4 April 2023
Letter to ASBH advocating for increased JCo standards

To the Board of Directors of the American Society for Bioethics and Humanities (ASBH):

We are writing as clinical ethics practitioners, who are deeply committed to quality in clinical ethics, to call upon ASBH to embrace the recommendations outlined in the recently published “Recommendations for Improving Joint Commission Standards” by Aaron et al.[1] Specifically, we urge ASBH to petition the Joint Commission to revise Joint Commission standards to align with ASBH’s own promulgated standards for ethics practices.

Conversation about accrediting bodies like the Joint Commission requiring appropriate clinical ethics standards continues to increase within the field. At the 2022 Clinical Ethics Unconference, attendees from 40 health care institutions voted this subject as a top issue to be addressed. As a result, an initial group of clinical ethicists organized to envision what such advocacy efforts could look like. Notably, this group formed independently and without the knowledge that Aaron et al. were in the process of publishing a paper on the very same topic. More recently, in response the Joint Commission eliminating all standards relating to clinical ethics practice, other commentators have called for dialogue with the Joint Commission to revisit and make stronger the retired standards.[2,3]

Ultimately, the originally formed group decided to appeal to ASBH to advance this effort, resulting in the letter you are now reading. A number of clinical ethicists and ethics consultants who share the conviction that the time is now for ASBH to work with accrediting bodies like the Joint Commission to increase standards have also co-signed this letter. We explain our reasons for holding this conviction below.

With the goal of promoting quality in healthcare, the Joint Commission is committed to advancing safety and quality through setting quality standards and evaluating healthcare organizations’ performance.[4] While the Joint Commission maintains comprehensive standards for other clinical practices by outlining expected practice standards and qualifications for providers, as noted above the organization recently eliminated all standards relating to clinical ethics practice. This includes prior requirements that “[h]ospitals provide a mechanism for resolving ethics and value questions that arise in the care of patients”[5] and that “[t]he hospital follows a process that allows staff, patients, and families to address ethical issues or issues prone to conflict.”[6] Notably, this latter requirement — what was once the last remaining standard to address ethical issues in patient care — was still in place when Aaron et al. published their article. However, it was eliminated in February 2023.[7] In essence, Joint Commission standards have gone backward when it comes to clinical ethics quality. According to the Joint Commission standards development process, emerging quality and safety issues can indicate a need for additional requirements.[8] We contend that a standard for addressing ethical issues in patient care ought to be reintegrated into the Joint Commission’s manual at minimum, that more robust guidance in the realm of clinical ethics is needed as compared to prior standards, and that ASBH is best positioned to advocate for increased standards.

The value that high-quality ethics practices contribute to healthcare has been well described in the literature,[9,10] and the harm that stems from individuals performing clinical ethics consultations without the basic education, training, or expertise to do so has also been commented upon.[11] A study of ethics consultation practice in the US found that 41% of those performing clinical ethics consultations have no education or training in ethics.[12] More concerning still, 47% of ethics practitioners reported being “not at all familiar with” ASBH’s Core Competencies.[13] Given the high-stakes decisions that ethics consultants are sometimes asked to deliberate upon, including end-of-life situations, low-quality clinical ethics consults can lead to subpar care, recommendations at odds with widely-accepted ethics standards and professional society policy statements, and, in some instances, to wrongful patient deaths.[14] These grave consequences clearly indicate a quality and safety issue that demands improved ethics standards.

We are grateful that ASBH has organized to develop professional standards, competencies, and educational opportunities. The 2011 ASBH update expanding its Core Competencies and emerging health care ethics consultation standards reflects an important step in professionalism and recognizing minimum standards of practice for clinical ethics consultation.[15] However, without some form of regulatory oversight, it is unlikely that healthcare institutions will adopt new practices. It is our resolute belief that ASBH, as the preeminent leader in the field of bioethics, is the only voice loud enough to command such action. Moreover, because ASBH has assumed the role of promulgating standards, we believe it has the additional responsibility to meaningfully advocate for the adoption of the standards it has developed. In this way, ASBH has a unique opportunity to represent its clinical ethicist and ethics consultant constituency to the Joint Commission to advocate for improved ethics practice standards.

We suggest that collaboration with organizations that have built on ASBH’s work to develop quality assessment for clinical ethics work and programming, such as the Catholic Healthcare Association (CHA)’s Striving for Excellence tool and Veterans Administration’s IntegratedEthics® Facility Workbook,[16,17] might strengthen these efforts. We are also aware that other institutions are currently building on this work to create assessment standards for their own ethics programs (at individual hospital and system levels). These tools provide a foundation to identify the minimum necessary standards (infrastructure, processes, qualifications, etc.) to promote quality of clinical ethics services and could be incorporated into more robust and specific Joint Commission standards.

We now urge ASBH to advocate on behalf of its membership for revised Joint Commission standards regarding hospital-based clinical ethics practices. This is a vital next step in the field’s pursuit of professionalization and quality standards. It will mitigate ongoing concerns of unacceptable deviation from minimum quality ethics practices, remedy Joint Commission standards going backward, enhance integration of clinical ethics work into hospital operations across the country, and support ASBH membership in demonstrating value to the institutions within which they work. It will also make meaningful the important standards that ASBH has invested time, expertise, and energy into developing.

Sincerely,

All co-signatories to this letter

[1] Aaron B, Crites JS, Cunningham TV, Mishra R, and Lesandrini J, “Hospital Ethics Practices: Recommendations for Improving Joint Commission Standards,” The Joint Commission Journal on Quality and Patient Safety (2022) 48, no 12: 682–85.

[2] McLeod-Sordjan R, Swindler R, and Fins JJ, “Where is Clinical Ethics in the Revised Hospital Accreditation Standards?” The Hastings Center: Bioethics Forum Essay, March 24, 2023, thehastingscenter.org/where-is-clinical-ethics-in-...

[3] Brown VA, Riches JC, and McLeod-Sordjan R, “Health Equity Without Ethics Perpetuates Marginalization,” The Hastings Center: Bioethics Forum Essay, March 29, 2023, thehastingscenter.org/health-equity-without-ethics...

[4] The Joint Commission, “Who We Are,” Accessed March 31, 2023, https://www.jointcommission.org/who-we-are/.

[5] The Joint Commission. RI.1.1.6.1. Rights and Responsibilities of the Individual. In: 1992 Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 1991.

[6] The Joint Commission. LD.04.02.03, EP 1. Leadership. In: Comprehensive Accreditation Manual for Hospitals (E-dition), effective July 1, 2022. Oak Brook, IL: Joint Commissions Resources, 2022.

[7] The Joint Commission. Prepublication Requirements, Select Retired and Revised Accreditation Requirements, Issued December 20, 2022, Effective February 19, 2023, LD 04.02.03, EP 1, jointcommission.org/-/media/tjc/documents/standard...

[8] The Joint Commission, “About Our Standards,” Accessed March 31, 2023, jointcommission.org/standards/about-our-standards/...

[9] Repenshek M, “Examining Quality and Value in Ethics Consultation Services,” The National Catholic Bioethics Quarterly (2018) 18, no. 1: 59–68.

[10] National Center for Ethics in Health Care, “A Brief Business Case for Ethics,” Accessed March 31, 2023, https://www.ethics.va.gov/businesscase.pdf.

[11] Kon AA, “Clinical Ethicists Have an Ethical Obligation to Create Professional Standards and a National Certification Process,” American Journal of Bioethics (2016) 16, no. 3: 30–32.

[12] Fox E, Danis M, Tarzian AJ, and Duke CC, “Ethics Consultation in U.S. Hospitals: A National Follow-Up Study,” American Journal of Bioethics (2022) 22, no. 4: 5–18.

[13] Ibid.

[14] Kon AA, “Clinical Ethicists Have an Ethical Obligation to Create Professional Standards and a National Certification Process,” American Journal of Bioethics (2016) 16, no. 3: 30–32.

[15] Tarzian AJ, “Health Care Ethics Consultation: An Update on Core Competencies and Emerging Standards from the American Society for Bioethics and Humanities' Core Competencies Update Task Force,” American Journal of Bioethics (2013) 13, no. 2: 3–13.

[16] Catholic Health Association of the United States, Striving for Excellence in Ethics: A Resource for the Catholic Health Ministry (St. Louis, Mo.: Catholic Health Association, 2014).

[17] National Center for Ethics in Health Care, “IntegratedEthics® Facility Workbook: Guide to Understanding Your Results, 2020 Version,” Accessed March 31, 2023, ethics.va.gov/docs/integratedethics/IEFW_2020_Guid...

152
signatures
145 verified
  1. Hilary Mabel, Clinical Ethicist, Wellstar Health System, Atlanta, GA
  2. Kristin Furfari, MD, Univeristy of Colorado, Denver
  3. Susannah Lee, Clinical Ethicist, MedStar Washington Hospital Center, Washington DC
  4. Jeanie L. Sauerland, Director Ethics Services, University Health, San Antnonio
  5. Cristie Horsburgh, Clinical Ethicist, Cleveland Clinic, Cleveland, OH
  6. Jeanie Sauerland, Ethicist, University Health, San Antonio
  7. Joshua Crites, Clinical Ethicist, Cleveland Clinic, Cleveland, OH
  8. Meisha Brown, Clinical Ethics Fellow, Wellstar Health System, Atlanta, GA
  9. Kate Molchan, Clinical Ethicist, Wellstar Health System, Altanta
  10. Chelsey Patten, Director, Clinical Ethics, Novant Health, Charlotte, NC
  11. Jordan Potter, Director of Ethics, Community Health Network, Indianapolis, IN
  12. Curtis Coughlin, Associate Professor, University of Colorado AMC, Aurora
  13. Jeffrey S. Farroni, Director, Institutional Ethics Program, UTMB, Galveston, TX
  14. Cindy Bruzzese, Executive Director & Clinical Ethicist, Vermont Ethics Network, Montpelier, VT
  15. Jonathan Marron, Director of Clinical Ethics, Harvard Medical School Center for Bioethics, Boston
  16. Parker Crutchfield, Associate Professor, Western Michigan University School of Medicine, Kalamazoo
  17. James M. Hunter, Jr., Physician, University of Alabama at Birmingham, Birmingham, AL
  18. Mary Devereaux, Bioethics faculty, UC, San Diego, San Diego
  19. Colleen M Gallagher, Sr. Counselor, Bioethics & Health Policy, MD Anderson Cancer Center, Houston
  20. John Zell Sadler, Psychiatrist, Dallas
...
105 more
verified signatures
  1. Leonard Fleck, Professor, Michigan State University, BATH
  2. Maggie Procunier RN MSN HEC-C, RN ethics committee co-chair, Cleveland Clinic Indian River Hospital, Vero Beach
  3. Joel Wu, Clinical Ethics Assistant Professor, University of Minnesota, Minneapolis
  4. Catherine McCarty, Professor and Healthcare Ethicist, University of Minnesota Med School, Duluth
  5. Tim Stratton, PhD, RPh, Professor of Pharmacy Practice, University of Minnesota College of Pharmacy, Duluth, MN
  6. Matthew K Wynia, phyician, University of Colorado, Aurora
  7. Rev. Dr Julie Vaughn, M.Div, MACE, MA, BCC DBe (c), BCC, VMFH St. Anne Hospital, Burien
  8. Dulcy E. Wolverton, MD, Associate Professor of Radiology, University of Colorado School of Medicine, Aurora, CO
  9. Jane Jankowski, Clinical Bioethicist, Cleveland Clinic, Cleveland
  10. Kathryn Huber, resident physician, University of Colorado School of Medicine, Aurora
  11. Kristine Keough, M.S., D.BE, Bioethicist, Longview
  12. Andrew (Andy) Oppenberg, Professor/Bioethicist, CSUN/ Asclepius Bioethics, ERM, Pt Safety Consultants, Northridge
  13. Patrice M Tadel MSN, RN, Clinical ethicist and consultant, Respecting Choices, La Valle, WI
  14. Katherine Brown-Saltzman, Retired, Co-director UCLA Health Ethics Center, UCLA School of Nursing, Los Angeles
  15. Keren Tanguay, Director of Clinical Ethics, KetteringHealth, Kettering
  16. Joseph Bertino, Ethics Director, UPMC, UPPER ST. CLAIR
  17. John Frye, Clinical Bioethicist, Sutter Health, Oakland CA
  18. Kathy Kinlaw, Clinical Ethicist/Assistant Professor, Emory University Center for Ethics, Atlanta
  19. Jeffrey Spike, Professor, Children's National Hospital and George Washington University, Alexandria
  20. Michael Horton, Physical Therapist, Evergreenhealth Home Health + Ethics Committee, Lynnwood
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