Requisite Abilities,The ability to identify ethical issues

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1.    The ability to identify ethical issues coupled with the ability to sensitize others to ethical issues.

2.    The ability to acquire relevant information (e.g., clinical information, psychosocial information) when gaps are revealed, coupled with the ability to know which questions to ask when attempting to fill in the gaps.

3.    The ability to bring systematic thinking to ethical problem-solving.

a.     The ability to analyze the meanings of concepts and principles. Such analysis should include a consideration of the meaning of words in casual everyday contexts, their technical meaning, and their idiosyncratic use.

b.    The ability to identify underlying assumptions and to question those that are believed to be flawed or misleading.

c.     The ability to reframe a presenting ethical problem when appropriate (i.e., not in an attempt to evade or to distract), and thereby to shift the ethical discussion so as to allow for a consideration of alternative options that might otherwise not be considered.

4.    The ability to make and defend sound ethical judgments that reflect an understanding of the values of others, including:

a.     The ability to identify possible alternative courses of action. to outline the associated values and possible consequences. and to provide the best arguments for and against the various options; and

b.     The ability to provide a recommendation "for consideration." without attempting to manipulate the decision making process.  



5.    The ability to communicate effectively with (which includes actively listen to) health care workers, patients, patients' families, administrators, and social agencies.!'

a.     The ability to elicit, appreciate, explore, and (when necessary) help clarify the evolving/ changing viewpoints, beliefs, and values of others.

b.     The ability to represent the evolving/changing viewpoints, beliefs, and values of one party to another.

c.     The ability to observe and perceive interests and relationships that influence discussion and behavior.

6.    The ability to facilitate (e.g., mediate, negotiate, and arbitrate), coupled with an ability to ascertain when one or more of these activities is appropriate.

7.    The ability to recognize and work within the limits of one's knowledge balanced with the ability to accept challenges.

8.    The ability to recognize one's own partiality and not to introduce personal beliefs (i.e., values or traditions one finds persuasive) in an inappropriate manner. Specifically, personal beliefs and value commitments should be identified in a timely fashion when there is an overriding commitment to a specific value system that is informing the discussion (e.g., religious or political beliefs). Personal beliefs and value commitments should not be introduced: (a) in a clandestine or subliminal way, or (b) under false colors-as facts when they are not, as consensually agreed on when they are not, or as legal requirements when they are not.

9.    The ability to participate in group decision making, even when this may generate a conclusion with which one disagrees, and a willingness to tolerate such group decisions. This ability must be coupled with a strong sense of personal and professional integrity so that one may distinguish outcomes that one will not, on moral grounds, endorse/sanction (e.g., an outcome that violates an important moral principle, but is chosen to avoid confrontation) from outcomes that one disagrees with, but will endorse/sanction (e.g., an outcome within communal and institutional norms).

10.     The ability to withstand the influence of public opinion and to question existing traditions, customs, and laws.



          To be sure, different clinical settings and different clinical situations necessarily require the exercise of different abilities. The Profile attempts to provide a reasonably complete listing of the minimum skills one should be able to draw on, as necessary. It is not expected, nor for that matter would it be productive, for an ethics consultant to exercise all of these abilities at anyone time. Consider, for example, the ability to facilitate (e.g., mediate, negotiate, and arbitrate) (A6). Clearly, different facilitation roles


Knowledge of medical terminology and health care problems

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In this article I want To elaborate briefly on the knowledge requirements listed in the previous article, it is important to note that these requirements are essentially summary statements. Consider, for example, knowledge requirement number 6 (K6). It is a succinct reference to the subject areas in medicine that a health care ethics consultant should be familiar with. A somewhat expanded version of this requirement would include the following:

1.    Knowledge of medical terminology: An effective health care ethics consultant should understand a wide range of medical terms from such basic terms as diagnosis, prognosis, benign, malignant, fetus or embryo, to more complex terms, such as multiorgan or multisystem failure, coma, brain-stem function, persistent vegetative state, and brain death. However, the health care ethics consultant would not be expected to have knowledge of less common, more esoteric terms, such as panhypopituitarism or holoprosencephaly, if s/he had never been involved in a case where these diagnoses were relevant.

2.    Common health care problems: An effective health care ethics consultant should appreciate the clinical dimensions of common diseases, for example, the etiology, medical work-up, diagnosis, course of illness, prognosis, and available interventions for lung cancer. By contrast, the ethics consultant need not be as familiar with Jakob-Creutzfeldt disease; s/he need only know how to find and select relevant information when this is missing.

3.    Emerging health care problems: Although the health care ethics consultant could not be expected to be aware of recent developments in every branch of medicine, s/he should become familiar with health care issues as soon as they are recognized to have potentially significant implications-either because of the extent of their impact, or because of potential social and political ramifications (e.g., Resource Allocation, Acquired Immunodeficiency Syndrome [AIDS], and Assisted Reproductive Technologies).

          Second, although not listed strictly in order of importance, the knowledge requirements fall into two distinct broad categories. First, "extensive knowledge" of facilitation techniques, self, fundamental concepts in health care, ethics, and health care ethics is required-these areas of knowledge being at the core of health care ethics consultation. For the rest, only practical "working" knowledge-actual or potential-is needed. Potential working knowledge presumes the ability to become knowledgeable "enough" for the task at hand. In any case, the value of the knowledge (whether extensive knowledge or working knowledge) lies in the ethics consultant's ability to use the knowledge.

Knowledge Requirements of ethics literature

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 1.      Extensive knowledge not only of the current health care ethics literature, 16 but also of "classic" articles and influential cases in health care ethics.
2.      Extensive knowledge and critical understanding of at least one ethical theory/tradition/cultural belief system that is rich enough to allow one to develop a style of thought, habits of rigor, and judgment. 17
3.      Extensive knowledge and critical understanding of the concepts of "health," "illness," "clinical practice," and "medical research" in the health care system in which one is working (e.g., Western medicine, a comprehensive government-funded health care system).
4.      Extensive knowledge of one's own biases/partiality.
5.      Extensive knowledge of facilitation (e.g., mediation, negotiation, and arbitration) techniques, and knowledge of underlying theory.
6.      Knowledge of the following:
a.     Medical terminology. 18
b.    Common health care problems.
c.     Emerging health care problems.
d.    The range of health care settings.
e.     The strengths and limitations of the scientific method and the medical model of health care.
f.  The health care system's structures and decision making methods.
g.     Relevant institutional ethos and policies.
h.    Relevant professional guidelines-? and codes of ethics.

7.      Knowledge of various ethical theories/traditions/cultural belief systems that are most commonly held by health practitioners, patients, families, administrators, and social agencies in the health care system in which one is working.
8.      Knowledge of the human dimension(s) of ethical problem-solving which includes an understanding of the social and cultural circumstances that affect the patients' and caregivers' emotional responses to a health problem.
9.      Knowledge of health law, including knowledge of relevant government regulations, policy statements, legislation, and legal cases.
10.Knowledge of cultural differences relevant to beliefs about health care.
11.Knowledge of available resources (e.g., community support systems, contact persons, and national organizations). 






must have Skills of ethics consultant

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the health care ethics consultant must have the following "other sorts of skill:"

First, the ethicist should be a skilled participant-observer, able to identify informal social structures and arrangements and to assess his or her developing role in them. Second, the ethicist should understand the dynamics of small group behavior, with an ability to recognize the interplay between socio-metric structures and decisional outcomes. Third, the ethicist should be a competent mediator, familiar with negotiating strategies and having sound interpersonal skills.

Moreover, "the non-physician ethicist must be familiar with the language of health care in order to be effective.''
In a subsequent article, published in the same year, "Call Me Doctor? Confessions of a Hospital Philosopher," Moreno adds:

One must be acquainted with relevant statutory and case law, the institutional structure of the health care system, the financing of health care, and the prevailing consensus and current issues in health policy. Some understanding of the economies of health care is very useful and an appreciation for the sociological and political processes of the clinical setting is essential. Finally, sound interpersonal skills, particularly tactfulness and the ability to mediate among deeply felt differences while honoring them, can vastly enhance the value of the ethics consultant.
         
Clearly, Moreno's description of the ethics consultant improves significantly on earlier descriptions provided by Singer. Caplan, Ackerman, and others. Further refinement is nonetheless possible, and the following functional description ofthe health care ethics consultant is offered in that spirit. This Profile lists knowledge, abilities, and traits of character for case consultation (clinical or research), committee consultation (clinical or research), and policy formulation.


effective health care ethics consultant by Terrence Ackerman

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Terrence Ackerman accepts Caplan's general critique of the engineering model of applied ethics, and explicitly endorses the claim that the ethicist must be skilled in the classification and diagnosis of moral problems. Ackerman then adds that the primary role of the ethicist in the health care setting is to facilitate the reflective process

by clarifying relevant moral values, conveying significant factual information, identifying alternative solutions, comparing the moral consequences of adopting these alternatives, and making recommendations for resolving the moral problem .

These abilities, according to Ackerman, require:

Knowledge of the purpose and process of moral reflection, familiarity with major moral principles and the historical source of their development, and skill in logical analysis of moral problems current know l- edge of the literature of bioethics basic knowl- edge of medicine and medical terminology ... [and] basic knowledge of the psychosocial literature relevant to moral issues in clinical care.

The debate continues with Jonathan Moreno. In his article, "Ethics Consultation as Moral Engagement," Moreno provides what is perhaps the most recent comprehensive account of the effective health care ethics consultant. In addition to ethical expertise, which "involves at least (1) the knowledge of general principles and theories of morality, (2) analytic skills such as discernment and insight, and (3) the strength of will not to take the easy way out,"

Historical Context of health care ethics consultant

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     A health care ethics consultant, at a minimum, is a person who helps to identify shared values by engaging others in ethical discourse as facilitator (e.g., mediator, nego-  tiator) or other (e.g., confidant), and assists those who are confronted with ethically complex health care decisions in making choices that are morally acceptable to themselves and "within the bounds of communal and institutional acceptability'' It follows that an effective health care ethics consultant is someone who has the knowledge, abilities, and attributes of character to facilitate this type of ethical discourse in case consultation on ethical issues in clinical care or clinical research, and in ethics consultation to ethics committees, to research ethics boards (institutional review boards), and to policy formulation committees.

For Peter Singer, expertise in ethics requires a familiarity with moral concepts, an understanding of the logic of moral argumentation, and ample time to gather relevant information." Essential for an ethical expert is:



the ability to reason well and logically, to avoid errors in one's own arguments, and to detect fallacies when they occur in the arguments of others ... an understanding of the nature of ethics and the meaning of moral concepts reasonable knowledge of the major ethical theories [and finally, knowledge of] the facts of the matter under discussion.



          For Arthur Caplan, this conception of moral expertise is too narrow. He is critical of the engineering model of applied ethics-a model that focuses exclusively on conceptual clarification, mastery of ethical theory, and impartiality-and he underlines the importance of moral diagnosis and moral judgment. In his view, to be effective in the health care setting, one must have the ability to identify and classify moral problems not previously discerned, and the ability to use moral knowledge to view moral problems from different perspectives. Caplan concedes, however, that in appropriate circumstances "engineering is a valuable and helpful activity even in a field such as ethics." That is,  at times the engineering model of applied ethics is a useful art that "requires practical knowledge, theoretical understanding, and experience.''

virtues and traits of characters which the ethics consultant must strive

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the virtues and traits of character listed in the Profile represent the ideal toward which the ethics consultant must strive. In addition to certain dispositions of the mind, effective ethics consultation requires certain dispositions of the heart, hence, the importance of virtue and character. Acknowledging human frailties, however, the virtues and traits of character are not proposed as minimum standards, but rather as standards to be pursued! practiced over a lifetime.

 the knowledge, abilities, virtues, and traits of character listed are neither exhaustive nor immutable. On reflection, there may be requirements listed that should be deleted, and others that should be added. Proposed changes to the Profile, however, should be the result of a process similar to the one that generated the Profile-from within and by consensus.

the Profile of the health care ethics consultant is not a "stand-alone" document, and so to focus narrowly on the lists provided is to ignore the context within which the Profile was developed. This risks a serious misunder-standing of the initiative the Profile represents-a genuine effort to understand precisely what qualifies someone to be a health care ethics consultant.

The Profile was developed with a narrow focus on the role and responsibilities of the health care ethics consultant in the clinical setting. Of particular interest were the following questions: What should the ethics consultant know? What skills should s/he have? Who should s/he be? As far as possible, the Profile was developed without any starting assumptions about professional background or practice. In the spirit of a true quest for insight into an important question, the focus was on the end to be achieved (i.e., a functional description of the health care ethics consultant), and there were no assumptions made about the most appropriate means to the end. The discussion of "means to the end," found in the chapter on feeder disciplines, followed discussions of the Profile.

Finally, two brief comments are offered to those who will argue that the Profile sets the standard of practice far above that which can be achieved by the average person currently working in the clinical setting as a health care ethics consultant. First, we do not dispute the accuracy of this claim. Second, we do dispute the assumption that "what is, should be," particularly since in our view, there is a world of difference between a consultant and a dilettante, whether s/he works in ethics, medicine, engineering, architecture, and so forth. In our view, the Profile is an appropriate professional inventory of the knowledge, abilities, and traits of character required for effective health care ethics consultation.

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