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Cultivating Ethics Committee Members

Hospital ethics committees provide doctors and allied health care providers guidance for approaching difficult dilemmas in patient care – such as when to remove a patient from life support, who is the best surrogate, whether to seek a court order to treat a minor, how to resolve maternal/fetal conflicts, and who is to receive the next available organ transplant. Rather than coming up with the right answer for these cases, ethics committees are responsible for exploring relevant medical and contextual features and promoting communication between primary stakeholders. Recently, ethics committees have extended their sphere of influence beyond doctors and patients to institutional, professional and even national health policy. Which begs the question(s), "Who are the consultants that make up an ethics committee; and are they qualified?”

Similar to other types of committees I’ve served on in the past, an ethics committee can only make recommendations. It is up to the care provider and his or her patient as to what to do with those recommendations. As an analogy, I serve on a faculty promotions committee whose function is to review the history of a teacher’s performance and come up with a recommendation in favor of promotion or not. We don’t actually approve promotions - that’s up to the dean. If the dean was a member of the committee, then perhaps we could review, assess and promote (or not) all in one fell swoop. But, part of the genius of the current setup, is that it promotes the most unbiased recommendation possible. In a similar way, the ethics committee acts as a "third-party” that can focus on features relevant to ethical principles such as beneficence, nonmaleficence, respect for autonomy, justice and fairness. The difference is that a faculty promotions committee is usually made up of fellow faculty members, whereas an ethics committee is made up of a much more diverse group of members.

I don’t know where it was or what bioethical question was addressed, but I can imagine the first ever ethics committee meeting. Most likely, the first committee was composed solely of doctors – a natural extension of a "What would you do?” discussion in rounds. Eventually, hospital administrators became involved (either by invitation or not) to answer questions of policy and procedure. Financial considerations require someone from insurance and billing. Religious features of the case are likely to require a chaplain. Whether it should be a priest, rabbi or minister reminds me of the old joke about two nuns who are outraged when they see a rabbi and a minister go into a brothel; but, five minutes later, they see a priest go into the brothel and say, "So sad, one of the poor gals must have died.” One can imagine how an ethics committee can quickly turn into a town hall forum of everyone from the superintendent of schools to the local chief of police and a couple of nuns. After all, if the old adage claims "two heads are better than one,” then a diverse multitude of heads is even better.

In reality, service on a hospital ethics committee is usually voluntary, which has probably been the single most important factor in limiting the actual number of participants to a nurse, a social worker, a couple of patient advocates, and a handful of employees who are volunteered by their superiors just to make sure that any over-zealous patient advocates don’t turn the hospital into a Gesundheit Institute.1 The Gesundheit Institute is a clinic and teaching center in West Virginia that operates on the premise that a patient’s health is inseparable from the health of the family, the community and the world at large – which, when applied to the task of assembling an ethics committee may be interpreted as meaning we are all, each and every one of us, stakeholders in each other’s health and illness. Good in theory, but not really plausible considering the average person’s lack of training in medicine, as well as the absence of any core competencies in bioethics, cultural sensitivity or healthcare administration. In fact, the hospital accreditation process requires an approach for ethical consultation that identifies key stakeholders, recognizing that because people have different values there are going to be different perspectives on the best resolution to an ethical dilemma.2 To prevent emotions from overriding rational approaches, the primary core competencies of an ethics committee member is defined as 1) The ability to conduct an ethical assessment (i.e., knowledge of how ethical theories and principles apply to patient care), and 2) The ability to demonstrate interpersonal skills such as honesty and integrity.3

That brings us back to the typical ethics committee, which consists of a nurse, a social worker and a couple patient advocates – those rare and special individuals who have taken the extra time to study medical ethics and develop professional attitudes that are founded on excellence, humanism, accountability and altruism.4 The smaller the committee (reduced to a single consultant in some hospitals), the greater the dependency on the ethical skills, integrity and compassion of its member(s). Because committees are usually comprised of unpaid volunteers, let’s hope hospitals continue to recognize the value of their ethics committee members by encouraging continuing education and professional development.

References

  1. Gesundheit Institute. Retrieved from www.patchadams.org. Accessed December 5, 2012.
  2. The Joint Commission. Ethics committee. Retrieved from http://www.jcrinc.com/Ethics-Framework/Organizational-Ethics-Statements/Ethics-Committee/. Accessed December 5, 2012.
  3. Aulisio MP, Arnold RM, Youngner SJ. Health care ethics consultation: nature, goals, and competencies. Ann Intern Med. 2000; 133:59-69
  4. Stern DT. Measuring Medical Professionalism. Oxford University Press: 2006; pp. 31 – 32.

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