The Ethics Committee Consortium: Working Together to Make Better Ethics
Believe it or not, even though clinical ethics has been around as a formal discipline for well over 20 years and many ethical issues are more or less settled both ethically and legally, there are still areas of ethical consternation. Most hospital ethics is the pervue of a committee (usually called the hospital ethics committee) now specifically required for hospital federal certification. I have described the history, composition and function of the hospital ethics committee in my posting of December 17,2004. Each committee in each hospital in the U.S. creates its own policies or guidelines, in their own terms, to deal with numerous situations which may arise from "do not resusitate" to organ donation to withdrawal of life support. If any of these issues ever went to court because of a conflict which could not be resolved within the hospital, each policy and guideline would be specifically scrutinized by the court and then perhaps compared with those from other hospitals. This potential for court scrutiny and the possiblity that some legal error might be found to the detriment of the hospital's case has become of more concern when yet controversial issues persist such as the definition of futility.
To mitigate against this possibility is one of the motivating forces that has led to the development of ethics consortiums in which a number of hospital ethics committees within a geographic area have come together to meet and present to each other their issues and the actions taken. Besides disseminating experiences, these consortiums are able to work together to try to form a consensus regarding policies and guidelines for these still controversial issues. If this is sucessfully completed and utilized by all the hospitals participating, such consensus documents would be expected to represent a standard of acceptable ethical decision-making if a conflict is taken to court.
As an example of such an active consortium, I am participating as representative of my local hospital in the Southern California Bioethics Committee Consortium where over 50 hospitals in the Southern California area are members. Each representative reflects their committee members who comprise mixed professional disciplines and include community (not hospital affiliated) members. The current issue is who should be the surrogate decision maker for incompetent patients who have no family, friends or anyone else who knows the patient and could be a surrogate. Hopefully, if we all can come to a consensus our final guidelines on this topic will bear more legal clout and ethical comfort than a document written by each hospital alone. ..Maurice.
posted by Maurice Bernstein, M.D. @ 8:08:00 PM
2 comments
2 Comments:
In California, the only individual who can provide "substituted judgment"--that is, speak for the patient as if the incompetent patient was actually at the time voicing a decision, is the individual who the patient had designated as the legal Durable Power of Attorney for Health Care. The opinion of others including family members, friends and various healthcare providers who knew and spoke to the patient in the past can contribute valuable information to the attending physician and ethics committee if no Attorney for Heath Care had been designated. This information regarding their understanding of the goals and wishes of the patient will help to establish what decision would be in the "best interest" of the patient. The final decision would be made by the physician with the support, if necessary, of the ethics committee.
The hospital's dilemma is when there is no legal surrogate to make "substituted judgment" and there are no family or friends available to contribute to "best interest" judgments and the decision is left solely to a physican who may not have known the patient previously.
By the way, in California, we have a law that permits a competent patient at the time of an illness to assign a surrogate to hear the facts of the patient's illness and treatment options and make informed consent decisions for the patient depite the patient taking no part in the decision-making process. What this means is that if the awake and alert patient doesn't want to hear the "bad news" or make a medical decision the patient doesn't have to and the assigned surrogate substitutes. By the way, this assignment is only for the immediate period of an illness and according to the law, the decisions of this surrogate will trump those of the patient's Durable Power of Attorney for Health Care surrogate if a different person. Interesting, huh? ..Maurice.
Another ethics committee consortium which has a far longer history than ours in Southern California and also national recognition is the Kansas City Area Ethics Committee Consortium and the associated Center for Practical Bioethics. You can learn more about these organizations and their activities in clinical ethics by going to the above links. ..Maurice.
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