No Easy Answers in Bioethics Podcast
The Medical Ethics Resource Network of Michigan: a History - Episode 3
November 9, 2017
Dr. Leonard Fleck, Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Philosophy, sits down with producer Liz McDaniel to discuss his involvement in the Medical Ethics Resource Network of Michigan (MERN), a non-profit organization that existed for about twenty years, beginning in 1986. Dr. Fleck discusses the reasons why there was a need for such a network, and provides insight into the work they did in sharing expertise and helping individuals develop skills that were needed to thoughtfully address ethics issues within a clinical setting.
This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.
Top left image: pictured are MERN members Ray Pfeiffer, Leonard Fleck, Len Weber, and Matt Weiss, date unknown. Bottom left: a group photo of many individuals at the first MERN boot camp in Shanty Creek, MI, August 1990. Right: a MERN brochure.
Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Today I'm joined by Dr. Leonard Fleck, Professor in the Center for Ethics, and we're going to talk about an entity called MERN. Dr. Fleck?
Leonard Fleck: Hello how are you Liz?
LM: I'm good, thanks for joining me today.
LF: You're welcome.
LM: So can you tell us what is MERN? What does MERN stand for? And how and when did it get started?
LF: First of all the word MERN stands for Medical Ethics Resource Network of Michigan. It really got started roughly in early 1986. And it started in some sort of an informal faculty meeting. My recollection is that there were three of us who sort of kicked around this idea. That was Howard Brody, who was the director of the Center at the time, Len Weber who is, who was a faculty member at the University of Detroit, and then myself. And we were we just had the idea that maybe it would be a good idea to have some sort of a mechanism for bringing together hospital ethics committees at various hospitals throughout Michigan. Because most of them were very isolated and had very little ability to provide the kind of intellectual support that was needed for members of hospital ethics committees. And so that was just an idea, a rough idea that we had. And we wondered how it would get off the ground. And we decided we would have a small conference at the Kellogg Center and we invited about thirty individuals, clinicians, folks who did medical ethics or members of hospital ethics committees to serve as a kind of basic organizing group. And that was in the fall of 1986. And that was the real beginning of MERN.
LM: Okay. So now I'm interested in when you say providing intellectual support to the hospitals and ethics committees, what that means and then that kind of ties into my next question of why, why did you want to start this network and why did you see it as a good or a necessary thing to do for the state?
LF: It was necessary because among the things you have to keep in mind is that in 1986, the dinosaurs had barely disappeared and the Internet was not existed, at least as we understand it today. There is some government thing called the internet but this was not something that was publicly available. And so in terms of having ethics committees become more informed and more able to do their work as ethics committees and dealing with some of the kind of complex ethics problems and the development of policies around those issues at local hospitals. It would be helpful to have some kind of centralized resource. And it would also be helpful to have an institution that facilitated networking among these different hospital ethics committees. And so that was there was a basic idea behind what MERN was doing. Then beyond that we had to think about how exactly we wanted to foster that networking and foster the develop-- the improvement of knowledge about problems and health care ethics. So we did several things. One was, we developed a number of what we called ethics modules, that addressed some of the specific problems or very common that hospital ethics committees had to look at. So a module that looked at foregoing life sustaining treatment. A module on form consented truth telling, and so on. One of the other things you need to keep in mind here is that nowadays probably almost every college or university offers a course in health care ethics. That's available to students, and particular students who intended to pursue careers in health, some area of health care. Back in 1986 that was much less common. And so the folks who are on hospital ethics committees had relatively little in the way of what you would call formal academic training in addressing problems with health care ethics. So that was the first reason we had for developing the modules.
Among other things we did, we put together an annual conference. It was typically, it was a two day conference. And it was a conference that typically brought together somewhere between 100, 130, 140 individuals from all around the state. And we would have a number of speakers and workshops and so on. And again this was another opportunity for individuals to meet in person, folks from other hospital ethics committees to talk about the problems and issues and challenges they had to face. And so that was the annual meeting, something that worked very well.
In addition to that, we put together something called the MERN newsletter. Which we put out on a quarterly basis. Again this is a way of just keeping everybody in touch. It was the equivalent of a paper internet of sorts. And then fourthly, we put together a week long summer intensive course in health care ethics. We had in mind when we first put that together, that we would be doing this primarily for members of hospital ethics committees in Michigan. But we thought it might not be a bad idea to advertise it more broadly. So in point of fact we would typically have forty or fifty individuals for this week long session. And probably at least a third of them came from various parts of the country. That in itself was something that was educationally valuable, that they… cause folks from other parts of the country, they brought their own experiences with dealing with ethics committees and ethics issues in their institution, into that discussion. So that turned out to be another very valuable part of what MERN was doing. We offered also a Speaker's Bureau. So those of us who were available and willing to travel to these different hospitals to do different kinds of electors or workshops and so on, this was another way of facilitating things. And we also wanted to offer the, some expertise in helping to develop hospital policies that addressed a lot of these issues. And lastly we felt it was important to do broad community education. You have to keep in mind that even though a lot of these issues nowadays are relatively well understood by a relatively large segment of the public, at that time there were an awful lot of issues that were extremely controversial. And the idea of withdrawing withholding life sustaining care from individuals in various situations was something that was done only with a great reluctance and there would be a lots of conflict, perhaps within an institution, and legal concerns on top of the ethics concerns and so on. There would have been the cases at the time. The Brophy case was one that would have elicited in the literature and in the public mind concerns about what are they doing in these hospitals nowadays. And so it's important that the broader public come to better understand what some of these issues were and how they were being addressed and why they are being addressed in a certain way.
LM: That's interesting that the conferences and events would also draw people from the rest of the country. Do you think there are other similar entities around the country at the time? Like a statewide known network or do you think this was fairly unique?
LF: No that, the one things we were relatively mindful of, was the fact that we had something very unique here. We were aware of the fact that around several large cities, New York and Chicago, I think we had in mind. There were these ethics networks among hospitals that were concentrated in that urban area. But nobody had attempted to reach out to a whole state. And so this was something that was unique, and we felt that this was a genuine public service for health care within the state of Michigan.
LM: I want to ask about maybe the logistics of how you financed the group and who made up the board?
LF: In terms of financing this was something of course that we had to think about. It wasn't as if we had some huge financial obligations that had to be met. Basically we had one person on our payroll. We had Jan Holmes, who was the department administrator, and we simply in effect bought a part portion of her time to take care of things like registering individuals for the MERN annual conference, for the summer workshop, and for the collection of dues from MERN members. One of the experiences that I had that served as the basis for figuring out the finances of this organization, was when I was in South Bend, Indiana in the mid to late 1970s, I helped to organize a hospice program there. And one of the challenges we faced, was that there were four hospitals in the community and we were concerned that each one of those hospitals would want to have its own hospice program. Which would be costly and inefficient. And so the idea I had was that we would go to the CEO's of each of those hospitals and ask them to put up something like five thousand or ten thousand dollars a year to support the hospice program at that time. Because there was no federal funding of hospice at that time. It had to all be based on community resources. And in that way each hospital had a stake and in that organization and we avoided the kind of inefficient competition that otherwise would have occurred. So with that idea in mind, I thought we're going to do the same sort of thing with MERN. We're going to ask each of the hospitals on the basis of their bedsides to contribute in annual dues, to supporting MERN. So if the hospital had five hundred beds or more the dues were typically $750 a year, and then there was a $350 dues and a $200 dues and for a nursing home or hospice programs or other non-hospital based entities, home health programs we had a $100 due structure. For individuals it was $35. And basically that money provided us with a basic budget that paid for the secretarial services we needed. That paid for duplicating phones, printing, just all that sort of basic stuff. I served as a kind of informal executive director for MERN, unpaid but somebody who just paid attention to all the nitty gritty managerial details that had to be paid attention to. As… and that basically that seemed to work very well.
LM: So what would you say was like the peak of MERN and at that time like ballpark how many hospitals and other institutions where part of the network?
LF: We had, we probably had somewhere between forty and fifty hospitals that were part of the network. And probably about one hundred individuals who were individual MERN members. That would have been our peak size and that would have been in the roughly the late 1990s and the early 2000s.
LM: So MERN began in 1986 and when did it cease to be?
LF: It ceased to be roughly, and it was kind of a slow dying process, somewhere in the vicinity of 2007, 2008, 2009. And basically here are the sorts of things that contributed to, I guess the word of the undermining MERN and its mission. There is nothing nasty about this. It was just the evolution of the health care system. And the evolution of knowledge about medical ethics and so on. And so a lot of the things we did as part of our work, were really unnecessary. So the modules were much less necessary as the years went by, because there were so many textbooks and courses that were offered on healthcare ethics. So the modules simply duplicated that. But basically what happened was, that we began to see by certainly by the late 1990's, the beginning of the consolidation of the healthcare system. So what they're merged these different networks of hospitals in Michigan. So you have Spectrum Health on the West of Michigan and you got Beaumont, you got Henry Ford and the Mercy Corporation. You have all these different hospitals there were started banding together and forming one more or less corporate entity. And then what they said to us was well we shouldn't have to pay for each of the hospitals to belong to MERN because we're now really one organization so we just want to pay one $750 dues. Well that began to erode our financial strength. And so after a while that became, that was one thing that became more problematic. But the other sort of thing that happened was that these hospital systems began to hire their own in-house medical ethicists or ethics consultants, who work with the hospital ethics committees both to do training and education and to consult on individual cases. So when MERN started in 1986 the only health care systems that had their own in-house ethicists, were the two Catholic healthcare systems that are dominant within the state. Nobody else had an in-house ethicist. Len Weber from Detroit, he served as an informal consultant sort of to the Mercy Corporation. But then I mean, since then Spectrum Health has its own internal ethicist. Beaumont has its own internal ethicists. Henry Ford, the Catholic hospitals continue to have theirs and so on. And so again the need for having this network became, it was duplicative and less, seen as a less needed relative to the availability of in-house talent. And of course when I say in-house talent if a hospital like Spectrum, which has now ten or eleven other hospitals affiliated with it. That talent extended to those ten or eleven other hospitals who are part of that system and consequently there wasn't something much more that we could do. The only thing that we could offer was that we would of course have access to these enormous libraries of medical journals, medical ethics journals, and so on. Which no hospital could afford to have access to in the way that large universities like Michigan State or the University of Michigan would have access to. So we continue to provide those kinds of resources but it's now in a much more sporadic and informal kind of way. And so as I said, the need for MERN’s size of our board saw and gradually diminished over a period of several years. And eventually we simply had to in a formal way dissolve as an institution.
LM: I want to backtrack a little bit and just clarify for maybe folks that might not know much about how ethics committees work. So talking about how the hospital started moving more toward hiring an in-house person, are ethics committees or at the time I guess and presently usually made up of people who are in more or less a volunteer position or are the employees of the hospital?
LF: The hospital ethics committees are mostly made up of individuals who are employees of the hospital, but they are volunteer members of the ethics committee. That is they do not get any additional pay. This is something that they simply do as part of their professional role on a volunteer basis. Hospital ethics committees are formal organizations so individuals are in fact chosen or elected to serve on the Ethics Committee. Typically these ethics committees are very diverse in terms of the types of individuals, the particular health care roles that are occupied by individuals on those committees. So they have some number of physicians, but you'll have nurses and social workers, pastoral care. Sometimes you'll have somebody with a legal background, who will be part of those committees but in general that's, that's the kind of makeup of the committees. Part, one of the reasons why a number of the very large hospitals and hospital systems have hired their own ethicist, is that ... is that a practical problem that those committees faced, is that when there was need for an ethics consult, typically in the past that meant we're going to bring the whole committee together. And the whole committee who might be ten, fifteen, or twenty individuals, it's extraordinarily difficult in a hospital setting, where everybody has their own job to do. To get that many people together to talk about a case. And so some ethics committees would say well we're going to have two or three of our members do the bedside consultation and we'll kind of rotate their responsibility. But even that was sometimes kind of awkward, given that these individuals had other responsibilities. They had patient care responsibilities and they couldn't easily just walk away from those, in order to have a meeting that might take an hour, or two, or three, depending on how complex the case might be. And so it became much more, it became easier and more efficient to actually hire somebody, who would be the prime individual, who would do the bedside work oftentimes with one member of the formal committee. Talking to family, talking to the patient, talking to various caregivers involved with that case to get a sense of what it was all about. And in fact to make oftentimes a formal recommendation of what was an appropriate decision to make with regard to that particular case. For the most difficult cases where the most, there is the most complexity and the most conflict among members of the family or with caregivers and so on, it would then be the case that they would call a meeting of the entire committee, to talk to, talk through that case and sort out all the complexities of it and to perhaps meet with family members and so on. But otherwise, it's more efficient to use the hospital ethics consultant.
LM: Thanks. So we're talking about an organization that existed for about twenty years right? And, and through that time period a lot of significant changes were happening just in even, in just our society. So if you had to say maybe one thing that was the most important accomplishment or most meaningful accomplishment what comes to mind?
LF: It's, it’s hard to identify some one thing that was most important. Overall the thought I have is that MERN did, what it was essentially designed to do for the twenty or so years of its existence. It brought together provided expertise and networking mechanism for most of the ethics committees, hospital institutional ethics committees that existed in the state of Michigan. It got people comfortable with talking to one another, with sharing policy, sharing information. It helped provide individuals with skills that they needed to address thoughtfully and sensitively the kinds of ethics issues that occur within a clinical setting. And in doing all of those kinds of things I think that was overall the most important sort of thing we did.
LM: Do you have any funny stories or personal anecdotes you want to share?
LF: Oh the one personally that I can think of is that my partner Jean Edmunds is somebody who actually attended three of our summer intensive workshops. And so the last of which was in the year 2000 and so this was, this was somebody who turned out to, ended up being my partner. My what I refer to as my partner in life and love and labor. And she's just, and that was that was probably the most personal and best thing that came out of our summer workshops.
LM: Awesome. Well thank you so much for joining us today on the No Easy Answers in Bioethics podcast. Please visit our website for more information and some more historical tidbits about MERN.
LM: Thank you for joining us today. Please visit us online at bioethics.msu.edu, and follow us on Twitter @MSUbioethics. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel.