Society's Choices Social and Ethical Decision Making in Biomedicine (1995) / Chapter Skim
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Institutional Ethics Committees: Local Perspectives on Ethical Issues in Medicine
Institutional Ethics Committees: Local Perspectives on Ethical Issues in Medicine
Pages 409-431
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From page 409... ...
However, the practical nature of clinical ethics and constraints of law and institutional policy have also led IECs to a theory and practice distinct from academic ethics. The first public calls for an advisory body on clinical ethics2 came in 1971 from the Catholic Hospital Association of Canada (CHAC)
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From page 410... ...
Participants' experience of the roles and constitution of such bodies differed, but they generally agreed that multidisciplinary committees, well versed in the ethical issues of medicine, could serve in a valuable advisory capacity to physicians and families confronted with difficult treatment decisions (5~. In 1983, the President's Commission for the Study of Ethical Issues in Medicine and Biomedical and Behavioral Research issued its report on the ethical, medical, and legal issues in decisions to forego life-sustaining treatment (6~.
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From page 411... ...
The AHA, AAP, and American Medical Association (AMA) filed suit to have the rules invalidated, and later that year, the AAP issued guidelines for the establishment of multidisciplinary "infant bioethics committees" to review the proposed nontreatment of severely impaired infants using a best-interests standard that recognized the limits of technological intervention (8~.
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From page 412... ...
In 1987, the state of Maryland enacted legislation requiring hospitals to establish IECs to advise caregivers, patients, and family members on ethical aspects of the treatment of terminal illness (13~. The law also suggested that committees review and formulate institutional policy on the use of life support as well as conduct educational programs for hospital staff and patients and their families on ethical issues in medical decision making.
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From page 413... ...
the education of hospital staff, patients, family members, and the community on ethical issues and the philosophy and policies of the institution; and (c) the consideration of and consultation on ethical issues in patient care generally and questions about the treatment of specific patients.
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From page 414... ...
orders; · Informed decision making and informed consent; · Advance directives and their implementation, and withholding and withdrawing life-sustaining treatment generally; · Surrogate decision making for incompetent patients, including infants, children, and the unconscious; · Assessment and management of pain; · Transfer of patients to other facilities; and · Respect for patients' religious and cultural preferences. The IEC should be sufficiently familiar with existing policies and procedural guidelines and state and federal law, to clarify, rather than complicate, the standards of clinical practice.
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From page 415... ...
Turnover of committee membership implies a need for introductory materials for new members and ongoing committee education to ensure that the members have a common framework, without which the committee risks inconsistency in policymaking and consultation. Physicians and hospital staff need ongoing education on the institution's policies and relevant law on such issues as DNR orders, advance directives, withholding and withdrawing treatment, and surrogate decision making.
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From page 416... ...
In some facilities, this limitation has led to the creation of parallel "nursing ethics committees," where nurses seeking advice or interpretation of policy may get an answer directly; often their issues involve conflict with physicians (42~. Clinical ethicists typically advocate broad access to a central IEC, concerned that nursing committees marginalize nurses and compartmentalize institutional issues along disciplinary lines.
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From page 417... ...
The question of how and by whom the information should be relayed is tied into: What documentation should be kept, and where? The President's Commission and most other bodies with guidelines on the conduct of IECs call for a consultation record to be put in the patient's chart in much the same way that other consultations generate chart notes; additional copies of the recommendation could be provided to the attending physician, patient, or person seeking the consultation, as needed.
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From page 418... ...
Increasingly, such situations have involved family members' requests for treatment that physicians and IECs contend are unduly burdensome for the patient, inappropriate to the goals of treatment, or "futile" (34; 4749~. Many hospitals claim to follow the guidelines of the Society of Critical Care Medicine (34; 48)
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From page 419... ...
The maintenance, availability, and discoverability of the IEC's records may also be affected by its placement in the hospital's administrative structure (22; 23; 27; 29; 45~. The IEC's minutes and case reports might be safeguarded like quality assurance materials if the IEC is an administrative committee; records might come under peer review protection if the IEC is a medical staff committee.
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From page 420... ...
Typically, IEC membership may include: Physicians of various specialties, particularly critical care for expertise in life support and resuscitation; neurology for expertise in states of consciousness; psychiatry for expertise in decision-making capacity, competence, and the mental consequences of physical illness and its treatment; gerontology, to provide a comprehensive view of elderly patients; and other specialties that may be important in the individual institution.
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From page 421... ...
They can be helpful in case consultation because they often give social and emotional support to patients and families, and their teaching skills often enable them to communicate complex medical concepts to lay people.
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From page 422... ...
Many of the country's first IECs were started in collaboration with faculty from such programs. Some universityaffiliated hospitals now have clinical ethics programs that offer ethics consultation services, as part of or independent of the IEC.
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From page 423... ...
Ethicists themselves are far from agreed on whether clinical ethics consultation is a profession, and if so what level of education, training, and expertise should be expected of its members. iCAHO is interested in the practice and credentials of clinical ethicists, but is particularly concerned about the quality of IECs in small and rural hospitals where ethicists are virtually nonexistent and few caregivers are likely to be proficient in clinical ethics.
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From page 424... ...
Some research and anecdotal evidence suggests that many do not inform patients or their families about their right to an advance directive or their options for treatment, and few have established IECs (58-61~. For many hospital IECs, nursing homes and other long-term care facilities are a source of ethical problems, as their residents are repeatedly hospitalized for the treatment of strokes, infections, and fractures from which they will neither recover nor die.
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From page 425... ...
The role for IECs in long-term care facilities must be one aspect of a comprehensive assessment of the care of the elderly and severely disabled under health care reform. IECs' Inability for Malpractice and Other Legal Action Ethics committees were first suggested as a forum for resolving the conflicts that might lead to a court's intervention; both the New jersey Supreme Court and Congress anticipated that IECs would help to keep medical decisions out of the courtroom (3; 16~.
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From page 426... ...
In a recent nonfiction book portraying the work of an IEC in a large urban hospital, economic issues lie behind every treatment decision (65~. Although the IEC never discusses the cost of care, the book is laced with descriptions of caregivers and other institutional bodies considering the financial impact of the intensive care and technological intervention provided to indigent patients.
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From page 427... ...
The establishment of formal standards should not be left to iCAH[O alone, however, but should involve the ethicists, clinicians, and policymakers whose work has led to the growth of clinical ethical theory and the rise of active IECs, and the individual committees themselves. Anecdotal evidence suggests that IECs have been successful at the widely claimed goal of limiting court intervention in treatment decisions.
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From page 428... ...
"Hospital ethics committees: A guarded prognosis." Hastings Center Report, 1977, 7 (June)
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From page 429... ...
Institutional Ethics Committees and Health Care Decision Making. Ann Arbor, MI: Health Administration Press, 1984.
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From page 430... ...
"For experts only? Access to hospital ethics committees." Hastings Center Report, 1991, 21 Qan./Feb.)
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From page 431... ...
"Evaluating ethics committees." Hastings Center Report, 1989, 19 (Sept./Oct.)
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