As part of Project Legacy, the Catholic Health Association (CHA) identified a need for a pipeline of ethics positions to train, hire and develop ethicists in Catholic health care.1 Having standard terminology, expectations and structure for these positions, even a very loose standard, would help the field of Catholic health care ethics create such a pipeline and ease of entry into the field for potential applicants.
To that end, I propose Catholic health systems should have at least three categories of ethics positions: system, local and student2 (Table 1) Given their size, larger systems should consider sub-categories for each level or perhaps add a category. With this proposal, every system would have at least three ethics positions, at least two of which are paid.3
Most systems now have an ethicist at the system level. For those with more than one system ethicist, these roles often overlap; differences depend more on individual skill sets and system needs than title. In general, directors work more supporting local ethicists, while vice presidents work less with local needs and more with collective needs, system needs, or the common good of the system itself. However, an exhaustive list of differences between the scope of a vice president and director would be onerous and probably unhelpful.
Most Catholic systems also have at least one local ethicist. For those with multiple local ethicists, differences again likely lie in individual skills, but with scaled responsibilities and scope. Those farther down the organizational ladder are closer to the bedside, while those higher up are farther away from the bedside and more involved in regional decisions. This is why local positions are important for effective succession planning. Perpetually recruiting from outside is not a sustainable model for Catholic health care as a whole, especially since the percent of ethicists who plan to retire soon has not changed much: 67.5% in 2018 down from 70.5% in 2014.7 Developing consistent entry-level positions with a relatively small scope of responsibility is critical to this process. In no other field would a regional director for six hospitals be considered entry-level, yet for ethics it often is.
Yet, most of the opportunity seems to lie in creating student positions, especially fellowships. Consistency with titles and expectations would assist students in understanding which steps to take when starting their career path. For fellowships especially, the titles should clearly reflect the substance of the work; if the training is primarily clinical, then the title should include "clinical", while those at a system office should have "system" or "organizational". While time consuming for preceptors and mentors, internships and mentorships are crucial for introducing students to the field, even if only for a summer. Many interns choose another career path, so an increase in internship opportunities is necessary to create a sustainable pipeline.
FUNDING FOR CLINICAL ETHICS FELLOWSHIPS
Clinical ethics fellowships are an integral component of training clinical ethicists. They provide practical experience and an opportunity to develop the requisite skills for a career in clinical ethics under the supervision and tutelage of an experienced ethicist. CHA states fellowships are preferred for applicants to local ethics positions, but acknowledges that "not many of these fellowships exist at this time, and therefore, criteria and standards need to be developed further."8 As of this writing, I am aware of only one recurring ethics fellowship in a Catholic health system, while outside of Catholic health care at least 20 programs exist.9 A major obstacle to expanding fellowships is cost. One unexplored option for funding of clinical ethics fellowships is reimbursement from Medicare.
The Centers for Medicare and Medicaid Services (CMS) provides funding to hospitals to educate students in allied health professions. Federal statute identifies two possibilities for funding nursing and allied health education programs: if the profession is licensed by the state (which ethics is not) or if the education program "is accredited by the recognized national professional organization for the particular activity."10 The statute specifically calls out the Association for Clinical Pastoral Education (ACPE) as an example of just such an accrediting organization.
Since the funding is Medicare pass through, it is based in part on fellows' clinical hours and the percentage of Medicare patients at the hospital. Also, as with Clinical Pastoral Education programs, funding would not cover the costs entirely, but it could cover much if not most of a program's budget, including student stipends and faculty salary. No organization currently offers accreditation for clinical ethics fellowships.
There are several other requirements for funding. (Table 2) Given these, a non-clinical ethics fellowship, or one that is primarily located at a system office, would not qualify. However, clinical ethics fellowships theoretically could meet this requirement if an accrediting body for clinical ethics fellowships existed. The difficulties creating or identifying such a body and crafting an accreditation process are numerous, but the potential benefits to the field are unprecedented.
Complete unanimity throughout Catholic health care in ethicists' functions, scope, and role is not achievable or desirable. Titles and modifiers (like senior, executive, or system) will clearly fluctuate and differ by health system. However, more consistency would help the ministry as a whole develop corresponding pipelines and cultivate sustainability for our field.
Becket Gremmels, Ph.D.
System Vice President, Theology and Ethics
- Smith, Brian. Project Legacy: Succession Planning for the Ministry. Health Progress. March-April 2019, 100:2.
- Thanks to Mark Repenshek and Elliott Bedford for helping develop these categories.
- I am focusing here on the concept and terminology for these roles. For costs or how to justify the positions, see: Homan, Mary E. "Factors Associated with the Timing and Patient Outcomes of Clinical Ethics Consultation in a Catholic Health Care System." The National Catholic Bioethics Quarterly 18, no. 1 (2018): 71-92. Repenshek, Mark. "Examining Quality and Value in Ethics Consultation Services." The National Catholic Bioethics Quarterly 18, no. 1 (2018): 59-68.
- CHA's Theology and Ethics Committee, "Qualifications and Competencies for Ethicists in Catholic Health Care", May 2018.
- Mark Repenshek, "Hiring Clinical Ethicists: Building on Gremmels' Staffing Model Approach." Health Care Ethics USA, 29:1, 2021. Gremmels, Becket. "When to Hire a Clinical Ethicist." Health Care Ethics USA. 28:1, 2020.
- CHA, "Fellowships and Internships in Mission and Ethics: A Summary of Current Practices in Catholic Health Ministry", 2019.
- Hamel, Ron. "Ethicists in Catholic Health Care: Taking Another Look", Health Care Ethics USA, 2015, 23:1. Speckart, Jenna. "Ethics Recruitment and Role Awareness: What We're Hearing." Health Care Ethics USA, 2018, 26:4.
- CHA, Qualifications and Competencies for Ethicists in Catholic Health Care.
- Association of Bioethics Program Directors, Graduate Bioethics Education Programs, www.bioethicsdirectors.net/graduate-bioethics-education-programs-results
- 42 CFR § 413.85(e).