[T]he Commission must be especially careful about how it describes what certification does and does not mean, lest others mistakenly equate uncertified with being un/disqualified…).” Scofield points to the Commission’s conflicting interests—to entice test-takers by suggesting the HEC-C creates a competitive advantage while also being honest about the limitations of certification, which may deter test-takers and fail to be persuasive to their employers.
The debate reflected in the target article and OPCs is whether to set a high bar to begin with or to be inclusive, given that many who function as HECs do not presently meet the lower bar. I think certification will raise the standards and improve the quality of ethics consultation—circuitously—by encouraging those with little education and mentorship to receive more, and by slowly excluding those who are certainly unqualified. Meanwhile, the certification process will be improved and refined. The new HEC certification is a good first step, but it is only one step. Improving the competencies of ethics consultants requires a multi-prong approach, which I expect the certification process to support over time.