CHRISTUS Health is an international Catholic health care system, with health care in Chile, Colombia, and Mexico in addition to the U.S. The organization, structure, and operation of ethics programs in CHRISTUS Health are different by country because each nation expects different things from ethics.¹ In June 2023, the large ministry in Mexico, CHRISTUS Muguerza, held a two-day ethics symposium in Monterrey, Mexico, titled Ethics and Bioethics in CHRISTUS Muguerza: Present and Future. The symposium’s five modules, each with several topics or talks, contributed to the conference objective for participants to understand the importance of ethics and bioethics in daily activities. The modules were based on teamwork aimed at developing an ethical culture by continuously updating it considering medical advances that create present and future ethical challenges.

One of many insights led to a significant change in CHRISTUS Health’s U.S. ethics programs. Comparing ethics’ function in Mexico to ethics’ function in the U.S. catalyzed and accelerated this change. In the U.S., the three-prong function of education, case consultation, policy review, and development arose in the 1980s after cases such as In re Quinlan and guidance such as the President’s Commission’s Deciding to Forego Life-Sustaining Treatment.² Mexico shares two of three prongs – education and case consultation – that assume or subsume policy review and development. Whether a third prong or part of the others, a significant ethics program function in Mexico translated to “promotions,” referring to the process of how ethics program members engage, mainly internal, stakeholders about what ethics is and does.

Being unintentional about promoting ethics, or sending the wrong message, can lead to disaster in my experience. Some approaches have sent those with ethics interest, but not yet in an ethics program, to the same ethics trainings or boot camps that consultants and ethics committee members attend. It’s not a mystery why this generates low return, meaning few people joining ethics programs, after trying to sip from a firehose of information with little to no context. Some years ago, an associate who had interest in joining an ethics program asked a seasoned veteran with ten years as a consultant, committee member, and leader, “What do you do in ethics?” Her response was a serious, “I don’t know; I’m not sure.” The associate didn’t join ethics.

Promotions start with the strategy that anyone interested in ethics should know ethics programs’ purpose, process, structure, and function as well as what ethics is... and is not. Interested parties should know what ethics does prior to joining a program. A tactic is to leverage CHRISTUS Health’s skill and scale to centralize information shared across ethics programs while not losing the personal touch of the local program (e.g., personal invitations and onboarding from the local ethics leaders).

Three tools were developed. Intended audience members of the first tool are ethics leaders. The ethics program interest and onboarding checklist, shown in part below, is an interactive pdf, also printable, for leaders to track new member onboarding.

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Second, a recruitment “one-pager,” was supplied to local ethics leaders for distributing and displaying hard copies. Two versions of the one-page brochure are almost identical – the associate-facing has a QR code for an ethics foundation site and the other, without the code, is for patients and families. Both versions have two printing options, informal for office printing or with bleeds for print shops.

The brochure outlines at a high level:

• What ethics is and its function within health care,
• Clinical and organizational differences,
• Committee and consultant descriptions,
• Five functions of ethics at CHRISTUS Health (community outreach and process improvement in addition to the three described previously),
• Ethics program member expectations,
• Additional consultant expectations,
• Committee member training, and

Additional consultant training

Associates are extremely busy. Ethicists and ethics leaders should make every effort to minimize time burdens and maximize personal and organizational benefits for those in ethics. Communicate this in simple, understandable ways prior to them starting on the committee and/or consult team. For instance, many ethics committees meet for about an hour every other month (some quarterly). Being an ethics committee member takes less than one day per year, factoring in meeting time, homework such as reading before the meeting, and teaching between meetings. Even members of ethics committees who meet hourly once per month, only spend half a day per year in meetings. The projected time impact is also included in the brochure, (one side of the page) shown below.

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Third, the brochure’s QR code links to a landing site called the ethics program foundation site, which includes more high-level information about ethics. A short video welcomes people. Another video gives five tips for new ethics program members. Ethics consult stats are on a page. Other modes and topics include:

• Five strategic priorities of ethics at CHRISTUS Health on the home screen (shown below); The purpose with the goals of ethics (e.g., “improve health care quality through the identification, analysis, and resolution of ethical questions or concerns”);³
• Common beginning-of-life and end-of-life issues, named with little detail (e.g., prenatal testing, pregnancy and substance abuse, pregnancy complications for beginning-of-life and decision-maker discord, potentially inappropriate treatment, benefits and burdens of treatment for end-of-life);
• Expanded function of and roles with the ethics consult process and ethics committee meetings (e.g., committee meetings typically have a welcome, reflection, approval of minutes, announcements, old business, ethics consult report, new business, and close);
• Differentiating between five ethics roles – committee members, consultants, program co-chairs, program chairs, and ethicists; and
• Resources about what ethics is and is not (e.g., not to tell what is legal to do, tell another that he or she is being unethical, rubber stamp someone).

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A case provides options for action and resolution that are consistent with different ethics theories and approaches, such as rule-based, consequence-based, values-based, and so on. An ethics contact list has the names of ethics program chairs by region along with email and phone number so interested parties can contact their leaders for more, site-specific information. A link takes folks who commit to being in ethics directly to the training, five modules (ethics in health care, Catholic teaching and the Ethical and Religious Directives or ERDs, common ethics issues, end-of-life ethics issues, and beginning-of-life ethics issues) in the ethics program member basic education on CHRISTUS Health’s internal education platform, called Genesis. Consider resources, the ethics program foundation site for instance, as supplements to local, interpersonal interactions. The “multiplication of resources and relationships does not alter the personal character of interactions” with associates who show interest in ethics, in this case.”⁴ A lesson from Latin America is to treat promotions with intention, considering it part of your education plan or curriculum, irrespective of if it is a formal prong of ethics … or not.

STEVEN J. SQUIRES, PHD, MA, MED

Vice President, Ethics

CHRISTUS

Health Irving, Texas

ENDNOTES

1. For instance, ethics program members in Mexico often serve as investigators for issues such as associate behavior concerns, which go to human resources (HR) in the U.S.
2. In re Quinlan, 70 N.J. 10, 355 A.2d 647, 671, cert. denied, 429 U.S. 922 (1976); President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment: A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions (Washington, D.C.: U.S. Government Printing Office, 1983), 162-165.
3. Anita Tarzian et al., Core Competencies for Healthcare Ethics Consultation (American Society for Bioethics and Humanities, 2011), 3.
4. United States Conference of Catholic Bishops, The Ethical and Religious Directives for Catholic Health Care Services, sixth edition (Washington, DC: United States Conference of Catholic Bishops, 2018), 13.