Interview: Becket Gremmels
Ethics and Mission in Catholic Healthcare Institutions
This week the newsletter features an interview with Dr. Becket Gremmels, the System Vice President of CommonSpirit Health, the largest Catholic healthcare system (and the largest nonprofit healthcare system) in the United States. The conversation addressed Dr. Gremmels’s personal journey toward becoming a professional healthcare ethicist and some of the major trends shaping the field of healthcare ethics today. We also discussed some of Dr. Gremmel’s research, including research hoping to set guidelines for the future use of artificial intelligence in healthcare settings.
In 2019, Dr. Gremmels wrote an article for the Journal of Moral Theology arguing that the increased specialization needed for practicing professional healthcare ethics, and the practical and specialized sorts of questions addressed by professional ethicists in their day-to-day work, are contributing to an increasing divide between the work of moral theologians and professional healthcare ethicists. Some of the topics that came up in our conversation certainly illustrate this contention, but hopefully this conversation between a moral theologian and a professional healthcare ethicist is a small step toward bridging that divide.
You can listen to the interview by clicking on the audio file below. The interview is about the length of a typical podcast, and you should be able to listen on your computer or phone. A full transcript of the interview is also published below for your reading convenience, along with some links and notes not available in the audio. (The transcript may be cut off in your email, but you should be able to click where it says “View entire message” to see the rest of the transcript.)
Join the conversation by leaving a comment below! Also let me know if you had any issues with the audio.
Don’t forget to subscribe, if you haven’t already, so you can get more great content like this from Window Light!
MATTHEW SHADLE: Hello, I'm with Becket Gremmels, who is the System Vice President for Theology and Ethics at CommonSpirit Health. He's located in Dallas-Fort Worth, Texas. Although he has told me that he is really into the ethics and not so much the theology. Is that correct, Becket?
BECKET GREMMELS: It's both. I think it really depends on how you define it in the practical . . . and just, kind of, what shows up at my door each day.
SHADLE: So tell us a little bit more about yourself. So, I just gave your job title, but tell us who you are, what you do.
GREMMELS: Yeah. So I am a bioethicist slash philosopher slash theologian slash clinical ethicist, and I've been working in Catholic healthcare for, gosh, fifteen years now, sixteen, almost sixteen years.
SHADLE: Okay.
GREMMELS: And really, my entire career has been as an ethicist in Catholic healthcare.
SHADLE: Okay. Well, that's a good lead in. So, how did you become interested in ethics in a healthcare setting?
GREMMELS: My undergraduate degree is in philosophy. And that was during the time of the [President George W.] Bush stem cell debates1 and Terri Schiavo’s case,2 and that was very prominent in the media, and that always kind of interested me. And I didn't know you could actually do anything with that. I didn't know that was a profession. And one of my professors mentioned it, and I applied and got into graduate school. You know, who knew?
Also, we had a couple, I would say I had a couple of experiences that made me a little more interested in the healthcare side of things. We were on a pilgrimage to Europe with our parish, and we had one of our parishioners actually had a heart attack in the middle of the trip. And just listening to the kind of . . . the priest talk about how the experience was in the hospital, there were jackhammers going on in the ER, so that the patient’s wife, our parishioner’s wife, couldn’t hear ninety-nine percent of what was being said. The doctor wouldn’t speak to her at all. There was a little bit of, I would say, I guess, misogyny going on. He would only speak to the priest even when the wife asked him a question. So, it was a really bad experience and the patient actually ended up—our parishioner—he ended up dying. There were a lot of issues about transporting the body back across the country, you know, across the ocean, all that kind of stuff.
And then, three days later, we actually had another parishioner have a heart attack. And one of the other parishioners with us happened to be a doctor, and he jumped up and started doing CPR on the guy, and they called an ambulance, and the ambulance didn’t have half of the meds that the doctor was used to having for, you know, doing CPR. And he was just shocked that they wouldn’t have these medications. And that guy ended up dying also, on the exact same trip. And there were a lot of questions that the doctor in our church raised about, “Why didn’t they have these medications?” And, “I think I could have saved him if they had meds X, Y, and Z.” But in that country they don’t take those meds on an ambulance to keep it in the hospital. So it raised a lot of questions for me, about why do hospitals do things the way that they do? And why does medicine do the way that it does, work the way it does.
SHADLE: Remind me, what country was that?
GREMMELS: One of those was Ireland, and one of those was England. We went to both of those.
SHADLE: Okay. Yeah, and that's . . . Another interesting thing about that story is that it shows that healthcare ethics is more than just bioethics. It's more than just some of those hot button issues that generate a lot of controversy, like the ones you mentioned earlier about Terri Schiavo and end of life care, but also it’s about how we interact, how professionals interact with patients and how we, you know, care for them, and also the resources that are available to care for patients. So that’s interesting that you got, you know, the life incidents that pointed you in this direction, gave you a very broad perspective on what healthcare ethics is. I did want to go back to your examples of what was going on in the media when you got interested in healthcare ethics. You mentioned the stem cell debate and the Terri Schiavo debate, and for readers who may not remember, that was about a woman in a permanent vegetative state, and there was a dispute over whether to remove artificial nutrition and hydration. That's correct, right?
GREMMELS: Yeah.
SHADLE: So what I wanted to add is not just that those cases were in the media, but there was also significant Catholic conversation about them, right, that, you know, there was this flurry of writing and, you know, comments on these events from a Catholic perspective because there wasn't, you know, Catholics weren't . . . especially the Terry Schiavo case, I think . . . but were not of one voice on this issue. And so it was a really . . . I think part of what you’re getting at is it was a really interesting time to be thinking about Catholic healthcare ethics at that time. And I even still use the example of . . . it was around that time that Pope John Paul II, the pope at the time, came out with some new directives for patients on artificial nutrition and hydration that generated some controversy,3 and I still use that as a discussion prompt in my healthcare ethics classes, so I can relate to what you’re saying there. So going back to your job, do you . . . I was just curious . . . do you work in a corporate office, or do you actually work in a hospital facility?
GREMMELS: So, I actually work from home.
SHADLE: Oh, okay, do tell me more about that. How does that work?
GREMMELS: Working at a national system . . . So we are the largest Catholic health system in the country, the largest nonprofit system in the country. We’re in twenty-four states. We have 150,000 employees, so there’s no way for me to be in one place. That’s true for all of our leaders. So, most of our national-level employees actually work from home because we’re traveling, we’re in different places a lot. So yeah, that’s, I’d say, not unique to me or to ethics, at least in our system.
SHADLE: Okay, I think that’s great. I think that’s a great adaptation. How long has that been the case for you?
GREMMELS: So, it started in April of 2020. It was, oddly enough, not actually related to COVID. When I took the job, agreed to take the job a few months before that, it was meant to be this kind of radical thing, working from home, and then when I started in April, everybody’s working from home!
*Laughter*
SHADLE: “I don’t feel special anymore.”
*Laughter*
GREMMELS: I didn’t, at all, but yeah. So, it’s been about three years that I’ve worked at home. Before that, I did work in a system office. But before that, in my . . . two jobs ago, I did work in a hospital—I was bedside clinical ethics, you know, in the ICUs, in the ED, and, you know, med surge floors, you name it.
SHADLE: Oh wow, great. Okay, so all right, what is the role of the ethics team at a Catholic healthcare system or at the institution level? What is their role?
GREMMELS: We don’t make decisions. I think sometimes people think that, and even doctors will sometimes, the nurses will say, “Hey, here’s an issue I have. Tell me what to do.” And our role is not to make the decision. Our role is to advise those who make decisions. You know, the phrasing that I like to use, at least, the three tasks that we look at a lot of times, actually, in clinical ethics is, we identify, analyze, and resolve value-laden concerns or ethical issues that arise in patient care. Or I’d say, you know, in organizational ethics, what hospital leaders do. So we were there, really, primarily as a resource for doctors, nurses, patients, families, anybody else involved in patient care, to help them with the ethical issues or questions or concerns they encounter.
SHADLE: And my sense is that it’s not just to provide advice when a case arises, but to also provide ongoing training. Is that correct to you?
GREMMELS: Yeah, I’d say there’s five functions an ethics committee serves. Sorry, my assistant toddler has joined me here.
SHADLE: That’s fine.
GREMMELS: And so I’d say there’s five main functions an ethics committee serves, and as an extension of that, there’s this debate going on right now in the field, of committee versus team versus person: What’s the best structure for it?
SHADLE: Sure.
GREMMELS: There’s five main functions. Consultation is one of them. I think that’s the one that often gets the most attention because it’s exciting and the cases are difficult and complex and they’re new. It does . . . It is one that personally gives me a lot of interest, but there’s education, too, right. We will work on education for doctors, nurses, again, anybody involved in healthcare about ethical topics that come up. I actually just had a call this morning planning a three hour series over the summer of “lunch and learns” for case managers and social workers on ethical issues that they might encounter in their work. So, we do that regularly, and we also educate our ethics committee members, or maybe our first responders, about ethical issues to get a little more heavy stuff about what the process of consultation is like. So that’s the second function.
The third is policy review, so if you have a policy on informed consent or do not resuscitate orders or policy on . . . I’m trying to think of another one I’ve done recently . . . on brain death or withdrawing life support. We will review policies, we’ll edit policies. They have to be reviewed every three years, per regulation. So, any time they come up for review, we’ll review it and say, “Yep, this looks good,” or “No, there’s things that have changed. We need to add here or there.”
The fourth policy that I would . . . sorry, the fourth function would be process improvement. So we will have different issues that we’ll say, you know, this issue comes up a lot, we get like ten consults on this exact issue in this unit of this hospital in two months. Maybe we need to change the way that they work to give the caregivers the tools that they need to resolve issues on their own. Or maybe there’s a professional society, like one that comes to mind, the American College of Surgeons, they have a position statement on this particular issue, and we will work with our clinical teams to say, “Let’s embed that position statement or best practice in the way that you work.” So we’ll change consent forms or checklists or protocols to help head off issues before they really become an ethical issue, I guess, a major consult, and give people, again, the tools to deal with things on their own.
The one that comes to mind is the American College of Surgeons one. So they have a position statement that says, you cannot revoke a patient’s, or you should not revoke a patient’s, DNR order for a surgical procedure without their consent, without talking about it. So it’s very common to revoke a DNR order4 that the patient has agreed to before a procedure or surgery, reason being that a lot of the things you do during surgery are basically very similar to resuscitation, and so that would be violating the DNR order. So, they revoke it beforehand. Also, depending on the kind of surgery intervention you’re doing, it’s a lot easier to resuscitate. It’s not really like CPR, so it’s not quite the same. But the American College just simply says, if you’re going to do that, tell the patient or the family before you do it. And that way you don’t end up ten days after surgery, the patient’s on the ventilator, and the family is saying, “I don’t know what happened. She didn’t want to be on life support and she had a DNR order. You should have done this.” Because I have had that case, unfortunately.
SHADLE: Okay.
GREMMELS: And then they’re upset, the doctor’s upset, so we might work with our hospital to say, well, in the consent form, ask the question to the patient, yes or no, and put a little check box, right? And the pre-op checklists, have the surgical nurse, the circulator, have a little thing in their checkbox to say, have you had a . . . is the patient . . . do you have a DNR order? Have you had a conversation about this? Just to clarify. That way you don’t end up with somebody . . . because I’ve also had patients where they’re being wheeled into surgery, and the surgeon says, “Okay, you’re full code,” and the patient objects, and then they have to postpone surgery until they work it out. So that’s the process we approved.
SHADLE: Right. I was going to say, I can imagine an opposite situation, too, where, you know, they do have a DNR, but you’re in the middle of surgery and, I mean that, I don’t think this is what they imagined when they signed that.
GREMMELS: Right, and that’s also why they say, let’s have the conversation, because I think when most people, you know, want to have a DNR order in place, tha’ts not the context they’re thinking of it in.
SHADLE: Exactly.
GREMMELS: They’re thinking of, “I’ve got terminal cancer, I’m not going to survive it anyway. Let me go peacefully. Keep me comfortable.” Not, “I’m having . . .” I’m making this up, “I’m having my appendix out or I’m having a thoracentesis and getting fluid drained so I feel better.” Something happens, and you can just tweak the anesthesia settings and now I’m better, right? It’s not the same context, but all ACS says, just have a conversation, and so we might work with them to improve their processes, to embed that best practice in there. The fifth function, I would say, is community outreach, and that is working with our community members, or maybe community leaders, maybe government officials, maybe advocacy departments, maybe bishops, maybe parishes, dioceses, just to . . . usually it’s about education, sometimes it’s about information gathering. So, what are people’s opinions or thoughts on this? But I’d say community outreach is probably the fifth function we primarily work on.
SHADLE: Okay, so building off of that, just my impression is that one trend is that ethics professionals or ethics teams, you know, however you want to describe it, in the past few years are looking beyond just the bioethical and clinical issues, and issues of patient consent, but also looking at what you could call more institutional issues, so things like diversity and inclusion in the workplace, sustainability, you know, access to healthcare for patients. I’m going to ask you a little bit more about this one later, but taking care of patient data. Is that a trend that you see, and could you say more about this expansion of the purview of the ethics professionals?
GREMMELS: So, the way I would term that is “organizational ethics.”
SHADLE: Yeah, yeah.
GREMMELS: So it’s not really clinical ethics where you’re looking at an individual patient. It’s more organizational questions about, not how should I as a doctor or I as a patient think about this, or as a nurse respond to this—or physical therapist—particular issue, but how should we as a hospital, we as a health system, as a health plan, how should we think about this, that, or the other? What actions should we take? So, oddly enough, I do see it as very similar. Instead of helping individuals live out their values, you’re helping organizations live out their values.
SHADLE: Yeah.
GREMMELS: But it certainly is a very different subset of issues that you are involved in. I would say that, on the one hand, it's relatively new to think about this in an organized manner the way we think about clinical ethics. However, these questions are not new, at all, especially for Catholic hospitals. We’ve been thinking about these questions of our Catholic identity and what it means to live out our mission, and what it means to live out our values, for decades, certainly probably at least a century. But to do so in a really robust, organized, professional manner is probably more on the newer side.
SHADLE: I mean, well, I’m just going off script here a little bit, but having worked in higher ed for a long time, does that create any tension with hospital administrators? You know, these . . . you know, because they face competing demands, they have budget demands and facilities demands, but also ethics demands, so with the ethics team looking at these organizational issues, does that ever create any tensions with the administrators, or what?
GREMMELS: It certainly can. I wouldn’t say that they’re usually inappropriate tensions. I think it’s more a question of, how do we live out our values. I mean, you could set it up easily, if you wanted to, to be cynical, set it up easily as, well, we either make money or we live out our mission.
SHADLE: Yeah.
GREMMELS: If you wanted to. I don’t necessarily see it that way because I would argue that stewardship is a strong part of our mission, right? And if we’re not financially viable, the hospital’s closed and then we don’t live out our mission anymore, so I don’t see it as the question of no mission . . . or no money, no mission. I see it more as a question of, well, on the one hand, I’d say, if you don’t have a mission, then what the heck do you need the money for. But the other thing I’d say is that we cannot be all things to all people. It’s just not possible. One hospital, one health system, cannot care for 330 million Americans. It’s never going to happen, right? So there has to be a targeted goal that we’re focusing our mission on, right? What is that goal? What are we looking at? So, I think it depends on the context and the specifics of the question at hand. But I wouldn’t necessarily frame it the way you did as far as tensions with leaders. I would say leaders encounter difficult questions and situations that they, you know, need help thinking through just as much as doctors and nurses and pharmacists do.
SHADLE: Yeah, that’s well said. Well, okay, so let’s go back. So, I mentioned that you have done some work on ethical questions related to patient data because we do live in a world where hospitals and clinics are collecting and storing quite a bit of data, and now it’s digital. You know, in the past they just had a big cabinet full of paperwork or whatever, but . . . So tell us about what sorts of questions you’ve been researching and what you said.
GREMMELS: What I’ve been researching, or what’s in the article, or both, really?
SHADLE: In the article, I guess, but we could expand on it.
GREMMELS: So the . . . I would really look at the article first, because that was a . . . What’s the word I’m looking for? . . . It was kind of a proactive article in a lot of ways, and aspirational, because this is so new, it’s really hard for anybody to kind of get their heads around what’s going on with this in general. Our goal in the article . . .
SHADLE: And I’ll link to the article5 when this is all posted . . .
GREMMELS: Okay, great.
SHADLE: . . . so the listeners know what we’re talking about.
GREMMELS: So, our goal in the article was to really take a first stab at saying, what does data ethics, or what should data ethics look like in Catholic healthcare.
SHADLE: Okay.
GREMMELS: Knowing that there isn’t a lot of theology around this in general out there, or even philosophy, and there isn’t a lot from our Catholic colleagues or from our secular colleagues, whether in healthcare or even outside of healthcare, like Google or IBM, right, or Facebook? There’s not a ton of thought on this yet, because just, it moves so fast. It’s so new. But our goal is to say, what does this look like or what could, or should, this look like practically? So, we tried to outline some of the main issues that might arise, and then we took the . . . The Vatican actually, thankfully, has taken the step of being a huge leader in this space internationally. They issued the Rome Call for Ethics a few years ago, which IBM and Microsoft and the UN have signed on to, to try and say let’s come up with a set of values and principles that we can all agree on, and hopefully that will then trickle down into something more practical and productive. So, what we tried to do is outline the issues that you are probably most commonly going to see at this point in time, and then say, how do the Rome Call principles that they outline apply to these issues, and let’s make them practical. So we actually even come up with lists of questions that, you know, IT leaders or even, I would say, programmers can look at in different steps of data use to ask themselves and create that into a practical process that then they can use to help use data respectfully, appropriately, and design algorithms that, I would argue, hopefully foster human dignity in a respectful manner.
SHADLE: And let me pause there. I actually wrote a little bit about the Rome Call a few weeks ago for this newsletter, and just to inform readers, it mainly deals with artificial intelligence and data analytics, so using the data to generate algorithms to solve problems and things like that. So, okay, you’re kind of taking a first stab at exploring some of those issues that may arise with data collected in healthcare settings and looking to that statement as kind of a starting point or as a guide for thinking through that. I think that’s awesome. Was there anything more you wanted to say about the article?
GREMMELS: No, I mean, I would say what we toyed with doing was kind of giving a kind of critique and saying, okay, here’s the Rome Call. What do we think about it conceptually? We decided to really be more practical and say that we’re going to take . . . assume the Rome Call as a starting point, and how would we as ethics leaders in Catholic healthcare implement that. That’s primarily what we’re looking for.
SHADLE: Oh, and I should add, this is how I met Becket in the first place, there was a session at the Society of Christian Ethics in January where Becket and a couple of other scholars were discussing these issues and discussing this article. So, discussing issues of artificial intelligence and data analytics and healthcare. So, I just wanted to throw that out there, that that’s where I met Becket. So, it sounds like you are doing further research on this. Do you want to share that, or do you want to hold it close to your vest?
GREMMELS: I’d say . . . So, it’s tricky because I can’t really talk specifics about what we’re doing to implement, necessarily. I would say research wise, we’re continuing to think about, again, what does this look like practically? How can this help our patients? And I’ll tell you, that article came out in, what? August, I want to say, of last year.
SHADLE: Yeah.
GREMMELS: Which was two months before ChatGPT really kind of hit the waves and it’s basically obsolete now, and even ChatGPT is obsolete now with GPT 4 and other things. So Bard, I guess, is Google’s response to it. So, it brings up a whole different ball of wax there, which you wouldn’t even touch. So, again, we’re thinking about how do we think through these things, how do we help our doctors and our leaders work through the questions that they’re getting, or the technologies that they’re having offered to them, or maybe pushed on them from developers.
SHADLE: Yeah, and that’s kind of interesting because in a lot of these . . . in the more traditional cases the doctors are the technical experts, but now they’re having to deal with issues where they have very little technical expertise and they’re going to need advice from ethicists, but also people in technology, to kind of figure this stuff out. Okay, so . . . Well, I mean is there anything else you’ve written about that you want to share? I mean, this is your chance to show off or, you know, sell yourself here, so . . .
GREMMELS: Related to data?
SHADLE: No, just anything. What are some other topics you’ve published on?
GREMMELS: Oh, gosh. I want one that I did recently. I wrote an article in CHEST6 about some work we did at my last job. So, this is one that I would say, from a theoretical standpoint, doesn’t . . . like, if you’re a theologian in a university, it doesn’t seem that interesting, I would say. From a practical, on the ground standpoint, I cannot tell you how much time is spent on this. This is a regular, almost daily, issue that doctors and ethicists deal with, and that is options for DNR orders. What options do you have? And practice varies so much, there is no best, there’s no gold standard for what this looks like everywhere. You have some hospitals where you have two options, you’re full code, or you’re DNR, and that’s it. And you have some options where you’re full code, you’re DNR, and then you have different subsets of it or limited options. Like some places, it’s a checkbox where they kind of hand you a menu, and you can say, what would you today with your CPR?
SHADLE: Yeah, that’s what I’ve seen.
GREMMELS: And I mean, I have the . . . This started because we had, as we say in the article, we had requests for nineteen different options in there, which—if you know what nineteen factorial is—so if you took every single possible combination of those . . . Because sometimes people actually do request for a specific order: “So I want you to try chemical code first, and if that doesn’t work, then you can do chest compressions, and then you can intubate me,” or the other. So, nineteen factorial is 1.2 with seventeen zeros on the end of it. There is no way that anyone, as a nurse, could ever remember all of those possible combinations for all of your six, seven patients that you’ve got, or eight patients, how many have you got, depending on what setting you’re in, and be able to communicate that within thirty seconds to the rapid response team who’s responding to a code.
SHADLE: Yeah, right, because you only have mere seconds to, like, work through those options.
GREMMELS: Right. So, what that ends up resulting in is a code team who shows up . . . because the people who actually do CPR, 99 percent of the time, they don’t know the patient, never seen the patient before ever.
SHADLE: Yeah, yeah.
GREMMELS: They’re being pulled emergently from other rooms and other units, because if you have the entire team on that unit respond to a code, then nobody else is getting care on that unit. So, you have a rapid response team who’s on call, and they get pulled from all different units. They don’t know the patient, so they end up doing everything that’s clinically appropriate at the time, and then somebody who finally knows the patient shows up after a few minutes, and they’re like, “Oh, wait, he didn’t want this. Oh, wait, he didn’t want that.” You know. And so then you end up giving them stuff that you’ve documented in the chart you know they didn’t want. What we worked on was two things. We worked on . . . And this is what the article is about, the justification for limiting it to two options of full-coded and DNR, or do not attempt resuscitation. And the other thing we did, which I think was really helpful, is we looked at other treatment options that are similar to, or maybe parts of, a code and are helpful in some scenarios, but not really in a cardiopulmonary arrest. And so the other issue is that sometimes we get kind of lazy and we just lump all of this end of life stuff into code status orders, and so, for example, a chemical code is one that’s crazy. So a chemical code is where you give somebody, you know, epinephrine or norepinephrine, and you’re injecting them with the medication to basically keep their blood pressure up, right, a vasopressor.
SHADLE: Okay.
GREMMELS: And that’s a common medication you give in a code. But it’s also a situation you give to somebody who just has low blood pressure. But for somebody who has cardiopulmonary arrest, they’re not breathing or they’re heart’s not pumping. You can give them all the medicine in the world you want to in their arm, but if your heart stops pumping, the medicine is not going anywhere.
SHADLE: Yeah, right. Right.
GREMMELS: It’s literally sitting in their bicep or their forearm. And so you would have these situations where somebody would say, “I want a chemical code,” and so their heart’s not pumping and all we do is sit there and put pressors in their arm, and it literally does nothing. It makes no sense at all. But for somebody who comes in and has very low blood pressure and is possibly going to code in a matter of minutes to hours if you don’t intervene, boy, pressors make a lot of sense and that’s really good. So, we separated out those conceptually, are they having an arrest versus is there some other non-arrest emergency, and we put all that other stuff in that order set. And it seems to have gone . . . It went rather well. It took a year, literally one year, of education across the system before we began to implement this. So that’s one, I’d say, one of the recent articles I’m pretty excited about.
SHADLE: And I don’t know if you framed it that way, but that seems like an exercise of the moral virtue of prudence, of, you know . . .
GREMMELS: Yeah.
SHADLE: . . . without sacrificing the ethical issues involved, how can we deal with these situations in a practical way that will best serve the patients and the healthcare professionals, right?
GREMMELS: Yeah, I think the difficulty is that I would argue when you lose the concept of a person in the traditional Christian anthropology . . . anthropological sense that we have it, right, when you lose that and substitute for it an automaton—and I would say somewhat in the Kantian sense, but I think honestly the way it’s often used today, it even gives Kant a bad rap because Kant had concern for the common good in his concept of autonomy also—but the way respect for autonomy is very often used on the very practical level, oftentimes in healthcare today, it turns into, well, whatever the patient wants.
SHADLE: Yeah.
GREMMELS: I don’t really care what it is, whatever you say, I’ll go do it. And the doctor becomes a . . . and the nurse, they become an executor of the patient’s will almost, or the family’s will, or whoever’s making decisions’ will, as opposed to, again, a living, breathing subject who has rights and has opinions and who has experience and education. So, saying that we’re going to limit that autonomy, that there might be limits on the obligation to respect autonomy, in this context, is, in many hospitals, it’s extraordinarily controversial.
SHADLE: Yeah, yeah.
GREMMELS: And so we had to work a lot to help our doctors and nurses understand that, no, that’s not what respect for autonomy means, especially when you’re doing something like a chemical code where, you know for a fact there’s no possible way it could benefit the patient, and can only harm them.
SHADLE: Right, where it’s almost like common sense tells you that’s not the patient’s wishes. Right?
GREMMELS: Yes. And so that’s what we had to work a lot to do, and you know, if you think about it, there are a lot of other scenarios in which we actually limit patients’ autonomy, right? You can’t just come up and ask for chemo because you want it. That’s not going to happen. There are limits to those kind of things. Patients and . . . One that comes up a lot of times is antibiotics, right? You ever try to get antibiotics for your kid with a cold, or when you have a cold? You’ve got to show evidence that you have a bacterial infection nowadays, because we know that there’s harm done to the broader community by breeding antibiotic resistance, of just giving people antibiotics because they want it when they don’t really need it.
SHADLE: Right. So, there’s questions of the objective good of the individual patient, but then also questions of the common good, right, like with those antibiotics. So, let’s really shift gears here. And so, in Catholic healthcare, the ethics team is usually paired with the pastoral care and chaplaincy team. So, they’re separate, but they may be under the same umbrella, right?
GREMMELS: Yeah. Yes.
SHADLE: Yeah. So part, you know . . . Under that umbrella of Catholic mission, I think, a lot of times.
GREMMELS: Yeah, I’d say the umbrella is what we would call “mission integration.”
SHADLE: Yeah, yeah, so . . .
GREMMELS: You’ve got different areas underneath that, of which ethics and spiritual care are two.
SHADLE: So, what is the relationship between those, the ethical side and the pastoral side?
GREMMELS: Well, as I said, we’re usually both in the same department in the hospital, right, under the mission department. There’s certainly a lot of overlap, and we work well together and, in many cases, sometimes it is the chaplains who end up doing ethics consults or who are members of our ethics committees, and in some cases actually lead that work. And there certainly is a lot of overlapping components there, I would say. If I had a very difficult consult back when I was doing bedside ethics, I would usually make sure I had a chaplain involved in those conversations. They’re very insightful, they’re very helpful, and in certain cases it’s absolutely critical that you have them involved. And so, on the flip side of that, I think that a lot of our consults come from chaplains. Chaplains are often times the ones to identify, “Hey, this could be an issue in a few days or a few weeks if we don’t settle this or resolve this or have some conversation about it now. I would like the ethicist involved, I would like an ethics consult on this.” So they’re one of our very common requesters for consults.
SHADLE: So, going back to what you said about the Catholic view of the person and how essential that is . . . You know, I think one way that the two are related is that we are not just Kantian, transcendent subjects, right, but we are persons, and part of that is that we have that spiritual dimension. And I think that’s why, so often, when there’s a difficult ethical decision to make, there is a spiritual aspect to that, too, and that’s why it’s so important to have the two integrated or, you know, be able to work together, it's that, you know, whether it’s the patient or the healthcare professionals having to make these decisions, it’s not a purely, you know, rational process. It involves the whole person. And so I think that’s what they’re tying to get at, would you agree with that?
GREMMELS: Completely. And I think the phrase that I would use is care for the whole person.
SHADLE: Yeah.
GREMMELS: We provide care for the whole person, as you know. We might say, integrally and adequately considered, that’s the phrasing that we might use. But you’re looking at not just the physiological issues that are wrong with them, but the spiritual issues, the social issues, the emotional, psychological, mental. That’s why we have not just people who care for the physical, but also chaplains for the spiritual. We’ve got, you know, mental health professionals for the emotional and the mental. We’ve got social workers for the social. And it is very much the case that illnesses, I would say in one area of someone’s life, spill over into the other areas, and in certain cases it’s extremely obvious, and so you can have a physical illness that has spiritual or emotional or mental or social symptoms. And you can have others, like you can have a social ill that manifests itself physiologically. You can even have spiritual illness that manifests itself emotionally and physiologically. And so if you only treat the thing in front of you, that’s most obvious, without getting to the root cause and treating the ultimate, you know, foundation of what’s causing these symptoms, you’re only treating the symptoms as opposed to the problem, right? So if your underlying issue is ultimately social, and it’s only happening to manifest itself physiologically, you can treat the physiological all day long, but you’re not going to resolve the underlying issue. It’s going to keep coming back, coming back, coming back. The same is true for spiritual illness that manifests itself physically, and etc., etc.
SHADLE: So, another theological-related question, what is the relationship between an ethics professional at a Catholic healthcare institution and the Church’s Magisterium? And then also, what role does the local bishop play? So, if you could kind of weave all that together.
GREMMELS: Wow, how much time do we have? That’s a big question right there. So, you know, as Catholic healthcare, we are a work of the Church, right? So we have an obligation to follow magisterial teaching just like any other Catholic ministry would, right. So in that regard, obviously we follow the ERDs and we follow magisterial teaching, and . . .
SHADLE: The “ERDs” being the Ethical and Religious Directives . . .
GREMMELS: . . . for Catholic Healthcare Services,7 that’s the document put out by the US Conference of Catholic Bishops that talks about . . . Well, I would say, in a nutshell, it talks about what it means to be Catholic healthcare . . . , what it means to be a Catholic hospital or clinic, how you live that out in accordance with Church teaching. So our advice and our recommendations that we would give in all those functional areas I mentioned, would be consistent with magisterial teaching.
SHADLE: Right. It’s kind of like . . .
GREMMELS: We are not an executor of the . . . We’re not part of the Magisterium, necessarily, right?
SHADLE: No, no, no.
*Laughter*
GREMMELS: Right. But we would follow that just like any other Catholic ministry would.
SHADLE: So the ERD is kind of like a playbook . . .
GREMMELS: Yeah.
SHADLE: . . . but it doesn’t . . . it’s not going to tell you what to do in every case, is it?
GREMMELS: No, it doesn’t, and it flat out says that, right. These are the bullet points, basically. And, I have worked for Catholic hospitals in other countries . . . Because this is a US bishops document, most other countries don’t have something like that. And it takes the 2000 years of tradition—well, 2,000 plus years—and boils it down to seventy-seven directives. And you know, what is it, thirty-five pages or something like that? And when you try to do this without that, it is extremely difficult. It is hard. There are definitions in there, there are phrases in there. There is—I would argue—some novel teaching in there that is not anywhere else. Like the definition of abortion is a perfect example. That definition that’s in the ERD, is not, word for word, anywhere else in Church teaching. It’s not inconsistent with it. It is certainly consistent with, you know, Evangelium Vitae and things you’d find elsewhere, but it’s not word for word the same. And the definition in the ERDs was carefully crafted to be applicable and understandable in the clinical setting. And I think it does that very well.
SHADLE: Yeah. You have to be familiar with that kind of document that says, “This is how we’re defining tat term, and this is how we’re going to use it throughout this document. It may have a different definition in another context, but. . . this is how we are using it, for clarity’s sake.”
GREMMELS: Yeah, and the same for “proportionate” and “disproportionate means.” Again, those definitions, those exact words are not anywhere else in magisterial teaching anywhere. And I like those definitions they’ve got there, because they’re very practical. They’re . . . again, they’re not inconsistent. They are consistent with the deposit of faith, but they are uniquely crafted to fit the hospital setting. And having worked in countries in Catholic healthcare where they didn’t have that, the first thing I did was say, “Let’s go back to the ERDs,” because, boy, I wish I had that definition right now, right?
SHADLE: Okay, so what about the local bishop?
GREMMELS: So the flip side of that is that, at least for us . . . Now it does vary by hospital, right? So, we have some hospitals that are diocesan-sponsored hospitals.
SHADLE: Okay.
GREMMELS: And so the relationship with the bishop in those hospitals is going to be very different than other hospitals. Now we, at least the hospital network, we’re not sponsored by the diocese, right? We’re a PJP, “public juridic person,”8 and so in that regard our relationship with the local bishop is like any other PJP or ministry, right? If you have an order of Jesuits coming, right, they’re not sponsored by the diocese, but they get permission, they check in with the bishop, you know, they have regular meetings, that sort of thing. So that’s our relationship, I’d say, with the local ordinary.
SHADLE: Okay. So now you work for CommonSpirit, which arose out of a merger of different Catholic healthcare systems. But . . . so that’s one thing. But another trend is that Catholic institutions are, have been engaging in mergers or partnerships with secular healthcare systems, or maybe other religious systems that operate on different ethical frameworks. So how does that impact the work of Catholic ethics professionals, that there are these increasing mergers and partnerships?
GREMMELS: The sixth part of the ERDs is really primarily geared toward that question that you just had, and it’s governed by really primarily the principles of cooperation. And the most recent edition’s changes to the ERDs were really entirely focused on part six. It wasn’t a total rewrite, but it was pretty substantive changes, I would say. And a lot of . . . Not just a lot, I’d say almost everything really comes down to that, those moral principles of cooperation that we’ve developed in the tradition over what, the past 500 years, 600 years or so.
SHADLE: So you mean like material cooperation, remote and proximate, and then formal cooperation?9
GREMMELS: Formal, material, yeah. Immediate and mediate. So, that’s a big component of organizational ethics that we do in Catholic healthcare, I would say, which is probably unique to us and not going to happen in non-Catholic hospital settings. Although I would argue they could benefit from it in a lot of ways, but yeah. So everything we do would be governed by that, and we would . . . again, consistent with Church teaching, and anything we do is going to be . . . we have to make sure that any merger we have is either going to completely follow the ERDs in all ways, which it does, but as part of the ERDs, what you’re performing as a Catholic ministry is going to be either justifiable, remote, you know, mediate material cooperation, or it’s going to be directly consistent with the ERDs, so . . . and that would mean sometimes we may not, you know, do a proposed venture or merger or acquisition.
SHADLE: Oh, okay.
GREMMELS: There have definitely been proposed things that we’ve said, “We can’t do that” because it doesn’t meet these principles.
SHADLE: Oh, wow.
GREMMELS: But there have also been times when we say, “Okay, here’s the proposed merger,” and I’ll say . . . or a proposed venture or proposed transaction . . . and we’ll say, “Okay, well, as you’ve described it, that’s not going to work. But here’s what would work, and let’s talk about how it’s appropriate to apply these principles so that we’re doing something consistent with our tradition.”
SHADLE: Right, right. Because you need to be constructive, right? Instead of just saying, “No.”
GREMMELS: Exactly. Yeah, my answer is not going to be, “No,” but let’s try option one or two . . . or two or three instead of number one, right, and option . . . most of the time, that’s going to work, and there’s ways that we can work around that, work with it, I’d say.
SHADLE: Okay, and just to close us out, just kind of an open-ended question. But so, what are . . . What’s another challenge, or maybe even just something interesting or significant, that you see in your field today that we haven’t talked about?
GREMMELS: I think over the next probably ten or twenty years or so, we’re going to see a lot more questions about gene therapy. And we’re starting to see FDA approved treatments now, right? For decades it was, “This is a very interesting theoretical argument, but there’s really no practical application.” And then we had some practical applications in the 90s, and unfortunately people died, and so it stopped. And now we’re getting to the point where, at least technologically, we are able to provide interventions that improve illness, help people, and are safe.
SHADLE: So, for those who are not science-inclined, what do we mean by gene therapy?
GREMMELS: I would actually use . . . So this is my dissertation topic . . . So I would actually use the term “genetic alteration” because “gene therapy” implies a therapeutic purpose . . .
SHADLE: Yeah, yeah, yeah.
GREMMELS: . . . which not all alterations do, and so I would use “genetic alteration.” Basically, what you’re doing is you’re taking the DNA of the person and you’re changing that DNA . . . Here’s my toddler again . . . You’re changing that DNA for a particular purpose.
SHADLE: So, not genetically engineering a newly-fertilized embryo, but changing the genetics of a grown person?
GREMMELS: So, you . . . theoretically I would say it does cover an embryo, as well, although when I . . . again, when we look at what’s actually happening today, like if I needed it, what could I get tomorrow, it’s adult, or born people, after birth. There was one instance of someone, of a scientist changing embryos basically to make them, to give them a gene that we know provides immunity to HIV. And that was done in China a few years ago, and he was internationally just ridiculed for it. He was arrested. It was a huge deal. Even though practically that may be possible, and theoretically might cover it, that’s not what we’re really talking about on a day-to-day basis. We’re talking about something like . . . Leber’s congenital amaurosis is a perfect example that . . . LCA is a form of congenital blindness. It basically . . . Not being an ophthalmologist myself, my understanding is that it causes the rods and cones in your eyes to be misshapen, so that you can’t see. Well, by injecting a virus into the, behind your eyeball right into your cornea and retina, that has the correct, or a correct, version of that genetic malformation, they can fix it and make it better. Now, you’re not seeing 20/20 necessarily, but you can have enough vision that you aren’t really needing, you know, the typical things that someone who was blind would have to have in order to interact with their environment. You can navigate an obstacle course, you can pick up things around the house, you can do dishes. So it . . . and that’s really just the fast cut. And that’s amazing that we can actually do that now. There are . . . One of the things that’s probably the biggest hope over the next maybe four or five years is a cure for type one diabetes, that at this point ten years ago, I would have said that sounds a little fantastical. At this point, I’d be surprised if it doesn’t happen.
SHADLE: And so my first impression is that although the technology is novel, some of the ethical issues are ones that we’ve been wrestling with in other contexts, like you even suggested. Like the distinction between therapeutic uses and other uses like enhancements or even things that are destructive, right? So, is that your sense, too, that it’s maybe just moving into a new horizon, but similar sorts of ethical issues, or are there even some new sorts of questions that are coming?
GREMMELS: Well, I think that there are some new sorts of questions, because that . . . some of the technologies have evolved a little bit. So, for example, CRISPR is a brand new one, and there’s even stuff newer than that, right? You can have direct base editing now, whereas, you know, twenty years ago you were looking at kind of putting patches over a hole, so to speak. Now, with CRISPR and especially direct base editing—although CRISPR is probably the more common technology right now—you have the ability to kind of edit the DNA like you would a Word document. You can delete this and substitute that and move the . . . It's incredible what they are able to do. I would say . . . So, I would actually . . . I think too much stock is put into the distinction between therapeutic, therapy, and enhancement, in large part because a lot of what we do in therapy, whether it’s in the genetic space or any other space, is in and of itself an enhancement, and yet that is also therapeutic. So, for example, let’s say someone has muscular dystrophy and for whatever reason this genetic cause is so complex that we can’t fix it, we can’t make it go away. But what we can do is increase your muscle mass, so you will still have that genetic malformation that causes muscular dystrophy. You’ll still have muscular dystrophy, but we can counteract it by enhancing your muscles. That is simultaneously a therapy and an enhancement.
SHADLE: Or like a classic example is your glasses, right?
GREMMELS: Yep!
SHADLE: They may be treating a condition like short-sightedness . . . or near-sighted. I’m sorry. But they may also make your vision somewhat better than average.
GREMMELS: Another one that really comes to mind for me is an immune system.
SHADLE: Short-sightedness!
*Laughter*
GREMMELS: Short-sightedness, yeah, that . . . hopefully not intended here. But the immune system. If you could find a genetic profile of different combinations of genes that gave someone a much improved immune system so they wouldn’t be susceptible to it, right? I’ve got four kids, so in my house, somebody gets sick, everybody’s sick. For whatever reason, I’m always the last one to get it, and I only have it for like a day or two, and everybody else has it for a week. For whatever reason. I’m not as susceptible as much as others are to that. What if you could find what makes . . . And I hear that common story from other families, too, right, somebody is going to get hit a lot less by different illnesses. What if you could find whatever profile that someone has genetically that makes them that way and give it to other people? That is clearly an enhancement. It’s also preventive therapy. So I think that distinction that’s been around for fifty years, of enhancement versus therapy, is somewhat helpful, it’s kind of like a yellow flag, but I don’t think it holds up as a bright line, perhaps as it was originally conceived to be.
SHADLE: Yeah, I would probably agree with that. But, yeah . . . But then where do we go from there?
GREMMELS: We do . . . And this is another area where there’s not a ton of magisterial teaching on it, but actually John Paul II, in one of his speeches, lays out some principles. So there’s some initial conversation about it, about what that looks like for non-therapeutic stuff.
SHADLE: Well, I think we need to wrap this up, but this has been very informative and interesting. So thank you so much, Becket.
In 2001, President George W. Bush announced a long-awaited policy on research using stem cells derived from embryos, allowing federal funding for research on the then-existing lines of cells derived from embryos, while restricting federal funding for research conducted on new stem cell lines.
In 1990, Terri Schiavo experienced cardiac arrest and went into a coma, and later was declared to be in a permanent vegetative state. In 1998, her husband petitioned the Sixth Circuit Court of Florida for her feeding tube be removed, but her parents contested the request. The court decided in the husband’s favor in 2001, and after several appeals and interventions from the government of Florida and the federal government, her feeding tube was finally removed in 2005.
"Do not resuscitate” order: A directive from a patient stating that they do not want CPR or other life-saving measures if they go into cardiac arrest or stop breathing.
Rachelle Barina, Becket Gremmels, Michael Miller, Nicholas Kockler, Mark Repenshek, Christopher Ostertag, and Kirsten Dempsey, “Data Ethics in Catholic Health Systems,” in National Catholic Bioethics Quarterly 22 (Summer 2022): 289-317. (subscription required)
Becket Gremmels and Sam Bagchi, “Resuscitation à la Carte: Ethical Concerns About the Practice and Theory of Partial Codes,” in CHEST Journal 160 (Sept. 2021): 1140-44. (subscription required)
United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Healthcare Services, sixth edition (2018).
"Public juridic persons are aggregates of persons (universitates personarum) or of things (universitates rerum) which are constituted by competent ecclesiastical authority so that, within the purposes set out for them, they fulfill in the name of the Church, according to the norm of the prescripts of the law, the proper function entrusted to them in view of the public good; other juridic persons are private.” Code of Canon Law (1983), Canon 116, §1.
This short article from the Catholic Health Association explains these distinctions.