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Maureen Pontarelli, D.Be, describes her career path as a bit unconventional.

The Rochester, New York, native attended college in Rhode Island and graduated in May 2020 with a bachelor’s degree in chemistry. She then moved to Massachusetts, where she worked as a chemist while pursuing a master’s degree in Catholic clinical ethics. She worked during the daytime and took online classes at night. 

Raised Catholic, Pontarelli had minored in theology and taken a bioethics course in college that she found really intriguing. That led her to study Catholic clinical ethics in graduate school.

“I was engaged from the first class,” she recalls. “I couldn’t fall asleep that night because my mind was still thinking about all the things we discussed in class. I knew then what I wanted to do as a career.”

Clinical Ethics Fellowship at MD Anderson

Pontarelli developed a close relationship with one of her professors. They shared an interest in clinical ethics, which focuses on ethical, social and legal issues in health care. 

“She became a mentor to me,” says Pontarelli. “I was already following a similar career path, so she recommended I get a doctoral degree and then complete a fellowship. She had done the same.”

Pontarelli took her advice. She earned a doctorate in bioethics and then applied for a Clinical Ethics Fellowship at MD Anderson. It was the same fellowship her mentor had completed years earlier.

Pontarelli was accepted into the program, so she and her boyfriend moved to Houston. Being from the East Coast, they had to adjust to the heat. But she loves the southern hospitality everyone displays in Houston. Pontarelli is now in her first year as a fellow, and she is focused on gaining valuable experience as a trainee. 

The value of mentorship

At MD Anderson, Pontarelli quickly found another mentor in Gavin Enck, Ph.D., director of the Clinical Ethics Fellowship. She attends ICU rounds with Enck four days a week and is helping him with a project to make clinical ethics documentation and data collection more efficient.

“Maureen is an exceptional fellow,” says Enck. “While she has been pivotal and immensely helpful with my project, it’s her dedication to addressing the needs of patients, families and providers that makes her exceptional.” 

After working independently as a chemist, Pontarelli had to adjust to the collaborative environment of clinical ethics. Enck helped make that transition easier.

“We have the same thought processes on a lot of things because we’re both very analytical and detail-oriented,” says Pontarelli. “He’s really showed me the ins and outs of clinical ethics in hospital systems – things you can’t learn from a textbook. The whole purpose of a fellowship is to get hands-on experience, and I’m grateful I’m able to do that.”

At Enck’s encouragement, Pontarelli also became certified in pediatric and neonatal bereavement. She learned valuable lessons on how to communicate with and be supportive of families during times of loss. She plans to use these tools to help patients and families at MD Anderson.

Gaining knowledge

Pontarelli continues to explore her interests. Concurrent with her fellowship, she is writing papers on ethics issues concerning women’s health, such as the inclusion of pregnant women in clinical research and the use and ethics of birth plan-like documents for women in labor. She is also writing about ethical misconduct of health care providers in South Africa.

Pontarelli is of childbearing age, so women’s health is a topic near and dear to her heart.

She and the ethics interns at MD Anderson were introduced to the issues within South Africa’s health care systems by Executive Director for the Center of Clinical Ethics in Cancer Care Nico Nortjé, Ph.D., who is from South Africa.

Pontarelli has taken on a mentorship role with the interns. Together, they are looking at public data about fines and penalties for different medical professions in South Africa. Their goal is to emphasize that education about clinical ethics could help reduce some of these ethical transgressions.

Making an impact at MD Anderson

Pontarelli describes a clinical ethicist’s role as being the liaison between a patient and their care team: a neutral party that helps communicate and manage any ethical issues that may arise. 

“I think a lot of times clinical ethicists are seen as firefighters that come in at the last minute,” she says. “It’s really important that we take on a more preventive role.”

Pontarelli is hoping to use data from the project she’s working on with Enck to implement preventive ethics at MD Anderson.

“This might mean increasing our footprint on certain floors, reducing patients’ length of stay or initiating conversations with patients and families about advance care planning earlier and following up more often,” she says.

Pontarelli, who is 26, used to fear her age would hinder her in her career.

“Many lawyers, risk managers and retired physicians become clinical ethicists, and I didn’t have as much life experience and insight as them,” she says. “But now I see it as somewhat of an advantage coming straight from graduate school and my fellowship into clinical ethics. My ethical lens doesn’t have time to develop any type of bias.”

She’s excited about the work MD Anderson is doing in the field of clinical ethics, as well as what’s to come.

“MD Anderson has expansive resources as well as a great reputation and legacy in health care,” she says. “Everyone here wants to help patients and make a better world overall. I’m excited to be a part of that.”

Learn about education and training opportunities at MD Anderson.

When you think of your care team, doctors and nurses might be the first people that come to mind. And while these clinicians are essential members of your primary care team, they may call on another person to assist when certain ethical issues arise.

That’s where a clinical ethicist comes in.   

Here, I’ll explain the role of clinical ethicists, why they’re becoming more important in today’s health care systems and what it takes to become one.

What is clinical ethics?

Clinical ethics asks questions about what is ‘good’ and ‘right’ within the clinical setting of medicine, or health care at large.

The work of a clinical ethicist is not to address issues in a theoretical manner, but rather to focus on decision-making with the goal of doing the right thing for the patient, health care team and society.

What does a clinical ethicist do?

Clinical ethicists are neutral parties who help manage ethical issues that arise among patients, their families and their care teams.

An ethics issue includes any conflict or uncertainty involving a patient’s values and preferences, or a clinician’s professional obligations when caring for a patient.

Clinical ethicists’ duties may also include sitting on ethics committees, teaching health care professionals about ethical decision-making and helping to develop policies for medical institutions.

How does a clinical ethicist’s role differ from that of a social work counselor?

Unlike social work counselors, clinical ethicists are not counselors, and they do not offer counseling support to patients.

UT MD Anderson has six full-time clinical ethicists who are certified and professionally trained to the doctoral level, as well as two Clinical Ethics Fellows.

How we approach an ethics issue

As clinical ethicists, the first thing we do is talk to every party involved: the patient, their family members and care team members. This is done one at a time. We want to understand each of their values and what influences their decision-making. At this point, we’re fact-finding. This is important because I can’t base my ethical recommendations on hearsay, like something a team member told me about the patient, for example.

No patient makes decisions in a vacuum. Each decision is based on the patient’s value statement, or what matters most to them. For a patient, that might be a good quality of life. For a doctor, that might be safe treatment options.

The clinical ethicist’s job is to break down what matters most to each party and try to reconcile any differences. The clinical ethicist is a facilitator, helping to build a bridge between all parties through collaboration and communication. We don’t take sides, we don’t label and we don’t judge. In the end, we provide our ethical recommendation for the issue.

How do you navigate ethics issues that are particularly sensitive or complex?

This is very important to address because it happens often.

For example, a family member could be having trouble accepting a patient’s preferences in their advance care documents. Perhaps the patient’s daughter wants the doctor to place her mother on a mechanical ventilator even though her mother has declined life-sustaining treatment for a terminal illness.

As a clinical ethicist, I first want to understand why there’s pushback from the daughter. Maybe she feels guilty because she didn’t spend much time with her mother, or perhaps the last conversation that they had was an argument.

Part of clinical ethics is doing the right thing for the patient, but we also understand the significant impact of losing a loved one. The last thing I would do is wave a living will in front of the daughter and say, “It’s in the paperwork. That’s it. Keep quiet.”

Instead, I’d start by connecting the daughter and patient to resources at UT MD Anderson, like a social work counselor or a chaplain. Then I’d touch base with all parties again to help facilitate communication and understanding.

Another example is when a patient asks a doctor to use an alternative or controversial cancer treatment.  

Clinical ethics honors the goals of medicine, which include curing illness when possible and relieving suffering. Many times, alternative treatments exacerbate a patient’s suffering. If something is obviously harmful to a patient, we cannot ethically recommend it.

We advocate for informed consent, which involves making sure patients understand the treatment their doctors recommend, as well as the treatment’s risks and benefits.

But the issue is often not the request for alternative treatment. It’s usually the intention behind the request: maybe the patient doesn’t trust their doctor, or they want control in a situation that they feel like they’ve lost control of.   

I’d start by asking the patient why they want the alternative treatment. If it’s something that hasn’t yet been decided, I’ll tell the patient we can certainly investigate it. As a clinical ethicist, we’d never make the decision to give or not give a patient a particular medicine, but there are expert groups at UT MD Anderson we can speak with to provide guidance.

If you tell a patient a straight-up “no,” that’s often when their resistance comes in. Whereas, patients tend to be more accepting if we respond with: “We’re not saying yes or no, but we’ll investigate and get back to you.” After all, every patient just wants to be heard.

What are issues a clinical ethicist cannot help with?

Clinical ethicists give guidance and ethical recommendations. We cannot:

• Convince or force a patient, family member or clinician to do something
• Provide medical care
• Provide counseling to patients
• Give legal advice

Clinical ethicists do not replace the members of your medical team. Rather, they work alongside them to help resolve ethical issues that arise during your care.

Why has clinical ethics become more important in modern health care?

Clinical ethics is a field that is rapidly evolving, and as it does, the demand for clinical ethicists is growing. There are several reasons for this:

1. A lot of people don’t share their health care preferences with their loved ones. That’s why advance care planning is so important.
2. The family structure is changing. The sandwich generation describes adults who are ‘sandwiched’ between raising their children while also caring for their aging parents. That can be stressful.
3. Medicine is advancing at a rapid pace, so treatment possibilities can seem endless. Once you add in the influx of social media and “Dr. Google,” misinformation can spread quickly.
4. Many health care providers are under a lot of physical and moral distress, which can lead to burnout.

What kind of training and education are required to become a clinical ethicist?

To become a clinical ethicist, it’s best to have the following:

• Master’s degree (in almost any discipline – e.g., nursing, psychology, chemistry, philosophy)
• Doctor of Philosophy (Ph.D.) in ethics
• Fellowship in clinical ethics
• Healthcare Ethics Consultant-Certified (HEC-C) credential: Offered by the American Society for Bioethics and Humanities, this credential is the national standard for clinical ethics in health care.
• Excellent communication skills, including active listening

Not all employers require all of the above, but the more education, training and experience you have will help you stay competitive among the pool of candidates.  

What educational resources does UT MD Anderson offer aspiring and current clinical ethicists?

UT MD Anderson offers the following educational and training opportunities in clinical ethics:

• Center for Clinical Ethics Internship
• Center for Clinical Ethics in Cancer Fellowship
• Certificate in Oncology Ethics
• Clinical Ethics Resource Nurse (CERN) program

How can patients and families request a clinical ethics consultation at UT MD Anderson?

Clinical ethicists are available to all UT MD Anderson patients and families 24 hours a day, seven days a week. To request a clinical ethics consultation, page 713-404-2863.

Nico Nortjé, Ph.D., is associate vice president of Clinical Ethics and Goal Concordant Care at UT MD Anderson.

Request an appointment at UT MD Anderson online or call 1-877-632-6789.