Student-Edited AMA Publication Examines Ethical Consults

You may have not heard of the term “ethics consult,” but you have undoubtedly seen the headlines that reveal personal accounts of ethical conflicts among families, physicians, and hospitals:

Parents of boy declared brain dead after asthma attack fight to keep him alive

State fines nursing home for violating do-not-resuscitate order

Three hospitals deny 7-month-old baby heart transplant

Now an almost ubiquitous presence in health care, ethics committees existed in only 1 percent of U.S. hospitals in the 1980s. The rapid adoption of ethics committees has created new questions about the consults: Who should perform consults and what kind of training do they need?

Karel-Bart Celie, a second-year medical student in the Columbia-Bassett Program, edited the May issue of the American Medical Association’s Journal of Ethics, which took a deep look into the topic.

We asked Mr. Celie how he came to edit the issue and what he has learned about ethical consults.

Q: How did you—a second-year medical student—become editor of an issue of AMA-JOE?

AMA JOE produces a theme issue every month, and every fall they put out a call for medical students and residents to apply to develop and edit an issue. I first became fascinated with bioethics in college at Boston College, where I majored in philosophy while also completing my pre-med coursework. Bioethics turned out to be a natural synthesis of my two interests—the sciences and philosophy.

I was looking for a way to remain involved in philosophy and medical ethics during my first two years of medical school, so when someone sent me the AMA-JOE announcement, it seemed like a great opportunity. I had been involved as an editor for the undergraduate philosophy journal at Boston College for two years, serving as chief editor my senior year, so I had that element in my background as well.

Q: What did you know about ethics consults before you started editing the issue?

I had half a grasp of it and that’s why I wanted to learn more about its history, current practice, and debates about its future. So I proposed the idea to the AMA JOE editors and they liked it.

Obviously, I had to learn a lot about ethics consults myself and I did a lot of reading. My first responsibility was to develop ideas for the issue’s articles, and once I had those ideas, I looked for authors who could contribute an article along that theme. In my reading, I came across several authors that I was fortunate enough to be able to include in this issue. I also received a lot of help from my adviser, Dr. Kenneth Prager, who is director of the medical ethics committee at NewYork-Presbyterian/Columbia University Medical Center.

Q: When you started learning more about the topic, did anything surprise you?

I’ve really been struck by the need for standardization in the education and training of ethics consultants. Bioethics is such a new field, and the need for health care ethics consultation kind of grew exponentially alongside that of medical and technological progress.

There’s a lot of debate now about standardizing ethics consults. Currently there is no national accrediting body. The American Society for Bioethics and Humanities has a code for ethics consultants, but there are no uniformly accepted rules governing who can and who can’t perform ethics consults.

Consultants vary from institution to institution. Academic hospitals have more access to physicians who are trained in medical ethics and have degrees or experience in bioethics. But it’s a different story in a small community hospital where’s there’s less access to people with that type of specialty. The latest statistic I saw showed that only 5 percent of health care ethics consultants had a fellowship or graduate degree in bioethics, but that’s probably going to change going forward because there’s increased attention to quality and consistency of ethics consults.

Standardization would in no way mean a one-size-fits-all approach to ethics—in fact, a diversity in backgrounds has been acknowledged as a strength to ethics committees. What can be standardized, however, is the education, tools, and approaches that are employed in ethics consultation. This would go a long way toward ensuring that both patients and physicians are getting the same quality of consultation without some of the inter-institutional variability that is currently out there.

Q: Is there something you’ve learned during this process that you’ll take with you in your own encounters with patients?

I’ve learned that ethics consultation—like medicine itself—is in many ways most valuable when it is preventative. I was not aware of this before I began this project, but an important responsibility of any ethics committee is to educate the health care workforce at its institution about communicating with patients and their families when there is a difference in values.

Many of the situations that result in ethics consultations are a consequence of feeling misunderstood, and these situations can be prevented by good communication and by listening to the other party in good faith. This is a lesson that I want to carry forward in my own clinical practice. Health care ethics consultations should be a last resort.