From “Black Box” to Moral Space
Designing a Behavioral Intervention to Increase Clinical Ethics Consultation Utilization
Abstract
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.
The Problem
Awareness Gap: For Advanced Practice Providers (APPs), the primary reason for not requesting a consult was a lack of awareness—33.3% didn't know the service existed.
Access Gap: For nurses, the main barrier was not knowing how to contact the service (30.8%). This also affected APPs (27.8%), indicating a clear need for improved communication channels.
Misconceptions: While many healthcare professionals felt the need for help, a significant number, particularly physicians (41%), stated they "never felt the need for help." This suggests a misunderstanding of the service's full scope, which extends beyond crisis intervention to proactive support.
High Satisfaction, Low Utilization: The data shows that when the service is used, it is highly rated. The median satisfaction scores were high for all groups (Physicians: 76, APPs: 89, Nurses: 70), yet this positive feedback is not translating into increased utilization. This is a crucial point: the service is effective, but people aren't using it.
DOI:10.1186/S12910-021-00613-7.
Resolving the problem:
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The draft manuscript can be found here.
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The pilot study design can be found here.
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Acknowledgements
The author would like to thank 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.