Introduction to ASBH’s Code of Ethics and

Introduction to ASBH’s Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants

Introduction The material in this presentation was developed by members of the Clinical Ethics Consultation Affairs (CECA) Committee of the American Society for Bioethics and Humanities (ASBH) to introduce ASBH’s Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants (the Code of Ethics or the Code) to those engaged in ethics-related work. Special recognition goes to Courtenay Bruce for her efforts in developing this presentation.

Objectives Describe the process used to develop the Code of Ethics. Discuss key elements of the Code of Ethics. Identify opportunities and strategies for using the Code of Ethics.

Intended Audience Students and trainees in healthcare ethics consultation (for learning about the responsibilities involved in ethics consultation) New and seasoned ethics committee members who are new to ethics consultation (for self-study and for use in mentoring) Experienced practitioners in ethics consultation (for self-assessment)

Definitions Healthcare Ethics Consultation A set of services provided by an individual or group in response to questions from patients, families, surrogates, healthcare professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in health care ASBH’s Core Competencies for Healthcare Ethics Consultation (2011)

Definitions Healthcare Ethics Consultant A professional in a healthcare setting who seeks to identify and support the appropriate decision maker(s) in a given situation involving ethical questions and to promote ethically sound decision making by facilitating communication among key stakeholders, fostering understanding, clarifying and analyzing ethical issues, and including justifications when recommendations are provided ASBH’s Core Competencies for Healthcare Ethics Consultation (2011)

Development of the Code of Ethics

Why Was a Code of Ethics Needed? To establish boundaries for professional practice To provide guidance to practitioners To further the professionalization of the HCE consultant’s role

Brief History

Development Process Initial elements of the Code drafted Input from practitioners sought through survey Survey responses analyzed by CECA subgroups. – Findings reflected broad support for initial draft. – Feedback led to revisions of content and language. Efforts made to build consensus Final revisions made Approval given by ASBH board

Sample Comments Content Clarify the document’s scope and target audience. Clarify the relationship between ASBH’s Code and other professional codes. Language Clarify the language to make it understandable to those affected by ethics consultation. Clarify the language taken from ASBH’s core competencies.

Preface and Responsibility Statements

Preface Purpose “The statements in this code set out the core ethical responsibilities of individuals performing healthcare ethics consultation (HCEC).” Scope “The content largely but not exclusively addresses patient-focused consultative activities, often referred to as clinical ethics consultation.” ASBH’s Code of Ethics (2014, p. 1)

1. Be Competent Competence requires receiving continuing education and experiential training meeting standards that have achieved fieldwide acceptance, including those in ASBH’s Core Competencies for Healthcare Ethics Consultation (2011).

2. Preserve Integrity Preserving integrity involves making a commitment to HCEC core values and cultivating attributes, attitudes, and behaviors that enable one to perform HCEC well fostering learning and facilitating respectful interactions during moral deliberation refraining from giving a stamp of approval to practices believed to be inconsistent with ethical standards recusing oneself when a conflict involving the consultant’s core beliefs or values arises in a case.

3. Manage Conflicts of Interest and Obligation Conflicts of interest: situations in which the professional judgment of an HCE consultant is or may appear to be affected or compromised by competing interests such as personal, professional, or financial interests Conflicts of obligation: situations in which the HCE consultant’s work is or may appear to be affected or compromised by competing professional or personal responsibilities

4. Respect Privacy and Maintain Confidentiality Respecting privacy and maintaining confidentiality involves honoring others’ right to control access to their private information, including information entrusted to the HCE consultant discreetly sharing the minimum amount of information necessary when divulging confidential information is necessary to provide significant benefit (protecting life or preventing serious harms).

5. Contribute to the Field Advancing the field of HCEC involves fostering the collective good of the profession and the constituencies it serves publishing, mentoring, teaching, conducting community outreach, conducting or participating in research, and participating in professional organizations.

6. Communicate Responsibly Responsible communication involves being informed about issues on which one comments in the public arena declining to comment (or referring a question to others) when one lacks sufficient knowledge on an issue acknowledging uncertainty about norms and lack of consensus where they exist demonstrating cultural humility and sensitivity to different values.

7. Promote Just Health Care The promotion of just health care in HCEC involves being attentive to the possible role of healthcare disparities, discrimination, and inequities in HCEC ensuring that all stakeholders have access to HCEC ensuring that the HCEC process is fair identifying and including relevant voices in HCEC identifying systemic issues that may influence fair outcomes in HCEC and responding appropriately.

What the Code of Ethics Does The Code of Ethics formalizes efforts to professionalize HCE consultants professes a commitment to shared values and responsibilities establishes an aspirational tone outlines some key ethical issues in the field.

What the Code of Ethics Does Not Do The Code of Ethics does not discuss or endorse other aspects of professionalization codify the knowledge and skill that consultants should possess address how the code is enforced discuss evaluation criteria.

Applying the Code of Ethics A Resource for Ethics Consultation Services, Bioethics Teachers, and Ethics Committees

Study Question 1 An ethics consultant is eating lunch in the cafeteria with two nurses and a social worker. The ethics consultant and the social worker had recently participated in a family meeting involving a patient with suicidal ideation. The two nurses are not involved in the patient’s care. The ethics consultant and the social worker begin talking about the patient and what occurred in the family meeting, including specific details about sensitive information. Their conversation can be overheard by the nurses at their table and by others in the cafeteria. This is a violation of the responsibility statement dealing with which area? A. Managing conflicts of interest B. Respecting privacy and maintaining confidentiality C. Promoting just health care D. Contributing to the field

Study Question 1 An ethics consultant is eating lunch in the cafeteria with two nurses and a social worker. The ethics consultant and the social worker had recently participated in a family meeting involving a patient with suicidal ideation. The two nurses are not involved in the patient’s care. The ethics consultant and the social worker begin talking about the patient and what occurred in the family meeting, including specific details about sensitive information. Their conversation can be overheard by the nurses at their table and by others in the cafeteria. This is a violation of the responsibility statement dealing with which area? A. Managing conflicts of interest B. Respecting privacy and maintaining confidentiality C. Promoting just health care D. Contributing to the field

Study Question 1: Explanation The best answer is B. The HCE consultant is entrusted with private information, and privacy and confidentiality should be respected. In this case, the social worker and the ethics consultant are talking in a location where the likelihood of being overheard by others is high. The risk of breach of confidential information is high, and the risk of harm could be high, especially because the case involves particularly sensitive information. Confidential information should be shared only in limited circumstances when necessary to provide significant benefit (e.g., to protect life or prevent serious harms). Even in these rare circumstances, only the minimum amount of information necessary should be shared discreetly.

Study Question 2 In an on-line forum called “The Bioethics Blurb,” an ethics consultant writes a commentary about Jehovah's Witnesses who refuse blood transfusions. In her commentary, she writes that “it is ethically inappropriate to allow patients to make foolish decisions. Blood products should be given, even against patients’ wishes.” This is a violation of the responsibility statement dealing with which area? A. Managing conflicts of obligation B. Respecting privacy and confidentiality C. Preserving integrity D. Communicating responsibly

Study Question 2 In an on-line forum called “The Bioethics Blurb,” an ethics consultant writes a commentary about Jehovah's Witnesses who refuse blood transfusions. In her commentary, she writes that “it is ethically inappropriate to allow patients to make foolish decisions. Blood products should be given, even against patients’ wishes.” This is a violation of the responsibility statement dealing with which area? A. Managing conflicts of obligation B. Respecting privacy and confidentiality C. Preserving integrity D. Communicating responsibly

Study Question 2: Explanation The best answer is D. Communicating responsibly requires that HCE consultants be sufficiently informed about the issues on which they communicate in the public arena. Public comments should acknowledge uncertainty about norms and lack of consensus where they exist. The ethics consultant’s statement is problematic for at least two reasons: 1.The comment runs counter to ethical consensus about a patient’s right to refuse treatment, but the consultant does not indicate that her position is outside the scope of consensus. 2.The comment demonstrates an insensitivity to values different from the consultant’s own.

Study Question 3 A physician requests assistance from the HCE consultant regarding goals of care for a patient with end-stage pancreatic cancer. The patient is willing and able to participate in decision making. The HCE consultant recommends a family meeting with the patient’s surrogate decision maker, the attending physician, the nurse, and the social worker. The HCE consultant conducts the meeting in a conference room outside the patient’s room. The patient is not present and is not asked whether she wishes to participate.

Study Question 3 (continued) This is a violation of the responsibility statements dealing with which areas? A. Being competent; promoting just health care within HCEC B. Respecting privacy and confidentiality; managing conflicts of interest and obligation C. Contributing to the field; managing conflicts of interest and obligation D. Communicating responsibly; respecting privacy and confidentiality

Study Question 3 (continued) This is a violation of the responsibility statements dealing with which areas? A. Being competent; promoting just health care within HCEC B. Respecting privacy and confidentiality; managing conflicts of interest and obligation C. Contributing to the field; managing conflicts of interest and obligation D. Communicating responsibly; respecting privacy and confidentiality

Study Question 3: Explanation The best answer is A. HCE consultants should meet standards of competence that have achieved fieldwide acceptance, including those in ASBH’s Core Competencies for Healthcare Ethics Consultation (2011). In the interest of serving justice in HCEC, consultants have a responsibility to identify and include relevant voices in the discourse. To successfully respond to request for an ethics consultation, the consultant must be able to identify which individuals need to be involved. A patient with decision-making capacity should be asked to participate in a meeting involving the patient’s treatment plan.

Study Question 4 An ethics committee is consulted on a case involving a 32-year-old woman who is 12 weeks pregnant with her third child and is suffering from pulmonary hypertension. Her physicians believe she is at imminent risk of dying if the pregnancy continues. The ethics committee is asked to provide an ethics analysis addressing the question of whether the pregnancy can be terminated to protect the patient’s health and life. The chair of the ethics committee is morally opposed to abortion for any reason.

Study Question 4 (continued) The committee chair should A. Try to put aside personal feelings during the consultative process. B. Disclose to the patient’s husband that he is morally opposed to abortion and allow the patient’s husband to decide whether and how the chair should be involved. C. Recuse himself from chairing the committee for this consultation after identifying another committee member who is willing and able to lead the committee meeting. D. Ask a chaplain what he should do and follow the chaplain’s advice.

Study Question 4 (continued) The committee chair should A. Try to put aside personal feelings during the consultative process. B. Disclose to the patient’s husband that he is morally opposed to abortion and allow the patient’s husband to decide whether and how the chair should be involved. C. Recuse himself from chairing the committee for this consultation after identifying another committee member who is willing and able to lead the committee meeting. D. Ask a chaplain what he should do and follow the chaplain’s advice.

Study Question 4: Explanation The best answer is C. If a conflict involving the consultant’s personal beliefs or values arises in the course of performing HCEC, the consultant should recuse himself or herself from the case after securing the services of a replacement. If no replacement is available, the primary obligation of the HCE consultant is to maintain professional integrity. This obligation is discussed in more detail under the second responsibility statement in the Code of Ethics, “Preserve integrity.”

Study Question 5 A hospital administrator recognizes that the HCEC service has been effective in resolving ethical disputes and addressing ethical concerns. She believes that the service can be used to meet hospital goals in reducing length of stay. She approaches the director of the HCEC service, who is also an attending physician in the intensive care unit, and asks the director to “focus on length of stay and on moving patients out of the hospital regardless of the measures necessary.”

Study Question 5 (continued) What action(s) taken by the director of the HCEC service would be considered appropriate under the Code of Ethics? (Check all that apply.) A. The director should disclose the administrator’s request to her supervisor. B. The director could explain why focusing on length of stay may not be in the patient’s best interest. C. The director could explain the nature and purpose of ethics consultations and explain that the administrator’s request does not align with HCE consultants’ professional obligations.

Study Question 5 (continued) What action(s) taken by the director of the HCEC service would be considered appropriate under the Code of Ethics? (Check all that apply.) A. The director should disclose the administrator’s request to her supervisor. B. The director could explain why focusing on length of stay may not be in the patient’s best interest. C. The director could explain the nature and purpose of ethics consultations and explain that the administrator’s request does not align with HCE consultants’ professional obligations.

Study Question 5: Explanation The best answers are B and C. It is not unethical to consider length of stay if it relates to the patient’s best interest, but this factor as it relates to the hospital’s bottom line should not be the driving force behind the ethics analysis or recommendation. Conflicts of obligation involve situations in which HCE consultants’ work is or may appear to be affected or compromised by competing professional or personal responsibilities. The conflicting obligation here is between the HCE consultant’s two roles: director of the HCEC service and attending physician in the ICU.

Case Study 1 An HCE consultant on call for the HCEC service has to pick up her 6-year-old son from school. Just as she is leaving the hospital, she receives a page requesting a consultation. The requester, a resident physician, asks how decisions should be made for a patient that lacks decision-making capacity and has no family members (i.e., is unrepresented). Because the HCE consultant has to leave to pick up her son, she quickly cites the relevant state statute, which says that the medical team can make treatment decisions on behalf of a patient who lacks capacity and is unrepresented, in accordance with the patient’s wishes (if known) or, secondarily, the patient’s best interest.

Case Study 1 (continued) Citing the grounds of the patient’s best interest, the resident physician withdrew life-sustaining treatment after this advice was given, and the patient died. Had the HCE consultant looked at the medical record or talked to the attending physician or the social worker, she would have learned that the patient had several family members, all of whom were willing and able to make treatment decisions in accordance with the patient’s wishes (which would have supported continued aggressive measures). Exercise: Which, if any, of the responsibilities in the Code were violated?

Case Study 1: Discussion This case involves issues of competence and conflicts of obligation. The HCE consultant’s professional obligations were compromised because of competing personal obligations. She was not able to allocate the time necessary to properly conduct the consultation.

Case Study 1: Discussion (continued) Competent HCEC processes include reviewing the medical record and interviewing involved parties. As part of the information-gathering process, the HCE consultant should interview relevant healthcare team members. In this case the HCE consultant should have anticipated that the social worker and attending physician would be valuable informants who could contribute to wise management of the case.

Case Study 2 A novice HCE consultant is acting as the lead HCE consultant for the first time. He receives an HCEC case involving a patient who is dead according to neurological criteria but who remains on mechanical ventilation. The patient’s wife asks the physician about post-mortem sperm retrieval. The physician seeks advice from the HCE consultant, who is unacquainted with this ethical issue. The consultant provides advice without reviewing the bioethics literature or determining whether ethical consensus on the issue exists. Exercise: Which, if any, of the responsibilities in the Code were violated?

Case Study 2: Discussion This case involves issues of competence and integrity. HCE consultants must identify sources of relevant information necessary for them to competently conduct an ethics consultation, including relevant policies, professional codes and guidelines, published literature, and precedent cases.

Case Study 2: Discussion (continued) Professional integrity involves commitment to HCEC’s core values and cultivation of attributes, attitudes, and behaviors (e.g., self-awareness, fair-mindedness, humility, moral courage) that enable one to perform HCEC well. HCE consultants must recognize when an issue is outside the scope of their knowledge and seek assistance. Novice HCE consultants should seek guidance from mentors to ensure that HCEC-related competencies are being cultivated.

The Future of the Code of Ethics The Code of Ethics will evolve as the profession evolves. The Code of Ethics is one piece of an overall effort to professionalize the practice of HCE consultation. Work in the field remains to be done: – Identification of a process to address code breaches – Accreditation of programs that train and educate HCE consultants – Certification or quality attestation of individuals who practice HCE consultation – Accreditation of consultation services

References American Society for Bioethics and Humanities. (2011). Core Competencies for Healthcare Ethics Consultation (2nd ed.). Glenview, IL: Author. American Society for Bioethics and Humanities. (2014). Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants. Chicago, IL: Author.

Recommended Reading Carrese, J. A., & Members of the American Society for Bioethics and Humanities Clinical Ethics Consultation Affairs Committee. (2012). HCEC pearls and pitfalls: Suggested do’s and don’t’s for healthcare ethics consultants. Journal of Clinical Ethics, 23(3), 234 240. Tarzian, A. J., Wocial, L. D., & the American Society for Bioethics and Humanities Clinical Ethics Consultation Affairs Committee. (2015). A code of ethics for health care ethics consultants: Journey to the present and implications for the field. American Journal of Bioethics, 15(5), 38 51. doi: 10.1080/15265161.2015.1021966