Adventist Healthcare in the US: Who are these people?

The second goal of the recent national meeting of SDA bioethicists was to “explore the potential for future cooperation in bioethics across the Adventist health systems.” I am excited at the possibilities but see two challenges to this idea within Adventist healthcare in the United States. The first is financial and the second is structural. Let’s look at the first problem by starting with the question, "Who, exactly, are we talking about when we use the term, 'Adventist health systems?' ”

When I Google for “Adventist health systems” it takes me to: “Adventist Health System,” - the Florida-based institution that is by far the largest in the U.S. I found nothing there to indicate they have sibling Adventist institutions. I also found nothing on any of the other Systems sites indicating their Adventist connections. Nor did I find any connecting links on the NAD or GC sites that would direct readers to our Healthcare Systems. I find it curious that, for all the talk about strengthening connections between the Church and our healthcare ministry, there doesn't appear to be much evidence of it on our various websites. We should begin, for instance, with a full fledged statement of acknowledgment and support for each other. Then, how can we cheer each other on?

We can find information at the Adventist Health Policy Association website under the tab “About Us/AHPA Members.” Here five AHPA members are identified, noting their location, inpatient admissions, staffed beds, and personnel. Combined, the systems are in 17 states, with over 619k inpatient admissions, just short of 15k staffed beds, and over 126k employees. By system, the breakdown is as follows:

  1. Adventist Health has 20 hospitals: https://www.adventisthealth.org/pages/home.aspx

  2. Adventist Health System, by far the largest with over 70k employees and over 350k admissions annually: http://www.adventisthealthsystem.com/

  3. Loma Linda University Health, with 35k admissions annually and 6 hospitals: http://medical-center.lomalindahealth.org/

  4. Kettering Health Network, unique in several ways, presently serving in Ohio with just short of 10k employees: www.ketteringhealth.org

  5. Adventist Health Care, works in Maryland, New Jersey, and the District of Columbia with just over 40k inpatient admissions: http://www.adventisthealthcare.com/

The AHPA website goes on to compare the size of the Adventist systems with "other major systems" around the US. But it doesn’t offer a comparison with other faith-based, non-profit healthcare systems. It surely is a blessing that our healthcare systems are doing well, but I do wonder what our healthcare ministry would look like if our large institutions were failing? What would SDA healthcare ministry look like if it were completely dispersed throughout other, non-Adventist healthcare systems; if we all worked for some other faith-based or secular healthcare organizations? For example, Hoag Memorial hospital in Southern California, a Presbyterian heritage hospital, recently joined another faith-based hospital system which isn’t Presbyterian. Could we Adventists imagine doing that?

So, if Adventist bioethicists are hopeful for more cooperation amongst ourselves and the systems we work for, what models of cooperation might we find among those "other major systems" listed on the AHPA website or, better yet, among other faith-based healthcare systems in the US?

For instance, is there a Lutheran, Jewish, Catholic, Baptist or Methodist hospital-system association of some sort? In secular healthcare in the U.S., the American Hospital Association (AHA) is the main body in which we might see some cooperation for public good. Some of our Adventist systems are members of the AHA. But the AHA does not have an active ethics sub-culture. For cooperation and connectivity among ethicists we have to turn to a stand-alone society: the American Society for Bioethics and the Humanities. A few of us are routinely involved there, but so few that I can't imagine forming a parallel structure with it like we have with the Society of Biblical Literature or the American Society of Religion. And this goes to my point about being dispersed among others in a professional field, for which we have no claim of particularity.

An editorial piece on Jewish healthcare in the U.S. might be instructive here. Among other things, the author asks: "Does the disappearance of Jewish hospitals matter? It is to the detriment of Jewish commitments to education, to the provision of health care to the poor, and is a loss to the extent that Jewish hospitals are a 'public face' of the Jews."i What would be the loss of an Adventist institutional healthcare presence in our communities? Who among those we serve (or ourselves) would suffer loss?

While there are many faith-based hospitals and systems caring for communities through a Protestant perspective, I am unaware of any general or particular association for the various Protestant healthcare systems. History demonstrates that we Protestants don’t particularly play well together. So, kudos to Adventists for at least creating an association for ourselves. Here again, we might learn from our Catholic brothers and sisters. The USA-centric Catholic Healthcare Association has been around for over 100 years and they represent about 85% of all Catholic healthcare providers. There is a Theology & Ethics department at the CHA with at least two full time theological ethicists and a number of supporting educational and administrative staff members. Their website says the CHA is "Comprised of more than 600 hospitals and 1,400 long-term care and other health facilities in all 50 states, the Catholic health ministry is the largest group of nonprofit health care providers in the nation. Every day, one in six patients in the U.S. is cared for in a Catholic hospital."ii

But let’s return to the main point of this column: how can Adventist healthcare systems cooperate more effectively to advance both overall care for our communities and with specific regard to ethics/bioethics? The "potential for future cooperation" across our Adventist healthcare business subcultures is immense and wide open at the moment. But business systems in the U.S. don't cooperate, they compete. This is just as true for "us" as it is for any business venture, even in healthcare. In the U.S. today, healthcare is an income generating industry. Indeed, one can invest in healthcare industry stocks and potentially make significant money. This does not say anything about how easy or difficult it is to profit from people’s ill health. Nor does it ponder the associated moral questions. Healthcare in America is as much, if not more, about business than ministry. Indeed, an oft stated refrain among faith-based hospital finance personnel is, “No margin, no mission.” Perhaps we should look somewhere overseas for a more authentic form of Adventist healthcare ministry?

So, what does it mean for us to imagine a future with a meaningful bioethics cooperation across Adventist healthcare systems in the U.S.? A few issues may immediately emerge. The first is paying for bioethicists and their work. Hospitals and their associated health ministries make money for providing direct services that customers/patients pay for. When was the last time you paid for an ethicist’s work? American healthcare is paid through a complex system of coded services. And bioethics services are not “billable.” So, hospitals must “eat” the cost of such staff, which typically means they simply don’t employ any. More frequently a healthcare professional, already working for the hospital (often an MD, but many other professions have joined the effort), is asked (or allowed) to spend some time “doing” ethics – most often “clinical ethics.” For hospitals to employ ethicists there needs to be a pretty strong felt need and, thus far within our Systems, they have apparently not felt that need. To my knowledge there are no ethicists presently employed in any Adventist Healthcare Systems who are dedicated to, and working solely as, an ethicist. Only academicians, chaplains and clinicians, working in associated positions and professions, who serve hospitals simultaneously – with no direct payments for ethics services. If there are bioethicists directly working within any of our Systems, it would be news to me.

The second issue is that there are very few “Adventist” bioethicists. One of my former colleagues at LLU has bemoaned our present condition for many years, saying “Who will fill our roles and positions once we’ve retired?” Mind you, he refers to those associated positions I mentioned above, rather than embedded hospital and Systems level ethicists. While our MA level program in Bioethics at LLU’s School of Religion has educated a good number of students through the years, only a few have gained employment as clinical ethicists. There just aren’t many full time jobs out there for ethicists, inside or outside of an Adventist context. Looking more broadly at our undergraduate colleges and universities one will not find an ethics degree program anywhere, and in some cases not even a single required course in ethics for a four year degree.

Finally, given these conditions, the type of “cooperation” at issue will be an important consideration. Clinical ethicists are fairly good at cooperative work arrangements. As I noted above, most of us combine ethics with some other profession that can charge for their services. The better healthcare systems develop and use cooperative methods for clinical consult services. The US Government Veterans Hospital System is the shining example of such cooperation. Their clinical ethics consultation service is miles ahead. What might we learn from them as we develop a cooperative model for Adventist healthcare? I am hopeful for the willingness of our Systems’ CEO’s to make this happen, though given their budget constraints, I recognize how difficult that will be. For all the money made in American healthcare, it remains a very competitive business.

Given the real and difficult problem of paying for healthcare ethics services, what can ethicists do for these institutions? A typical, clinical ethicist job description in healthcare includes three elements: 1) clinical case consultation; 2) educational work for the caregivers working with patients; and 3) development and/or management of policies associated with ethical issues. On this last element, for instance, hospitals have been developing policies over the last 10-15 years concerning palliative sedation.iii Other issues requiring policy work include: abortion, cessation of life-sustaining treatments, death by neurological criteria. When such policies are developed it is necessary to make sure caregivers understand the hospital’s positions, making education an essential part of a clinical ethicist’s work. Finally, when a patient and family are struggling with making decisions for their loved one they can ask for an ethics consult. Or when a physician is trying to make appropriate medical decisions for an ICU patient with no known family or friends, she/he can talk to an ethicist about it. Or when a pregnant girl, raped by her uncle, wonders whether or not it would be morally appropriate to get an abortion, clinical ethicists can be present, to talk and think together with her and her loved ones.

Some recognize this work as essential to present day hospitals and health systems. Next time, I’ll pull back the curtains a bit more with the hope that you will understand what ethicists do: clinical ethicists, organizational ethicists, religious/theological ethicists, and professors of ethics.

i Read more at: http://www.thejewishweek.com/editorial-opinion/opinion/jewish-hospitals-are-becoming-extinct#AXmp11XhjCGJLyY8.99

ii https://www.chausa.org/about/about

iii See also: https://www.capc.org/about/press-media/press-releases/2010-1-6/palliative-sedation-myth-vs-fact/

Mark F. Carr is an ordained minister and theological ethicist with experience as a pastor, pilot, commercial fisherman, professor, and now clinical ethicist. He writes from his home town of Anchorage, Alaska.

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This is a companion discussion topic for the original entry at http://spectrummagazine.org/node/7605

With the recent legislation in several states allowing a terminal patient to choose ending his life, there should be more need for ethicists. But the writer presents several other situations where an ethicist consultation would be valuable.

Not only for end-of life, whether abortion or terminal patient’s choice, there is a need when patients die while in the hospital’s care. Many families are confused and do not know how to question the attending physicians but a third person could evaluate the hospital record, with consent of the family, and more completely explain their loved one’s death. Perhaps this could defuse needless and costly lawsuits, which are a problem in all hospitals.

Just a few places where they should be employed. Perhaps with more laws allowing patients more control over their bodies, legislators will see the need for “third-party” explaining and intervention.

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Mark, it seems to me that the above quote describes many of the situations that are now addressed by chaplains in Adventist healthcare institutions. Could you elaborate on whether or not you see ethicists as replacing, working-in-collaboration-with, or being-identical-to… hospital chaplains?

Early. post war, we received a patient burned over 90 % of hi s body. we did removed as much dead tissue as possible and covered him with vasoine gauze and shipped him to a hospital ship. the prognosis was ten days until his kidneys etc would shut down and he would die. that did not prevent our efforts. he was under pain management the entire time. A drunken playful. Accident that went terribly wrong. That did not impact our best efforts.

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Mark’s List of SDA Hospitals is just a short list in the U.S.
There are quite a few more not mentioned.

Mark – in the communities where our SDA hospitals are located, DO the hospitals HAVE to Employ a Full Time Ethics Person?
OR, are there persons in the Community [not necessarily SDA] who can be called upon, be used As Needed, and then just paid for their time?
Actually, some NON-Sda hospital have an ETHICS COMMITTEE, not just one person where situations
can be discussed and the best solution is decided.

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Hi,
At the core of an ethics consult is careful conversation and extended communication. The same can be said of a chaplain’s work, I suspect. While I’ve never filled the role of chaplain, I am certain that our training/education is very different; ethics tends to be more analytical while chaplaincy tends to be more tuned into patient experience and felt need. In the system I work in, chaplains and ethicists work very closely with each other. Additionally, palliative care teams work very closely. Palliative care can bill, chaplains and ethicists cannot. Finally, while faith-based facilities typically employ chaplains, I think non-faith based places will simply allow volunteer chaplains to have access if and when patients request it.
Thanks for the question,
Mark

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Steve,
It’s not “my” list. Its the AHPA list and it is not of hospitals it is of Hospital Systems, each of which has many hospitals.
Thanks,
Mark

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Interesting. A couple of observations:

  1. There are probably more Adventist health employees than Adventists in the pews each week. Thus AH has a lot of autonomy.

  2. On death issues - Adventists have no idea what Adventist Health has to do with providing abortions or assisted suicide (where legal). I read last week that Adventist Health in California had decided to permit doctors to perform assisted suicides but there’s nothing from AH saying whether or not they are doing this. Same with abortion. Rumors are that Adventist hospitals perform abortions and there have been extremely prominent abortion doctors who identify as Adventist (La Sierra named a center in their business school after one) but nothing from the hospitals as to whether they do this or not.

  3. The church has no role in setting hospital policy and defers to the hospitals. And the hospitals and church claim independence from each other when convenient to do so, but the church claims the large hospital system for bragging rights.

  4. When the hospitals mess up and have to pay huge fines for Medicare Fraud (such as in Florida) it is an embarrassment to Adventist Church members and the hospital system played it off as a usual and customary fine even though it was one of the largest fines in history. Sometimes Adventists love the hospitals, other times they make us cringe.

  5. Hospitals operate as a “shadow” church and would likely never take denominational policy to heart if it conflicted with a profit motive.

  6. Hospital profits which seem to be huge will never go to sustain local congregations that are struggling anyway why should church members really care? The hospitals operate in parallel lines to the church and for most, the two never meet.

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Does a Faith Healing Church need assigned handicap parking?

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If they’re going in for healing!

The Latter-day Saints (whose church bldg that appears to be, having been both LDS and architect), are not known for faith healing, though they will take the time to anoint the sick and afflicted, as well as their sanctuaries, though there is no accounting of its beneficence.

May it be blessed.

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I am no longer an Adventist, but enjoy reading Spectrum. As a middle manager in non-profit healthcare for the last 30 years, this article caught my attention.

I am currently a Bio-ethics Committee participant in a 500+ bed hospital with a contracted bioethicist who consults for several other area (unaffiliated) hospitals as well. The bioethicist works in coordination with a palliative care team composed of palliative physicians, social workers and chaplains. I believe supporting the patient/family in identifying goals of care is one of the most tangible acts of caring that occurs in modern healthcare.

I am bemused that Adventist Healthcare does not employ ethicists. Further, I would ask a long held question as I heard of Adventist Healthcare from the pew - What does a patient receive at an Adventist hospital they would not receive elsewhere?

Healthcare is an evidence based science, not a ministry. Accreditation requires that patients’ spiritual needs are met. Reimbursement requires the shortest possible length of stay - with little time for evangelism. Patient education on post discharge health (tobacco and alcohol) is also a requirement in some states. Patient comfort and satisfaction are measured in a governmental process tied to reimbursement for care.

All healthcare has a marvelous beneficent history that led to the delivery system we utilize today. How is Adventist Health different…and to return to the subject at hand, why don’t they need ethicists?

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Hi Courage and thanks for chiming in. Your description of the way your ethics committee is set up and functioning is typical. And in some ways it makes my point. Your ethicist is under contract as opposed to being a regular employee. Of course there are lots of people working in hospitals under contract. When hospital systems have enough hospitals amounting to enough work, the contract occasionally becomes a full time job. Like my job, full time ethicists typically have more than one hospital to care for; I have five facilities (including a transitional and long term care facility) on my list. And yes, working with the palliative care team (who can bill for their services) is a daily reality. Some ethicists actually bemoan the growth of palliative care because it has, in their view, taken away from the workload of ethicists. In fact, as I noted above, at the core of a good ethics consult is careful conversation and palliative care specialists are superb at that.

Finally, there is no need in my view to single out Adventist Systems as ignorant of or willfully neglecting the need for ethicists. We do use ethicists, but as I noted they are typically (like your own situation) practitioners who have other jobs who serve either voluntarily or under some measure of contract for their time in ethics. What I would hope, however, is that we do catch a vision of the value of employing ethicists as full time members of the healthcare team. And you are oh so right, the history of healthcare and its altruism for those who suffer is a fantastic thing to be a part of. Evidence is at its core, but so also is that human spirit (instilled by God in my view) to care for others. In my view, that transforms it into a ministry; one that I’m privileged to be a part of.
Mark

Pastor Mark,

Some of your research is very narrowed; when you wrote: “we all worked for some other faith-based or secular healthcare organizations? For example, Hoag Memorial hospital in Southern California, a Presbyterian heritage hospital, recently joined another faith-based hospital system which isn’t Presbyterian. Could we Adventists imagine doing that?”

There are a couple of Adventist hospitals that partnered with a Catholic healthcare system. “Centura Health is a non-profit, faith-based health care system based in Englewood, Colorado which was formed in 1996 as a joint operating agreement between Catholic Health Initiatives and Adventist Health System. The system expanded its operations into Kansas in 2011.”

Also, I have found a few connections (that I have time to search for) between the church websites and the AH systems; I find indiscretion in your statement: “I also found nothing on any of the other System sites indicating their Adventist connections. Nor did I find any connecting links on the NAD or GC sites that would direct readers to our Healthcare Systems. I find it curious that, for all the talk about strengthening connections between the Church and our healthcare ministry, there doesn’t appear to be much evidence of it on our various websites.”

http://www.nadhealthministries.org/article/103/resources/adventist-health-institutions,
http://healthministries.com/resources/online (GC) and I even found on the right side of a Central California Conference Health Ministries page is a set of links to their area Adventist hospitals.

Let me respond to the financial piece; the Adventist Health systems (all of them) have plenty of money. It’s how they spend it is the problem. They receive grants from the Federal government in research areas, for upgrading/remodeling their infrastructure, etc. The AH companies also invest in the financial markets. There is money to spent, if appropriated correctly for bioethics. LLU has the Center for Christian Bioethics and there is this:. Adventist Health Systems attended a bioethics conference at LLU (just a few months ago). If they don’t have the financial resources for this, they wouldn’t be talking about it.

Therefore, because there doesn’t seem to be validity with your article, as I have found proof against what you’re saying isn’t available, I am unable to figure out what you’re trying to point out. Please clarify.

Hi Kris,
And thanks for asking me to clarify. I’m sorry you find my piece to be lacking validity and discretion. I am well aware of Centura Health as I once worked for them as an ethicist under contract. The point of that part of my essay was to question how we would relate to working for (or with) other faith-based systems. Arguably, Centura (and another system in the Chicago area just recently) is an exception. In fact, it is said that some of the Church administrators who helped facilitate the Centura merger were black listed for their career advancement because of it. I’ve heard it voiced that some church members in the areas affected would rather have seen our facilities close than join hands with Catholics.

As for those pages you found with links between Church Administration and Healthcare Systems; wonderful!! Indeed, lets cheer together. I’m not sure why you would feel the need to impugn my work because you found a counter example. But whatever your motive, thanks for pointing it out. I’m glad to see it.

Finally, regarding the financial part of the piece, your examples are well known to me. I was the director of the LLU Center for Christian Bioethics for eight years. The Center is not funded by the LLU Health System, per se. It is a University entity and though the finances of LLU Health are very complex, the Center remains a University endeavor, not one of LLU Health. I was present at the recent meeting of Adventist bioethicists. And like you, I tend to think that there is enough money to dedicate more to ethics in general. However, and this is a big however, I know enough about criticizing the other (any other) to know that the complexity of the issue always appears lower from the outside and uninformed perspective. As I said in my article, there is money to be made in healthcare in America, but it is an incredibly complex and difficult thing to manage the budget of entities as large as, say, Kettering or Adventist Health or LLU Health. Again, why you would imagine that what you found invalidates the points I’ve tried to make is a mystery to me but I’ll try harder next time.
Best,
Mark