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When it's really not optional.

When It's Not Really Optional

Most ethics committees follow what has come to be known as the "optional/optional" model in reviewing cases. [1] That is, the committee is not required to review a case, and its recommendation need not be followed by the attending physician. Questions are being raised, however, about whether an "optional" ethics committee recommendation is truly optional. [2] The institutional force of some recommendations is so strong that they are, in effect, mandatory.

There is a range of "optionality" among ethics committee recommendations, from truly optional to nearly mandatory. There are several reasons for this variation.

Many see the case review function of an ethics committee as a form of consultation, and believe that committee conclusions should have the same optional standing as the recommendation of a medical consultant. Yet there is an important difference between the two. The course recommendered by a medical consultant can be set aside by an attending physician who does not wish to follow it; he or she will feel free to justify this decision in the progress notes. That approach is also available for an ethics committee recommendation--at least in theory. The problem is that many attending physicians are unfamiliar with the language and concepts of ethics and, consequently, may find it difficult to provide counterarguments to a committee's conclusion. This, by default, gives the committee's "optional" recommendation more weight than is warranted.

Not all committees that consult on cases come to a formal conclusion. Some try to ensure that major ethical questions are raised, but do not conclude their discussion by endorsing a particular approach. Such deliberations can nonetheless carry considerable weight. If, as often happens, one point of view predominates, the attending physician may feel pressured to follow it. And in those committees that do come to formal conclusions, whether by taking a vote or by consensus, a unanimous decision may be interpreted by the attending physician as nearly mandatory.

The composition of the committee can also affect how its opinions are perceived. Initially, ethics committees tended to be informal groups composed of people in the institution interested in ethics. Today's ethics committees are more likely to be deliberately balance in composition and to have official status within the institution. As a result, they often command greater notice and their recommendations may be seen as more binding. The status of the individual who brings a case to the committee will also affect the "optionality" of its recommendation. A house officer who brings a case may feel more obliged to follow committee opinion than would an attending physician.

The term "optional," then, is not always descriptive of the actual effect of an ethics committee's recommendation. The committee may, intentionally or not, place a great deal of pressure on caregivers to conform to "optional" committee determinations.

Whether ethics committee recommendations should have this weight is another question. Some maintain that there should be pressure on physicians to comply with ethics committee opinions, especially when these reflect a widespread ethical consensus on an issue. Others feel that committee recommendations that are optional in theory, but not in practice, represent an undesirable intrusion into the choices of the physician and patient or family.

If committees believe that classifying a recommendation as "optional" will absolve them of legal responsibility for a decision, they are probably mistaken. Although it is not yet clear how the courts will view ethics committee opinions, they are not likely to ignore the institutional weight that some putatively "optional" ethics committee conclusions can have.

However the ethics committee views its role, the terminology that it uses to describe the force of its recommendations should convey this accurately. Some committee recommendations actually are optional, and should continue to be called that. Mandatory determinations should also be clearly labeled as such. When the force of a recommendation is somewhere between "optional" and "mandatory" it would be more appropriate to label it "recommended." This would occur, for example, when an ethics committee has reached a clear consensus about a difficult ethical issue in a case, and its conclusion concurs with opinions expressed in current bioethics literature. By using the term "recommended" dissenting viewpoints are not suppressed and the attending physician is free to follow his or her own conscience and medical judgment. More accurate terminology may help an ethics committee to clarify the effect it wishes to have within the institution and to understand more realistically its potential legal role.


[1] John A. Robertson, "Ethics Committees in Hospitals: Alternative Structures and Responsibilities," Quality Review Bulletin 10 (1984), 6-10.

[2] Joan M. Gibson and Thomasine K. Kushner, "Will the 'Conscience of an Institution' Become Society's Servant?," Hastings Center Report 16:3 (June 1986), 9-11.

[3] Mark Siegler, "Ethics Committees: Decisions by Bureaucracy," Hastings Center Report 16:3 (June 1986), 22-24.

Karen Ritchie is a physician and bioethics consultant in Overland Park, Kansas. Members of the Ethics Committee Consortium of the Midwest Bioethics Center provided assistance.
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Title Annotation:ethics committee
Author:Ritchie, Karen
Publication:The Hastings Center Report
Date:Aug 1, 1988
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