Alyson Isaksson
Health Care Ethics Intern
Columbia St. Mary's
Milwaukee
[email protected]

Mark Repenshek, Ph.D.
Healthcare Ethicist
Columbia St. Mary's
Milwaukee
[email protected]

In 2002, I recall meeting Eileen Jaskolski, vice president of mission and ethics at Columbia St. Mary's, for the first time. I had just completed my doctoral coursework at Saint Louis University at the Center for Health Care Ethics. The program director, Gerry Magill, called Eileen on my behalf to inquire if Mark Repenshek, one of his students with ties to Milwaukee, might be able to shadow for a summer to get a better sense of the ethics function at a Catholic hospital. Eileen, at the time, was the co-chair of the Milwaukee campus ethics committee and was cautiously optimistic that this would be an interesting opportunity. Years later, I recall Eileen's sharing with me that just as she had accepted the observation/mentor role for a summer, she sat in her chair and contemplated, "what am I going to do with a graduate student for an entire summer?" Nearly ten years later, I credit that summer observation and the multitude of experiences it availed, both at the time and in forthcoming summers, as the impetus for full employment at Columbia St. Mary's today.

My point in briefly reflecting on this opportunity is to say that serendipity and the goodwill of a vice president should not be the basis for formal experience in health care ethics, especially in light of the growing shortage of qualified professionals. To this point, we have designed a series of summer internships in health care ethics along with a culminating semester-long master's fellowship that we will discuss at length. We are doing this both for the purpose of obtaining helpful feedback from our colleagues as well as to make an argument for the importance of other hospitals or health systems seeking to address the growing concern regarding the shortage and competencies of future health care ethicists in Catholic health care.

Solidarity
It is not without some apprehension that we suggest that internships and fellowships in health care ethics can be properly circumscribed by the principle of solidarity. Yet, there are aspects of the current reality in our field that seem to call out this principle's relevance. Turning to Sollicitudo rei socialis, John Paul II describes solidarity as a "virtue," as a "firm and persevering determination to commit oneself to the common good."¹ He goes on to elaborate on the principle, suggesting that those who are in positions of power or influence should feel compelled by a sense of communal responsibility for those who may be weaker or more vulnerable. John Paul II is careful not to eliminate personal responsibility from the equation — rather he suggests persons lacking power or influence should "do what they can for the good of all."² It is at the intersection of these two points that we suggest that the principle of solidarity provides the justification and grounding for the claim that Catholic health care should begin to create opportunities for professional development of budding health care ethicists.

To be clear, we are not suggesting that one who has the privilege of both the means and intellect for graduate studies is necessarily "vulnerable" in a traditional sense. Rather, a person desiring to adequately contribute to the mission of Catholic health care in the field of health care ethics absent the experience to complement his/her academic preparation, is in an unnecessary position of vulnerability. Perhaps too is the vulnerability of Catholic health care in general. Ron Hamel, Ph.D., CHA senior director, ethics, alludes to this point by expanding on the work of John Glaser. He writes:

Some years ago, theologian and ethicist John Glaser, S.T.D., observed that there are "no ethics-free zones"; that is, virtually everything we do in Catholic health care (and elsewhere) has an ethical dimension. Whenever decisions are made or actions performed that affect human dignity and well-being, ethics has a role. This suggests that ethics is an ever-present reality in the day-to-day operations of Catholic health care, not just at the bedside, but throughout the organization.³

So, in borrowing Glaser's and Hamel's argument that virtually everything we do in Catholic health care has an ethical dimension, the risk of not properly cultivating the professional development of the health care ethicist through experiences that engage critical junctures in human experience fails our tradition's commitment to solidarity. Such critical junctures occur by taking the academic preparation of a master's degree level of study to the bedside of a dying patient, where the ethicist assists the family in discerning appropriate end-of-life care; to the leadership table to discuss the principle of justice and its application to adequate health care benefits for employees; to the Institutional Review Board to ensure the proper ethical protections for potential human subjects in research; to the medical staff to engage critical issues of quality and safety from an ethics perspective; and to the system level to participate in decisions that may impact numerous hospitals and thousands of employees — done so in a manner faithful to the values we espouse. The translation of academic training to the multitude of complex environments in which the health-care ethicist must comfortably operate is essential to proper development of the field. Grounded in the principle of solidarity, we as colleagues of these future ethicists, have an obligation to create formal structures in which such flourishing and professional maturation may take place.

Making the Case
According to a 2008 survey conducted by the Catholic Health Association, the majority of ethicists working in Catholic health care are over 50 years of age and nearing retirement, and the lack of adequately prepared graduates to fill vacant positions could have a negative impact on Catholic health care ethics.⁴

CHA recommends ethicists have at least a master's degree with education in both Catholic moral theology and health care ethics; however, few programs exist that provide both the theological training and clinical experience necessary to prepare aspiring ethicists for open positions.⁵ It seems appropriate to suggest, or at least in Catholic health care's interest, that Catholic hospital systems should have a vested interest in supporting the education of these ethicists. The master's fellowship in Catholic health care ethics proposed here may be used as a model for Catholic health systems to facilitate the integration of clinical and theological experience necessary to prepare these ethicists to take on forthcoming challenges in Catholic health care.

Catholic health care needs well-prepared, degreed individuals who are committed to advancing ethics in a manner consistent with the Catholic tradition. In various health systems, ethicists provide necessary services in areas of education, consultation, administration, and research in order to establish or enhance the use of ethical decision-making within the health care organization. In Catholic health care, the ethicist has the added responsibility to align initiatives in these areas with the mission, vision and values of the individual Catholic hospital and Catholic health care as a whole. Thus, an individual's preparation for becoming proficient in Catholic health care ethics requires more than rigorous academic coursework and scholarly contributions. Practical clinical experience in Catholic health care ethics — coupled with a strong foundation in Catholic social teaching and moral theology — is paramount to the development of the skills necessary for expertise in Catholic health care ethics. One way this can be done is by sponsoring students as master's fellows in ethics.

At Columbia St. Mary's hospital system, we have developed a model for a master's fellowship in ethics. This fellowship integrates theological coursework with clinical experience so that the aspiring ethicist can apply knowledge gained through master's coursework to practical clinical and organizational situations in Catholic health care. The fellow will gain not only clinical and organizational skills, but also cultivate character traits recommended by CHA.⁶ The mentoring and guidance of a Ph.D.-trained ethicist is integral to this model — like many fellowships in the hospital setting, the master's fellow should be educated and evaluated by an expert in the field. Also, this model is intended for a student in her final semester of a master's program. At this stage, she has gained as much knowledge through coursework as possible at the master's level, though has not yet received her degree, and thus should continue to enhance her skill set before seeking employment as an ethicist or matriculation into a doctoral program.

We are proposing a model for master's fellowships in ethics that utilizes evidence-based metrics to prepare ethicists for clinical and organizational work in a Catholic health care facility. This master's fellowship builds upon the CHA Recommended Qualifications and Competencies for Ethicists in Catholic Health Care, goals and duties for an ethics internship developed by Ph.D.-trained ethicists, best practices developed by two ethics interns, and practical experiences gained through the ethics internship at Columbia St. Mary's over the past three years.⁷ (See Appendix D in attached PDF.) This model lists goals and duties for the master's fellow, accountabilities toward these goals and duties, and corresponding CHA-recommended qualifications and competencies. It also provides a tool for measuring the level of responsibility the master's fellow ought to assume over the course of the internship. Since this fellowship is meant to prepare a master's student for employment as an ethicist, she should ultimately gain experience in an advisory role in a number of clinical and organizational situations. Presuming the internship follows the course of a 16-week semester, the master's fellow ought to be accountable to the goals and duties in an observatory role during the first eight weeks, progress to a participatory role by week 14, and reach the apex of her fellowship by advising on some appropriate ethical issues under the direction of the ethicist by week 16.

The model for this master's fellowship is presented in the Ethics Fellowship Matrix (below).This matrixis a tool to be utilized by the master's fellow and the mentoring ethicist both to plan experiences and assess progress. For example, the master's fellow needs to gain knowledge and experience that will contribute significantly to a proficiency in clinical consultation (G7 on the Ethics Fellowship Matrix). This goal corresponds with eight competencies recommended by CHA — five listed under knowledge, skills and abilities, and three listed as character traits. To attain this goal and gain these competencies, the master's fellow should become accountable to the corresponding experiences: developing a personal methodology for ethics consultation, attending ethics grand rounds presentations, working with data available from an ethics consult database, and/or setting up a time to meet with a physician in the ICU to discuss recent cases. Further, the master's fellow can track her progress toward proficiency in this area of ethics by interacting in the above experiences in an observatory, participatory, or advisory role depending on her place in the 16-week trajectory. For example, if she is in week ten of her fellowship, she should be able to present some educational material alongside the ethicist at an ethics grand rounds presentation. If she is in week 15, perhaps a fitting cumulative project would be presenting alone with input from the ethicist where necessary. As mentioned before, paramount to this model is the mentorship of a Ph.D.-trained ethicist.

The master's fellowship in ethics presented in this article is meant to provide a model for fostering the professional development of aspiring health care ethicists through a commitment to solidarity. The forthcoming shortage of ethicists in Catholic health care, the ambiguous yet serendipitous nature of current initial opportunities in ethics, and the recent recommendations for competency in health care ethics from CHA demonstrate the need for an integrated model like this one to supplement graduate studies in theology and bioethics. It is our opinion that practical experience with clinical and organizational ethics, coupled with the mentorship and guidance of an ethicist, is an essential component of the education necessary to become an adequately prepared ethicist.⁸ We hope the model presented in this article will be useful for health ministries as they join us in advancing the field of health care ethics.

1. John Paul II, "Sollicitudo rei socialis" in Catholic Social Thought: The Documentary Heritage, eds., David J. O'Brien and Thomas A. Shannon (New York: Orbis, 1992): 393-438, 421.
2. Ibid, 422.
3. Ron Hamel, "A Critical Juncture," Health Progress 90: 2 (March-April 2009): 14.
4. Ibid., pp. 14-15.
5. "Recommended Qualifications and Competencies for Ethicists in Catholic Health Care," The Catholic Health Association, accessed September 2011, http://www.chausa.org/Pages/Our_Work/Ethics/Ethicist_Competencies.
6. In its Recommended Qualifications and Competencies for Ethicists in Catholic Health Care, CHA lists character traits including respect, empathy, compassion, listening, self-confidence, collaborative, motivating, trustworthy, commitment to the mission, respect for the Catholic church, humility, prudence, courage, tolerance of ambiguity, open-mindedness, balanced judgment and demeanor, initiative and accountability, and good stewardship of resources.
7. In 2009, Mark Repenshek and John Paul Slosar developed goals and duties for the Columbia St. Mary's ethics internship, which are being used in the model for this Master's Fellowship. In 2010, Elliot Bedford and Alyson Isaksson presented best practices for ethics internships to the Ascension Health Ethics Advisory Group, which have been integrated into the accountabilities toward goals and duties.

Copyright © 2011 CHA. Permission granted to CHA-member organizations and Saint Louis University to copy and distribute for educational purposes. For reprint permission, contact Betty Crosby or call (314) 253-3490.