A patient and his or her doctor have a “fiduciary” relationship, one based on mutual trust in which each has different but definite rights and responsibilities. If they disagree about a diagnosis or recommended course of treatment, the patient may seek a second professional opinion. In a clinical setting, a case involving conflicts between medical personnel or with the patient’s family can be referred to a hospital ethics committee.
This article examines the reasons for the development of hospital ethics committees (HECs) in recent decades and describes the composition and actual duties of HECs at several American health care facilities.
Medical ethics is as old as medical science. It is founded on the Hippocratic Oath and the moral teachings of the Jewish, Christian, and Muslim faiths. With advances in Western European medicine came the development of a code of professional ethics and the custom of consultation, in which several physicians meet to deliberate on a complex case.
HECs became widespread in North America in the 1970s. Some textbooks trace this phenomenon to the 1976 New Jersey Supreme Court decision In the Matter of Karen Ann Quinlan, which ruled that the “Ethics Committee” of the hospital then treating the young woman had to agree that her comatose condition was irreversible before the doctors and her family could decide to withdraw life support. The publicity surrounding that case led to a new interest in medico-moral problems among professional philosophers.
Earlier, in 1971, however, the Canadian Bishops’ Conference called for “Medico-Moral Commissions” in all Catholic hospitals to ensure compliance with the Ethical and Religious Directives for Catholic Hospitals, which had been developed by a team of American and Canadian theologians, published in 1949, and widely adopted by dioceses in North America. Since then Catholic health care institutions led the way in establishing HECs.
According to a 1983 report by the US government, at the time 36 percent of Catholic hospitals in America had ethics committees but only 1 percent of secular hospitals did. As of 1989, 75 percent of Catholic hospitals had ethics committees, while an additional 13 percent intended to establish them. Since 1995 the national Joint Commission on Accreditation of Health Care Organizations has strongly recommended ethics committees at all acute-care hospitals.
Over the past half-century medical science has grown more and more complex while medical training programs have become increasingly specialized. Health care is now a big business, with the government already deeply involved through its entitlement programs. Catholic hospitals and care facilities are more likely today to have lay administrators and many non-Catholic physicians and nurses on staff. Contemporary society, being secular and pluralistic, tends to equate ethics with legality. All of these trends have led to a greater demand for HECs.
While the health care field is vast, the role of an HEC can and should be defined narrowly. In 1989, Father Kevin D. O’Rourke, OP told of a hospital executive who supposed that it was the ethics committee’s job “to explain any actions on the part of the hospital that were unpopular, such as laying off employees or reducing services.” But an HEC is not part of the public relations department.
It is not a jury either. Its purpose is to assist and advise those who do have authority to make decisions about treatment—the physician and the patient (or proxy). An HEC is an interdisciplinary support structure that facilitates the proper exercise of medical responsibility.
AT A SECULAR HOSPITAL
Greg F. Burke, MD, is a Catholic physician, a generalist employed by Geisinger Health System based in Danville, Pennsylvania. The system comprises three hospitals and a senior care center serving rural communities; the main facility is a 400-bed tertiarycare hospital that also trains medical students and residents.
Dr. Burke has served on the all-volunteer ethics committee at Geisinger Hospital for 15 years. Membership has varied, but averages 20-25. Although the percentage of doctors is usually higher, presently one quarter of the members are physicians, both practitioners and academicians; the committee also includes a group of nurses, a couple of Protestant ministers, two Catholic theologians, and several people from the local community with training in science or education. A lawyer employed by the hospital acts as a non-voting consultant on legal issues.
Each year the HEC at Geisinger Hospital handles around 10 cases that come up for consultation. Dr. Burke notes, “The most common clinical scenarios by far are end-of-life issues: the removal of life support, disagreement between family and physicians about whether to take a patient off a ventilator, whether a feeding tube should be inserted…. [O]ccasionally issues come up in the pediatric intensive care unit.”
Another ongoing item of business for the HEC at Geisinger in the past was review and approval of internal hospital policies. “Our prior chairman was an intensive care doctor…. The intensive care unit would develop a policy directly; the policy came to our committee’s attention” for evaluation and recommendations. The committee worked, for instance, on the hospital’s protocol for non-heart-beating organ donors.
“A lot of the HEC’s work has to do with institutional procedures, conscientious objection [by hospital employees], grievances, etc.” Again, the HEC did not actually “own” or write the policy; it was developed by the personnel department and then discussed by the committee. Any policy, of course, must finally be approved and implemented by the trustees of the institution. Dr. Burke describes the HEC’s role in policy development as “consultative.”
Social justice concerns are rare. “The hospital where I work is non-profit. Patients are not turned away if they can’t pay.” Although theoretically an HEC can identify recurring problems and recommend organizational change, in practice it is difficult for a committee to act as “an institutional watchdog” when “a large majority of its members, including all the physicians, are employees of Geisinger. They found that they were most comfortable staying with medical issues.”
Consults and policy review, though important, are not the primary functions of an HEC; education is. Dr. Burke explains: “This is a big part of our work. We do educate ourselves, encourage committee members to take courses, give out textbooks to members, and plan lectures on special issues. During a consult we can educate physicians, patients, and family. Geisinger sponsors system-wide courses (open to the public as well) on hot topics such as reproductive technologies or assisted suicide.” The health system reaches out to the local community with forums on topics such as “Nursing Home Care.”
AT CATHOLIC HOSPITALS
Stephen Napier, PhD is a staff ethicist for the National Catholic Bioethics Center in Philadelphia. His experience includes work on ethics committees at a large secular hospital and at two large Catholic hospitals, one of them associated with an academic institution. These HECs were composed “mainly of medical professionals (more doctors than nurses), some administrators, and a token risk-management person.”
Catholic hospital administrators are committed to implementing the Ethical and Religious Directives for Catholic Health Care Services; their presence on an HEC is in no way a conflict of interest, since all committee members, regardless of their background, are expected to uphold those directives. Although he has observed “little interaction” between an HEC and the diocesan bishop, Napier declares, “I have never in the context of a Catholic ethics committee come across challenges to Church teaching…. Having said that, I do think that some Catholic hospitals experience pressure in the area of ethically handling anencephalic infants [who will die shortly after birth]. The secular custom seems to be to induce labor, whereas Church teaching clearly forbids it.” For years tube-feeding was controversial, as Catholic moral theologians debated whether it constitutes ordinary or extraordinary treatment, but in practice “most tube-feeding cases involved patients who depended on a lot more than [artificial] feeding,” so that other factors usually determined the final recommendation.
The HEC at one Catholic hospital was consulted about specific cases 20- 30 times a month. “The average, from what I have been told by reliable sources, is…two consults a month.” Napier has participated in discussions about organ donation protocol and drafted “a policy/procedures for managing conflicts between medical staff and patient/surrogates” over treatment that is deemed futile.
In his experience, HECs “have educated members primarily through case analysis. There were very few meetings set aside for formal presentations. This is notable in that case analysis does not always give one a comprehensive picture and relies too heavily on [the members’] ‘intuitions’ or emotional ‘gut reaction.’” Compliance with the Directives does not necessarily mean understanding the teaching that informs them. “I sense a need to enlist more pedagogical approaches.”
When asked to speculate on how national health care reform might affect the work of an HEC, Dr. Burke replied, “It could create more consults.” If cost containment measures result in rationing, “families [would be] asking for treatments that the insurance company doesn’t cover any more; I can see how physicians might then turn to the ethics committee to help resolve [the conflict].”
Could this lead to depersonalized health care and the return of medical paternalism? “Hospital administrations are the first to bear the brunt of new regulations. Through accrediting agencies some of that could be pushed onto the local community. Smaller hospitals may feel the impact more.”
Napier says that national health care reform could require HECs “to shift their focus, and they may be enlisted to carry out some aspects of the [new policy], in particular to address end-oflife issues with their patients on a more proactive basis.” Currently, demands from patients or family members for “futile” treatment (which brings no medical benefit) are “a huge problem.” “I would favor a proposal that would empower physicians to say no. But there is a good way to do this and a bad way…. The good way limits a treatment option based on the evidence of the treatment’s effectiveness. The bad way is to limit a treatment option based on a judgment of a person’s worth [‘quality of life’]. It would be great if a national health care policy would have the effect of diminishing or altogether eliminating futility cases in a good way.”
Bishop Elio Sgreccia, past president of the Pontifical Academy for Life, has described a hospital ethics committee as “a consultative body to help those who must make informed and well-grounded decisions” about clinical care. He warns, however, that if separated from fundamental reflection on human dignity and ethics, such committees could become “tools without content…a sort of observatory from which to study the social tolerability of certain specific behaviors in the biomedical field.”
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