Should the role of a hospital ethics committee be that of a patient's advocate?
Hospital ethics committees, generally have been a function of hospital organization in the United States for perhaps a bit less than a generation and yet after all these years there has not been any final decisions by any organized body regarding uniform composition, ethics education or common roles and practices of these committees. One issue which may be debated even among ethicists is what position hospital ethics committees should take with regard to their relationship to the hospital patient or the patient's families particularly in the midst of an ethical dilemma or conflict. For whom should the hospital ethics committee serve? Should it be the source for ethics and legal education and a resource for mediation for all the stakeholders involved in an issue (physicians, nurses, hospital administration, patient and patient's family as examples) or should the committee be in the end, after "all is said and done", simply an advocate for the patient? If this is the goal of the ethics committee then that would suggest that the ethics committee would be the decision making body for ethical conflicts in order to preserve that goal. But that would mean that the ethics committee would be making a judgment as to what decision would be in the best interest of the patient perhaps ignoring the ethical interest of the other stakeholders rather than mediate and facilitate a decision to be finally made by all the parties involved.
Since there is no firm answer to my question by those involved, it is right to ask the public what they think is the best role and why. So, should the role of a hospital ethics committee be that of a patient's advocate? ..Maurice.
Since there is no firm answer to my question by those involved, it is right to ask the public what they think is the best role and why. So, should the role of a hospital ethics committee be that of a patient's advocate? ..Maurice.
p.s.- For more discussion about other issues regarding the function of hospital ethics committees, click here to go to the thread "Ethicists and Ethics Committees: As Police, Judges or What?"
posted by Maurice Bernstein, M.D. @ 5:40:00 PM
10 comments
10 Comments:
Sometimes the ethical thing to do is not what the patient or the family wants.
My personal belief is that the ethics committee should be free to focus entirely on matters of ethics, and I question whether they can do this if their hands are tied by having to take an advocacy position.
But I think whenever there is an issue involving patient care, be it an ethical question or a medical error that causes harm, someone should be assigned to advocate specifically for the patient and family. Preferably someone not associated with the hospital.
I've been on the receiving end of a medical injury that also involved some ethical issues about how the situation was handled, and the clinicians involved basically trampled all over me. If you've ever spent some time listening to the stories of medical injury, you would quickly become aware that this is extremely common.
Patients and families do need a skilled advocate who can speak for them and make sure their perspective is heard. But at some point, an ethics committee or peer review panel needs to be able to focus on the facts and on the bigger picture.
- AM
I have followed the development of clinical ethics in the US since the "God committees of the 1960s. At that time I was working as an intern and resident at King's County Hospital in New York.
From this rather unsual beginning I followed things through the Karen Quinlan era where an ethics committee was tasked with deciding whether life support should be withdrawn or not.
Then came the President's commission on ethical problems (1983) which led to a proliferation of clinical ethics committees in the US. Within 5 years I understand that 60% of hospitals had a cliniical ethics committee
You pose the question should clinical ethics committees be patient advocates? I will attempt to answer this from the perspective of working in New Zealand ( The first country in the world to have a public health system-1938). In New Zealand we also spend in real terms about 1/3rd of the funding that is currently the case in the US. Surprisingly our health outcomes in many areas are actually as good of better than the US.
It is my impression that in the US individualism; perhaps aided by the fact that clinical ethics committees support the concept of automomy, and minimise or ignore the complementary concept of collectivism, that there is en emphasis on providing all the treatment options that individuals want. This is an unsustainable situation for the US.
Unfortunately in the recent healthcare debate in the US it is interesting to see this concept of a collective approach being dismissed as "socialism"
In New Zealand the concept of clinical ethics committees is quite recent to the extent that only a few hospitals have them. Is this a disadvantege? Probably not.
With time for reflection I think we can look at the sustainability of our comparatively poorly funded health system and use the platform of clinical ethics to address quaestions as to the possible limitation of services which are too expensive or lacking in evidence of effectiveness to be available in our public health system.
People might still be able to access the care through our small privately funded health services.
The flip side of this lack of collectivism is that even though the number of uninsured people in the US has decreased from 45 million to about 16 million, it si salutory to remind those in the US that in New Zealand everyone has access to properly funded healthcare.
I hope people wil take my observations as being constructive. I have fond memories of my 5 years living in the US. Good wishes to all your readers
allyboy, thanks for your comments and reporting regarding practices in New Zealand. My own experience with two hospital ethics committees here in Southern California is that we have given attention to the issue of scarce resources and have included this in the education of the physicians who request our consultation. Some physicians though will side with patients and families who want "everything done" even if the actions become "waiting for a miracle". ..Maurice.
I believe the ethics committee members who conduct ethics consultations should provide information, advice and counsel to doctors, nurses, other healthcare personnel, the patient, and the patient's family and friends. The ethics committee members do not set out to advocate for the patient, but they do protect the patient by insisting upon respect for the patient's rights and wishes and by ensuring ethical treatment of the patient.
Some hospitals have "patient advocates" whose role is to argue on behalf of what a patient wants or needs, whether that is a certain kind of care or coverage of treatment by Medicare or another insurer. If ethicists are doing their job properly, a patient advocate should not be necessary in the ethics consultation situation, since a vital component of that consultation is a review of the patient's own written directives or expressed wishes. In some cases, a patient's family members may want doctors to provide certain treatment that the patient (now unconscious or lacking mental capacity) previously expressed a clear wish to refuse. In that case, the ethics committee members would serve as patient advocates, since it is of primary importance that the patient, and not others (no matter how well-intentioned they may be) have control over the patient's own medical care.
I fully agree with Maura. In fact, the ethics committee being an advocate for an ethical decision in terms of the patient, believe it or not, the ethics committee should also be the advocate that ethical principles and ethical consensus and laws be followed for all stakeholders. That is why the ethics consultative committee's function of educating the stakeholders in the pertinent ethics and law is so very important. ..Maurice.
A thorny issue at best. The hospital ethics committees are often front end loaded by the hospital cooperation, some have independent legal council some have in house council. The function of the ethics committee in educating the healthcare team and patient about the pertinent ethics and law is vital yet easily influenced. As quality scores become the link to increased reimbursement perhaps the patient's religious, philosophical and political beliefs will once again be back in the physcians purview and an individual ethic will become clear. J. Meyer
J.Meyer, as chairperson of a local community hospital ethics committee, I have found no institutional influence on our education of the stakeholders except as a Catholic hospital we relate the established religious directives, if necessary. ..Maurice.
It is fundamental that Clinical ethics committees are independent of influences outside the deliberations of such a group.
If administrators and other health professionals etc can have any influence on what is or is not referred to the committee then the credibility of the committee is compromised. In our own situation in New Zealand, a clinical governacne group prvoides the necessities for the committee to function. Our obligation to them is to provide feedback to document our success ( or lack of it) and to provide this group with a twice yearly report which documents the cases discussed, any participation in hospital policies and any educational endeavours that have taken place.
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True ethics committees cannot be employees of a hospital. When it comes down to it money is the only thing that matters, so hospitals are not going to pay people to tell the truth and expose their unethical practices.
Ethics committees must be government officials that have nothing to lose if they expose a hospital's unethical methods or decisions.
I would quit as chairman of my hospital ethics committee if the hospital administration or other members of the committee tried to bias our work to simply that of the benefit of the hospital. We are not payed for our job as ethics committee member and the only influence I have had from my hospital is the need to incorporate the Catholic religious directives. Most patients if not aware of them and made aware during the hospitalization.
I worry about "government officials" since they can set their own view of the hospital based not on money but on politics. ..Maurice.
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