Earl Weaver Was Right: It's What You Learn after You Think You Know It All That Counts

When I began my job as an intensive-care social worker, I was the latest in a series of clinical social workers who had been thrown into the intensive care units of a university-based hospital. At the time I was not even aware that a specialty of this kind existed and wasn't sure of all the aspects of the job for well over a year. When I started in the intensive care units, I had no experience and little knowledge of the complexity of the problems faced at the end of life. My master's degree in social work had prepared me with theory and with some clinical experience on issues related to the care of those with health or mental health problems. However, I had received little training on the care of the dying; in that area I was a novice. As fate would have it, however, despite my lack of knowledge I was frequently asked to handle the most troublesome cases.

My first such case was Jesse, a 22-year-old woman who, during a suicide attempt, had taken multiple medications, including canine heartworm medicine. She survived the attempt but was supported by a ventilator, and was receiving kidney dialysis. Jesse had no known family except for her 21-year-old boyfriend of 15 months. Jesse's case was discussed in detail in the morning rounds, and the team felt that some significant decisions had to be made regarding the limitation of care. One physician felt that life-sustaining therapy could not be discontinued because Jesse was admitted after attempting suicide and if we withdrew care we would be participating in her death. Another physician felt that we were providing futile care and that it should be discontinued. I was unsure of how to approach the case, so I asked some of the more seasoned nurses how these types of issues were handled before I came on board. I learned that the hospital occasionally used an ethics consultant from the University of Pittsburgh's Center for Medical Ethics. This was my first introduction to the field of biomedical ethics. The consultant was a Ph.D./M.D. and a wonderful teacher. He gently guided me through each step in this case and the many that followed. My clinical social work training initially helped with the communication skills and with certain aspects of the problem solving utilized in negotiation of end-of-life care. However, it was obvious that the ethics consultant had a knowledge base and a set of skills that I lacked. I applied to the master's program in medical ethics at the University of Pittsburgh the year Jesse died.

The master's program at the University of Pittsburgh has a strong philosophical base, and at the time I was a student it was housed in the History and Philosophy of Science Department. Admission standards were quite rigorous; the program accepted only eight students a year when I applied.

Because the master's program is based in philosophy, I learned how to formulate a lucid argument and produce a coherent thesis in writing. The program's weakness, however, is a lack of courses in and minimal coverage of health law, the clinical application of principles, and preparation for the clinical environment.

The ethics program requires 14 weeks of clinical experience, and the clinical site director worked hard to find unique sites for each student. It is important to note that this experience is mostly observational in nature and does not prepare one for doing ethics consultations. In fact the program director states openly that this degree alone will not secure a future in the field of biomedical ethics. During the clinical training time the students are matched with a mentor with whom they meet weekly. The provision of a mentor was invaluable...