Ethics Committees and Consultation

NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion.  Please check back soon for updates!

Author:

Robert A. Pearlman, MD, MPH, Professor, Dept. of Medicine, Adjunct Professor, Department of Bioethics & Humanities, and Department of Health Services, University of Washington and the VA Puget Sound Health Care System  
 

Topics addressed:

• What does an ethics committee or program do?
• Who becomes a member of an ethics committee or program?
• What is the difference between an ethics committee and an ethics consultant?
• Under what circumstances should I call the ethics consultant/service?
• What will the ethics consultant do if I page her or him?
• How do I contact the ethics committee or request an ethics consultation?
   

Most hospitals are now required to have an ethics committee, and many in the Seattle area provide an ethics consultation service. In the United States some ethics committees have expanded their functions and become more comprehensive ethics programs. This topic page will discuss the role and activities of these groups.

What does an ethics committee or program do?

Historically, ethics committees involve individuals from diverse backgrounds who support health care institutions with three major functions: providing clinical ethics consultation, developing and/or revising policies pertaining to clinical ethics and hospital policy (e.g., advance directives, withholding and withdrawing life-sustaining treatments, informed consent, organ procurement), and facilitating education about topical issues in clinical ethics.

The underlying goals of traditional ethics committees are:

• to promote the rights of patients;
• to promote shared decision making between patients (or their surrogates if decisionally incapacitated) and their clinicians;
• to promote fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes; and
• to enhance the ethical environment for health care professionals in health care institutions.

Ethics committees or select members often help resolve ethical conflicts and answer ethical questions through the provision of consultations.

More recently, some ethics committees, particularly those affiliated with academic institutions and large health care systems, have expanded their traditional functions to become more comprehensive ethics programs. They address both clinical and organizational ethics issues. Ethics programs may provide ethics consultations in response to non-clinical ethics questions, identify and remedy systems-level factors that induce or exacerbate ethical problems and/or impede their resolution (often using quality improvement methods), and promote a positive ethics culture throughout the institution. Thus, the additional goals of expanded ethics programs include:

• integrating ethics throughout the health care institution from the bedside to the boardroom,
• ensuring that systems and processes contribute to/do not interfere with ethical practices, and
• promoting ethical leadership behaviors, such as explaining the values that underlie decisions, stressing the importance of ethics, and promoting transparency in decision making

Who becomes a member of an ethics committee or program?

Ethics committee members usually represent major clinical services and other stakeholders in health care delivery. Thus, it is not uncommon for committee members to include clinicians (physicians and nurses) from medicine, surgery, and psychiatry, social workers, chaplains, and community representatives. These committees may also have a quality improvement manager, an individual responsible for the education program at the facility, a lawyer, and at least one individual with advanced training in ethics. This latter representative can come from a number of disciplines, including philosophy, law, medicine, theology, and anthropology. All members of the ethics committee take responsibility for learning techniques of ethical analysis (see Bioethics Tools) and the arguments surrounding most of the ethically charged issues in clinical practice.

Some ethics committees allow guests. These can include health sciences students, philosophy graduate students, physician trainees, facilitators, and patient representatives. Guests need to maintain the confidentiality of the information discussed at the meetings, often signing oaths to that effect.

In order to integrate ethics throughout the institution and effect cultural change, ethics programs may include senior leaders in disparate services, such as fiscal, human resources, patient safety, quality improvement, and compliance and business integrity. At some institutions a special ethics council is formed to address ethical issues across the institution, providing a more integrated approach to addressing ethical issues.

What is the difference between an ethics committee and an ethics consultant?

An ethics consultant is an expert in ethics who provides ethics consultations and may also serve as an educator to the committee or program. In some health care institutions an ethics consultant provides ethics expertise to workgroups that are addressing systems issues and have the need to better understand the ethics and preferred practices from an ethics perspective. Sometimes in lieu of having an ethics consultant address ethics questions or concerns, the ethics committee will develop a subcommittee to handle these functions. The decision to have an ethics consultant versus a subcommittee rests with the available resources and the expertise of the committee members.

In general, the strengths of having an ethics consultant is that she is a recognized expert, and the logistics of having someone perform a consultation is straight forward. The weaknesses are that clinicians can rely on this outside person for the answers to their questions and not develop their own expertise, and only one voice/perspective gets expressed. The major strength of having subcommittees or a consultation service (having 2-3 people per month) perform consultations is that this structure incorporates a diversity of views. The major weakness is the logistical difficulty of having more than one person respond to a consult request. Regardless of the ethics consultant versus subcommittee structure, peer-review of ethics consultations should routinely occur at a subsequent ethics committee meeting to ensure quality.

Under what circumstances should I call the ethics consultant/service?

You should consider asking for a case consultation when two conditions are met:

1. You perceive that there is an ethical problem in the care of patients, and
2. Health care providers have not been able to establish a resolution that is agreed upon by the patient/surrogate and the clinicians caring for the patient

While a communication breakdown is often a factor in ethics consultation, an ethical dilemma occurs when two courses of action may both be ethically defensible. These dilemmas are often due to a conflict between principles (e.g., autonomy, beneficence, justice) or between principles and outcomes.

At most hospitals, anyone may request an ethics consultation including the patient or family. Please check the hospital's policies to learn how to request an ethics consultation.

You should consider asking for an ethics consultation even when patient care is not the central issue if you believe that there is a lack of clarity about an ethics policy or concept that would benefit from education. The following are examples:

• a question about professionalism,
• a general question about patient privacy or confidentiality, and
• a question about ethical practices in the workplace, human resources,  resource allocation, or the business practices of the institution.

What will the ethics consultant do if I page her or him?

The consultant will usually ask you to specify the nature of the perceived ethical problem, and the question that you would like answered. She will meet with you and the other people involved in the situation. In clinical consultations she will review the medical record and meet with the patient (or surrogate decision maker) and family members. Often the consultant will arrange an interdisciplinary meeting to review the specifics of the case and to facilitate communication across disciplines or between clinicians and the patient (and/or the family). The consultant will write a note and attempt to answer the proposed question(s). In the Seattle area, the recommendations may be anchored to the 4 box analysis of relevant case information, utilization of principles of clinical ethics, rigorous analysis of similar and dissimilar cases, and supporting arguments and data from the literature. If definitive recommendations cannot be made because there is disagreement among the ethics consult team, a clear explication of the ethics standards (e.g., laws, consensus statements, policies), and analytic arguments (i.e., claims and counterclaims, such as reliance on established codes, consideration of short- and long-term consequences, analysis of comparable features of the case) will be presented in the consultant's note. If several ethically permissible options exist, the consultant will present them in a note including their justifications.

How do I contact the ethics committee or request an ethics consultation?

Check with your hospital to identify the pager number to reach the ethics consultant. There should be an individual at each hospital that carries a pager for responding to ethics consultations.

At UWMC, the ethics consultant can be reached through the hospital’s paging operator at 206.598.6190. At Harborview Medical Center, you should call 206.744.3000, and at VA Puget Sound Medical Center, you should call the ethics consultation service pager, 206.762.1010.