Many ethicists play an important role in addressing burnout at their organizations — by identifying moral distress, connecting clinicians with resources, or holding debriefings after difficult cases. Yet ethicists themselves are experiencing burnout.
“As clinical ethicists, our experience of burnout is unique in some ways. Different types of solutions are required to address it,” asserts Ryan J. Dougherty, PhD, MSW, HEC-C, an assistant professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine, and a clinical ethics consultant at Houston Methodist Hospital.
Ethicists “have really proven their worth during the pandemic. There is a new appreciation and reliance on the expertise of ethicists,” notes Dougherty. However, the resulting burden on individual ethicists is considerable. For some ethicists, it has caused them to leave the field entirely. “I know ethicists who have left their role, both in fellowship programs and in their careers. The burden was too great, and not proportionate to the compensation,” Dougherty reports.
Hospitals are investing in wellness programs to combat burnout.1 However, evidence suggests that healthcare providers place higher value on improvements in staffing, workload, and work environment.2 “While wellness programs do play an important role, those are wholly insufficient,” says Dougherty. “Those are sort of like Band-Aids. It needs to be complemented by really creative thinking on how to support people in the day-to-day of their labor.” For ethicists, a typical day’s work is cognitively and emotionally demanding. Ethicists routinely facilitate the resolution of intense conflicts; interview people who are experiencing emotional turmoil in the face of very high-stakes decisions; and witness disease, illness, and disability. “Our day-to-day work exhausts the personal resources that we bring to the table — and that’s true for a lot of medical professions. But what makes the work of clinical ethics interesting is that we are a relatively new profession,” observes Dougherty.
Some ethicists perceive a continuous need to demonstrate the value they bring to the institution. At the same time, ethicists must establish boundaries for the workload (and compensation) they are willing to accept. “It’s a very difficult position for many ethicists, because there really isn’t a standard. You have to really advocate for what your role should be at the institution,” explains Dougherty.
Ideally, that burden does not fall solely on the shoulders of individual ethicists. “Avoiding burnout really requires a novel way of structuring a clinical service,” says Dougherty. Baylor’s ethics service recently switched to a new model to prevent burnout. A different ethicist is now on call every week, and a second ethicist is designated to support the on-call ethicist. The second ethicist is there in case there are too many consult requests for a single ethicist to handle, and also serves as an available resource to process complex cases. “That could mean talking about one’s own ethical reasoning or thinking about a strategy. Or, it could just be an opportunity to vent and emotionally process some of the emotional, spiritual, or existential aspects of working on difficult cases,” says Dougherty.
Currently, Baylor College of Medicine employs five professors who also serve as clinical ethics consultants for Houston Methodist Hospital. The other hospitals in the Houston Methodist system use volunteer ethicists who review difficult cases as a group. Distributing the burden among multiple ethicists lessens the risk of burnout. In contrast, some community hospitals have only one full-time ethicist; others rely solely on volunteer physicians. Thus, says Dougherty, “every service needs to develop its own strategy for addressing burnout that is sensitive to whatever resources are available to it.”
Standardized solutions to burnout prevention are hindered by the heterogeneity of ethics services, adds Dougherty. “There doesn’t seem to be a uniform service model. The field needs to come together and share solutions to identify some common things that would work across services,” says Dougherty. Ethicists can, for instance, set realistic expectations (such as refusing to be on call 24/7 without additional compensation, or declining to take non-urgent calls during off-hours). “We need to think about broader professional solutions to help ethicists set standards for what a sustainable role would look like, in terms of hours and compensation,” suggests Dougherty.
Variation in the role of ethicists at institutions is another hurdle. “We don’t even know how to characterize what ethicists do at every institution. There is not a shared script describing the work that we do,” adds Dougherty. As the ethics field evolves, identifying the best ways to prevent burnout may become somewhat easier. “Ethicists are beginning to coalesce around a particular set of standards, an identity, and what one should expect in terms of pay,” says Dougherty. “That will go a long way in terms of protecting junior ethicists from walking into situations or roles that would certainly lead to burnout.”
Ethics program leaders should regularly check in with ethicists — about cases, about obstacles to providing quality patient care, about professional needs, and about challenges, including any burnout issues they may be encountering, says Ruchika Mishra, PhD, program director of bioethics at the Program in Medicine and Human Values at Sutter Health. “Burnout is not an individual healthcare professional’s problem. It is a structural problem,” underscores Mishra. For ethics program leaders, the challenge is to obtain support from administrators for an adequately resourced ethics service. “Otherwise, the program may not be sustainable, with risk of ethicist burnout and attrition,” warns Mishra. Mishra says that to mitigate burnout risk, ethicists’ work environment should include:
• sustainable work hours;
• adequate compensation;
• full-time equivalent structuring to prevent excessive workload;
• professional development opportunities (such as publishing their work in the literature or presenting at conferences);
• appropriate boundaries regarding scope of work;
• a culture of open communication so that ethicists feel comfortable speaking up about any challenges they are encountering;
• a platform for peer and leadership support (such as staff meetings where ethicists can get colleagues’ perspectives on challenging patient care dilemmas);
• built-in coverage during time off. “This allows ethicists to completely switch off when away from work, and be fully present and engaged when back at work,” says Mishra.
Encouraging ethicists to report burnout also is important. Joelle Marie Robertson-Preidler, PhD, MA, recently shared her own struggles with burnout at a presentation, and initially worried about stigma. However, the topic resonated with many of the ethicists in attendance, who reported their own experiences with burnout. “If you look at risk factors for burnout, such as dysfunctional workplace dynamics, unclear job expectations, lack of social support, and lack of work-life balance, it is clear that clinical ethics work puts people at high risk,” says Robertson-Preidler, an assistant professor in the McGovern Center for Humanities and Ethics at the University of Texas Health Science Center at Houston.
Some clinical ethicists are on call 24 hours per day for up to a week, lacking time to emotionally recover from their work. Feelings of powerlessness also contribute to burnout. Ethicists often deal with cases where there are no clear solutions to greater structural inequities, such as lack of social support or limited discharge options. “Addressing burnout will require both structural changes and empowering clinical ethicists to set appropriate boundaries,” says Robertson-Preidler.
A combination of external and internal factors contributed to burnout, in Robertson-Preidler’s experience. External factors included having little control over work schedule, conflicting commitments, no dedicated downtime during call weeks, missed holidays, and lack of formal structures for emotional support. Internal factors included not setting appropriate boundaries, wanting to be liked, witnessing unnecessary suffering and feeling powerless to change the situation, and inability to “switch off” or take breaks. “Some things that helped me through the burnout were peer support, building support systems, and creating boundaries around my scope of practice and work hours,” Robertson-Preidler reports.
Open communication among ethicists also is important, both to ascertain the extent of burnout and to find solutions. “Clinical ethicists should start talking to each other, collaborating, and advocating for needed changes. It is harder to ignore a united front,” urges Robertson-Preidler.
REFERENCES
- Pipas CF, Courand J, Neumann SA, et al. The Rise of Wellness Initiatives in Health Care: Using National Survey Data to Support Effective Well-Being Champions and Wellness Programs. Washington, DC: Association of American Medical Colleges; 2021.
- Aiken LH, Lasater KB, Sloane DM, et al. Physician and nurse well-being and preferred interventions to address burnout in hospital practice: Factors associated with turnover, outcomes, and patient safety. JAMA Health Forum 2023;4:e231809.
Many ethicists play an important role in addressing burnout at their organizations — by identifying moral distress, connecting clinicians with resources, or holding debriefings after difficult cases. Yet ethicists themselves are experiencing burnout.
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