The Maryland Healthcare Ethics Committee Network
Ethics Committee Functions & Goals
Ethics committees generally focus on three main functions:
Ethics consultation. The American Society for Bioethics and Humanities’ (ASBH, 2011) Core Competencies for Healthcare Ethics Consultation defines ethics consultation as “a set of services provided by an individual or a group in response to questions from patients, families, surrogates, health care professionals, or other involved parties who seek to resolve uncertainty or conflict regarding value-laden concerns that emerge in health care.” A distinction is made between “case consultations” [involving an identified patient for whom one or more recommendations is made by the ethics consultant(s)] and “non-case consultations” (basically, all other consultations). The Core Competencies document is available for purchase at http://www.asbh.org/. It is also summarized in the article, “Health care ethics consultation: An update on core competencies and emerging standards,” published in the American Journal of Bioethics (Tarzian & the ASBH Core Competencies Update Task Force, 2013, 13(2), 3-13). Also, review this list of Pearls and Pitfalls of Ethics Consultation, drafted by ASBH’s Clinical Ethics Consultation Affairs (CECA) Committee in 2011.
Ethics education. Many ethics committees engage in activities to educate others, both formally and informally. Informal education occurs during ethics consultations (i.e., explaining ethical concepts and issues to those involved in the consult) and other interactions with staff or family members. Formal education can include giving ethics lectures, sponsoring conferences, orienting new staff to ethics, or educating staff and family members about the ethics committee’s services. Ethics committees also must educate their own members. ASBH’s Inproving Competence in Clinical Ethics Consultation: An Education Guide is a useful resource for identifying ethics knowledge content and ways to educate ethics committee members or staff.
Policy development. Policies are generally considered to be any governing principle, plan or course of action that an institution has adopted. Protocols are the means to implement the policies. Ethics committees traditionally weigh in on developing, reviewing, and revising policies that impact ethical decision-making in their organization. Examples of topics that ethics committees have addressed in policies include Do Not Attempt Resuscitation (DNAR, or “Allow Natural Death”) orders, artificial nutrition and hydration, informed consent, surrogate decision making, guardianship, determination of decision-making capacity, do not hospitalize orders, and advance directives. In addition to guiding health care providers, policies help advise patients/residents and family members prior to admission to help them make a more informed decision and to seek alternative care if the facility cannot accommodate their treatment preferences. For example, currently in Maryland, as stipulated in Maryland’s Health Care Decisions Act, if two physicians certify that cardio-pulmonary resuscitation attempts would be medically ineffective for a dying patient, they can write a DNAR order and inform the patient or family about everything that will be done to care for the patient, explaining that CPR attempts will not be attempted because they would not be appropriate or effective for a person whose death is imminent and unavoidable. Formalizing this in an institutional policy promotes transparency and increases the likelihood that “like cases are treated alike.” Read more about how one Maryland hospital did this in MHECN’s Winter 2014 newsletter »
There is often conflation between the functions of ethics committees and the goals of ethics committees. Proposed goals of ethics committees include:
- Offering an alternative to the legal system for resolving conflicts about what the right course of action is in providing care for a particular patient. While landmark legal cases such as Elizabeth Bouvia, Karen Quinlan, and Nancy Cruzan have informed bioethics, once a standard is established (e.g., regarding when it is acceptable to withhold or withdraw life-sustaining interventions), ethics committees can help ensure that disputes are handled fairly, without having to resort to courts. In these cases, it is important to distinguish between the practice of law and the practice of ethics case consultation.
- Leveling power hierarchies within health care institutions to ensure that all voices are heard when dealing with ethical issues or conflicts, as depicted in David Rothman’s classic book Strangers at the Bedside. Read Robert Baker's review of how this book impacted bioethics.
- Providing ethics expertise. While the nature of medicine has been described as a “moral enterprise” and requires a basic understanding of professional and applied ethics, the scope of expertise required to address the range of ethical issues that arise when delivering 21st century health care across the lifespan has outpaced what most health care providers master in their primary discipline’s education and training. Ethics committees are one place within an institution where others can access ethics expertise, which is generally categorized as skill-based (e.g., facilitating communication, mediating conflict, ensuring that all relevant voices are heard, clarifying values, identifying ethical issues, accessing relevant ethics literature) and knowledge-based (e.g., explaining the difference between mental competence and decision-making capacity, or the distinction between persuading a patient or family member to consider a beneficial course of action and coercing). Foundation publications outlining the scope of expertise that ethics committee members should have, published by the American Society for Bioethics and Humanities, include the Core Competencies for Healthcare Ethics Consultation and Improving Competencies in Clinical Ethics Consultation: An Education Guide. A summary of the second edition of the Core Competencies is published in the American Journal of Bioethics (Tarzian & the ASBH Core Competencies Update Task Force, 2013, 13(2), 3-13).
- Raising the level of administrators’ and staff members’ ethics proficiency throughout the institution. This goal is an extension of the goal above. While ethics committees can house ethics experts who are available to weigh in when needed to address questions or concerns, they can also take a more proactive approach to integrate ethics competency and comportment throughout an institution. This is partly achieved by the ethics committee’s education initiatives (e.g., sponsoring conferences, giving grand rounds talks, educating new staff about ethics, advertising the ethics committee’s services, offering journal club or book/film club discussions). But it can also take the form of other services, such as “ethics advisement” or “coaching,” debriefing on difficult cases, doing ethics rounds, and implementing ethics quality improvement initiatives. The National Center for Ethics in Health Care provides several resources to support this Integrated Ethics approach, A Brief Business Case for Ethics, which provides justification to health care administrators for funding an ethics program.
- Protecting “moral spaces” in fast-paces health care delivery settings. In Margaret Urban Walker’s landmark article, “Keeping Moral Spaces Open,” published in the Hastings Center Report in 1993, ethics consultation and ethics committee work is conceived as an opportunity to protect a “moral space” around complex or troubling situations. It can be conceived as way to call a “time out” to sort through complex facts and emotions in an otherwise fast-paced health care delivery system. This is thought to mitigate build-up of moral residue or moral distress that so commonly plagues health care providers in settings where ethics is not integrated throughout the organization and thus not viewed as a priority.
- Raising the quality of patient care delivery. This is the ultimate goal of ethics committee work. When health care providers are more knowledgeable about ethics and feel supported in the work they do, this should raise the quality of care provided to patients and families.