Chaplains often serve on ethics committees, as ethics consultants, and as institutional review board members. Yet there are no standardized ethics curricula in Clinical Pastoral Education (CPE) programs. “Chaplains’ training in ethics varies a great deal,” says the Rev. David Fleenor, STM, BCC, ACPE, director of education at the Center for Spirituality and Health at the Mount Sinai Icahn School of Medicine in New York City.
In reviewing the curriculum for the CPE residency program, Fleenor noted an insufficient focus on ethics. Three of the 31 competencies for board certification focus on ethics. Based on personal communications with committee leaders for chaplaincy certifying bodies, says Fleenor, “two of those three are frequently failed by board-certification candidates.”
To prepare CPE residency graduates to become board-certified chaplains, “we needed to improve this area of the curriculum,” Fleenor says. He contacted the Mount Sinai bioethics program “to learn what they taught and to whom.”
An ethicist agreed to provide education to residents and also help develop appropriate curricula. Formerly, an ACPE-certified educator taught a 60-minute didactic on the basics of bioethics. “This only skimmed the surface,” Fleenor says.
Once the ethicist agreed to teach in the CPE residency, 12 one-hour sessions were added. These cover important issues like confidentiality, justice, respect for autonomy, and assessing decisional capacity. “Our CPE residents now receive much more comprehensive coverage of ethics,” Fleenor reports.
To find out more about how other programs teach ethics, Fleenor and colleagues recently surveyed 84 CPE residency program directors about their ethics curricula.1 Seventy-three percent of programs included a required ethics component in their curriculum, 10% were in the process of developing one, and 18% included none. Among the programs that did include an ethics component, the amount of training varied widely.
“Some programs offer as little as occasional discussion of ethical situations that occur in spiritual care cases. Others offer formal ethics courses that run for 12 to 16 weeks,” Fleenor says.
Fleenor suggests ethicists provide training to chaplains and spiritual care trainees and/or partner with ACPE-certified educators to teach CPE residents together. “While chaplains generally need to learn the same bioethics information as other healthcare professionals, they also have discipline-specific learning needs,” Fleenor notes.
A few years ago, M. Jeanne Wirpsa, MA, BCC, HEC-C, created an ethics curriculum tailored to the unique role of the healthcare chaplain on the interprofessional care team. “The goal of the modules is not to prepare chaplains to become professional healthcare ethicists, though many of them will be tapped to lead ethics committees and conduct ethics consultations,” says Wirpsa, a clinical ethicist and research chaplain at Northwestern Memorial Hospital in Chicago.
Rather, the hope is chaplains can contribute meaningfully to ethical care. “Chaplains are experts in communication; values-clarification; cultural awareness; and the impact of religious beliefs, emotions, family dynamics, and cultural practices on medical decision-making,” Wirpsa says.
Chaplains often do not see the connection between this expertise and medical ethics. “When you look at the competencies and professional virtues outlined by the American Society for Bioethics and Humanities for ethics leaders and consultants, there is notable overlap with chaplaincy identity and training,” Wirpsa says. The ability to consider competing perspectives is one example.
“Training in counseling and narrative approaches to medicine prepares chaplains to discern values, deeply held beliefs, and goals embedded in patient and family stories,” Wirpsa explains.
At Northwestern Memorial, ethicists frequently partner with chaplains in complex cases where religious beliefs feature predominantly in an ethical conflict. Recently, a family stated that “hope for a miracle” was their primary reason for continuing aggressive ICU care. A chaplain stepped in to acknowledge the family’s religious beliefs and emotions, including grief and guilt.
“With time, the family member became ready to accept the patient’s preference not to be kept alive on mechanical ventilation, even as she hoped God would perform a miracle when life support was discontinued,” Wirpsa recalls.
Some families perceive their religious beliefs are at risk of violation during the delivery of healthcare. Chaplains offer respect and appreciation for what is at stake in these cases. “Chaplains serve as ‘translators’ between the medical team and patients and families,” Wirpsa notes.
Solid ethics education adds to chaplains’ foundational knowledge of religious traditions. For example, chaplains benefit from understanding that traditional Jewish ethics focuses on duties and relationships rather than individual rights. In some cases, this means the rabbi is the primary decision-maker authorized to apply relevant Jewish law to the specifics of the patient’s situation. “Chaplains can intervene to ensure this alternative approach to decision-making is implemented,” says Wirpsa.
As part of a study published in 2019, Wirpsa and colleagues surveyed 463 chaplains on their role of chaplains in medical decision-making.2 “We discovered that chaplains need to have a ‘seat at the table’ to fully contribute,” Wirpsa reports.
For example, chaplains should be included in family meetings and goals of care conversations. “It goes without saying that every ethics committee should include the unique lens of the healthcare chaplain,” Wirpsa says.
When chaplains are tapped to lead ethics programs or ethics consultation services, they might need more training than they received during their residencies. Chaplains can take advantage of programs offering bioethics degrees or certification in healthcare ethics consultation. “A proliferation of online courses makes gaining this additional layer of skill and knowledge relatively accessible,” Wirpsa adds.
REFERENCES
- Fleenor DW, Cummins P, Hirschmann J, Sharma V. Ethics education in clinical pastoral education: Prevalence and types. J Health Care Chaplain 2021:1-10.
- Wirpsa JM, Johnson ER, Bieler J, et al. Interprofessional models for shared decision making: The role of the health care chaplain. J Health Care Chaplain 2019;25:20-44.
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