What makes a ‘good’ clinical ethicist?

As the American Society for Bioethics and Humanities (ASBH) annual conference kicks off next week, numerous ethicists will converge upon Anaheim to show off their latest research and discuss and debate ideas. One topic that’s bound to come up, and is known to get clinical ethicists arguing, is the HEC-C Program — often colloquially exclaimed using the pun, “What the HEC-C!”

”HEC-C” stands for “healthcare ethics consultant-certified” and is described as the first-ever certification program that identifies and assesses a national standard for the professional practice of clinical healthcare ethics consulting.

At first glance, the program may not seem controversial, but it has become a source of disagreement amongst ethicists. Some of the controversy revolves around the certification requirements. Becoming certified requires a bachelor’s degree, 400 hours of experience in clinical ethics over the last four years, and passing a 110-question, multiple-choice exam. These requirements seem fairly lenient given what other medical professionals have to go through when meeting a “national standard” in their fields.

But the more pressing critique is related to the goals, skills, and actions of clinical ethicists. A central task of the ethicist is to assist patients, families, and medical professionals in deciding the best course of action for the patient, according to the patient’s own idea of what is important. Connecting this essential task with simply having ethics-related experience and passing an exam can be seen as a stretch.

The HEC-C Program justifies the 400-hour requirement by appealing to a survey, which found the average clinical ethicist in the United States devotes about 100 hours a year to clinical ethics activities. However, I am not sure how it follows that 400 hours should be a minimum requirement for certification.

In my mind, if there is going to be an hour-based requirement, it should be based on the amount of time it takes to become a good ethicist rather than the average amount of time ethicists perform related tasks.

Some hold that the complexity of clinical ethics consultations couldn’t be reduced to multiple-choice questions based on a few sources, arguing that creating multiple-choice questions that reflect the challenges of doing clinical ethics is nearly impossible. Most of the time, the HEC-C Program is careful to emphasize that they are testing knowledge of issues in clinical ethics, not the ethicist’s ability to apply this knowledge to the practice of clinical ethics.

This is a nuanced distinction that may be lost on those outside the field. For example, an administrator might view the HEC-C Program as separating a good ethicist from an inadequate ethicist simply because they have 400 hours of experience and can pass a multiple-choice exam.

Others disagree with the source material (called “core references”) that serves as the basis for exam questions. I believe the core references, if repetitious, are important works in the field. My concern is that these works do not pay sufficient attention to some of the most pressing and challenging issues in clinical ethics today: income inequality, care for non-citizens, drug abuse, race, religion, sex and gender, to name a few areas.

Also, it’s feasible that inadequate ethicists will become certified. I can imagine an ethicist might meet the requirements, but fall short of being a good ethicist because in practice they are poor communicators, lack empathy, are authoritarian when analyzing ethics issues, or have an off-putting presence.

On the other hand, I know some ethicists I would consider experts in the field who are not going to undergo the certification process because they disagree with it. Both of these scenarios show that HEC certification should not be the single requirement that separates a good ethicist from an inadequate ethicist.

All this being said, I am in favor of the HEC-C Program as it now stands. I will be taking the exam in mid-November, in fact. My hope is that the certification efforts move forward, adapt, and soon incorporate evaluating the practice of clinical ethics into the process. Ethicists, as a group, are able to adapt. I see no reason to think that if unsavory consequences follow, our field will not evolve.

If this experiment in certification doesn’t meet its goals, then I believe the field is honest enough to name shortcomings and continue to move forward –finding a balance between establishing our authority and separating good from inadequate ethicists.

–By Trevor Bibler, Ph.D., assistant professor of medical ethics at the Center for Medical Ethics and Health Policy at Baylor College of Medicine