Healthcare Ethics Certification 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.

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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


  • Did you participate in gathering relevant factual information in a case that was helpful in forming an analysis? 
  • Did you serve as a peer reviewer or “sounding board” to a mentee or colleague who asked for your assessment or input on the data that were gathered?

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


  • Did you research your hospital policies and/or state laws and provide that information to others as a way to help resolve or address an ethical question?
  • Did you apply ethical principles/frameworks which help address the central ethical question(s)?

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


  • Did you explain to patients, families, or clinicians what to expect or not expect as part of the consultation processes?
  • Did you ask relevant questions to determine that the issue would best be resolved by another hospital service and referred the case to the appropriate service? 
  • Did you facilitate a family meeting involving clinicians and family members? 
  • Did you facilitate a team-only meeting that did not involve family members but only involved healthcare professionals? 
  • Did you attend and participate in discussions about transplant candidacy for a patient who was reviewed by the hospital selection committees for transplantation?

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


  • Did you survey involved clinicians about their experience with ethics consultation? 
  • Did you enter data into an internal database or other method internal recording?
  • Did you draft or finalize an ethics consultation note in the electronic medical record?

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

Core Competencies Task Force (2011). Core Competencies for Healthcare Ethics Consultation (2nd ed.). Chicago, IL: American Society of Bioethics and Humanities.

Clinical Ethics Consultation Affairs Committee. (2017). Addressing Patient-Centered Ethical Issues in Health Care: A Case-Based Study Guide for. Chicago, IL: American Society of Bioethics and Humanities.

Clinical Ethics Consultation Affairs Committee. (2015). Improving Competencies in Clinical Ethics Consultation: An Education Guide, 2nd ed. Chicago, IL: American Society of Bioethics and Humanities.

Applebaum, P. S. (2007). Clinical practice. Assessment of patients’ competence to consent to treatment. New England Journal of Medicine, 357(18), 1834-1840.

Beauchamp, T., & Childress, J. (2012). Principles of Biomedical Ethics (7th ed.).Oxford, UK: 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, UK: Oxford University Press.

Diekema, D., Mercurio, M., & Adam M (Eds). (2011). Clinical Ethics in Pediatrics: A Case-Based Textbook. Cambridge, UK: Cambridge University Press

Dubler, N., & Liebman, C. (2011). Bioethics Mediation: A Guide to Shaping Shared Solutions. Nashville, TN.: Vanderbilt University Press.

Fletcher, J., Lombardo, P., & Spencer, E. (2005). Fletcher's Introduction to Clinical Ethics (3rd ed.). Hagerstown, MD: University Publishing Group.

Ford, P., & Dudzinski, D. (Eds.). (2008). Complex Ethics Consultations: Cases That Haunt Us. Cambridge, UK: Cambridge University Press.

Hester, DM and Schonfeld, T. (2012). Guidance for Healthcare Ethics Committees. Cambridge, UK: 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, Shepard, E. K., Sederstrom, N. O., Swoboda, S. M., Marshall, M. F., Birriel, B., & Rincon, F. (2016). Defining futile and potentially inappropriate interventions: A policy statement from the Society of Critical Care Medicine Ethics Committee. Critical Care Medicine, 44(9), 1769-1774. doi: 10.1097/CCM.0000000000001965

Lo, B. (2013). Resolving Ethical Dilemmas: A Guide for Clinicians (5th ed.). Philadelphia: Lippincott Williams & Wilkins.