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Why cases sometimes go wrong.

Why Cases Sometimes Go Wrong

Consultation? Case review? Counseling? Case discussion? The lack of a single term to characterize ethics committee reviews of difficult questions that arise in the care of patients suggests that there is no single understanding of this distinctive committee function. Those who request a meeting of a committee may arrive with one understanding of this function only to meet a group with a wholly different approach. As a consequence, they are likely to talk past each other and to part dissatisfied. This is why case discussions sometimes go wrong.

There are at least three different understandings of the case review function of ethics committees. One is that it involves a consultation. This conception comes from the medical model of consultation in which a primary physician who faces a difficult or unusual patient care question seeks the advice of another physician with special expertise in that area. Ethics committees that follow this model believe they are being asked to use their expertise in ethics to advise about perplexing ethical issues that arise in the care of a patient. They may ask such questions as whether they must personally see the patient, read the chart, and interview family members. They wonder whether the committee must write its recommendation in the chart and what they are to do if the physician does not follow the committee's recommendation. Committees functioning on this model are not likely to talk about whether the committee should make a recommendation but to whom it should make the recommendation.

As the medical model of consultation depends on perceptions of medical norms, so the ethics committee consultation model depends on perceptions of moral norms. For example, when considering a case that involves a comatose patient with AIDS and pneumonia who is on a respirator and whose mother and lover disagree about appropriate care, an ethics committee working with the consultation model might focus on what is in the patient's best interests and what most people would want in this situation.

Other committees may follow a case review model; this is indebted to the legal system. The emphasis in this model is on the procedural precision of the committee and its ability to weigh evidence, rather than its substantive expertise. The committee is expected to make a decision on this model; the critical question is how it (as judge and jury) comes to that decision.

When the case review model is dominant, the committee asks such questions as who can bring a case to the committee, who attends the review, who provides information, who votes, and who acts as the patient's advocate. Ethics committees with this understanding of their function regularly speak of the decision they reach about a case, even as they say that they are not the decisionmakers.

When substantive issues are addressed on this model, committees are more likely to focus on identifying the proper decisionmaker than the appropriate decision. Thus, in the previously described case of the man with AIDS, the committee might be particularly attentive to whether the mother or the lover is the best surrogate decisionmaker for the patient.

A third approach that some ethics committees use to discuss patient care questions is educational. On a counseling model, committees shape the understanding of a problem and give advice on the basis of this. They develop morally acceptable alternatives and explore management strategies that either enlarge or dissolve the problem. The counseling model involves ethics through conversation, for it assumes that talking about the case and discussing the relevant moral principles will make the appropriate action apparent.

There is virtually no concern about such matters as attendance, voting, recordkeeping, or first-hand patient data on the counseling model, for its primary focus is on communication and understanding. The discussion does not explore the situation as a problem with a single solution, but views it as the reconstruction of a narrative with many possible endings, most of which are ethically acceptable.

This model is action-oriented, not decision-producing. It presumes that talking can re-shape the participants understanding of the problem. For example, if the case of the patient with AIDS were considered on this model, the committee might suggest that maintaining or removing the ventilator are both morally permissible, but it would be more interested in other issues such as how to facilitate a meeting between the mother and lover to explore what is best for the patient, or how to help the mother come to grips with the fact that her son is dying.

Individuals or entire committees may use one of these models for one case, another for a second case. Or they may mix them in a single discussion. Furthermore, the term identifying the model being used may not reflect what is actually being done. Those who label their activity "consultation" may, in reality, function according to the case review or counseling models.

These three models derive from different professional conceptions of problem solving that each provide satisfying and unsatisfying qualities. When individuals ask an ethics committee for help, they may find the consultation model too directive, the case review model too process-oriented, and the counseling model too vague.

The consultation and case review models provide recommendations to physicians and preempt results that are clearly unacceptable to the larger society. Yet their insistence on providing recommendations (and even decisions) may interfere with physicians' ability to make decisions about how to care for patients. The counseling model may expand everyone's understanding, but it can be dissatisfying because it is nondirective and apparently inconclusive ("a copout" in the phrase of one medical student who observed such a session). Ethics committees guided by this model may fall into disuse due to lack of interest from those who perceive them as ineffective.

When individuals leave an ethics committee meeting with the complaint, "This wasn't what I expected," and do so with some degree of frequency in an institution, that committee ought to consider whether it has clearly articulated an understanding of its mission to itself and to its community. Before the committee's process has hardened into an unalterable tradition, it behooves members to ask which model of the distinctive function of ethics committees they are implicitly following--and whether they ought to continue to do so.
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Title Annotation:Ethics Committees
Author:Ross, Judith Wilson
Publication:The Hastings Center Report
Date:Jan 1, 1989
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