Healthcare Ethics Consultant-Certified Examination Content Outline and Item Development

The 2017 ASBH Role Delineation Study was the key document used to create the HEC-C examination content outline. The content outline is divided into four domains: assessment, analysis, process, evaluation, and quality improvement—with supporting tasks for each. The role delineation study also identified 63 knowledge statements that are included as a part of the content outline and represent foundational knowledge that will be assessed through the examination.

The content outline was used by the volunteer item writers who developed 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 and is an essential preparation tool for those planning to take the exam.

The full content outline and core references are listed below along with real-life examples that fulfill each domain. Please note these examples are provided for clarification purposes and by no means provide an exhaustive list of qualifying experience. You also can download a printable PDF for your convenience.

Application Information

Assessment (32%)

  1. Gather and discern factual information relevant to the case (e.g., clinical, psychosocial, spiritual, institutional, legal)
  2. Assess the social and interpersonal dynamics of those involved in the consultation (e.g., power relations, racial, ethnic, cultural)
  3. Distinguish the ethical dimensions of the consultation from other dimensions (e.g., legal, institutional, medical)
  4. Elicit the moral views of those involved in the consultation
  5. Identify relevant assumptions, beliefs, values, and interests of those involved
  6. Identify the ethical concern(s) and the central ethical question(s)
  7. Identify your own relevant experiences, values, and intuitions and how these might influence the consultation

+ Examples

  • Did you participate in gathering relevant factual clinical and psychosocial-spiritual information regarding a specific case that was helpful in performing an analysis?
  • Have you reviewed the published literature regarding ethical analyses or ethical position statements by professional societies?
  • Have you purposefully sought input from multiple disciplines (such as medicine, surgery, nursing, social work, chaplaincy) even if the requestor of the consultation did not identify them as relevant?
  • When dialoguing with participants in an ethics consultation, do you ask questions to identify, clarify, or explore their underlying beliefs, values, and interests?
  • Have you consulted with legal colleagues within your organization in order to clarify the relevant law regarding an ethics consultation?
  • Did you serve as a peer reviewer or "sounding board" to a mentee or colleague who asked for your assessment or input regarding an ethics consultation?
  • Have you taken an implicit bias test and reflected on how bias might be influencing your ethics recommendations and how to counteract bias?

Analysis (28%)

  1. Evaluate and apply relevant healthcare ethics information (e.g., law, institutional policy, professional codes and formal guidance)
  2. Clarify relevant ethical issues (e.g., confidentiality, privacy, informed consent, best interest, professional duties)
  3. Identify a range of ethically acceptable options and their consequences
  4. Evaluate evidence and arguments for and against different options
  5. Offer recommendations

+ Examples

  • Does your analysis identify the relevant ethical issues or problems raised by the ethics consultation?
  • Does your analysis clarify the goals or objectives of the various parties involved in the ethics consultation?
  • Does your analysis consider a broad range of possible options, potentially beyond the options posed by the parties involved in the ethics consultation?
  • Does your analysis apply ethical principles/frameworks that help address the central ethical questions in ethics consultations?
  • Does your analysis evaluate the pros (advantages or positive consequences) and cons (disadvantages or negative consequences) of each possible option?
  • Does your analysis examine whether an option is consistent with professional societies' guidelines, standards, or recommendations?
  • Does your analysis consider whether options are consistent with hospital policies?
  • Does your analysis account for federal and state laws?

Process (27%)

  1. Create a respectful and trusting environment
  2. Promote respect for diversity
  3. Establish realistic expectations about the consultation process
  4. Determine whether a particular request will involve only the healthcare ethics consultant service or is appropriate for joint effort
  5. Facilitate effective communication among all parties
  6. Identify who should be involved in a consultation (e.g., patient, healthcare professionals, family members)
  7. Collaborate with other responsible persons, departments, or divisions within the institution
  8. Facilitate formal meetings (e.g., clarifying participants' roles, identifying the goal, establishing expectations and confidentiality)
  9. Educate involved parties about the ethical dimensions of the consultation
  10. Recognize and attend to relational barriers to communication (e.g., suffering, moral distress, strong emotions)
  11. Represent the views of the involved parties to others
  12. Identify underlying systems issues and bring them to the attention of the appropriate institutional resource for handling such concerns at the appropriate level
  13. Document consultations in internal healthcare ethics consultation service records
  14. Document consultations in patient health records
  15. Summarize and communicate documentation to relevant parties
  16. Identify the need for and establish the timeline for and complete follow-up activities
  17. Provide informal guidance or sounding-board (e.g., "curbside" consultation)
  18. Use institutional structures and resources to facilitate implementation of recommendations

+ Examples

  • Did you draft or finalize an ethics consultation note in the medical record?
  • Have you provided via discussion or in writing a clear set of recommendations for an ethically appropriate resolution to the problem at hand?
  • Have you explained via discussion or in writing the rationale for your recommendations, and (if applicable) why one or more of the possible options are ethically inappropriate?
  • Did you explain to patients, families, or clinicians what to expect or not expect as part of the consultation processes?
  • If your analysis of the problem at hand revealed that it would best be resolved by another hospital service, did you refer the case to the appropriate service or otherwise help to escalate the case within the organization?
  • Did you facilitate a family meeting involving clinicians and family members?
  • Did you facilitate a healthcare team-only meeting that did not involve family members?

Evaluation and Quality Improvement (13%)

  1. Obtain feedback from persons involved in ethics consultations
  2. Use criteria to evaluate ethics consultation outcomes (e.g., satisfaction, conflict resolution, knowledge acquisition)
  3. Ensure systematic recording of ethics consultation data
  4. Use data to analyze structural or systemic barriers to effective consultation process
  5. Use data to analyze structural or systemic obstacles to excellent care that may have contributed to the need for the consultation
  6. Identify patterns (e.g., frequently repeated consultations about the same issue, or from the same unit or department)
  7. Consider the implications of outcomes of consultations for the wider organization, including its mission and ethical standards
  8. Recommend policy and practice changes within the organization

+ Examples

  • Did you survey involved clinicians about their experience with ethics consultation?
  • Did you contact participants in a particularly challenging consultation to obtain feedback?
  • Do you use a specific template when documenting in the patient's medical record, to facilitate more consistent documentation?
  • Did you enter data regarding consultations into an internal database that you use to assess the performance of the ethics consultation service?
  • Have you initiated and proposed staff educational or training opportunities based on your evaluation of consultation data?
  • Have you discussed with leadership of a particular service line or hospital unit the occurrence of specific problems identified by your evaluation of consultation data?
  • Have you recommended changes to one of your organization's policies, based on your evaluation of either your ethics consultation data or new or revised ethics statements by professional societies?

Knowledge statements that may be incorporated into the above domains and tasks

+ Moral Reasoning

K01 Approaches to moral reasoning (e.g., theories, methods, concepts)

+ Healthcare Ethics Issues and Concepts

K02 Advance care planning
K03 Autonomy, informed consent, and refusal
K04 Beginning-of-life decision making
K05 Common barriers to "patient adherence"
K06 Confidentiality and privacy
K07 Conflicts of interest and of obligation
K08 Decision-making capacity
K09 Determination of death
K10 Difficult-to-care-for patients and surrogates
K11 Disclosure and truth telling
K12 Disruptive or impaired providers
K13 Duty to warn
K14 End-of-life decision making
K15 Genetic testing and counseling
K16 Life-sustaining treatment
K17 Moral distress
K18 Organ donation and transplantation
K19 Palliative care and pain management
K20 Parental permission, decision making, and assent for children and adolescents
K21 Patients' rights and responsibilities
K22 Potentially inappropriate treatment/futility
K23 Professional codes of ethics and guidance documents
K24 Professionals' rights and responsibilities (and conscientious objection to treatment)
K25 Public health issues
K26 Reproductive issues
K27 Resource allocation
K28 Shared decision making
K29 Social determinants of health
K30 Staff and patient safety
K31 Surrogate decision making, substituted judgment and best interest standards
K32 Vulnerable populations

+ Healthcare Systems

K33 Continuum of care delivery
K34 Delivery and payment systems
K35 Development of health policy
K36 Healthcare organization administration
K37 Relevant regulatory and accreditation standards

+ Clinical Context

K38 Basic concepts and processes used in diagnosis, treatment, and prognosis
K39 Clinical course of commonly seen illnesses
K40 Current and emerging technologies
K41 Distinctions between clinical research and therapeutic innovation
K42 Factors that influence the process of health care decision making
K43 Grieving process and psychological responses to illness and loss
K44 Healthcare professionals and their roles, relationships, and responsibilities
K45 How care is provided on various services, settings, and levels of acuity
K46 Treatment goals and the related plan of care
K47 Understanding how patients or their surrogate decision makers interpret health, disease, and illness

+ Local Healthcare Organizations and Policies

K48 Community beliefs and perspectives that bear on the health care of marginalized groups
K49 Decision making processes or frameworks
K50 Healthcare ethics consultant resources and relationships
K51 Healthcare organization policies
K52 Local health care facility's code of professional conduct
K53 Medical records system
K54 Mission, vision, and values
K55 Organizational culture
K56 Perspectives of those who are physically, developmentally, or behaviorally challenged and their surrogates
K57 Range of services, sites of delivery, and populations served
K58 Resources for understanding and interpreting cultural and faith communities
K59 Structure, including departmental, organizational, governance, and committee structure

+ Health Law

K60 Relevant health law
K61 Federal, state, and local statutes and case law
K62 Relationship between law and ethics
K63 Reporting requirements

+ 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

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


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