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BY: MARK REPENSHEK, Ph.D.

Dr. Repenshek is health care ethicist, Columbia St. Mary's, Milwaukee.

Defining the role of ethics and ethicists in Catholic health care now and into the future is made difficult by a single factor: Catholic health care ethicists have been largely silent on the issue of core competencies for their profession.¹ This problem is further complicated by the rapid growth of consultation,² concerns about accountability and quality,³ and no agreed upon standard of education or training for those who provide these services within Catholic health care.

This is not a call for licensing or certification of ethicists or ethics committees. Instead, it is a call for Catholic health care ethicists to develop a core set of competencies for their field. The importance of this task for the future of Catholic health care ethics is directly proportionate to the degree to which patients, families, health care providers and the health care ministry trust ethics consultants to assist in a variety of complex issues, faithful to the mission, vision and values of Catholic health care.

In the spring 2008 issue of Journal of Law, Medicine & Ethics, author Giles Scofield, J.D., writes:

"… if ethics is the moral limitation placed on power, and medical ethics consultants have not themselves set any discernible limits whatsoever to their own power, what more does one need to know in order to demonstrate, if not prove, that the field of ethics consultation is and can only be what it purports not to be—a moral, if not an ethics, disaster?"⁴

Scofield's assessment is largely critical of the efforts by the American Society for Bioethics and the Humanities in this regard.⁵ Yet it is important to note, that the society has published—and is currently reviewing—"Core Competencies for Health Care Ethics Consultation." It is a substantive document that calls for standards among ethics committee members in both skills for ethics consultation and knowledge for ethics consultation.⁶

Beyond the potential for the shared use of this document, Catholic health care ethics may be a far more appropriate target for Scofield's critique.⁷ For health care ethics, ethics committees and ethicists serving within Catholic health care ministries, it is critical that we develop a companion document to the society's core competencies for health care ethics consultation within Catholic health care, one that reflects the principles of the Ethical and Religious Directives for Catholic Heath Care Services.⁸

Returning to a previous point, this request does not suggest that licensing and certification of ethics committees and/or ethicists necessarily follows.⁹ Mark Aulisio et al., have made some significant points in this regard in a July 2000 article in Annals of Internal Medicine. Two are worth reiterating here.¹⁰

First, certification increases the risk for displacing providers and patients as the primary moral decision-makers at the bedside. Within the Catholic theological ethics tradition, significant deference is given to the prudential judgment of the patient.¹¹ It seems therefore appropriate to echo this point here.

Second, both certification and accreditation could undermine disciplinary diversity if they were controlled by a particular discipline and widely adopted. Many ethics committees within Catholic health care thrive on the diversity of perspectives brought to bear on requests for consultation (i.e., physicians, nurses, social workers, chaplains, etc.). These interdisciplinary committees have the added benefit of housing that diversity within the context of the mission, vision and values of the Catholic health care ministry.

Certification and accreditation of an ethicist might give the impression of an "ethics expert" who could overshadow the essential interaction and dialogue among members of an ethics committee, who bring their respective and relevant expertise.

Therefore, rather than calling for licensing and/or certification, some ethicists within the Catholic health care ministry, such as Thomas Shannon, Ph.D., make the case for a theological background. Theologians were able to join the early debates in bioethics so effectively because they were able to enter the discourse with a long-standing tradition of theological reflection on life, death, suffering and the intersection of these with medicine and the good of health.¹²

In the current context, it is a matter of whether Catholic theological health care ethics has come to some conclusions, based on this long-standing tradition of theological reflection, about what should be core competencies for health care ethics in the Catholic health care ministry. Once distilled, these core competencies should complement the core competencies defined by the American Society for Bioethics and the Humanities. Until we reach such a point, it seems fair to question whether Catholic health care ethics has been faithful to the development of "appropriate standards for medical ethical consultation within a particular diocese that will respect the diocesan bishop's pastoral responsibilities as well as assist members of ethics committees to be familiar with Catholic medical ethics and, in particular, these Directives [emphasis added by author]."¹³

In pondering what this might look like for Catholic health care ethics into the future, the society's document serves as an appropriate starting point. Not all committee members will need to be ethical "experts," nor would this be advisable. What would be advisable is that all members must be committed to the mission of the institution within the broader ministry of Catholic health care, with some members able to articulate the Catholic moral tradition in consideration of the Ethical and Religious Directives for Catholic Health Care Services.

This does not mean that "expertise" entails mere application of the directives. It is in fact the directives that call for continued examination of the Catholic theological tradition in light of medical research or public policy.¹⁴ The need for an adequate response to this appeal is reinforced by the fact that, although openness to the ethical wisdom found in other religious traditions and secular culture greatly enriches the ethical wisdom and discourse within an ethics committee,¹⁵ an ethics committee in a Catholic health care ministry presumes a normative tradition as a necessary part of the dialogue.¹⁶

Therefore, basic competencies in Catholic theological health care ethics should be present within the competencies of an ethics committee serving within the Catholic health care ministry. Clearly articulating these basic competencies will create appropriate standards for medical ethical consultation faithful to Catholic theological ethical methodology and context. A failure to do so may, unfortunately, further legitimate Scofield's critique, not of the American Society for Bioethics and the Humanities, but rather of Catholic health care.     

NOTES

1. For a contribution to the discussion on core competencies in clinical ethics consultation in Catholic health care, see John Tuohey, "Ethics Consultation in Portland," Health Progress 87, no. 2 (March-April 2006): 36-41. Ascension Health has begun to develop a set of core competencies to complement the American Society for Bioethics and Humanities' set of core competencies.
2. Keith Swetz et al., "Report of 255 Clinical Ethics Consultations and Review of the Literature," Mayo Clinic Proceedings  82, no. 6 (June 2007): 686-691; Also see Mark Repenshek, "An Empirically Driven Ethics Consultation Service," Healthcare Ethics USA  [forthcoming].
3. Calvin Leeman et al., "Quality Control for Hospitals' Clinical Ethics Services: Proposed Standards," Cambridge Quarterly of Healthcare Ethics 6 (1997): 257-268.
4. Giles R. Scofield, "What Is  Medical Ethics Consultation?" Journal of Law, Medicine & Ethics 36 (2008): 95-118.
5. Scofield, 110.
6. American Society for Bioethics, Core Competencies for Health Care Ethics Consultation  (Glenview, Ill., 1998), available for purchase at www.asbh.org.
7. For efforts in other associations or entities regarding competencies in ethics consultation, see Matthew K. Wynia, "AMA's Ethical Force Program Aims for Measures," Medical Ethics Advisor 24 (2008): 138-140; or U.S. Department of Veterans Affairs, IntegratedEthics Initiative, www.ethics.va.gov.
8. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, 4th ed. (Washington, D.C.: USCCB, 2004), no. 37.
9. For further discussion on this issue, see Charles Bosk, The Licensing and Certification of Ethics Consultants: What Part of 'No!' was so Hard to Understand?" in Mark Aulisio et al., eds., Ethics Consultation: From Theory to Practice  (Baltimore, Md.: Johns Hopkins University Press, 2003); Aulisio et al., "Health Care Ethics Consultation: Nature, Goals, and Competencies," Annals of Internal Medicine 133 (2000): 59-69; Benjamin Freedman, "Bringing Codes to Newcastle: Ethics for Clinical Ethicists," in Barry Hoffmaster et al., eds., Clinical Ethics: Theory and Practice  (Clifton, N.J.: Humana, 1989); Robert Baker, "A Draft Model Aggregated Code of Ethics for Bioethicists," American Journal of Bioethics vol. 5, issue 5 (September 2005): 33-41; Albert Jonsen, "Watching the Doctor," New England Journal of Medicine  308 (1983): 1531-35; John Fletcher and Diane Hoffman, "Ethics Committees; Time to Experiment with Standards," Annals of Internal Medicine 120 (1994): 335-338; Mark Siegler, "Defining the Goals of Ethics Consultations: A Necessary Step for Improving Quality," Quality Review Bulletin  18 (1992): 15-16; Deborah Cummins, "The Professional Status of Bioethics Consultation,"  Theoretical Medicine & Bioethics  23 (2002): 19-43; Mark Fox et al., "Paradigms for Clinical Ethics Consultation Practice," Cambridge Quarterly of Healthcare Ethics  7 (1998): 308-314; and Albert Jonsen, "Beating Up Bioethics," Hastings Center Report  31 (2001): 40-45.
10. Mark Aulisio, Robert Arnold and Stuart Youngner for the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation, "Health Care Ethics Consultation: Nature, Goals, and Competencies," Annals of Internal Medicine, 133 (July 4, 2000): 59-69.
11. USCCB, nos. 56 and 57.
12. Thomas Shannon, "Bioethics and Religion: A Value-Added Discussion," in Notes from a Narrow Ridge: Religion and Bioethics, Dena S. Davis and Laurie Zoloth eds. (Hagerstown, Md.: University Publishing Groups, 1999), 31; David F. Kelly, The Emergence of Roman Catholic Medical Ethics in North America  (New York: The Edwin Mellen Press, 1979); Gerald Kelly, Medico-Moral Problems  (St. Louis, Mo.: The Catholic Hospital Association, 1958); and Lisa Sowle Cahill, Theological Bioethics  (Washington, D.C.: Georgetown University Press, 2005), 15.
13. USCCB, no. 37.
14. USCCB, Preamble.
15. Daniel O'Brien, "Establishing a Hospital Ethics Committee," in Ethical Principle in Catholic Health Care ed., Edward James Furton and Veronica McLoud Dort (Boston, Mass.: The National Catholic Bioethics Center, 1999).
16. David Kelly, Contemporary Catholic Health Care Ethics  (Washington, D.C.: Georgetown University Press, 2004), 41-47, 88-98.

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