Ethicists see need for clinical training for next generation

November 1, 2022


The immersive experience Amanda Altobell got in Catholic health care ethics, mission and spiritual care through a virtual internship followed by an in-person fellowship within Bon Secours Mercy Health provided a vital link between her academic studies and her career.


She completed the semester-long online internship last fall as part of her work toward a PhD with an emphasis on Catholic health care ethics that she's close to finishing at Duquesne University in Pittsburgh. The online curricula included rounding with clinicians and joining ethics consultations involving doctors, patients and families.

The fellowship was at Bon Secours hospitals in Richmond, Virginia, where she spent six months training under the mentorship of senior ethics leaders. She got exposure to discussions and decisions around ethical and spiritual challenges that arise in intensive care, palliative care and other units. By the end, Altobell was leading ethics consultations.

Michael McCarthy, Esther Berkowitz, center, and Lena Hatchett, who are all affiliated with Neiswanger Institute for Bioethics and Healthcare Leadership at Loyola University Chicago, participate in a simulated ethical consultation. The simulation is part of a tool called Assessing Clinical Ethics Skills that uses case studies to put students into virtual situations closely based on those that take place in clinical settings.

This summer, Altobell was hired on as director of mission at Bon Secours Southside Medical Center in Petersburg, Virginia, and Bon Secours Southern Virginia Medical Center in Emporia, Virginia. She is also lead ethics consultant for those hospitals and collaborates with another consultant at five other Bon Secours hospitals in Richmond.

"I would say I was very fortunate that through Bon Secours Mercy Health I was able to really get the experience I needed to be well versed and trained and be able to provide guidance for the clinical team and launch my career," Altobell says. "I would not be where I am now without it."

Scarce opportunities
Throughout Catholic health care, leadership and mid-level mission, ethics and spiritual care openings are going wanting. An onslaught of retirements has added to the strain. For years, it's been hard to fill vacancies because of a dearth of candidates.

In 2021, CHA set up an online Career Center and has promoted it with communications across the ministry. The center created a space within the ministry to link employers and qualified applicants for some of the harder-to-fill posts. In mid-October, a majority of the 23 positions listed on the job board included ethics, mission or pastoral care in the descriptions; several of the jobs were director-level or executive posts. Many of them listed experience within Catholic health care as an essential qualification.

Internships and fellowships like those Altobell took advantage of to gain that critical experience remain scarce. There is no central repository for those opportunities; only a few health systems appear to offer them.


Brian Kane, a senior ethics director at CHA, says experience in clinical settings is a key part of the training ethicists and mission leaders need in their roles as facilitators of complex discussions that delve into medical science, law, public health, financial sustainability and more. The discussions may involve hospital executives, clinicians, patients, families and communities.

Kane says ethics consultants must be ready to "lead structured conversations around questions that others might not have considered and also to make them aware of the limits of their decision-making." As an example, he points out that sometimes people who think they have agency to make choices such as around end-of-life decisions do not, and ethicists have to help explain the complexities involved.

Shortly before the COVID-19 pandemic disrupted many health care training programs, CHA issued a call across the Catholic health ministry for the creation of more ethics and mission fellowships. The call came at the behest of members who reported on how challenging it was to recruit qualified candidates for ethics and mission positions.

It's unclear how many systems took up the call. Providence St. Joseph Health, for one, reports that it is developing an ethics fellowship. Trinity Health offers a mission integration fellowship that covers "leadership and Catholic identity, formation, ethics, and spiritual care ethics training."

Grow your own
At Bon Secours Mercy Health, Vice President of Ethics Dr. Kelly Stuart describes the pool of qualified candidates for her system's openings for ethics and mission leaders as "teeny." The system's own fellowships have proven to be a primary source for new hires.


"We have kept the vast majority of the people we've trained," she says. "They've gotten very good jobs in our health system and really been assets to the system."

Stuart says Bon Secours Mercy Health uses a model for its on-site training that is tailored to its own structure and might not suit those of other systems. She points out, for example, that since the system has few positions that deal only with ethics, the fellows also are immersed in mission and spiritual care work.

The fellowship program goes back years and is open to applicants with advanced education in ethics or extensive clinical experience. The health system's virtual internship started last year and is a collaboration restricted to graduate students at Duquesne University's Center for Global Health Ethics.

Jessica Weingartner, director of mission for Bon Secours' Greenville, South Carolina, market, says the online experience was borne from necessity during the pandemic. When clinical sites cut off in-person training because of the contagion, Weingartner and Alex Garvey set up the internship. Garvey, who received his PhD in health care ethics from Duquesne, was vice president of mission in Bon Secours' Greenville market at the time.

The Greenville market is now host to its third Duquesne intern and plans to continue the semester-long program. The interns participate virtually in ethics education, ethics committee meetings, ethics consults and other real-time events from 500 miles away.

Weingartner considers the experience gained through internships and fellowships like those at Bon Secours Mercy Health to be a critically important complement to the academic training of health care ethicists.

"One of the interns that I had said 'I think about some of these things completely differently now, seeing it in the context of actual patients in the actual hospital rather than just thinking about it theoretically, which is totally different,'" Weingartner says.

She was a graduate assistant in ethics at Ascension and a mission fellow with Bon Secours before she moved into the mission director position.

Pipeline proposal
Becket Gremmels is vice president of theology and ethics at CommonSpirit Health and among those recognized in 2018 as one of CHA's Tomorrow's Leaders. He had a fellowship at an Ascension hospital as he pursued his PhD in health care ethics. He went from that experience into director of ethics posts with Ascension before moving on to CHRISTUS Health and then to CommonSpirit.

Gremmels says that he got a solid grounding in Catholic theology and ethics from his higher education at the University of Notre Dame and Saint Louis University. However, he says his on-site clinical experiences were what prepared him for his day-to-day ethics work.

"I think the biggest benefit that grad school teaches you for this field is how to learn, because I'd say what I use on a daily basis, 90% of it, I learned in the field after I finished classes," he explains.

CommonSpirit is among the Catholic systems that offer ethics internships. Its one-year program gives students systemwide training and practical experience in resolving ethical challenges. The program, which is remote and unpaid, has five students in its current cohort. CommonSpirit has a relationship with several universities that allow the interns to receive course credit for their work.

Gremmels is part of what he calls a loose-knit "coalition of the willing" who favor designating a professional association to accredit clinical ethics fellowships that provide advanced on-site training for ministry and secular posts. Once that happens, the coalition hopes to persuade the Centers for Medicare and Medicaid Services to fund the fellowships, just as the federal agency does for other health professionals such as chaplains and pharmacists.

Gremmels has drafted a proposal to create a pipeline of Catholic health care ethicists that calls for a stairstep approach to training. "Developing consistent entry-level positions with a relatively small scope of responsibility is critical to this process," the proposal states. "In no other field would a regional director for six hospitals be considered entry-level, yet for ethics it often is."

Simulated training
Michael McCarthy is an associate professor and director for the graduate program in health care mission leadership at the Neiswanger Institute for Bioethics and Healthcare Leadership at Loyola University Chicago. The online program offers advanced degrees in mission leadership and bioethics. McCarthy says the program attracts top-notch students, many of them already in health care, who can bring their knowledge and skills to Catholic health systems.


Because there are few opportunities for its students to get hands-on training before they take on lead roles in the ministry, the Neiswanger Institute has developed tools that simulate experiences like those that ethicists have in clinical settings. One of those tools, called Assessing Clinical Ethics Skills, takes students through a series of case studies in ethics consultations to develop their competency and proficiency.

While the tools aren't replacements for actual experiences, McCarthy says they get ethicists-in-training closer than most classroom settings do to what it's like to be in consulting and lead roles.

CHA offers a one-year ethics internship that is in its third year. The current fellow, Amanda Berg, is working on her PhD in theology and health care ethics at Saint Louis University. Berg says she feels her studies have given her a strong theoretical understanding of Catholic health care, ethics and morality.

Her hope for her fellowship, she says, is to learn to apply that theory. "I don't have a lot of practical experiences," she says. "That's partially why I'm excited to be a fellow at CHA this year."

Pandemic, abortion ruling bring ethical issues to forefront

Just as the COVID-19 pandemic heightened awareness of the function of health care ethicists, the Supreme Court ruling that pushed decisions on the legality of abortion back to the states has the potential to do the same, some Catholic health care ethicists say.


Nate Hibner, a senior ethics director at CHA, believes both the pandemic and the Dobbs abortion ruling have shaken up the health sector and made the role of those trained to lead ethical discussions more apparent and vital.

"When we get these kind of disruptors, people start to say, 'Do we continue to do the things we've always done or do we have to do something differently?'" Hibner says. "That kind of ambiguity, that grayness, is where we ethicists thrive."

The University of Pennsylvania School of Nursing says it found in a study that clinical ethicists have "played an expanded role during the pandemic, supporting hospital operations across the country." The topics the ethicists have been asked to advise leadership teams on have included end-of-life care, resource scarcity and care decisions for incapacitated patients without health care advocates.


Becket Gremmels, vice president of theology and ethics at CommonSpirit Health, says he thinks the pandemic has brought to the forefront the skills in leading complex and sensitive discussions that ethicists bring to the table.

During the pandemic, Gremmels says ethicists have been asked to weigh in on urgent issues in which various stakeholders had competing interests, such as how to equitably distribute the early and scarce supply of COVID vaccines.

"I found that ethicists being involved in those discussions has been very helpful for our leaders," Gremmels says. "We had at least a framework to go with when they were ready to start thinking through those questions."


Jason Eberl is a professor of health care ethics and philosophy and director of the Albert Gnaegi Center for Health Care Ethics at Saint Louis University. Early in the pandemic, he helped survey hospitals across the nation on their ventilator triage policies to ensure that best practices and fairness were observed in the treatment of COVID patients, including in the event that resources had to be rationed. One of the survey's findings, Eberl says, was that about half the hospitals did not have a policy.

Some Catholic hospitals called on Eberl and other faculty from the Gnaegi Center to help establish those policies, he says. It was just one example of how they have been tapped by health systems to offer guidance amid the thorny issues raised by the health care emergency.


Michael McCarthy is associate professor and director for the graduate program in health care mission leadership at the Neiswanger Institute for Bioethics and Healthcare Leadership at Loyola University Chicago. He says he thinks ethicists were brought into more meetings when critical decisions were being made during the pandemic than before the health crisis began and that their participation led to more open conversations.

McCarthy is hopeful that Catholic health care ethicists will be invited to play similar roles in framing and clarifying ethical, theological and medical issues that are arising around the Supreme Court's ruling on abortion in the Dobbs v. Jackson case. The decision struck down a national protection for abortion access and left the issue up to individual states to decide.

Dr. Kelly Stuart, vice president of ethics for Bon Secours Mercy Health, points out that states' reaction to the Dobbs ruling has been political. Stuart moved to ethics from neonatology.

Some states, she says, are legislating policies that fail to reflect medical standards of care and that are more proscriptive than what is prohibited for Catholic health care providers established in the Ethical and Religious Directives for Catholic Health Care Services by the United States Conference of Catholic Bishops. That policy defines abortion as "the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus."

"I think part of ethicists' role, especially around the Dobbs decision, is helping clearer heads to prevail so that we can think about what is good policy — one that acknowledges the medical vulnerability of both mother and baby and seeks to protect both," Stuart says.



CHA, members collaborated to meet need for mission and ethics leaders

Almost a decade ago, CHA members surfaced concerns about a shortage of qualified applicants for high-level mission and ethics openings, especially given a number of impending retirements.

In response, CHA collaborated with its members to establish a multistep process to assess the scope of the shortage and identify the competencies needed in entry-level, middle management and leadership positions.

The first step was an initiative named Project Legacy. Nate Hibner, a senior director of ethics at CHA, says it was focused on data collection and framed as a call to action to create a pipeline of talent for ethics, mission and pastoral care positions.

It was followed up by Faithfully Forward, an initiative that CHA launched in 2019. "This is the stage where we created resources and implemented strategies," Hibner explains.

As part of Faithfully Forward, CHA worked with members to produce a brochure that sets out the qualifications and competencies for ethicists in Catholic health care, such as knowledge of the Catholic moral tradition and the Ethical and Religious Directives for Catholic Health Care Services established by the United States Conference of Catholic Bishops. It also put out a summary of best practices in fellowships and internships in mission and ethics.

Because of the COVID-19 pandemic and the workforce challenges it has spurred, training programs across the health care sector have been disrupted. "With that crisis seeming to ease, and the increased visibility of ethical challenges facing health care today, CHA is hopeful that new energy will be placed into the training and recruitment of qualified ethical consultants," Hibner says.


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