Module 14: Ethics Committees
Upon completion of this module, the resident should be able to:
- Describe the principal functions of an ethics committee.
- Describe four models of ethics consultation.
- Describe and critique three different approaches to ethics consultation.
- Describe the range of opinion on key questions about the education and training required for clinical ethics consultation and about the process of formal credentialing of ethics consultants.
Module: 14 / Ethics Committees and Ethics Consultation
At Bayside General Hospital, a review of the charts of patients admitted to the ICU over the last two years reveals that only 13 percent included advance directives. How should this problem be addressed and by whom?
Dr. Frank Huron is the chief of service in the Department of Urology at Bayside and he has issued a verbal (but not written) policy that if and when ethical dilemmas arise “at the bedside” in the department, they are to be “handled” by him and other attendings—and never referred to the ethics committee or the ethics consultation service. Is this policy an appropriate one? Is it consistent with the accreditation standards of the Joint Commission?
The ethics committee at Bayside has conducted a review of 79 ethics consultations performed by the committee over a two-year period and found that 61 of these consultations were called due to futility conflicts. What should the ethics committee do about this apparently “systemic” problem?
Introduction: In health care organizations, ethics committees are usually multidisciplinary groups of individuals, established and convened for three purposes or functions: (1) to develop, revise and/or provide advice concerning policies in the domains of clinical—and, in some institutions,--organizational ethics; (2) to educate internal constituencies on topics and issues in clinical ethics; and (3) to provide ethics consultation to organizational leaders, staff physicians and nurses, and patients and their families. Ethics consultation is a process of identifying, clarifying, and contributing to the resolution of ethical questions or problems arising in either clinical or, more broadly, organizational contexts.
The origins and growth of ethics committees are intimately bound up with the same forces that gave birth to bioethics in the 1960s and 1970s: revelations about the abuse of human subjects in biomedical research; the development and application of dialysis and other forms of life-sustaining treatment; questions about the scope and limits of physician decision making and patient autonomy, especially in the context of serious or terminal illness; and, in the background, the civil rights movement and other catalysts to social change. Although ethics committees had been established in the early 1970s, the 1976 decision by the New Jersey State Supreme Court in the Quinlan case called for their establishment as a means of facilitating the often vexed process of reaching solutions to ethical dilemmas like those presented in the case at hand. Today, the Joint Commission on the Accreditation of Healthcare Organizations mandates that, as a condition of accreditation, hospitals form and maintain ethics committees.
The formal process of ethics consultation, however, did not “come into its own” until the mid-1980s. Today, some health care organizations have ethics consultation services in place that are, to one degree or the other, distinct from an ethics committee; in other organizations, ethics committees themselves, or some subset of their members, are responsible for the formal process of ethics consultation. Ethics committees and ethics consultation both serve the goal of improving the care of patients and patient outcomes and both are animated by the conviction that the realities of contemporary health care can generate both complexity and difficulty in decision making and that the process of decision making can benefit from a diversity of perspectives, informed by both concern for, and expertise in clinical ethics.
Purposes and functions: The educational function of an ethics committee is two-fold. First, members of an ethics committee are responsible for engaging in on-going activities in self-education. The practice of clinical ethics is continually shaped and reshaped by developments in scholarship and the law, as well as in biomedical research and clinical medicine. Competence in the performance of committee duties and the integrity of committee and its work all hinge on a membership that is knowledgeable and skilled. Second, the committee is responsible for ensuring that the leadership and staffs of the organization are informed and educated about clinical ethical issues in the care of patients. Lectures, ethics rounds, seminars, journal clubs, and written forms of communication are all useful means toward this end.
As for the development of organizational policies in clinical ethics, ethics committees can serve any one or more of several interrelated functions. In some organizations, ethics committees are responsible for conceiving, developing, and authorizing policies (often in concert with other decision making bodies, e.g., a board of directors). Some also are pivotal in the process of implementing new and evaluating established policies. In other organizations, ethics committees play a more limited advisory role in policy development and implementation. Typical examples of organizational policies in clinical ethics include: withholding and withdrawing life-sustaining treatment; do-not-resuscitate and do-not-intubate orders; advance directives; participation of patients in human subject’s research; artificial hydration and nutrition; organ procurement and donation; and, assisted reproduction.
Ethics consultation—models and approaches: Although ethics consultation may be conducted in a variety of ways, four models are basic. (For an analysis of the four models, see PA Singer, ED Pellegrino, M Siegler. Ethics Committees and Consultants. The Journal of Clinical Ethics, Vol. 1, No. 4, Winter 1990, pp. 263-267/265-266). With the first, the pure committee model, the ethics committee as a whole provides consultation, upon requests submitted to its membership by medical or nursing staff or patients and/or their families. With the second model, a member (or subset of the membership) of the ethics committee receives the request for consultation and conducts the initial analysis; the consultant(s) may also make recommendations for resolving the problem at hand and such recommendations may or may not be subject to the approval of the committee. In the third model, the ethics committee undertakes a post-facto review either of a particular case and its recommended resolution or of more than one case (e.g., all consultations provided during a particular time period, such as a month or a quarter); with this model, consultations are performed by an individual or team of individuals, but not by the committee as a whole. In the fourth model, the pure consultation model, requests for consultation are submitted to individual consultants or consulting teams, who conduct the analysis and make recommendations.
In its report on the core competencies required of ethics consultants, the American Society for Bioethics and Humanities describes three approaches to the process of ethics consultation—two of which represent opposing extremes with the remaining approach constituting a more appropriate via media or middle way between the two extremes. (Source: ASBH. Core Competencies For Health Care Ethics Consultation. October 1998.) With the authoritarian approach, ethics consultants assume the role of primary moral decision makers with the power to determine the process and/or outcome of consultation. Here, the critical role of the most immediate and legitimate moral decision makers—the patient’s caregivers, the patient, and/or the patient’s family—is ignored, truncated or otherwise undermined. As a result, the process of consultation may be more exclusive rather than inclusive and thus be more subject to individual bias, prejudice or ignorance; the outcome of the consultative process itself may be similarly impaired or defective. At the other extreme is the pure facilitation approach: with this approach, the overarching aim of the ethics consultant is to achieve consensus among the various moral decision makers in a particular case. Although the process of consultation may be inclusive with this approach, the chief criterion by which its outcome is to be judged is not the ethical validity of the decision; the chief criterion is that agreement has been reached.
Against the authoritarian and the pure facilitation approaches, the ASBH report recommends a third approach as a middle way between these two extremes: the ethics facilitation approach. According to the report, the ethics facilitation approach
… best meets the need for health care ethics consultation as it emerges in our society, while remaining consistent with the fundamental values that drive our liberal constitutional system … [this approach] … is informed by the context in which ethics consultation is done and involves two core features: identifying and analyzing the nature of the value uncertainty and facilitating the building of consensus. To identify and analyze the nature of the value uncertainty or conflict underlying the consultation, the ethics consultant must: gather relevant data, clarify relevant concepts, clarify related normative issues, help to identify a range of morally acceptable options within the context. Health care ethics consultants also should help to address the value uncertainty or conflict by facilitating the building of consensus among involved parties (e.g., patients, families, surrogates, health care providers). This requires them to ensure that involved parties have their voices heard, assist involved individuals in clarifying their own values, [and] help facilitate the building of morally acceptable shared commitments or understandings within the context.
The report goes on to compare the ethics facilitation approach with the authoritarian and pure facilitation approaches:
In contrast to the other approaches, the ethics facilitation approach recognizes the boundaries for morally acceptable solutions normally set by the context in which ethics consultation is done. In contrast to the authoritarian approach, ethics facilitation emphasizes an inclusive consensus-building process. It respects the rights of individuals to live by their own moral values by not misplacing moral decision-making authority or acceding to the personal moral views of the consultant. In contrast to the pure facilitation approach, ethics facilitation recognizes that societal values, law, and institutional policy, often as discussed in the bioethics literature, have implications for a morally acceptable consensus. The ethics facilitation approach is fundamentally consistent with the rights of individuals to live by their own moral values and the fact of pluralism. It, therefore, responds to the need for ethics consultation as it emerges in our society.
Ethics committees are now a well-established feature of the institutional life and daily operations of contemporary hospitals, nursing homes, hospices, and other health care organizations. The same is true of the practice of ethics consultation, which is the focus of scholarly research, education and training programs, and symposia and conferences. The preceding description of the functions of ethics committees and of models of, and approaches to ethics consultation indicates the variety of ways in which a particular organization may choose to constitute and sustain an ethics committee and/or ethics consultation practice. As for persistent questions and controversies, several may be identified with respect to the practice of ethics consultation:
What educational background, training, and experience should an ethics consultant possess? Effective ethics consultation requires the ability
- to read, understand, and communicate intelligently about a patient’s medical record, therapeutic options, etc.;
- to communicate with the patient, the patient’s family, and the clinician-caregivers and, often, to mediate among differing points of view;
- to analyze the problems in a case from an informed, knowledgeable perspective on clinical ethics, the law, and institutional policy; and
- to frame and communicate options and recommendations for resolving these problems.
This multifaceted ability is dependent upon different forms of “expert” knowledge, including clinical knowledge (e.g., diagnostics, prognostics, therapeutics) and knowledge of the scholarly literature in ethics and the law; it is dependent, as well, on experience in clinical settings and a high degree of interpersonal and communication skills. In light of these requirements, one might conclude that only clinicians are competent enough to undertake the demands of ethics consultation. Those who view clinical ethics as a subspecialty of medicine, rather than as a separate, distinct discipline, tend to affirm this conclusion and argue that the anticipated outcomes of ethics consultation—resolution of ethical dilemmas leading to decisions about diagnosis and treatment—are such that only those with the primary ethical and legal responsibility for patient care, that is, physicians, should be entrusted with this activity. Against this view, there are those who contend that with the appropriate education and training, nurses or non-clinicians can achieve the required competence and, indeed, function just as effectively as clinicians in providing ethics consultation. In support of this position, some proponents of this view argue that being a physician can be both “enabling,” as well as “disabling” when it comes to discerning and addressing the factors that lead to ethical conflicts in patient care.
Should ethics consultants be subject to a formal process of credentialing? There is a wide range of opinion on this question as well. In light of the impact and anticipated outcomes of clinical ethics consultation on patient care, some commentators argue that a formal process of credentialing would help to ensure adequate, minimal standards of education, training, and demonstrated skill and would, thereby, help to promote the integrity of the consultative process and engender trust in that process on the part of clinicians, patients, and their families. Others worry that credentialing may tend to “enshrine” a particular value-inflected point of view in clinical ethics consultation. Still others contend that these practices are still in the early stages of their development and any decision on the question of formal credentialing should be postponed until there are more data on the outcomes and efficacy of clinical ethics consultation.
In lieu of the usual case-based analysis and discussion, the recommended group activity for this module involves the following steps: (1) identify the chair of the ethics committee in your institution; (2) ask that s/he meet with you and other residents in your group; and (3) ask him/her the following questions:
- What are the roles and functions of the ethics committee? Is ethics consultation included among these roles and functions? Is policy formation, development, and implementation? Is intra-institutional education on issues in clinical ethics among the roles and functions of the committee?
- If ethics consultation is among the roles and functions of the committee, what types of issues or dilemmas most frequently necessitate ethics consultations? Of patients, families, physicians, and nurses, who most frequently makes the request for ethics consultation?
- If policy formation, development, and implementation are among the roles and functions of the committee, what are the steps in this process at the institution? Describe the institutional policies for futile treatment; do not resuscitate orders (especially perioperative DNRs); withholding and withdrawing treatment; advance care planning and advance directives.
- What intra-institutional educational initiatives has the committee launched or participated in? Which have been judged as successful? Which have been evaluated as less than successful?
An on-line core curriculum for ethics committees, developed by the University of Buffalo Center for Clinical Ethics and Humanities in Health Care is available at: http://wings.buffalo.edu/faculty/research/bioethics/CC.html. Although it is somewhat out of date, much of its content is still useful.
“Case Consultation" is the first chapter of the book, "Ethics Consultation: A Practical Guide" by John La Puma, MD, and David Schiedermayer, MD; it is available on-line at: http://www.mcw.edu/bioethics/ce/cons-toc.html.