Healthcare Ethics Consultant-Certified Examination Content Outline and Item Development
The November 2023 HEC-C Examination will reflect the updated HEC-C Examination Content Outline released May 2023. The major domains of the content outline have not changed. Domain-level knowledge and skill statements are now organized under each domain. Weighting for each domain has been updated as well.
The content outline is used by volunteer item writers who develop questions (i.e. items) for the certification examination. Each item links back to a task and knowledge statement included in the content outline and will appear in the exam based on the weighting of each domain. The core references used for item writing were limited to only those listed at the end of the content outline. Therefore, the content outline and reference list represent the exam specifications.
Learn more about the process for updating the HEC-C Examination Content Outline.
Assessment (29%)
1. Gather and discern factual information relevant to the case (e.g., clinical, psychosocial, spiritual, institutional, legal)
+ Knowledge
- Basic medical terminology and abbreviations
- Basic concepts and processes used in diagnosis, treatment, and prognosis
- Clinical treatment course and decision points of commonly seen illnesses
- Distinctions between clinical research and therapeutic innovation
- Health care professionals and their roles, relationships, and responsibilities
- How care is provided on various services, settings, and levels of acuity
- Treatment goals and the related plan of care
- Medical records system
+ Skills
- Reviewing and interpreting the medical record
- Communicating with key stakeholders and understanding their viewpoints
- Explaining the role of the ethics consultant and the consultation process
- Separating factual information from opinion
2. Assess the interpersonal, family, and social dynamics involved in the consultation (e.g., power relations, racial, ethnic, cultural)
+ Knowledge
- Grieving process and psychological responses to illness and loss
- How patients or their surrogate decision makers interpret health, disease, and illness
- Common barriers to patient adherence
- Cultural and religious approaches to health and decision making
- Patients' rights and responsibilities
- Professionals' rights and responsibilities (and conscientious objection to treatment)
- Vulnerable populations
- Community beliefs and perspectives that bear on the health care of marginalized groups
- Resources for understanding and interpreting cultural and faith communities
+ Skills
- Obtaining the views of key stakeholders on dynamics involved in the consultation
- Utilizing various approaches to health and decision making
3. Identify the ethical concern(s) and the central ethical question(s)
+ Knowledge
- Approaches to ethical reasoning (e.g., theories, methods, concepts)
- Most common ethical concerns (e.g., surrogate decision making, conflicts of interest, end-of-life care)
- Knowledge of legal, institutional, and medical dimensions of consultations
- Relevant health law
- Mission, vision, and values of the organization
- Organizational culture
- Health care organization policies
+ Skills
- Clarifying the specific ethical concern(s)
- Distinguishing the ethical dimension of the consultation from other dimensions (e.g., legal, institutional, medical)
- Identifying problems that can be solved and problems which cannot
4. Elicit the views of those involved in the consultation
+ Knowledge
- Cultural and religious approaches to health and decision making
- Modes and methods of decision making
- Inquiry methods (e.g., humble, open-ended question)
- How patients or their surrogate decision makers interpret health, disease, and illness
- Community beliefs and perspectives that bear on the health care of marginalized groups
- Perspectives of those who are physically, developmentally, or behaviorally challenged and their surrogates
+ Skills
- Obtaining the relevant assumptions, beliefs, values, morals, and interests of those involved
- Recognizing your own relevant experiences, biases, values, and intuitions and how these might influence the consultation
Analysis (28%)
1. Clarify relevant ethical issues (e.g., confidentiality, privacy, informed consent, best interest, professional duties)
+ Knowledge
- Ethical theories (e.g., principlism, consequentialism, virtue ethics)
- Approaches to ethical reasoning (e.g., casuistry, narrative ethics, feminist ethics)
- Relevant ethical concepts (e.g., autonomy, fiduciary responsibility, beneficence, positive and negative rights)
- Most common ethical concerns (e.g., surrogate decision making, conflicts of interest, end-of-life care)
- Professional codes of ethics and guidance documents
- Health care organization policies
- Local health care facility's code of professional conduct
- Factors that influence the process of health care decision making
+ Skills
- Applying bioethical method(s) to identify pertinent ethical issues (e.g., four-box method, CASES)
- Evaluating and applying relevant health care ethics information (e.g., law, institutional policy, professional codes and formal guidance)
2. Identify a range of ethically acceptable options
+ Knowledge
- Ethical theories (e.g., principlism, consequentialism, virtue ethics)
- Approaches to ethical reasoning (e.g., casuistry, narrative ethics, feminist ethics)
- Relevant ethical concepts (e.g., autonomy, fiduciary responsibility, beneficence, positive and negative rights)
- Causes of moral distress/moral injury
- Decision making processes or frameworks
- Patients' rights and responsibilities
- Professionals' rights and responsibilities
+ Skills
- Defining what constitutes the ethically acceptable options
- Evaluating evidence and arguments for and against different options
- Anticipating the consequences of the defined ethically acceptable options
- Formulating potential recommendations from the range of identified ethically acceptable options
Process (27%)
1. Prepare for effective ethics consultation
+ Knowledge
- Health care professionals and their roles, relationships, and responsibilities
- How care is provided on various services, settings, and levels of acuity
- Perspectives of those who are physically, developmentally, or behaviorally challenged and their surrogates
- Resources for understanding and interpreting cultural and faith communities
- Organizational culture
- Health care ethics consultant resources and relationships
- Resources for understanding and interpreting cultural and faith communities
- Basic medical terminology and abbreviations
- Basic concepts and processes used in diagnosis, treatment, and prognosis
- Relevant health law
- Federal, state, and local statutes and case law
- Relationship between law and ethics
- Mission, vision, and values
- Advance care planning (e.g., advance care directives, goals of care)
+ Skills
- Creating a respectful, trusting, and inclusive environment
- Promoting respect for diversity
- Determining the type of consult needed, including the benefits and drawbacks of each approach (e.g., formal consultation, "curbside" consultation, application of relevant policy)
- Establishing realistic goals and expectations for the consultation process
- Determining whether a particular request will involve only the health care ethics consultation service or would also benefit from the involvement of other health care services (e.g., palliative medicine, spiritual health/chaplaincy, physical therapy)
- Identifying who should be involved in a consultation (e.g., patient, health care professionals, family members, other relevant stakeholders)
- Reviewing existing advanced care documents for the patient
2. Facilitate effective and inclusive communication, ethical deliberation, and problem-solving among all parties
+ Knowledge
- Ethical theories (e.g., principlism, consequentialism, virtue ethics)
- Approaches to ethical reasoning (e.g., casuistry, narrative ethics, feminist ethics)
- Relevant ethical concepts (e.g., autonomy, fiduciary responsibility, beneficence, positive and negative rights)
- Confidentiality and privacy
- Autonomy, informed consent, and refusal
- Conflicts of interest and of obligation
- Decision-making capacity
- Disclosure and truth telling
- Patients' rights and responsibilities
- Understanding how patients or their surrogate decision makers interpret health, disease, and illness
- Health care professionals and their roles, relationships, and responsibilities
- Strategies of consensus-building
+ Skills
- Advising involved parties about the ethical dimensions of the consultation
- Collaborating with other responsible persons, departments, or divisions within the institution
- Facilitating formal meetings (e.g., clarifying participants' roles, identifying the goal, establishing expectations and confidentiality)
- Recognizing and attending to relational barriers to communication (e.g., suffering, moral distress, strong emotions)
- Eliciting and representing the views of the involved parties to others during the consultation
3. Formalize ethics recommendations
+ Knowledge
- Medical records system
- Structure, including departmental, organizational, governance, and committee structure
- Health care organization policies
- Basic medical terminology and abbreviations
- Treatment goals and the related plan of care
- Relationship between law and ethics
+ Skills
- Documenting consultations in patient health records
- Summarizing and communicating documentation to relevant parties
- Utilizing institutional structures and resources to facilitate implementation of recommendations as needed/requested
4. Complete the ethics consultation
+ Knowledge
- Range of services, sites of delivery, and populations served
- How care is provided on various services, settings, and levels of acuity
- Mission, vision, and values
- Organizational culture
- Structure, including departmental, organizational, governance, and committee structure
- Health care ethics consultant resources and relationships
- Health care organization administration
- Appropriate diversity, equity, and inclusion terminology and documentation
+ Skills
- Identifying and completing follow-up activities, as needed, in a timely manner
- Documenting consultations in internal health care ethics consultation service records
- Identifying underlying systems and policy issues and bring them to the attention of the appropriate institutional resource for handling such concerns at the appropriate level
Evaluation and Quality Improvement (16%)
1. Assess one’s own performance and effectiveness in ethics consultation at regular intervals
+ Knowledge
- Current bioethics literature
- Current ethics consultation standards
- Methods of eliciting/utilizing feedback (e.g., data management software)
+ Skills
- Obtaining feedback from persons involved in ethics consultations in a timely manner
- Utilizing assessments (e.g., self, peer) to evaluate the process and outcomes of ethics consultations
- Integrating national and international health care ethics consultation practice standards into one’s consultation process
2. Ensure systematic and comprehensive recording of ethics consultation data
+ Knowledge
- Relevant regulatory and accreditation standards
- Current bioethics literature
- Current ethics consultations standards
- Basic data management and analysis (e.g., Excel, Redcap)
- Basic methods of quality improvement (e.g., plan-do-check-act cycles)
+ Skills
- Identifying and utilizing appropriate criteria to evaluate ethics consultation outcomes (e.g., intractable conflict, knowledge acquisition, satisfaction)
- Confirming data is recorded for all consults, in a consistent manner (e.g., clear definitions for terms)
3. Monitor for and address relevant trends in ethics consultation within the organization (e.g., frequently repeated consultations about the same issue or from the same unit or department)
+ Knowledge
- Vulnerable populations
- Appropriate diversity, equity, and inclusion terminology and documentation
- Organizational culture
- Mission, vision, and values
- Moral distress
- Factors that influence the process of health care decision making
- Community beliefs and perspectives that bear on the health care of marginalized groups
- Public health issues
- Resource allocation
- Social determinants of health
+ Skills
- Utilizing data to identify and analyze structural or systemic barriers to effective consultation process
- Utilizing data to identify and analyze structural or systemic obstacles to excellent care that may have contributed to the need for the consultation (e.g., health and social inequities)
- Allocating ethics resources (time, outreach, presence, education) to respond to unmet needs
4. Recommend policy and practice changes within the organization as needed
+ Knowledge
- Organizational culture
- Mission, vision, and values
- Structure, including departmental, organizational, governance, and committee structure
- Health care organization policies
- Development of hospital system policy
- Health care organization administration
- Relevant regulatory and accreditation standards
- Relationship between law and ethics
- Relevant health law
- Basic data management and analysis (e.g., Excel, Redcap)
- Basic methods of quality improvement (e.g., plan-do-check-act cycles)
+ Skills
- Assessing the implications of outcomes of ethics consultations for the wider organization, including its mission and ethical standards
- Revising concepts and processes in current policies to reflect changes in practice including improvements based on evidence, experience, and professional standards
- Advocating for/recommending resources within the organization be allocated to address suboptimal situations in patient care and/or staff support
Core References
American Society of Bioethics and Humanities. (2011). Core Competencies in Healthcare Ethics Consultation (2nd ed.). Chicago, IL
American Society of Bioethics and Humanities. (2017). A Case-Based Study Guide for Addressing Patient-Centered Ethical Issues in Health Care. Chicago, IL
American Society of Bioethics and Humanities. (2015). Improving Competencies in Clinical Ethics Consultation: An Education Guide (2nd ed.). Chicago, IL
Applebaum PS. Clinical Practice. Assessment of Patients’ Competence to Consent to Treatment. N Engl J Med, 2007 Nov 1; 357(18); 1834-40.
Beauchamp, T., Childress, J. (2019). Principles of Biomedical Ethics (8th ed.). Oxford: Oxford University Press
Berlinger, N., Jennings, B., Wolf, S. (2013). The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life. Oxford: Oxford University Press
Danis, M., Wilson, Y., & White, A. (2016). Bioethicists Can and Should Contribute to Addressing Racism. The American Journal of Bioethics, 16(4), 3-12. doi:10.1080/15265161.2016.1145283
Diekema, D., Mercurio, M., Adam M (Eds). (2011). Clinical Ethics in Pediatrics: A Case-Based Textbook. Cambridge: Cambridge University Press
Dubler, N. N. (2013). The Art of the Chart Note in Clinical Ethics Consultation and Bioethics Mediation: Conveying Information that Can Be Understood and Evaluated. The Journal of Clinical Ethics, 24(2), 148-155.
Fiester, A. M. (2015, March 1). What Mediators Can Teach Physicians About Managing ‘Difficult’ Patients [Editorial]. The American Journal of Medicine, 128(3), 215-216. Retrieved from https://doi.org/10.1016/j.amjmed.2014.09.017
Ford, P. (Ed.), Dudzinski, D. (Ed.). (2008). Complex Ethics Consultations: Cases That Haunt Us. Cambridge: Cambridge Press.
Hester, DN and T. Schonfeld. (2012) Guidance for Healthcare Ethics Committees. Cambridge: Cambridge University Press
Jonsen, A., Siegler, M., Winslade, W. (2015) Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (8th ed.). New York: McGraw Hill
Kon AA, et al. Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee. Crit Care Med. 2016 Sep; 44(9); 1769-74.
Lo, B. (2020). Resolving Ethical Dilemmas: A Guide for Clinicians (6th ed.). Philadelphia: Lippincott Williams & Wilkins
Marcus, L. J., Dorn, B. C., & Mcnulty, E. J. (2012). The Walk in the Woods: A Step-by-Step Method for Facilitating Interest-Based Negotiation and Conflict Resolution. Negotiation Journal, 28(3), 337-349. doi:10.1111/j.1571-9979.2012.00343.x
Morreim, H. (2018). Mediating Healthcare Disputes More, Earlier . . . And Differently: Mediating Directly in the Clinical Setting. The Health Lawyer, 31(1), 18-29.
Reynolds, J.M. (2018). Three Things Clinicians Should Know about Disability. AMA Journal of Ethics, 20(12):E1181-1187.
Saltman, D. C. (2006). Conflict management: A primer for doctors in training. Postgraduate Medical Journal, 82(963), 9-12. doi:10.1136/pgmj.2005.034306
Sherwin, S., & Baylis, F. (2003). The feminist health care ethics consultant as architect and advocate. Public Affairs Quarterly, 17(2), 141-158.
Stramondo, J.A. (2016). Why Bioethics Needs a Disability Moral Psychology. The Hastings Center Report, May-June, 22-30.
Wahlert, L., & Fiester, A. (2014). Repaving the Road of Good Intentions: LGBT Health Care and the Queer Bioethical Lens. The Hastings Center Report, 44(S4). doi:10.1002/hast.373