The second goal of the recent national meeting of SDA bioethicists was to “explore the potential for future cooperation in bioethics across the Adventist health systems.” I am excited at the possibilities but see two challenges to this idea within Adventist healthcare in the United States. The first is financial and the second is structural. Let’s look at the first problem by starting with the question, "Who, exactly, are we talking about when we use the term, 'Adventist health systems?' ”
When I Google for “Adventist health systems” it takes me to: “Adventist Health System,” - the Florida-based institution that is by far the largest in the U.S. I found nothing there to indicate they have sibling Adventist institutions. I also found nothing on any of the other Systems sites indicating their Adventist connections. Nor did I find any connecting links on the NAD or GC sites that would direct readers to our Healthcare Systems. I find it curious that, for all the talk about strengthening connections between the Church and our healthcare ministry, there doesn't appear to be much evidence of it on our various websites. We should begin, for instance, with a full fledged statement of acknowledgment and support for each other. Then, how can we cheer each other on?
We can find information at the Adventist Health Policy Association website under the tab “About Us/AHPA Members.” Here five AHPA members are identified, noting their location, inpatient admissions, staffed beds, and personnel. Combined, the systems are in 17 states, with over 619k inpatient admissions, just short of 15k staffed beds, and over 126k employees. By system, the breakdown is as follows:
1. Adventist Health has 20 hospitals: https://www.adventisthealth.org/pages/home.aspx
2. Adventist Health System, by far the largest with over 70k employees and over 350k admissions annually: http://www.adventisthealthsystem.com/
3. Loma Linda University Health, with 35k admissions annually and 6 hospitals: http://medical-center.lomalindahealth.org/
4. Kettering Health Network, unique in several ways, presently serving in Ohio with just short of 10k employees: www.ketteringhealth.org
5. Adventist Health Care, works in Maryland, New Jersey, and the District of Columbia with just over 40k inpatient admissions: http://www.adventisthealthcare.com/
The AHPA website goes on to compare the size of the Adventist systems with "other major systems" around the US. But it doesn’t offer a comparison with other faith-based, non-profit healthcare systems. It surely is a blessing that our healthcare systems are doing well, but I do wonder what our healthcare ministry would look like if our large institutions were failing? What would SDA healthcare ministry look like if it were completely dispersed throughout other, non-Adventist healthcare systems; if we all worked for some other faith-based or secular healthcare organizations? For example, Hoag Memorial hospital in Southern California, a Presbyterian heritage hospital, recently joined another faith-based hospital system which isn’t Presbyterian. Could we Adventists imagine doing that?
So, if Adventist bioethicists are hopeful for more cooperation amongst ourselves and the systems we work for, what models of cooperation might we find among those "other major systems" listed on the AHPA website or, better yet, among other faith-based healthcare systems in the US?
For instance, is there a Lutheran, Jewish, Catholic, Baptist or Methodist hospital-system association of some sort? In secular healthcare in the U.S., the American Hospital Association (AHA) is the main body in which we might see some cooperation for public good. Some of our Adventist systems are members of the AHA. But the AHA does not have an active ethics sub-culture. For cooperation and connectivity among ethicists we have to turn to a stand-alone society: the American Society for Bioethics and the Humanities. A few of us are routinely involved there, but so few that I can't imagine forming a parallel structure with it like we have with the Society of Biblical Literature or the American Society of Religion. And this goes to my point about being dispersed among others in a professional field, for which we have no claim of particularity.
An editorial piece on Jewish healthcare in the U.S. might be instructive here. Among other things, the author asks: "Does the disappearance of Jewish hospitals matter? It is to the detriment of Jewish commitments to education, to the provision of health care to the poor, and is a loss to the extent that Jewish hospitals are a 'public face' of the Jews."i What would be the loss of an Adventist institutional healthcare presence in our communities? Who among those we serve (or ourselves) would suffer loss?
While there are many faith-based hospitals and systems caring for communities through a Protestant perspective, I am unaware of any general or particular association for the various Protestant healthcare systems. History demonstrates that we Protestants don’t particularly play well together. So, kudos to Adventists for at least creating an association for ourselves. Here again, we might learn from our Catholic brothers and sisters. The USA-centric Catholic Healthcare Association has been around for over 100 years and they represent about 85% of all Catholic healthcare providers. There is a Theology & Ethics department at the CHA with at least two full time theological ethicists and a number of supporting educational and administrative staff members. Their website says the CHA is "Comprised of more than 600 hospitals and 1,400 long-term care and other health facilities in all 50 states, the Catholic health ministry is the largest group of nonprofit health care providers in the nation. Every day, one in six patients in the U.S. is cared for in a Catholic hospital."ii
But let’s return to the main point of this column: how can Adventist healthcare systems cooperate more effectively to advance both overall care for our communities and with specific regard to ethics/bioethics? The "potential for future cooperation" across our Adventist healthcare business subcultures is immense and wide open at the moment. But business systems in the U.S. don't cooperate, they compete. This is just as true for "us" as it is for any business venture, even in healthcare. In the U.S. today, healthcare is an income generating industry. Indeed, one can invest in healthcare industry stocks and potentially make significant money. This does not say anything about how easy or difficult it is to profit from people’s ill health. Nor does it ponder the associated moral questions. Healthcare in America is as much, if not more, about business than ministry. Indeed, an oft stated refrain among faith-based hospital finance personnel is, “No margin, no mission.” Perhaps we should look somewhere overseas for a more authentic form of Adventist healthcare ministry?
So, what does it mean for us to imagine a future with a meaningful bioethics cooperation across Adventist healthcare systems in the U.S.? A few issues may immediately emerge. The first is paying for bioethicists and their work. Hospitals and their associated health ministries make money for providing direct services that customers/patients pay for. When was the last time you paid for an ethicist’s work? American healthcare is paid through a complex system of coded services. And bioethics services are not “billable.” So, hospitals must “eat” the cost of such staff, which typically means they simply don’t employ any. More frequently a healthcare professional, already working for the hospital (often an MD, but many other professions have joined the effort), is asked (or allowed) to spend some time “doing” ethics – most often “clinical ethics.” For hospitals to employ ethicists there needs to be a pretty strong felt need and, thus far within our Systems, they have apparently not felt that need. To my knowledge there are no ethicists presently employed in any Adventist Healthcare Systems who are dedicated to, and working solely as, an ethicist. Only academicians, chaplains and clinicians, working in associated positions and professions, who serve hospitals simultaneously – with no direct payments for ethics services. If there are bioethicists directly working within any of our Systems, it would be news to me.
The second issue is that there are very few “Adventist” bioethicists. One of my former colleagues at LLU has bemoaned our present condition for many years, saying “Who will fill our roles and positions once we’ve retired?” Mind you, he refers to those associated positions I mentioned above, rather than embedded hospital and Systems level ethicists. While our MA level program in Bioethics at LLU’s School of Religion has educated a good number of students through the years, only a few have gained employment as clinical ethicists. There just aren’t many full time jobs out there for ethicists, inside or outside of an Adventist context. Looking more broadly at our undergraduate colleges and universities one will not find an ethics degree program anywhere, and in some cases not even a single required course in ethics for a four year degree.
Finally, given these conditions, the type of “cooperation” at issue will be an important consideration. Clinical ethicists are fairly good at cooperative work arrangements. As I noted above, most of us combine ethics with some other profession that can charge for their services. The better healthcare systems develop and use cooperative methods for clinical consult services. The US Government Veterans Hospital System is the shining example of such cooperation. Their clinical ethics consultation service is miles ahead. What might we learn from them as we develop a cooperative model for Adventist healthcare? I am hopeful for the willingness of our Systems’ CEO’s to make this happen, though given their budget constraints, I recognize how difficult that will be. For all the money made in American healthcare, it remains a very competitive business.
Given the real and difficult problem of paying for healthcare ethics services, what can ethicists do for these institutions? A typical, clinical ethicist job description in healthcare includes three elements: 1) clinical case consultation; 2) educational work for the caregivers working with patients; and 3) development and/or management of policies associated with ethical issues. On this last element, for instance, hospitals have been developing policies over the last 10-15 years concerning palliative sedation.iii Other issues requiring policy work include: abortion, cessation of life-sustaining treatments, death by neurological criteria. When such policies are developed it is necessary to make sure caregivers understand the hospital’s positions, making education an essential part of a clinical ethicist’s work. Finally, when a patient and family are struggling with making decisions for their loved one they can ask for an ethics consult. Or when a physician is trying to make appropriate medical decisions for an ICU patient with no known family or friends, she/he can talk to an ethicist about it. Or when a pregnant girl, raped by her uncle, wonders whether or not it would be morally appropriate to get an abortion, clinical ethicists can be present, to talk and think together with her and her loved ones.
Some recognize this work as essential to present day hospitals and health systems. Next time, I’ll pull back the curtains a bit more with the hope that you will understand what ethicists do: clinical ethicists, organizational ethicists, religious/theological ethicists, and professors of ethics.
Mark F. Carr is an ordained minister and theological ethicist with experience as a pastor, pilot, commercial fisherman, professor, and now clinical ethicist. He writes from his home town of Anchorage, Alaska.
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