Name-only ethics committees abound
Most ineffective due to lack of training
Hospital ethics committees are meant to be both a key resource and watchdog at their institutions, helping clinicians work through difficult cases and helping ensure the facility provides medical care in an ethical and equitable manner.
But many hospital ethics committees do little more than exist on paper, established to fulfill the requirement by the Joint Commission, then largely forgotten as the hospital leadership moved on to more pressing matters, say experts.
Though expected to provide ethics consultations to clinicians struggling to resolve conflicts with families or to make difficult decisions, they often lack the appropriate training and background.
"You got to the hospital and find that [the committee] exists on paper. It met once, three years ago, or it meets quarterly, or it may even meet all the time. But you ask what they have read, what they’ve done to get themselves in a position to believe they are capable of addressing these serious issues, and they hem and haw, or say nothing," says Matt Weinberg, MB, a consultant with Clinical Consultation Services in Philadelphia. "That’s why they aren’t getting requests for consults. Why would anyone call them?"
Hospitals have to do more than just recruit willing volunteers to serve on the ethics committee, adds David M. Price, director of the Center for Healthcare Ethics at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School in Newark. They must give careful consideration to the people who will serve on the committee and what will be expected of them.
"Ethics committees differ so widely, it’s not funny," he explains. "Most of them have very little sense of themselves — they don’t read the ethics literature, their leadership doesn’t read the literature. They don’t think a lot about what their ultimate role is and then creatively work from there to deciding how often to meet and how they should be constituted."
Hospital administrators and/or the medical staff leadership also often don’t have a clear idea of what they want from the ethics committee, Price adds.
"If we don’t expect anything from them, then they don’t do anything," Price continues. "We don’t hold them accountable for what they ought to be contributing because we don’t know and then we are busy with other things that are more urgent."
As a result, many committees stagnate and drift year to year without having a true impact on the functioning of their institution.
Support from hospital leadership
For a hospital to have an ethics committee that functions meaningfully, it must be a high priority of both the hospital administrative and clinical leadership, Price says.
"If it is established as a medical staff committee, then it needs to the chief physician, or the top administrator, if it is an administrative committee," he notes. "If that person is not a member of the committee, then he or she should at least have a strong expectation of the committee’s function and the willingness to make inquiries if that doesn’t happen."
Hospital ethics committees should have a definite, stated mission and one that aims high, as well, he adds.
"It ought to be, and think of itself, as an engine of progressive thinking about the mission of the institution, whether it is an acute care hospital or nursing home or hospice," he says. "And it therefore wants to have nothing less than an impact on the culture of the institution. If you want a statement of an ultimate goal — not just a functional description — it should try to impact the culture of the caregiving institution. This is where ideas ought to percolate that will try to make that kind of impact and will keep thinking outside the conventional modes of doing things."
When procedural habits get separated from the mission of the institution, they get in the way of the institution’s success, he emphasizes. It is the role of the ethics committee to keep this divorce from happening.
"When people just do what they always do and don’t keep asking, How does this play out relative to our purpose?’ that has serious consequences. It is the job of the ethics committee to keep asking those questions," he adds.
Who should serve?
The committee must also comprise representatives from a variety of disciplines who will be committed, interested participants, adds Weinberg.
Too many times, different personnel simply do time on the committee, rotating on and off at specific times during the course of a year.
"Every July, or a particular month, committees switch membership and many people typically just get assigned," he explains. "They might happen to have an interest in the assignment, but typically it is random."
In some cases, busy physicians are assigned to the committee when they don’t have the time to serve or give thoughtful input, he notes.
"And if the physician members aren’t showing up at the meeting, everyone else on the committee will not take it seriously," he notes.
The hospital leadership need to recruit people from all of the different disciplines at the hospital (physical therapists, respiratory therapists, social workers, pastoral care, paramedics, ICU and surgical nurses, obstetric nurses, and patient care coordinators, as well as physicians in different specialties).
And the committee should include some representation from the community where the facility is located.
"My personal bias for community reps is that I try to call the local high schools and find the person that has the biology class or teaches the pre-health profession courses," he notes. "They tend to be the best community members. They are very outspoken and ask the wild-card questions, which is why you need them there."
It is also important to select representatives from all of these areas who are known to be thoughtful and who will be willing to show up at the meetings, he adds.
"You especially have to get good physicians who will find it interesting and spend time reading the material and have time to show up at meetings," he emphasizes. "And figure out a good time when everyone else can be there consistently. Then, I usually make them almost stand up and raise their right hand and swear that, notwithstanding emergencies, they commit to being there."
Choice of leadership is key
Committees must be particularly careful in their choice of a chairperson, say both Weinberg and Price.
The ideal chair needs to be someone with a strong personality, but not someone who is very authoritarian and will dominate the rest of the membership, says Price.
"You have to have somebody who can administer a committee — who sets an agenda and can discipline a meeting," he advises. "I’ve seen committees where good people come and we have a good discussion because these are very smart folks who would not otherwise be sitting around a table talking — these committees by definition are broadly constituted. It is stimulating and we may have stimulating bull sessions — But it doesn’t go anywhere."
Education before consults begin
Once a committee has been formed and has a clear definition of their mission in front of them, they still require an intensive period of education before they are ready to perform ethics consults and truly serve as a resource to the hospital staff, Price and Weinberg state.
"There is a huge body of literature in medical ethics," Price says. "There are more books and journals published every year, and there is a huge body of knowledge. If you are going to do this seriously, then you have to be prepared to learn some things and to read."
When Weinberg consults with hospitals, he often helps establish the institution’s ethics committee or works with a new committee as it begins to meet. As part of that process, he institutes a formal yearlong education program for committee members.
"You have to start with basic education," Weinberg emphasizes. "In many institutions, we think nothing of putting people on the committee who may have no background in medical ethics or health care delivery whatsoever, and then saying, Go out and do consults.’ Then, they just have to walk around and make it up as they go along."
You wouldn’t allow a surgeon to operate without ever taking anatomy and physiology, nor hire a nurse who had never been to nursing school, and you shouldn’t ask untrained people to perform ethics consults, he continues.
While his committees-in-training are going through the educational process, Weinberg functions as the hospital ethics consultant and performs ethics consults as needed. At the same time, he is taking the committee through an organized educational program as part of their monthly meeting.
"At the meeting, the first 45 minutes will be an educational seminar on a particular topic, and the last 45 minutes will be new business and old business," he explains. "I start off with ethical theory and give them a general overview of the different ways to think about ethical issues."
Weinberg then expands the sessions into specific ethical issues that the committees will likely face — end-of-life decision making, withdrawal or termination of treatments, and specific ethical issues related to different medical specialties — then onto some of the more controversial topics like euthanasia and assisted suicide, he notes.
It’s important that the educational programs be weighted more toward practical application than abstract theory, Price and Weinberg add.
"Most of the members learned what they do as health care professionals by an apprenticeship-type training program — learning by doing," Price says. "They are not philosophy majors. If it doesn’t apply at the bedside, it doesn’t make any difference to them."
Weinberg agrees. "My sessions are not a philosophy class," he notes. "The readings tend to be practical and have to be digestible. They need to have some ethical theory to understand practice, but if it is too deep into the theory then they will never read them."
It’s also important, Weinberg believes, to let the rest of the hospital staff know about the educational process that the committee is undertaking and how this can be of benefit to them.
"When I go out and do consultation inservices with the nurses and medical staff, I am sure to mention that this is also what I am working with the ethics committee on," he notes. "That builds confidence that the committee members are really learning something and can be called upon when the time comes."
Consults should be the focus
Although most committees feel that they have a trifold purpose of providing ethics consultations on individual cases, developing hospital policy, and serving as an educational resource to the rest of the staff, Price says the committee should keep consults as the main focus of what they do.
"Successful committees are almost always committees that have case consultation as their central priority," he states. "Physicians and nurses and other providers are patient-care folks. That is what gets them. That is what is important and that is the ultimate activity that justifies the institution in the first place — patient care."
The cases the committee has as consults should drive the educational and policy initiatives it takes on.
"The educational agenda flows out of the case consults," he explains. "We discover what we don’t know because we run up against some pattern of ignorance when we do our case consultations. Then, we know what we ought to be trying to do. The same thing is true of policy formation. That agenda inevitably arises out of discussions of cases because we find out our current policies don’t work or are inadequate."
Suggested reading
• Hinman L, et al. Ethics: A Pluralistic Approach to Moral Theory. Third ed., Belmont, CA: Wadsworth Publishing; 2002.
• Blackhall LJ, et al. Ethnicity and attitudes toward patient autonomy. JAMA 1995; 274:820-825.
• Macklin R. Ethical relativism in a multicultural society. Kennedy Inst Ethics J 1998; 8:1-22.
• Kuczewski M. Reconceiving the family: The process of consent in medical decision making. Hastings Cent Rep 1996; 26:30-37.
• Dresser R. The incompetent patient on the slippery slope. Hastings Cent Rep 1994; 24(4):6-12.
• Dubler N. The doctor-proxy relationship: The neglected connection. Kennedy Inst Ethics J 1995; 5(4):289-306.
• Hall R. Confidentiality as an organizational ethics issue. J Clin Ethics 1999; 10(3):230-6.
• Cranford R. The persistent vegetative state: The medical reality. Hastings Cent Rep 1988; 18(1):27-32.
• Schmitz P. The process of dying with and without feeding and fluids by tube. Law Med Health Care 1991; 19(1-2):23-6.
• Asch D, et al. Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: Conflicts between physicians’ practices and patients’ wishes. Am J Respir Crit Care Med 1995; 151:288-92.
• Gazelle G. The slow code — should anyone rush to its defense? N Engl J Med 1998; 338(7):467-9.
• Cohen C. Required reconsideration of "Do-Not-Resuscitate" orders in the operating room. Law Med Health Care 1992; 20(4):354-63.
• Dodds S. Exercising restraint: Autonomy, welfare, and elderly patients. J Med Ethics 1996; 22(3):160-3.
• Post S. The fear of forgetfulness: A grassroots approach to an ethics of Alzheimer’s disease. J Clin Ethics 1998; 9(1):71-80.
• Bernabei R, et al. Management of pain in elderly patients with cancer. JAMA 1998; 279(23):1,877-82. Erratum in: JAMA 1999; 281(2):136.
• Pierce S. Neonatal intensive care: Decision making in the face of prognostic uncertainty. Nurs Clin North Am 1998; 33(2):287-97.
• Rosenbaum S. Who should determine when health care is medically necessary? N Engl J Med 1999; 340(3):229-32.
• Mechanic D, Schlesinger M. The impact of managed care on patients’ trust in medical care and their physicians. JAMA 1996; 275(21):1,693-7.
• Arnold R. The dead donor rule: Should we stretch it, bend it, or abandon it? Kennedy Inst Ethics J 1993; 3(2):263-78.
• Glannon W. Responsibility, alcoholism, and liver transplantation. J Med Philos 1998; 23(1):31-49.
• Corley M. Ethical dimensions of nurse-physician relations in critical care. Nurs Clin North Am 1998; 33(2):325-37.
Source: Matt Weinberg, MB, Clinical Consultation Services, Newtown Square, PA.
Sources
• David M. Price, MDiv, PhD, Director, Center for Health-care Ethics, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, BHSB F-1401, P.O. Box 1709, Newark, NJ 07101-1709.
• Matt Weinberg, MB, Clinical Consultation Services, P.O. Box 316, Newtown Square, PA 19073.
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