Bioethics Forum Essay
Confusing Equity for Ethics Standards: Where Do We Go from Here?
The country’s leading hospital accreditation body recently eliminated 168 standards after a comprehensive review that considered three questions: Does the requirement still address an important quality and safety issue? Is it redundant? Are the time and resources needed to comply with the requirement commensurate with the estimated benefit to patient care and health outcomes?
One of the eliminated standards was the only standard that governed clinical ethics services. However, the accreditation organization—The Joint Commission—says that additional review is ongoing. We argue the removal of the ethics standard requires additional review, and we have the following recommendations.
First, The Joint Commission should include bioethics and equity experts to rethink the performance standard for assessing the contributions of the ethics consultation process to patient welfare. Together, they should explore multiple means of enhancing patient safety.
Second, the commission should restore and strengthen the clinical ethics standard. This standard served to promote the establishment of clinical ethics services in hospitals. Clinical ethics services are entrusted with the difficult task of addressing moral conundrums that jeopardize patient health, safety, welfare, autonomy, and dignity. At many hospitals, ethics consultants are needed most when the treatment offered by a health care professional conflicts with a patient’s preferences or unique characteristics, or when uncertainties cloud medical decisions. Clinical ethics services help improve patient safety and quality of care. They are also key stakeholders in improving health care equity, including addressing health care disparities and developing equitable metrics for analyzing social injustice. The clinical ethics standard should be bolstered with a requirement for clinical ethicists to refer patients to receive equitable services that address their ethical dilemmas.
Finally, The Joint Commission should adopt more practical, objective, and consistent means of assessing clinical ethics performance in hospitals as it relates to equity. Equity standards need to consider multiple types of patient vulnerability, drawing on not only indices of race and ethnicity, but also of education, housing, and poverty. The COVID-19 pandemic has made multiple sources of health care inequities dramatically more evident, as illustrated, for instance, in wide disparities in morbidity and mortality and in difficulties optimally allocating scarce resources. Elements of performance should thus put greater emphasis on addressing socioeconomic factors and the role they can play in clinical conflicts and, more broadly, in creating mistrust in the health system. The clinical ethics standard should be strengthened by including a requirement that defines the qualifications and number of care providers that are available to address inequities through ethics consultation.
The Commission’s alteration of the ethics standards will have a ripple effect on other entities that depend upon accreditation as proxy for their own evaluation of programs. For example, the Accreditation Council for Graduate Medical Education might not want its trainees educated in residency programs that lack clinical ethics services. Professional identity formation is one of the six core competencies endorsed by graduate medical education, and it requires demonstration by physicians of their “commitment to carrying out professional responsibilities and an adherence to ethical principles.”
In addition, a key policy priority for the Centers for Medicare & Medicaid Services is for health care professionals to address disparities at the point of care and meet the needs of the communities they serve, particularly minority and other underserved communities. Ethicists are among those key professionals. While the CMS approved the Joint Commission’s new standards, the priorities of the two entities should be harmonized to meet their common goals for the pursuit of health care justice.
In short, The Joint Commission should not still the voices and concerns of patients, caregivers, nurses, and physicians who, for decades, have relied on a process of ethics consultation for mediating patient care conflicts. Rather, the commission should reinstate and bolster the ethics performance element to further provide patients and those entrusted with their health care with clear approaches for managing moral or technical dilemmas. Integrating broader social determinants would be a more pragmatic and successful pathway for achieving The Joint Commission’s laudable goals of improving equity in the provision of “safe and high-quality” health care to marginalized populations. We look forward to consideration and implementation of the above recommendations.
Louis Voigt, MD, MBe, HEC-C, is an attending physician in the department of anesthesiology, pain and critical care medicine and chair of the ethics committee at Memorial Sloan Kettering Cancer Center. He is also an associate professor of medicine in clinical anesthesiology and of clinical medicine in medicine at Weil Cornell Medical College.
Robert Klitzman, MD, is a Professor of Psychiatry in the Vagelos College of Physicians & Surgeons and the Mailman School of Public Health and the director of the Masters of Bioethics Program at Columbia University. @RobertKlitzman
Renee McLeod-Sordjan, DNP, PhD.c., F.A.A.N., HEC-C, is director and system chair of the Division of Medical Ethics at Northwell Health. She is a professor and the inaugural Vice Dean of the Hofstra-Northwell School of Nursing and Physician Assistant Studies
The authors are members of the Empire State Bioethics Consortium. The ideas and views are not necessarily those of ESBC or institutions with which they are affiliated.
This is the third and final essay in a series on a recent change in ethics performance standards made by the country’s leading accrediting body for hospitals. The first essay: “Where Is Clinical Ethics in the Revised Hospital Accreditation Standard.” The second essay: “Health Equity Without Ethics Perpetuates Marginalization.”
Kudos to Hastings Center for publishing and the writers for this important 3 part series on the importance of ethics in healthcare.
Your concerns have impacted policy.
The Joint Commission released an updated Element of Performance in the May 2023 issue of Joint Commission Perspectives©. This update may be a result of the concerns from ASBH, other organizations, and individual practitioners shared with the Joint Commission when their most recent streamlining appeared to eliminate previous ethics standards. Effective August 27, 2023, Standard LD.O4.02.03 reads: “Ethical Principles guide the [hospital’s] business practices”. Related Element of Performance 1 is has been updated to “The [hospital] develops and implements a process that allows staff, [patients], and families to address ethical issues or issues prone to conflict.”