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Abstract
With the increasing professionalization of clinical ethics, some hospitals and health systems utilize both ethics committees and professional clinical ethicists to address their ethics needs. Drawing upon historical critiques of ethics committees and their own experiences, the authors argue that, in ethics programs with one or more professional clinical ethicists, ethics committees should be dissolved when they fail to meet minimum standards of effectiveness. The authors outline several criteria for assessing effectiveness, describe the benefits of a model that places primary responsibility for ethics work with professional clinical ethicists—the PCE-primary model, and offer suggestions for alternative ethics program structures that empower healthcare professionals to contribute to ethics work in ways more tailored to their strengths and skills while minimizing the shortcomings of ethics committees.
ACKNOWLEDGMENTS
This paper began as a discussion at the 2020 clinical ethics Unconference hosted by the Center for Medical Ethics and Health Policy at Baylor College of Medicine. The authors thank participants in that conversation. The authors are particularly grateful to Ruchika Mishra, Kerri Kennedy, and Jessica Roumillat for their contributions to that discourse and the development of early versions of this paper.
DISCLOSURE STATEMENT
No potential conflict of interest was reported by the author(s).
Notes
1 We define a traditional hospital ethics committee as one that reflects the historical ethics committee structure and functions—a multidisciplinary committee of volunteers tasked with ethics consultation, education, and policymaking that meets regularly, often monthly. We define a professional clinical ethicist as someone who has at least basic-level proficiency in clinical ethics consultation and competency to manage non-consultation aspects of ethics work (such as education development and delivery, as well as policy work) and whose full-time equivalent (FTE) is entirely dedicated to clinical ethics work. By basic-level proficiency we draw on the work of Fox et al. (Citation2022b, 3 note 1) to mean clinical ethicists who are “able to perform common and straightforward consultations without supervision,” as opposed to novice-level proficiency, meaning “unable to perform ethics consultations without supervision,” or advanced-level proficiency, meaning “able to perform the most complex ethics consultations without supervision.”
2 For example, 47.1% of respondents to Fox et al.’s study reported being “not at all familiar” with ASBH’s Core Competencies (Fox et al. Citation2022b, 26). The study authors note that their findings suggest that “in many hospitals, . . . individuals who perform [ethics consultation] do not view it as a professional activity that requires a great deal of training or expertise” (Fox et al. Citation2022b, 28). Relatedly, study data indicate that “in most hospitals, ethics practitioners thought it should take fewer than 20 hours to train someone to perform [ethics consultation] at the basic level, and fewer than 40 hours to train someone to perform [ethics consultation] at the advanced level” (Fox et al. Citation2021), which is far less training than most professional clinical ethicists have. We assert that competencies and standards should account for the full range of practice within the field—including at non-academic medical centers or hospitals in non-urban locations. Among respondents in the aforementioned study, it is unclear what they used as a basis for self-evaluation. We find it challenging that there is overlap between those claiming to be unfamiliar with standards in the field as outlined in Core Competencies and those evaluating the needs of their own programs or amount of training required to meet those needs.
3 The requirement that hospitals have a “mechanism” to address ethical issues has since ended and a different requirement that hospitals utilize a process for resolving ethical issues in patient care has taken its place. See Aaron et al. (Citation2022). Of note, the Joint Commission temporarily eliminated this newer clinical ethics standard in February 2023 but reinstated the standard with minor changes effective August 2023 (Joint Commission Citation2022; Joint Commission Citation2023; see also Letter to ASBH Citation2023; McLeod-Sordjan, Swindler, and Fins Citation2023; Brown, Riches, and McLeod-Sordjan Citation2023).
4 The Fox et al. study does not provide an estimate of the number of professional clinical ethicists practicing ethics consultation in U.S. hospitals. Our interpretation of the study data is that 2% of ethics consultation practitioners have a primary professional identity as an ethicist based on the cited figure. While individuals who have a primary professional identity as a physician or social worker may be doing ethics consultation, we would distinguish those who engage in ethics consultation from those who work as professional clinical ethicists. See footnote 1. Of note, the Fox et al. study also provides that 23.7% of respondents indicated their main role included the term “ethics” or similar (Fox et al. Citation2022a, 12). This data point seems to contradict the 2% data point. Without further explanation, and because it is our experience that far less than a quarter of hospitals have a dedicated ethicist, our interpretation is that respondents’ may have considered roles like “ethics committee member” or “ethics committee chair” when answering this question and may have been considering their main ethics role in connection with study participation.
5 We note that a single professional clinical ethicist may be sufficient to replace an ethics committee at a single hospital, or even at a small health system. However, we recognize that a single ethicist may be insufficient to support a large health system. The exact ethicist-to-bed ratios that may be sustainable fall outside the scope of this paper. Our proposal assumes adequate staffing. Other commentators have published on staffing models (see Gremmels Citation2020; Repenshek Citation2021).
6 ASBH’s Core Competencies call for ensuring that at least one member of the ethics consultation team has advanced training in several knowledge competency areas (Core Competency Task Force Citation2011, 27). We believe this is inadequate and this competency should be updated to require more of ethics consultation services. Additionally, as noted by Ong et al. (Citation2020), most training programs for hospital ethics committees fail to cover all elements and competencies defined in ASBH’s Core Competencies. As such, while no one form of training is necessarily perfect, training that is specifically tailored to ASBH’s Core Competencies will be superior to training that does not take into account the Core Competencies.
7 As a caveat, an output/input ratio of one-third is a rough figure, meant to capture the general concept that simply meeting for self-education or enjoying camaraderie on a friendly ethics committee is not enough to justify the committee’s continued existence in a hospital or health system with professional ethicists.
8 We offer this hypothetical not to create a strawman but to provide an example of a situation that matches many of our experiences. We include assumptions that we think are reasonable for an average health system and we articulate these assumptions explicitly and concretely so others can compare and contrast their own experiences.
9 The figure of 2,460 hours per year is calculated by adding total time spent on ethics consultation (4 persons x 4 hr per person x 15 consults per yr x 5 hospitals) to time spent preparing for (1 person x 12 meetings x 2 hr per meeting x 5 ethics committees) and attending (20 persons x 50% attendance x 1.5 hr per meeting x 12 meetings per year x 5 ethics committees) committee meetings to time spent attending regional educational sessions (20 persons x 5 committees x 20% attendance x 12 meetings per year x 1 hr per meeting).
10 For a physician-dominant ethics committee, we draw on the disciplinary composition outlined in the work of Courtwright et al. (Citation2014), with revisions to simplify the model. Specifically, we assume the composition is 45% physician (with 1/10 being residents), 10% social worker, 18% nurse practitioner or specialist, 8% registered nurse, 4% chaplain, 8% other healthcare provider, 5% hospital administrator, and 2% ethics. For a more balanced, multidisciplinary hospital ethics committee, we assume the composition is 20% physician (with 1/10 being residents), 12% social worker, 20% nurse practitioner or specialist, 12% registered nurse, 6% chaplain, 18% other healthcare provider, 8% hospital administrator, and 4% ethics. Utilizing wage data from the Bureau of Labor Statistics and publications that report attending physician and resident salaries produces the estimated hourly wages for a generic ethics committee member under both models, as described in more detail in the Appendix.
11 Wasserman et al. (Citation2023) show that the average salary in 2021 for a clinical ethicist consultant who holds a non-clinical doctorate was $146,134.85 and that those who hold clinical doctorates average higher salaries, while those holding a master’s degree average lower salaries. To calculate the average wage in 2022 dollars, we multiplied the annualized compensation figure for ethicists holding a non-clinical doctorate reported by Wasserman et al. for 2021 by 6.1% per the Federal Reserve’s estimate of nominal wage growth from 2021 to 2022 (Gregory and Harding Citation2023).
12 $70.35 x 29.1 hours per week x 52 weeks = $106,454.
13 See footnote 3 for information about evolving Joint Commission standards.
14 We would like to express our gratitude to one of the reviewers for this potential counterargument.
15 It is worth noting in this context that in one empirical assessment of ethics committee success, data suggested that “the higher the rank of the chairperson, the lower the success of the committee” (Scheirton Citation1992, 347).
16 The PCE-primary model has been implemented at Wellstar Health System, and its ethics program is currently drafting a manuscript detailing the experiences of implementing this new model. Cleveland Clinic is also in the process of shifting to a PCE-primary model that replaces traditional ethics committees with complementary and integrated networks of healthcare professionals and community members. Nevertheless, we describe our proposal as aspirational in the sense that many hospitals and health systems may not have the resources or support for implementation at this time.