The Consortium Ethics Program: An approach to establishing a permanent regional ethics network

H E C FORUM 1995; 7(1): 13-32.

© 1995 Kluwer Academic Publishers. Printed in the Netherlands.

THE CONSORTIUM ETHICS PROGRAM: AN APPROACH TO ESTABLISHING A PERMANENT REGIONAL ETHICS

NETWORK

ROSA LYNN PINKUS, PH.D., GRETCHEN M. AUMANN, R.N., B.S.N., MARK G. KUCZEWSKI, PH.D., ANNE MEDSGER,

M.S.HYG., R.N., ALAN MEISEL, J.D., LISA S. PARKER, PH.D., MARK R. WlCCLAIR, PH.D.

Abstract: This paper describes the first three-year experience of the Consortium Ethics Program (CEP-1) of the University of Pittsburgh Center for Medical Ethics, and also outlines plans for the second three-year phase (CEP-2) of this experiment in continuing ethics education. In existence since 1990, the CEP has the primary goal of creating a cost-effective, permanent ethics resource network, by utilizing the educational resources of a university bioethics center and the practical expertise of a regional hospital council. The CEP's conception and specific components stem from recognition of the need to make each hospital a major focus of educational efforts, and to provide academic support for the in-house activities of the representatives from each institution.

INTRODUCTION

The Consortium Ethics Program (CEP) is a three-year program to educate hospital ethics resource persons. It is sponsored cooperatively by the University of Pittsburgh Center for Medical Ethics and the Hospital Council of Western Pennsylvania and is generously supported by the Vira I. Heinz Endowment. 1 The primary goal of the CEP is to provide a cost-effective way to help healthcare professionals, their hospitals, and communities develop and sustain an awareness of and expertise in clinical medical ethics. It originated in 1990 as a response to local and regional needs for medical ethics education which individual hospitals were unable to meet through their own resources. Prompting development of the CEP was the realization that traditional continuing education lectures and conferences on medical ethics were a hit-or-miss effort which fell far short

13

14 The Consortium Ethics Program

of an integrated and continuous educational program that built on previous learning and experience.

The alternative to traditional continuing medical education that we chose focused on utilizing the resources of a university-based medical ethics center to develop, nurture, and sustain ethical expertise in individual hospitals. With access to these resources, an individual hospital's medical ethics educational efforts could be supported and encouraged to move beyond the basic day-to-day approach of addressing current and specific ethical concerns in the hospital. Instead, ethics could be viewed as an integral aspect of patient care, policy development, and even long-term organizational planning.

Therefore, an underlying assumption of the program was that consistent and continued access to medical ethics educational resources would encourage the effective utilization of those resources. With that assumption, the following program goals were established:

[1] educating representatives from participating hospitals -- whom we refer to as "hospital ethicists" -- in the language, literature, and reasoning of medical ethics and in the process of decisionmaking about ethical problems in clinical contexts;

[21 assisting the hospital ethicists in the formulation and implementation of ethics plans tailored to their particular hospitals' needs;

[3] training the hospital ethicists, depending on the particular hospital's needs and wishes, to serve as resources in medical ethics in their hospitals by providing educational programs, assisting in policy development, or creating or helping to operate an ethics committee or an ethics consultation service;

[41 establishing a network of hospital-based ethicists to facilitate the sharing of information, resources, and experience.

In attempting to meet each of these goals, the University of Pittsburgh Center for Medical Ethics would provide the necessary educational resources and would support the hospital ethicists with their work within their individual hospitals. The approach was designed to foster an institutional continuity for medical ethics as particular individual

Pinkus, Aumann, Kuczewski, Medsger, Meisel, Parker, Wicclair 15

participants might come and go and interest among them or their hospitals might wax or wane over the years.

WHY THE CONSORTIUM DEVELOPED

Background

When the Consortium began in 1990, hospitals in western Pennsylvania were subject to the same general technological, economic, and legal developments facing hospitals nationally (1). These developments included the rapid proliferation of new and expensive medical technology and interventions, increasing costs, and changing relationships between healthcare providers and patients. Although medical problems still needed medical solutions, many of the problems created by these developments were not solely medical in nature. Because such quandaries also involve questions about individual values, personal meanings of life, views of illness and death, and considerations of fairness, some healthcare decisions were recast as social, legal, moral, and personal issues to be weighed and balanced in the context of an individual's life. Consequently, the traditional methods of handling conflicts were proving ineffective or inadequate, and individual healthcare professionals, as well as healthcare institutions, found themselves groping for ways to handle many of the ethically problematic situations they face.

Hospitals in western Pennsylvania employed several strategies to meet these needs. A very small number had the resources and inclination to hire an ethics specialist to work full-time within the hospital. Others attempted to create an expert from among existing hospital staff by providing resources for such a person to obtain comprehensive education in medical ethics. The most common solution hospitals used to meet their new ethical dilemmas was to create a healthcare ethics committee (HEC). Even prior to the mandate of the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) to create an HEC or "equivalent mechanism" (2, standard R1.1.1.3.2.1), court decisions (3), national guidelines (4) and administrative regulations (5)(6) promoted (and occasionally required) the formation of such committees. By 1985, it was estimated that 60% of acute care hospitals nationally had an ethics committee (7).

Each of these strategies, however, had its own shortcomings. Fiscal realities in most hospitals prohibited hiring an ethicist. Many


hospitals did not have the commitment to medical ethics that was necessary to support a medical ethicist's efforts even if financial resources were not a barrier. This approach also lacked the strength that a collaborative environment could foster. A single ethicist within even a small hospital ran a serious risk of becoming isolated. If the ethicist was someone who had long served in the hospital in some other role, there was the additional difficulty of being recognized for his/her new expertise in medical ethics rather than the former familiar role in the hospital.

Finally, by 1990, there had been enough documented experience with institutional ethics committees to suggest that this mechanism was not a panacea for many hospitals. The approach of establishing HECs commonly met with three difficulties (8)(9)(10). One was the lack of institutional support. Many ethics committees were formed by an order from some high administrative official, the board of trustees, or the medical staff hierarchy, and little guidance was given to members regarding its mission or how to proceed. Second, even when an ethics committee was formed with a specific goal in mind -- for example, to write a DNR policy -- it often lost momentum or a sense of mission after this initial task was completed. The combination of enthusiastic institutional and staff support for the difficult work of policy writing, education, and consultation proved a delicate balance to maintain: "Creating a viable, effective, lively, cohesive and 'ethical' ethics committee" was not an easy task (8, p. xi). Finally, there had been vigorous debate and a great deal of skepticism within the bioethics community itself about the value of ethics committees. While there was often support for the idea of ethics committees, the proper role and functions of ethics committees en- gendered substantial disagreement.

Developing the CEP Concept

The CEP was developed with an eye toward combining the best aspects of existing hospitals' ethics efforts while attempting to avoid their drawbacks. Although the idea of creating the CEP originated in the university-based Center for Medical Ethics, we were aware that it would be difficult, if not impossible, to bring the CEP into being with university efforts alone. Because of tensions and distrust between academic health centers and other hospitals, as well as an increasing climate of competition rather than cooperation among healthcare institutions, we recognized that the CEP would be stillborn without the cooperation of the hospitals them-


selves or some other entity in which they reposed trust. These problems were resolved by enlisting the support of the

Hospital Council of Western Pennsylvania. Center faculty worked closely with the Hospital Council's public affairs committee, which eventually set up a medical ethics task force. Over a four year period, the Director of Continuing Education for the Center for Medical Ethics and the task force, composed of representatives of member hospitals of the Hospital Council, met monthly to develop an inter-institutional appreciation and awareness of the ethics needs of individual hospitals and to devise tactics for meeting them.

After approximately three years of providing traditional continuing educational conferences on medical ethics, co-sponsored by the task force and the Center, a consistent demand by hospitals for further educational support was documented. It was obvious that the time had come to initiate a more in-depth effort. The Center for Medical Ethics drafted a prospectus for the CEP and sought funding for its operation. The proposal was further refined and shaped in discussions with project offi- cers of the Vira I. Heinz Endowment, which ultimately agreed to provide support for the program.

Eliciting Participation in the Program

In the spring of 1990, the Hospital Council conducted an extensive process to elicit and to determine the level of interest of its member hospitals in participating in the CEP. Of the 92 member hospitals, 35 indicated an intent to participate by completing a survey of their current activities in medical ethics. The criteria for a hospital to join the CEP included a hospital's declared willingness to make medical ethics a significant part of its mission. Many of the responding hospitals demonstrated this willingness by citing previous efforts to tap ethics resources of the Hospital Council and the Center for Medical Ethics. Interested hospitals were asked to sign a non-binding letter of intent to participate. This served to evaluate a hospital's commitment to and interest in joining the CEP, for it required that hospitals be willing to:

[1] appoint personnel to participate in the CEP as "hospital ethicists," whose roles, stature, and responsibilities in the hospital were likely to make them effective medical ethics facilitators;


[21 commit these individuals for a minimum of three years (the equivalent of several weeks per year of the hospital ethicists' time);

[31 commit time, effort, and financial resources necessary for successful continuation of education programs in-hospital, and pos- sibly for community education programs;

[4] provide a collaborative working environment for the hospital ethicists; and

[51 contribute an annual participation fee ranging from $1,000 - $3,000 (determined by the AHA documentation of the hospitals' number of acute care beds).

Twelve hospitals signed this non-binding "intent to participate" and formally joined the CEP at its inception in October 1990.

STAFFING

Faculty and Staff. The regular staff of the CEP consisted of a Director (Rosa Lynn Pinkus, Ph.D.) and a Consortium Ethicist (Gretchen Aumann, R.N., B.S.N.). Pinkus had been a full-time University of Pittsburgh faculty and an Associate Director of the Center for Medical Ethics. Aumann was hired after a national search to fill a newly created position in the Consortium. The CEP also employed a part-time evaluation consultant (Anne Medsger, R.N., M.S.Hyg.) to chart the progress of each hospital and to devise ways to measure the impact of the program. A full-time secretary provided administrative support. In addition, a number of Center for Medical Ethics faculty lectured and conducted seminars in the formal educational components of the program. Their efforts were supplemented by a core faculty member from another area university and occasionally by visiting faculty from universities across the country.

Hospital Participants. Each participating hospital selected two members of its professional staff to be trained as "hospital ethicists." These individuals were supposed to have positions of sufficient visibility and influence to provide leadership in development of ethics activities in their hospitals. We suggested to CEOs that ideally, one representative


should have clinical responsibilities (a nurse, physician, or social worker) and the other some administrative role. Of the original 24 hospital ethicists, there were 4 administrators, 2 social workers, 12 nursing staff or nurse managers, and 6 physicians. We originally thought that patient-care responsibilities of physicians might prevent them from devoting the necessary time to attend the seminars. Although this assumption was partially borne out by the withdrawal of one surgeon from the program, our ongoing experience indicated that generalizations about physician participation should be avoided. In fact, our experience has been that physicians -- along with other healthcare professionals -- attended seminars, participated actively in discussion, and added an invaluable dimension to the program. They also tended to have considerable influence in their hospitals.

DESC"RIPTION OF THE THREE-YEAR PROGRAM

The CEP was designed to combine the resources of many healthcare institutions to provide what none individually was willing or able to do. This permitted the financing of a comprehensive, sustained program, and set the stage for learning to occur among the healthcare professionals of CEP member hospitals. Seeking to implement a practical, self-sufficient approach, the CEP proposed to train two ethicists from each participating hospital. Once trained, however, these hospital ethicists were not expected to educate their peers on their own. They were offered substantial support over a three-year period from faculty members of the Center for Medical Ethics to create a permanent institutional environment receptive to broad-based education in medical ethics. Considerable effort was made to assure hospital ethicists that if they assumed the status as medical ethics resource persons within their hospital, they would be supported by both an institutional commitment and by the faculty of the Center for Medical Ethics. Finally, the CEP was conceived as an educational program tailored to the needs of individual hospitals. By the end of three years, each institution was to have some type of "ethics plan" to insure its sustained use of its ethics resources.

Initiation and Assessment Component

The design of the CEP required that before educational programming could begin, each participating hospital would select two repre-


sentatives to serve as hospital ethicists. The first formal educational effort was a weekend retreat. After the retreat, CEP faculty visited each hospital tO meet with the hospital ethicists and follow up on ethics needs identified in the earlier HCWP survey. During these visits, hospital ethicists were encouraged to express concerns and interests related to clinical ethics that were of importance to the hospital. Possible ways to address these issues, often building on existing continuing medical education programs, were discussed. Then the CEP faculty worked with each pair of hospital ethicists in formulating preliminary ethics plans to meet their hospital's needs. Information obtained during these meetings provided a framework for fine-tuning the seminars that the CEP would subsequently provide for the hospital ethicists; this information also contributed to the establishment of pre-education baselines to use in the evaluation of the program. Visits by CEP faculty members continued throughout the program for planning, teaching, and evaluation purposes.

Basic Education Component

The Basic Education Component provided formal education in medical ethics to the hospital ethicists. Throughout the three-year program a variety of educational forums, such as teleconferences, day-long seminars, and videotaped instruction, were also made available to participating hospitals. Continuing education credits were awarded to hospital ethicists for successful completion of the Basic Education Compo- nent. Withineach year of the program and throughout the larger program, one of the overriding goals was to provide formal education and other training that built on previous experience, as is usually the case with university undergraduate, graduate, and professional education, but which is so often lacking in continuing education.

The educational objectives of this component were for the hospital ethicists to:

[1] recognize the competing values and interests implicated in the provision of healthcare and in decisionmaking about healthcare;

[21 examine and evaluate traditional moral distinctions frequently employed in medical ethics -- e.g., ordinary and extraordinary therapies, failing to initiate treatment and stopping therapy, acting and omitting to act, and therapies which relieve suffering but have


the likely effect of hastening death and those which primarily hasten death;

[31 discuss the ethical implications of technological advances, the high costs of healthcare, and the aging of the population on decisionmaking in the clinical setting;

[4] examine the decisionmaking process in the clinical setting, including such topics as informed consent, assessment of competence, and decisions to withdraw life-sustaining treatment (including DNR orders);

[5] discuss the role of religious beliefs and cultural influences in the medical decisionmaking process;

[6] distinguish "macro-issues," e.g., allocation of resources, from "micro-issues," which primarily and directly concern individual patients and their families;

[7] consider whether the values and goals of certain types of healthcare, for instance, geriatric or neonatal care, differ;

[8] discuss methods for resolving conflicts between patients or families and healthcare providers, or between different members of the healthcare team;

[9] study the functions, benefits, and drawbacks of ethics committees;

[10] integrate perspectives from the humanities and social sciences into the discussion of ethics in healthcare;

[111 elucidate the importance of theories of moral development in medical ethics; and

[12] discuss how principle-based approaches to medical ethics differ from and are related to other humanities-based approaches, like literature and history.

Medical Ethics Retreat. Each year, the Consortium Ethics


Program began with a two-and-one-half day retreat. These retreats preceded and laid the foundation for the subsequent in-depth classroom sessions. In addition to the general educational goals previously mentioned, the retreats had specific educational objectives. In Year 1, for example, the retreat sought to:

[a] introduce basic medical ethics concepts, terminology, and frameworks for analysis;

[21 expose hospital ethicists to the wide range of medical ethics issues so that they could better identify their hospitals' needs;

[3] establish rapport among the hospital ethicists and the CEP faculty, to begin, and later to strengthen, the process of developing a network for the sharing of information and experiences; and

[4] introduce the hospital ethicists to the range of ethics resources housed in the Hospital Council Educational Library and the Center for Medical Ethics.

Introductory Seminar in Medical Ethics. During the second six months of Year One, the hospital ethicists met monthly at the Hospital Council's educational facilities, which are in a location easily accessible to the Consortium membership. Some of the hospitals were quite a distance, and their ethicists had a three-hour ride in each direction; most, however, were within a one-hour drive. Instruction was provided in fundamental medical ethics issues and concepts, the framework of ethical reasoning, and the role of ethics education and ethics committees in primary care hospitals. The seminar meetings fostered the informal collaborative relationship initiated at the retreat and facilitated the formation of a network among the hospital ethicists.

Advanced Seminar in Medical Ethics. In Year 2, hospital ethicists met again on a regular schedule with CEP faculty to discuss more specific medical ethics problems, to engage in role-playing of patient/healthcare professional interactions, and to conduct simulated ethics committee case-consultation meetings. During this year, the focus gradually shifted from a consideration of ethical concepts and their clinical


application to the establishment of ethics study groups or ethics committees, the formulation of policy, and the institution of case review procedures.

In addition, hospital ethicists chose an ethically significant clinical case from their hospitals which they developed for intensive study over the course of 18 months. This consisted of identifying relevant ethical principles, interviewing people involved in the case, and including various perspectives of the parties to the conflict in their case discussion and analysis. These cases, which captured a range of dilemmas occurring in community hospitals, as opposed to academic research hospitals, were compiled in a casebook, and served as an additional teaching resource for the hospital ethicists (11).

Applied Skills Component

The Applied Skills Component, which was continued throughout the three-year period, sought to assure that the expertise in medical ethics obtained by the hospital ethicists in the Basic Education Component survived and flourished in a larger hospital setting. CEP faculty provided support and assistance to the hospital ethicists as they established or expanded an ethics presence in their hospital. In addition, this component sought to disseminate medical ethics knowledge within each hospital beyond the two intensively trained hospital ethicists. To accomplish these goals, additional programming aimed at the larger hospital community, including continuing professional education and community education, was provided.

This applied skills component was integral to the process by which an ethics plan for each hospital was formulated. Its keystone, in sum, was consultation provided by CEP faculty members and designed to help integrate medical ethics knowledge and skills into each Consortium hospital.

Formulation of Hospital Ethics Plan. Our expectation was that toward the end of Year 1 and throughout Year 2, the hospital ethicists would begin to formulate an ethics plan both for introducing and enhancing medical ethics in their respective hospitals. This would be accomplished with the assistance of CEP faculty members and others in the hospital setting who were actively involved in the educational process. Progress in implementing and, in some cases, in devising the plan varied


at each institution. The CEP faculty had to be responsive to the circumstances participants faced in their own hospitals. This adaptive and flexible response by CEP faculty was one of the major strengths of the program.

Hospital ethicists tailored their plans in light of such factors as the current state of medical ethics expertise in their hospital, whether or not an ethics committee already existed, the needs of the hospital's professional staff, and the needs of the community that the hospital served. Some hospitals chose initially to establish a medical ethics study group. Others opted to form an ethics committee, revitalize an inactive one, or create a new function for the ethics committee such as policy making or case consultation. Thus a hospital ethics plan could include hospital-based education in medical ethics for the entire professional staff or for particular disciplines or clinical units, and could also include educational programming aimed at the community.

After formulation of the hospital ethics plan, the CEP faculty members served as resource consultants. If, for example, the ethics plan of a particular hospital called for a program of medical ethics education within the hospital or for the community, then a CEP faculty member worked with hospital ethicists to provide the resources necessary for such programming. CEP faculty members were available to assist each hospital in the formulation of policies about medical ethics concerns, such as policies on utilization of acute care resources, resuscitation, termination of life-sustaining treatment, HIV testing, confidentiality, and genetic counseling. Ordinarily, consultation on cases raising ethical issues was a function and responsibility of the hospital ethicists, the hospital's ethics committee, or both. Nevertheless, in situations in which they wished to obtain additional advice, the CEP faculty members provided it.

Community Education

Consortium hospitals were encouraged to include community education programs as part of their ethics plans. CEP faculty members provided guidance and educational programming for community outreach initiatives. It was envisioned that hospitals might, for instance, want to offer a series of public discussions about such topics as advance directives, surrogate decisionmaking, the evolution of the physician-patient relationship, and the allocation of healthcare resources. In fact, hospital ethicists provided a large volume of outreach programs on the topic of


advance directives following the enactment of the Patient Self- Determination Act. They were called upon repeatedly to speak to community groups and uniformly attributed their ability to take on these assignments with confidence to the CEP experience and training. Such community education programs not only provided communities with up-to-date information and a forum in which people could express their concerns, but also afforded the hospital ethicists an opportunity to understand their communities' concerns.

Evaluation

Both the CEP's designers and its funding agency felt strongly about incorporating a rigorous evaluation component into the overall plan and thus earmarked financial resources for an evaluation consultant. The consultant (Anne Medsger) employed traditional approaches to participant evaluation of instructional sessions in a continual effort to assess the didactic portion of the program. In addition, she assisted in devising creative ways to assess individuals' proficiencies in using ethical principles and procedures for case analysis.

The mainstay of the evaluation component was the use of a "portfolio approach" to evaluation, which provided material for the development of a series of case studies documenting each hospital's experiences over the three-year course of the CEP. The case studies described individual hospital settings, beginning with initial assessments of the hospitals' ethics needs and goals, and culminated in conclusions about the achievement or revision of those initial goals. At the end of Year Two, a summary of their hospital's case study was sent to the hospital representatives as a self-evaluation guide.

This evaluation approach, designed to assess the impact of the CEP on individual participants and on the hospitals they represented, was based on the following three assumptions:

[1] effectiveness in medical ethics training has several dimensions and therefore was not easily measured solely by knowledge-based evaluation tools;

[2] the most important dimension to be measured was the ability of the participating individuals to draw on the resources offered by the CEP and the ability to translate their own


ethics training into the development of effective approaches to dealing with ethics issues and concerns in their hospitals; and

[3] for this "translation process" to succeed, the leadership role and influence of the hospital ethicists had to be matched with support and receptivity from the larger institution.

We believe that given these assumptions, our assessment of the changing environment of each hospital over a three-year period, in a narrative, portfolio manner, was a realistic indicator of the CEP's effectiveness?

NEXT PHASE: C ~ - 2

The CEP was intended to be a demonstration project; that is, a project to demonstrate that its goals could be accomplished, and that the program could become self-supporting. With just 12 hospitals participating, however, the latter aspect was unachievable. Furthermore, it became clear that although the educational goals of the CEP had been largely accomplished, the structural goal of institutionalizing a medical ethics program in each of the hospitals needed further reinforcement. Additional incentives for hospitals to continue in the program came from the emergence of previously unforeseen national developments such as the Patient Self-Determination Act, the 1992 JCAHO standards, and President Clinton's Administration's proposals for healthcare reform.

A Mandate to Continue

In the third year of the CEP, participating hospitals were invited to continue their participation in the Consortium for another three-year period. All but one agreed, and the single exception was a hospital that wished to establish its own program in medical ethics. Of the original eleven hospitals that continued, five elected to reinforce their commitment to medical ethics by sending new representatives. The other six chose to send their previously selected hospital ethicists (now referred to as "senior ethicists") to an advanced program aimed at implementing each hospital's ethics plan and cementing the permanence of the network. Each of the eleven hospitals agreed to continue to contribute its annual


participation fee to aid in the financial support of the Consortium. As the completion of three years of the CEP approached, par-

ticipation in and financial support for the Consortium was opened to other Hospital Council members, including rehabilitation centers and long-term care institutions. Seventeen new institutions enrolled. This new support, along with the original participants' enthusiasm to continue, prompted the Center for Medical Ethics and the Hospital Council to seek a continuation of foundation funding. Another three-year grant was secured from the Vira I. Heinz Endowment to create a permanent regional ethics education network and to support the continuation of the CEP with the eleven original and seventeen new institutions. This has provided a sound financial base and has permitted the consolidation of the gains made with the original CEP hospitals.

New CEP Components

Regionalization. The central structural innovation of the CEP-2 will be the regionalization of the program. The newly enrolled hospital ethicists will receive the same education that original hospital ethicists enjoyed, and the Center for Medical Ethics will remain the hub of information and programming for the entire Consortium. However, not all activity will emanate directly from it. Instead, an increasing number of the support activities will be planned for several hospitals in a geographic area.

Senior Ethicists. The "senior hospital ethicists," i.e., those who were trained in CEP-1, will serve as ethics resource persons for their region, and as such they will participate in teaching in some of the basic components of the program (such as in-hospital conferences); but they will primarily participate in advanced coursework components designed espe- cially for them. In this way, as they supplement their knowledge base, they will also become acquainted with the new hospital ethicists.

RegionalFaculty. In each region, faculty members from nearby colleges and universities with an academic background in medical ethics have been recruited to participate in the CEP. They will work with Center for Medical Ethics faculty in providing educational programs and will direct some on their own. They will be encouraged to obtain clinical experience by working with senior ethicists in nearby hospitals by attending ward rounds or clinical case conferences. Senior hospital ethicists and local faculty will also be available to jointly run continuing


education programs in medical ethics at other hospitals in their region not participating in the CEP.

Center for Medical Ethics. The Center for Medical Ethics will continue to support these activities with newly developed teaching materials, as well as with standardized materials made available to the regional ethics faculty. The Center for Medical Ethics will also help to plan activities for the hospital ethicists in each region through the coordination of the continuing medical education offices of the hospitals. Some of these sessions will be targeted to hospital CEOs and administrators.

Staffing and l:rmancial Self-Sufficiency

CEP-2 retains essentially the same staffing as the original program although there are now 1.5 FFE faculty positions rather than 1.25 in the original program. A full-time administrative assistant has been added, but the secretarial position has been reduced from full-time to half-time. The rest of the faculty and consulting faculty remain the same as in the original program, except that, as previously noted, staffing of programs will also draw on faculty members from area colleges and universities and on the senior hospital ethicists who have completed three years of training and have elected to complete another three. The formal evaluation component will be continued in a modified form to follow and document progress in each of the participating hospitals. As in CEP-1, this evaluation provides an ongoing basis for planning within each institution. It will not be feasible, however, to maintain complete case studies on all member institutions.

The fact that few additional resources were needed for a program more than twice the size of the original provides hope that the anticipated economies can now be realized. At the conclusion of CEP-2, the Consortium Ethics Program will be funded exclusively by fees from the healthcare institutions that choose to participate in the program and from contributed resources from the Center for Medical Ethics and the Hospital Council of Western Pennsylvania. It is our hope that, at that time, the hospital ethicists can efficiently continue the work of the CEP among themselves and with any new healthcare institution that may then wish to join the consortium. Dependence on the Center for Medical Ethics will be reduced, but the Center will continue to provide support to the CEP.


CONCLUSION

For a number of reasons, the creation of a significant base of expertise in medical ethics in most hospitals cannot be successfully undertaken by the hospitals themselves. Many hospitals lack the financial resources. In those that have the resources and commitment to hiring a full-time medical ethicist, that person might find himself/herself to be isolated and marginalized. Even when a hospital ethicist participates fully in the life of the healthcare institution, the intellectual stimulation from similarly trained colleagues will be lacking in all but the largest health centers that are able to employ more than a single bioethicist. Many hospitals have, through the creation of ethics committees, attempted to create the expertise in medical ethics that they believe they need. Despite the best of intentions, however, the effectiveness of ethics committees can be compromised by a variety of problems.

The Consortium Ethics Program aims to provide hospitals with the expertise in medical ethics that they need in a cost-effective way. At the program's core is a university program in medical ethics -- the University of Pittsburgh Center for Medical Ethics -- which provides the CEP with expertise in theoretical and clinical medical ethics through teaching and consultation. Equally important, the Center for Medical Ethics provides an organizational structure which helps to assure continuity and is intended to withstand the vicissitudes of interest in and financial support for medical ethics in individual health care institutions.

Securing a three-year commitment from the participating hospitals for both financial support and support of key institutional representatives lends further stability to the program. Such institutional commitment then reinforces the efforts of the individual hospital ethicists with an institutional vote of confidence in the goal of integrating medical ethics into its overall working environment. While substantial outside funding was required at the outset to provide resources for development, fees from member institutions should eventually underwrite the cost of the program.

Given this general foundation, the resources and organizational structure of the CEP have enabled it to pursue its broad-based educational objective successfully. During its first phase, the CEP utilized faculty members from a university bioethics center to offer a three-year program of comprehensive educational activities to member hospitals. These educational activities included retreats, seminars, and on-site


presentations, conferences, and consultations, which had been pioneered at the university (12). The CEP's assessment component and general structure enabled it to respond to the specific and changing needs and conditions of member hospitals. This flexibility has enabled it to provide educational services to hospitals that initially had differing degrees of expertise in medical ethics.

Looking toward the future, the capacity to expand CEP membership and to offer assistance and support to member hospitals will require the effective use of healthcare professionals already trained by the CEP, as well as faculty members from colleges and universities located near member hospitals. The CEP is also now in a position to benefit from increasing interaction with the variety of other programs that are being pioneered nationally in continuing medical education, such as the Decisions Near the End of Life program 3 and other ethics committee net- works (13)(14, pp. 892-94)(15). Recognizing that medical ethics education takes place outside academic bioethics centers, as well as within them, the Consortium Ethics Program joins with and contributes to the initiatives that have been underway for the past decade (16).

ACKNOWLEDGEMENT

The authors appreciate the technical assistance provided by Ms. Jody Chidester and Mr. Alan Joyce during the preparation of this manuscript.

NOTES

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The Vira I. Heinz Endowment is one of the Pittsburgh-based Heinz Endowments, which together form one of the nation's largest philanthropic organizations. The Endowments' mission is to support progress in community development, the arts, education, health, human services and the environment. A detailed discussion of this evaluation component and its results is contained in a forthcoming paper. Decisions Near the End of Life. An Institution-based, multi- disciplinary continuing medical education program developed jointly by The Education Center, Inc, The Hastings Center, The Hospital Research and Educational Trust, in collaboration with the American Medical Association.

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Thornton BC, CaUahan D, Nelson JL. Bioethics education: Expanding the circle of participants. Hastings Center Report. 1993; 23(1):25-29. Fleetwood, J. The Philadelphia story. Hastings Center Report. 1990; 20(2):33-34.

Documents

The Consortium Ethics Program: An approach to establishing a permanent regional ethics network