BY: RON HAMEL, Ph.D.
Dr. Hamel is senior director, ethics, Catholic Health Association, St. Louis.
Do we need to think differently about ethics committees in Catholic health care? It's an important question to ask for many reasons. In my previous column, "Health Care Ethics: Changes on the Way," in the September-October issue, I wrote the following:
"Catholic health care ethics must come to the realization that it is central not only to helping shape the culture of an organization, its identity, but is also central to guiding the organization's decision-making and behavior, its integrity. … Ethics should assist the organization to be what it claims to be in regard to identity, character, culture and to discern what it ought to do (and not do) in light of who it claims to be. It should help Catholic identity to permeate the entire organization and to be integrated throughout the organization."
The point of these comments was to underscore the centrality of ethics in the life of Catholic health care organizations, and to emphasize the need for a more comprehensive understanding of the role of ethics in our organizations. Ethics is critical to promoting and supporting identity and integrity, whether it has an organizational focus or solely a clinical focus.
The centrality of ethics to health care is even recognized by a secular health care system such as the U.S. Department of Veterans Affairs. The introduction to the organization's IntegratedEthics materials states:
"Throughout our health care system, VA patients and staff face difficult and potentially life-altering decisions everyday — whether it be in clinics, in cubicles, or in council meetings. In the day-to-day business of health care, uncertainty or conflicts about values — that is, ethical concerns — inevitably arise.
"Responding effectively to ethical concerns is essential for both individuals and organizations. When ethical concerns aren't resolved, the result can be errors or unnecessary and potentially costly decisions that can be bad for patients, staff, the organization, and society at large. When employees perceive that they have no place to bring their ethical concerns, this can result in moral distress, a recognized factor in professional 'burnout,' which is a major cause of turnover, especially among nurses.
"A healthy ethical environment and culture doesn't just improve employee morale; it also helps to enhance productivity and improve efficiency. Organizations that support doing the right thing, doing it well, and doing it for the right reasons tend to outperform other organizations in terms of such measures as customer satisfaction and employee retention. Failure to maintain an effective ethics program can seriously jeopardize an organization's reputation, its bottom line, and even its survival."1
Who is primarily charged with overseeing ethics in our organizations? In some instances, it is an individual trained in ethics. In others, it is the mission leader, who also has responsibility for ethics within the organization. But, in most Catholic health care organizations, it is probably the ethics committee, perhaps under the guidance of the mission leader or, in some cases, the pastoral care director. For the most part, ethics committees are composed of volunteers. These individuals usually have considerable interest in health care ethics and often are highly motivated and committed. They are willing to volunteer time from their busy schedules to attend meetings and educational activities. Unfortunately, their dedication and efforts often don't count for much in annual performance reviews. From the perspective of many supervisors, their involvement with the ethics committee is nice, but peripheral to their core responsibilities. Furthermore, these individuals have varying degrees of knowledge about ethics and Catholic health care ethics, and training in these areas seems to be varied and uneven across the ministry.
Regarding the competencies of ethics committee members, the American Academy of Pediatrics has stated that membership in institutional ethics committees "requires a commitment to acquire, and then maintain, the knowledge sufficient to address the complex issues" faced by these committees.2 Each ethics committee should establish a continuing education program designed to assist members in fulfilling the stated mission of the committee, especially as new issues emerge."3 Yet, in a survey of ethics committees in Catholic health care, the researchers reported that health care ethics committees "vary greatly in the educational programs they require of members and in the programs they sometimes offer to them. For the most part, training is an 'invitational' affair; there are no specific requirements for participation."4 The authors of the VA materials on ethics consultation make the rather sobering comment that "ethics consultation may be the only area in health care in which we allow staff who aren't required to meet clear professional standards, and whose qualifications and expertise can vary greatly, to be so deeply involved in critical, often life-and-death decisions."5 Although this comment is directed specifically at ethics consultation, just one of the functions of ethics committees, it could also be said of ethics committees' other functions.
Given the importance of ethics in Catholic health care organizations, the fact that in most Catholic health care facilities, the ethics committee primarily is charged with ethics, and the variability in preparedness and unevenness in training, good reason exists to raise the question about the competencies and preparedness of members of ethics committees to carry out their responsibilities. Furthermore, are their competencies and is their (ongoing) preparedness commensurate with their responsibilities and with the critical role of ethics within their organizations? This is not to suggest that ethics committees have sole responsibility for the role of ethics within their organizations, but they certainly have a key responsibility. As theologian and ethicist Jack Glaser has said, multiple centers of ethical responsibility exist within an organization.
Responding to Challenges
Several Catholic health care systems and facilities are addressing the challenges facing ethics committees. It's not an easy task, but it is vital to Catholic health care. Establishing competencies6 and a training program with a "core curriculum" are important steps in the right direction. CHA officials hope to do some work in these areas during the coming year. But even more is needed. Perhaps we need to think differently about ethics committees in Catholic health care - their role, the scope of their responsibilities, their composition, and their organization. And perhaps this needs to begin with leadership.
The researchers of the survey of ethics committees in Catholic facilities concluded that Catholic health care facilities should "take a more vigorous stance in encouraging committee members to undergo formal training of some sort" and suggest the "responsibility for seeing that such training is encouraged and adequately resourced may fall to hospital administrations, rather than being left for [ethics committees] to handle themselves."7
The U.S. Department of Veterans Affairs takes an even stronger stance. The third part of its IntegratedEthics program — obligatory in all its facilities — is devoted to ethical leadership, which is defined as "activities on the part of leaders to foster an ethical environment and culture."8 One of the steps suggested for leaders to foster such an environment is to "support your local ethics program."9 What does this entail? It means knowing what the ethics program is and what it does, being a champion for the program, and supporting participation in the program.10 Among the recommended behaviors in "supporting participation" are the following:
- Making time available for employees to participate in the ethics program and designating interested staff to participate
- Ensuring that employees who participate in the ethics program have ethics-related responsibilities clearly delineated in their performance plans
- Recognizing and rewarding employees for their ethics-related activities and accomplishments11
Conclusion
Much more could be written about this topic, but the primary purpose here is to raise the issue, to invite the ministry into reflection and conversation about it and, even more, to spark additional efforts toward change. An important opportunity exists for improving the competency and effectiveness of ethics committees so that they can better contribute to the identity and integrity of their organizations. Continuing the present course would be unfortunate and will have its price.
NOTES
- U.S. Department of Veterans Affairs, National Center for Ethics in Health Care, Part I, Ethics Consultation: Responding to Ethics Questions in Health Care (Washington, D.C.: VA, May 2007), 1-2. Available online at www.ethics.va.gov/integratedethics.
- American Academy of Pediatrics, "Institutional Ethics Committees," Pediatrics 101, no. 1 (January 2001): 209.
- American Academy of Pediatrics.
- Francis Bernt, Peter Clark, Josita Starrs and Patricia Talone, "Ethics Committees in Catholic Hospitals: A New Study Assesses Their Role, Impact, and Future in CHA-Member Hospitals," Health Progress 87, no. 2 (March-April 2006): 22.
- Ethics Consultation: Responding to Ethics Questions in Health Care, 6.
- American Society for Bioethics and Humanities, Core Competencies for Health Care Ethics Consultation (Glenview: ASBH, 2006). These competencies are intended for ethics consultation. Available for purchase online at www.asbh.org/publications/core.html. Other competencies would need to be developed for other ethics committee functions.
- Core Competencies for Health Care Ethics Consultation, 23.
- U.S. Department of Veterans Affairs, National Center for Ethics in Health Care, Ethical Leadership: Fostering an Ethical Environment and Culture (Washington, D.C.: VA, May 2007), 13. Available online at www.ethics.va.gov/integratedethics.
- Ethical Leadership: Fostering an Ethical Environment and Culture, 21.
- Ethical Leadership: Fostering an Ethical Environment and Culture, 37-39.
- See note 9. Similar suggestions are made by David Blake, "Reinventing the Healthcare Ethics Committee," HEC Forum 12, no.1 (2000): 8-32.