Clinical Ethics Committees Research Paper

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Abstract

Clinical ethics committees (CECs) are multidisciplinary and independent groups, including health professionals and lay members that aim to provide support for decision-making on ethical issues arising from several aspects of patient care. Their primary functions are ethics education, policy development and review, and case consultation. More recently, some CECs, particularly those affiliated with academic institutions and large healthcare systems, have expanded their traditional functions to become more comprehensive ethics programs, addressing both clinical and organizational ethics issues.

Introduction

The modern practice of medicine raises several complex issues, coming from different areas involved in the care, such as medical, ethical, and legal. Healthcare professionals, in daily practice, increasingly must face these issues and try to resolve them. Sometimes, physicians, nurses, and other professionals may have also to do so in a context where the contrary opinion expressed by patients and/or their relatives arises. While clearly qualified in the medical ground, and although there is now more ethics teaching in the medical curriculum, healthcare professionals are rarely qualified to recognize and resolve ethical or legal matters. Yet, clinical practice requires that a solution is found when this kind of questions displays, and the patients and their families take for granted that decisions about patient care, resources, and therapeutic choices should be taken on the base of the best interest of the patient and on appropriate ethical, legal, as well as scientific principles.

The acknowledgment of these needs leads, over time, to the emergence of ethics consultation and then the establishment of clinical ethics committees to address ethical issues in clinical settings. Ethics committees are usually standing committees with multidisciplinary representation – including medicine, nursing, social work, law, pastoral care, healthcare administration, and various specialty areas – whose primary functions are ethics education, policy formation and review, and ethics consultation (Aulisio 2004).

Historical Notes

In the second half of the twentieth century, clinical practice underwent a quick and drastic evolution. Organ transplantation, new life-prolonging technologies, genetics, assisted reproductive technologies, and other medical advancements gave rise to new ethical dilemmas.

In 1978, in the USA, the Congress established the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (President’s Commission). The three key tasks of the commission were (1) an ethical analysis of particularly problematic clinical cases, (2) the drawing up of recommendations and guidelines to address recurrent ethical problems, and (3) the promotion or direct management of training programs to increase ethical awareness among healthcare workers. The final report of the President’s Commission was published in 1983.

Though the President’s Commission and the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (established in 1974 in response to the disclosure of unethical experiments) were established to address different areas of concern, there are similarities in their results.

The President’s Commission did not recommend the immediate establishment of an ethics committee in every hospital, but it supported the formation of interdisciplinary committees to help health professionals in controversial decisions, to promote ethical education, and to contribute to the drafting and adoption of guidelines and institutional policies.

Many other institutions (e.g., American Hospital Association, American Medical Association) recommended the establishment of clinical ethics committees. The proposals from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) are particularly worthy of attention.

In this way, the characteristics and functions of so-called healthcare ethics committees – or more frequently called clinical ethics committees (CECs) – were more precisely defined, and their presence has increased in hospital settings but also in many other healthcare settings, such as hospice, nursing homes, and long-term care.

This type of ethics committee has been distinguished from the Research Ethics Committee (dedicated only to clinical trials), and this distinction was clarified in many countries, for instance, the “Comités Asistencial de Ética” in Spain, the “institutional ethics committees” in the Netherlands, or the “clinical ethics committees” in the UK (Byk and Mémeteau 1996).

In the UK, committees had largely worked alone until a meeting of committee representatives in January 2001 led to the development of the UK Clinical Ethics Network (Slowther et al. 2004).

But there are countries such as Italy, Portugal, and others where the problem of distinguishing between clinical ethics committees and Research Ethics Committees is still up for debate not clearly resolved. The development of CECs in Latin America is discussed and elaborated by Pessini (Pessini et al. 2010).

Functions

The traditional missions of clinical ethics committees have not changed substantially since the proposal formulated by the US President’s Commission.

There is agreement, even if there is a discussion about the priority, and there is the development of new functions (e.g., allocation of resources and organizational ethics). Regarding the primary functions, there are ethics education, policy development and review, and case consultation, in decreasing order of time commitment (McGee et al. 2001).

Education

There are efforts for ethics education of the committee itself and education of the clinical staff and all hospital employees. Relevant are also “special” education/open discussion on bioethical issues for the population, as a kind of “bridge” between healthcare institutions and society.

Ethical Guidelines, Policy Development, And Organizational Ethics

The CEC may propose and draft ethical guidelines and policies regarding widespread and frequent problems, finding approaches to prevent or quickly resolve these situations. Or the committee may review and comment on guidelines and policies written by other hospital committees.

The CEC needs to focus also on organizational ethics, a field that is attracting increasing attention. Typical ethical issues in healthcare organization are allocation of resources, professional integrity, employees’ rights and responsibilities, business and service plans, and relationship between the institutions in the social context. For example, ethics committee members must educate themselves also in the demands in this field.

Case Consultation

It may be a “Retrospective Case Review,” concerning already decided clinical cases in order to evaluate patterns of ethical decision-making at an institution, i.e., a type of bridge between education and case consultation. The consultation could be a “Prospective Case Review,” concerning an ongoing clinical problem, in order to offer an advice for making the proper decision.

There is broad agreement about these functions, even if there is an open discussion about the priority and about the activity of case consultation. In fact, clinical ethics consultation is more and more frequently provided by individual consultants or small consultative team (part or not of the whole CEC). There is a trend to accept the individual for handling urgent cases at the bedside; the CEC could do a review of the individual consultant’s activities, as well as be involved in complex cases. When the same cases appear over again, the CEC could design a strategy for handling these cases and draft guidelines or policies for the problems.

The functions of CEC would best be focused on education and guidelines and policy development, in cooperation with specific structures of clinical case and ethics consultation (ASBH 2011).

What is the function of CEC and what is not its function is sometimes hard to distinguish or separate. For example, the legal protection of the hospital and the hospital’s professional staff is not a responsibility of the CEC. Added to these non-responsibilities or mistaken responsibilities are the function of a professional review board, the legal protection of hospital and healthcare professionals, and the management of economic and human resources. The CEC cannot be responsible for every issue faced by a modern hospital. Another example of ethical issues that do not fall under the CEC responsibility is the broader surrounding social and economic conditions and circumstances even when these issues may have to take into consideration when deciding a clinical ethics case or problem.

Organization And Administration Of CEC

Membership In The CEC

CEC is multidisciplinary and independent. So the number of members can vary and some members should not be on the staff of the institution.

A CEC should be composed of representatives from various professions and perspectives, usually from the following groups: medical staff, nursing staff, administration, community, patient associations, social services, clergy, clinical ethicist, and lawyer.

The members of CEC represent different points of view: professional and cultural. The different members of the CEC do not advocate for their different professions, but they offer different professional perspectives and individual perspectives. The different members guarantee dialogue and intercommunication between medical and social-cultural perspectives.

Leadership

In healthcare institutions, a physician chairperson tends to have more credibility with colleagues than other members (e.g., philosophers, jurists, etc.). It is important to have attitudes of dialogue, coordination, and management of discussions avoiding the risk of imposing an authoritarian approach or to have a consensus only based on group dynamics instead of the best argument (Lo 1987).

Location

Although the choice of a location may not be of crucial importance, the organizational context may play a significant role. A committee from an administrative perspective may be perceived as a bureaucratic encumbrance. A committee in the head office (director, president) may be perceived as an imposition. The best place for a clinical ethics committee to be located may vary according to the circumstances and may change in any institution.

Access To The Consultation

Earlier, there was a discussion about whether to restrict access only to clinical staff or to open access for patient and family. Now it is everywhere common to permit both to have access trying to handle the issues to avoid to become a kind of court or disciplinary commission for malpractice.

Mandatory Or Optional Consult

In principle, it is more common that consultations and recommendations are optional for clinical cases. In particular circumstances (e.g., very sophisticated and expensive technologies for specific patients, off-label treatments), mandatory review by CES is more frequent.

Bylaws

Bylaws should address terms of membership, scope of the three functions (education, policy review, consultation), length of service, frequency of meetings, kind of outcomes expected, etc.

In most cases, clinical committees are advisory and do not make decisions on physicians’ behalf. Bylaws should cover the advisory role and define the procedures for this. In a small subset of cases, committees are given explicit decisional authority. These cases should be spelled out carefully in the bylaws.

Record Keeping

It is appropriate to have a note in the patient’s chart of the consultation for a clinical case including recommendations and supportive reasons. This note and all other documents, guidelines and policies, and reviews by the CEC are appropriate to keep in the register of CEC. This could be also for less formal consults for single cases or reviews so that documentation remains in the CEC records without written recommendation provided to the applicant. All is done always with respect for confidentiality.

Evaluation

Following an initial phase of the establishment and activation of the CECs, taking into account the different types of health care, as well as the sociocultural-legal contexts, it is important to define criteria for assessing the work of the CECs.

Therefore, this would involve the identification of the items to be evaluated and how this assessment would be carried out: how to access the CEC, response times, the impact of the recommendations on clinical cases, and the application of ethical guidelines (Povar 1991).

Guidelines For CECs

UK Clinical Ethics Network

In 2004, guidance on the structure, composition, and function for established and developing CECs was published by the Ethox Centre of the University of Oxford, jointly with the UK Clinical Ethics Network (Slowther et al. 2004).

In 2010, the UK Clinical Ethics Network published the document “Core competencies for clinical ethics committees” (Larcher et al. 2010). The document lists a series of characteristics required for clinical ethics committees (summarized in Gillon 2010). The main recommendations from the UK Clinical Ethics Network are listed in the following ways:

Skills Required Of Clinical Ethics Committees (CECs)

1. Ethical assessment skills comprise the ability to:

• Identify and discuss the nature of the moral conflict and the need for consultation
• Elicit and understand the moral beliefs and values of all parties:

– Analyze moral uncertainty and conflict

– Explain the ethical dimension of a case to those involved and to others

– Formulate and justify morally acceptable solutions

2. Operational and procedural skills

• Facilitation, of both case consultation discussions and CEC meetings
• Mediation and negotiation of conflict resolution in situations of emotional distress

3. Interpersonal skills

• Communication skills, e.g., active listening, clarity, and nonverbal communication
• Advocacy skills to enable articulation of the views of those who find it difficult to express themselves
• Non-judgmentalism and awareness of power imbalances

Knowledge Required Of Clinical Ethics Committees (CECs)

1. Basic concepts of ethical theory and principle and the application and practice of moral reasoning (advanced knowledge of ethical theory and moral reasoning required by at least one committee member and the lead member of any case consultation group)
2. Knowledge of the position of the CEC in the hospital framework and links to clinical and legal governance
3. Relevant knowledge of clinical terms and disease processes
4. Cultural context of patient and staff population and of local community
5. Relevant professional codes of ethics, e.g., General Medical Council and General Nursing Council
6. Relevant healthcare and statute law, including the UK human rights legislation
7. Local/national government policy, e.g., national guidelines on funding of treatments

Personal Characteristics And Values Important For Ethics Consultations

• Tolerance, patience, and compassion
• Honesty, fair-mindedness, self-knowledge, and reflection
• Courage
• Prudence and humility
• Integrity

The possession of these values enables:

• Disparate views to be held in difficult situations
• Recognition of personal limitations and development of relationships based on trust and respect
• Recognition of power imbalances between individuals and how to address them
• Voices of the weak and vulnerable to be heard and dissenting views to be put to those in authority, involving the skill of advocacy
• Individuals not to go beyond their level of competency and/or to acknowledge conflicts between personal moral views and their role in consultation
• Pursuit of ethically relevant options when it might be convenient to do otherwise
• Sensitivity to changing circumstances that have ethical impact

UNESCO

Since 2005, UNESCO has been publishing three different “Guides” devoted respectively to the establishment of bioethics committees, to procedures and policies for their work, and to the education of committee members. These are important documents, in an international perspective, to offer some standard basic criteria in the different sociocultural contexts.

UNESCO’s Guide N 1: Establishing Bioethics Committees

The “Guide n 1: Establishing Bioethics Committees” (UNESCO 2005a) provides suggestions for the setting up of bioethics committees. The document is based on a review of the experiences of many member states that have already established bioethics committees at the national, regional, or local levels. The Guide distinguishes several forms of bioethics committees pursuing different goals. Four types of bioethics committees are thus identified:

1. Policy-making and/or advisory committees (PMAs), operative at the national or regional level
2. Health professional association (HPA) committees, operative at the national, regional, and sometimes at the local level
3. Healthcare/hospital ethics committees (HECs), operative at the local level
4. Research ethics committees (RECs), operative at the regional, local, and sometimes at the national level

For each kind of committee, the Guide of UNESCO discusses and indicates the functions, the ideal size, the appointment of chairpersons and members, the funding, and other aspects. The Guide indicates procedures and operations for the setup of ethics committees and describes instruments for their self-evaluation and external evaluation.

UNESCO’s Guide N 2: Bioethics Committees At Work

The “Guide n 2: Bioethics Committees at work” (UNESCO 2005b) suggests procedures and policies for the organization of committees, the appointing of chairpersons and members, the carrying out of meetings and following agendas, the recording of minutes, and so on. Some procedures are more specific and targeted for the different kind of committees (those mentioned in Guide n 1).

As regards healthcare ethics committees, procedures and policies are proposed for:

– Accessing the committee

– The bioethical review of patients’ cases

– Committee consultations on patients’ cases

UNESCO’s Guide N 3: Educating Bioethics Committees

The “Guide n 3: Educating Bioethics Committees” (UNESCO 2007) offers guidance for continual and self-training of chairpersons and members of bioethics committees. It suggests several procedures for continual education: the collection of basic educational resources, the discussion of relevant material, the invitation of experts and speakers, the organization of intensive educational sessions, and so on.

The Guide mentions topics and general principles that “all bioethics members need to know,” stated in the UNESCO’s Universal Declaration on Bioethics and Human Rights and in other documents: human dignity and human rights, benefit and harm, autonomy and individual responsibility, consent, respect for human vulnerability and personal integrity, privacy and confidentiality, equality, justice, equity, nondiscrimination, and so on.

According to Guide n 3, there are important topics that bioethics committee members must acknowledge, in particular, those regarding controversial bioethical issues: human procreation; modification of human organs, tissues, and cells; use and misuse of biotechnologies; genetic enhancement; and others.

“Core Competencies For Healthcare Ethics Consultation” Report

The report “Core Competencies for Healthcare Ethics Consultation” published by the American Society for Bioethics and Humanities in 2011 (ASBH 2011) updates an earlier edition of 1998 (by the Society for Health and Human Values and the Society for Bioethics Consultation Task Force on Standards for Bioethics) and states the procedures of the ethics consultation for clinical cases made by CECs.

Problems And Pitfalls Of The Clinical Ethics Committees

The experience of the CECs has become extensive and numerous in different parts of the world, as well as in the literature. The positive aspects of these committees are emerging, but there are also difficulties, risks, and problems. To bring attention to these problems and risks could be useful to a growing presence of CECs, along with the quality of their duties, within the various contexts of healthcare institutions, according to the development of clinical ethics as a whole.

They can be highlighted as follows (Drane 1994; Wilson Ross 1986):

– Lack of clarity in purpose of the committee. There is the risk inside the committee, at level of hospital management and healthcare professionals, to not know the specific functions of CECs, with a misunderstanding about their purposes. Therefore, it is important to clarify that CECs have not a legal function and do not act as a decision-maker but as a counselor and it is not a complaints department.

– Importance of accepting the evolution of the different functions and, therefore, the relationship between education, discussion, and writing guidelines, as well as, consultation on the cases.

– Insufficient member education. Committees should provide adequate education for new members, making sure that everyone understands basic information about the committee’s purpose, goals, prior activities, functions, membership expectations, and general nature of ethics in clinical care. A “buddy system” pairing a new member with an experienced member may be a suitable way for helping new members to develop competency and to integrate them into the committee.

– Enthusiasm and frustration. Establishing realistic goals is vital for the committee and should be of special concern to the committee chair, to avoid that abundance of enthusiasm collides with shortage of time and many of the committee’s enthusiastic plans simply burn out.

– Hierarchy and domination. Hierarchy problems can manifest in the following ways: if only the physicians express disagreement, if the nurses do not offer opinions on anything of importance or if their opinions are never solicited, and if the lay members or nonhospital community members never speak or if when they speak they are listened to politely but effectively ignored.

– Inadequate resources. If the hospital believes that the committee should exist, then it has an obligation to provide enough resources (both financial and labor) to meet expectations.

– Committee overlap. Committee members need to be sensitive to the potential overlap between clinical ethics committees and other hospital and medical staff committees that also deal with ethical issues in clinical care. The clinical ethics committee should be aware of the fact that, despite its name, it is not the only entity in the hospital responsible for and capable of dealing with ethical issues. The ethics committee should complement these groups, not substitute for them or interfere with their work.

– Underutilization. Some medical staff members may be resistant to CEC because they fear an intrusion into the doctor-patient relationship or because they underestimate its role.

Conclusion

The issue of theoretical pluralism and multidisciplinarity and then the possibility and the usefulness of CECs must be seriously considered in this context.

Some people think that ethics is strictly a private matter, but in this case, we are dealing with clinical “public” decisions that must be well founded and justifiable. And ethical pluralism does not prevent agreement on individual cases or on the guidelines to be developed. In this same way, multidisciplinary settings are not always easy to handle, but they do allow a richer and more complete view of cases and problems. For some, the CEC is impossible (because of pluralism and multidisciplinarity); for others, it is unnecessary because ethics has already been theoretically defined. For many, experience has shown that with education, training, and good leadership, the work of the CEC is both possible and useful.

A CEC can be important in the clinical setting, but also in a cultural perspective as a bridge with society, careful to economic, environmental, sociocultural aspects needing an always more open, dialogic, critic, and inspiring bioethics.

Bibliography :

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