The role of organizational ethics committees.

Institutional ethics committees, largely in hospitals, evolved from the need to provide consultative help to physicians and patients' families faced with ethical decisions. They are often patient-centered, dealing primarily with issues of patient autonomy and beneficence (patients' best interests). Sometimes, these committees resolve communication problems or help decide whether to withhold or stop treatment for patients with poor prognoses. Often, the focus is on an appropriate surrogate for a person incapable of expressing his or her wishes. These bodies ratify such decisions, easing the burden of decision making on physicians and family. In some cases, they help confirm prognoses or define death.[1]

Initially, ethics committees focused on the appropriate use of "Do Not Resuscitate" (DNR) orders. Over time, they have addressed additional issues[2]:

* Informed consent

* Patient decision-making capacity

* Refusal of life-saving treatment

* Confidentiality

* Use of restraints

* Disclosure of medical errors

* Organ transplantation:

Harvesting

Allocating limited organs

* Medical triage in intensive care

units

* Resuscitation of very low birth-weight

infants

* Refusal of cesarian section with

severe fetal distress 

* HIV testing of health care workers

* Rights of health care workers to

refuse to treat

* Expending scarce resources on

hopelessly ill patients

* Use of new and unproven technology

* Pain relief that hastens death

* Euthanasia

The Function of Hospital-Based Committees

The standard model for a hospital-based ethics committee is a multidisciplinary body that meets periodically to discuss ethical issues in health care. Often, it critiques decisions in which ethical dilemmas were present. Did the physician use sound ethical decision-making procedures? Does the committee agree with the decision? If not, how should it have been handled? How can the committee make decisions known to the facility's health care workers and encourage better future decisions?[1] These committees are also involved in education and policy making for the specific hospital, although this role is not universally accepted.[1] Under the umbrella of the hospital medical staff organization, most states legally protect committee proceedings from discovery.

If a dilemma takes weeks to resolve, a committee that meets monthly can research and discuss the problem, becoming part of the decision process. Usually, however, physicians and families must decide within days or even hours, making it difficult to convene all committee members. In some hospitals, ad hoc subcommittees often assist in deciding these issues. Representatives of the full committee serve on this subcommittee, along with physicians, nurses, and social workers involved in the specific case.

In other organizations, physicians often consult a key member of the ethics committee about ethical issues. The committee becomes a resource to that person, instructing him or her in the process and values involved in ethical decision making.

A key role of a facility-specific ethics committee, then, is to educate its own members to act as bioethics consultants. Members not only must understand the mechanics of the ethical decision process, but also must comprehend the organization's ethical values. Bioethics policies document an organization's values. However, most people learn values best by experiencing a series of decisions that define the weightings among competing values.

Institutional Policies

Ethics committees must develop institutional policies on ethical matters. Such policies include do not resuscitate, termination of life support, defining brain death, complying with advanced directives, determining the appropriate surrogate decision maker, triaging, determining capacity to refuse consent to treatment, and other issues. Often the committee is the driving force behind such policy development. If other stakeholders develop policies independently, the ethics committee should assist in adapting the policy to the entire organization. The very act of debating these policies internalizes the organization's values.

Committees must identify deficiencies in policies. Such deficiencies become glaringly evident when the absence of policies causes confusion or conflicts among health care workers in individual cases. The committee need not wait for a problem to identify a lack of a policy but can proactively step in to anticipate policy needs.

Designing procedures to support the organization's values is useful only if staff members know and adhere to the procedures. Determining the organization's need for education about bioethical issues is an important ethics committee role. After identifying these needs, the committee members can often assist in meeting them.

In some cases, the committee might act as a quality assurance committee to assess compliance with established bioethics policies and procedures. If the assessment reveals nonconformance, the committee can design corrective actions.

Bioethics involves many disciplines--medicine, nursing, social work, law, and philosophy--so it is difficult for committee members to stay abreast of new developments in the field. The committee can act as a clearinghouse for literature, courses, and networking opportunities to keep its members aware of society's values.

Ethical Values

Members of a society share certain key values. Most responsible people would agree on a few of them, regardless of the philosophical basis of their ethics.[3,4] These values, which must be understood and considered during any decision-making process, include:

Autonomy. The right of the individual to make choices about his or her own life, when they do not jeopardize another person.

Beneficence. The duty of persons to do what is best for others. This duty is especially strong for health care workers in their interactions with patients.

Nonmalfeasance. The duty of persons to do no harm to others. Again, this is especially strong for health care workers.

Fidelity. The duty to keep promises. Verity. The duty to tell the truth.

Human Life. The value of human life, of whatever quality, for itself.

Relief of Suffering. Health care workers are enjoined to relieve suffering when possible.

Fairness, Social Justice, or Distributive Justice. In health care, resources should be allocated fairly among all those who do or might need them.

Ethical Dilemmas

An ethical dilemma exists only where these values conflict. For example, in the abortion debate, the value of human life conflicts with autonomy. The duties of beneficence and respect for human life for one person conflict with those of another during triage of the critically ill. The values of nonmalfeasance and human life conflict with, the values of relief of suffering and autonomy in the issue of patient-requested euthanasia. In the debate over providing futile care for a terminally ill patient who requests it, the value of autonomy conflicts with the value of social justice. Fairness suggests that scarce resources be expended where they do the most good.

In some cases referred to an ethics committee, there are no conflicting values. Such instances are often shown to be communication problems, not ethical dilemmas. Thus, the process of identifying conflicting values is a critical element in the ethical decision-making process.

Some institutions emphasize certain values above others. For example, some ethics committees deal only with autonomy issues, ignoring questions of social justice. For others, distributive justice is an integral value in all decisions. Retrospective review and critique of prior cases by committee members of various disciplines is a powerful method of imparting the organization's values.

What Are Our Values?

We do not codify societal values with any consistency. There is minimal legislation on this subject. Oregon has struggled with distributive justice in its attempt to develop an explicit process to determine how to distribute Medicaid funds. The state of Washington recently voted on legalizing euthanasia, and a similar proposition appeared on the California ballot. Usually, however, value choices are made in court decisions, regulations, and organizational policy.

The institution has an interest in both the outcome and the process of ethical decision making. The outcome of a bioethical decision can result in the organization's involvement in a lawsuit or criminal case. The facility can suffer adverse publicity or become financially liable for expensive medical care. The same concerns affect physicians and other caregivers. To reduce the effects of these external factors, the bioethical decision-making process must be thorough, reasoned, and accepted.

Bioethical Decisions

Although published guidelines for bioethical decision-making processes are available,[5,7] each organization may wish to adopt its own. Following such a process will ensure that all relevant information is available, accurate, and considered. uncovering the stakeholders and values involved in the decision.

The hospital ethics committee's most important role, then, is to impart the institution's values and processes to its members. These committee members can then advise subcommittees or individual health care workers. They can ensure use of appropriate process and attention to the institution's values.

The Organizational Ethics Committee's Role

As health care has moved to horizontally and vertically integrated delivery systems, I believe there is a role for organizational ethics committees (OEC) in addition to hospital ethics committees. An OEC can expand the development of ethical theories and practice to encompass an entire organization. For organizations that include hospitals, the OEC and hospital ethics committee are complementary, moving the entire organization toward consistent attitudes and philosophies on ethical issues. A few university hospital-clinic systems have joint ethics committees.[1] However, OECs have rarely been described for HMOs or PHOs (physician-hospital organizations).

An organizational ethics committee aids in establishing and communicating values. It may train leaders of participating hospitals' ethics committees in the bioethical decisionmaking process. It can develop a resource bank of literature, legal case histories, workshops, exercises, and courses for organization members who have interest in or responsibility for ethical decision making. It can review existing committee activities to ensure that necessary support and training are available for effective functioning. It can identify areas that lack but require ethics committees, such as skilled nursing facilities. It can foster development of facility-based committees.

For some departments, such as a home health agency or ambulance department, an independent ethics committee may prove impractical. The OEC can help develop policy or review specific cases to expose personnel outside the hospital to the bioethical decision-making process.

The OEC can influence affiliated organizations to address ethical issues by providing requirements, education, examples of policies, or case discussions. Potentially, OEC members could consult on establishing and maintaining ethics committees. The OEC would be in a position to identify conflicting policies among facilities or affiliating institutions and work toward consensus. The goal is to express a consistent set of organizational values wherever its members receive care.

By focusing on policy development, an organizational ethics committee can reduce the policy-writing work of individual facility committees, possibly eliminating duplicative efforts. This permits these committees to concentrate on specific cases, educate staff, and implement policies.

An OEC can amplify the effect of scarce and, at times, expensive bioethical expertise by sharing information with personnel in individual facilities and departments. This includes ethicists and health care attorneys with experience in this area of the law.

An OEC can identify the lack of needed policies at affiliated institutions. It can also pinpoint educational deficits, planning organization-wide responses. For example, during case discussions at several facilities, it may become apparent that many physicians do not understand the definition of brain death. The OEC may sponsor a program to teach that diagnosis. Or, if patients and members lack knowledge of ethical issues, the OEC may design literature to educate them about the organization's values.

The OEC may become involved in logistical or operational issues within the organization. Suppose patients fill out durable power of attorney forms with the help of social services departments at ambulatory care centers. How is that information transmitted to the emergency department or the hospital when that patient becomes ill? Suppose the attorney-in-fact does not yet know of the hospital admission. The document can only be honored by treating physicians if it is available. The OEC may design an information transmittal system to ensure an effective means of communicating the patient's authority. Or it may request such a system from operations management. A purely hospital-based ethics committee, or a committee dealing only with ambulatory care, would not become involved or have the organizational authority to deal with such interstices of care if it did.

Ethical issues permeate health care. Once we look beyond the patient-physician relationship, other questions emerge. Will the organization tolerate physicians who refuse to treat HIV-positive patients? Will it tolerate patients who refuse to see HIV-positive physicians? Some organizations have developed separate bodies to handle HIV-related issues.

Many persons involved in bioethics would prefer to ignore the cost of health care. Encouraging advanced directives will both honor a patient's rights and save money. It may be wise to focus on these win-win opportunities first. Considering the ethics of resource allocation may improve the quality of decisions and result in greater overall fairness.

If rationing is a method of allocating insufficient resources, we ration care now and will continue doing so. De facto rationing occurs when barriers to access occur. These barriers might be physical, financial, educational, or matters of inconvenience. Rationing care does not necessarily result in poorer patient outcomes.[9] Eventually, we will need to answer some disturbing questions.[10] What criteria will the organization use to ration care? Will it be ability to pay, ability to access the system, squeakiest wheel, or the most urgent illness? Or will it be what appears to benefit the greatest number of people? Will the organization succumb to public pressure to pay for an unproven treatment that, in turn, reduces its ability to provide proven treatments for others? In a world of limited resources, is it ever justified to spend money on a procedure that is lower on a scale measuring "quality-adjusted life-years per dollar spent?"

Some large insurers and HMOs have technology assessment and/or benefits interpretation committees to formalize this decision process. They weigh the value of new technologies and compare them to old ones. They may decide whether to pay for or provide some technologies, knowing that lives will be affected by either decision. The values of the organization are evident in some of these decisions.

For example, if patients demand bloodless surgery for religious reasons, is the organization obligated to provide it? What if affiliated physicians refuse to operate under these conditions? If the organization has a religious bias, its values will need to be reflected in its benefits interpretation and in other bioethical problems.

OECs must have their scope specified. If HIV, technology assessment, or benefits interpretation committees do not address ethical issues, they are likely to be eventually presented to the OEC.

As society addresses bioethical issues, some consistent policies are emerging. Much of this consensus is fostered by networks of bioethics committees. In Southern California, for example, California Health Decisions, the Orange County Bioethics network, and the California Association of HMOs discuss, educate, and otherwise communicate community values. The OEC can participate in such networking opportunities.

Participation in such grass-roots networks may lead to public advocacy for certain bioethics issues. OECs can be instrumental in influencing public policy. Some have suggested this expanded role.[11] Still others have suggested that ethics committees consider business ethics for health care institutions.[12]

Although hospital-based ethics committees can and do involve themselves in networks, public advocacy, and business ethics, unless the hospital is the total organization and senior management participates at the committee level, it would be very difficult for a hospital committee to represent the organization. In a complex organization, an OEC is best suited for these roles.

Dangers in Organizational Ethics Committees

There are dangers in any ethics committee. The OEC is no longer patient-centered. It focuses more on organizational and societal needs and balances these with duties and rights. Whether for profit or not, the organization will have a strong economic incentive to save money.

What is the role of the physician on such a committee? Is he or she advocate for the patient, for the organization, or for him- or herself? Some have argued that physicians should not make allocation decisions, because doing so conflicts with their role as individual patient advocates.[13] Yet such decisions must be made. It is ludicrous to exclude physicians from allocation decisions, because they understand their impact best. When possible, the committee should include one or more members from outside the organization, such as a bioethicist, a member of the clergy, or a sophisticated consumer representative, to assist in clarifying the other members' advocacy.

A bioethicist or ethics consultant is not absolutely necessary, but some committee members need knowledge and experience in dealing with ethical issues. Otherwise, there is a danger that the committee will become a "participatory exchange of ignorance."

Creation of an OEC may generate a new concern that rarely pertains to hospital ethics committees: loss of legal protection. In some states, laws protect peer review bodies, other than hospital medical staffs, from discovery.[14-16] If the committee develops policies and educates physicians and others in ethical decision making, such protection may not be needed. The OEC can focus on these activities and leave actual case discussion to individual hospital and SNF committees. Even that precaution may not be necessary. Case discussions and recommendations to the primary physician serve much as an individual patient consultation. A cardiologist places his consultation in the chart. It is protected by patient confidentiality laws but is discoverable by the legal system. A bioethics consultation could be treated similarly.

Protection from discovery is of most concern when the committee critiques prior cases. It may find fault with a decision. The committee members, and the primary physician involved, would likely not want a plaintiff s attorney to have access to this type of constructive criticism. Physicians would be reluctant to have their cases reviewed retrospectively if proceedings of such meetings did not have protection from legal discovery.

One solution is for the committee to refrain from retrospective reviews. Another is to charter the committee as a subcommittee of the organization's quality assurance (QA) program. Most states have laws protecting QA proceedings, even of nonhospital QA programs, from legal discovery. The committee members should also refrain from sharing committee activities outside of formal QA mechanisms.

The Patient Self-Determination Act 

Implementation of the Patient Self-Determination Act (PSDA) in a mixed model HMO illustrates the value of an OEC. This federal act, effective Dec. 1, 1991, requires that hospitals and HMOs have policies about the use of advanced directives. Living wills, directives to physicians, and durable powers of attorney are written advanced directives. It also requires a policy to provide patients information about their rights to execute advanced directives at the time of admission to a hospital, skilled nursing facility, or home health agency, or at the time of enrollment in an HMO. For this example, we will ignore other provisions of the Act.

The OEC can coordinate the drafting of policies to comply with PSDA. It may outline the requirements of the policies and ensure conformance with those requirements. It will thus establish an overriding policy regarding honoring and promoting advanced directives. It might produce a patient brochure on the subject. It may use resources from community organizations working on this same project and make them available to representatives from affiliated facilities.

Contracted hospitals and medical groups must also develop a response to PSDA. The OEC will need to ensure that the HMO's values are consistent with the values expressed by its affiliates. It would be confusing for patients to receive one policy on enrollment in the HMO and another on admission to the hospital. In some cases, the OEC may help affiliates develop their responses to this Act.

Why a Committee?

Do we need a committee to perform these coordinating functions? Meetings are expensive. Consensus building is an inefficient process. However, committee meetings can produce policies that meet legal, operational, customer, and other needs. The best possible product requires the synergy of group process, and the perception of committee approval may lend legitimacy to the product. Moreover, education is a primary goal of ethics committees, and group involvement will spread knowledge more quickly than individual involvement.

A single manager with knowledge of all relevant disciplines might, in some organizations, be able to develop policies, educate staff and patients, and coordinate activities more efficiently than a committee. But, as the organization becomes more complex, the likelihood that any one person can have that knowledge diminishes rapidly.

Summary

Hospital ethics committees have been developed to create and transmit a coherent set of organizational values in the resolution of case-specific ethical dilemmas. Health care, however, is no longer predominantly hospital-based. Complex, integrated delivery systems now manage a significant portion of this nation's health care. Organizational ethics committees have a role in transmitting a coherent set of values to patients and staff through policies, educational programs, and operational programs.

References

[1.] Cranford, R., and Doudera, A., Eds. Institutional Ethics Committees and Health Care Decision Making. Ann Arbor, Mich.: Health Administration Press, 1984, pp. 5-51, 250-300. [2.] Hofmann, P. "A Summary of "Values in Conflict: Resolving Ethical Issues in Hospital Care."' In Making Choices: Ethics Issues for Health Care Professionals, Emily Friedman, Ed. Chicago, Ill.: American Hospital Publishing, Inc., 1986, pp. 169-74. [3.] Gillon, R. Philosophical Medical Ethics. New York, N.Y.: John Wiley & Sons, 1985. [4.] Loewy, E. Textbook of Medical Ethics. New York, N.Y.: Plenum Medical Book Company, 1989. [5.] Guidelines for Bioethics Committees. Chicago, Ill.: American Hospital Association, 1984. [6.] Guidelines for Ethics Committees. Chicago, Ill.: American Medical Association, 1984. [7.] Ross, J., and others. Handbook for Hospital Ethics Committees. Chicago, Ill.: American Hospital Association, 1986, pp. 25-6. [8.] Medical Ethics Advisor 7(9):109-11, Sept. 1991. [9.] Singer, D., and others. "Rationing Intensive Care--Physician Responses to a Resource Shortage." New England Journal of Medicine 309(19):1155-60, Nov. 10, 1983. [10.] Evans, R. "Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions." In Making Choices: Ethics Issues for Health Care Professionals, Emily Friedman, Ed. Chicago, Ill.: American Hospital Publishing, Inc., 1986, pp. 27-55. [11.] Cohen. C. "Ethics Committees as Corporate and Public Policy Advocates." Hastings Center Report 20(5):36-7, Sept.-Oct. 1990. [12.] Boyle, P. "Business Ethics in Ethics Committees? Hastings Center Report 20(5):37-8, Sept.-Oct. 1990. [13.] Relman, A. "Use of Medical Resources-Overview." Preventive Medicine 19(6):688-92, Nov. 1990. [14.] California Health and Safety Code, Section 1370, 1990. [15.] California Evidence Code, Section 1157, 1990. [16.] California Business and Professional Code, Section 805, 1990.

Further Reading

The following additional sources of information on organizational ethics committees were obtained through a computerized search of databases. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/287-2000. "Community Ethics Committee Models

Start to Emerge." Hospital Ethics 9(5):16,

Sept.-Oct. 1993. Felder, M. "An Ethics Committee for a

HMO an Oxymoron? Certainly Not!"

HEC Forum 4(4):261-7,1992. Haddad, A. "Developing an Organizational

Ethos." Caring 11(6?4,7-8,10-1, June

1992. Skipper, "Launching an Agency Ethics

Committee." Caring 11(6):12-5, June

1992. Thornton, B., and others. "Bioethics

Education. Expanding the Circle of

Participants." Hastings Center Report

23(1):25-9, Jan.-Feb. 1993.