May 1983 IV/9
ETHICS COMMITTEES IN HOSPITALS
Recently, the American Hospital Association (AHA) recommended that each hospital institute an ethics committee, Perhaps the action of the AHA is due to the study of ethics committees recently published by the President's Commission for Ethics in Medicine and Behavioral and Biomedical Research.(1) While the Commission stopped short of recommending that an ethics committee be established in each hospital, it clearly recommended that education, consultation and review be available in each hospital for difficult decisions of patient care. The purpose of this essay is to consider the purpose and functions of an ethics committee in hospitals and to evaluate its utility.
Purpose
Ethics committees in hospitals received their main impetus from the decision of the New Jersey Supreme Court in the Karen Quinlan case. The court, assuming inaccurately that most hospitals had ethics committees, declared that such committees rather than the courts should be involved in decisions concerning withdrawal of life-support systems, In analyzing the hospital ethics committee, the President's Commission lists six potential functions:
1. review a case to confirm the physician's diagnosis or prognosis of patient's condition;
2. review decisions made by physicians or surrogates about specific treatment;
3. make decisions about suitable treatment for incompetent patients;
4. provide general educational programs for staff on how to identify and solve ethical issues;
5. formulate policies to be followed by staff in certain difficult cases;
6. serve as consultant for physicians, patients, or their families in making specific ethical decisions.
Clearly, the last three functions are of an educational nature, and they could be carried out in regard to ethical issues of a routine nature as well as in regard to crises events. The first three functions are not educational; rather we shall call them jurisdictional powers because they bespeak a review power and, in some cases, a decision making power, These jurisdictional powers are needed, the Commission maintains, in ethical cases that involve the medical treatment of incompetent patients who are in danger of death, For example, the ethics committee with these powers might be called upon to affirm or deny the medical opinions that a patient is in a coma, to make such a decision about withdrawing life-support equipment, or to review the decision making process to ensure that all concerned people were consulted.
The Quinlan court and the American Hospital Association are interested in having hospitals form ethics committees with jurisdictional powers. The main concern of the court seemed to be that cases concerning treatment for incompetent moribund patients be settled in the hospitals and not referred to the courts. The main concern of the American Hospital Association seems to be that costs be controlled by removing life-support systems as soon as possible, observing necessary safeguards that will avoid malpractice suits, While the concerns of the court and the AHA are legitimate, there are definite difficulties that accompany giving jurisdictional power to a committee within a hospital. First of all, it may remove the medical and ethical decisions from the persons who are responsible for the decisions. In caring for dying people, whether competent or incompetent, physicians have the responsibility to make ethical decisions based upon medical facts. This responsibility cannot be given to other persons nor to a committee. The patient, or the patient's family if the patient is incompetent, also has ethical responsibilities that should not be delegated.
Secondly, giving review or decision making power to the ethics committee may dilute the ethical decision making process rather than improve it by weakening the concern for the good of the patient, Everybody's business is nobody's business, Tn referring ethical decisions to a committee, there is a built in potential for enervating the decision making process by emphasizing secondary factors, such as economic concerns,
Thirdly, the introduction of a review system for treatment of patients at time of death could lead to a wider review system of all cases which have cost control implications, The use of high technology in diagnosing patients' conditions could be subject to these committees also, Tn sum, then, it does not seem that placing the review or decision making powers in the hands of the ethics committee will lead to better treatment of people who are in danger of death, On the other hand, it seems the ethics committee would be able to fulfill its purpose through educational functions alone, Formal health care education in recent past has not prepared people for competent ethical decision making and the immediate future does not hold much hope that the situation will improve. But the solution to this perceived lack of preparation is not to put ethical decision making in the hands of a few, Rather, there should be "on the job" opportunities for health care professionals to assimilate the general and specific knowledge pertinent to ethical decision making, This can be done in a number of ways. Through workshops, case studies, and consultation in individual cases, health care professionals can acquire the knowledge necessary for ethical decision making.
In addition, knowledge may be enhanced if the ethics committee outlines policies, to be approved and put into effect through the usual administrative process, for specific ethical problems. For example, several hospitals are formulating policies in regard to withholding cardiopulmonary resuscitation, These policies do not remove the ethical responsibilities from the concerned persons; rather, they assure more effective personal decision making because they set the limits within which such ethical decisions will be made.
Conclusions
Decisions concerning the care of people who are near death, whether they are old or newborn, involve many·medical and ethical difficulties, There is no way to ensure that such decisions will be easy. But we can ensure that insofar as humanly possible such decisions will be well-informed and responsible and made with the benefit of the patient as the foremost and determining factor. I submit that given the history of health care and medicine, and given the tendency to Impersonal decision making by committee process, we will be better served if we rely on education and keep the responsibility for decision making with the physicians, patients and families of patients,
Kevin O'Rourke, OP
Footnote 1, Deciding to Forego Life Sustaining Treatment; Washington, DC; U.S. Government Printing Office; March 1983,
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