From “Black Box” to Moral Space
Designing a Behavioral Intervention to Increase Clinical Ethics Consultation Utilization
Zoe Lewczak, BS
About this Project
Across U.S. healthcare, clinicians encounter ethical dilemmas, yet many perceive Clinical Ethics Consultation (CEC) as a “black box”—a misunderstood resource despite its high user satisfaction. Evidence suggests that CEC remains underutilized due to a lack of awareness, procedural confusion, and skepticism regarding its practical value. To address these barriers, this capstone proposes an intervention grounded in behavioral economics, designed to guide clinicians toward ethics resources without limiting professional agency. Much like an architect designs a space to facilitate natural movement, this approach repositions CEC as a seamless, readily available support system. The intervention includes several mechanisms, such as a dedicated webpage, informational fliers, and peer-led Ethics Grand Rounds, to increase CEC visibility and reduce the navigational burden on clinicians. This normalizes CEC as a functional component of the hospital's daily flow, ensuring that ethics support is intuitive and ready when it matters most. To measure the impact of this intervention, a pilot study was designed for a non-profit, safety-net academic medical center. The study will track changes in CEC utilization and reason for consult over a 12-month period, while also evaluating ethical integrity and perceived value through a mixed-methods approach. By framing CEC underutilization as a communication challenge, this research demonstrates how a behavioral intervention can increase CEC’s utilization and evolve the perception of the ethicist from a “moral expert” to an “architect of moral space.” Ultimately, by simplifying access and humanizing ethics teams, healthcare systems can foster a culture of moral resilience, ensuring ethical complexity is no longer a solitary burden.
Think about an architect designing a physical space: they might strategically place walkways and doors to facilitate natural movement throughout a building, while avoiding the enforcement of a specific path. In the same way, a conscientious choice architect structures options to help people make decisions that align with their own best judgment.
In a similar way, a clinical ethicist is the choice architect who might provide a nudge to reduce distress; a nudge is not a command or a mandate, rather it is moral lubricant, removing the friction that prevents a clinician from acting on their best judgment.
By facilitating a family meeting or clarifying a DNR conflict, the ethicist is not making a medical decision—they are clearing the cognitive and emotional debris, so the clinician can finally see the path they already knew was right. This clearing of uncertainty ensures that the ethically appropriate path is not a hypothetical, but the most accessible route for a team under pressure.
What is a Clinical Ethicist?
Pilot Study Design
Objective: To increase Clinical Ethics Consultation (CEC) utilization by transforming the service from a “black box” into a transparent, accessible resource that enhances clinician moral resilience.
Hypothesis: If we deploy a behavioral intervention, the Clinical Ethics Consultation (CEC) utilization among clinicians will increase because there will be a better understanding of how the services works and how to access it.
How: To capture the human impact, a Nested Mixed-Methods Cohort Study will be employed, which includes:
Baseline: The primary diagnostic tool to establish the pre-intervention state of Clinical Ethics Consultation (CEC) utilization.
Primary Outcome: Utilization Rates of Clinical Ethics Consult Services.
Tracked via the Visual Analytics Dashboard using the Consultation Index to isolate level and trend changes.
Secondary Outcome: Moral Resilience and CEC Utility.
Measured via the Rushton Moral Resilience Scale-16 (RMRS-16) integrated into the Post-Consult Follow-Up Survey (T1) to correlate increased CEC access with improvements in moral efficacy and self-stewardship.
Operationalized through the Analytic Case Evaluation for Clinical Services (ACECS) system to measure how the service was used. The Post-Consult Follow-Up Survey (T1) measures instrumental (actionable resolutions), hedonic (reduction in moral distress), and cognitive (integration into practice) benefits.
More information:
Acknowledgements
Special thanks to Michael Ieong, MD, HEC-C and Casey Rojas, JD, MBE, for their invaluable mentorship and guidance throughout the development of this project. And a special thanks to the Harvard Medical School Center for Bioethics faculty and peers for their feedback and support throughout this past year. Finally, thank you to Boston Medical Center’s Ethics Team for their support of this project and commitment to ethical practice.
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