Rapid advances in medical technologies in the 1960s presented society with ethical questions it was ill prepared to answer. For example, at the dawn of kidney dialysis technology, there were many more patients with end stage kidney disease than there were dialysis machines to treat them. What is the most ethical way to resolve this rationing dilemma? In the early 1960s, kidney dialysis selection committees were established to introduce community representatives into the process of deciding which patients would receive kidney dialysis. Thus the notion of ethics committees dawned in the field of bioethics. Once Medicare was expanded in 1965 to include coverage for kidney dialysis, this particular rationing problem was resolved.
In the late 1960s, some states called for abortion review committees to determine which requests for therapeutic abortions were legitimate. The US Supreme Court Decision Roe v. Wade settled the issue in 1983 with the legalization of abortion. In the early 1980s, infant care review committees were established in some states to satisfy the federal mandate that intensive care nurseries be prevented from engaging in discriminatory practices against critically ill newborns. The Baby Doe Law in 1984 made such discrimination illegal. Drawing on these experiences, the 1976 New Jersey Supreme Court decision in the Karen Quinlin case was interpreted by many as giving credence to the importance of ethics committees for end-of-life cases.
The 1991 Patient Self-Determination Act required that every health care organization in the United States receiving Medicare or Medicaid payments convene meetings of a committee to assure compliance with the requirements of the Act regarding “advance health care directives”. And in 1992, the Joint Commission on the Accreditation of Healthcare Organizations passed a mandate that all JCAHO approved hospitals must put in place a means for discerning ethical concerns. Numerous examples were tried but most settled upon the health care ethics committee model. The 1991 Law and 1992 JCAHO regulation spawned a rapid increase in number of Ethics Committees in hospitals of all sizes.
The Hospital Ethics Committee promotes shared decision-making between patient/surrogate and the clinician. It enhances the ethical tenor of health care professionals and health care institutions. And it promotes fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes.
WHAT DO HOSPITAL ETHICS COMMITTEES DO?
Perhaps the most important function of Hospital Ethics Committees is to provide ethics consultation to the hospital community. When physician and patient/family cannot come to agreement about an important treatment decision, the Hospital Ethics Committee is consulted. One or more of its members, with formal training in bioethics, will make a thorough evaluation and then present her findings to the committee at large. The entire Committee will then meet to discuss the case and make a recommendation, which the physician and patient/family will then discuss. If disagreement still remains, referral is made to the Courts for final adjudication.
Another important function is ongoing ethical formation of committee members through self-study, lectures, and conferences. They will become grounded in ethical theory and learn how to apply theory to clinical decision making. As the committee grows in competency, it will develop an ethics education program for the entire hospital community. Questions to be addressed are:
- What ethical issues are currently relevant at your institution?
- What individuals in the institution or in the area possess ethics expertise and the ability to put theory and language of ethics into practice?
- What is the most appropriate teaching forum?
The third function is to develop and/or revise select policies pertaining to clinical ethics, e.g. advance directives, DNR and Comfort Care Policies, withholding and withdrawing life-sustaining treatments, informed consent, organ procurement, etc. Hospital Administration may request ethical review of new or updated hospital policies. And new issues requiring policy review may surface during ethical consultations
Typically the Hospital Ethics Committee has representation from the following areas:
- Physician Medical Staff
- Hospital Administrator
- Other Clinical Specialists
- Social Services
- Community Representative
- Pastoral Care
- Legal Counsel
- Quality Improvement
RESPONSIBILITIES OF MEMBERS
- Commit to the Mission and Values of the Institution.
- Understand role and function of Ethics Committee
- Orientation Program for new members
- Competent in their own areas of expertise and generally knowledgeable about issues in health care ethics
- Familiar with institutional policies related to clinical and organizational ethics.
TYPICAL AGENDA FOR MEETING
- An established leader who structures the meeting dates and topics, and leads the session
- Presentation of the particular issue or topic by Consultation Sub-Committee.
- A brief didactic overview of literature, ethical principles, or pertinent factors
- Review of facility policy or previous management
- Group discussion related to the issue
- Summary via policy or facility understanding
- Consensus Recommendation for Clinical Team
WHO MAY REQUEST ETHICS CONSULTATION?
At most hospitals, anyone may request an ethics consultation including the patient or family. Need to check the hospital’s policies to learn how to request an ethics consultation
WHEN TO ASK FOR AN ETHICS CONSULT
Consider asking for a consult when two conditions are met:
- You perceive that there is an ethical problem in the care of patients.
- Resolution does not occur after bringing this to the attention of the attending physician.
Most “ethical problems” are caused by lack of communication. However, sometimes a true ethical dilemma occurs, frequently because there is a conflict between principles (autonomy, beneficence, and justice) or between principles and outcomes.