Addressing Racism in Ethics Consultation: An Expansion of the Four-Box Method.

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.

Developing Skills in the HEC Communication Competency: Diagnostic Listening and the ADEPT Technique.

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.

What the HEC-C? An Analysis of the Healthcare Ethics Consultant-Certified Program: One Year in.

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.

The Advent of the Professional Ethicist: Moral Expertise and Health-Care Ethics Certification.

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.

The Role of Oncology Nurses as Ethicists: Training, Opportunities, and Implications for Practice.

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 Work of ASBH's Clinical Ethics Consultation Affairs Committee: Development Processes Behind Our Educational Materials.

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.

The Development and Rationale for CECA's Case-Based Study Guide.

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.

Membership recruitment and training in health care ethics committees: Results from a national pilot survey.

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.

What Nurse Bioethicists Bring to Bioethics: The Journey of a Nurse Bioethicist.

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.

Bioethicists Can and Should Contribute to Addressing Racism.

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.

Moral Philosophy, Moral Expertise, and the Argument from Disagreement.

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.

Preparing the Next Corps of Ethicists.

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

Moral Reasoning among HEC Members: An Empirical Evaluation of the Relationship of Theory and Practice in Clinical Ethics Consultation.

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.

Weaponizing principles: clinical ethics consultations & the plight of the morally vulnerable.

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.

Teaching and Learning the Techniques of Conflict Resolution for Challenging Ethics Consultations.

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.