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Integrating Ethics Services in a Catholic Health System in Oregon

Authors:
© 2018 The National Catholic Bioethics Center 111
Abstract. At Providence St. Joseph Health in Oregon, many factors contribute
to the integration and success of our ethics services. There are three princi-
pal lenses through which one can understand the distinct way in which we
operationalize and integrate ethics services: the theological foundations of
ethics as a service, the institutional ecology, and the professionalization of the
eld of health care ethics. We review key realities that have shaped our work
through these three lenses and then describe the activities of the Providence
Center for Health Care Ethics regarding its strategic objectives and clinical
and administrative integration. National Catholic Bioethics Quarterly 18.1
(Spring 2018): 111–132.
Ethical issues are embedded in every patient encounter. In the majority of patient-care
situations in Catholic health care, caregivers practice in ways that reect the mis-
sion, values, and ethical commitments of their professions. Therefore, ethical issues
rarely become problematic or interfere with or delay appropriate care. Yet questions
for ethicists arise when these issues create barriers to the ethically sound delivery of
quality care. In these situations, the ethicist’s role is to assist decision making, for an
ethicist is not a primary moral agent but, like Socrates, is akin to a midwife, drawing
forth the moral wisdom of the agents.1 For instance, an ethicist may coach a resident
physician through the identication of an appropriate surrogate decision maker. At
other times, the ethicist may be a gady, stinging those who need to be reminded of
Nicholas J. Kockler, PhD, MS, is the endowed chair in applied health care ethics and
the regional director of the Providence Center for Health Care Ethics, in Portland, Oregon.
Kevin M. Dirksen, MDiv, MSc, is a senior ethicist and the director of ethics education at the
Providence Center.
1. Plato, Theaetetus, 150a–b.
Integrating Ethics Services in a
Catholic Health System in Oregon
Nicholas J. Kockler and Kevin M. Dirksen
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112
the proper course of action—for example, bearing prophetic witness to the needs of
the poor and vulnerable at the margins of society.2 Ultimately, in carrying forward
the healing ministry of Jesus, each person has a role in and a responsibility for liv-
ing with integrity and practicing in a manner consistent with the Catholic tradition.
The ways an ethicist assists the exercise of moral wisdom reect a complex
array of strategies and tactics that teach, support, and cultivate responsible decision
making.3 This goes well beyond the classical formulation of health care ethics as
education, consultation, and policy formation. Integrating ethics into the delivery and
administration of health care calls for innovative ways to be proactive, interactive,
and reactive to ethical issues from bedside to boardroom.
Drawing on an Eastern philosophical tradition, ethics services are like water:
“The highest form of goodness is like water. / Water knows how to benet all things
without striving with them. / It stays in places loathed by all men.”4 Water lls the
cracks, enters empty spaces, and settles with the sediment and impurities. This is
analogous to the way Jesus carried out his healing ministry: caring for lepers, blind
persons, and beggars as well as accompanying tax collectors, sinners, and outcasts.
At Providence St. Joseph Health (PSJH) in Oregon, many factors contribute to
the integration and success of our ethics services. First, recognizing and respecting the
primacy of the conscience of moral agents by exercising subsidiarity in conscience
formation demarcates the social role of ethicists in health care. Second, embracing
a culture of encounter as solidarity enables ethicists to build trust and rapport with
those served in their contexts. Third, respecting human dignity and seeking social
justice through alliances with colleagues, stakeholders, and other institutions promotes
the common good and orients ethics services to ultimate goods. Lastly, sustaining
our work through adequate funding and commitments of administrative and clinical
leadership as well as compassionate, holistic self-care and formation of our ethics
staff provides the necessary milieu to continue high-quality ethics services.
We understand the distinct way in which we operationalize and integrate eth-
ics services through three principal lenses: the theological foundations of ethics as a
service, the institutional ecology, and the professionalization of the eld of health care
ethics. In this article, we review key realities that have shaped our work through these
three lenses. Then we describe the activities of the Providence Center for Health Care
Ethics regarding its strategic objectives and clinical and administrative integration.
Theological Foundations of Ethics as a Service
The theological foundations of ethics as a service are several. First, ethics ser-
vices occur in the context of a Catholic health care ministry that serves the social good
of health care of all people in need. Second, ethics services support the formation of
2. US Conference of Catholic Bishops, Ethical and Religious Directives for Catholic
Health Care Services, 5th ed. (Washington, DC: USCCB, 2009), dir. 3.
3. Patricia Talone, “Catholic Health Care Ethics Consultation: A Community of Care,”
HEC Forum 15.4 (December 2003): 323–337, doi: 10.1023/B:HECF.00.
4. Lao Tzu, Tao Te Ching, trans. John C.H. Wu (Boston: Shambhala, 1989), no. 8, p. 17.
KocKler and dirKsen integrating ethics services
113
the conscience of a diverse community of Catholic and non-Catholic moral agents
within the parameters of the Catholic tradition. Finally, theological inquiry shapes
the distinct manifestation of ethics services through discernment.
Health care is a social good that should be accessible to any person in need, and
many Catholic and non-Catholic health care professionals participate in the ministry
of Catholic health care. As a whole, Catholic health care ministry has a large pres-
ence in the United States.5 In the Oregon region of PSJH, we have eight acute-care
hospitals (1,452 licensed acute beds), received over 2.8 million outpatient visits at
more than ninety clinics and ambulatory care centers, made over 280,000 home
health visits a year, and had approximately 600,000 health plan members, over $400
million in community benet, and over 20,000 employees.6 In addition, we have
four medical residency programs, one clinical pastoral education program, and one
clinical pharmacy residency program; local nursing students also rotate through our
hospitals. Combined, our ministries constitute a large, complex organization marked
by continuous learning, innovation, and compassion.
There is tremendous diversity in our workforce and in the communities we serve.
In Oregon, the most commonly identied religious preference in patient records is “no
preference.” This creates a care environment that is rich, full of creativity, and ripe
for challenge; it also evokes questions about how to sustain Catholic identity while
delivering quality care in a nondiscriminatory, culturally competent, and reexive
way.7 In fact, provider religiosity may affect the content and form of clinical practice,
which may limit patients’ ability to access certain procedures.8 Some commentators
argue that this is a violation of individual rights; moreover, health care professionals
may hold personal or professional opinions that conict with organizational policy and
Church teaching.9 These tensions can manifest in practitioner distress, interfere with
provider recruitment, and deter patients from seeking care. It is not easy to navigate
these dynamics and remain faithful. To be sure, we seek conscience protection to
exercise religious freedom in this context.
5. “U.S. Catholic Health Care,” fact sheet, Catholic Health Association (CHA), 2017,
https://www.chausa.org/.
6. Julie Trocchio and Indu Spugnardi, “Community Benet: CHA Members Engage
with Communities to Improve Health,” Health Progress 98.4 (July–August 2017): 66–68;
and “Providence in Oregon at a Glance 2016,” Providence Health and Services, April 2016,
http://oregon.providence.org/~/media/Files/Providence OR PDF/About us/Oregon at aglance.
pdf. These statistics represent data from 2015.
7. Robert Aronowitz et al., “Cultural Reexivity in Health Research and Practice,”
American Journal of Public Health 105 suppl 3 (July 2015): S403–S408.
8. Farr A. Curlin et al., “Religion, Conscience, and Controversial Clinical Practices,”
New England Journal of Medicine 356.6 (February 8, 2007): 593–600, doi: 10.1056/NEJM
sa065316.
9. Stephanie Slade, “Why Is the A.C.L.U. Targeting Catholic Hospitals?,” America,
May 31, 2017, https://www.americamagazine.org/; and Debra Stulberg et al., “Obstetri-
cian–Gynecologists, Religious Institutions, and Conicts regarding Patient Care Policies,”
American Journal of Obstetrics and Gynecology 207.1 (July 2012): 73.e1–73.e5, doi:
10.1016/j.ajog.2012.04.023.
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114
Nevertheless, we are called to demonstrate delity to the demands of those
relationships, whether they are therapeutic, interprofessional, or interinstitutional.10
Thus, a social justice aspect is at the core of ethics services and calls us to demon-
strate solidarity, advocate for subsidiarity, act in mercy and charity, protect religious
freedom, and maintain the public order, all while respecting human dignity from the
womb to natural death and promoting the common good.
Fidelity to the demands of these relationships requires the formation of con-
science, or synderesis, of the moral agents involved in a decision-making process,
which unfolds in distinct ways for each individual and situation. In this respect,
ethics education and consultation serve the human good of conscience formation by
assisting those confronted with a challenge to their integrity, for example, in deci-
sions to forgo life-sustaining treatment, acquire an other-than-Catholic health care
facility, or adopt alternative standards of care during natural disasters or pandemics.
One should make a distinction between two different connotations of conscience
formation, however. On the one hand, the formation of conscience that occurs in a
patient-care situation—which is, in a sense, a microcosm of a public square—is what
we have in mind relative to the role of ethics services. On the other hand, the forma-
tion of the conscience of a Catholic patient, family member, health professional, or
administrator is the traditional sense referenced when discussing conscience in the
Catholic moral tradition.11 It does not apply to all patient-care situations.
Catholic social teaching captures this dynamic in three ways: subsidiarity, or
empowering individuals and groups to deal with problems on their own at the lowest
level; social justice; and religious freedom. Subsidiarity is a fundamental principle
of decision making: “Just as it is gravely wrong to take from individuals what they
can accomplish by their own initiative and industry and give it to the community, so
also it is an injustice and at the same time a grave evil and disturbance of right order
to assign to a greater and higher association what lesser and subordinate organiza-
tions can do.”12 In other words, one task of an ethicist is to empower moral agents
to address ethical issues instead of resolving them for the agents.
Similarly, social justice and the autonomy of people are essential to making
decisions: “In order that the right to development may be fullled by action: (a) a
people should not be hindered from attaining development in accordance with their
own culture; (b) through mutual cooperation, all peoples should be able to become
the principal architects of their own economic and social development.”13 Respect
for autonomy binds us to two obligations: avoiding undue restrictions and facilitating
10. John R. Donahue, “The Bible and Catholic Social Teaching: Will This Engagement
Lead to Marriage?,” in Modern Catholic Social Teaching: Commentaries and Interpreta-
tions, ed. Kenneth R. Himes (Washington, DC: Georgetown University Press, 2005), 14–15.
11. Kevin D. O’Rourke and Philip J. Boyle, “Formation of Conscience,” in Medical
Ethics: Sources of Catholic Teachings, 3rd ed., ed. Kevin D. O’Rourke and Philip J. Boyle
(Washington, DC: Georgetown University Press, 1999), 16–27.
12. Pius XI, Quadragesimo anno (May 15, 1931), n. 79.
13. World Synod of Catholic Bishops, Justice in the World (1971), n. 71, https://
www1.villanova.edu/.
KocKler and dirKsen integrating ethics services
115
autonomous living.14 Consequently, the notion of noninterference is a crucial matter
of justice,15 as is the recognition of cultural competency and reexivity.16
Finally, Catholic social teaching afrms religious liberty: “A sense of the dig-
nity of the human person has been impressing itself more and more deeply on the
consciousness of contemporary man, and the demand is increasingly made that men
should act on their own judgment, enjoying and making use of a responsible freedom,
not driven by coercion but motivated by a sense of duty.”17 Ethics services help form
the consciences of moral agents involved in any given situation—a fundamentally
ecumenical and secular reality—in the context of a Catholic health care organization.
As Pope St. John Paul II teaches, following one’s conscience is not mere relativism
or subjectivism; it references objective moral truth. Catholics form their consciences
in a community guided by the magisterium.18 For ethics services in Catholic health
care, this formation of conscience occurs within certain parameters; for example,
the scope of services denes such parameters and helps individuals and institutions
navigate the competing claims of values and principles in the clinical and institutional
realities of health care. Again, this formation of conscience in a health care setting
is markedly different from that of Catholics alone, since not all the participants are
members of the Catholic Church. Catholics turn to magisterial teaching and moral
theology, but these are not normative sources of truth for many who enter our doors.19
In most cases, ethicists can accommodate a range of practices and decisions,
since these are understood, usually implicitly, as occurring in a context that presup-
poses a scope of services delimited by norms derived from the Ethical and Religious
Directives for Catholic Health Care Services (ERDs) and Catholic tradition. At times,
ethicists may remind individuals of what is within or beyond the scope of services
available at Catholic health care organizations, although this is atypical. Some ques-
tions that reach an ethicist may focus explicitly on areas of theological ambiguity
or legitimate theological disagreement. In those cases the ethicist, often in dialogue
with institutional leaders and local ordinaries, helps shape institutional parameters.
14. Tom Beauchamp and James Childress, Principles of Biomedical Ethics, 6th ed.
(New York: Oxford University Press, 2009), 103–105, especially 104.
15. See David Hollenbach, “The Common Good and Urban Poverty,” America, June
5, 1999, 8–11; and Pius XII, Address to Italian Jurists (December 6, 1953), available at http://
www.ewtn.com/.
16. See, for example, Henry S. Perkins, “Ethics Expertise and Cultural Competence,”
AMA Journal of Ethics 8.2 (February 2006): 79–83.
17. Vatican Council II, Dignitatis humanae (December 7, 1965), n. 1.
18. John Paul II, Veritatis splendor (August 6, 1993), n. 27.
19. “As Catholics, we form our consciences in community, not in splendid isolation.
The major, but not the only, vehicle of the community’s moral knowledge is the authentic
magisterium. We believe that the ordinary sources of error are better excluded when Catholics
form their consciences in tune with the magisterium of the Church. I say ‘better excluded,’
for the ordinary magisterium does not absolutely exclude error unless we are lost in a haze
of historical amnesia. Thus we speak of the presumption of truth, not absolute certainty.”
Richard McCormick, A Critical Calling: Reections on Moral Dilemmas since Vatican II
(Washington, DC: Georgetown University Press, 2006), 34.
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In this respect, the tasks of the ethicist are distinct but not entirely different from
those of the moral theologian or philosopher.20 Whereas the moral theologian works
within the community of the faithful, the ethicist works within and beyond that com-
munity. In describing moral theology, John Mahoney cites Josef Fuchs: “The primary
task of moral theology, according to the letter and spirit of the [ Second Vatican]
Council, must be to explain that man is called personally in Christ by the personal
God.”21 Mahoney indicates that this occurs in a pattern of renewal in “fellowship
with the Holy Spirit.”22 More specically, ethicists help cultivate a shared sense of
integrity among those making a particular decision. As ethics is a social phenomenon,
there is a shared dimension to this conscience-forming activity. Moreover, there is
also a dimension of reconciliation: restoring right relationships and proper social
structures to alleviate moral distress and brokenness.
Similarly, the ethicist is not an apologist or evangelist. Whereas the apologist
argues from and explains Church doctrine to defend it and dene the tradition, the
ethicist must articulate such doctrine to educate and form those unfamiliar with
Catholic theology and tradition. Ethicists do not defend a particular doctrine or
recruit converts to the faith per se. Rather, they explain and invite participation in
the ministry. Most often, this occurs in the context of leadership formation programs
aimed at deepening an individual’s sense of his or her calling—Catholic or not—in
Catholic health care ministry and what that means.23 One may distinguish a forma-
tion program from other leadership development programming by its emphasis on
personal and spiritual development, for example, a sense of vocation, rather than
functional skills or knowledge for a particular organizational role.
Another essential dimension to practicing ethics is the nature of theological
inquiry.24 Here, metaethical questions25 inform the substantive framework, or horizon,
in which decision makers and the ethicists who support them participate in the mis-
sion of the organization. The nature of theological inquiry in its most foundational
dimensions includes a subjective pole, that is, the person seeking answers, and an
objective pole, that is, data from science, society, and the world as well as Church
20. See Alasdair MacIntyre, A Short History of Ethics: A History of Moral Philosophy
from the Homeric Age to the Twentieth Century, 2nd ed. (Notre Dame, IN: University of
Notre Dame Press, 1998), 12–13.
21. John Mahoney, The Making of Moral Theology: A Study of the Roman Catholic
Tradition (Oxford: Clarendon Press, 1987), 339.
22. Ibid., 341–343.
23. John Mudd, “When Knowledge and Skill Aren’t Enough,” Health Progress 90.5
(September–October 2009): 26–32.
24. James J. Walter, “Horizon Analysis and Moral Stance: An Interpretation of Cardinal
Bernardin’s ‘Consistent Ethic of Life,’” in Contemporary Issues in Bioethics: A Catholic
Perspective, ed. James J. Walter and Thomas A. Shannon (Lanham, MD: Rowman and
Littleeld, 2005), 33–48. See also David Tracy, Blessed Rage for Order: The New Pluralism
in Theology (Chicago: University of Chicago Press, 1975).
25. David Kelly, Contemporary Catholic Health Care Ethics (Washington, DC:
Georgetown University Press, 2004), 77–87.
KocKler and dirKsen integrating ethics services
117
teaching and other aspects of Tradition.26 In addition, these poles are related to the
normative sources of truth. Ethicists make more or less intentional efforts to demarcate
the way theological inquiry unfolds in their professional practices.
The manner in which theological inquiry unfolds in a Catholic health care
organization will affect the manner and range of components that go into ethical
decision making, including the state of worldly affairs, natural moral law, religious
freedom, the autonomy of the sciences and their relationship to faith, and the process
of discernment.
All modes of theological inquiry must account for the state of worldly affairs,
for example, cultural, social, legal, professional, and scientic realities, at a particular
historical moment: “The Church has always had the duty of scrutinizing the signs
of the times and of interpreting them in the light of the Gospel. Thus, in language
intelligible to each generation, she can respond to the perennial questions which men
ask about this present life and the life to come, and about the relationship of the one
to the other.”27 Individuals and organizations are called to respond to the signs of
the times with integrity. Ethics services in general and ethicists in particular aid in
fullling this call.
In addition, theological inquiry must illuminate the way in which the human
person is considered through the lens of the natural moral law:
God provides for man differently from the way in which he provides for beings
which are not persons. He cares for man not “from without,” through the laws
of physical nature, but “from within,” through reason, which, by its natural
knowledge of God’s eternal law, is consequently able to show man the right
direction to take in his free actions. In this way God calls man to participate
in his own providence, since he desires to guide the world—not only the
world of nature but also the world of human persons—through man himself,
through man’s reasonable and responsible care. The natural law enters here
as the human expression of God’s eternal law.28
Particularly important in a pluralistic society, theological inquiry must show how
stakeholders and decision makers account for and respect the religious freedom of
the institution, its employees, and those it serves in the community:
All men should be at once impelled by nature and also bound by a moral
obligation to seek the truth, especially religious truth. They are also bound to
adhere to the truth, once it is known, and to order their whole lives in accord
with the demands of truth. However, men cannot discharge these obligations
in a manner in keeping with their own nature unless they enjoy immunity
from external coercion as well as psychological freedom. Therefore the right
to religious freedom has its foundation not in the subjective disposition of the
person, but in his very nature. In consequence, the right to this immunity con-
tinues to exist even in those who do not live up to their obligation of seeking
26. Walter, “Horizon Analysis and Moral Stance,” 35.
27. Vatican Council II, Gaudium et spes (December 7, 1965), n. 4.
28. John Paul II, Veritatis splendor, n. 43, original emphasis.
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the truth and adhering to it and the exercise of this right is not to be impeded,
provided that just public order be observed.29
One of the more contested areas of Catholic health care is the relationship
between the appropriate exercise of religious freedom and the preservation of just
public order. For example, in a given public policy change or organizational deci-
sion, institutional and individual conscience protections, professional standards, or
the validity of human laws may be at stake.30
Especially in the health care context, theological inquiry must reconcile the
autonomy of the sciences and the inuence scientic ndings with the sources of faith:
Investigation . . . carried out in a genuinely scientic manner and in accord
with moral norms . . . never truly conicts with faith, for earthly matters and
the concerns of faith derive from the same God . . . [and are] led by the hand
of God. . . . Consequently, we cannot but deplore certain habits of mind, which
are sometimes found too among Christians, which do not sufciently attend
to the rightful independence of science and which, from the arguments and
controversies they spark, lead many minds to conclude that faith and science
are mutually opposed.31
Commentators question the legitimacy of science, the undue inuence of politi-
cal or other social interests, and the interplay between scientic ndings, professional
standards, patient preferences, Church teaching, and Catholic health care. A current
example of this is the discourse on how to best care for persons who suffer from
gender dysphoria.
Finally, theological inquiry must reveal and operationalize the specic manner
of discernment. This is, in a sense, how the organization participates in the ongoing
renewal of moral theology: “‘Discernment,’ as we generally use the term, refers to the
quality of perception and the capacity to discriminate degrees of importance among
various features before making a judgment. The ability to discern involves a keen-
ness of perception, sensitivities, affectivities, and capacities for empathy, subtlety,
and imagination.”32 Discernment and ethical decision making are not merely cogni-
tive exercises: they have affective and spiritual dimensions as well. Operationally,
theological inquiry occurs in the context of formal discernments and discerning
decisions, primarily at the organizational level, although clinical consultation may
be characterized better as “discernment” rather than a mere service of advisement
or mediation. In the Ignatian tradition, the discernment of spirits is more about bet-
ter understanding who we are becoming individually and collectively than about a
29. Vatican Council II, Dignitatis humanae, n. 2.
30. See, for example, Marie T. Hilliard, “Contraceptive Mandates and Immoral Coop-
eration” in Catholic Health Care Ethics: A Manual for Practitioners, 2nd ed., ed. Edward
Furton (Philadelphia: National Catholic Bioethics Center, 2009), 275–281.
31. Vatican Council II, Gaudium et spes, n. 36. See also John Paul II, Fides et ratio
(September 14, 1998).
32. Richard M. Gula, Reason Informed by Faith: Foundations of Catholic Morality
(Mahwah, NJ: Paulist Press, 1989), 315.
KocKler and dirKsen integrating ethics services
119
particular decision for choice A or B.33 Indeed, discernment manifests the pattern
of renewal for a particular community. Lastly, to this end, Pope Francis calls us to
embrace local discernment—attentive to the distinctive context of a given region,
culture, and local needs—while also seeking unity of the Church.34
Institutional Ecosystem
If ethology is the study of animal behavior, if behavior is shaped by the eco-
logical context, and if ethics is the practical science of normative behavior, then the
integration of ethics accounts for the institutional ecosystem in which the behaviors
occur. Two dimensions of health care shape the ecosystem of ethics services: the
nature of the delivery of care and the institutional expectations that shape ethics.
First, contemporary health care delivery systems are extraordinarily complex.
To begin, health care delivery is predicated on the encounter with a person in need—a
human person with inherent dignity—by health care professionals entrusted by the
public to exercise their duciary responsibility to serve the health good of the person.
In part, the evolution of health care into a faster-paced, multidisciplinary enterprise
reects this growing complexity: contemporary health care involves more caregivers,
reects more specialties, and provides less time for interacting with and caring for
patients. Ultimately, ethics services aim to renew and enhance the human dimen-
sion of health care beyond the technical skills and knowledge of professionals and
administrators and locate them in authentic therapeutic relationships. Strategically,
health care leaders shift care to upstream and preventive health care, wellness, and
population health management. This is challenging ethics services to move across
the continuum35 and reframe their activities to population health.36 Delivery systems
offer multidisciplinary care in an interdisciplinary fashion, which reects whole-
person care while also accommodating the increasing specialization of medical
competencies. Historically, health care has been very hierarchical, and asymmetries
of power persist. Yet there is a trend toward more participatory decision making as
an aspirational norm.37 Care delivery is also characterized by the urgency of one’s
33. See Mark E. Thibodeaux, God’s Voice Within: The Ignatian Way to Discover God’s
Will (Chicago: Loyola Press, 2010).
34. Francis, Amoris laetitia (March 19, 2016), n. 3.
35. See Rachelle Barina and Emily K. Trancik, “Moving Ethics into Ambulatory Care:
The Future of Catholic Health Care Ethics in Shifting Delivery Trends,” Health Care Ethics
USA 21.2 (Spring 2013): 1–5; and John P. Slosar, “Embedding Clinical Ethics Upstream:
What Non-Ethicists Need to Know,” Health Care Ethics USA 24.3 (Summer 2016): 3–11.
36. Michael Rozier, “Embracing New Competencies for Ethics in an Era of Population
Health,” Health Care Ethics USA 25.2 (Spring 2017): 7–19.
37. See, for example, Gabriel Bosslet et al., “An Ofcial ATS/AACN/ACCP/ESICM/
SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in
Intensive Care Units,” American Journal of Respiratory and Critical Care Medicine 191.11
(June 1, 2015): 1318–1330, doi: 10.1164/rccm.201505-0924ST; and Ann B. Hamric and
Leslie J. Blackhall, “Nurse–Physician Perspectives on the Care of Dying Patients in Intensive
Care Units: Collaboration, Moral Distress, and Ethical Climate,” Critical Care Medicine 35.2
(February 2007): 422–429, doi: 10.1097/01.CCM.0000254722.50608.2D.
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need and the reversibility of care decisions. This informs the clinical nuances of a
given decision-making process as well as the need for timeliness of ethics services.
Second, a number of expectations for ethics help shape institutional consider-
ations. (1) The Catholic tradition articulates an expectation for responsible decision
making, which is reected in directive 37 of the ERDs: “There should be appropri-
ate standards for medical ethical consultation within a particular diocese that will
respect the diocesan bishop’s pastoral responsibility as well as assist members of
ethics committees to be familiar with Catholic medical ethics and, in particular, these
Directives.”38 PSJH in Oregon operationalizes directive 37 in a distinct way, with an
array of ethics committees distributed across our geographic footprint and service lines
as well as with a professionally staffed ethics consultation service with bylaws and
protocols informed by the ERDs. Ethics services must be able to educate, form, and
support decisions, practices, and structures that reect Catholic identity and values.
(2) The Joint Commission standard for accreditation requires accredited health
care organizations to have some mechanism to address ethical issues, but like the
ERDs, it does not specify the precise way that should be operationalized.39 Generally,
the commission gives wide latitude to organizations in operationalizing this standard.
Historically, many chose to establish an ethics committee. Thus, ethics services have
an important integrative role in connecting normative behavior and policies across
disciplines and departments in accredited hospitals and other settings.
(3) Organizations are expected to have ethics support to qualify for Magnet
Status, a credential signifying organizational recognition of nursing excellence.40
Historically, ethics has been listed as an “exemplary professional practice” alongside
privacy, security, accountability, competence, autonomy and others.41 This demon-
strates that the care environment supports the nursing profession. A core theme of
the American Nursing Association’s Code of Ethics calls on nursing professionals to
be advocates for patients.42 Similarly, the American Medical Association’s Council
on Ethical and Judicial Affairs holds that health care organizations should have a
38. USCCB, Ethical and Religious Directives, dir. 37.
39. George Annas and Michael Grodin, “Hospital Ethics Committees, Consultants, and
Courts,” AMA Journal of Ethics 18.5 (May 2016): 556, doi, 10.1001/journalofethic.2016.18.05.
sect1-1605.
40. See American Nurses Credentialing Center, “Magnet Recognition Program: A
Program Overview” (2011), 19, http://nursecredentialing.org/Documents/Magnet/MagOver
view-92011.pdf (site discontinued). More recently, the ANCC has updated its Magnet
Recognition Program. Information is available at https://www.nursingworld.org/organizational
-programs/magnet/.
41. See American Nurses Credentialing Center, “Exemplary Professional Practice:
Criteria for Nursing Excellence” (2011), http://www.nursecredentialing.org/Magnet/Magnet
ProductsServices/Magnet-PublicationsManuals/MagnetPubs/ExemplaryProfessionalPractice
.html (site discontinued). Updated information is available at https://www.nursingworld.org
/organizational-programs/magnet/magnet-model/.
42. American Nurses Association, Code of Ethics for Nurses with Interpretive State-
ments (Washington, DC: ANA, 2001), no. 2.1, p. 9.
KocKler and dirKsen integrating ethics services
121
mechanism for addressing ethical questions and issues that emerge in practice.43 These
norms call on ethics services to enable collaborative, cross-disciplinary caregiving
in support of excellence and quality care. Taken together, there exists an array of
professional expectations for mechanisms to support ethical decision making in care
delivery.
Finally, seeking high reliability in care delivery and a just organizational culture
are more recent phenomena that provide internal motivation for safe quality care.44
These are more specic manifestations of the general thrust of an organizational
culture that takes ethics and values-based decision making seriously. In addition to
characterizing human activity in ways correlative to the Catholic moral tradition,45
these paradigms emphasize patient safety and quality of care by, in part, leveling
the playing eld, neutralizing unjust power asymmetries, cultivating a collaborative
workplace, and providing concrete mechanisms and processes to enable consistent
communication and decision making. Such characteristics evoke a proactive, interac-
tive, and retroactive disposition toward potential disruptions in the delivery of safe,
high-quality, and responsible care.46
Professionalization of the Field of Health Care Ethics
Health care ethics is evolving into a professional discipline.47 The eld is
currently wrestling with the features that dene a profession, such as the nature of
its duciary responsibility to a public good, and a discipline, for example, compe-
tencies, approaches, and methods. To unpack this development, we will comment
on professionalization by reecting on the public good, for which ethicists have a
duciary responsibility, and the distinctive features of the emerging discipline of
professional ethics in health care.
Public Good Served by Professional Ethicists
The public good served by professional ethicists is a difcult concept to dene.
Core Competencies for Healthcare Ethics Consultation describes the general goal
of health care ethics consultation as improving “the quality of health care through
43. See American Medical Association Council on Ethical and Judicial Affairs, “Eth-
ics Consultation,” opinion 10.7.1, and “Ethics Committees in Health Care Institutions,”
opinion 10.7, in Code of Medical Ethics, 2016, https://www.ama-assn.org/delivering-care/
ethics-consultations and https://www.ama-assn.org/delivering-care/ethics-committees-health-
care-institutions.
44. See Philip G. Boysen II, “Just Culture: A Foundation for Balanced Accountability
and Patient Safety,” Ochsner Journal 13.3 (Fall 2013): 400–406; and Mark Chassin and Jerod
M. Loeb, “High-Reliability Health Care: Getting There from Here,” Milbank Quarterly 91.3
(September 2013): 459–490, doi: 10.1111/1468-0009.12023.
45. Peter J. Cataldo and Joseph Pepe, “Manage Risk, Build a Just Culture,” Health
Progress 92.4 (July–August 2011): 56–60.
46. Susan E. Kelly et al., “Understanding the Practice of Ethics Consultation: Results of
an Ethnographic Multi-Site Study,” Journal of Clinical Ethics 8.2 (Summer 1997): 136–149.
47. Albert R. Jonsen, The Birth of Bioethics (Oxford: Oxford University Press, 1998),
325–346.
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the identication, analysis, and resolution of ethical questions or concerns.”48 Yet
the way an ethicist or ethics consultant achieves this goal is different from the way
a clinician or administrator per se does.
As described above, the ethicist plays a role in helping moral agents form their
consciences in order to establish right relationships. Only within right relationships,
in which we meet the demands of delity to those relationships, may caregivers
intentionally deliver quality, responsible health care. Conceptually, right relation-
ships reect a critical component of the quality of responsible health care.49 Thus,
assisting the formation of conscience is at least operationally how we envision the
good to which ethicists exercise their duciary responsibility.
Features of Health Care Ethics as a Discipline
The professional practice of ethics services reects a practical science; it
requires a discipline to assist moral agents in the potentially chaotic setting of con-
temporary health care. We hold that health care ethics is dissimilar but complementary
to academic ethics, which is a speculative science.50 The features of competencies
(skills and knowledge), approach (modality of practice), and methodology (synthetic,
normative dynamic of moral reasoning) constitute core components of the discipline.
CompetenCies. The American Society for Bioethics and Humanities (ASBH)
sets forth an array of competencies necessary to perform health care ethics consul-
tation but does not presuppose that any one individual possesses all competencies,
as there are different ways to operationalize a consultation service.51 The Catholic
Health Association has compiled its own sets of competencies for facility and system
ethicists in Striving for Excellence in Ethics.52 Indeed, as Elliott Bedford argues,
the competencies required for the practice of ethics in Catholic health care differ in
substantive ways from those articulated by the ASBH.53
Within our context, we hold that ethics competencies pertain to the cognitive,
affective, and behavioral tasks of identifying, addressing or managing, and prevent-
ing default decisions, moral hazards, and moral distress. Our center has organized
such competencies in four domains: comprehension, interpretation, analysis, and
pragmatism. Comprehension holds that ethicists have mastered the laws, principles,
imperatives, norms, rules, and methods, including the Catholic theological tradition,
48. American Society for Bioethics and Humanities, Core Competencies for Healthcare
Ethics Consultation, 2nd ed. (Chicago: ASBH, 2011), 3.
49. Charles E. Curran, The Catholic Moral Tradition Today: A Synthesis (Washington,
DC: Georgetown University Press, 1999), 77–83.
50. See Laurie Johnston, “The Future of Bioethics: A New Professor’s Reection”
(32–34), and Nicholas Kockler, “Response” (37–39), in Health Care Ethics USA 20.2 (Spring
2012).
51. ASBH, Core Competencies, 19–33.
52. Catholic Health Association (CHA), Striving for Excellence in Ethics: A Resource
for the Catholic Health Ministry, 2nd ed. (St. Louis: CHA, 2014), appendix A (pages 44–49).
53. Elliott Louis Bedford, “The Core Competencies: A Roman Catholic Critique,”
HEC Forum 23.3 (September 2011):147–169, doi: 10.1007/s10730-011-9169-2.
KocKler and dirKsen integrating ethics services
123
which apply in health care. Interpretation holds that ethicists demonstrate sufcient
appreciation of social, legal, clinical, organizational, scientic, and systemic facts
and data. Analysis holds that ethicists have sufcient insight into the relationships
between ethics knowledge and relevant data. Finally, pragmatism holds that ethi-
cists have the mastery to confront conscientiously decisions, questions, ambiguity,
conict, and distress by communicating, discussing, and acting appropriately, that
is, in a manner consistent with the degree of moral accountability for the reality at
hand. These specic competencies and those of other lists (e.g., ASBH and CHA)
are not mutually exclusive. Rather, they mirror the encounter of ethical issues in the
practice of health care ethics.
There is an expectation that accountability for ethical behavior is shared and that
all professional participants in patient care demonstrate sufcient mastery of ethical
competencies to varying degrees. That is, we recognize the primacy of the moral
agency of the persons acting in a given case. They each have to tap into, explore, and
express their value commitments and form their consciences in relation to the role
they play in a case. Thus, health care professionals draw on the ethical components
of their professional competencies.54 Ethicists aid in eliciting that process and teach
to it. While some health care organizations operationalize a committee or team-based
approach to consultation, we seek to empower the members of the care team to actu-
alize their own ethical decision making through ethics consultation.
In this sense, ethics competencies reect the exercise and facilitation of dis-
cernment. The primary paradigm or model we use to describe ethics consultation is
coaching.55 Again, evoking the metaphor of the midwife, the ethicist coaches moral
agents and helps transform their technical skills and knowledge into professional
practices in therapeutic relationships.56
Finally, it is overly simplistic to reference only those competencies necessary
for discernment and consultation. An ethicist must demonstrate a wealth of other
competencies, including those in theology, adult learning pedagogy, group facilita-
tion, organizational behavior, communications, personnel management, and others.
ApproAChes. ASBH presents three operative approaches to ethics consultation:
the pure consensus approach, the authoritarian approach, and the ethics facilitation
approach. Core Competencies identies ethics facilitation as the normative or pre-
ferred approach: “The consultant helps to elucidate issues, aid effective communica-
tion, and integrate the perspectives of relevant stakeholders. The consultant helps the
relevant decision makers fashion a plan that respects the needs and values of those
involved and that is within the bounds of ethical and legal standards.”57 The phrase
54. See Nicholas J. Kockler and John Tuohey, “Ethics Education Enhances Skills of
Doctors in Training,” Health Progress 93.3 (May–June 2012) 29–37.
55. John Tuohey and Nicholas J. Kockler, “Aconselhamento ou coaching? A con-
sultoria ética no contexto da pós-graduação em educação médica,” Revista Bioethikos 6.1
(January–March 2012): 39–48.
56. Nicholas J. Kockler and Kevin M. Dirksen, “Competencies Required for Clinical
Ethics Consultation as Coaching,” Health Care Ethics USA 23.4 (Fall 2015): 25–33.
57. ASBH, Core Competencies, 7.
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“within the bounds of ethical and legal standards” refers in part—in the context of
(Catholic) health care—to those normative parameters consistent with Catholic moral
and social teaching. Striving for Excellence in Ethics discusses “advisement and
consultation” but does not specify a particular approach. Our center countenances
the ethics facilitation approach but acknowledges an appropriate function of the
authoritarian approach for dening the scope of available services within Catholic
health care. This latter approach tends to occur less in specic patient-care situations,
unless the question is about a clarication of policy, and more in organizational cir-
cumstances involving institutional arrangements or policy development and review.
In general, an ethicist’s work is not mere application of the ERDs; it is fundamentally
ecumenical and inclusive while operating within parameters and in a manner that is
consistent with the ERDs and the broader Catholic tradition.
methodology. In secular settings, the narrowing of certain normative meth-
odologies, such as principlism, and the “thinning” of public discourse on the ethical
good have been criticized.58 In Catholic health care, however, ethics services draw
additionally from the rich theological foundations of the Catholic tradition. This is
not to say that ethicists can ignore developments in the secular world. To the con-
trary, professional ethicists need to share in the development of other professional
ethicists and enrich that experience with the additional requirements of practicing
in a Catholic setting.
The methodologies employed by our ethicists reect a synthesis of normative
models of ethical thinking, predicated on conceptual ethical theories such as teleol-
ogy, deontology, and character ethics. In this narrow sense, methodology refers to
the operant ways theoretical ethical thinking applies to practical questions of moral
signicance.59 Historically, there have been numerous competing ways of undertaking
and applying such normative methods. In practice, however, the purity of conceptual
thinking is stirred in with the concrete variables and human realities of a given situ-
ation. Thus, the practice of ethics and its methodology must come to some practical
application of these conceptual underpinnings. For us, the synthetic paradigm is
integrity in right relationships. Integrity reects a sense of wholeness or completeness
in decision making. Right relationships reect the mutually corrective application
of consequences, compliance, and character at the intersection of the moral agents’
narratives in a clinical situation or therapeutic relationship.
We operationalize this concept of integrity with a disclosure model that rep-
resents the ethical thinking in a given case: “Disclosure or analogue models do
not provide exact details, but like the drawing for a sculpture, they evoke the nal
product. They are a basic sketch, a guiding tool for inquiry, simplifying for the sake
of identication. Their imaginative conguration approximates the result and invites
58. See John H. Evans, “A Sociological Account of the Growth of Principlism,” Hast-
ings Center Report 30.5 (September–October 2000): 31–39, doi: 10.2307/3527886.
59. For examples, see Jeremy Sugarman and Daniel P. Sulmasy, eds., Methods in
Medical Ethics, 2nd ed. (Washington, DC: Georgetown University Press, 2010); and Nancy
S. Jecker, Albert T. Jonsen, and Robert A. Pearlman, eds., Bioethics: An Introduction to His-
tory, Methods, and Practice (Sudbury, MA: Jones and Bartlett, 1997).
KocKler and dirKsen integrating ethics services
125
understanding. . . . In disclosure models, one distinguishes between two poles: the
subject investigating and the object or world disclosed by the study.”60 Like other
forms of representation, the goals of a disclosure model include exploration and
explanation of relevant analytical thinking.61 The decision-making model that we
bring to bear on each clinical ethics “service encounter” asks four fundamental ques-
tions of integrity: What is the honest practice of medicine and delivery of quality of
care? How do we demonstrate dependability to benet patients in terms of health
outcomes? How are we fair to patients in their context? How are we accountable
for broader obligations regarding justice and nonmalecence? 62 Since our ethics
service is staffed by multiple ethicists, a consistent model reinforces the commitment
to quality and reliability and may help mitigate ethicist-selection bias by those who
request ethics consultations.
We also use a visual representation of the model during consultation and edu-
cation. The ethicist graphically maps out and represents the dialogue using visual
symbols and annotations. This helps analytical thinking by drawing connections and
highlighting the signicance of different facts, values, and other realities. Furthermore,
using a visual model in a group setting facilitates the formation of a “third story,”
comparable to conict mediation techniques.
Similarly, the methodology employed by ethicists in a formal ethical discern-
ment process at the organizational level reects the same fundamental concept of
integrity but with an institutional frame of reference. At this level, the fundamental
questions become, What is an honest expression of the mission and core values of
our distinct heritage as a Catholic health care ministry? How is our organization, this
service line, or business unit dependable for its contribution to the common good?
How are we fair to stakeholders and partners, with special attention to the poor and
vulnerable? How are we accountable to our commitments to broader traditions, such as
the Catholic tradition as a whole, as well as to applicable health law and regulations?
Here the model of theological inquiry employed by ethicists becomes acutely salient.
Ethics at Providence St. Joseph Health in Oregon
Overall, we have endeavored to walk among our colleagues, patients, and
families, and we have sought to foster a culture of ethical sensitivity and competence.
To accomplish these, our approach to operationalizing integrated ethics services has
evolved over time. There is a dynamic relationship between these activities that,
when taken together, achieves the goals identied above.
60. Walter, “Horizon Analysis and Moral Stance,” 35.
61. Edward Tufte, Beautiful Evidence (Cheshire, CT: Graphics Press, 2006).
62. Laura L. Nash, Good Intentions Aside: A Manager’s Guide to Resolving Ethical
Problems (Boston, MA: Harvard Business School Press, 1993); and Albert R. Jonsen, Mark
Siegler, and William J. Winslade, Clinical Ethics: A Practical Approach to Ethical Decisions
in Clinical Medicine, 7th ed. (New York: McGraw-Hill, 2010).
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Strategic Objectives
The Providence Center for Health Care Ethics began with an endowment that
established a chair in applied health care ethics in the medical residency program
at Providence St. Vincent Medical Center. The intent was to engage physicians-in-
training in ethical reection and expand their professional identities beyond technical
skill and knowledge. Over time, we have enriched and expanded this intent across
other disciplines and institutions in our region.
Our strategic objectives—education, consultation, discernment, scholarship,
and service and outreach—articulate how we operationalize and achieve our purpose.
eduCAtion. Through ethics education, we build and enrich the ethical compe-
tencies of health professionals, administrators, and others to enhance their ethical
decision-making capacity. The primary purpose of this education is not to train health
professionals to be ethicists, ethics consultants, or ethics committee members, but
rather to empower them to address ethical issues they encounter in their roles. Con-
sequently, we have developed curricular maps that emphasize specic ethical com-
ponents of each disciplines’ competencies. Our educational programming generally
fosters an ethically sensitive and relatively competent critical mass of caregivers who
also know to solicit the assistance of professionally trained ethicists when needed.
First, the center offers a range of targeted opportunities for specic audiences of
allied health professionals and medical residents. Currently, the center provides ethics
education in residency programs, a pastoral education program, a pharmacy program,
and nursing education. For example, in the residency programs, our ethicists participate
with physicians-in-training in weekly clinical rounding, dedicated ethics teaching
rounds, didactic conferences, and ethics elective rotations that range from one to three
weeks. Second, the center provides several multidisciplinary opportunities through its
Ethics Core Program, which constitutes a coordinated, scope-and-sequence-organized
series of modules. Third, the center manages three funded lectureships through which
nationally and internationally known speakers give medical grand rounds and other
talks at various ministries throughout our region on ethical reection and excellence,
palliative care, and the medical humanities in patient care. Fourth, many leaders
often invite the center’s ethicists for ad hoc in-service workshops or presentations on
such topics as care for hospice patients who have a history of intravenous drug use,
ethics consultation in the ambulatory care setting, and the ERDs. Last, the Campbell
Reference Library and Resource Center, located at the Providence Center for Health
Care Ethics, contains a rich collection of manuscripts and periodicals across several
disciplines, including theology, philosophy, cultural anthropology, medicine, law, and
sociology. The library consists of online resources and a physical location, which is
often used as a retreat space for groups throughout our organization.
ConsultAtion. Consultation facilitates the ability of individuals and groups
engaged in patient care and business activities to demonstrate integrity through the
exercise of prudential judgment and an experience of inner peace that reects a fully
formed conscience. Professionally trained ethicists provide real-time support in
our clinical ethics consultation service. Ethicists rotate coverage, are available by a
paging service, and are accessible at any time. Ethics consultations occur across the
continuum of care, although the majority occur within our eight acute-care hospitals.
KocKler and dirKsen integrating ethics services
127
Reecting the evolution of ethics services, ethics committees may not always
have a role in clinical ethics consultation. In the fast-paced, complex, and ever-
evolving nature of health care, a committee is not always nimble enough to provide
real-time support. In Oregon, we have evolved from a committee structure to consul-
tation teams and to professionally trained ethicists performing clinical consultations
in ways analogous to the ways other medical professionals consult on cases.
This last point is controversial and warrants further explication, as many
organizations operationalize ethics services differently. We maintain that health
care providers and administrators, who have varying degrees of sophistication with
formal and informal training in ethics, should not serve as professional consultants
but should participate in ethics consultations within the scope of their respective
roles and disciplinary perspectives. Health care ethics, including the practice of eth-
ics consultation, is a professional practice to be performed by professionally trained
personnel, that is, ethicists. However, ethicists do not have a monopoly on moral
knowledge, and multidisciplinary voices should be woven into ethics consultation.
This is in many respects analogous to medical care in general, in which an attending
provider seeks the input of professionals from multiple disciplines as needed.63 While
not all aspects of this journey of professionalization are settled, there is increasing
convergence on such a paradigm throughout the United States.
The evolution of ethics consultation into a team-based model in many settings,
for example, a subcommittee of an ethics committee or a specially designated roster
of people, creates a pretext for well-intentioned volunteers to perform a professional
practice. There is also a justice concern in asking individuals to add additional respon-
sibilities, for which they may have limited training and little or no compensation,
to their already demanding responsibilities. Yet a person who is an amateur in one
role may be an expert in another. Our strategy is to empower individuals to use their
professional competencies to address ethical issues within the scope of their roles. A
cadre of ethically formed health care professionals can address more straightforward
queries that are currently posed to ethics committees and consultation teams. Ethics
consultation by professional ethicists remains available for more challenging cases
and serves as a mechanism to ensure interdisciplinary dialogue and the weaving of
multiple narratives.
We embrace the evolution of ethics services, especially the implementation
of a professional clinical ethics consultation service, for a variety of reasons. First,
clinical ethics consultation is increasingly complex: a given committee or team may
not have adequate training to address such requests. This complexity may result
from new issues demanding professional expertise or from old issues requiring
revised approaches. Second, health care providers may need ethics consultation in
a manner correlative to the urgency of a question. In some cases, this may derive
from expectations of other clinical consultants; as a clinical consultation, ethics
consultation should be no different. In other cases, it may derive from the specic
63. Cynthia M.A. Geppert and Wayne N. Shelton, “A Comparison of General Medical
and Clinical Ethics Consultations: What Can We Learn From Each Other?,” Mayo Clinic
Proceedings 87.4 (April 2012): 381–389, doi: 10.1016/j.mayocp.2011.10.010.
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nature of a given case; for example, a provider needs to know immediately whether
it is ethically appropriate to initiate rescue interventions when a patient suddenly
but expectedly decompensates. Third, as clinical ethics consultation may have a
direct effect on patient care, often in life-and-death situations, it is incumbent on an
organization and caregivers to ensure that it be seen as a professional service staffed
by adequately trained individuals. This is not to say ethicists are infallible. They are
not, just like any other professional. However, if ethics are to provide reliable and
trusted guidance in ethically challenging patient-care situations, then caregivers,
patients, and families need to be able to trust that ethics consultations are done by
competent individuals within a professional scope of practice. In this regard, like
other professionals, ethicists qua professionals need to monitor and develop their
competencies by engaging in peer evaluation, attending professional conferences,
reviewing relevant professional society statements, and such.
Returning to how we operationalize ethics consultations, anyone who is directly
involved in the care of a patient may request an ethics consultation. Often, no single,
clear ethical issue precipitates an ethics consultation. Generally, ethics consultation
occurs when one or more ethical issues emerge, for example, regarding ambigu-
ous decision-making mechanisms or patient preferences, institutional policies, or
condentiality. The format of a consultation varies in relation to the urgency, scope,
complexity, and contingency of a case.
Ethicists also support regional and local ethics committees. At present, most
ethics committees in our region are developing ways to reect intentionally on the
particular ways our ministries can remain faithful to our Catholic identity, promote
high-quality care, and embody a just culture. As a body, they are generally not account-
able for ethics consultation but instead attend to the organizational context within which
ethical issues emerge. That said, members of ethics committees outside Portland do
play a role in ethics consultation: they function either as caregivers involved in the
various cases for which an ethics consultation occurs or as liaisons to facilitate the
performance of a consultation if the attending ethicist is unable to be present in person.
The members of the ethics committees receive ongoing ethics education through recur-
ring case studies facilitated by an ethicist as well as through our Ethics Core Program.
As part of their role in cultivating a just culture, ethics committees are charged with
ongoing formation of select institutional policies. The program manager of the center
recently joined the regional body responsible for operational procedures to facilitate
coordination and review of the ethical components of such policies.
There is one regional ethics committee, four ethics committees for service
areas outside Portland, one for our health insurance plans, and one for our elder-
care (PACE) program. The regional director of the center chairs the regional ethics
committee. Center ethicists support local ethics committees, which are chaired by
mission integration directors or medical staff. The regional ethics committee is a
forum for dialogue and action and represents our acute-care hospitals, clinics, and
home and community services. Membership reects a cross-section of clinical and
administrative roles, disciplines, and geographic distribution as well as local ethics
committees. Also, the ethicists at the center sit on one of the organization’s institu-
tional review board (IRB) panels as voting members who review clinical protocols
and consent forms for biomedical research on human subjects.
KocKler and dirKsen integrating ethics services
129
Finally, the center provides ethical analyses of general questions and practice
patterns. These questions may be related, for example, to crisis-care management,
medical repatriation, discharge safety practices, and the care of persons who insist
on continuing to use tobacco products, which are prohibited on hospital campuses.
disCernment. We cultivate a discerning approach to informal and formal
decision making grounded in the institution’s mission and core values as well as its
Catholic identity. Theologically, formal ethical discernment helps an organization
respond to the signs of the times with integrity. While there are no strict criteria for
when a formal ethical discernment is warranted, we have facilitated discernments
involving mergers and acquisitions, signicant capital investments, the opening or
closing of service lines, and other decisions that could have a profound effect on
mission or caregivers. All participants are called to promote the interests of the most
vulnerable vigilantly as the discernment and decision-making process unfolds.
Ethical discernments may be helpful if there is ambiguity regarding issues or
decisions in a particular domain, such as the appropriate mechanism for decision
making, institutional interests, service and business practices, or condentiality.
Ethicists, collaborating closely with a mission integration director, may play one
of two roles in a formal ethical discernment. The rst role is that of a discernment
facilitator, who coordinates with the mission department and the executive leader, or
decision maker, to facilitates dialogue. The second role is that of a theological and
ethical expert who participates like any other stakeholder.
A formal ethical discernment begins with determining the question, decision
makers, and stakeholders. It proceeds to the collection of background information,
which is then put into a report that provides baseline data, information, and opinions
that most participants feel are necessary for an informed discussion and decision.
Finally, key stakeholders and the decision maker meet for one to two hours, and
using our visual ethical decision-making model, the facilitating ethicist maps out
the dialogue on a whiteboard. The ethicists then write an executive summary of the
dialogue and send it to the decision maker with an image of the visualization.
sCholArship. Through research and scholarship, we participate in the intel-
lectual heritages of health care ethics, the medical humanities, and the Catholic
tradition as well as promote the professionalization of the eld of health care eth-
ics. As professional ethicists, we believe it is incumbent on us to continue to learn,
study, and contribute to the intellectual growth and renewal of our eld. Building on
the work we do and the programming we offer, we attend and present at regional,
national, and international conferences. We also publish our research in scholarly
periodicals. These activities enable us to bring back to our practice setting a set of
enriched competencies and ideas to further the quality and value of ethics services
for our organization and the communities we serve.
serviCe And outreACh. Finally, we support various individuals and groups
through collaborative engagement within the organization and the broader commu-
nity, serve as a community resource for excellence in ethics services, and support the
ethical components of an effective ecclesial communion with our local ordinaries.
Locally, we participate in regular meetings with leaders in ethics from other health
systems. We also present at local schools to generate interest in health care and
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ethics. We support county and state agencies engaged in crisis-care management.
Nationally, we support the Catholic health ministry, as one of us sits on a Catholic
Health Association committee for our eld. A range of institutions invite us to speak
regionally and nationally on health care ethics.
Clinical and Administrative Integration
Clinical and administrative integration serves as the foundation for the edu-
cation, formation programming, and other services we provide. We rmly believe
that success in our education and consultation depends on embodying a culture of
encounter and seeking solidarity with those who are closest to the moral quandaries
and who experience moral distress. There is a reciprocity of benet and feedback
with our consultation services, discernments, and educational programming on the
one hand and our clinical and administrative integration on the other.
In other words, integrating ethics services is the way in which we embody
solidarity and embrace a culture of encounter. Such integration occurs in interper-
sonal connections that enable effective, real-time communication. Ethicists are not
an add on” to administrative and clinical work. Ethicists are part of the team and
the organization. The interpersonal connections, whether they take place in person
or not, enable emotional attunement with stakeholders so that ethicists are better
able to assess the cognitive and emotional content of a given situation. Moreover,
solidarity cultivates the possibility of compassion. For ethicists, this type of solidar-
ity breeds deeper understanding of the complexities of a given situation as well as
an awareness of the challenges of practical considerations. What may be clear from
a principled argument is not always clear in terms of implementation. This kind of
integration requires solidarity that demonstrates both doctrinal awareness and pastoral
sensitivity. It is how we walk with and accompany those who request our services.
Currently, the center’s ethicists and staff participate in a wide array of admin-
istrative committees, councils, and other groups that are not, in a narrow sense,
“ethics” entities, such as administrative and clinical leadership, government affairs
and advocacy, community development, and mission integration.
In addition to the broad array of administrative integration, our ethicists routinely
make rounds in critical-care units and regularly participate in medical-surgical unit
multidisciplinary rounding at our community and critical-access hospitals.
Characteristics of Integrated Ethics Services
Being embedded in clinical and administrative work, with the set of expectations
derived from our institutional ecosystem, and based on the theological foundations
illuminated above, we have found a number of ways to characterize excellence in
the integrated ethics services we offer. We divide these characteristics into formative
metrics, which dene the quality of our services to the organization, and summa-
tive metrics, which dene the value of the services and programming we provide.
In evaluating our ethics services, we not only identify the indicators of quality and
value, but intentionally dene the measures of those indicators, the standards against
which we measure our success, and the rubrics we use to assess our successes and
opportunities for improvement.
KocKler and dirKsen integrating ethics services
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Formative metrics dene the quality of integrated ethics services. Indicators of
quality services include effectiveness, comprehensiveness, congruence, integration,
and accessibility. Each branch of our services has its own set of indicators—educa-
tional programming and consultation services will operationalize these indicators
differently. In the most general terms, effectiveness pertains to whether the intended
outcomes are achieved. Comprehensiveness corresponds to whether the activity
adequately addresses the full range of topics or issues. Congruence relates to whether
the content or activity is congruent with institutional policies and the ERDs. Integra-
tion describes whether and to what extent content is delivered in an interdisciplinary
way and embedded in the workows of caregivers. Accessibility denes whether
our services are available in a meaningful way that is, for example, not onerous to
those we serve.
Summative metrics dene the value of integrated ethics services. Indicators
include effectiveness, comprehensiveness, congruence, and sustainability. Effective-
ness pertains to how well we meet our objectives. Comprehensiveness means how
well we manage the full range of issues of ethical and theological signicance for our
organization in pursuing our strategic objectives. Congruence denes how well we
embody the aspects of our mission—for example, Catholic identity; this also relates
to how well our strategic objectives support the core strategy of our organization.
Sustainability here describes how well we are stewards of the resources with which
we have been entrusted.
To evaluate ourselves according to these metrics, we distinguish indicators,
measures, standards, and rubrics that compose the whole picture of a given metric.
We utilize a variety of measures to determine whether and to what extent an indicator
is evident. We then compare the measure against a standard. We also apply a rubric
to see, for example, whether we meet, exceed, or can improve a given indicator.
Some measures may be true or false. Therefore, we either meet or do not meet
our standard and thus can determine whether there is evidence of value or quality.
For example, we can measure accessibility by asking whether our staff ethicists have
functional pagers and whether clinicians can order an ethics consultation in the elec-
tronic medical record. Other indicators may necessitate less discrete measures. For
example, how effective is our Ethics Core Program? Although there are aws with this
methodology, we ask whether participants have learned something that will change
the way they practice. The results are tabulated in a Likert scale and aggregated.
Integrated Ethics Services and Accompaniment
Borden Bowne once said, “Life itself is the eld of morals, and the realization
of ideal life the aim. . . . Our present duty consists, not in the pursuit of a mythical
or unnatural virtue, but in faithfulness and helpfulness in the actual relations of the
family, of neighbor, of citizen.”64 The successful integration of ethics services is
64. Borden P. Bowne, The Principles of Ethics (New York: Harper and Brothers,
1892), v–vi.
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predicated on essential theological foundations, an appreciation of the institutional
ecosystem that shapes expectations of ethics services, and the evolution of the
eld of health care ethics into a profession. Through our ethics services, we aim to
accompany the people with whom we work and those we serve through health care
delivery, insurance provision, and other organizational activities.
We conclude with the words of Pope Francis:
There is no shortage of men and women of goodwill, scholars included, with
differing approaches to religion and with a variety of anthropological and
ethical visions, who are agreed on the need to propose more authentic wisdom
about life in view of the common good. Open and fruitful dialogue can and
must be pursued between all those committed to seeking meaningful founda-
tions for human existence. . . . The responsible accompaniment of human life,
from conception to its natural end, involves discernment and an understanding
born of love; it is a task for men and women who are free and dedicated, a task
for shepherds, not hirelings.65
May we all accompany each other as a pilgrim Church in a health care ministry
animated by the love of Christ.
65. Francis, Address to the Pontical Academy for Life (October 5, 2017).
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