Efforts Underway to Diversify Clinical Ethics Field
March 1, 2023
There are many efforts underway to diversify the healthcare workforce, the medical school applicant pool, and clinical trial participants, but the field of clinical ethics also needs diversification.
“Increasing diversity in this field is critical to ensure that ethicists do not unintentionally worsen health disparities and cause harm to patients, thereby breaking the ethics tenet of nonmaleficence,” says Barquiesha Madison, BS, program coordinator in the Wellstar Health System Ethics Program.
Madison and colleagues recently developed a proposed framework with actionable steps to expand diversity.1 The authors argued teams with multiracial representation are better prepared to address the ethical concerns of the patient populations served.
“We hope that our actionable steps will help to spearhead the ‘diversity problem’ and also help to create change, not just conversation,” Madison says.
If there is no diversity in the organization, then it is not possible to create an ethics committee that is diverse. “Creating diversity within the organization is a huge task that requires a lot of buy-in and stakeholders,” Madison notes. “It is important to recognize that this may be a barrier to forming diverse ethics committees.”
The best approaches depend on the available ethics resources. Some ethicists are sole practitioners at hospitals. Others are part of an ethics program with several people handling consults. “It is unusual to have even one full-time equivalent at a hospital,” notes Thomas V. Cunningham, PhD, MA, MS, bioethics director at the Kaiser Permanente West Los Angeles Medical Center.
Ethicists can advocate within the organization to expand opportunities to train aspiring professionals, including advanced undergraduates, people in graduate school, or recent graduates. This is a way to open the pipeline of people to join the ethics field. One obstacle is these opportunities usually only exist for people who already are hospital employees. “Because of the complexity and perceived controversy of the topics that we work on in the field, organizations are reluctant to create pathways for people who are not already employed to get access to these kinds of conversations,” Cunningham reports.
This is similar to medicine in that in many hospitals, there are few opportunities for students to participate in observational work with physicians or with nurses. “You usually have to be part of an accredited degree program to do that, and we don’t have as much of that in clinical ethics as with other allied professions,” Cunningham explains.
This leaves it up to individual ethicists to advocate for the importance of finding pathways for hospital employees to become clinical ethicists. “In fact, for most hospitals around the country, it will be logistically and fiscally easier to retrain existing employees for this work,” Cunningham notes.
In Cunningham’s experience, most intensive ethics seminars in the United States cost less than $5,000. If a hospital allocates $5,000 to $10,000 annually to a program that targets expanding diversity in ethics work, that would be enough to help someone complete enough coursework, experience-based training, and supervision to be a good candidate for the HEC-C credential. “That is a nice pathway from bedside health provider to part-time clinical ethicist,” Cunningham says.
Cunningham would like to see healthcare leaders asking a basic question: What are we doing to improve diversity in ethics work? For individual ethicists, the challenge is how to find the ear of leaders who care about improving diversity. “The ethicists would then need to connect with experts who actually do the work, and figure out together how to build a more diverse ethics program,” Cunningham explains.
The field of ethics already faces a pipeline issue. “That makes it even harder for people of color and people of diverse ethnicities to get access to the work,” Cunningham laments.
At the collegiate level, undergraduates might express interest in taking bioethics courses. Some might be philosophy or religious studies majors, but many could be pre-healthcare professionals who want careers as nurses, social workers, or physicians. “They are already the right audience. They are already interested in helping professions and already thinking about the possibility of going into the field,” Cunningham observes.
Ideally, the faculty teaching bioethics courses could connect those students with ethicists in a hospital. This would allow the faculty to know about funded internship programs that could expose students from diverse backgrounds to ethics work as a career pathway. Such programs are uncommon, according to Cunningham. “That’s partially a visibility problem, and partially an issue of funding,” he says.
There are not many opportunities for people to be hired for entry-level jobs offering exposure to ethics work. “Bolstering those kinds of programs, and then advertising their existence, would be a really big step forward to increase pathways for undergraduates to make bioethics a career choice,” Cunningham offers.
Currently, there is a need to pay specific attention to recruit undergraduates from diverse backgrounds into those programs. One obstacle is most programs offer ethics work only on a volunteer basis.
“It’s really hard for people to go from being an underemployed student to a volunteer position and needing to pay bills. It’s a disincentive to being in the profession,” Cunningham says.
As for diversity on hospital ethics committees, those positions typically are volunteer, too. Many people on ethics committees are paid to perform another job other than ethics, or are not paid at all.
“Adding people to that mix isn’t really helpful, because most rational people come away from that thinking ‘there is no paid work here,’” Cunningham says.
Many healthcare professionals are interested in ethics work and demonstrate talent for it, but then go into other professions. “Then, they try to recover that interest in ethics after they already have a career,” Cunningham says.
For example, some people might have majored in philosophy in college and loved ethics, then went on to medicine, nursing, or social work. Later in their careers, maybe they want to serve on an ethics committee on a voluntary basis because they really like the work.
“If we make the assumption that more diverse candidates are more likely to have greater need of funding, and are less likely to be able to be underpaid or do volunteer work, that compounds the disincentive for that population of people,” Cunningham stresses. “Despite this, it’s a barrier that can be overcome at the individual level.”
Bioethics professors at community colleges or major research colleges can be on the lookout for promising students from diverse backgrounds and try to find pathways for those students to connect with compensated ethics work.
“Colleges sometimes have access to different pools of funding that we don’t have access to in the hospital area, like graduate teaching assistantships or research assistantships, which can be the things that can support a student,” says Cunningham, adding he believes this would bring students into the hospital for exposure to ethics work.
Ethicists in hospitals can look for promising staff with an interest in ethics and try to find pathways for them to become involved in ethics initiatives. “It’s not just new graduates, but also people already in the healthcare workforce who are good candidates for ethics roles,” Cunningham says.
For instance, a social worker with a talent for clinical ethics could be cross-trained to take on an ethics role. “Often, those people make phenomenal ethicists because they have rich clinical backgrounds. Add in the right training, and you get really strong clinical ethicists,” Cunningham says.
By providing on-the-job, compensated training and credentialing, the ethics pipeline could be made more diverse. “Right now, that is probably the most promising approach for the field of clinical ethics because ethics is still a field where individual practitioners are still really the ones steering the evolution of the field,” Cunningham explains.
As it stands, that pathway is not a reality in hospitals. People would have to risk leaving good employment prospects, and go out of their way to obtain additional ethics training, at their own expense, without knowing if an ethics job is ever really going to materialize. “Those are big personal risks that many people will not take for very reasonable reasons,” Cunningham notes.
Broader changes to the ethics field resulting in more diversity would require regulatory, legal, or accreditation oversight. Absent that, it is going to be one institution at a time, or one or several ethicists at a time, trying to create the right kind of mix of diversity and representation. “The more people you hire, the more you increase the diversity of the job itself,” Cunningham adds.
If there is one person responsible for ethics consults, one employee handling project management or support work, and one person above those two at the director level, that is three different ethics positions for which the hospital could hire with an eye toward diverse representation. “But when you have zero of those positions, you don’t have anywhere to put people — and people can’t make money doing the work,” Cunningham says.
For ethicists in hospitals looking to diversify their workforce, Madison offers these approaches:
• Appoint at least one person on the ethics committee who is a member of the community (or an administrative assistant or administrative coordinator). Many ethics committees consist solely of clinical ethicists and members of high rank in the organization (e.g., physicians, VPs, or chief nursing officers).
“Admins can contribute views and opinions similar to the community that the ethics committee is making policies or guidelines for,” Madison says. “This creates a diverse ecosystem of people who are all working toward the same mission.”
This presents its own set of challenges. “Ethics committee members often require special privileges, so the membership is often overseen by senior leaders,” Cunningham explains.
Those individuals would need to be on board with the approach. Also, the committee member role requires time to train, to prepare for meetings, and to attend meetings. This time must be approved by employees’ supervisors. “It easily could be eight hours or more a month, which is equal to an entire day a month of work, and could easily be 12 full days a year,” Cunningham says.
• Invite a diverse group of speakers to present during committee meetings. Pastors; professionals at historically Black colleges and universities; or physicians, nurses, and other professionals who work in medically underserved areas can present on ethical challenges that are prevalent among diverse populations.
• Present on topics that would interest diverse crowds. “There will be less participation by people of color if the topics are not relatable or easily understood. Some possible topics may include maternal mortality, abortion, surrogacy, and eugenics,” Madison offers.
• Ensure people know what clinical ethicists are and what they do. “A lack of awareness of the field is a barrier to people of color joining the field,” Madison says.
REFERENCE
1. Madison B, Peden S, Young J, et al. Becoming inclusive: Actionable steps to diversify the field of clinical ethics. J Clin Ethics 2022;33:323-332.
Success depends on available ethics resources and overall organizational diversity. Broader changes to the ethics field resulting in more diversity would require regulatory, legal, or accreditation oversight. Absent that, it is going to be one institution at a time, or one or several ethicists at a time, trying to create the right kind of mix of diversity and representation.
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