Many Ethics Committees Lack Formal Process for Education, Orientation

By Stacey Kusterbeck

One of the primary functions of an ethics committee is education — for members, for clinicians, and for patients and their family members. Yet most ethics committees have no formal orientation process, and many have no ongoing ethics education process, according to a recent survey of hospital leaders at AdventHealth.¹ “The effectiveness of clinical ethics committees (CECs) in achieving their goals, as well as the educational needs of ethics committees and the best format for such education, are still debated in the bioethics field. We are gratified this data set begins to provide some detailed answers in the context of a sizable hospital system,” says Dennis deLeon, MD, vice president of clinical ethics for the Central Florida Division of AdventHealth and chief medical officer for AdventHealth Kissimmee.

Researchers interviewed 132 individuals at 51 facilities in 2020, including chief executive officers, chief medical officers, chief nursing officers, risk management coordinators, and chaplains. Most (57%) respondents were unsure or unaware of the process used in their facility for resolving ethics dilemmas.

“This is concerning. It points to the importance of formalizing ethics education, not just for CEC members but, more widely, for staff,” says deLeon.

Only 29% of respondents indicated there was an ongoing educational process for CEC members, and 13% said there was a formal orientation process. Since the dissemination and publication of these findings, AdventHealth’s Central Florida Division, consisting of eight hospitals, began to redesign and update its CEC orientation program. “We also started a monthly educational series for current committee members, focusing on classic cases in recent bioethics history from the 1970s into the present,” reports deLeon.

Not all members of an ethics committee are going to have the same amount of training and education that would be expected of individuals who perform ethics consultations. “But because part of their charge is education, ethics committee members need to have at least baseline knowledge of clinical ethics, if not more than that,” says Mary Faith Marshall, PhD, HEC-C, director of the Center for Health Humanities and Ethics and director of the Program in Biomedical Ethics at the University of Virginia School of Medicine.

Back in the 1970s, the first hospital-based ethics committees were comprised of healthcare providers who had no specific ethics expertise — they simply were interested in ethics. “But that was generations of ethics committees ago. And we shouldn’t still be operating at that same level,” says Marshall. “Ethics committees that do not have a well-founded sense of purpose often fail to thrive within their institutions.”

A solid orientation process ensures that new members of ethics committees start out with basic clinical ethics knowledge. For instance, ethics committee members need a working knowledge of all institutional policies with an ethics component (such as policies on informed consent or on potentially inappropriate treatment). “Ideally, orientation should happen before the new member attends their first ethics committee meeting,” Marshall recommends. The ethics committee chair or co-chairs can oversee the orientation process, using resources from the bioethics literature, and internal or external experts in clinical and organizational ethics.

The ethics committee policy or charter should specify the committee’s roles, its multidisciplinary composition, a rotation schedule for chairs and members, which roles are voting members and which are ad hoc, who can access the committee or the ethics consult service, and the fact that there should be no intimidation of or reprisal against those who request ethics committee guidance or intervention, says Marshall.

When new members join an ethics committee, they need to be informed on the basic elements of how the committee does its work, says Stuart G. Finder, PhD, director of the Center for Healthcare Ethics at Cedars-Sinai in Los Angeles.

Finder recommends that ethics committees have a formal charter that clearly and simply spells out:

• the role of the ethics committee in the institution;

• the members and leadership of the ethics committee;

• the responsibilities of ethics committee members;

• the schedule for meetings of the ethics committee;

• recordkeeping and reporting structures of the ethics committee.

When new members join the committee, time should be set aside to review the charter. “This can ensure continuity over time, as old members leave and new members join,” says Finder.

New ethics committee members should know specifically what is expected of them. For example, if members are expected to participate in ethics consultations, this should be addressed upfront. Some committees expect members to obtain ongoing continuing education on their own. If so, members should know who covers the cost.

It is equally important for ethics committees to provide continuing education for existing members. “That is part of what the institution owes them as committee members. There are a lot of ways that can be done, depending on the size of the institution and their resources,” says Marshall. Academic medical centers might have adequate financial resources for some ethics committee members to attend a national bioethics meeting every year. “Members can gain new knowledge, and a perspective on the strengths and needs of their own institution compared to others,” says Marshall. In contrast, less well-funded ethics committees at small community hospitals might expect members to spend a certain amount of time at each meeting discussing an article from the ethics literature. “They could have a file with required reading for new members that is frequently updated and stays there in perpetuity for members to go back and review,” suggests Marshall.

There often are differing levels of education among members of ethics committees. Some members might have minimal ethics training or none at all. Others have a master’s degree in bioethics. “Committee leadership also needs to lay out expectations for members’ engagement with one another to ensure that discussion and interaction is respectful and encouraging of open communication,” says Finder.

The concern is that a small group of members might dominate discussions, due to having more education than other members. “That may become a set-up for tension and difficulty and, ultimately, failure of the committee’s work,” warns Finder. Ethics committees can prevent this by setting clear expectations about respectful engagement during orientation. Committee leadership also must set the example. “At every meeting, it should be clear that all voices matter, and all perspectives matter,” says Finder.

Funding for ethics education is another concern. Ethics committees are more likely to obtain those resources if hospital leadership understand what they do. “It is vitally important that those in the chain of command above the committee have a full and proper understanding of the committees’ function and processes,” underscores Finder.

REFERENCE

1. Araujo LG, Shaw M, Hernández E. The structure of clinical ethical decision-making: A hospital system needs assessment. HEC Forum 2024; Jun 8. doi: 10.1007/s10730-024-09534-5. [Online ahead of print].