Abstract
In the process of professionalization, the American Society for Bioethics and Humanities (ASBH) has emphasized process and knowledge as core competencies for clinical ethics consultants; however, the credentialing program launched in 2018 fails to address both pillars. The inadequacy of this program recalls earlier critiques of the professionalization effort made by Giles R. Scofield and H. Tristram Engelhardt, Jr.. Both argue that ethics consultation is not a profession and the effort to professionalize is motivated by self-interest. One argument they offer against professionalization is that ethics consultants lack normative expertise. Although the question of expertise cannot be resolved completely, the accusation of self-interest can be addressed. Underlying these critiques is a concern for hubris, which can be addressed in certification and the vetting of candidates.
Drawing on the virtue ethics literature of Alasdair MacIntyre and Edmund D. Pellegrino, I argue that medicine is a moral community in which ethics consultants are moral agents with a duty to foster the virtue of humility (or what Pellegrino and Thomasma call self-effacement). The implications of this argument include a requirement for self-reflection in one’s role as a moral agent and reflection on one’s progress toward developing or deepening virtuous engagement with the moral community of medicine. I recommend that professionalization of clinical ethics consultants include a self-reflective narrative component in the initial certification and ongoing renewal of certification where clinical ethics consultants address the emotional dimensions of their work as well as their own moral development. Adopting a teleological view of ethics consultation and incorporating narratives that work toward that purpose will mitigate the self-interest and hubris of the professionalization project.
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Notes
Materials on ASBH certification are taken from two documents, The Core Competencies and the HCEC Certification Commission’s document on the HEC-C exam (Tarzian et al., 2011). The documents are available at ASBH.org. For additional information on the credentialing effort, see also Kodish et al., (2013).
A target article and many of its commentaries in a recent issue of the American Journal of Bioethics share my concerns. See Claire Horner, et al., “What the HEC-C?“ (2020). See also the 30th anniversary issue of the Journal of Clinical Ethics (Siegler, 2019).
Part of the problem that Horner, et al. identify with the credentialing program ASBH launched in 2018 is confusion about goals. It is unclear whether certification is to indicate competence or a minimum threshold. Horner, et al. demonstrate that ASBH equivocates on the matter. (Horner, et al., 2020) Competence would be better than a minimum threshold given the moral weight of the role. I use the word “trustworthy” here because a credential communicates that one can be trusted to fulfill the duties of a profession.
Terminology has varied throughout the discussion on credentialing ethics consultation. I use “healthcare ethics consultation” and its abbreviation, HEC, throughout this paper. To refer to healthcare ethics consultants as persons, I use the phrase “ethics consultant” unless it specifically applies to those who are already credentialed or hypothetically credentialed. For those credentialed ethics consultants, I use the abbreviation HEC-C(s). Where HEC is too narrow, I use the term “bioethics” or “bioethicist” to refer to the entire discourse and discipline.
I am indebted to Friedrich (2018) for labeling this moment an “identity crisis.”
I contend that Engelhardt may be overstating the difference here. For the purposes of this paper, I accept his view because it elucidates the problem of pluralism and a lack of metaphysical foundation within HEC. This problem may also be a part of the etiology for other health care disciplines, but that factor is not relevant to this paper.
Certainty and uncertainty have been key aspects of the ethics expertise debate. The disagreement comes down to whether (and the degree to which) moral uncertainty delegitimizes a claim to expertise. For an example, see the debate between Brummett & Ostertag and Rasmussen in HEC Forum (2018).
Arnold’s work on culture has been controversial. For a thorough and sympathetic look at Arnold and his Victorian context, see Caufield (2012).
I do not share every aspect of Engelhardt’s view of this history or his dismay at the loss of moral certainty at the end of Christendom. I do agree that shared religion provided a shibboleth for trustworthiness that our pluralist society lacks. I agree that the loss of that shibboleth (regardless of whether it was effective or not) created a need that bioethics filled.
The way ethics consultation services have arisen within American health care organizations suggests this view. It is not a billable service but an ancillary service to the department of medicine. Credentialing has the potential to embolden ethics consultants to start billing.
In defense of credentialing, Dubler et al. (2009) argue that salaries are required for the necessary work to be done. Compensated time indicates that institutions are dedicated to providing quality services rather than expecting the work to be done in volunteer service time.
Uwe Reinhardt (2019) has shown how the rising costs of health care are in part due to the increase in administrative and ancillary care roles in health care organizations while the roles that provide bedside care have not seen staffing increases in decades. The public has good reason to wonder why we need ethics consultants when we are so short on nurses.
Indeed, Horner et al., (2020) suggest it barely meets a minimum threshold of knowledge.
There is good reason to consider whether a sectarian approach to credentialing would be better. Catholic health care has unique requirements of HEC that stem from the organizations’ ecclesial relations.
For an extended argument in favor of this alternative view see Kevin Wildes, Moral Acquaintainces (2000).
Brummett and Salter critique the ASBH taxonomy for forcing the debate into three options which do not actually reflect the diversity of opinions. Indeed, the taxonomy ASBH offers creates a goldilocks situation, so that the preferred model (facilitation) is seen as the mean between two extremes (authoritarian and consensus). Salter and Brummett deftly argue that this is a false paradigm. Too many important distinctions are conflated into the two extremes. Their taxonomy is more complex and more reflective of the debate than the one ASBH used in the Core Competencies report.
Kodish, et al. (2013) recommended a two-phase approach that included requiring a portfolio of evidence that a candidate for certification was qualified. We would do well to revisit that recommendation even though it would be a more labor-intensive process.
Ellen Fox presents an argument for why contracting with a testing company is a good approach, and it relates to expertise in testing to ensure quality standards for testing are met (Fox, 2014). This paper does not necessarily disagree with her, but it does challenge testing as the primary mechanism for credentialing.
“Developing valid and reliable measurement tools to demonstrate that individuals possess the required core competencies is a formidable endeavor. Knowledge is easier to test objectively than skills, which typically require resource-intensive observations. However, testing objective knowledge alone would fail to demonstrate that an individual had the requisite skills to practice [HEC] at an advanced level.” (Tarzian et al., 2011).
This critique was also offered by Horner et al. (2020) and many of their commentators.
In response to critiques, the second edition of the core competences changed the word “character” and its derivatives to its supposedly benign synonyms: “traits,” “behaviors,” and “attributes.” I infer from this change that some people do not like the connotations of the word character and its association with virtue ethics. As this paper relies on virtue ethics, the word character is perfectly appropriate and will be reclaimed.
It is worth noting here that the author has undergone the certification process in hospital chaplaincy. In 2016 the cost of board certification with the National Association of Catholic Chaplains was $475. That fee has since gone down to $395. The certification process includes a mentor chaplain, a host organization, an admin office, and a team of three certified chaplains who review a binder of written materials provided by the applicant and then conduct a one-hour interview with the applicant. Much of this labor is unpaid service that NACC counts toward continued education requirements for certification renewal. In contrast, ASBH charges members $495 for the HEC-C exam. Certification of chaplains is more labor intensive and more helpful in professional development, yet it is less expensive. This economic discrepancy cannot simply be explained by the difference in wages of each profession. Chaplains are doing more meaningful work for less money, and ASBH would do well to learn from their approach. This is especially true if cost containment is the justification for compromised rigor.
To be clear, the conscious intentions of the people involved in the credentialing effort are probably very noble. I do not intend to accuse anyone of bad intentions. I propose that the behavior indicates an unexamined motivation to hurry along the process, perhaps frustration and impatience with the way the metaethical debate about the nature of ethics expertise has stalled credentialing. See Ellen Fox’s characterization of the credentialing debate in 2014. I agree with her when she writes, “When I hear that ‘perfect is the enemy of the good,’ my thought is, ‘Yes, but not good is also the enemy of the good.’ I do not in any way mean to imply that perfection should be the goal. I am merely suggesting that ‘forging ahead’ has a number of significant downsides, given that the potential consequences of efforts to professionalize are significant. Because there are always better and worse ways to approach a problem, it’s important that we exercise due diligence to make sure our methods our [sic] sound.” (Fox, 2014).
Some may disagree that this is necessary. I am still concerned that HEC lacks a purpose if medicine has no clear purpose. I think much of our confusion about our own expertise comes back to this uncertainty about the ends of medicine. Revisiting our field’s roots as philosophers in the halls of medicine may help us to find some common vision for the profession.
It is not my aim in this paper to offer Pellegrino’s philosophy of medicine as a sweeping solution to these problems such that we only have to implement his vision. The debate about the social dimensions of disease as well as the complex relationship of mind, body, and soul will not be resolved by an appeal to teleology. Here I distinguish ultimate ends and proximate ends. Pellegrino and his followers take positions regarding specific procedures (proximate ends) that I do not endorse here. My hope is merely for a teleological approach to guide conversations in bioethics toward a shared understanding of the ultimate ends of medicine. If such a teleological approach to bioethics is embraced, there will still be room for robust discourse about the nature of healing and disease as well as how to integrate technology into life, but this discourse will be guided primarily by therapeutic goals that prioritize restoration of health over opportunities for enhancement.
Mark Siegler states something similar in his critique of the current iteration of HEC credentialing. He expresses concern that the current program does not require enough experience or understanding of clinical situations (Siegler, 2019).
Indeed many of the developments in bioethics and law have been around the protection of patients from exploitation in research and development. The problem may be rooted in deeper and more pervasive problems around the commodification of medicine and the injustices that inevitably arise from that mechanism for health care delivery. See Paul Farmer (2003). Granted, changing the health care delivery system is beyond in sphere of influence of HEC, but bioethicists should not become so resigned to the injustice that we both enable it and benefit from it.
For a good critique of this approach, see Friedrich (2018).
To Siegler’s point, it also requires more than 400 hours in the clinic (2019). Four hundred hours is barely enough to get oriented to the clinical culture.
This is what Lisa Rasmussen (2016, 2018) gets at with her “all-things-considered judgments.” Generally, HEC involves highly complex, “hard cases.” Brummett and Ostertag (2018) make a surprising accusation that her analysis of what HEC expertise entails leaves one either unable to recognize bad decisions or unable to resist bad decisions. They refer to an ethicist not “having the ‘teeth’” to call out an “obviously wrong decision.” What is at stake in this debate is courage, or trustworthiness to stand up to powerful people who proffer poor reasoning. The ability to recognize and defend against slipperiness and bullying is a high order social skill, and the willingness to do anything about it is a matter of character, not knowledge.
Matthew Arnold has an idea that is similar to self-effacement, called “self-renouncement,” which is heavily influenced by the work of Arthur Schopenhauer, who was influenced by The Upanishads. Arnold’s renouncement differs from Pellegrino’s self-effacement in its emphasis on detachment. As Pellegrino is coming from an Aristotelian tradition, “detachment” cannot be imposed on self-effacement. Although each of these ideas is helpful in thinking about placing limits on the will, I believe that Pellegrino and the virtue tradition are much more elpful to HEC than Arnold. Arnold relied on rhetoric as a tool for persuasion over careful moral argumentation, which he saw is ineffective. The virtue tradition offers a holistic approach by blending narrative and argument, drawing on both aesthetics and ethics. For more on Arnold’s “self-renouncement” see Caufield (2012).
In Fox, et al.’s empirical studies on HEC practice in the US (2007, 2022), they argue that credentialing is required for quality, but quality is not clearly defined. Quality is presumed to be the integration of recognized professionals in roles that provide HEC. This approach to quality is indistinguishable from the establishment of a guild. A guild is not bad, but a guild without a clear sense of what exactly it offers the public is bad. I have not seen a convincing explanation for why an HEC-C is a better person to counsel a patient or physician on clinical decision making than her local pastor or family attorney.
ASBH has embraced the proceduralism of these trailblazers in the field, yet Zaner is not mentioned anywhere in the literature on Core Competencies or HEC-C. Zaner’s warnings of hubris have been ignored or diminished in recent years.
For example, if a physician on the case that a HEC-C is consulting on has a close relationship with the HEC-C’s supervisor or a significant donor to the organization, the HEC-C would be motivated to remain in that physician’s good graces and tolerate conduct s/he would not from a less influential member of the interdisciplinary care team. Alternatively, the HEC-C could have strong camaraderie with a fellow clinician serving on a case and hope to publish together on the experience. Those goals would influence the attention given to the case.
I have written on this elsewhere. See Squires and Thornton (2022).
Because the consult is a pastoral care consult, theological analysis is included as well.
May (2020) makes the astute point that whatever we do for credentialing is only meaningful insofar as it affects standards for training new professionals. Educational programs will inevitably be affected by the requirements.
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Thornton, A. Credentialing Character: A Virtue Ethics Approach to Professionalizing Healthcare Ethics Consultation Services. HEC Forum (2023). https://doi.org/10.1007/s10730-023-09505-2
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DOI: https://doi.org/10.1007/s10730-023-09505-2