Chaplaincy and Clinical Ethics: A Common Set of Questions

The ethical imperative for quality improvement in health care requires that all health care personnel engage in attentive observation, reflection, innovative thinking, and action. A core QI question for everyone working in a clinical setting is this: How can the delivery and service systems I participate in be improved to enhance and improve quality of care for patients and families? Chaplains, chaplaincy programs, clinical ethics consultants, and ethics committees all share this commitment. A challenge for both chaplains and ethics consultants is to articulate their unique roles, purposes, goals, and objectives so that they can establish adequate educational and training standards and programs, measure what they are doing against what they should be doing, and initiate, participate in, and maintain QI initiatives.

Both chaplains and ethics consultants generally claim to have distinctive roles, activities, knowledge, skills, and competencies. Nevertheless, similarities in their activities suggest that advantages may result from partnering as each group searches for its place in the health care system and for ways to best introduce QI interventions. Chaplains and clinical ethicists together could identify, recommend, and promote methods useful to both groups in the clinical context.

Chaplains and ethics consultants engage in many similar activities. For example, both meet with patients and their families one-on-one and during patient care conferences; both serve on interdisciplinary teams and participate in multidisciplinary clinical rounds; both document their interventions in patients' medical records; both provide services to and routinely interact with clinical staff and other employees; both participate as members of ethics committees and may lead ethics committees; and both participate as members of other organizational groups, such as institutional review boards and conflict of interest committees. In some hospitals and other health care settings, a chaplain may be the ethics consultant (where the individual consultant model is used) or may be included routinely as a member of ethics consultation teams. Both chaplains and clinical ethicists can serve as patient advocates, assist with advance care planning, facilitate communication and reduce conflicts among various stakeholders, and refer patients, families, and staff to other organizational resources after identifying their needs.

As a result, both chaplains and clinical ethicists need similar skill sets, knowledge areas, and character traits. They should be attentive listeners who are able to communicate interest, respect, support, and empathy. They must be adept at recognizing verbal and nonverbal cues, especially during difficult conversations, and they must be able to assertively articulate their own assessments, insights, and recommendations. Both groups must understand not only the health care systems and clinical contexts in which they work (including relevant institutional policies, procedures, and practices), but also any special beliefs and perspectives of patients, families, and staff. Character traits both groups share include compassion, integrity, humility, honesty, courage, and self-knowledge. Further, the activities and services of both chaplains and clinical ethicists usually do not generate income, and so both groups must demonstrate their "value-added" impact in ways other than by just adding up billable hours.

Neither chaplains nor clinical ethicists can claim a monopoly on expertise in their principle areas of service and focus-spirituality and ethical decision-making, respectively. Other members of the health care team and staff may have significant expertise in these areas as well. Further, in addition to certified chaplains, some health care organizations use chaplain volunteers, some with less-but some with more-knowledge, skills, and experience than their certified colleagues. Similarly, in addition to (or instead of) paid clinical ethicists, many organizations have volunteer ethics committee consultants, some with less-but some with more-knowledge, skills, and experience than their paid counterparts.

Both chaplains and clinical ethicists, then, struggle with a common set of questions: What are our unique roles and contributions? What are the core elements of our work that only we can bring to the health care encounter? What character traits enable someone to become a contributing practitioner of a "professionalizing profession"? What measures of effectiveness should we use to evaluate our work and inform quality improvement? Should clinical ethics permit multiple certifying bodies (as currently exist for chaplains) or one centralized certifying organization? Should clinical ethics follow [End...