Institutional ethics committee and case consultation: is there a role?

• Author: Gramelspacher, Gregory P.

In the brave new world of modern American medicine, institutional ethics committees (IECs) have taken hold. The number of hospital ethics committees has grown dramatically over the past ten years. In 1981, Dr. Stuart Youngner surveyed 602 U.S. hospitals, and only 1% reported having an IEC, (1) whereas by 1990, the American Hospital Association (AHA) estimated that more than 60% of all U.S. hospitals had formed IECs. (2) In addition, in 1987, Maryland became the first state to enact legislation that requires all hospitals to establish patient advisory committees, (3) and in 1989 Senator Danforth (R., Missouri) introduced legislation to Congress entitled the "Patient Self-Determination Act," seeking to amend the Social Security Act to require all U.S. hospitals to establish IECs. (4)

The rise of IECs is linked to the growth of the bioethics movement, but three landmark events have spurred the proliferation of IECs. These three events are the New Jersey Supreme Court decision in the Karen Ann Quinlan case, the report of the President's Commission for the Study of Ethical Problems in Medicine, and the dispute over the federal Baby Doe regulations. (5)

The seed that led to the growth of contemporary IECs was planted in 1976 by the New Jersey Supreme Court in the Quinlan decision. In its opinion, the court held that Karen Quinlan's respirator could be disconnected as requested by her guardian if her physician consulted with a hospital ethics committee. The ethics committee, or "prognosis committee" as it was called, had to agree with the physician's prognosis in order for the respirator to be unplugged. (6) The court urged hospitals to develop prognosis committees to review patient cases and to provide assistance and safeguards for patients and their medical caregivers. (7) After Quinlan, other state courts disputed both the effectiveness and the legitimacy of ethics committees in resolving ethical dilemmas, and it was not until the early 1980s that the opinion of the New Jersey court began to have a national impact.

The second stimulus to promote IECs came in 1983 from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. In its most influential report, "Deciding to Forego Life-Sustaining Treatment," the President's Commission suggested that IECs may be able to assist with difficult ethical problems. (8) The commission proposed several tasks for IECs but specifically stated that ethics committees have the potential to become involved in particular patients' cases. (9) A large number of organizations representing hospitals, physicians, nurses, and patient advocacy groups quickly endorsed IECs to facilitate discussion of ethical issues.

At the same time, several controversial cases focused national attention on the limitation of treatment for newborns with disabilities and accelerated the momentum to form IECs. The Baby Doe cases in 1982 and 1983 signaled the turning point for the practical and widespread use of IECs, solidifying the institutionalization of ethics committees. As the result of the Baby Doe case in Bloomington, Indiana, the U.S. Department of Health and Human Services issued regulations to expand or clarify section 504 of the Rehabilitation Act of 1973. (10) The Baby Doe regulations required all hospitals to provide life-sustaining treatment for newborns with disabilities or risk losing their federal funding. (11)

As an alternative to the cumbersome and intrusive Baby Doe regulations, the American Academy of Pediatrics (AAP) and the American Hospital Association (AHA) suggested the establishment of infant care review committees in all hospitals caring for newborn babies. The AAP and the AHA recommended that the infant ethics committees review all decisions to forgo life-sustaining treatment for newborns with disabilities and ensure that decisions to limit treatment are ethically appropriate. (12)

Functions of Ethics Committees

As they have evolved over the past decade, ethics committees perform three major functions: education, policy-making, and case consultation. IECs typically begin with educational activities directed to committee members and the hospital community. After an initial period of education, committees often turn to the task of making or guiding hospital policy in ethical dilemmas such as orders not to resuscitate, brain death, confidentiality, and informed consent. Some clinicians and professional ethicists insist that education and policy-making should be the primary emphasis of the committee's work. (13) These experts agree that if these two activities are done well, there will be little need for consultation or prospective case review. (14)

Even though most ethics committees define their primary tasks as education and policy formation, case consultation receives the most attention and provokes the most controversy. Rather than debate whether ethics committees can carry out educational and policy-making activities, this article will concentrate on the most innovative and controversial function of IECs--that of case consultation.

Consultation by Committee

Case consultation refers to prospective case review in which a patient, family member, nurse, physician, or other member of the health care team brings a particular ethical dilemma to the IEC for deliberation. After discussion and debate of the ethical dilemmas presented by the case, the IEC advises participants how to resolve the dispute or conflict. Some optimists believe that ethics committees offer an attractive way out of the moral...