Bruce D. White

Structuring a Written Examination to Assess ASBH Health Care Ethics Consultation Core Knowledge Competencies

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities (ASBH) has published core knowledge competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models—both objective and written—must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization.

Realistic Goals and Expectations for Clinical Ethics Consultations: We Should Not Overstate What We Can Deliver

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In Particular Circumstances Attempting Unproven Interventions Is Permissible and Even Obligatory

Shah, Wendler, and Danis (2015) consider whether it can be permissible to offer certain types of “unproven” interventions to seriously ill patients. They view unproven treatments as those “with a limited evidence basis to patients outside the context of research” and as those “given without prior testing in humans for safety and/or efficacy” (12). The limited situations they discuss against the backdrop of the Ebola crisis appear unnecessarily to weight arguments against interventions that have not been proven by a relatively high evidence-based standard akin to the double-blinded, randomized controlled trial (RCT) or some other irrefutable benchmark. This overly stringent standard of evaluation risks distorting the more commonly accepted understanding of when interventions are permissible and obligatory. For example, as the authors point out, there appears to be historical precedent for using unproven interventions in some cases, particularly when the patient is dying, and when mainstream or “accepted” treatments are not effective or beneficial. In such situations it seems reasonable that physicians are permitted and even obligated to offer unproven interventions when the risk–benefit ratio assessment undeniably tilts in the patient’s best interests, and the patient’s preferences are respected. However, the evidence on which a responsible physician makes this assessment rarely meets an RCT-like standard or analysis. In many cases, these interventions are contestable and open to debate, but may still meet the threshold for permissibility. It may be useful here to recall the ethical arguments that HIV–AIDS patients made in the early 1980s when the context for understanding and treating HIV–AIDS was somewhat comparable to Ebola. Those arguments supported offering unproven—yet believed by some to be possibly effective—treatments earlier than would be possible if subjected to RCT-like evaluation and before being “approved” by some authoritative entity or “widely accepted” by physicians. (Fauci 2012) Patients at risk then claimed that a health care delivery system interested in promoting good care for individuals who are seriously ill or dying (beneficence), and in providing better care for the community (justice), should counterbalance provider fears or worries, within reason, about the possible harms from unproven or unapproved treatments (nonmaleficence). Recently, these patient and physician views were dramatically portrayed in the Academy Award-winning Dallas Buyers Club (Borten and Wallack 2013). Such contexts permit and may require physicians to tailor medical interventions and employ modified standards of informed consent in ways that acknowledge the evolving and dynamic nature of situations that do not permit the imprimatur or luxury of knowledge gained from RCTs. Of course, there are professional limits to what interventions are morally permissible for dying patients. Even in situations where the physician determines that there is “nothing to lose” in the care of a dying patient by trying an unproven intervention, the assessment still must—first and foremost—be based on a reasonable belief that more benefit than harm will follow, even if the benefit is marginal. It is this due diligence assessment of available evidence and sound

Healthcare ethics and pain management

The phrase professional ethics is used to describe more accurately the study of the right conduct of professionals (such as physicians and pharmacists) and the critical examination of how professional persons might determine which professional acts or behaviors are ethical or right. Effective pain management has been an ethical obligation of physicians and pharmacists since the professions were first recognized. Few ancient or modern references are necessary to support this idea and acknowledged professional commitment. Four hypothetical cases dealing with pain management presented in the following review may offer opportunity for practice ethics issue identification and analysis. Ethical dilemmas are by their very nature not settled without difficulty, sometimes many difficulties. The number of ethics dilemmas about pain management that physicians and pharmacists will face in the future is certain to increase.

Balancing the Surgeon’s Responsibility to Individuals and Society

While there are real dangers involved with surgical innovation, calling for vigilance in safeguarding patient well-being and autonomy, it is important not to overplay the dangers of innovation or underplay its benefits. One only needs to consider the history of surgical innovation to understand this point (Science 200:937–941, 1978). That history suggests that physicians should—to the degree possible—consider, suggest, and provide insightful, studied, and cogent innovative treatments that are peer-acknowledged—accepted, or—reviewed, while taking care to balance their obligation to respect patient autonomy and benefit their patients. To achieve this balance, it is essential for innovative practitioners to be thoroughly embedded in, and engaged with, their peers in the medical community. Certainly it would be awkward, if not almost impossible, for a reasonably prudent, competent physician to offer an unproven treatment as a lone wolf, acting in a manner radically afield from similarly situated practitioners, without some collegial involvement and support.

The Process to Accredit Clinical Ethics Fellowship Programs Should Start Now

in the Core Competencies, would that consultant be disqualified?What if the applicant explains that ethics consultants at his institution never talk with patients? Would that matter? It should not if the goal is to assess an individual’s competency. If an applicant’s chart notes are dismal, but her philosophy statement and recommendations are good, could she pass?What if the consultant does not sufficiently understand the salient clinical dimensions of the case? There should be lines no one can cross.What are they? I see the wisdom in quality attestation, but with the proliferation of academic and fellowship programs, equal attention should be devoted to accrediting training programs, perhaps replacing quality attestation in the years ahead. Many of the conflict resolution and communication skills necessary in CEC are nurtured in clinical training and practice. These skills are also easily incorporated into ethics fellowship, graduate, and certificate programs. What clinical programs do not teach are the distinguishing characteristics of an ethics consultant: aptitude in clinical ethics and moral reasoning. If a portfolio is submitted demonstrating vague understanding of clinical details, I suspect the problem would be noticed immediately and I am skeptical that the portfolio would “pass.” However, vague or insufficient ethical analysis might actually raise fewer concerns. An ethics consultant who does not understand ethics is like a nephrologist who does not understand kidney disease. I am happy to report that I successfully completed Phase I. But if my scores were low, would that mean I was not qualified? Would I be convinced that someone who passed the quality attestation process was ready for our consultation team? I am not sure, but the quality attestation process moves our profession miles in the right direction. I will continue to participate and provide constructive feedback because trial and error are necessary for success, and if we are committed to improving, we will. In other words, I am still “all in.” Wish me luck on Phase II. &

Putting Children at Risk in the Name of Religion.

ISSN: 1526-5161 (Print) 1536-0075 (Online) Journal homepage: http://www.tandfonline.com/loi/uajb20 Putting Children at Risk in the Name of Religion Wayne N. Shelton & Bruce D. White To cite this article: Wayne N. Shelton & Bruce D. White (2016) Putting Children at Risk in the Name of Religion, The American Journal of Bioethics, 16:1, 32-33, DOI: 10.1080/15265161.2015.1115144 To link to this article: http://dx.doi.org/10.1080/15265161.2015.1115144

Becoming a Competent Ethics Consultant: Up to Code?

defined differently in different settings, or defined in terms of the CEC model adopted in a given case—before the code of ethics can be sufficiently elaborated to serve as a real-world guide. I expect that the “integrity” portion of this code (except for the bits that seem really to deal with conflicting interests), like the “justice” portion, will see little use. Whether the other portions of the code become useful will depend in part on whether a practical means for their elaboration and application can be set up. Perhaps, following the lead of many professional associations, the American Society for Bioethics and Humanities (ASBH) could formally establish an ethics committee to apply the provisions of the code to particular cases, and to elaborate a “common law” of code interpretation. Whether the code obtains community sanction may also depend upon whether CEC becomes central enough in health care decision making to become the target of litigation, as institutional review boards (IRBs) have begun to be. And finally, it may depend upon whether the models of CEC can become sufficiently standardized that the duties of consultants (whether as agents or as neutrals) can be seen to flow from them in a consistent, predictable fashion. One day, perhaps, fat, annotated versions of this code may sit on the shelves of medical malpractice attorneys and human resources officers and hospital compliance officers everywhere. If that day arrives, CEC will have professionalized. &