Clinical ethics consultations, which first emerged in the 1970s and '80s, have rapidly developed to the point that it is nearly impossible to imagine hospitals without ethics committees or clinical ethics consultants (CECs). While CECs have quickly become established in hospital wards, there are still important ongoing conversations about the role of this health care profession and debates about how best to use their services.
Over the past decade, organizations like CHA and the American Society for Bioethics and Humanities (ASBH) have developed various competencies and certifications for clinical ethicists, which have proven beneficial for the training and support of CECs.1 Yet, as useful as these competencies and certifications are for those seeking to do ethics consultations, CECs still need to find a way to succinctly introduce their role to patients and health care providers.
DISCERNING GOD'S WILL
As a priest who spent several years in pastoral ministry and is now pursuing a PhD in health care ethics, I frequently contemplate the relationship between spiritual care and the hospital's CECs. Many of my previous parishioners sought pastoral care for spiritual accompaniment during their illness, as well as for assistance in recognizing and following God's will in the circumstances of that illness.
This art of discernment, however, presupposes a clear understanding of the available treatment possibilities, which is the role of the medical team, and a clear understanding of which of these possibilities are ethically appropriate, the responsibility of the CEC. Only after a patient or their surrogate decision-maker understands what is ethically appropriate can they properly discern the best course of treatment in their unique circumstance.
While most patients understand the role of a chaplain, very few patients, families and sometimes even members of the hospital team understand the role of CECs. If hospitals are going to become places of true discernment, we need to find a way to explain what exactly this field of health care ethics is. Through trial and error, I have found several different elevator pitches that, for better or worse, seem to assuage the curiosity of those who have not heard of health care ethics. But as spring dawns and baseball returns, I can't help but wonder if perhaps drawing a comparison between umpires and CECs may be a helpful analogy for introducing the role and responsibility of CECs.
Umpires have a precarious relationship with the game of baseball. They are both part of the game and, at the same time, not part of it. They are part of the game because, without an objective eye to call balls and strikes, the game would descend into chaos. At the same time, as arbitrators of the game, they must stand outside the game and ensure it is played according to the rules.
Similar to how umpires are beholden to these rules, CECs are beholden to the way that God formed humankind and the kinds of actions that lead to a person's flourishing. They are responsible for having an intimate knowledge of the principles and theories of bioethics so that they can inform patients and the medical team if their proposed treatment is in the zone or outside.
Just as it is not the umpire's job to make tactical decisions about where the ball should be thrown, it is not the CEC's responsibility to determine what type of care should be given. Doctors and the medical team have the expertise and knowledge to inform the patient of the best strategy to approach their condition; however, it is up to the patient to determine what care they believe is most appropriate for them in their unique circumstance.
For as much as umpires may be despised from time to time, they are still a necessary part of the game. Sure, there are many pitches, like a fastball down the middle, that everyone in the stadium knows is a strike, but there are also those borderline pitches that require the objective eye of the umpire to judge if it qualifies as a strike or not.
Similarly, CECs help patients and the medical team understand what is ethically permissible and assist in the discernment process related to the patient's care. For example, a clinical ethics consultation is probably not needed to help the family of an 85-year-old diagnosed with Stage 4 lung cancer discern that artificial nutrition and hydration (ANH) will not be used when he stops eating while he is dying on hospice care. A CEC, however, can be extremely beneficial for a family to decide if this same type of treatment is appropriate for a 65-year-old with advanced dementia who refuses to eat because he does not feel hungry and, due to his confusion, continues to remove the tube used to provide him with nutrition.
In the case of the 85-year-old cancer patient, the doctor's explanation of how the body reacts during the dying process is usually enough for the patient or his surrogate decision-maker to comfortably decide to withhold ANH. However, in the case of the patient with advanced dementia, the family may find the assistance of the CEC helpful for understanding ethical obligations to feed those who cannot feed themselves, important ethical distinctions like killing and letting die, and even the Catholic Church's position on the use of ANH. In this case, the CEC can help the patient's surrogate understand the parameters of ethical care, which will assist them in determining if their desired choice, either to continue with ANH or to withdraw that care, is ethically justified or not.
Just as it is not the umpire's job to make tactical decisions about where the ball should be thrown, it is not the CEC's responsibility to determine what type of care should be given.
Being a good umpire requires comprehensive knowledge of the rules of the game, but it also requires a certain demeanor that is professional, impartial and exudes confidence while remaining calm under pressure. A good umpire not only calls balls and strikes but forms relationships with players and coaches to ensure that, even in contentious times, the game moves smoothly. Likewise, CECs need to have not only an intimate knowledge of the principles of bioethics but also interpersonal skills to navigate difficult and stressful circumstances, often among parties who are seeking to understand and perhaps disagree with each other.
CREATING A SPACE TO PAUSE, REFLECT AND ASSESS
For all the benefits of using this analogy between an umpire and a CEC, it falls short at some point. Perhaps the biggest weakness in this analogy is that umpires deliver decisions or verdicts, while CECs offer recommendations. While umpires choose sides in a disagreement, a good CEC mediates disagreements and helps all sides come to a consensus about the best path forward.
CECs bring ethical expertise to create a space where all parties involved can pause, reflect and assess if the proposed treatment is ethically appropriate. For example, rather than coming in and issuing a judgment "from on high" about whether the 65-year-old with advanced dementia can have the ANH removed, a good CEC takes the time to meet with the surrogate decision-maker to understand the wishes of the patient, explain the ethical and moral implications of the desired choice, and, where necessary, encourage conversation surrounding areas of confusion that ultimately leads to the surrogate decision-maker making a more informed decision.
Patients have the often-challenging responsibility of deciding on the best possible treatment available for their illness. This art of discernment requires a space where patients or their decision-makers can pause, reflect and assess their unique circumstances before discerning the best path forward.
When discerning what care is most appropriate, patients can benefit from the assistance of the medical team to discover what is medically possible, CECs to distinguish which treatment options are ethically appropriate, and chaplains to recognize God's will in their unique circumstances. While not all medical decisions require the skills of a CEC, in more complicated cases, they facilitate conversations that help the patient objectively determine if their desired course of treatment is ethical.
Like an umpire, who ensures the game of baseball is played according to the rules, a CEC brings ethical expertise to assist the patient in making medical decisions that lead to the flourishing of the patient and the practice of medicine.
FR. PETER FONSECA is director of Continuing Formation for Priests in the Archdiocese of St. Louis. He also serves as a mission fellow for the Catholic Health Association, St. Louis.
NOTE1. Qualifications and Competencies for Ethicists (Catholic Health Association, 2018), https://www.chausa.org/store/products/product?id=3804; American Society for Bioethics and Humanities, Core Competencies for Health Care Ethics Consultations, 2nd Edition (American Society for Bioethics and Humanities, 2010).