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Institutional agendas and ethics committees.

Institutional ethics committees serve the needs of patients. They also help doctors and nurses, providing collegial assistance in resolving ethical dilemmas. But what account should ethics committees take of the institution's interests?

Institutions have interests of their own. In part, this is due to the multiplicity of tasks and goals to which a complex organization devotes itself. Success in some of these hinges on the disposition of others, and the problematical cases and policy quesdons that come before the ethics committee are likely to have wider effects within the institution. Keeping Mr.jones alive in the I.C.U. may have the effect of denying intensive care to Ms. Smith. The continued operation of the genetic counseling service may depend on the kind of hospital policy on late-term abortions the committee advises the administration to adopt. The institution as a whole, regarded simply as the aggregate of these particular activities, could be harmed by disadvantageous trade-offs in these and similar instances.

A hospital, however, is more than a collection of individual services. It is a community resource, with a history and a social position, responsive to public expectations and pressure. It is an employer and spender, the largest one in many towns. It is a doctovs workshop"' in which physicians pursue both healing and entrepreneurship. It may be a cash cow in its own fight paying dividends to bondholders or profits to shareholders. And it may be, in the view of its employees, patients, and the public, a moral agent, whose moral character is determined and expressed in the way it sets its policies and handles its problem cases. Ethics committees must decide whether to take these institutional interests into account. The answers they reach will determine whether ethics committees view themselves as pan of a management team or as an independent agency working at times in tension with the overall direction of the hospital. A pufist' might reason that any ethics committee worthy of the name should disregard institutional interests, since its job is to determine "what is right," rather than "what is feasible." Giving some weight to institutional concerns, in this view, would deliberately skew the results of moral judgment toward expediency; better to deliver a purely ethical judgment and let the hospital administration weigh this against other relevant considerations. If Mr. jones ought to remain in the I.C.U., morally speaking, let the financial officer decide whether the hospital can afford to pay for his care; if Ms. Smith should be allowed to die at home, hospital management can deal with the referring physician.

The purist'view calls for a division of labor. For the administrator, in this view, "what is right' is one of several considerations that must be taken into account in decisionmaking. It is up to the ethics committee to clarify this consideration for the actual decisionmaker, whether this is the patient, doctor, or administrator. The committee, in performing this limited function, is not and ought not be making the final decision. This should be made by the person or persons with overall authority over the case. It will represent the best choice, everything considered.

The administrator, however, can contest this "Purist"'view on plausible grounds. It presents a false picture of the role of ethics in decisionmaking, for "what is righte' is not just one consideration among many, but what ought to be done, everything considered. The conscientious administrator thinks about ethics just as much as the patient, doctor, and ethics committee. The difference among them is in the scope of their decisions, that is, in the range of considerations each must take into account, given his or her role.2 The administrator must consider such issues as financing and community attitudes because doing so is a part of the administrators responsibility, and because the administrator's authority covers not only the case or policy choice before the ethics committee, but the full range of cases and policies in the institution. The trade-offs the administrator must consider can be severe; one expensive case can so drain the budget that a ward or service must be closed; if the hospital angers too many doctors in town, its beds will remain empty. Nevertheless the "purist" has, in my opinion, the better of the argument; the ethics committee will generally do its job best if it does not concern itself with the hospital's interests. Here are three arguments supporting this view: Less than noble institutions. Not all institutional interests deserve protection. The hospital may be a for-profit, investor-owned operation that is skimming and dumping its way to riches, bankrupting the serviceoriented hospitals across town. Or it may be a not-for-profit "shell" for physician entrepreneurs who excel in devising ways to separate payers from their money,3 relying on well compensated administrators to err on the side of cash flow in dealing with conflicts of interest. Vigorous representation of the institution's point of view cannot aid ethical reflection in such cases. Indeed, ethics committees have a special problem in such contexts that stem from their lack of established methodology. Since what they do is 100 percent'judgment with accountability nearly impossible, it is crucial that they be insulated from the less-noble imperatives in their midst. For example, the IRB responsible for approving the protocol for the artificial heart found itself under intense pressure (which it resisted) to approve it. The entire program was eventually moved to a for profit hospital in another state. Wide variations by location in the process and outcomes of ethical reflection call for an explanation.

Balancing mission and margin. The competitive strategy that is currently popular for containing costs puts pressure on those hospitals inclined to sacrifice profits (or surplus) in favor of such "mission objectives" as care for the uninsured or maintaining unprofitable, but needed, services.' Though administrators may try to resolve the apparent dilemma with the slogan, "No margin, no mission," in fact the balance is not mechanically fixed. The ethics committee can be a force within the institution that applies pressure in the direction of "mission" where this is needed to reach the optimal outcome in difficult cases and policy choices. Indeed, it may be the one decisionmaking body that remains fully insulated from the need to act as a team player in a competition which rewards narrow institutional gains, rather than success in meeting community needs. managers accept the inevitability of conflict, roiled waters are not to many managers' tastes. just as the hospital lawyer often provides the most conservative and protective counsel, regardless of the instrinsic desirability of that outcome for the patient, the manager looks to avoid a fight with such key players as the town doctor who refers patients for tertiary care. The ethics committee, being constituted specifically for moral reflection, can continually remind the institution that harmony and lack of offense may amount to lack of commitment to principle. Its independence helps the hospital to stand for something. This, in turn, may bolster the institution's standing with the community, and may help to determine what kind of people choose to work in the hospital.6 These three arguments constitute a case for operating ethics committees independently of the overall administration of the hospital. But how can this be assured? Since the committees' operating procedures are so indeterminate in any case, it would be difficult to write this narrow focus into the committee's charter. Beyond educating committee members themselves on the issue, the most concrete step would be to avoid giving hospital administrators representation on the committee, even in ex officio status. The cost of such a policy could be significant, depriving the committees of key expertise and information and making coordination with the institution's overall operations difficult. It is a fact of life, however, that the administrator who might sit on the committee can control perquisites, salaries, and career paths for some of the other committee members. Independence may require a measure of anonymity. An empirical study of the effects of management representation is needed to determine the best trade-off. None of these cautions completely removes the potential for compromising the ethics committee's mandate by improper admixture of administrative concerns. The committee as a whole may owe its existence to institutional interests. A functioning committee cannot but help assure the public of the institution's high moral purpose, and may reduce the kind of patient and staff dissatisfaction that could erupt in malpractice litigation and resignations, respectively. A quite real, and quite troubling, consideration is the coincidence of patient autonomy concerns and cost containment in allowing the termination of life-supporting medical care. Some ethics committees no doubt pay their way many times over in dollars saved on care forgone as a result of their consultations and consensus. This coincidence does not necessarily suggest any influence on decisionmaking by the hospital financial officer, but one might question whether the institution would so gladly bear the committee's expenses were the costs affected in the opposite direction. This potential for co-optation is not cause for reversing the substance of ethics committee advice, but it does, in my view, provide a reminder that continued monitoring of the actual function of the committee within the institution is advisable.

Good administrators ought to be ethical," as ought clinicians and ethics committee members. None of the arguments advanced here suggest that the administrator's work occurs on a lower moral plane; indeed, as mentioned, the consideration of ethical problems in their widest scope is the province of the administrator, rather than of the individual clinician. Nevertheless, this responsibility is best discharged independently of the hospital ethics committee.

(The author thanks Dr. Norman Fost for important suggestions incorporated into this paper.)
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Author:Wikler, Daniel
Publication:The Hastings Center Report
Date:Sep 1, 1989
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