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BY: SR. PATRICIA A. TALONE, RSM, Ph.D.
Sr. Patricia is vice president, mission services, Catholic Health Association, St. Louis.

"A good beginning makes a good ending," says the English proverb. The aphorism is particularly appropriate when setting out to launch an organizational ethics committee (OEC) in either a health care facility or a system. Catholic theology reminds us that we must direct our actions toward our ultimate "end," which is love of God and love of neighbor. While Catholic health care may have led the industry in establishing institutional or clinical ethics committees, we have not been as swift in doing so organizationally. In this article, I intend to outline some practical and concrete steps for beginning such a committee.

Why Form an OEC?
Catholic health care quickly followed the suggestion of the 1976 New Jersey Supreme Court opinion involving Karen Quinlan to establish "mechanisms" providing guidance and education regarding challenging ethical issues.¹ There were many reasons for this timely response.

First, Catholic theology had a more than 400-year tradition of grappling with medical ethical cases; this rich body of literature informs Catholic ethical analysis. Second, Catholic facilities had in 1976 already begun to establish mission integration committees and mechanisms to ensure Catholic identity, support the ministry's commitment to the human dignity of each patient, and oversee such groups. Third, the congregations that had expended so much time, energy, and dedication in establishing Catholic health care recognized that the spiritual and corporal works of mercy include ethical treatment for patients and employees alike and desired to establish frameworks to ensure the dignity of each person. Fourth, on a very practical level, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) soon demanded clear evidence of such mechanisms.

In general, health care facilities and systems did not respond with the same alacrity or specificity to the JCAHO's 1994 organizational ethics standards calling for "mechanisms" to attend to ethics departmentally across health care facilities. Again, there were several reasons for this.

The standards themselves did not demand creation of ethics committees per se, but more broadly suggested a code of ethics and methods to ensure ethical integrity. Many establishments were concomitantly developing corporate compliance programs. Some people believed that compliance and ethics were interchangeable and that structures for the former would address concerns for the letter as well. Furthermore, while the scope of clinical ethics is comprehensive, it does have parameters, principles, and guidelines with which systems, hospitals, nursing schools, and internship programs have some fluency. To some, "organizational ethics" seemed almost boundaryless, encompassing all of the cultures and complexity of American health care itself. Many ethicists met marked resistance from senior administrators when suggesting the formation of OECs. Some systems felt that organizational ethics fell more within the purview of corporate counsel than that of mission and ethics departments.

The function or purpose of an OEC is not essentially different from that of a clinical ethics committee, although its focus is certainly different. Since the inception of ethics committees in health care, there has been general consensus that the purpose of such a committee is threefold: education, policy formation, and case consultation. Education begins with the committee or core group and then extends throughout the organization, providing employees with both the requisite decision-making principles and the tools to address dilemmas. Policy formation is almost never totally the purview of an ethics committee but, rather, arises within appropriate departments, members of which then work with ethics subcommittees to ensure ethical consistency and integrity. Consultation, if it is to be done well, follows upon extensive education and policy review, providing ethical principles, tools, and guidance to various departments throughout the organization.

A fourth purpose for ethics committees has gradually emerged in ethical literature and been embraced by many. This is what some call "preventive ethics." Arising from the continuous quality improvement process in health care, committees that employ this approach do not wait for a challenge to appear; they intentionally evaluate, foresee, and prepare staff to address difficulties before they arise.

When establishing a new ethics committee, be it clinical or organizational, the creators should keep the group's task in mind, lest expectations become unrealistic. Not every challenge within an organization is ethical, nor is it within the purview of any OEC to address what may be fundamentally legal, compliance, or administrative challenges.

Needs Assessments
Before initiating an OEC, those responsible should conduct a needs assessment to provide a necessary foundation for the committee's work. Such a review will not only surface areas needing education and policy analysis but also provide colleagues with an opportunity to voice ethical concerns. This data is invaluable for those administering the committee and likewise ensures that a broad range of employees understand that their ethical concerns and questions matter to the overall moral integrity of the system or institution.

While there are many ways to conduct a needs assessment, two widely used models come quickly to mind.

Intranet Surveys
A survey containing carefully crafted and open-ended questions will aid analysis of ethical challenges and even misunderstandings within the organization. If the survey is to be truly organizational, those persons invited to respond should come from within a broad range of institutional levels (administrative, senior and middle management, frontline personnel) to ensure that the responses provide an extensive ethical picture.

A quick perusal of the categories suggested by JCAHO for "business" ethics might reveal key departments to survey. These include, in addition to some key clinical areas, finance, marketing, human resources, materials management, managed care contracting, billing, information technology, outpatient services, and many others. If the ministry has a large number of employees in a particular area of service (for example, women's and children's health), it is obviously wise to include that sector in the survey. Such surveys can be conducted online through a system's intranet, taking a minimum amount of employee time and providing responses very quickly to those who are developing the OEC.

Focus Groups
Assessing needs through focus groups is a more time-consuming but often deeper and richer method for surfacing ethical issues. If the system has a full-time ethicist, he or she can conduct these meetings over a period of time. In some facilities, the ethics committee chair, accompanied by a small subcommittee, can perform this function.

Some ethicists prefer to ensure that the focus groups themselves are multidisciplined, comprising individuals from a variety of departments and job levels. Others have had success with small groups from the key departmental areas mentioned above. Much depends upon the time allotted for the assessments and employee availability for the sessions. Experienced ethicists often note that information garnered from both surveys and focus groups provides extensive material upon which an OEC can work for an extensive period of time.

Choosing the Members
Each organization sets its own bylaws for ethics committees,² often citing the types of persons who should be invited to participate. Even so, the committee's originators should expect to find certain qualities in such individuals, remembering always that membership is voluntary and not remunerated and is intended to be at the service of the organization's mission. One would trust such individuals to be:

• Knowledgeable, experienced, and competent in their own field of expertise.
• Able and willing to do the preparatory work necessary for such deliberations (including professional reading, workshops, programs, or courses).
• Capable of ethical discourse, as distinguished from apologetic or argumentative discussions.
• Sufficiently oriented to, and informed and supportive of, the normative principles of the Ethical and Religious Directives for Catholic Health Care Services (ERDs). This includes a broad-based understanding of the church's social justice teaching.
• Recognized for their honesty and integrity.

Just as a clinical ethics committee is largely composed of persons caring for patients, so an OEC, for the most part, includes management personnel.³ JCAHO has outlined areas for ethical reflection, and these areas can serve as a guideline for relevant persons to serve on the OEC. However, as Leonard J. Weber sagely observes, one should also include some employees who are not in management positions.⁴ Experienced ethicists often note that such individuals are frequently acutely aware of the challenges the organization confronts, and they help to keep the work of the OEC relevant and honest.

Who Chairs the Committee?
A review of the characteristics for OEC membership reveals that the leader of such a group should be a woman or man of recognized strength, integrity, and moral leadership. That having been said, it is easier to state who should not head such a group.

It is best that the system or facility ethicist not assume this role. While he or she provides necessary educational and consultative resources to the committee, the ethicist is one of a community of equals. Nor should the organization look to legal counsel (either internal or external) to serve in this capacity. As mentioned previously, too many persons (especially in the post-Enron era) tend to conflate law and ethics, not recognizing that, while the former deals with what one should not do, the role of ethics is more aspirational — ethics shapes corporate character and guides actions. Too frequently, legal opinions (no matter how humbly offered) tend to shut down the moral discourse necessary in an OEC.

Neither should the vice president for mission services assume the committee's helm. An organization's strong ethical integrity comes within the purview of each and every employee. It is the opinion of this ethicist that, although mission service departments have made tremendous strides in moving into the mainstream of our institutions, some institutions have a continuing tendency to relegate organizational ethics to the realm of mission, instead of recognizing that ethical realities permeate throughout every aspect of health care.

Neither, ordinarily, should the chair of the OEC be the CEO of the organization. While the CEO is indeed the chief mission and ethics officer responsible to both sponsors and the board for these activities, the fact is that he or she holds tremendous power. Because the CEO is powerful, many people may hesitate, if he or she is also the OEC chair, to challenge the chair or provide alternative views.

Even if they forgo appointing such persons as the committee's chair, the committee's creators will find that the organization has numerous women and men with the requisite skills, moral integrity, and leadership necessary to direct an OEC.

Supporting the Committee
A person charged with leadership of an OEC usually has a great many responsibilities. He or she will require institutional support to ensure the venture's success. The kinds of support needed tend to be quite practical and measurable. They include (but are not restricted to):

• Administrative assistance for scheduling meetings, taking minutes, calling ad hoc consults, managing calendar, and numerous other services.
• Sufficient funds to ensure adequate education for committee chair and members. This includes books, subscriptions to ethics journals, and tuition to workshops. While these tuitions are costly, many committees rotate attendance, the participants promising to share their learning with the entire OEC.
• Use of the system's or facility's public relations and educational mechanisms to inform colleagues about the committee's existence, role, and function. This includes simple and clear information about how to access the committee for a consultation.
• Cooperation from, and the active involvement of, individuals who manage key departments in the organization. Those areas highlighted by JCAHO are a good place to start relationship-building.
• The participation of all who commit to involvement on the committee. While membership in an OEC may look quite good on a professional resume, it does not serve the organization if members do not do their homework or fail to attend meetings.

Get Started!
Once the assessment is completed and analyzed, members have been invited to participate, and support structures are in place, it is time to get started. The first step in forming an ethics committee is educating the members. A wealth of information is available from texts, journals, and websites (including www.chausa.org, CHA's site) to provide hours of informative reading and discussion.

People who come to the table of an OEC bring a wealth of knowledge and experience with them. Within a Catholic organization, this group should have familiarity with the ERDs of the U.S. Conference of Catholic Bishops. While an OEC's purview is not clinical ethics, the normative principles contained in Part One of the ERDs provide a solid grounding for the business and social recommendations the group will be asked to make. An educational method integral to Catholic ethics is the study of cases, and the group can analyze either hypothetical or retrospective cases in light of the ethical principles and norms they study. These "practice" discussions will equip them for the challenging ones they will later face.

A Community of Ethical Discourse
The first of the ERDs depicts Catholic health care as a "community of care" — women and men who join forces in the service of the sick and vulnerable. The care of the sick today requires numerous people of clinical skill and expertise who share a primary vision — extending the healing ministry of Jesus in today's world. A contemporary OEC can further this vision by providing a community of ethical discourse, a gathering of equals committed to the moral integrity of that broader community of care. Beginning such a group well ultimately serves the "end" for which the organization was founded — serving God by serving God's sick.

NOTES

1. Matter of Karen Quinlan, 70 N.J. 10, 355 A.2d677 (1976).
2. See John Monagle, ed., Medical Ethics: Policies, Protocols, Guidelines & Programs, Aspen, Rockville, MD, 2005, for examples of codes of ethics and bylaws of ethics committees.
3. See Brian O'Toole, "St. Louis System Has Corporate Ethics Committee," Health Progress, March-April 2006, for a model in which a small, core team functions as the OEC, bringing relevant persons to the table for specific discussions.
4. Leonard J. Weber, Business Ethics in Health Care: Beyond Compliance, Indiana University Press, Bloomington, IN, 2001, p. 173.