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Making policy by committee.

Making Policy by Committee

Are ethics committees well-suited to devising policies? Thomas Murray has doubts. [1] As an example of problems committees are likely to face in developing policies, he cites the efforts of one committee to deal with refusal of blood transfusions by patients who are Jehovah's Witnesses. [2]

To the contrary, I contend that ethics committees hold out the best hope of keeping ethics in the forefront of hospital policies with moral implications. The difficulties that emerged in the effort noted by Murray to develop a policy for Jehovah's Witnesses were, I believe, more idiosyncratic than typical.

Murray observes that the experience of my committee "shows that there can be plain agreement on one category of cases, but profound disagreement on a closely related one." That is surely true. But should we conclude that because members of the committee held widely disparate views about patient autonomy, any attempt to devise a policy must therefore be flawed? Murray does not draw that conclusion explicitly, but he voices his concern that ethics committees will have difficulty creating many policies, except on matters where there is already a strong consensus.

What should be the solution where a strong consensus does not exist? Should it be to leave policymaking in such cases to one individual authority who most probably holds a single, consistent view about the matter? That has the virtue of efficiency. But it also carries the distinct danger of a dogmatic imposition of one viewpoint about an issue on which reasonable people disagree, and where society as a whole remains in conflict.

The idiosyncracy in the difficulties encountered by my committee lay in the fact that the policy had to address the problem of treatment refusals by pregnant women, which touches issues about which our society is deeply divided. As Murray notes, people who agree on the answers to many other ethical questions disagree about the moral status of the fetus, our obligations (if any) toward that fetus, the threat that women may be treated as line more than "reproductive vessels," and other related concerns. Our ethics committee reflected the larger societal disagreement about these questions. And that, I would argue, is a virtue rather than a drawback of the committee approach.

But the sorts of conflicts that typically come within the purview of an ethics committee making policy rarely fall into this category. The tension between the hospital's interest in minimizing liability or costs and the ethical obligation to respect the rights of patients may always be a source of conflict, one that ethics committees need to deal with in formulating policies. The wishes of some paternalistic physicians to continue practicing the way they did in an earlier era will no doubt provide an ongoing source of conflict that will need resolution through policy development. Although they may pose difficulties for an ethics committee, these issues are not the sort that reflect deep divisions in the moral views of citizens in the larger society. They are, however, typical of the conflicts committees do and will face in their work on hospital policies.


[1] Thomas H. Murray, "Where Are the Ethics in Ethics Committees?" Hastings Center Report 18:1 (February/March 1988), 12-13.

[2] Ruth Macklin, "The Inner Workings of Ethics Committees: Latest Battle over Jehovah's Witnesses," Hastings Center Report 18:1 (February/March 1988), 15-20.

Ruth Macklin is professor of bioethics in the Department of Epidemiology and Social Medicine at Albert Einstein College of Medicine, Bronx, NY. She is also an adjunct associate of The Hastings Center.
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Author:Macklin, Ruth
Publication:The Hastings Center Report
Date:Aug 1, 1988
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