the role of chaplains in applying ethics in spiritual care philip boyle, ph.d. vice president,...
TRANSCRIPT
![Page 1: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/1.jpg)
The Role of Chaplains in
Applying Ethics in Spiritual Care
Philip Boyle, Ph.D.
Vice President, Mission & Ethics
www.CHE.ORG/ETHICS
![Page 2: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/2.jpg)
Goals for today’s conversation
• Is the role of the chaplain any different than ethics facilitation?
• Boundaries
• The nature of ethics & facilitation
• Responsibilities of those engaging in ethics facilitation– Common risks
![Page 3: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/3.jpg)
Cases
• The curbside consult
• Religious ethical differences
• Interpreting the ERDs
• Looking for moral approval
![Page 4: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/4.jpg)
Case
• Fr. Dave is a respected member of the hospital staff and member of the facilitation team, often providing “curbside” consults. The difference between pastoral counseling and an ethical issues with the patient is a blurred line. When a nurse pulls Fr. Dave aside for an ethics consult about nutrition and hydration, what should he say? Patient with end-stage Alzheimer’s is refusing to eat. Family wants everything stopped. RNs alleging ‘starvation” and against religious teaching.
![Page 5: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/5.jpg)
NACC Standards
• 302.4 Incorporate a working knowledge of ethics appropriate to the pastoral context
– 302.41 Demonstrate an understanding of the ERDs
![Page 6: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/6.jpg)
Who is providing consultations?
• ASBH study
• 15,000 consults annually– 36% MDs– 30% RN– 11% LSW– 10% Chaplains– 10% Administration
![Page 7: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/7.jpg)
• The nature of ethics
• The nature of ethics mechanisms– Promoting appropriate moral agency
• Distinctions– Consultation– Mediation– Facilitation
![Page 8: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/8.jpg)
What is ethics facilitation?
• A service provided by individual or groups to help patients, families, surrogates, healthcare providers to address uncertainty or conflict regarding value-laden issues.
![Page 9: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/9.jpg)
What’s the goal of facilitation?
• “The proper role of ethics facilitation is to advocate for an unbiased robust process and not to privilege the needs and agenda of any one part.” ASBH, 2007
![Page 10: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/10.jpg)
Commonly performed tasks• Navigating clinical setting• Gathering information• Evaluating, interpreting, and analyzing info• Facilitating meetings, understanding each
perspective, assessing options for moral acceptability
• Promoting ethically acceptable plan of action• Implementing quality assurance measures
![Page 11: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/11.jpg)
“Qualified facilitation model”• Identify and analyze nature of value
uncertainty– Gather relevant data– Clarify relevant conceptual issues– Clarify related normative issues– Help identify range of morally acceptable options
• Resolve value uncertainty by building consensus– Ensure concerned parties have voices heard– Assist in clarifying values– Help build morally acceptable share commitment
![Page 12: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/12.jpg)
Core competencies
• Skills of ethical assessment– Identify the nature of the value uncertainty– Analyze the value uncertainty
• Process and interpersonal skills
![Page 13: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/13.jpg)
The facilitation Ability to facilitate meetings• Introducing oneself properly, explaining what an ethics
facilitation is and what a person taking the lead does, the purpose and limitation of the facilitation and his or her recommendations, and the relationship between the ethics facilitation mechanism and institution.
• Ensure that all relevant parties have been invited and encouraged to participate.
• Ensure that all parties are introduced and explain their perspective roles
• Explain the goals and process of meeting and what can be expected.
• Elicit medical facts• Elicit views and values of principles regarding issue• Facilitate reflective listening, clarifications, summarizing
interests.
![Page 14: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/14.jpg)
The facilitation
Ability to build moral consensus
• Help individuals to critically analyze their underlying assumptions
• Negotiate between competing moral views
• Recognize possible areas of conflicts between personal moral views and one role in facilitation
![Page 15: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/15.jpg)
Practical considerations
• Focus on “interests” not arguments
• Ethics facilitator is not a judge!– No constraints on evidence– But some statements are more useful in
resolution
![Page 16: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/16.jpg)
Practical considerations
• Summarizing—most critical aspect– Lets the parties know facilitator is listening– Lets the facilitator test her understanding– Helps parties organize thoughts– Helps parties to hear what others are saying– Shows areas of common interest– Provides order to discussion– Lets facilitator remind parties of progress– Repeat in nondestructive language– End with question: “Have I missed anything?”
![Page 17: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/17.jpg)
Practical considerations
• Questioning – To obtain a broader view– To obtain information– To clarify abstract ideas/generalizations– To focus discussion– To introduce hypothetical– To generate new options– To encourage participation
![Page 18: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/18.jpg)
Practical considerations• Generating movement
– Asking problem solving questions– Reframing– Raising issues– Hearing proposals– Stroking– Allowing silence– Holding caucuses– Reality testing– Reversing roles– Normalizing
![Page 19: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/19.jpg)
Place of personal views
• Cannot remain value neutral
• Do you offer your personal views?
• How to attend to sociological power and authority?
![Page 20: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/20.jpg)
Case
• Fr. Dave is a respected member of the hospital staff and member of the facilitation team, often providing “curbside” consults. The difference between pastoral counseling and an ethical issues with the patient is a blurred line. When a nurse pulls Fr. Dave aside for an ethics consult about nutrition and hydration, what should he say? Patient with end-stage Alzheimer’s is refusing to eat. Family wants everything stopped. RNs alleging ‘starvation” and against religious teaching.
![Page 21: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/21.jpg)
Potential risks
• Scope & limitation of role
• Conflicting interests
• Challenges of the role
• Responding to unethical practice
• Evaluation & accountability
![Page 22: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/22.jpg)
Role Limitations
• Institutional role v. ethics facilitation
• Misperception & misuse of role
• Explaining the role
• Appearance, comportment, interpersonal skills
• Power & ethics consultations
![Page 23: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/23.jpg)
Role Limitations
• Role confusion– Primary institutional role
• Administrator• Chaplain • Lawyer• Nurse• Physician• Social worker
– How could there be role confusion?– How do you avoid role confusion?
![Page 24: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/24.jpg)
Role Limitations
• Misperception & misuse of role– Should ethics facilitators be held to a
higher standard of comportment?– Common presumptions:
• Moral police• Exemplar• Fixing the institution
– Common requests that are inappropriate?– How do you or institution describe ethics
facilitations?
![Page 25: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/25.jpg)
Role Limitations
• Appearance, comportment, interpersonal skills– Implications of wearing white coat, scrubs,
stethoscope, clericals– How does appearance of gender, ethnicity
influence facilitation? • Can you name a time that appearance, gender
or ethnicity influenced a facilitation?
![Page 26: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/26.jpg)
Role Limitations
• Power & ethics consultations– Expertise as power– Negotiator as power– Insider as power
• What are the reasons why judgments & actions of ethic facilitator be misinterpreted and misunderstand and lead to abuse of power?
• How do you limit the abuse?
![Page 27: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/27.jpg)
Conflicting interests • What situations would be considered
conflicts of interest?– Under what set of circumstances would
you recuse yourself?
• Competing obligations– Name primary obligations
• What ways to avoid – Individually– By all members of team– During the actual consultation
![Page 28: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/28.jpg)
Challenges to the role• Boundaries & moral weight of consultations• Distinctions among
– Moral uncertainty: is there a dilemma, which values apply
– Dilemmas: good reasons for opposing actions– Distress: discomfort & unable to act
• Experience of marginalization– Silencing– “Obviously unethical”
![Page 29: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/29.jpg)
What does it mean to incorporate ethics?
• Case of Fr. Dave– Place ERD 58
• 302.4 Incorporate a working knowledge of ethics into pastoral context
– Help parties apply theory to case– Help RN with moral distress and issues of
conscientious objection
![Page 30: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/30.jpg)
Directive 58 As a general rule, there is an obligation to provide
patients with food and water, including medically assisted nutrition and hydration for those who cannot take food orally. This obligation extends to patients in chronic conditions (e.g., the “persistent vegetative state”) who can reasonably be expected to live indefinitely if given such care. Medically-assisted nutrition and hydration become morally optional when they cannot reasonably be expected to prolong life or when they would be “excessively burdensome for the patient or [would] cause significant physical discomfort, for example resulting from complications in the use of the means employed.”
![Page 31: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/31.jpg)
Directive 58
For instance, as the patient draws close to inevitable death from an underlying progressive and fatal condition, certain measures to provide nutrition and hydration may become excessively burdensome and therefore, not obligatory in light of their very limited ability to prolong life or provide comfort.
![Page 32: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/32.jpg)
Conclusion• Dual agency:
– Ethics facilitator & pastoral counselor
• At minimum: qualified facilitation• Religious interpretation• Helping patients in religious coping over
values disputes– Feeling at odds with religious norms
• Clarity about what you are being asked and transparency in what you can & cannot do
![Page 33: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/33.jpg)
Evaluation• http://www.meddean.luc.edu/depts/bioethics/online_masters/ethics%20
consult/ethics_consult_eval.html• Q1: Does the ethics facilitator do an adequate job of gathering the
facts of he case from the physicians? What kinds of things must the ethics consultant gather in advance of facilitating a conference?
• • Q2: Does the ethics facilitator give the physicians an adequate idea
what they might expect from an ethics case consultation, in general, and in this case, in particular?
• • II. The Case Conference
• Q3: Does the ethics facilitator do an adequate job of introducing himself
and explaining what he does or what the goal of the conference is? Should he have said anything else?
• • Q4: Does the case conference result in the patient’s surrogate decision
maker, understanding the medical facts of the case adequately?
![Page 34: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/34.jpg)
• • Q5: Does the case conference result in the patient’s attending
physician understanding the patient’s values and wishes adequately? Does he adequately understand the surrogate decision maker’s understanding of the situation?
• • Q6: Does the ethics facilitator do a reasonable job of “supporting” the
surrogate decision maker through the conference? That is, does the consultant reinforce the notions that the surrogate’s understanding of the case is welcome in the discussion and that the patient’s legitimate rights will be respected?
• • Q7: Does the conference “flow” well or should the facilitator have
redirected it at points? If so, please be specific regarding when.• • Q8: Does the facilitator help to summarize and delineate the acceptable
options? Is it clear what will happen next and how matters will proceed?• • Q9: Are the options highlighted within ethically acceptable norms?
![Page 35: The Role of Chaplains in Applying Ethics in Spiritual Care Philip Boyle, Ph.D. Vice President, Mission & Ethics](https://reader038.vdocument.in/reader038/viewer/2022103123/56649d0e5503460f949e4526/html5/thumbnails/35.jpg)
Resources
• Bioethics Mediation: A Guide to Shaping Shared Solutions, Nancy Dubler and Carol Liebman, United Hosptial Fund, 2004.
• Mediation Information Resource Websites
• Http//www.mediate.com
• http://www.crinfor.org/narrative_new _developments.cfm