The hospital ethics committee--then and now.

The Joint Commission on Accreditation of HealthCare Organizations (JCAHO) does not require a hospital ethics committee. With a few scattered exceptions, neither does anybody else.

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Requirements do exist for ethical organizational mechanisms and behavior, (1) but not for an ethics committee. Thus, any ethics committee activities in your organization's hospitals are voluntary and of your own design.

Meanwhile, sea changes in both health care and ethics have led to the development of 21st century health care ethics, a combination of traditional medical ethics, medical bioethics and organizational health care ethics. (2) What should hospital ethics committees be doing now? Indeed, do we truly need an ethics committee anymore? There are no required answers. The choices are ours.

In April 1975, 21-year-old Karen Ann Quinlan collapsed at a party after over-dosing on alcohol and Valium. She was resuscitated but suffered brain damage and lapsed into a persistent vegetative state. Quinlan was kept alive only by the use of artificial life support machinery that her husband and physicians sought to discontinue.

The resulting judgment of the New Jersey Supreme Court includes the following language: "(Quinlan's) attending physicians ... shall consult with the hospital "Ethics Committee" or like body of the institution in which Karen is hospitalized. If that consultative body agrees that there is no reasonable possibility of Karen's ever emerging from her present comatose condition to a cognitive, sapient state, the present life-support system may be withdrawn ..." (3)

Right to die

The Karen Ann Quinlan case ushered in the "right to die" era that includes routine use of living wills and advance directives. Less well known is another lasting contribution of that case. The court assumed that an "Ethics Committee or like body of the institution" existed in most hospitals. But many hospitals had no such resource. This realization spurred development of a requirement by the Joint Commission that hospitals develop an organizational mechanism to deal with ethical dilemmas.

As with other JCAHO standards in those days, many assumed that the only acceptable mechanism was a committee. If someone had required us to bake a cake, we would have appointed the cake committee, hired someone to staff it, obtained legal review of the recipe, and kept carefully crafted minutes of our meetings.

Indeed, at one point in time, JCAHO actually required that every existing committee meet monthly. If you took August and December off, you didn't meet the requirement. Go to the kitchen? Who had time to go to the kitchen? We were busy baking a cake!

While the cake committee metaphor might make you chuckle, even funnier is the notion of complying with requirements to be ethical. Compliance and ethical behavior are completely different. (4)

Compliance activities are externally motivated but internally focused; the goal is to game the requirements while continuing with business as usual.

Ethical activities are internally motivated but externally focused; the goal is to include consideration of all stakeholders and possible long range impacts in the decision-making process.

Required ethical activity is, by definition, not ethical activity at all. For example, dismissing ethics by tacking ethics onto the duties of the compliance officer is a good way to show the public that genuine ethics is of very little if any importance to us.

In spite of that legalistic, compliance-oriented beginning, most hospital ethics committees made themselves into extremely valuable, if not indispensable, resources. They rose to the challenge of change, providing valuable consultative and educational assistance with issues such as living wills, advance directives and hospice care.

In addition, many hospital ethics committees extended their usefulness by assisting with issues such as informed consent, privacy of medical information and organ transplantation.

21st century ethics

Now that medical ethics has expanded its horizons to become 21st century health care ethics, the ethics committee should again rise to the challenge by making itself into an even more visible, valuable available resource.

With the support of senior executives and the board, the ethics committee should expand its activities and agenda to encompass all three parts of today's health care ethics--traditional medical ethics, medical bioethics and organizational health care ethics.

As you guide the hospital ethics committee into uncharted new territory, be aware of and avoid two common mistakes.

* Don't start talking ethics then stray inadvertently into a discussion of legalities or religion.

* Distance ethical activities from compliance activities.

Traditional medical ethics

Don't let the word "traditional" fool you. Even in this area new challenges must be met. Today, not tomorrow (except in hospitals where religious directives preclude flexibility), the ethics committee should draft, discuss and recommend a hospital euthanasia policy. Then the ethics committee should educate individuals and groups hospital-wide about the four kinds of euthanasia and how the proposed policy relates to each.

Medical bioethics

Human cloning is still futuristic science fiction, so we can table our concerns about human cloning. But stem cell research and therapy, gene therapy, nanotechnology and other biomedical ethics issues are not science fiction anymore. Believe it or not, these issues will increasingly impact patient care in all kinds of hospitals.

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Should the hospital cafeteria serve genetically modified foods? Who cuts through the emotional aspects of this issue, examines the facts and ethical aspects, and makes a recommendation? Hello, we're the ethics committee. What are we, invisible? Why not ask us to help with that one, too?

As ethics committee members become increasingly conversant with biomedical ethics issues, offer that expertise to the community in various kinds of educational programs. Why not help people truly understand the issues they love to talk about?

For example, help people separate facts about somatic nuclear cell transfer from myths and questionable claims. Explain what reasonable, realistic rewards can truly be expected from stem cell research and how soon.

Put information about medical bioethics issues on your website. Establish a roster of available speakers for schools, service clubs, and churches.

Prepare and provide basic fact sheets available for pick up at agreeable local grocery stores. In addition to providing a public service, such activities could do more for our public image than a six-figure marketing plan.

A caveat: Don't take sides in the stem cell research debate or on any other issue unless you are forced to by an absolute religious directive. Keep in mind that a genuine ethics committee will keep itself out of politics and religion and avoid focusing on legalisms.

Organizational health care ethics

Whole books have now been written about ethical aspects of organizational issues in health care companies. (5) Corporate ethical issues are no longer limited to conflict of interest and avoiding illegal activities.

What definition of "reasonable profit" considers all stakeholders and considers possible future impacts? Do we take advantage of acceptable exaggeration in advertising without crossing the line by making fraudulent claims? Do we look beyond legal aspects to address ethical aspects of gender issues? In the health care business is a sense of social justice and human worth a liability or an asset?

The most difficult task in organizational ethics is helping executives learn the value of an ethical attitude. We'll take a closer look at this issue in my next column.

Richard E. Thompson, MD, is former vice president of the Illinois Hospital Association, taught ethics at St. Petersburg College and Missouri State University, and is author of Think Before You Believe, Xlibris, 2005. He can be reached at [e-mail].

References

1. 1993 Accreditation Manual for Hospitals (AMH). p. 106. Joint Commission on Accreditation of Health Care Organizations (JCAHO). Oakbrook Terrace, IL. 1993 and subsequent yearly manuals.

2. Thompson, RE. "Look what's happened to health care ethics." The Physician Executive, 32(2):60-2, March/April 2006.

3. In re Quinlan, 70 N.J. 10, 355 A.2d647, cert. denied, 429 U.S. 922 (1976).

4. Thompson, RE. On Beyond Compliance. ACPE. Tampa. 2001.

5. Hall, RT An Introduction to Healthcare Organizational Ethics. Oxford University Press. New York and Oxford. 2000.

By Richard E. Thompson, MD