Now in the final year of my formal education in Medical Ethics, I am reflecting back on the last 10 years of professional development in “clinical ethics.” I look forward to serving in a new role as Ethics Consultor in a hospital and clinic. I feel such great affirmation about the competency of social workers to serve in the ethics processes of their hospitals. I hope, here, to encourage members (as I have done on occasion in the past) to actively engage with the ethics leaders in their settings, and also to become the ethics leaders.

The 19 years I have worked in oncology and palliative care social work have been the most rewarding of my career. I have met people in the most trying of circumstances in life; so many of their stories are unforgettable. I have had the good fortune to work alongside some very dedicated coworkers and physicians. Together, sometimes in harmony and sometimes in discord, we have tackled some extremely complex situations. I have seen very poor outcomes as well as very good outcomes.

Beginning in 2005, I was asked to serve on the hospital’s Ethics Committee. While I learned much there, I was puzzled that few cases ever actually reached the Ethics Committee. That fact was presented as a mark of our “success.” The assumption was that because few ethics consults were requested, problems were satisfactorily resolved. That did not fit with the reality of the many difficult dilemmas we were seeing in the clinical setting. Sometimes poor outcomes reflect the inadequacies in process and quality of our decision-making, thus providing opportunity to examine and review ethics processes and decisions.

I also began to see the ways in which more ethics education was enhancing my own practice with patients and my collaboration with members of the team. In 2007, I began looking into formal education in ethics studies. By 2009, I let the VP for Mission and Ethics know that if the opportunity arose, I would pursue a graduate ethics education. My idea was to complete a 10-credit certificate program, but I was encouraged instead to enroll in a very rigorous 30-credit online Masters Program in Bioethics and Health Policy. Finally, in 2011, my work circumstances permitted me to enroll and by the fall of 2012 I began the masters program. A vacancy in hospital leadership allowed me to move into the Ethics Chair role beginning in 2013, and this week I began in a full-time Ethics Consultor position where ethics consultation has become my primary role. Next year, if everything stays on track, I will complete the masters program.

Ethics consultation has changed a great deal in the last 10 years. Formerly, a large committee would convene, only at the request of a physician, for a few cases of intractable ethics dilemmas. It is now common for members of our small but well-prepared Ethics Service to gather in a break room or consult room near the point of care with very short notice. The aim is to be responsive and proactive, providing opportunities for clinical ethics discourse around treatment and care-giving concerns, regardless of whom on the team generates the concern. We are working to recognize these issues as opportunities for clarifying obligations, enhancing the quality of care, and improving support for bedside caregivers and providers. In addition to prevention of the “intractable” dilemma, we also want to better address the caregiver moral distress associated with a lack of adequate channels for conflict resolution in complex cases.

Social workers have a skill set that is a terrific fit for a role within healthcare ethics. Our education and clinical training prepare us well to engage with the whole person within a context of a social and medical environment, and to explore the values forming the basis for medical decision-making. Often we already possess skills for managing conflict and a desire, wherever possible, to respect personal autonomy. We tend to work well in collaboration and to understand the ways in which power imbalances in the clinical setting impact equitable approaches to care. If you are not already involved with ethics in your work setting, I would encourage you to seek out ways to increase your involvement and enhance your own clinical ethics education. Cultivation of ethics expertise can happen in a variety of ways, most of which were suggested to me by my mentors in Clinical Ethics:

• Offer to serve on your Ethics or Ethics Service Committee.
• Complete any training or orientation offered to new committee members.
• Seek out ethics education, both continuing (non-credit) education and graduate programs. Ethics programs are often found in an online format or as hybrid (on-campus and online) programs.
• Discuss the ethics concerns you encounter with your Ethicist or Ethics Chair.
• Be familiar with your facility’s policy and procedure for ethics consults.
• Dialogue with physicians about complex medical and social cases and the ethics concerns raised.
• Develop a working relationship with Risk Managers and/or legal representatives. Many times the ethics concerns you encounter also have legal implications, and the legal/risk matters they engender have ethical repercussions.

The changes we can anticipate in health care in the years to come will challenge us all in many ways. Ethics services will have a role that will be increasingly important because technology and healthcare practices are progressing at an outstanding rate, forcing everyone to question values, justice, obligations, responsibilities, roles, etc. Social workers are uniquely prepared for this because of our professional obligation to ethics, social justice, self- determination, cultural sensitivity, holistic approach, environmental awareness and interdisciplinary/integrative/collaborative methods.