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Membership of institutional ethics committees.

In 1983, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral research [6] ascribed the following advantages of diverse membership for constitutional ethics committees: "First, having individuals from many different specialties, as well as those without professional specialization, can minimize the tendency to take the committee's task as essentially technical. Second, diversity can prevent ethics committees from becoming uncritically accepting of, or adverse to, the view of any professional or social group. Finally, since one of the central functions of ethics committees may be advise patients, families, and practitioners who are trying to make informed decisions, many different perspectives should be available to those who seek the committee's guidance." [2]

A national survey revealed the following general average composition of institution ethics committees. [7] Physicians 5.25 Lawyers 0.35 Clergy 1.05 Social workers 0.21 Administrators 0.58 Lay persons 0.15 Nurses 0.44

Qualifications

The general qualifications for membership on an ethics committee include:

* Interest

* Ability to think in a reflective manner.

* Full competence in own field.

* Willingness to commit the time involved for committee meetings and private study.

* Tolerance of ambiguity.

* Tolerance of conflicts.

* Respect for confidentiality.

* Being process oriented and prepared for long discussions and slow movement.

* Bringing a different point of view.

* Professional in interaction.

* Articulate and vocal.

* Counseling skills.

* Analytical skills regarding ethical alternatives.

* Communication skills in clarifying to the patient and/or family the medical and social implications of alternative therapies.

Not every member will meet all of these qualifications. A physician who by training and/or temperament is a doer and a problem-solver and who is accustomed to making rapid decisions and generally uncomfortable with ambiguity will often have difficulty with the operational mode of the committee. Further, if the physician follows the Golden Rule as outlined by Nesbitt ("The Golden Rule is as appropriate to medical conduct as it is to any other conduct, because essentially there is no difference. It tells us to treat our patients as we would want another practitioner to treat us or our loved ones." [8]), he or she may bring personal values regarding outcome to the patient encounter, which may differ from the patient's view of outcome. Finally, a paternalistic physician should not be a member of the committee. Rather the physician who is a teacher, not necessarily of students but of patients, [9] should be selected.

The decision of physicians to use the committee will be influenced by their perceptions of the make-up of the committee. In that regard, physician members are the backbone of the committee and should be highly qualified, highly respected members of the physician community.

Composition

Physicians should constitute about one-third of the committee, nurses one-third and "other" the remaining one-third. The physician members should be multidisciplinary and perhaps represent those medical specialties most often involved with critically ill or terminal patients, e.g., critical care internists, surgeons, anesthesiologists, neurologists, neurosurgeons, oncologists, nephrologists, emergency medicine specialists, and neonatologists. This is not meant to exclude family physicians, internists, psychiatrists, etc. The physicians selected should reflect the qualifications expected on the committee and the institutional culture.

Likewise, nurses may be selected from specialty areas such as oncology, emergency medicine, critical care, obstetrics, pediatrics, hospice, and others. Staff nurses as well as administrative nurses should be represented.

The "other" group may include social workers, clergy, patient representatives, lawyers, administrators, trustees, ethicists, philosophers, and lay people.

The two "other" member that seem to be the most controversial as potential members are lawyers and lay persons. If a lawyer is selected as a member, the general consensus appears to be that it should not be the hospital attorney. The institutional counsel may be concerned with protecting the hospital rather than with the ethical issues. The attorney selected should probably be knowledgeable regarding health care.

The lay person may bring a community perspective. A firm proponent of lay person's membership, Glantz argues: "When we consider the composition of institutional ethics committees we generally think about physicians, clergy people, nurses, lawyers and social workers. As a result such committees will tend to be white, middle-class, and profoundly overeducated. They will be people who value and are concerned about intellectual life .... It seems to me that if the committees are going to make decisions for handicapped people, we should try to involve people who have some of those handicaps." [10]

In short, the lay person may provide the link between the technical clinical world and the ordinary outside world. Those who oppose lay membership on the committee suggest that this increases the risk of breaking patient confidentiality. Further, it is suggested, they have no special training, even though they may ask very penetrating questions regarding prognosis, therapy, and/or alternatives. The concern regarding confidentiality can be legally circumvented as a "make or break" issue by appointing an outside member as an employee at one dollar per year. As an employee, the lay member can then take an oath of nondisclosure. [11]

The one "other' member who appears to be universally accepted is the ethicist, who brings to the committee basic ethical knowledge, including that of the literature, as well as a penchant for the pursuit of logical analysis.

Selection

Committee members are usually appointed by the person to whom the committee reports. For an institutional ethics committee, the president/CEO of the hospital may recommend membership with approval by the Board or may have sole appointing authority. If the committee reports to the medical executive committee, the president of the medical staff may have appointment authority.

Tenure

Continuity of membership is important and is often achieved by a staggered 2-3 year term of office. The number of terms that a member may serve may be prescribed.

Chairperson

The chairperson should have leadership qualities and a strong interest in bioethics. The chairperson may be a physician, nurse, or clergy. The leader is often a physician with recognized strong concern for patient care issues. Some committees are cochaired by a physician and a nurse. Opinion differs as to whether clergy or a pastoral care person should ever chair the committee. The resistance to such leadership derives from the potential perception that the committee is focused primarily on spiritual or religious issues rather than on ethical issues.

Summary

There is no state or federal prescription for the composition of an institutional ethics committee. The general guideline for the membership is that it be diverse in perspective.

References

[1] Cranford, R., and Doudera, A. Institutional Ethics Committees and Health Care Decision Making. Ann Arbor, Mich.: Health Administration Press, 1984.

[2] Hosford, B. Bioethics Committees: The Health Provider's Guide. Rockville, Md.: Aspen Publishers, 1986.

[3] Craig, R., and others. Ethics Committee: A Practical Approach. St. Louis, Mo.: Catholic Health Association, 1986.

[4] Kelly, M., and McCarthy, D. Ethics Committees: A Challenge for Catholic Health Care. St. Louis, Mo.: Catholic Health Association, 1986.

[5] Byley, C., and Cranford, R. "Ethics Committees: What Have We Learned." In Making Choices, Ethics Issues for Health Care Professionals, edited by Friedman, E. Chicago, Ill.: American Hospital Publishing, Inc., 1986, pp. 193-9.

[6] President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forgo Life-Sustaining Treatment. Washington, D.C.: U.S. Government Printing Office, 1983, p. 166.

[7] Younger, S., and others. "A National Survey of Hospital Ethics Committees." In President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forgo Life-Sustaining Treatment. Washington, D.C.: U.S. Government Printing Office, 1983, p. 450.

[8] Nesbitt, T. "Medical Ethics: Ever Old, Ever New." JAMA 245(3): 241-2, Jan. 16, 1981.

[9] May, W. The Physicians Covenant. Images of the Healer in Medical Ethics. Philadelphia, Pa.: Westminster Press, 1983.

[10] Glantz, L. "Contrasting Institutional Review Boards with Institutional Ethics Committees." In Cranford, R., and Doudera, A. Institutional Ethics Committees and Health Care Decision Making. Ann Arbor, Mich.: Health Administration Press, 1984, p. 134.

[11] American Hospital Association. "Legal Issues and Guidelines to Hospital Biomedical Ethics Committees: Report of the Adjunct Legal Task Force on Biomedical Ethics." Legal Memorandum,

Charles E. Hollerman, MD, FACPE, is Vice President, Medical Affairs, Mercy Hospital, Pittsburgh, Pa. He is an Associate Member of the College's Forum on Bioethics. Dr. Hollerman is also the author of two chapters--"The Functions of Institutional Ethics Committees" and "A Special Case: The Pediatric Ethics Committee"--in the College's new monograph, The Higher Ground: Biomedical Ethics and the Physician Executive.
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Author:Hollerman, Charles E.
Publication:Physician Executive
Date:May 1, 1991
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