Topic: Consultation
March 18, 2016 | Posted By Valerye Milleson, PhD

When I first moved to Albany several months ago in pursuit of the exciting and glamorous life of a clinical ethics fellow, I brought with me only a handful of my earthly possessions; if the Fates have their way with me, I will likely leave with even less.

During this past month, in the late-night hours one night I awoke from my slumber to discover that while I had slept the majority of my basement apartment had been transformed into a bog. Yes, I was experiencing wintery real-life application of the law of thermal expansion as it applies to dihydrogen monoxide (i.e., a water pipe burst). After an emergency call to my landlord, I proceeded with my own separation of sheep from goats: what could be saved and salvaged was transported to the little dry land remaining in my now water-logged kingdom, while those items clearly destined to doom and decay were left languishing amidst the advancing liquid army. Few of my books survived, but among them was one I thought quite fitting to the circumstances: Marcus Aurelius’ Meditations.

Essential reading for any good Stoic (and, to my mind, useful if not essential reading for all human beings), Meditations, and the ancient words of wisdom it contains, helped me to navigate through and reflect upon my experience of the flood and its corresponding aftermath. Some choice morsels include:

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

January 12, 2016 | Posted By Bruce White, DO, JD

As is their publishing practice, the American Journal of Bioethics recently invited submissions for an Open Peer Commentary to an article they plan to publish in the next few months. The article is entitled “A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants” and authored by Joseph J. Fins, MD, Eric Kodish, MD, and the other members of the American Society for Bioethics and Humanities (ASBH) Quality Attestation Presidential Task Force (QAPTF). This paper is a sequel to their earlier paper “Quality Attestation for Clinical Ethics Consultants: A Two-Step Model from the American Society for Bioethics and Humanities” which was published in The Hastings Report. [http://www.ncbi.nlm.nih.gov/pubmed/24092588] The first paper described the ASBH plans to “attest” to the “quality” of self-identified, randomly-selected pilot clinical ethics consultants who submit a “portfolio” illustrating their consultation activities. When the article appears, all involved in clinical ethics consultation and the training of future clinical ethics consultants should read the paper. The QAPTF and the ASBH should be congratulated for doing this work and sponsoring the activity.

However, in thinking through this process again, one wonders how much of this is about the past and not about the future. Shouldn’t any process be more prospective and less retrospective? Maybe this is not possible? But how important is it really to show that people who are currently offering clinical ethics consultation services and recording their efforts in portfolios for other “experts” to review and compare do their consultations satisfactorily? Will this “attestation” somehow change their employment or practice circumstances or patterns? Will their employers dismiss them if they fail to obtain “attestation” status and hire clinical ethics consultants are meet the attestation standard? Will it add public recognition? In truth, is “attestation” really a quality standard that matters?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

September 8, 2015 | Posted By Bruce White, DO, JD

Education reformer Abraham Flexner (1866-1959) is regarded by many as the father of Modern America’s medical education curriculum. He authored the Flexner Report for the Carnegie Foundation after making site visits to all the country’s medical and osteopathic medical schools of the day. He harshly criticized the vast majority of the schools he visited. His insightful recommendations were adopted for the most part within just a few years and his Report continues to influence medical education today.

In 1915, Flexner addressed the National Conference of Charities and Corrections. The title of his speech was “Is Social Work a Profession?” He answered that it was not. Flexner compared social workers of the day against the “benchmark” professionals of medicine, law, and preaching, and found that those who provided social work services had not yet achieved true professional status. He saw the social worker of the day as a “narrow minded technician.” In deference to social workers, Flexner also viewed nurses and pharmacists the same way.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

July 7, 2015 | Posted By Bruce White, DO, JD

In his last AMBI blog posted on June 18, 2015, Wayne N. Shelton, PhD, MSW, discussed recent movement toward the professionalization of clinical ethics consultants. He noted the adoption of a Code of Ethics for Health Care Ethics Consultants by the American Society for Bioethics and Humanities (ASBH), which has been praised as important milestone toward the professionalization of clinical ethics consultants. Moreover, Dr. Shelton listed several challenges that “professionals” who call themselves “clinical ethics consultants” currently face, including: “[1] how to make sense of the diverse educational backgrounds and training of those who perform clinical ethics consultations and how far to push such requirements; [2] the lack of a national body to set requirements that leaves local hospital leaders with little incentive to pay for highly qualified CECs and view this as a sound investment; and finally [3], most seriously, the way in which many problems in patient care are misidentified as clinical ethical problems while other serious clinical ethical problems may be entirely overlooked or if recognized, not viewed as requiring the expertise of a CEC.” He concluded his post with: “These challenges are indications that clinical ethics consultation will not likely achieve professional status in the healthcare system in the near future.” Of course, Dr. Shelton is correct in his analysis, but some might see the challenges he listed as surmountable if those who practiced clinical ethics consultation were to: (1) establish minimum uniform educational standards for new clinical ethics consultants; (2) create national certification and accreditation standards so employers would more fully understand the nature and value of their work; and (3) provide consultants themselves and other stakeholders unmistakable guidance on what clearly constitutes the work of clinical ethics consultants. (This third point sounds very much like a “scope of practice” definition found in state professional licensing statutes.) However, it may take something much more for clinical ethics consultants to be a separate professional category.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

June 18, 2015 | Posted By Wayne Shelton, PhD

Let me say emphatically at the outset of this blog, as someone who has been a clinical ethics consultant for over 20 years, I am quite sure that clinical ethics consultations overall improve the quality of patient care and currently are an important, even essential, part of the providing excellent patient care in hospitals. Contemporary medicine is filled with value laden questions and issues that often can be effectively addressed by someone with expertise and training in clinical ethics. Having said this, I am still somewhat skeptical about clinical ethics consultation becoming a professional area of healthcare that parallels other professional areas like medicine, nursing, and social work. I think there are some special considerations about the field of clinical ethics consultation that makes its future status as a professional activity uncertain.

First of all it is well-known that CEC’s come from a variety of backgrounds and training—from philosophers to physicians to social workers to nurses and lawyers and on and on. People enter the field of clinical ethics consultations from very different disciplinary backgrounds and seemingly learn a common vocabulary and methodology of clinical ethics and a basic familiarity with and ability to function in the clinical setting. They learn this vocabulary in very different ways—some informally, some through short 1-2 week long intensives, some with certificate programs, some with master’s degrees, and some with 1-2 year long fellowships. No other area of healthcare work admits of such diversity. Though this is a positive feature in some ways by providing diverse perspectives in understanding value dilemmas, it creates a challenge of considerable controversy when we try to define the kind of educational training a future CEC should have. At the moment there seem to be many pathways into the field and no clear answer has emerged.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 22, 2014 | Posted By Zubin Master, PhD

Recently Dr. Christopher Thomas Scott of Stanford University wrote a great paper titled “The Case of Stem Cell Counselors” in Stem Cell Reports which draws parallels from the field of genetic counseling arguing for the need for stem cell counsellors (1). Scott outlines that due to increases in the number of stem cell trials combined with fraudulent therapies being offered around the world, the time is ripe for having counsellors help patients navigate the clinical stem cell research/therapy landscape. These experts can help patients identify and distinguish legitimate trials from unproven interventions, explain the risks, benefits and therapeutic options, and serve as a resource to provide them with educational information.

On a related topic, my colleagues and I at AMBI were going to write a paper arguing that clinical ethics consultants should be involved in countering the impact of stem cell tourism and serve as a resource for patients who are contemplating undertaking an unproven stem cell based intervention (SCBI). We thought that clinical ethics consultants are in a unique position to offer advice and counselling to patients seeking unproven SCBIs for a few reasons.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

August 11, 2014 | Posted By Wayne Shelton, PhD

In my last blog I asked the question, “What is ethics doing?” where I contrasted the armchair, academic ethics that I knew as a graduate student with the clinical ethics cases in which I am now involved in clinical ethics consultations. I alluded to the famous paper by Stephen Toulmin (1922-2009), “How medicine saved the life of ethics” by providing ethics with many practical value laden problems to address. The very process of becoming involved with applied ethics and ethical problems of practicing physicians in the healthcare system was itself as, or perhaps more, transformational for ethics than it was for medicine. Even though medicine needed a serious study of its value-laden issues, which has evolved into bioethics and clinical ethics, the very activity of doing applied ethics has evolved into a better defined field of inquiry with a clearer purpose. But what about the armchair, academic pursuits of philosophical ethics of old? Is there anything left for it to do? This is the question I will attempt to answer in this blog.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

July 22, 2014 | Posted By Wayne Shelton, PhD

I recall being a PhD candidate in philosophy in the 1970’s, I often pondered the subject matter of my graduate courses in ethics. I would ask myself, what does any of this have to do with ethics? What are we doing?

As our courses went from Kant to Mill to G.E. Moore to the Emotivists and others, I couldn’t help but have a sense of unreality about the content of what I was learning.

How can we use reason to find a basis for knowing right action? What are the ways we can define right action based on a normative moral theory?

What is the meaning of good? Right? And obligation? Can these terms be defined within a theoretical, substantive moral framework or are they just expressions of feelings and emotions without any cognitive content? If they are more than the latter, what do they mean?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

June 12, 2014 | Posted By Wayne Shelton, PhD

For over a decade the faculty of the Alden March Bioethics Institute has been designing and developing simulated cases for our graduate students who wish to learn the core skills of clinical ethics consultation. The model that we use is called “mock consultations”, which provides students the opportunity to perform an ethics consultation on a simulated case from the beginning when the request is made, to data collection, interviewing key players in the case, and on to case analysis the final recommendation.

In the process of developing simulated cases we have made every effort to make them as real to life as possible. All of the cases we use are from ethics consultation cases that have been deidentified and made into anonymous teaching cases. We have benefitted immensely from working closely with Albany Medical College’s (AMC) Patient Safety Clinical Competence Center (PSCCC). Those involved in medical education will recognize the importance of simulated cases using standardized patients (SP) and the role they play in training new doctors to communicate effectively with patients and families.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website. 

February 20, 2014 | Posted By Wayne Shelton, PhD

Over the past few decades, clinical ethics consultations have become an important component in providing quality care in cases where there are value conflicts that must be resolved before viable goals of healthcare can be accomplished. With the development of this service and its acceptance as a necessary part of patient care, questions arise as to how and when will clinical ethics consultation be recognized as a specialized professional service comparable to medicine, nursing, social work and pastoral care? For physicians, nurses, social workers, and chaplains there are well-established pathways for practitioners to take in each of these areas in order to be recognized as fully qualified professionals. There is no such pathway to date for those individuals who provide clinical ethics consultations. For those of us who have been involved in this area it is interesting to reflect upon the vast improvements made in providing clinical ethics consultations and whether the field is ready for professionalization.

I recall my early years of training in medical ethics as a graduate student in philosophy at the University of Tennessee. As part of the requirements for the PhD in philosophy with a concentration in medical ethics, students had to spend 3 months at the Health Science Center in Memphis where we participated in intensive internship in medical ethics. At that time I was fortunate to have one of the early pioneers in medical ethics as a mentor, Professor David Thomasma, who was beginning to do clinical ethics consultations. During the 1970’s philosophers and others in fields pertaining to ethics were being invited to enter the medical setting to help physicians and nurses grapple with some of the ethical dilemmas that were becoming more evident with the increasing use of dialysis machines and mechanical life supports. There seemed to be an assumption, perhaps naïve in retrospect, that philosophers like professor Thomasma and others had some special understanding of ethical issues that would shed light on the emerging medical ethical dilemmas and therefore would be in a position to give helpful advice.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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