Mark
P. Aulisio, PhD
University of Pittsburgh
Executive Director, SHHV-SBC Task Force
What is the SHHV-SBC Task Force on Standards for Bioethics Consultation?
The SHHV-SBC Task Force on Standards for Bioethics Consultation (Task Force) is comprised of twenty-one scholars in the field of health care ethics, health care, and health policy. These scholars represent a variety of professional backgrounds ranging from medicine and nursing to law, philosophy, and religious studies. In addition to the Society for Health and Human Values (SHHV) and the Society for Bioethics Consultation (SBC), representatives from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the American Medical Association (AMA), the American Hospital Association (AHA), the Department of Veterans Affairs (VA), the College of Chaplains, and the American Association of Critical Care Nurses (AACN) serve on this Task Force. Funded by a grant from The Greenwall Foundation and contributions from numerous other organizations, centers, and networks, the mission of the Task Force is to explore standards for health care ethics consultation. The work of this Task Force is motivated by the belief that those who offer ethics consultation have an obligation to work to ensure that when patients, health care providers, or others request their assistance in resolving ethical conflicts or uncertainties, they are well equipped to offer that assistance.
What is the focus of the Task Force?
The focus of the Task Force is health care ethics consultation. The services offered by ethics committees and individual ethicists include education, research, policy development and consultation. In the report, we address only issues surrounding consultation. ìStandards,î for the purposes of this work, refer to the ìcore competenciesî our Task Force has identified as necessary for conducting ethics consultation. Though there may be considerable overlap between competencies required for ethics consultation and those needed for other ethics services, we do not address the latter. In the report, we are neutral on the question of whether ethics consultation is best performed by individuals, teams, or committees. We address the competencies important for conducting ethics consultation for each of these methods.
What is the content of the "Discussion Draft"?
There are two major parts of the "Discussion Draft." Part One outlines the tentative recommendations of the Task Force for using its report. Part Two is the report itself.
Part One: Recommendations for Using the Task Force Report
The Task Force considered three models for using its report: formal certification of individuals or groups, accreditation of educational programs, and voluntary guidelines. We reject the certification and accreditation models and endorse the voluntary model. Please see Part One of the "Discussion Draft" for a full discussion of our rationale. Ultimately, the Task Force hopes that its work will help to improve quality in ethics consultation and stimulate continued public discussion of the difficult issues considered herein.
Part Two: Core Competencies for Health Care Ethics Consultation:
The Report of the SHHV-SBC Task Force on Standards for Bioethics Consultation.
1. Health Care Ethics Consultation: Nature and Goals
Those conducting ethics consultation are often asked to assist in sorting through the ethical dimensions of complex clinical cases involving a variety of issues. These issues have moral and legal dimensions which may involve, among other things, patient autonomy, informed consent, competence, health care provider rights of conscience, medical futility, resource allocation, confidentiality or surrogate decision-making. The actual cases that give rise to these questions also often have complex interpersonal and affective features such as guilt over a loved one's sickness or death, disagreement among health care providers, possible conflicts of interest, or distrust of the medical system. Increasingly, ethical issues regarding clinical care are raised or complicated by organizational factors. Because of the complexity of these issues, it is imperative that those conducting consultation be well prepared to deal with them.
In our society, these multifaceted ethical issues emerge against a complex background of developing health care technologies and political, social, communal, institutional, professional and individual values. An expanding array of possible treatments pose difficult decisions for patients, providers and the broader community. At the same time, scarcity of resources and the need for cost containment raise equally complex questions about which treatments should be available and for whom. These decisions must be made in a pluralistic context in which individuals have the political right, arising from the basic societal value of autonomy, to pursue their own conception of the good. Pluralism is present in most contemporary health care settings where a wide variety of individuals from many different professional, cultural, and communal backgrounds are present. Since judgments concerning what should be done will inevitably reflect the values which underlie them, it is not difficult to see how value uncertainty or even conflict could arise in this pluralistic context. Thus, this context, to a large extent, gives rise to the need for ethics consultation and, as we discuss in the report, places effective limits upon it. In response to this need, health care ethics consultation is a service provided by an individual or group to help patients, families, surrogates, health care providers, or other involved parties address uncertainty or conflict regarding value-laden issues that emerge in health care.
Though there are a number of models for ethics consultation implicit in the literature, we believe that a qualified facilitation model is most appropriate for health care ethics consultation in our society.1 This is because a qualified facilitation role is consistent with the fact of pluralism and the political rights of individuals to live by their own moral values and, therefore, best meets the need for ethics consultation in our society. Our qualified facilitation model involves two core features2:
Those conducting the consultation should help to identify and analyze the nature of the value uncertainty or conflict underlying the consultation. This requires:
Those conducting the consultation should help to resolve the value uncertainty or conflict by facilitating the building of consensus among concerned parties (e.g., patients, families, surrogates, health care providers).3 This requires:
The general goal of health care ethics consultation is to:
improve the provision of health care and its outcome through the identification, analysis and resolution of ethical issues as they emerge in consultation regarding particular clinical cases in health care institutions.
This general goal is more likely to be achieved if consultation accomplishes the intermediary goals of helping to:
Successful health care ethics consultation will also serve the goals of helping to:
Health Care Ethics Consultation: Core Competencies
The ultimate concern of this Task Force is quality improvement in ethics consultation. Patients, families, surrogates, and health care providers deserve assurance that those from whom they seek assistance in sorting through the ethical dimensions of health care are competent to offer that assistance. Given the characterization of the nature and goals of ethics consultation laid out in the report and the issues identified above, we think that certain skills, knowledge, and character traits are needed to conduct it.
2.1 Core Skills for Ethics Consultation
We believe that ethics consultation requires two broad categories of skills: (1) skills of ethical assessment (for identifying and analyzing the nature of the value conflict or uncertainty) and (2) process and interpersonal skills (for helping to resolve the value conflict or uncertainty). These skills are necessary for conducting ethics consultation. Please see this section of the "Discussion Draft" for a more complete discussion of these skills.
Core Knowledge Areas for Ethics Consultation
There are nine knowledge areas required for ethics consultation. These include knowledge of: (1) Moral reasoning and ethical theory; (2) Common bioethical issues and concepts; (3) Health care systems as they relate to health care ethics case consultation; (4) Clinical terminology; (5) Health care institution in which the consultants work; (6) Local health care facility's relevant policies; (7) Beliefs and perspectives of local patient and staff population; (8) Codes of ethics, professional conduct and accrediting organizations as they relate to health care ethics case consultation; and (9) Relevant health law. Please see this section of the "Discussion Draft" for a more complete discussion of these knowledge areas.
Character and Ethics Consultation
Good character, valuable for all persons who work in health care, is also important for persons who perform ethics consultation. In raising this issue, the Task Force does not imply that ethics consultants have, or must claim, superior character to other health professionals. Even so, this report would be remiss if it did not emphasize the integral importance of character to ethics consultation. Some of these character traits include: patience, tolerance, honest, integrity, fairness, and prudence.
Health Care Ethics Consultation: Organizational Ethics
Ethical issues in organizational behavior have become more evident in recent years with the emergence of a more explicit market approach to medicine. Areas in which value conflict or uncertainty may arise include: billing practices, access to health care, financial incentives for clinicians to reduce utilization, restrictions on access to specialists, and marketing. Many of these issues and their potential for conflict have existed for years, but were largely hidden or ignored because of the traditional separation of the functions of providing individual care, improving population health, and financing health care. However, as the delivery and financing of health care has been increasingly centralized in health care systems that serve defined populations, and as cost containment has become a national concern, the important relationship between bedside and board room has become inescapable. For these reasons, the Task Force believes that no clear and absolute line can be drawn between organizational ethics and clinical ethics; hence, ethics consultants will increasingly be unable to provide consultation services to one area while ignoring the other.
Health Care Ethics Consultation: Importance of Evaluation
Helping to ensure that those who conduct ethics consultation possess certain competencies will not be sufficient to ensure quality. Improving the quality of consultations will require evaluating consultations themselves and modifying practice in order to better meet ethics consultation's goals. Thus, consultants need to possess the ability to conduct quality assessment and improvement within this field of practice.
5. Special Obligations of Ethics Consultants and Institutions
Abuse of Power and Conflict of Interest
By virtue of their role in health care institutions, ethics consultants are both granted and claim social authority to influence: the clinical care of patients; the behavior of health professionals towards families of patients and towards each other; and the behavior of health care institutions toward patients, families, health professionals, and the larger community. It is therefore inevitable that ethics consultants hold a certain degree of power which can, under certain circumstances, be abused. The potential for abuse of power is, of course, not unique to ethics consultants. It is a problem for all health professionals, inherent in the very nature of their role, special knowledge, and the vulnerability of the persons they serve. The fact of potential imbalances of power imposes a special obligation on ethics consultants not to abuse this power. Indeed, we thought that this report on "standards for bioethics consultation" would have a serious deficiency if we failed to address this issue.
Institutional Obligations to Patients, Providers, and Consultants
Likewise, health care institutions must be responsible to those who utilize ethics consultation services by providing support for those who offer such services in their institution. This support is needed in three areas. First, health care institutions should provide the resources for those who offer ethics consultation in their institution to ensure that they have the competencies to perform consultation. This will require time and tuition for continuing education and access to core bioethics resources (such as key reference texts, journals, on-line services, etc.) appropriate to the size of the institution. Second, institutions need to ensure that those who offer ethics consultation are given adequate time and compensation to conduct it properly. Third, health care institutions should seek to foster a climate in which those offering ethics consultation services can carry out their work with integrity (e.g., a climate free of concerns about job security, reprisals, undue political pressure). In such a climate, the pressures to abuse power or fall into conflict of interest will be significantly diminished. Without institutional support in these three areas, the obligation of quality assurance and improvement in ethics consultation will inevitably go unsatisfied and the temptations or pressures to cross the boundaries of acceptable behavior will be heightened.
What is the next step for the Task Force?
The "Discussion Draft" was mailed to every member of the American Association of Bioethics (AAB), SHHV, and SBC, and to various academic programs, centers, regional networks, and health care organizations. This draft has been posted on the Medical College of Wisconsin (MCW) web site with an invitation to comment via e-mail. It was also presented at the Joint Meeting of the AAB/SBC/SHHV, November 9, 1997 (9:00 a.m. - 12:00 p.m.) in Baltimore. After spending the last several months gathering feedback on its work, the Task Force is now revising and finalizing its report. Thus far, we have been overwhelmed by the positive response it has received. The report should be ready for release in late spring or early summer.
For the list of Task Force members and a complete text of the "Discussion Draft" please visit the MCW web site at http://www.mcw.edu/bioethics/DISDRFT4.html. If you would like to comment on the work of the Task Force feel free to contact:
Mark
Aulisio, Ph.D.
University of Pittsburgh
Center for Medical Ethics
3708 Fifth Avenue
Medical Arts Building, Suite 300
Pittsburgh, PA 15213
e-mail:
maa13@pop.pitt.edu
FOOTNOTES
1 There are other models
in the literature which range from more medical models to pure
or unqualified facilitation models.
2 Not all consultations
will necessarily involve multiple parties. Nonetheless, the relevant
role captured by this model remains appropriate even in those
cases.
3 By ìconsensusî
as it pertains to particular cases, we mean substantive agreement
by all relevant parties.
4 This goal has been taken
directly from John C. Fletcher and Mark Siegler, "What are
the Goals of Ethics Consultation? A Consensus Statement,"
The Journal of Clinical Ethics vol. 7, no. 2 (Summer 1996):
125.
5 Ibid.
6 Ibid.
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