Three institutions of higher education responded to special edition editors' request of programs respected for their scholarship and graduating ethicists into notable roles, particularly within Catholic health care. Programs were given the choice to respond to three prompt questions or feature a part of their curriculum that addresses educational needs or gaps in unique ways. Their responses are in alphabetical order by university. Duquesne University and Saint Louis University responded to the prompts about educating ethicists, which reads in an interview style. Loyola University Chicago featured the new disability elective for medical students at the Stritch School of Medicine, which reads as a short essay.
DUQUESNE UNIVERSITY, CENTER FOR GLOBAL ETHICS
JORIS GIELEN, PHD
Center Director and Associate Professor
What are some historic and current (Catholic) health care challenges that may necessitate future curricular development?
In our programs, we emphasize global health. It is very important that healthcare ethicists are aware of global healthcare connections. This includes connections at an international level, but, also, connections between local communities, diverse social, racial, ethnic groups, and the environment. This global health emphasis aligns with the Catholic mission of Duquesne University and is a great fit for our graduate programs that focus on Catholic healthcare ethics. While we already pay attention to global health in our programs, I listed this for future curricular development because it is something that is tremendously important to us and that we continuously aim to develop further.
What are some gaps remaining after comprehensive ethics academic programs and fellowships?
Academic programs and fellowships are, of course, very different and, in a way, complement each other. Moving from an academic program into clinical practice will always remain a significant step and we should aim to support future clinical ethics leaders so that that transition is as smooth as possible. Fellowships have an essential function there, while graduate degrees offer more scope to train in ethical theory and methods.
What do you think of the practice of educated ethicists going into, sometimes immediately, other Catholic health care careers?
You could think of this in a negative way, of course, as ethics expertise that is being lost or a "brain drain" from ethics, but this isn't the right way to look at the issue. Students learn a skill set. Our graduate programs aim for this skill set to form our students to become ethics leaders. An ethics leader can be in any number of different positions. Alumni integrate their ethics expertise in whatever position they accept after graduation, be it clinical ethicist, academia, or administrative leadership roles.
LOYOLA UNIVERSITY CHICAGO, NEISWANGER INSTITUTE FOR BIOETHICS AND HEALTHCARE LEADERSHIP
EMILY CARNES, MD
CARLA HANNA, MD
TYLER MORAD, MD
NANETTE ELSTER, JD, MPH
NATHAN DERHAMMER, MD
KAYHAN PARSI, JD, PHD, HEC-C
Educating Medical Students on Disability Health: Development and Implementation of a New Disability Healthcare Elective at Loyola University Chicago Stritch School of Medicine
People with intellectual and developmental disabilities (IDD) comprise one of the most neglected groups in healthcare. Although they have lower life expectancy and higher prevalence of chronic medical conditions, their health needs are often unmet due to insufficient resources, support, and healthcare provider training. The Liaison Committee on Medical Education (LCME) Standards do not currently require exposure to disability healthcare in medical school, which may contribute to poorer health outcomes for patients in this population. The mandate to better educate medical students on disability has been issued. Specifically, the Hastings Center issued a brief on March 13, 2024 that outlined a series of recommendations for medical educators to improve disability education. The recommendations consist of the following:
- Curricular components with learning goals tied to the Alliance for Disability in Health Care Education (ADHCE) and National Council on Disability (NCD) Core Competencies
- A procedure for identifying and removing curricular components that perpetuate harmful, outdated, or inaccurate understandings of disability
- A biopsychosocial approach to teaching about disability across the curriculum with an explicit focus on the relationship between ableism and health disparities
- Opportunities for learners to engage with disability culture in ways that model flourishing and challenge preconceived notions about quality of life
- Relationships with disability community groups and individuals who are acknowledged and compensated as expert educators
- Professional development opportunities for faculty and staff to incorporate a disability lens into their teaching
- Classroom and clinical environments built using Universal Design for Learning (note not in the original - UDL is a framework that promotes the development of flexible learning spaces to accommodate different learning styles)
The barriers and inequities that result from a lack of curricular attention to meeting the needs of patients with IDD led to a student-developed and student-run Disability Healthcare Elective at Loyola University Chicago Stritch School of Medicine. The course has now been successfully offered three times over the past few years. The course was developed by students with the inclusion of two faculty advisors from the Neiswanger Institute for Bioethics at Loyola and the Program Director of the Combined Internal Medicine & Pediatrics Residency Program at Loyola. The course was created to reduce the gap that exists in medical education regarding healthcare for patients with IDD and the disparities they often face. Individuals with disabilities engage with many specialties and aspects of healthcare; therefore, educating trainees on disability health is a crucial step in producing clinicians who are more comfortable and competent in treating these patients effectively and equitably. Considering the disability motto "Nothing About Us, Without Us," the course invited local members of the disability community to participate in clinical simulations. Moreover, leaders in the disability field presented on a variety of topics related to disability health with the ultimate goal of improving care and health outcomes for this patient population.The development and implementation of the course fit squarely within the Mission of Loyola University Chicago Stritch School of Medicine:
Loyola University Chicago Stritch School of Medicine (Stritch) is committed to scholarship and the education of medical professionals and biomedical scientists. Our faculty, trainees, students, and staff, are called to go beyond facts, experimentation, and treatment of disease to prepare people to lead extraordinary lives and treat the human spirit in an environment that encourages innovation, embraces diversity, respects life, and values human dignity.
While the Disability Healthcare Elective is not a bioethics course, per se, the curriculum presented and the skills gained by students are focused on professional identity formation, development of shared decision-making skills, social justice, and the importance of narrative in gaining a better understanding of patients' needs, concerns, goals, and values. In addition to the knowledge and skills that the students gained, community members gained a deeper understanding of what to expect in a clinical encounter, ways they might choose to effectively engage and advocate for their own healthcare, and the importance of developing a trusting therapeutic alliance between patient and provider.
What was gained by both students and participants illustrates the interplay between mission and ethics and how this collaboration can foster education, community engagement, and professional development. From the student perspective, the course:
- Helped to fill the gap that currently exists in medical education regarding how to interact with and care for diverse patient populations, including patients with IDD
- Ignited a passion for disability advocacy within healthcare
- Exemplified the struggles that individuals with disabilities continue to overcome in everyday life that make seeking adequate healthcare difficult
- Increased confidence and comfort in interacting with people with IDD and encouraged continued learning and adapting care for patients with IDD
- Exemplified the importance of both being aware of one's own choice of language and the idea that genuine curiosity and humility may sometimes be more important than a "perfect" vocabulary
- Highlighted that the current healthcare system is not suitable for all, and that intentional preparation is needed to best care for individuals with IDD
- Introduced them to alternative methods of taking histories to better accommodate individuals with IDD
- Helped them realize it is not a physician's job to protect an individual with disabilities from making a seemingly "wrong" healthcare decision, but rather to ensure they have the tools needed to make an informed decision for themselves
- Accentuated the value of patient narratives and lived experience
- Encouraged them to cultivate a mindset that embraces diversity, fosters empathy, and champions the provision of equitable healthcare for all
From the community perspective, the course:
- Allowed them to feel included and integral to the process of better understanding the needs of patients with disabilities
- Felt like an important step in training healthcare professionals to gain skills for improved interaction with disabled patients
- Promoted confidence in the patient-physician relationship to hopefully allow other patients with IDD to feel more comfortable in future healthcare encounters
The reciprocity and inclusivity in the course reinforced the social contract between physicians and the range of communities they serve. Integrating ethical awareness throughout the development and execution of the course has contributed to not only its success but also underscores the value of integrating bioethics in healthcare more broadly.
SAINT LOUIS UNIVERSITY (SLU), THE ALBERT GNAEGI CENTER FOR HEALTH CARE ETHICS
JASON EBERL, PHD
Center Director
ERICA K. SALTER, PHD
Department Chair
What are some historic and current (Catholic) health care challenges that may necessitate future curricular development?
Whatever the challenges faced by Catholic health care now or in the future requires forming ethicists who can adaptively respond in creative ways to those challenges, with the capacity to critically examine them through multiple lenses. A primary way in which such formation can occur is through education in not just the practical aspects of clinical ethics, but in the foundational methodologies of disciplines such as philosophy, theology, and the social sciences. To cite one historical example, when developing or evaluating crisis standards of care policies, ethicists are needed to provide expert consultation on questions such as whether it is fair to unilaterally withdraw life-sustaining treatment from a patient in order to make such treatment available for another patient during a surge, or whether certain conditions – e.g., cystic fibrosis – may be taken into account when triaging patients during a pandemic involving respiratory disease. Engaging these questions requires ethicists to be conversant not only with the ethical literature on distributive justice, utility, and double-effect but also property, disability, and even just war as evinced in the literature debating these topics. An additional example that has emerged as a pressing post-pandemic problem is the trend of increased moral distress, moral injury, and burnout among health care professionals. While not a traditional focus of clinical ethics education, ethicists may be called on more frequently to attend to the social, emotional, and spiritual needs of providers through strategies like moral distress rounds, incident debriefings, and targeted ethics education. Finally, we have seen an increase in ethics consults related to safe discharge planning which reveals the many barriers that exist beyond the acute care setting, like a lack of post-acute care options, limited community resources, and financial constraints. Thus, ethicists must learn how to navigate not only the organizational systems that construct the health care institution, but also the larger social systems that construct the environment into which patients are discharged.
What are some gaps remaining after comprehensive ethics academic programs and fellowships?
Depending on how comprehensive a particular ethics academic program or clinical ethics fellowship is, gaps may persist at either the theoretical or practical levels. With respect to the theoretical level, even students who enter a doctoral program with a bachelor's or master's degree in philosophy, theology, or a social science discipline would benefit from greater interdisciplinary formation. Thus, the SLU doctoral program in health care ethics includes required courses in philosophical, religious, and interdisciplinary methodologies in order to provide a more well-rounded theoretical foundation, and dual-PhD degrees with philosophy or theology for those who seek more in-depth formation. At the practical level, skill development in communication techniques, conflict management/mediation, and pedagogy would enhance one's capacities as both an ethics consultant and educator; the SLU program provides formation in the last of these by providing students with opportunities to teach undergraduate courses. Finally, there is increasing awareness that clinical ethics intersects consistently with organizational ethics; thus, some of SLU's doctoral students have taken an elective in health administration. Given the constraints of a doctoral curriculum involving 36-48 credit-hours of coursework, addressing some of the more practical gaps would best fit within a fellowship curriculum, while the doctoral program maintains its primary focus on the theoretical dimension with baseline clinical ethics skills developed through a required practicum (150 hours) and an elective advanced practicum (300 hours).
What do you think of the practice of educated ethicists going into, sometimes immediately, other Catholic health care careers?
Those formed by SLU's doctoral program are for the most part oriented toward either an academic career track, a professional career as a health lawyer or physician, or a career as a clinical ethicist within a Catholic or secular health care setting. However, there are sometimes more employment opportunities available in complementary areas such as mission integration or, if they have the appropriate background, pastoral care. It is not evident whether those who enter into one of these alternative career tracks do so because they perceive it to be easier than working as a clinical ethicist, or whether it is the case that there is simply more demand for theologically-formed graduates in these areas. If, for example, qualifying for an ethics position requires a postdoctoral fellowship or extensive clinical experience, whereas the requirements of a mission position are less demanding on the practical side and the applicant's theological formation is more pertinent, then the market will naturally shift in that direction.