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AbstractRacism is a pervasive issue in patient care and a key social determinant of health. Clinical ethicists, like others involved in patient care, have a duty to recognize and respond to racism on both individual and systems-wide levels to improve patient care. Doing so can be challenging and, like other skills in ethics consultation, may benefit from specialized training, standardized tools and approaches, and practice. Learning from existing frameworks and tools, as well as building new ones, can help guide clinical ethicists to systematically approach racism as it affects clinical cases. Here, we propose an expansion of the commonly used four-box method to clinical ethics consultation, where racism is considered as a potential factor in each of the four boxes. We apply this method to two clinical cases to highlight ethically salient information that might be missed using the standard formulation of the four boxes but captured with the expanded version. We argue that this expansion of an existing clinical ethics consultation tool is ethically justified insofar as it ( a ) creates a more just approach, ( b ) supports individual consultants and services, and ( c ) facilitates communication in contexts where racism impinges on effecting good patient care.

Proficient listening has been viewed as a critical skill in HEC (healthcare ethics consultation) from the inception of the practice, and it is included in the field's set of core competencies that practitioners need to master to become a certified healthcare ethics consultant (HEC-C). Despite its centrality to the work of HEC, practitioners and trainees receive little or no formal training in the craft of listening, and there are few available resources that ethics consultants and trainees can access to enhance their listening skills. This dearth of training in the skill of listening belies the enormous challenge of listening proficiently. Although many clinical ethics researchers refer to the need for "active listening" in HEC, the term is employed without description or instruction. In this article, I argue that a more helpful depiction of the requisite skill is conveyed by the term "diagnostic listening." After describing the strategy of diagnostic listening, I introduce a novel technique for honing the listening skills needed for HEC: the ADEPT Model. The ADEPT Model is a tool that can begin to fill the training gap for this important skill., (Copyright 2022 The Journal of Clinical Ethics. All rights reserved.)

Efforts to professionalize the field of bioethics have led to the development of the Healthcare Ethics Consultant-Certified (HEC-C) Program intended to credential practicing healthcare ethics consultants (HCECs). Our team of professional ethicists participated in the inaugural process to support the professionalization efforts and inform our views on the value of this credential from the perspective of ethics consultants. In this paper, we explore the history that has led to this certification process, and evaluate the ability of the HEC-C Program to meet the goals it has set forth for HCECs. We describe the benefits and weaknesses of the program and offer constructive feedback on how the process might be strengthened, as well as share our team's experience in preparing for the exam.

With the Healthcare Ethics Consultant Certification (HEC-C) offered through the American Society for Bioethics and Humanities (ASBH), the practice of clinical ethics has taken a decisive step into professionalization. But without an unambiguous sense of what clinical ethicists can contribute to the clinical environment, it is unclear what the HEC-C ensures clinical ethicists can do. Though the ASBH enumerates a set of core competencies, many disagree over what role those competencies empower ethicists to serve. Two recent publications are notable for advocating conflicting positions on the question of ethicists' competence: "Ethics Expertise: What It Is, How to Get It, and What to Do with It" by Christopher Meyers (2018) and Rethinking Health Care Ethics by Stephen Scher and Kasia Kozlowska (2018). In response to Scher and Kozlowska's argument that the primary role of ethicists is to create space to engage clinician's moral intuitions, this analysis follows Meyers in contending that ethicists can also contribute a kind of moral expertise. However, acquiring moral expertise is no easy task, and it is unlikely to be substantiated by a certification exam. This analysis draws on research from the psychology of expertise to outline the sort of training needed to cultivate and enhance moral expertise.

Ethical challenges are inherent in oncology clinical practice. Ranging from transitions in care to code status and treatment decisions, these ethical challenges can have an acute effect on nurses, with well-established connections to moral distress and other psycho-emotional sequelae. The availability of a nurse ethicist can provide invaluable resources to support nurses in awareness of ethical challenges and support for ethical decision making in practice.

The authors of this article are previous or current members of the Clinical Ethics Consultation Affairs (CECA) Committee, a standing committee of the American Society for Bioethics and Humanities (ASBH). The committee is composed of seasoned healthcare ethics consultants (HCECs), and it is charged with developing and disseminating education materials for HCECs and ethics committees. The purpose of this article is to describe the educational research and development processes behind our teaching materials, which culminated in a case studies book called A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care (hereafter, the Study Guide). In this article, we also enumerate how the Study Guide could be used in teaching and learning, and we identify areas that are ripe for future work.

This article discusses the approach of the Clinical Ethics Consultation Advisory Committee (CECA) in developing A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care. This article addresses the processes used by the CECA, its use of pivot questions intended to encourage critical reflection, and the target audience of this work. It first considers the salience of case studies in general education and their relevance for training ethics consultants. Second, it discusses the enfolding approach used in presenting the case material designed to engage the trainee in the details of the case while stimulating critical reflection. And, third, this article briefly comments on the target audience with the caveat that even superbly developed cases are prone to misuse, although that prospect should not deter their development., (Copyright 2018 The Journal of Clinical Ethics. All rights reserved.)

This pilot study reports on a survey regarding recruitment, appointment, and training of members for health care ethics committees (HCECs)., Background: Past studies have examined HCECs, but have focused on the roles of the committees and the broad makeup of membership. Thus, our study fills an important knowledge gap in trends of membership recruitment and appointment processes employed by HCECs to comprise their membership., Methods: We posted our survey on several bioethics listservs between June and August 2015. Of the 103 respondents that started the survey, 59 were eligible for inclusion based on our criteria. We analyzed survey results descriptively and qualitatively., Results: Overall we found no unifying standards of recruitment or appointment across the 59 respondents. Additionally, while responding committees varied in the professional backgrounds and attributes they valued in potential members, we found that most respondents valued traits of the applicants over specific knowledge or skills., Conclusions: This study provides a first look into how HCECs recruit members. Future research is needed to better understand the complexities of the issues discovered during this study, given that the HCEC members appointed are the individuals who fulfill committee obligations.

Nurses, one of the most trusted professional groups in our society, work with patients and their families at all stages of the illness trajectory. Nurse bioethicists are a small but special subset of the nursing profession and bioethics community, focusing on the moral complexities that arise in clinical care, research, and health policy. This article examines the career trajectory of a nurse bioethicist and the clinical, educational, and research experiences that shaped her career goals. It also addresses the uniqueness of nursing and the ethical challenges that nurse's encounter in their day-today interactions with diverse patient populations and calls for distinct conceptual and empirical bioethics inquiry. Training the next generation of nurse bioethicists requires a dialogue with nursing and bioethics scholars on the academic and philosophical skill set and mentorship requirements that will advance and contribute to the broader public good.

A study by the Catholic Health Association indicates that the national Catholic health care ministry may lose as many as 70 percent of its ethicists by the year 2031. Though about 2 of every 3 ethicists are now over the age of 50, there is a significant lack of succession planning for these vital positions in Catholic health care organizations.¹

Several recent articles have weighed in on the question of whether moral philosophers can be counted as moral experts. One argument denying this has been rejected by both sides of the debate. According to this argument, the extent of disagreement in modern moral philosophy prevents moral philosophers from being classified as moral experts. Call this the Argument From Disagreement (AD). In this article, I defend a version of AD. Insofar as practical issues in moral philosophy are characterized by disagreement between moral philosophers who are more or less equally well credentialed on the issue, non-philosophers have no good reasons to defer to their views., (© 2015 John Wiley & Sons Ltd.)

The problems of racism and racially motivated violence in predominantly African American communities in the United States are complex, multifactorial, and historically rooted. While these problems are also deeply morally troubling, bioethicists have not contributed substantially to addressing them. Concern for justice has been one of the core commitments of bioethics. For this and other reasons, bioethicists should contribute to addressing these problems. We consider how bioethicists can offer meaningful contributions to the public discourse, research, teaching, training, policy development, and academic scholarship in response to the alarming and persistent patterns of racism and implicit biases associated with it. To make any useful contribution, bioethicists will require preparation and should expect to play a significant role through collaborative action with others.

Professional mediators have long possessed a skill set that is uniquely suited to facilitation of difficult conversations between and among individuals in emotionally charged situations. This skill set has increasingly been recognized as invaluable to the work of clinical ethics consultants as they navigate conflicts involving families, surrogates, and providers. Given widespread acknowledgment that communication difficulties lie at the root of many clinical ethics conflicts, mediation offers techniques to enhance communication between conflicting parties. This special section of The Journal of Clinical Ethics focuses on core aspects of the mediation process designed for effective management of clinical conflict emanating from communication breakdowns, highly charged value conflicts, and instances of perceived disrespect., (Copyright 2015 The Journal of Clinical Ethics. All rights reserved.)

Bioethics mediators manage a wide range of clinical conflict emanating from diverse sources. Parties to clinical conflict are often not fully aware of, nor willing to express, the true nature and scope of their conflict. As such, a significant task of the bioethics mediator is to help define that conflict. The ability to assess and apply the tools necessary for an effective mediation process can be facilitated by each mediator's creation of a personal compendium of sources that generate clinical conflict, to provide an orientation for the successful management of complex dilemmatic cases., (Copyright 2015 The Journal of Clinical Ethics. All rights reserved.)

Contrasting traditional and common forms of ethics consultation with bioethics mediation, I describe the case of a "second opinion" consultation in the care of a patient with advanced cancer for whom treatment was futile. While the initial ethics consultation, performed by a colleague, led to a recommendation that some may deem ethical, the process failed to involve key stakeholders and failed to explore the underlying values and reasons for the opinions voiced by various stakeholders. The process of mediation ultimately led to creative solutions in which all stakeholders could reach consensus on a plan of care., (Copyright 2015 The Journal of Clinical Ethics. All rights reserved.)

Internationally, there is an on-going dialogue about how to professionalize ethics consultation services (ECSs). Despite these efforts, one aspect of ECS-competence that has received scant attention is the liability of failing to adequately capture all of the relevant moral considerations in an ethics conflict. This failure carries a high price for the least powerful stakeholders in the dispute. When an ECS does not possess a sophisticated dexterity at translating what stakeholders say in a conflict into ethical concepts or principles, it runs the risk of naming one side's claims as morally legitimate and decrying the other's as merely self-serving. The result of this failure is that one side in a dispute is granted significantly more moral weight and authority than the other. The remedy to this problem is that ECSs learn how to expand the diagnostic moral lens they employ in clinical ethics conflicts., (© 2014 John Wiley & Sons Ltd.)

In light of the ongoing development and implementation of core competencies in bioethics, it is important to proceed with a clear sense of how bioethics knowledge is utilized in the functioning of hospital ethics committees (HECs). Without such an understanding, we risk building a costly edifice on a foundation that is ambiguous at best. This article examines the empirical relationship between traditional paradigms of bioethics theory and actual decision making by HEC members using survey data from HEC members. The assumption underlying the standardization of qualifications and corresponding call for increased education of HEC members is that they will base imminent case decisions on inculcated knowledge. Our data suggest, however, that HEC members first decide intuitively and then look for justification, thereby highlighting the need to re-examine the pedagogical processes of ethics education in the process of standardizing and improving competencies., (Copyright 2015 The Journal of Clinical Ethics. All rights reserved.)

Checklists have been used to improve quality in many industries, including healthcare. The use of checklists, however, has not been extensively evaluated in clinical ethics consultation. This article seeks to fill this gap by exploring the efficacy of using a checklist in ethics consultation, as tested by an empirical investigation of the use of the checklist at a large academic medical system (Cleveland Clinic). The specific aims of this project are as follows: (1) to improve the quality of ethics consultations by providing reminders to ethics consultants about process steps that are important for most patient-centered ethics consultations, (2) to create consistency in the ethics consultation process across the medical system, and (3) to establish an effective educational tool for trainers and trainees in clinical ethics consultation. The checklist was developed after a thorough literature review and an iterative process of revising and testing by a group of experienced ethics consultants. To pilot test the checklist, it was distributed to 46 ethics consultants. After a six-month pilot period in which ethics professionals used the checklist during their clinical activities, a survey was distributed to all of those who used the checklist. The 10-item survey examined consultants' perceptions regarding the three aims listed above. Of the 25 survey respondents, 11 self-reported as experts in ethics consultation, nine perceived themselves to have mid-level expertise, and five self-reported as novices. The majority (68 percent) of all respondents, regardless of expertise, believed that the checklist could be a "helpful" or "very helpful" tool in the consultation process generally. Novices were more likely than experts to believe that the checklist would be useful in conducting consultations. The limitations of this study include: reduced generalizability given that this project was conducted at one medical system, utilized a small sample size, and used self-reported quality outcome measures. Despite these limitations, to the authors' knowledge this is the first investigation of the use of a checklist systematically to improve quality in ethics consultation. Importantly, our findings shed light on ways this checklist can be used to improve ethics consultation, including its use as an educational tool. The authors hope to test the checklist with consultants in other healthcare systems to explore its usefulness in different healthcare environments., (Copyright 2014 The Journal of Clinical Ethics. All rights reserved.)

The literature fails to reflect general agreement over the nature of the services and procedures provided by bioethicists, and the training and core competencies this work requires. If bioethicists are to define their activities in a consistent way, it makes sense to look for common ground in shared communities of practice. We report results of a survey of the services and procedures among bioethicists affiliated with the University of Toronto Joint Centre for Bioethics (JCB). This is the largest group of bioethicists working in healthcare organizations in Canada. The results suggest there are many common services and procedures of JCB bioethicists. This survey can serve as a baseline for further exploration of the work of JCB bioethicists. Common practices exist with respect to the domains of practice, individual reporting relationships, service availability within business hours and the education and training of the bioethicist.

Clinical ethics consultants represent a multidisciplinary group of scholars and practitioners with varied training backgrounds, who are integrated into a medical environment to assist in the provision of ethically supportable care. Little has been written about the degree to which such consultants are accountable for the patient care outcome of the advice given. We propose a model for examining degrees of internally motivated accountability that range from restricted to unbounded accountability, and support balanced accountability as a goal for practice. Finally, we explore implications of this model for training of clinical ethics consultants from diverse academic backgrounds, including those disciplines that do not have a formal code of ethics relating to clinical practice.

In contrast to issues such as treatment and research consent capacity, financial capacity has received relatively little clinical and ethical attention in the dementia literature. Yet issues of financial capacity emerge frequently in patients with Alzheimer disease, Parkinson disease, and related dementias, and commonly present ethical and clinical challenges for clinicians treating these patients. These issues include whether a patient with possible dementia has sufficient capacity to manage independently their financial affairs, needs referral for financial capacity assessment, and/or is being financially exploited or abused by others. The accurate identification, assessment and successful handling of such financial capacity issues can have a substantial impact on the financial and psychological well-being of patients and their family members. This commentary presents an overview of financial capacity and associated clinical and ethical issues in dementia and describes a set of possible clinician roles regarding these issues as they arise in clinical practice. The commentary concludes with a section describing educational resources available to clinicians and bioethicists seeking additional guidance in handling financial capacity issues. The ultimate goal of the article is to focus clinical and ethical attention on a neglected capacity that is of fundamental importance for patients, families, and healthcare and legal professionals., (Copyright © 2013 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

This commentary asks whether ongoing efforts to accredit, certify, and credential hospital ethics consultants are nothing other than an illegal restraint on trade masquerading as an effort to protect the public from harm.

In response to national trends calling for increasing accountability and an emerging dialogue within bioethics, we describe an effort to credential clinical ethicists at a major academic medical center.This effort is placed within the historical context of prior calls for credentialing and certification and efforts currently underway within organized bioethics to engage this issue.The specific details, and conceptual rationale, behind the NewYork-Presbyterian Hospital's graduated credentialing plan are shared as is their evolution and ratification within the context of institutional policy. While other programs will design their credentialing schema consistent with their local context and demographics, the description of one such effort is offered to be instructive to others who want to bring additional standardization to the assessment of the readiness and credentials of those who will engage in the practice of clinical ethics case consultation.

Most hospitals and nursing homes have individuals who engage in ethics consultation, and most do so with very little, if any, training. The goal of this article is not to advance the scholarly literature on training clinical ethics consultants, but instead to provide a road map for individuals doing ethics consultation who would like more training. In this way, I hope to advance the field in some small way, by educating, empowering, and encouraging small- to medium-sized hospitals to train the members of their ethics committee who engage in ethics consultation.

The movement advocating the formal certification of clinical ethics consultants may result in major changes to the field of clinical ethics consultation by creating a new standard of care. The actual certification process is still in the development phase, but unanswered questions include: What will certification cost, and, Who will pay? Currently there is little salary support for ethics consultants and no regulation requiring healthcare institutions to offer clinical ethics consultation. Without the support of healthcare administrators and accreditation bodies, this may remain unchanged. Healthcare administrators may be unwilling to pay for certification or professional services if accreditation bodies do not require healthcare institutions to provide certified ethics consultants' services. If consultants will not be reimbursed or paid, they may not seek certification. If certified consultants are required, healthcare administrators may look for ways to cover the costs for providing this service, including insurance or third-party reimbursement and direct billing of patients for consultations, which may affect who performs and who participates in ethics consultation. However, this is less than ideal, as bioethicists believe ethics consultation should be available to all as part of providing safe, quality ethical care and support and guidance for patients, families, and healthcare staff. Going forward, bioethicists should study quality improvement, patient safety, and cost-savings resulting from certification-eligible clinical ethics consultants' activities. Administrators and financial personnel can be surveyed regarding their support for the certification process. Bioethicists should enlist the help of patient rights and safety advocacy groups, professional medical associations, and healthcare administrators. Bioethicists should invite accreditation bodies, healthcare administrators, and financial personnel to collaborate in the development of the certification process. Without their support, certification may be of value only to the bioethics community, and may have little standing in actual clinical healthcare institution settings.