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The Ethics of Credentialing Clinical Ethics Consultants

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For a group of researchers from Weill Cornell Medical College and NewYork-Presbyterian Hospital, there's nothing more ethical than formalizing credentialing standards for ethicists who advise patients, families and clinicians on difficult cases.

For that reason, these researchers have devised and implemented a process at NewYork-Presbyterian Hospital they hope will forge a national paradigm for credentialing clinical ethics consultants who often counsel on issues of life and death.

Dr.Joseph J. Fins, chief of the Division of Medical Ethics at Weill Cornell Medical College

In a peer-reviewed paper published in the summer issue of the Journal of Clinical Ethics, senior author Joseph J. Fins, chief of the Division of Medical Ethics and The E. William Davis Jr., MD, Professor of Medical Ethics at Weill Cornell Medical College, and lead author and registered nurse Cathleen A. Acres, administrative director of the Division of Medical Ethics and lecturer in public health at Weill Cornell Medical College, analyze the two decades-long effort to establish credentialing or training certification guidelines for clinical ethics consultants — many of whom come from diverse career fields and have varying training and consultative experiences. Acres stressed the importance of their interdisciplinary approach, which, she said, "is a hallmark of bioethics itself."

The two Weill Cornell faculty, as well as Dr. Kenneth Prager, director of medical ethics at NewYork-Presbyterian Hospital/Columbia University Medical Center, and Dr. George Hardart, director of pediatric clinical bioethics for the Center for Bioethics at Columbia University and former chair of the ethics committee at NewYork-Presbyterian/Morgan Stanley Children's Hospital, outline the credentialing model established recently for NewYork-Presbyterian Hospital as one that can be adapted for institutions nationwide.

Clinical ethics consultants can be physicians, nurses, social workers, philosophers, lawyers, chaplains or administrators who, with their distinct perspectives, approach ethics cases slightly differently. While this diversity is intrinsically valuable in the practice of ethics, a 2007 survey of some 500 hospitals nationwide underscored the need for hiring standards.

Cathleen A. Acres, administrative director of the Division of Medical Ethics and lecturer in public health at Weill Cornell Medical College

According to a survey from the Veterans Health Administration National Center for Ethics in Health Care, only 5 percent of the ethics consultants hired by these hospitals had completed a fellowship or degree program in medical ethics. The survey also states that 41 percent had been trained by direct supervision of an experienced ethics consultant while 45 percent had unsupervised, independent training.

"There are variants in clinical ethics practice and we need to set standards for the work while also being interdisciplinary in the approach," said Dr. Fins, also a professor of medicine, professor of public health and professor of medicine in psychiatry at Weill Cornell Medical College and director of medical ethics at NewYork-Presbyterian/Weill Cornell Medical Center. "This level of variance would be unacceptable in other disciplines. These are people who are helping with life and death decisions, and it's remarkable to me that the standards have not become more stringent."

The Weill Cornell and NewYork-Presbyterian team proposed a tiered system for clinical ethics consultants at the assistant, associate, senior and director levels, specifying requisite academic and clinical training at each level.

"When evaluating an ethicist, we kind of know it when we see it, but we had no criteria" said Dr. Michael Stewart, vice dean, senior associate dean for clinical affairs and chair of the Department of Otolaryngology, who serves as co-chairman of the Medical Board's Credentials Committee. "Many have become quite expert based upon their experiences, but their training was informal. What we did was try to create some real criteria, based on experience, training, background and number of consults done, so that if you were then credentialed as an ethicist, it meant that you met a certain minimum standard."

This credentialing process, which was approved in 2010 by the NewYork-Presbyterian Hospital Medical Board, has already been utilized to hire an ethics consultant.

The research team has received positive feedback on the credentialing process from colleagues in the field who echo the call for its implementation in clinical settings nationwide. In an accompanying editorial in the Journal of Clinical Ethics, Dr. David Schiedermayer and Dr. John La Puma credit the team for its "thoughtful and measured" credentialing process while urging the rest of the field to embark on a similar process within their institutions.

The changing tide over credentialing ethics consultants reflects the maturation of the field, Dr. Fins said.

"We can have credentials and still have an interdisciplinary focus. You need not simply be a doctor to be credentialed; a philosopher, nurse and chaplain all have the potential to be credentialed," he said. "This is a local model we hope will have national implications."

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