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Abstract
Ethicists often struggle to maintain institution-wide awareness of and commitment to medical ethics. At Beth Israel Deaconess Medical Center (BIDMC), we created the Ethics Liaison Program to address that challenge by making ethics part of the moral culture of the institution. Liaisons represent clinical and non-clinical areas throughout the medical centre. The liaison has a four-part role: to spread awareness and understanding of Ethics Programs among their coworkers; share information regarding ethical dilemmas in their work area with the members of the Ethics Support Service; review ethics activities and needs within their area; and undertake ethics-related projects. This paper lists the notable attributes of the Ethics Liaison Program, and describes the purpose and structure of the programme, its advantages and the challenges to implementing it. The Ethics Liaison Program has helped to make ethics part of the everyday culture at BIDMC, and other medical centres might benefit from the establishment of similar programmes.
- Ethics Committees/Consultation
- Clinical Ethics
- Applied and Professional Ethics
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Introduction
Medical centres today face numerous challenges to providing high-quality and patient-centred care, and medical Ethics Programs must evolve to address those challenges proactively. Academic medical centres currently seek to provide care to sicker, older and more diverse patients than ever before, while using the most up-to-date complex technology, training young clinicians and conducting leading research. It is therefore imperative that these institutions create a moral culture in which practitioners of high-quality, cost-effective care can function at their best. To create and maintain a positive moral culture, institutions must rethink the traditional model for medical Ethics Programs, in which ethical issues are considered the designated responsibility of one or a few individuals, rather than as the responsibility of the institution as a whole and of all of the people within it.1–8 This paper describes an innovative programme at a Harvard-teaching hospital that has had success in addressing these challenges. The Ethics Liaison Program at BIDMC has helped to make ethics part of the culture of our institution, and we feel that other institutions would benefit greatly from the establishment of similar programmes.
BIDMC is a teaching hospital of Harvard Medical School, formed in 1996 as the result of a merge of Beth Israel Hospital and Deaconess Hospital. BIDMC is a tertiary care facility with a level 1 trauma centre and ranks third in the country for National Institutes of Health funding, with 649 licensed beds (including 77 critical care beds and 60 OB/GYN beds). Medical ethics has a long history at BIDMC: Beth Israel Hospital published the first Patient's Bill of Rights in 1972, and a Beth Israel clinician coauthored one of the first three published articles on Orders Not to Resuscitate in 1976.9 ,10
Ethics Programs at BIDMC began in 1998, with the establishment of the Ethics Support Service by Lachlan Forrow, director of Ethics Programs, and Stephen O'Neill, clinical ethicist. Stephen O'Neill was promoted to assistant director in 1998, and to associate director in 2005. Wendy McHugh joined the Ethics Support Service as clinical nurse ethicist in 2004, and was promoted to associate director in 2015. The Ethics Advisory Committee, a multidisciplinary body that oversees Ethics Programs at BIDMC, was created in 2003. In 2006, Wendy McHugh became the director of the Ethics Liaison Program.
Today, Ethics Programs at BIDMC address the typical functions of clinical ethics consultation, staff education and policy development and oversight. Ethics Programs at BIDMC are currently administered by the Ethics Support Service—Lachlan Forrow, Stephen O'Neill, and Wendy McHugh—and overseen by the Ethics Advisory Committee, a group of 15 people who represent clinical and non-clinical staff, trainees, patients and the community (see figure 1). The Ethics Advisory Committee does not participate in case consultation, which is conducted entirely by the Ethics Support Service; the Ethics Advisory Committee does, however, review the activities of the Ethics Support Service, including case consultation, on a monthly basis. The three members of the Ethics Support Service serve as clinical ethics consultants, averaging 10 ethics consults per month. They also conduct recurring ethics rounds in 19 locations throughout the hospital, hold a monthly Ethics Case Conference open to all 6000-plus hospital employees, and run the Ethics Liaison Program, the initiative highlighted in this paper.
Organisational chart of BIDMC Ethics Programs.
The Ethics Liaison Program was established to carry out the mission of Ethics Programs at BIDMC: To promote a culture in which all BIDMC staff appreciate the importance of the ethical aspects of their work (their decisions, actions, character and morale), and have the support they need to do that work in accordance with BIDMC's and their own highest moral standards. To create the programme, the director of Ethics Programs sent an email to the heads of services throughout the hospital, asking them to designate a representative from their area to serve as a link to the Ethics Support Service and the Ethics Advisory Committee. Currently, over 75 liaisons represent over 60 areas throughout the institution (see table 1). Liaisons have four responsibilities:
Areas represented by Ethics Liaisons
Informing colleagues in the liaison's clinical or administrative area about BIDMC Ethics Programs, including the liaison's role, the 24/7 availability of the Ethics Support Service, and educational activities provided through the Ethics Support Service.
Reviewing annually ‘ethics’ activities or needs (related to clinical or administrative practice, policy or education) in each liaison's area, so that an annual plan for how best to support those activities or address unmet needs can be developed in collaboration with the Ethics Support Service and the Ethics Advisory Committee.
Serving as primary liaison to or contact for the Ethics Support Service and the Ethics Advisory Committee if ethics issues related to the liaison's area are identified.
Creating an annual project that addresses an ethical issue within each liaison's department.
In addition to the leadership opportunities outlined above, liaisons also benefit from multiple opportunities to pursue various forms of education in ethics. Each month, liaisons are invited to a monthly meeting to discuss a deidentified listing of the previous month's ethics consults, as well as a journal article relating to a salient theme of that month's cases. Liaisons are also encouraged to attend ethics-themed presentations at the various Harvard Medical School-affiliated institutions and an annual 3-day bioethics course offered by the Harvard Medical School Center for Bioethics.
The budget for Ethics Programs at BIDMC comes from the Department of Medicine, Patient Care Services and grant funding, and the Ethics Liaison Program budget is a small subset of that budget. In addition, an anonymous donor has provided funding to support several Ethics Liaison projects.
In this paper, we will describe our Ethics Liaison Program, in the hope that ethicists at other institutions will follow our example and create similar programmes.
Programmes similar to ours
Several other institutions in the USA and elsewhere have created programmes called ‘Ethics Liaison’ services, but those programmes differ substantially from ours.11–13 However, those programmes are more akin to our unit-based ethics rounds than to our Ethics Liaison Program: the individuals referred to as ‘liaisons’ in the referenced programmes are clinical ethicists who round with clinicians, generally in the intensive care setting, whereas our liaisons are volunteer clinical as well as non-clinical staff from throughout the hospital.
A review of the literature reveals that there are two programmes similar to ours in Canada: The ‘Hub and Spokes Strategy’ at the Joint Centre for Bioethics in Toronto,3 and the ‘ethics network’ model at Providence Health Care in Vancouver.4 Like our Ethics Liaison Program, both of the aforementioned programmes were established with the goal of integrating ethics into the moral culture of the institution. In the ‘Hub and Spokes Strategy’ model, ‘the hub consists of the core clinical bioethics leadership, while the spokes consist of clinicians and ethics resource leaders with training in ethics who help integrate ethics awareness, knowledge and skills throughout the organisational structure’.3 The ‘hub’ is similar to BIDMC's Ethics Support Service, and the ‘spokes’ play a role analogous to that of our liaisons. The ‘ethics network’ model in Vancouver is a larger programme, and it includes a component similar to our liaisons and to the aforementioned ‘spokes’: the ‘ethics mentor,’ defined as ‘a local, “shoulder to shoulder” and immediate presence to their colleagues…ethics mentors were not to be “policemen” or “mini-ethicists” but rather a “first point of contact” to help others name and explore common ethics dilemmas… Fundamentally, ethics mentors are to assist in promoting a culture of proactive ethical improvement in practice in their particular workplace’.4 Like our liaisons, both the ‘spokes’ and the ‘ethics mentors’ can be either clinical or non-clinical personnel.
There have been no subsequent publications describing either the ‘ethics mentors’ or the ‘Hub and Spokes’ programmes, and it is therefore difficult to determine the extent to which these programmes have been sustained in the years since the publication of the articles cited above. The ‘Ethics Mentors’ programme seems to have transitioned into a smaller programme called the Ethics Resource Forum,14 a ‘multidisciplinary and cross-site team’ of 15 people. The ‘Hub and Spokes Strategy’ was mentioned in the Ten-Year Review published by the Joint Centre for Bioethics in 2006,15 but not in their more recent 2011 Review.16 However, the 2011 Review describes a new programme called the CORE (Clinical, Organizational & Research Ethics) Network of 35 ethicists and fellows, which may have developed out of the ‘Hub and Spokes Strategy’ and seems to have similar aims. In addition, the website for Sunnybrook Health Centre, a teaching hospital of the University of Toronto, includes a page describing their participation in the ‘Hub and Spokes Strategy’.17
Notable attributes of BIDMC's Ethics Liaison Program
The Ethics Liaison Program at BIDMC:
serves a need identified in the Mission Statement of BIDMC Ethics Programs (see p. 1);
involves staff from non-clinical areas in Ethics Programs as liaisons, including but not limited to nutrition services, public safety, communications and human resources (see table 1 for complete list);
enables long-term involvement in and preserves institutional knowledge about Ethics Programs: when members of the Ethics Advisory Committee complete their fixed terms, they can become liaisons;
provides a means by which individuals can easily get involved in Ethics Programs, without the considerable investment of time and departmental resources required of ethics committee members;
puts the interest and energy of those individuals to use through liaison projects;
provides a forum for open and honest monthly discussions of ethics issues;
facilitates a peer-review process for the primary ethics consultants through case discussions;
creates, maintains and grows a substantial and hospital-wide network of individuals involved in Ethics Programs;
increases ethicists' awareness of ethics issues throughout the institution;
enhances diversity of ethics committee membership, as ethics committee members are selected from the hospital-wide network of liaisons representing both clinical and non-clinical areas.
Building a moral culture through relationships
The Ethics Liaison Program fosters relationships between the liaisons and the members of the Ethics Support Service, as a standing mechanism influencing and maintaining a moral culture within the institution. The Ethics Liaison Program helps to shift the influence of those who ‘do ethics’ in the institution to everyone who works here, whether at the bedside, in the laboratory or in the office. The programme enables us to enact our mission statement that ethics is part of everyone's daily work. Strong relationships between individuals are an essential ingredient of institutional moral thriving.2–5 ,8 ,18 The Ethics Liaison Program encourages individuals who share an interest in ethics, but who would likely not have discovered that shared interest if they were not part of the Ethics Liaison Program, to discuss ethics issues at the hospital during monthly meetings. Those meetings also provide opportunities to spread the word about new policies, pertinent new state statutes or other ethics-related initiatives, to facilitate respectful debate among the members about specific cases, and to encourage moral reflection within a group of employees.
The Ethics Liaison Program facilitates communication, collaboration and mutual respect across traditionally ‘siloed’ groups within the hospital. Every liaison brings both personal and professional expertise that adds value to the monthly group discussion. For example, during a case discussion of a patient originally from India, the patient's family agreed to withdraw life support, but wanted that to be done on a certain day. The group did not fully understand the reason for that preference until the liaison from our Pathology Department, who is also from India, talked to the group about life and death traditions involving numerology. As another example, one of our monthly group discussions centred on the ethics of having a court-appointed guardian make decisions on behalf of an incapacitated patient. Our liaison from the legal department explained the guardianship process to the group.
The moral culture created through the Ethics Liaison Program creates conditions ideal for preventative ethics, where liaisons and ethicists work together to address potential ethical issues before they rise to the level of formal case consultation. By sharing the knowledge that they have developed within their areas of expertise, liaisons and ethicists help one another to resolve future possible conflicts before they develop into actual problems, and issues that might otherwise have occasioned ethics consults can be addressed upstream, mitigating the need for a consult. Liaisons and ethicists share knowledge and expertise through the monthly group discussions and on an ad hoc basis as well.
Increasing awareness of and involvement in Ethics PROGRAMS
The Ethics Liaison Program at BIDMC has made ethics explicitly part of the culture of our institution by increasing awareness of and involvement in Ethics Programs. The programme directly engages liaisons in Ethics Programs through invitation to the monthly Ethics Liaison Program meeting and monthly case conferences; the annual project undertaken by each liaison and opportunities to attend presentations on and to take courses in bioethics. Liaisons represent both clinical and non-clinical departments throughout the hospital, and the programme provides them with an entry point into ethics work that they would not otherwise have had.
Liaisons then bring their experiences back to colleagues within their departments, fostering hospital-wide awareness and use of Ethics Programs, including consultations from our Ethics Support Service and educational programmes such as BIDMC's monthly ethics rounds. Underuse of ethics consult services has been linked to a lack of awareness and/or understanding of the role of those services.11 ,19 ,20 In our model, liaisons get to know members of the Ethics Support Service personally, and they learn that ethics consultants advise and collaborate with clinicians, but the attending physician, not the ethics consultant, has decision-making authority. The liaisons then explain that to their colleagues, fostering familiarity with the Ethics Support Service and knowledge of other bioethics-related activities at the medical centre and other opportunities for learning through the Harvard Medical School Center for Bioethics and through professional association meetings.
Liaisons also serve as a communicative link between the Ethics Support Service and their colleagues within their departments; that link is a valuable asset given the current trend towards institutional growth, as the addition of smaller hospitals to the network creates the challenge of standardising services across locations. Liaisons who work primarily at smaller, affiliated hospitals can facilitate communication between their colleagues and the ethicists at the larger institution. At BIDMC, the liaisons at smaller hospitals within our system have helped us to connect with the leadership of those hospitals and with clinicians who have an interest in becoming involved with Ethics Programs (see table 2). While not a substitute for a systematised effort to unify Ethics Programs across affiliated hospitals, an Ethics Liaison Program would serve as a springboard from which to work towards achieving that goal.3 ,21
Sample Ethics Liaison projects
At institutions with smaller Ethics Programs, an Ethics Liaison Program might be particularly helpful in connecting ethicists with staff members throughout the institution and harnessing those staff members' interest in contributing to ethics programming. Liaisons functioning as ambassadors for Ethics Programs would also be particularly useful at institutions where the ethicist(s) struggle to maintain institutional awareness of those programmes.
Increasing diversity within and strength and sustainability of Ethics Programs
Our Ethics Liaison Program heightens diversity within Ethics Programs. Many have noted the need for increased diversity in hospital ethics committees.1 ,3 ,22 ,23 An Ethics Liaison Program seeks representatives from all departments throughout the hospital, thereby inviting a diverse membership. The programme is easy to join: would-be liaisons need only indicate their interest in the programme to their department head or to the ethicist who directs the Ethics Liaison Program.
Diversity within the Ethics Liaison Program also enhances the effectiveness of the Ethics Advisory Committee. At BIDMC, the Ethics Advisory Committee selects new members from the pool of existing liaisons (see figure 1). The Ethics Liaison Program enables liaisons to demonstrate and to improve on their knowledge of ethics and their leadership skills, and ultimately, to become strong candidates for serving on the Ethics Advisory Committee. Literature on the composition of ethics committees emphasises the importance of those attributes.3 ,18
The Ethics Liaison Program also contributes to the sustainability of Ethics Programs, because the Ethics Liaison Program does not have fixed terms. Liaisons can serve for as long as they are interested, able and effective, and multiple liaisons can represent a given department, so a liaison's decision to continue participating in the programme does not inhibit others from taking part. The Ethics Advisory Committee does have fixed terms and it benefits from the regular introduction of new members. When a member's term ends, they can remain a liaison, thereby continuing to take part in Ethics Programs and preserving institutional knowledge regarding ethics activities.
Furthermore, the Ethics Liaison Program allows more staff to become involved in Ethics Programs than would be possible if Ethics Programs consisted only in the Ethics Support Service and the Ethics Advisory Committee. If the Ethics Liaison Program did not exist, staff members interested in getting involved in ethics could only seek involvement in Ethics Programs through membership in the Ethics Advisory Committee. The number of Ethics Advisory Committee members is and should be limited so that all members can attend monthly meetings and can be required to participate actively in Ethics Programs. The Ethics Liaison Program, therefore, provides an opportunity for any interested staff members to become involved in ethics, while simultaneously preserving the administrative effectiveness of the Ethics Advisory Committee.
Liaison projects
In an effort to live by our philosophy that ‘ethics is in everyone,’ we encourage liaisons to complete an annual project addressing ethics-related needs within their areas. We ask liaisons to consider how their project might have a lasting effect on the institution, as well as the resources and support they will need. Since liaisons serve on a volunteer basis and have very busy schedules, some do not have time to complete annual projects; others can do so for 1 year but not the next. We estimate that around 20% of liaisons complete a project in a given year. When a liaison cannot complete a project, we frame that event not as a ‘failure’ on the part of the liaison, but rather as a reflection of the fact that liaisons have many competing demands on their time. We do not want the projects to have a chilling effect on staff members who may have an interest in becoming liaisons.
Liaison projects have ranged from the simple and informal to the complex and involved. Liaisons seek to address a wide variety of ethics issues through their projects, from the specialised to the systemic, and from direct patient care to organisational ethics. The members of the Ethics Support Service work with each liaison to find a project that they can complete within their time constraints. When a liaison does not have time to undertake a complex project but wants to find a way to build awareness of Ethics Programs in their area, they often find a time when one of the three members of the Ethics Support Service can meet with their colleagues. In planning these meetings, liaisons work with the Ethics Support Service and their managers, initiating mentoring relationships with both parties. Even a one-time meeting can spark interest in and build awareness of Ethics Programs, thereby strengthening the moral culture of the institution. In some cases, the excitement generated through one meeting leads to regularly scheduled or to ad hoc ‘ethics rounds’ within that area, and the liaison looks out for cases that merit discussion and informs the members of the Ethics Support Service when those cases arise. Several of the more complex projects that liaisons have undertaken are described in table 2.24 In this way, liaisons significantly broaden the reach of clinical ethicists and enable fruitful discussion of ethical concerns that, while worth discussing, would not have triggered formal ethics consultations.
At the end of each year, we ask liaisons to reflect on the status of their projects. Like an annual performance review, the process facilitates growth and reflection. This approach has allowed tremendous variability in the level of involvement for the liaisons, and yet serves collegiality and provides both personal and institutional benefit when liaisons are able to identify and complete projects. Keeping records of the progress of liaison projects also provides us with tangible evidence of the benefits of the Ethics Liaison Program.
Barriers to Ethics Liaison Program implementation
We have identified time, individual participation and funding as the major barriers to the implementation of our Ethics Liaison Program. Time is a key barrier for both clinical ethicists who run the programme and liaisons who participate; both groups have given freely of their time for this largely uncompensated activity. The expectations of the programme are clearly stated upfront, so that the time needed to participate is not a surprise to liaisons. However, the demands on individuals' time can vary in unanticipated ways, making it difficult for them to commit as much time to the Ethics Liaison Program as they had initially intended. Liaisons report that some of them complete their projects on their own time, and others work on their projects at times when their workflow is slower, as the demands of many positions vary depending on the time of year. For many liaisons, their projects complement their existing work in their home departments, and there is administrative support available for projects related to the work of those departments.
Similarly, given the inherent business and uncertainty of daily schedules, all 76 liaisons do not participate in each conference; an average monthly liaison meeting draws 12–15 participants. Individual participation is also highly variable in the breadth and depth of liaison projects. While liaisons are welcomed and encouraged to engage in ethics to the greatest extent to which they are inclined and which their busy schedules permit, the requirements of the programme are intentionally limited to allow all those who share an interest in ethics to serve as liaisons.
We believe that the loose requirements of the Ethics Liaison Program are one of the programme's strengths. Pape and Manning have criticised the ‘Hub and Spokes Strategy’ at the Joint Centre for Bioethics (see above) for ‘limited attention given to identifying and addressing knowledge and skill development of the ethics committee membership’, and they argue that there is a ‘need for some type of standardized core curriculum to support the training needs of the identified spokes’.25 Presumably, Pape and Manning would also find fault with our Ethics Liaison Program, on the grounds that we do not insist that our liaisons comply with any formal requirements.
We submit, however, that what could be viewed as a lamentable lack of accountability in our programme actually works to our advantage. As Murphy explains in his article on the ‘Ethics Mentor’ programme at Providence Health Care (see above), ‘the key feature of the [ethics mentor] role, which colleagues felt enabled them to participate, was that they were not required to come to monthly meetings as in the [Healthcare Ethics Committee] format’.4 The accessibility of our Ethics Liaison Program is one of its advantages: anyone interested in Ethics Programs can be a liaison, even if he or she can only attend occasional ethics programming. Ethics Programs have traditionally relied heavily on the work of volunteers, whose busy schedules sometimes inhibit their active and consistent participation; an Ethics Liaison Program gives them a way to take part in ethics activities to the extent possible for them.
Our programme can allow for that degree of flexibility because it corresponds to the specialised role of the liaison. Liaisons do not ‘decide’ or even ‘consult’ on ethics cases on a formal basis, though they may serve as ‘sounding boards’ for their colleagues regarding ethically complex cases. If our liaisons served as ethics consultants, they would need formal ethics training and oversight. But because they do not serve as ethicists in a formal capacity, they need not complete formal training. They are, however, invited to pursue a variety of educational ethics opportunities if they have the time and the desire to do so. Because liaisons undertake their projects in collaboration with the Ethics Support Service, the risk of liaisons' misunderstanding what is/is not ethics is mitigated. The development of a liaison project in collaboration with the Ethics Support Service can serve as a way for liaisons to learn more about what constitutes ethics. That said, because the members of the Ethics Support Service must juggle various other duties and responsibilities, the problem of liaison inactivity is not currently addressed in a systematic manner. This is a potential area for growth for the Ethics Liaison Program at BIDMC. Furthermore, given the relatively small amount of funding earmarked for ethics at our institution, we are limited in our ability to allocate funds for the Ethics Liaison Program. We use a portion of the overall ethics budget to cover Ethics Liaison Program costs, including lunch at the annual orientation programme and the monthly liaison meetings, at an annual cost of $1600; we have found that attendance dramatically improves if lunch is provided.
Conclusion
The Ethics Liaison Program at BIDMC has helped to make ethics an explicit, widespread and enduring part of the culture of our hospital, and we encourage medical ethicists and healthcare ethics committees to consider establishing Ethics Liaison Programs at their own institutions. To do so, we recommend emailing the heads of departments throughout the hospital to request that they nominate a colleague to serve as a liaison. Ethicists can then schedule a monthly meeting that will serve as a forum for discussion of complex cases. The establishment of an Ethics Liaison Program requires few resources and yields considerable returns, including the intangibles of improved staff engagement and retention.
Acknowledgments
We thank Christine Mitchell for her comments on an earlier version of this manuscript.
References
Footnotes
Contributors WM, LF and SON established the Ethics Liaison Program. WM leads the Ethics Liaison Program. SB, WM, AC, SON and LF drafted and revised the paper.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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