In a traditional or “reactive” model of ethics
consultation, the ethicist or ethics services were
available to clinicians and organizational leaders
on an “as-needed” basis. In such a model,
ethics services were almost entirely reliant on
the ethics expert, and increasing the capacity
to respond to ethical crises meant hiring more
ethics FTEs. Ascension’s Proactive Ethics
Integration (PEI) paradigm began with the
recognition that this expert-centered approach
to ethics integration was not sustainable, nor
did it allow for optimal integration. The PEI
Paradigm calls for both an embedded and
integrative service modality.
The embedded service modality consists of
equipping and empowering individuals in
key clinical and organizational roles who are
not trained ethicists to participate in ethics
processes (e.g. institutional ethics committee
members and key operational leaders, referred
to as Embedded Ethics Resources or EERs).
The role of these EERs is not necessarily to
resolve ethical issues, or replicate the role
of trained ethicists, but to integrate to a
greater-than-usual degree an “ethical lens” in
the daily work for which they have primary
responsibility. In this way, the EERs can help
identify and triage ethical issues, and perhaps,
in some instances, address some of the more common and less complex issues with the
support of tools and resources developed by
ethicists. One primary goal of this embedded
approach is to expand the number of people
paying attention and responding to the ethical
issues that most impact spiritually-centered,
holistic care in the clinical context and our
identity as a healing ministry of the Church in
the organizational context. This, in turn, helps
support a culture of mutual accountability
for our mission, vision, values and Catholic
identity across the entire organization and its
daily operations.
The integrative service modality, which is the
focus of this article, requires the integration
of ethics into other people’s processes. This
approach seeks to integrate the principles
of Catholic identity along with Ascension’s
mission, vision and values into clinical and
operational processes in such a way that
ethical issues are addressed with the ethicists
serving in the role most appropriate to the
circumstances. In this way, integration goes
beyond the embedded modality of providing
ethics services insofar as it strives to integrate
ethical considerations into the key processes
through which various operations occur with
minimal support from a professional ethicist.
This is done through mutual collaboration
between ethics and relevant subject matter
experts within other primary disciplines,
departments, and ministry wide functions in
developing the operational processes owned by those other subject matter experts that
include an explicit, if not prominent, ethics
component. Here the key distinction between
“embedded” and “integrative” is that, in the
embedded modality, ethics creates resources,
tools and processes into which others are
integrated, or embedded, into the delivery of
ethics services, whereas in the integrative service
modality, ethicists are collaborating with other
disciplines to integrate ethical considerations
into their processes, resources, and tools. In
this way, ethical considerations are accounted
for within the primary clinical or operational
process itself. That said, neither the embedded
nor integrative approach precludes the need for
professional ethicists’ subject matter expertise
as the complexity of the situation warrants.
When this type of integration occurs, the
ethical considerations inherent in a business
or clinical process are accounted for in a
self-sustaining way, and consultation with
an ethicist is only needed when the process
itself is limited or the complexity of the issue
requires it. This kind of integration is truly
self-sustaining and responsibility for ensuring
ethical issues are addressed within the process
is owned by the very persons who make up the
department or service line. In this case, the role
of ethics becomes continuous monitoring of
the processes to make sure they are functioning
as intended, to catch any misses, and provide
back-up support only when the process is not
sophisticated enough to account for every
possible ethical nuance. Two examples of such
an approach are outlined below.
INTEGRATION OF ETHICS INTO
ASCENSION MEDICAL GROUP
By way of context, Ascension operates about 2,600 sites of care in 19 states and the
District of Columbia and has about 9,000
employed providers and 40,000 aligned
providers. Ascension Medical Group (AMG)
is Ascension’s physician-led national provider
organization. As care delivery continues to
move from a volume to value-based system,
and from an acute care focused delivery model
to one which focuses on the continuum of care,
AMG is a key service line within which ethics
must integrate in order to meet the needs of the
clinicians and patients we serve.
One key area of focus for integration into an
AMG-owned process is service line committees
and workgroups, especially high priority service
lines such as maternal health and perinatal
medicine, behavioral health, palliative care,
patient safety and quality, and ad hoc work
groups such as those established during the
onset of the COVID-19 pandemic. Ethics
integration into these service line committees
and workgroups at both the national and
ministry market levels contributes to both
improved awareness and utilization of ethics
services as well as the ability to respond real-time to ethical considerations that arise within
the context of the committee’s scope of work.
In addition, it has proven to contribute to
collaboration in other areas such as education,
policy development and review, and both
organizational and clinical consultations.
Another significant area of integration
has been AMG processes for recruitment,
selection, onboarding, and orientation of new
providers. This includes the development of
Catholic identity and Ethical and Religious
Directives for Catholic Healthcare Services
(ERDs), talking points for recruiters, and, in
collaboration with AMG, the development of talking points and other resources for medical
directors and physician leaders regarding hiring
for fit, ERDs, and Catholic identity, which
provide guidance on responses to clinical
questions that may be raised by clinicians
both in the hiring process as well as during
onboarding. In addition, Ascension’s Ethics
Advisory Community (EAC) developed
a standardized, national New Clinician
Orientation which is facilitated by an
ethicist, but integrated into the existing AMG
orientation process. Lastly, as was expounded
upon in a previous issue of Health Care
Ethics USA1 the EAC has collaborated with
Ascension’s Graduate Medical Education
(GME) Council to develop and implement a
three-year Medical Resident Ethics Curriculum,
which is co-facilitated by ethicists, medical
residents, and GME faculty from across the
system and available live and on-demand to all
Ascension associates. These examples illustrate
both a responsive and integrative approach
to ethics services which, ideally, leads to a
self-sustaining model through which ethical
considerations are accounted for within the
primary clinical or operational processes of
AMG itself.
INTEGRATION OF ETHICS INTO THE
PROCESS FOR SOCIALLY JUST
TRANSACTIONS
Another benefit of integrating ethics into other
people’s processes is the ability to ensure that
ethics services are engaged in the right way at
the right time. This enables the ethics services
to better facilitate the completion of the
individual tasks required to ensure both that
the operational outcome is achieved, and that it
is achieved in a way consistent with Ascension’s Catholic ministry identity. One area in which
this is particularly important concerns those
processes in which Church relations has a role
and, specifically, when our local ordinaries
have input relative to particular decisions or
actions. One example of this type of process
is an Ascension procedure which governs
all transactions including divestitures (and
alienation when divesting of stable patrimony).
The critical tasks and responsibilities for
canon law, ethics, and Church relations
have been integrated in each stage of this
procedure. Depending on the stage of the
transaction, responsibility for ensuring that
our commitment to our identity as a healing
ministry of the Catholic Church is outlined
w
By way of example in the context of a
transaction that would involve a divestiture,
through this integration, we are able to ensure
that every divestiture is structured in a such way
as to:
- Minimize any potential negative impact on
the ability of the community’s needs to be
met;
- Minimize any potential negative impact on
the ability of those who may struggle with
economic poverty and/or suffer the effects
of social marginalization to access health
care;
- Ensure fair and just treatment of the
impacted associates consistent with
Ascension’s own policies and practices;
- Assess any impact on the Catholic presence
throughout the community;
- Ensure the transaction is consistent with
practices of good stewardship;
- Attend to the canonical requirements of
alienation;
- Obtain the support and/or necessary
approvals of the local ordinary (i.e., bishop);
and,
- Facilitate any potential agreements between
the purchaser and the local ordinary relative
to any continuing Catholic commitments
post-close, should either party desire such.
Some of these tasks require a collaborative effort
across some or all members of the transaction
team along with subject matter experts in
canon law, ethics and Church relations. This
approach of integrating into the existing
collaboratively-owned procedure results in a
seamless integration of considerations regarding
Ascension’s Catholic identity, mission, vision
and values are included throughout the entire
process in a way that is not dependent on
any one person. This further ensures that the
appropriate communications required to
secure the support and/or approval of the local
ordinary are completed at the appropriate time
within the process and in the appropriate way
so as to avoid any unforeseen delays.
The PEI paradigm continues to mature across
all of Ascension. Through this maturation, we
continue to gain new insights that enable us
to more clearly articulate the different ways in
which ethical considerations (i.e., our mission,
vision, values, Catholic social, moral teaching
and Catholic moral principles) are integrated
into clinical service lines and operations.
What we have come to realize through this maturation, is that the PEI paradigm calls us
to think differently about how we do ethics.
Within this paradigm, the goal is to influence
an organizational culture that prioritizes the
fulfillment of our mission, vision, values and
Catholic identity amidst competing pressures.
PEI, then, is best understood as a systems-thinking approach that includes but goes
beyond a “service delivery model” and enables
organizational transformation.
MARK REPENSHEK, Ph.D.
Vice President, Ethics and Church Relations
Ascension
St. Louis, Missouri
[email protected]
MATTHEW R. KENNEY, Ph.D.
Vice President, Ethics Integration and Education
Ascension
St. Louis, Missouri
[email protected]
ENDNOTES
- Kenney, M and Ward, C. “Standardizing virtual medical
residency ethics curriculum- a high reliability endeavor.
Health Care Ethics USA, Winter/Spring, 2022, 29-32.