Today’s ethics committees have several predecessors. In 1962, a Seattle committee selected the patients who would receive dialysis, and in 1966, the federal government mandated institutional review boards to oversee research to ensure it follows federal guidelines for human subjects.1 But it would be 10 more years before ethics committees were a solution to the decision-making problems of patients without mental capacity.1
In 1976, the parents of Karen Ann Quinlan petitioned the New Jersey Supreme Court to allow the removal of the respirator from their severely brain damaged daughter. The court ruled that her life support could be removed if an ethics committee determined that she had no chance of returning to a cognitive state. The court also recommended that all hospitals establish ethics committees to improve medical decision making.2
But in 1983, when the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research published “Deciding to Forgo Life-Sustaining Treatment,”1 only 1% of hospitals in the country had an ethics committee. The document defines the role of hospital ethics committees and describes their functions1; by 2000, most hospitals had an ethics consultation service by a full ethics committee, a smaller team or an individual consultant.3
The Joint Commission, the agency that accredits hospitals and other healthcare organizations, now requires that each organization develops and operates under a code of organizational ethics.4
United States Department of Veterans Affairs has established organizational ethics policies. In 1999, the VA introduced its Integrated Ethics
organizationwide program and established standards, roles, competencies, methods and performance metrics for the VA healthcare system. The VA’s Integrated Ethics is based on principles of continuous quality improvement and strategies for organizational change.
Its ethics consultation
function provides assistance to patients, families and staff. Consultation services are available at all 154 VA facilities and can help with decisions and actions using established tools. A preventive ethics
quality improvement system for staff addresses common ethics problems and ethical gaps at the system level. An ethical leadership
function helps leaders by fostering a strong ethical environment and culture and providing the tools and training to create an environment that supports doing the right thing.5
System-level and environmental concerns are important because ethics cases are influenced by the larger organizational context. Many ethics cases have systems-level causes, and similar ethics cases may continue to occur unless underlying systems issues are addressed. Ethics consultants, a limited resource, can help ethics cases from recurring.
What Is an Ethics Committee?
An ethics committee is an interdisciplinary group of healthcare providers from diverse backgrounds who usually fulfill three functions: ethics consultation, development or revision of policies related to ethical issues and ethics education.6
Consultations with ethics committees help healthcare providers, patients and families resolve ethical dilemmas so they can make informed choices. Ethics committees develop policies on issues such as advance directives, the withholding and withdrawing of life-sustaining treatment, informed consent and organ procurement. These policies ensure that patients are treated with fairness, that their decisions are honored and that choices made for those who lack decision-making capacity reflect their best interests.6
Ethics committees promote the rights of patients, help in shared decision making involving patients (or their surrogates) and clinicians, foster fair policies and procedures, encourage good patient-centered outcomes and bolster the ethical tone of healthcare professionals and institutions.6
The Role of the Committee
In addition to addressing ethical issues that involve each patient, there is an increasing interest for ethics committees to assume responsibility for organizational ethics and to apply the principles of ethics more broadly. (In conversation with T. Drought, RN, PhD, ethics committee training coordinator, Kaiser Northern California, July 2000.) Ever since the justices in the 1976 Quinlan case recommended that all hospitals establish ethics committees to improve medical decision making, governing boards of healthcare facilities and organizations, such as the Joint Commission and the VA, have become interested in ethics committees to determine proper action and manage the risk of liability.7 The present method of managing healthcare organizations causes many to worry about the effect of economics on the ethical care of patients. The increasing number of uninsured patients who can’t pay their medical bills at the same time as state and local governments are cutting funding can result in the rationing of healthcare in the ER as well as at the bedside.8,9
The Joint Commission states the most important function of the organizational ethics committee
is to educate its members; the committee then can educate staff, the board, patients and the community. The second function of an organizational ethics committee is policy formation, such as policies for patients’ rights, clinical policies and organizational policies regarding resource allocation and marketing. The third function is to review past cases to discover how they were handled from an ethical standpoint; the committee can learn from cases that were not handled well. The fourth function is case consultation, but since assembling the committee for a case consultation can be difficult because of members’ time constraints, ethics consultants or subcommittees of the ethics committee may be more appropriate. The fifth function is to provide psychological support for patients and families.4
Who’s on the Ethics Committee?
Interdisciplinary ethics committees usually comprise physicians, nurses, social workers and clergy. There may also be lay members who can help committee members better understand the patient.10 The committee may also have a quality improvement manager, a lawyer and at least one person with advanced training in ethics.6
The members of an ethics committee should be respected by their colleagues for their clinical judgment and interpersonal skills.10 They should be willing to learn about ethics, be receptive to different points of view and be able to deal with interpersonal disagreements.10
Many ethics committees include an ethicist. An ethicist is an expert in clinical ethics who has special training in bioethics and can provide ethics consultations to and education of the committee about the methods and trends for ethical and legal issues in healthcare.10 The ethicist’s background may be clergy, law, medicine, nursing or philosophy. Many ethicists are nurses with advanced degrees in bioethics.6
The American Society for Bioethics and Humanities
fosters scholarship, research, teaching, policy development and professional development among healthcare professionals interested in clinical bioethics. The society has established core competencies
for healthcare ethics consultations. The organization’s manual, Core Competencies for Health Care Ethics Consultation, contains information on ethics consultation, core competencies, the evaluation of consultation services and ethical dimensions of healthcare ethics consultation as an emerging professional practice.
A random sample survey found that U.S. hospitals with more than 400 beds typically had an ethics consultation service. Physicians and nurses performed the most ethics consults, at 34% and 31%, respectively. Among other professions performing consults were social workers, 11%, and chaplains, 10%. Only 41% of the individuals performing ethics consultation had formal supervised training in ethics consultation.3 (Level B)
Legal issues can be a concern. In several states, ethics committees have the authority to make end-of-life decisions for patients who have no surrogate decision maker. This could put the ethics committee in legal jeopardy if life-sustaining treatment is provided over the patient’s objection, for wrongful death for withdrawal or withholding of life-sustaining treatment or for breach of confidentiality and violation of privacy for the unauthorized disclosure of patient confidences. If the healthcare provider adopts the ethics committee recommendation, the committee and its institution could be at risk for a malpractice lawsuit. For this reason, risk management personnel have an interest in the actions of ethics committees.7
In states where following the recommendations of the ethics committee is optional, the risk to the patient representative, physician and institution is low. Risk management should not be involved in the presentation or deliberation of ethics issues. The legal counsel’s role to the institution should also be limited to procedural issues associated with the consulting process, and the legal counsel should not be a witness or provide counsel on the law or the ethical precepts that apply to a situation. The institution’s counsel should also help the ethics committee determine whether records of ethics consultation should be part of the medical record.7