How to become a clinical ethicist

What does a clinical ethicist do?

Typically, the main purpose of a clinical ethicist is to consult with physicians, nurses, hospital staff, patients, and families to identify and address ethical issues. Ethicists can take consultation requests from across the hospital, but will frequently have units where they focus their time (e.g., the intensive care unit).

The form each consultation takes will depend on its nature. The ethicist will speak with the person who made the request to determine next steps, which might involve gathering more information from other providers or speaking with the patient or family. At this point, the ethicist might have enough information to make a recommendation, or might determine that other steps (e.g., a meeting with the care team and family) are necessary.

Some consultations pose a truly difficult ethical question. In these cases, the ethicist’s ability to conduct a thorough ethical analysis of the situation is important. Sometimes, all the options have significant downsides, or it isn’t clear which option is best all things considered. However, in the majority of consultations, the most ethical option becomes clear early on. the ethicist’s work isn’t done though, since figuring out how to achieve that result is often more challenging than determining which result would be best. (And, even though the ethicist might believe that one option is clearly best, it is important to speak with all the relevant stakeholders and gather the facts before making a judgement.)

Clinical ethicists require the ability to create a respectful and trusting environment with patients and families who are going through one of the most difficult experiences of their lives. Since patient values play such an important role, ethicists must be able to elucidate the things people care most about with people they’ve usually just met. The ethicist must also be able to process medical information and communicate ethical concepts in a clear, jargon-free way. Some arbitration and negotiating skills are a must.

Apart from individual consultations, clinical ethicists can play other roles. Many hospitals have an ethics committee that the ethicist is involved with. Some ethicists take part in quality improvement programs to change aspects of how the hospital or health system functions. For example, when medical assistance in dying became legal in Canada, ethicists were involved in developing processes at their hospitals to enact the legislation. During the Covid-19 pandemic, many clinical ethicists have been involved in more policy-level work.

Why would someone want to become a clinical ethicist?

Clinical ethics combines the intellectual excitement of bioethics theory with the practical, hands-on application of actual cases. Most of the issues one encounters in an undergraduate bioethics course (or while watching medical dramas on TV) really do pop up from time to time: some Jehovah’s Witnesses really don’t want blood transfusions, patients get ‘Do Not Resuscitate’ tattooed on their chests, doctors find out that the person the patient believes to be her genetic father isn’t really, sometimes there aren’t enough ventilators for everyone who needs one, etc. It’s one thing to consider these as hypotheticals; it’s another to know that your input will alter the course of lives.

Of course, encountering these situations in real life can be hard. The ethicist isn’t usually consulted when things are going well. Many consultations are for end-of-life patients. Some of the situations are more tragic than any medical drama. Sometimes they involve children. Still, even in these situations, it’s a privilege to be trusted and let in and to be able to help. In the best cases, an agreement is reached or a plan is made that is a good outcome for everyone.

Those are the intrinsic reasons. There are good instrumental reasons too. Clinical ethicists are paid well. Jobs are fairly secure. Once you’re qualified, the job market is much easier than, say, academic philosophy. While many clinical ethics positions are just for clinical work, some ethicists are able to get teaching opportunities or other research affiliations at universities.

Of course, there are downsides. Some positions involve being on-call 24 hours. It might sound glamorous to be woken up in the middle of the night, and wearing a pager in the 2020s is a conversation starter, but it loses its appeal. As I said above, when a consult goes really well, you get to go home and think about how you made a meaningful difference to someone’s life. But when a consult goes poorly, its consequences stay with you. At a bigger level, the pandemic has changed healthcare. I haven’t seen reports that the rate of burnout among clinical ethicists is similar to nurses and physicians, but it has affected ethicists too.

How does someone become a clinical ethicist?

A strength of clinical ethics is that it draws from many fields. I have worked with people who have backgrounds in philosophy, social work, law, religious studies, nursing, medicine, or health studies (e.g., public health). Some people aim for clinical ethics early on in their post-secondary education, while others, including me, transitioned later on. (In my case, I pursued it as a PhD student who was also interested in academic philosophy jobs. I wrote my dissertation on normative ethics, not bioethics, and interviewed for some tenure-track philosophy jobs before taking a clinical ethics position. And now I’m back teaching bioethics at a university.)

Most people who become full-time clinical ethicists meet two criteria. The first is they have a terminal graduate degree (i.e., the highest degree one can reach in their field). A PhD is common. Those with a JD or MD often have another degree, such as a masters in bioethics (more about those below). There isn’t really a best option, though, obviously, one’s graduate work should have some application to clinical ethics. For instance, if you’re interested in law and clinical ethics, take some health law courses during your JD. Although my dissertation was on normative ethics, I taught bioethics courses and published a bioethics paper in the academic journal Bioethics during my PhD, and my dissertation demonstrated my general ability to do ethics work at a high level.

There are clinical ethicists who don’t have a terminal degree, and some clinical ethicist job ads say that a master’s degree is sufficient to apply. However, if you are interested in clinical ethics, I wouldn’t count on a master’s degree. As clinical ethics grows, more people with terminal degrees will compete for the full-time positions, which will make master’s degrees less competitive over time.

The second criteria is clinical experience. As I described above, the ethics analysis/theory is one part of the job, but equally important is one’s ability to work with doctors, medical staff, patients, and families. Having tough end-of-life conversations isn’t a skill one gets in most graduate programs, and not everyone is cut out for it. There’s also no guarantee that you’ll enjoy clinical work just because you enjoy the theory. It’s pretty different. Therefore, it’s essential to get some experience in a hospital shadowing a clinical ethicist.

One way to do this is as a formal part of your graduate program. This has lots of advantages, including that the work of getting that shadowing is taken care of. However, given your program, it might not be possible. The other way is to find someone who will let you shadow them. This is very difficult. For privacy reasons, it’s often difficult to get approval for a student to shadow, and the ethicist needs a reason to have students around. Still, it’s worth asking. Find out if there are clinical ethicists in your area and reach out. Maybe you can’t shadow right away but there are other opportunities for you to get some experience, such as sitting in on ethics committee meetings.

Although clinical ethics has been around for decades, over the past ten years two trends have emerged. The first is the rise of master of bioethics programs, which combine bioethics coursework and some clinical shadowing time. My own view of them is that there’s a lot of variation in their quality, so it’s important to find a good program. Also, while some clinical ethics job ads say that a masters in bioethics is sufficient to apply, the people who are most competitive for the jobs, and who do best out of these programs, have another degree, such as a JD. I’m also unaware of a lot of other opportunities for people who just have a master in bioethics. Therefore, I recommend against doing only that kind of program. Do a PhD or pair it with something else.

The second trend is a rise in professionalization. The American Society for Humanities and Bioethics (ASBH) has recently created the Healthcare Ethics Consultant Certification, which is a process for becoming a certified clinical ethicist (for those who are already practicing). There are pros and cons to this trend, but, in any case, it’s unlikely to go away. One result might be that, over time, the education pathways become more streamlined to more resemble professions such as law, medicine, or accounting. If you’re interested in clinical ethics, check in on these developments from time to time.

The Practical Takeaways

This best advice will depend on your current situation, but the two most common situations are undergraduates and graduate students considering what to do next.

Undergrads

If you’re an undergrad and want to pursue clinical ethics, then you’ll need more education. As early as possible, begin researching the different programs available that suit your interests so that you’ll know how to give yourself the best chance of getting into them. There’s no rule that says you need to pick one path: apply to as many programs as you can afford and see what you get. Get good grades. Graduate programs often require letters of recommendation, so figure out how to get those from professors. Prepare for relevant exams (LSAT, GRE, MCAT, etc.).

Apply to some conferences, even if they don’t have a specific category for undergrads. Getting into a conference as an undergrad is low risk and high reward. It looks great on applications, you’ll get to meet people and see how professional academics interact, and, even if your talk doesn’t go well, no one will remember. If you do get into a conference, ask your department if they have funding available.

While it isn’t essential, it’s a great idea to find some ways to get involved at the hospital. Almost all of them accept volunteers. Introduce yourself to the clinical ethicist and find out if there are ways you can get involved. 

Grad Students

If you’re already in a graduate program with a direct path to clinical ethics, then there isn’t a lot to consider. Do well and get as much clinical time as you can. If you’re in a program that has some clear application to clinical ethics, such as ethics as your area of specialization in a philosophy program, then you have to sort out a lot on your own. In my experience, philosophy departments are broadly unaware of clinical ethics, and even academic bioethicists are often removed from clinical ethics. (An exception: Peter Singer did some clinical ethics work when he was starting out. They called it ‘beeper ethics’ because of the pagers they had to wear. It’s delightful to think about requesting a clinical ethics consultation and having Peter Singer show up.)

It’s a disadvantage to lack a clear source of clinical experience, but opportunities are out there. Further, academically focused programs have their own advantages: the level of ethics analysis, knowledge of the literature, and research abilities you’ll obtain are an asset. Do all the usual things graduate students should do. Write a good dissertation, go to conferences, attend talks (look for ones in other faculties, such as medicine), and read as much as you can.

As you begin to think about the job market, know that there are paid postdoctoral programs that offer lots of clinical training and research time. I was a clinical ethics fellow at Baylor College of Medicine. There are other fellowships, including one at the The National Institutes of Health that requires no bioethics experience. (However, don’t take this to mean that you shouldn’t get clinical experience during grad school.) These are all highly competitive programs, but they’re great stepping stones to a permanent, full-time position.

Get Some Mentors

Clinical ethicists and academics are busy people. However, many of them are keen to help students as their schedules allow. The best way to get information is to speak to people who are doing what you want to do. To do this, send them an email asking for an informational interview, which is just a way of saying “can I ask you about your career?” (You don’t need to use the phrase ‘informational interview’, though you can.) If you don’t get a response to your first email, try again a week or two later, then move on. 

In the meeting, ask them how they got where they are and find out what they like and dislike about their job. Ask them what’s going on in the field. What are the interesting emerging topics? Prepare questions in advance so that you’re respectful of their time. If it went well, check in with them every once in a while. Mentors are such a valuable part of basically any career path, so take the time to find some who are a good match for you. Find out how you can be helpful to them. It can feel a bit ridiculous emailing someone to say, effectively, “can I ask you about your life?”, but a bit of effort will pay off.