BY: CARL MIDDLETON, DMin, MDiv, MA, MRE
A study by the Catholic Health Association indicates that the national Catholic health care ministry may lose as many as 70 percent of its ethicists by the year 2031. Though about 2 of every 3 ethicists are now over the age of 50, there is a significant lack of succession planning for these vital positions in Catholic health care organizations.1
This scenario has significant implications for future contribution to the common good, which St. John Paul II defined in this way: "The sum of those conditions of social life which allow social groups and their individual members relatively thorough and ready access to their own fulfillment."2
It is helpful to think of "common" as applying to each and every person without exception, and "good" as that which contributes to the basic needs for human development and flourishing.
The common good consists of three essential elements: respect for and promotion of the fundamental rights of the person; prosperity, or the development of the spiritual and temporal goods of society; and the peace and security of the group and of its members.3
The dignity of the human person requires the pursuit of the common good. Everyone should be concerned to create and support institutions that improve the conditions of human life. The challenge for us is "to make accessible that which is needed to "lead a truly human life: food, clothing, health, work, education and culture."4
ETHICISTS AND INSTITUTIONS
Ethicists have a significant role in assisting in the creation of health care institutions that strive to make health care more affordable and accessible for the people we serve. Here is my operational definition of ethics: a systematic attempt to answer two basic questions: "Who am I?" and "How should I behave?" The second question can be answered only in connection with the first.
This definition applies to Catholic health care institutions, as well. In light of who we say we are as Christian Catholic institutions, how should we behave as the health care environment rapidly changes, moving away from an acute care focus to the expansion of the continuum of care?
Ethicists assist the institution in reflecting upon who we are and who we are called to be in light of the heritage and legacy of the women and men religious who founded our ministries. Ethicists also facilitate discernment in how we should respond to the demands of the health care environment and how we should provide health care to each and every human person that needs it.
In my opinion, these are the significant contributions that an ethicist makes to the institution he or she serves in striving to meet the health care needs of the common good.
However, there aren't enough ethicists to serve in this vital role. If the CHA study is accurate and shortages loom in the ranks of these professions, the significant contributions of ethicists in Catholic health care could be in jeopardy.
WHAT PART DOES A HEALTH CARE ETHICIST PLAY?
In 1973, I began my ministry as a theologian/ethicist in Catholic health care. For most of my career, the focus of my role has been primarily in the area of clinical ethics. My role also has included organizational and social ethics for Catholic Health Initiatives, a national system that now operates 103 hospitals and hundreds of other care sites in 18 states. As vice president for theology and ethics, I have been responsible for providing leadership in those areas for the facility boards, national and facility leadership, facility physicians and staffs and to ethics committees throughout CHI.
My roles and responsibilities have aligned pretty closely with those identified in CHA's research about ethicists: Education (97.1 percent); clinical consultations and policy development (94.1 percent); advising leadership on organizational issues (88.2 percent); development of educational resources (88.2 percent); and working with ethics committees (85.3 percent).
Here's a breakdown of what those tasks mean, based on my contributions to the facilities I serve:
Education: Within CHI, we have created a system in which senior leadership teams serve as the facility's organizational ethics committee. We define organizational ethics as the study of ethical issues associated with the systems, structures and processes that shape encounters between health care providers and patients/residents/clients.
Organizational ethics is a disciplined process for incorporating ethical reflection and practices into the life and work of an organization. We teach the CHI discernment process as a decision-making tool that provides ethical reflection on major decisions and concerns. We also apply the principles of Catholic social teaching to creating and supporting the common good of the communities we serve.
We teach social ethics and principles of Catholic social teaching to board members on the facility's social ethics committee. The board usually has the fiduciary responsibility to give the organization feedback in terms of how it is fulfilling its commitment to the common good of the community, and how health care is being made more accessible and affordable to poor persons and the vulnerable.
Ethicists participate in regularly scheduled leadership orientation programs, foundations and other types of ministry formation. The purpose is to establish an ethics infrastructure that links crucial organizational processes and clinical practices to the organization's mission and core values, and to put in place the means to reflect, monitor and provide feedback on ethical performance.
In collaboration with other colleagues, we coordinate CHI's Ethics Associate Program, a one-year certification program that provides health care professionals with an opportunity to receive education and mentoring in health care ethics, especially the Ethical and Religious Directives for Catholic Health Care Services. Ethics associates serve as key resources in various areas of ethics along with their other professional responsibilities. Our ethics associates number more than 600 and include physicians, persons who serve as administrator on call, persons serving on institutional review boards and ethics committees, managers of intensive care and critical care units and emergency departments, and legal and corporate responsibility personnel. These individuals contribute to the common good of CHI through identifying and helping to resolve ethical issues within their facility or system.
Consultation: Upon request, ethicists provide consultation services in clinical, organizational and social ethics for national staff, committees and facilities. This service is provided 24 hours a day in order to resolve ethical issues and dilemmas that involve patients, residents, families and staff. Ethics consultation also includes issues regarding Institutional Review Board research and concerns in collaboration with IRB staff.
Ethicists provide consultation and analysis to the CHI Business Transaction Team regarding prospective affiliations, transactions and partnerships. This work also includes writing moral analyses of the transactions for bishops and other theologians.
Ethics Integration: CHI ethicists foster ethics integration in such major decision-making areas as the CHI discernment process, capital review and other business transactions. In addition to creating and sustaining an integrative ethics culture, ethicists nurture institutional conscience and contribute to the strengthening of mission and Catholic identity.
One key example is the development of criteria for the system capital review process, in which markets across the country request allocations for a wide array of projects, including new construction, renovations and equipment. In collaboration with our business strategy team, ethicists establish criteria based on CHI's core values of reverence, integrity, compassion and excellence, as well as the organization's behavioral attributes, in order to prioritize requested capital projects. There are times in the capital review process when there is a conflict between the needs of the individual entities and the amount of money the system has to spend. It can be challenging to resolve the tension between the common good of the individual health facilities and the common good of the system as a whole.
Policy Review and Development: We review national and market-based policies and participate in policy development discussions regarding ethical issues. For example, CHI became partners with Conifer, a for-profit revenue cycle company. Several of us from CHI's National Mission Group worked with the staff of Conifer to revise its policies and procedures to more accurately reflect the mission, vision and values of CHI. This work also involved rewriting scripts for communicating with patients and families regarding bill collection to further reverence the human person and to foster the common good.
Resource Development: Ethicists develop white papers, manuals and other resources to address clinical, organizational and social ethics issues as appropriate, such as the Ethics Committee Resource Manual; Integrative Health Care: An Emerging Approach to the Art of Healing; and Healing Ministry in the Age of Genetics. One white paper, for example, provided ethical analysis and reflection on the moral issues surrounding outsourcing of jobs in foreign countries and its impact upon the human person and the common good.
Research: Ethicists conduct research on current and developing ethical issues. For example, we did extensive research discernment on the issue of outsourcing of information technology and genetic testing.
Like the majority of ethicists, I have experienced changes in my role over the past five years, spending more time in church and episcopal relations in the analysis of new affiliations and partnerships; mission due diligence; organizational ethics issues; advanced care planning; and ethics development and integration throughout the organization.5
In the coming years, it is clear that ethicists will have to provide ethical input around the expansion of the health care continuum — including challenges around ethical issues and conflicts involving clinically integrated networks and accountable care organizations. The move to value-based payment models creates new ethical challenges and requires new skill sets for ethicists and mission leaders to ensure we preserve our values as we make this transition and assess the impact of these models on the human person and common good. The development of criteria for decision-making regarding allocation and rationing throughout the organization also will be necessary. Leadership development and ministry formation will remain a priority, as well as identifying and resolving ethical issues surrounding population health.
Senior leadership teams will need ethical input and reflection to balance the priorities of a facility's mission and values: health and well-being of patients and patient populations; professional excellence and long-term organizational viability (including economic viability); community access; public health and the common good. As many are today, tomorrow's ethical problems will be a combination of clinical, organizational and social ethics.
Ethicists of my era in Catholic health care have been, for the most part, theologians with doctorates in philosophy or sacred theology. Most of us, but not all, are clergy, former clergy, members of religious communities, or have been members of religious communities or seminary-trained. Through this background in theology, most of us had a strong foundation in the Catholic moral tradition and Catholic social teaching. Many of us also had clinical and/or health system experience and were good at communication with providers.
In their interactions with senior leaders, future ethicists will need not only clinical experience, but also the ability of systems-thinking and analysis, a grasp of business and strategy and a feel for overall health care operations. Clinical experience is of particular importance — tomorrow's ethicists will work more closely than ever with health care providers so must have a solid understanding of medical terminology. To participate intelligently in case consultations, ethicists must have fundamental medical knowledge and some exposure to a wide range of medical cases. Internships will need to be created to provide this valuable experience.
It is imperative that all future ethicists have a background in theology and the Catholic moral tradition, because bishops will require a moral analysis to be written for particular transactions. Many of the transactions among Catholic providers and others will call for working with institutions and cultures that are not Catholic. For example, in Louisville, Kentucky, CHI has six Catholic facilities, a Jewish hospital and the management of the University of Louisville Medical Center. An ethicist in this environment must be comfortable working with a Jewish rabbi, an academic philosopher/ethicist and several bishops. The ethicist of the future will need to have an appreciation for diverse cultures and approaches to resolving clinical, organizational and social ethics issues.
CHA is to be commended for developing relationships with Catholic universities and colleges regarding a career in the field of ethics, and for its sponsorship of student essay contests to stimulate interest and research in the topic. As the survey report stated, a popular suggestion was to reach out to health care professionals who might have an interest in ethics. CHI's yearlong Ethics Associate Certificate Program has stimulated much interest in this regard. The certificate program has equipped our chaplains to be more fully engaged and to provide leadership in case consultations that have implications for the common good. We have had chaplains, physicians and several people in administration wanting to do more course work in ethics.
Catholic health systems and Catholic health facilities will need to develop their own recruitment strategies, starting with speaking about careers in mission and ethics in local Catholic high schools — especially to junior and senior students who are beginning to think about their majors in college. This outreach could be in addition to developing career interests in mission and ethics at Catholic colleges and universities near our ministries.
Another potential resource: the ethics faculty of local colleges and universities. Two people with PhDs took our Ethics Associate Certification Program, which emphasizes Catholic moral teaching and the Ethical and Religious Directives for Catholic Health Care Services. With some mentoring, they now help with case consultations and the ethics committees in CHI facilities. For some of our Catholic facilities, an agreement could be drawn up and a retainer paid for ethics faculty to participate in ethics case consultation and to provide ethics education. There is a significant interest in ethics among our health care professionals, and we need to discover ways to assist with tuition reimbursement to help them get the further training they need.
Recruiting individuals who are finishing their degrees is a good strategy, but we must not forget that they might not have any clinical experience — or theological and spiritual formation. Most of the current ethicists have all three. We will need to find ways to develop internships and clinical experiences for persons who want a career track. We also will need to provide theological reflection and spiritual formation to complement university training.
Accountable care organizations, clinically integrated networks and population health all will need excellent mission leaders and ethicists to form the ethical framework and infrastructures that our ministries will require. The ethical complexities of value-based payments present inherent challenges, as will price variation, transparency and physician incentives.
It is imperative that we develop succession-planning strategies to replace the corps of retiring ethicists who have been pioneers in developing the policies, processes and programs that have contributed so significantly to the common good of the communities we serve as Catholic health care ministries.
CARL MIDDLETON was vice president for theology and ethics, Catholic Health Initiatives, Englewood, Colo., from 1997 to 2016. He is currently Interim senior vice president for mission at CHI St. Luke's Health, Houston, Texas.
- Ron Hamel, "Ethicists in Catholic Health Care: Taking Another Look," Health Care Ethics USA 23, no. 1 (Winter 2015): 34-44.
- John Paul II, Gaudium et Spes, paragraph 26.
- Catechism of the Catholic Church, 2nd edition (Washington, D.C.: USCCB, May, 2016), paragraphs 1907-1909.
- Catechism of the Catholic Church, paragraph 1908.
- Hamel, "Ethicists in Catholic Health Care," 38.
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