Ron Hamel, Ph.D.
Senior Ethicist, Emeritus
[email protected]

In 2008, CHA conducted a survey of ministry ethicists and a related survey of mission leaders who carry out the ethics function in their organizations. The purpose of the surveys was to obtain initial, baseline information about the ethics role and its multiple dimensions within Catholic health care. In addition to gaining a better understanding of the ethics role, the surveys were designed to obtain data that could be helpful for hiring and recruiting qualified ethicists, standardizing qualifications and competencies, providing educational and development programs, engaging in strategic planning, and planning for the future. Some results of the surveys generated concerns in light of their implications for the future role of ethicists and the future of ethics in Catholic health care. CHA responded to these concerns through a variety of initiatives including development of desired competencies and qualifications for ethicists in the ministry, fostering relationships with graduate students in ethics, and developing a hybrid online and in-person course for mission leaders who carry on the ethics function or are responsible for ethics in their organizations.

In early 2014, CHA conducted a follow up survey focusing on ministry ethicists associated with a system or facility. Eighty-one ethicists received the survey and forty-seven completed all or a portion of it for an overall response rate of 73 percent. Although everyone did not answer every question, generally there was a sufficient response to the questions to yield useful information. What follows is a summary of the survey divided into the same four parts as the original survey:

• Who are ministry ethicists?
• What do ministry ethicists do and think about?
• Perceptions of ethics within organizations.
• Looking to the future.

When relevant, comparisons are made with the results of the 2008 survey.

Who Are Ministry Ethicists?

Gender, Age, Religious Affiliation, and Educational Preparation
As with the earlier survey, the majority of professional ethicists in Catholic health care are male (62 percent), Caucasian (97 percent), lay (81 percent), and Roman Catholic (86 percent). The majority, 63.6 percent, hold a Ph.D. or the equivalent. Of those with a Ph.D. who responded, slightly more hold a degree in health care ethics or philosophy than hold a degree in moral theology or theology. These numbers have not changed significantly from the previous survey, although the percentage of males and those holding Ph.D.s is slightly down, whereas the percentages of lay and Roman Catholic ethicists have increased by 3 percent and 8 percent respectively.

Location
As noted in the 2008 survey, the "location" of professional ethicists in Catholic health care has important implications for desired qualifications and competencies of future ethicists. Survey results show that 20.6 percent of the ethicists who responded are employed by a national health care system, whereas 52 percent indicated that they are employed by a regional system, and 11 percent by an acute care facility.

Age, Experience, Longevity in the Role and a Succession Plan
As with the earlier survey, the age of ethicists in Catholic health care is of some concern. The largest percentage, 36.4 percent, is between ages 60-69. This is slightly higher than the previous survey that found 31.1 percent at 60 and above. The second and third largest age cohorts are 50-59 (25 percent) and 30-39 (18.2 percent) respectively. The three smallest age groups are 40-49 (13.6 percent), 20-29 (4.5 percent) and 70+ (2.3 percent). This means that approximately 63.7 percent of ethicists in Catholic health care are between the ages of 50-70+, while 36.3 percent are between the ages of 20 and 49.

One survey question asked about years of experience as an ethicist. Those who indicated that they had 6-15 years represented 38.2 percent, while 32.4 percent noted 16-29 years. The lowest numbers were at either end of the spectrum: 8.8 percent indicated 30 or more years, while 20.6 percent indicated 1-5 years.

When asked how many more years they planned to work as an ethicist, 29.4 percent responded 1-5 years. On the other hand, 41.2 percent said they planned on working as an ethicist 6-15 more years, 8.8 percent plan on 16-29 more years and 20.6 percent plan on working 30 or more years. This suggests that within five years, almost 30 percent of ethicists currently in Catholic health care will no longer be in that role. This is fairly significant for the future of the ethics role. On the other hand, almost 30 percent say they plan on remaining in the role for another 16-30 years. The largest group, 41.2 percent, plans on continuing for 6-15 years. Hence, within 15 years, Catholic health care could lose 70.6 percent of its ethicists.

Only 31.4 percent indicated that their organization has a succession plan for their position.

What was said about age in the 2008 survey applies today, especially when coupled with responses to the new question about expected length of time remaining in the role. "These numbers not only suggest an aging cohort of professional ethicists, but also, of even greater concern, disproportionately fewer ethicists coming into Catholic health care than those approaching retirement age. Absent some fairly aggressive measures, we are facing a shortage. Leaving these positions vacant or filling them with individuals who might not have the desired qualifications, competencies and experience could eventually have a negative impact on ethics in Catholic health care at a time when the issues are becoming increasingly complex" (Hamel, "A Critical Juncture," Health Progress 90, no. 2 [March-April 2009], p. 15).

Title and Reporting Relationships
Because titles may indicate the degree to which a particular role is valued by an organization, the survey asked about position titles of professional ethicists and the titles of those to whom they report. The majority of ethicists responding hold the title of Director of Ethics (33.3 percent), whereas 3.0 percent are Senior Directors, 9 percent are VPs of Ethics, and 6.1 percent are Senior VPs of Ethics. 6.1 percent hold the title of Ethicist. 42.2 percent indicated "Other." At least some of these are likely to be titles combining mission and ethics.

As might be expected, the majority of ethicists in an acute care setting hold the title of ethicist (20 percent) or director of ethics (80 percent). But surprisingly, 33 percent of ethicists at regional systems and 29 percent at national systems have the title of director of ethics. Only 6 percent of ethicists at a national or regional system have the title of vice president, ethics or senior vice president, ethics. Twenty-nine percent of ethicists at a national health care system hold the title of vice president, ethics and 14 percent have the title of senior vice president, ethics. It should be noted here, however, that other titles might also be at play. Fifty percent of respondents who are located in a regional system and 29 percent of those in a national system indicated "Other" for their title. Some of these have a variation on the ethics title (e.g., director, clinical ethics, executive director, ethics), while others combine mission and ethics in their title (e.g., vice president, mission and ethics; vice president mission services).

As might be expected, most ethicists report to a mission leader (58.8 percent). Those who report to someone with the title of senior vice president of mission represent 35.3 percent, while 23.5 percent report to a vice president of mission. Twenty percent report directly to the CEO.

At minimum, these results raise the question of whether the ethicist should be equal in title and status to the mission leader. This is especially true when one considers that the majority of ethicists hold a Ph.D. and deal with extremely complex and grave issues.

Compensation
CHA staff often receives inquiries about the range of compensation for professional ethicists in Catholic health care. Needless to say, compensation varies considerably depending on the size of the health care organization, whether it is a system or facility, region of the country in which it is located, professional degree, title, experience and responsibilities. The survey found that salaries ranged from about $50,000 to over $450,000.

• 8.8 percent earn between $50,000 and $75,000
• 20.6 percent earn between $75,001 and $100,000
• 14.7 percent earn between 100,001 and $125,000
• 8.8 percent earn between $125,001 and $150,000
• 8.8 percent earn between $150,001 and $175,000
• 8.8 percent earn between $175,001 and $200,000
• 11.8 percent earn between $200,001 and $225,000
• 5.9 percent earn between $225,001 and $250,000
• 2.9 percent earn between $250,001 and $275,000
• 2.9 percent earn between $300,001 and $325,000
• 2.9 percent earn between $425,001 and $450,000
• 2.9 percent earn $450,000 and above.

Approximately 60 percent of ethicists working in an acute care facility earn between $75, 001 and $100,000 and approximately 20 percent earn between $100,001 and $125,000 and another 20 percent between $150,001 and $175,000. Regional ethicists' salaries range from between $50,000 and $75,000 all the way to between $300,001 and $325,000. The majority lie between $75,001 and $150,000. Approximately 30 percent of ethicists at a national health care system earn in the $100,001 to $125,000 range with the remainder fairly evenly distributed in the other salary ranges up to $450,000 and above.

Ethicists with the title of "ethicist" earn between $50,000 and $100,000. Those with the director of ethics title fall into virtually every category above with the majority in the $75,000 to $100,000 category (approximately 37 percent), followed by approximately 28 percent in the $100,001 to $125,000 range and about 12 percent in the $125,001 to $150,000 range. Several of the higher ranges contain only about 6 percent each.

Vice presidents of ethics fall between the $125,001 to $150,000 range at the low end and the $250,001 to $275,000 at the high end, with the majority (about 56 percent) falling between $150,001 and $225,000.

Salaries for senior vice presidents of ethics range from $175,000 to above $450,000. About 75 percent earn between $175,000 and $225,000.

What Do Ministry Ethicists Do and Think About?

Roles and Responsibilities
To obtain a better picture of how professional ethicists in Catholic health care spend their time, the survey presented a list to indicate their primary roles and responsibilities. Not surprisingly, the roles and responsibilities that rose to the top were education (97.1 percent), clinical consultations and policy development at 94.1 percent, followed by advising leadership on organizational issues (88.2 percent), development of educational resources (88.2 percent), and working with ethics committees (85.3 percent). Research and writing for publication were the lowest at (52.9 percent) and (44.1 percent) respectively. The differences from the 2008 survey results are relatively minor. The most significant difference is that in the 2008 survey, working with ethics committees ranked second, whereas in the most recent survey, it came in much lower. This could be an interesting finding.

With the exception of leadership development and advising leadership on organizational issues, there was not much difference in the roles and responsibilities among ethicists at a national system office, a regional system office or an acute care responsibility. In all probability, however, while little difference exists in stated roles and responsibilities, differences occur among the three groups in the manner and degree in which those roles and responsibilities are carried out on a daily basis.

A majority of ethicists (57.1 percent) said that their role had changed over the past five years. This was often due to a change in title, a change in location (e.g., from an acute care setting to a regional position) or an explicit broadening of responsibilities under the same title. Changed responsibilities included more church relations, executive formation, analysis of new affiliations and partnerships, mission due diligence, organizational ethics issues, advance care planning, and ethics integration throughout the organization. Most of the role changes occurred with ethicists at a national system.

When asked whether they were a member of the senior leadership team, 31.3 percent of respondents said that they are a member of the senior leadership team, up from 21.4 percent in the previous survey. While this is an improvement, it still means that 68.7 percent of ethicists are not on the senior leadership team. This finding would seem to suggest something about the status of ethicists within their organizations. Similarly, 31.2 percent indicated that they are very or considerably involved in major decision making such as budgeting, planning, joint ventures, etc., while 40.6 percent of respondents said that they are not at all involved.

However, as noted in the earlier survey, "this should not necessarily be construed to mean that ethicists have little influence on senior leadership. What it does mean is that senior leadership may need to examine the degree to which ethics is valued in the organization, as well as how ethics is brought to bear on all dimensions of organizational life, including those areas of the organization represented by senior leadership. What is important is that ethics is brought to bear, and not so much how it is brought to bear. Some clarity about how the ethicist exerts influence is critical to the success of the role. Those ethicists who do not sit at the senior table might do well to examine how they exert influence on the organization as a whole as well as on senior leadership. Is it by participating in discussions on an ad hoc basis, through face-to-face conversations with senior leaders, or through the mission leader or another person to whom the ethicist reports" (Hamel, Health Progress 90, no. 2 [March-April 2009]"A Critical Juncture," p. 17).

Daily Activities
As with the 2008 survey, the activity that most occupied ethicists' time, and this is not surprising, is education (61.8 percent). Clinical consultations and working with ethics committees ranked next at 44.1 percent and 38.2 percent. Research came in at 5.9 percent and writing for publication came in at 2.9 percent.

When asked what they found most satisfying about their work, 44 percent said it was ethics consultations and helping others to resolve difficult ethical issues whether at the clinical or organizational levels. Twenty-seven percent said it was education, particularly of clinical and facility staff, but several also included management and executive leadership. Several mentioned graduate medical education. And 17 percent mentioned helping to shape the culture of the organization, strategy, and systemic change.

The greatest challenge ethicists indicated they face in their organization is being valued by leadership and the ability to influence (45 percent). Some noted that they are called upon at the last minute or are seen as an option of last resort. Twenty-seven percent indicated a range of characteristics associated with their position such as being alone, balancing multiple commitments/responsibilities, fragmentation of role and responsibilities, being spread too thin and not having sufficient time to fulfill responsibilities. Eighteen percent mentioned keeping up with changes in the health care environment.

Issues Occupying Attention
What three issues were most pressing for ethicists over the three months prior to the survey? Most frequently mentioned were ethical issues involved in partnerships, especially with other-than-Catholic organizations. Next were reproductive issues and balancing good patient care with the ERDs. The ACA and challenges around new models of health care delivery resulting from the ACA were next. Other issues mentioned several times each were advance care planning including POLST, contraception and the HHS mandate, and end-of-life care including futile treatment.

Professional Development
When it comes to professional development, a majority of respondents (80.6 percent) said that they attend 1-3 conferences per year, whereas 16.1 percent attend 4-6 conferences per year. These conferences include the CHA Colloquium (87.1 percent), followed by ASBH (the American Society for Bioethics and Humanities, 61.3 percent), the CHA Assembly (45.2 percent), and other programs (38.7 percent). Those who attend the annual meeting of the Society of Christian Ethics represent 25.8 percent and 16.1 percent attend the annual meeting of the Catholic Theological Society of America.

Professional publications most often read by ethicists responding to the survey were Health Care Ethics USA, the National Catholic Bioethics Quarterly, the Hastings Center Report and Health Progress. Distant seconds were HEC Forum, the American Journal of Bioethics, the Journal of Clinical Ethics, Ethics and Medics, Theological Studies and Christian Bioethics. JAMA and the New England Journal of Medicine received occasional mention. Most frequently used websites are those for CHA, NCBC, ASBH, Bioethics.net, and Ascension Health.

Contributions of Ethics
When asked what they saw as the most important contribution that ethics makes to their organization, the largest number of respondents noted something along the lines of improving the quality of decisions — ”clinical and organizational — across the organization. This was followed closely by contributing to the culture of the organization — in particular, creating and sustaining an integrative ethics culture, nurturing organizational conscience, and strengthening mission and Catholic identity. An almost equal number singled out assisting patients, families, and health care providers with difficult decisions.

When looking to the future and how ethics might contribute most to their organization in the next 3-5 years, most respondents to this question said providing ethical input into the development of new delivery systems of care, providing a moral foundation for population health, and providing new ways of offering ethics services in new models of care. Next most frequently mentioned were nurturing a strong ethics culture and ongoing ethics education to empower various individuals and groups (including medical residents and nurses) to better recognize and address ethical issues. These were followed closely by leadership development and formation, being an ethics voice at the organizational table and developing and/or hard wiring a decision-making process for the entire organization.

Moving beyond their organization, ethicists were asked how ethics might contribute to the ministry in the next 3-5 years. Here the largest number of respondents said finding ways to integrate ethics across the continuum of care and re-thinking our ethical frameworks in light of the shift in emphasis beyond the acute care setting. Also frequently mentioned were strengthening Catholic identity and ethics education, including the development of tools and apps for clinicians and organizational leaders. These survey results may well suggest a need of ongoing education of ethicists in Catholic health care to better address the changing health care environment and to better meet the challenges that it poses. They may also have implications for the preparation of new ethicists.

Looking to the Future: The Next Generation of Ethicists
Survey questions related to the future of the profession dealt primarily with educational preparation for future ethicists, desired experience, and suggestions for recruiting future ethicists for Catholic health care.

Desired Core Competencies
What two or three core competencies will future ethicists need in order to be effective for the ministry? The most frequently mentioned response centered on theological competency, including knowledge of the Catholic moral tradition, Catholic social teaching, and ecclesiology. Next came clinical experience, communication skills, knowledge of the health care system, including an ability to communicate with providers and awareness of organizational ethics issues. Finally, several respondents mentioned the ability to conduct clinical consultations. These results closely parallel those in the 2008 survey.

Needed Experience
When asked what experience future ethicists will need in order to be effective in the ministry, respondents most frequently cited clinical experience and previous work in a health care setting. Very close seconds were familiarity with the fundamentals of business and strategy, operations, and how to interface with senior leaders. Clinical/hospital/health care experience was also cited by slightly more than half of the respondents in the previous survey. These findings may be helpful not only in developing position descriptions, but also in preparing future ethicists for a career in the ministry.

Essential and Desired Educational Preparation
Asked about essential educational preparation for someone doing health care ethics in the future, 70.4 percent of respondents said that a master's degree is essential, while 29.6 percent said a Ph.D. is essential. This is different from the earlier survey when 51.3 percent said a Ph.D. was essential and 35.9 percent said a master's degree was essential. However, 75.9 percent said that a Ph.D. would be desirable. These results probably merit further discussion. Is a master's degree sufficient, especially if the ethicist is interacting closely with physicians or holds a system position? What impact if any might this have on how the ethics position is viewed by administration?

Recruiting Future Ethicists
Respondents offered several suggestions for attracting new ethicists into Catholic health care. One was to connect with high schools and universities (graduate and undergraduate) to help students become aware of possible careers in Catholic health care. Related to this was offering work-study programs, internships and fellowships to those students who may have an interest, and continuing to foster student participation in CHA activities together with scholarships to the annual Colloquium and the student essay contest and, possibly, student colloquia. The other most frequently mentioned suggestion was reaching out to health care professionals who might have an interest in ethics and who might consider professional training in ethics to accompany their current careers or who might consider a second career in Catholic health care ethics. In conjunction with this, a few also suggested a mentoring program for such individuals and developing an ethics career track or training program for them.

Concluding Observations
Readers will have their own interpretations and observations regarding the results of CHA's 2014 Ethicist Survey, but a few preliminary observations are offered here. Hopefully, these results will serve as a basis for ongoing discussions and will contribute to planning, programing, hiring and the like across the ministry.

1. Catholic health care continues to have an aging cohort of professional ethicists. While there are new and younger ethicists in the pipeline, it seems unlikely that there will be sufficient numbers to replace ethicists retiring in the next five to ten years. If this challenge is going to be met successfully, it would seem that all of Catholic health needs to redouble its efforts to make students at various educational levels aware of a possible career as a Catholic health care ethicist, develop and implement ways to nourish and support potential candidates, and perhaps look to existing health care professionals who might be interested in a second career or at least a concentration in Catholic health care ethics.

2. There is a lack of diversity among Catholic health care ethicists. As the survey results indicate, the majority of ethicists in Catholic health care are male and Caucasian. In the effort to recruit new ethicists, it would behoove Catholic health care to make deliberate efforts to attract and, perhaps, even identify and nurture, individuals who would bring gender and racial diversity.

3. There is a shift in the educational backgrounds of newer ethicists. The majority of older ethicists in Catholic health care were and are theologians. Their degrees, Ph.D.s or STDs, are in theology, mostly because they are clergy, former clergy, members of religious communities, or seminary trained. This is generally not true of newer ethicists who tend to be obtaining their degrees in health care ethics, a more multidisciplinary approach (which has its own strengths). While most of these programs do incorporate some theology in their curricula, it does not result in the theological breadth and depth of previous generations of ethicists. It may be that newer ethicists in Catholic health care need not be theologians in order to serve the ministry well, but they certainly need to be well-versed in the Catholic moral tradition at least, in order to adequately meet the challenges of a faith-based ministry of the Church, as a good number of respondents noted in the survey.

4. The responsibilities of ethicists seem to be changing with rapid changes in the health care delivery system. In many of the responses, there are early indications of a shift in the responsibilities of ethicists both in the acute care setting and at national and regional system levels. All three tend to be dealing with the extension of ethics services throughout the continuum of care. This will likely require knowledge of differing cultures across the continuum, new ways of delivering services, and some new skills. With the explosive growth in new affiliations and partnerships, system ethicists will likely be more involved in addressing ethical dimensions of these relationships, some of which will involve complex applications of the Principle of Cooperation (and, possibly, toleration). These developments have implications for the adequate preparation of new ethicists.

5. As in 2008, survey results raise some questions about how well the ethics role is valued and integrated within Catholic health care organizations. Are ethics and the ethics role viewed as integral to the life of the organization or are they seen as nice to have around when crises develop or other difficult problems arise? How is the ethics role positioned within the organization and how is it used? Survey results suggest that administrators and ethicists themselves would do well to reflect on the place of ethics and the ethics role within their organizations. Ethics is at the heart of mission. If ethics is seen as an optional add-on or is somehow marginalized, then something essential to mission is missing or diminished within the organization.

6. Research and publication continue to rank low. What is not clear in the survey results is why research and publication rank low. Is it because they are not being done or not being done much or because less time is devoted to them than to other responsibilities? If the former, this would be unfortunate and needs to be addressed. No one is better positioned to contribute to the field of Catholic health care ethics than ethicists within Catholic health care. These ethicists are not only part of their particular organizations, they are also part of a much larger whole — Catholic health care. The entire ministry, colleagues across the ministry, and numerous individuals beyond the ministry would benefit immensely from ministry ethicists bringing the Catholic moral tradition to bear on ethical issues that they encounter in their work.

These observations and the survey results themselves are intended to stimulate conversations across the ministry about how we understand, organize, and do ethics and how we ensure a strong and well-prepared cadre of ethicists for the future. Hopefully, such conversations will lead to taking concrete steps to enhance ethics and the ethics role within the Catholic health care ministry.

Copyright © 2015 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.