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Clinical Ethics Consultation and Ethics Integration in an Urban Public Hospital

Abstract

Clinical ethics committees, with their typical threefold function of education, policy formation, and consultation, are present in nearly all U.S. hospitals today, and they are increasingly common in other healthcare settings such as long-term care and even home care. Ethics committees are at least as prevalent in Canadian hospitals as they are in U.S. hospitals, and their presence is growing in Europe, much of Asia, and Central and South America. Although ethics committees serve a variety of needs, their ultimate goal ought to be to promote ethical practices or, in other words, to engender the integration of ethics into the life of the medical center. Of the three primary functions of ethics committees, ethics consultation has historically been the most controversial and problematic, and consult services in many healthcare institutions have struggled to thrive.

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1. The growth of ethics committees in U.S. hospitals was relatively rapid, from under 1% in 1983 (see Youngner SJ, Jackson DL, Coulton C, Juknialis B, Smith EM. A national survey of hospital ethics committees. Critical Care Medicine 1983;11(11):902–5) to over 93% by 1999 (see McGee G, Caplan AL, Spanogle JP, Asch DA. A national study of ethics committees. The American Journal of Bioethics 2001;1(4):60–4). Another recent study found ethics consultation services in 81% of all U.S. general hospitals and in 100% of U.S. hospitals with more than 400 beds (Fox E, Meyers S, Pearlman R. Ethics consultation in US hospitals: A national survey. American Journal of Bioethics 2007;7(2):13–25). There are a variety of causal factors that led to this growth, chief among them the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirement that hospitals have a mechanism for addressing ethical issues (JCAHO requirements available from http://www.jcrinc.com/26813/newsletters/28192/#RI> (last accessed 13 Jun 2008).

2. Lebeer G. Clinical ethics support services in Europe. Medical Ethics & Bioethics 2005;11(Suppl.):8–11; Akabayashi A, Slingsby BT, Nagao N, Kai I, Sato H. An eight-year follow-up national study of medical school and general hospital ethics committees in Japan. BMC Medical Ethics 2007;8:8.

3. This has been well documented in the literature. See, for example, Singer PA, Pellegrino ED, Siegler M. Ethics committees and consultants. Journal of Clinical Ethics 1990;1(4):263–7; Kuczewski MG. When your healthcare ethics committee “fails to thrive.” Healthcare Ethics Committee Forum 1999;11(3):197–207. Indeed, recently, an entire special issue of HEC Forum (2006; 18(4)) was devoted to the problem of HECs and “failure to thrive.”

4. Mission statements at MetroHealth, like many other organizations, have evolved over the years. Despite this, the commitment to serve irrespective of ability to pay has remained. The most recent iteration of its mission includes the statement, “We respect the dignity of those in our care, serving them with compassion and high quality, regardless of their ability to pay.” The full of MHS Mission Statement can be found at http://www.metrohealth.org/body.cfm?id=1177 (last accessed 1 Oct 2008).

5. See http://www.metrohealth.org for detailed information on the MetroHealth System and its flagship medical center.

6. The American Hospital Association's “The 2007 State of America's Hospitals: Taking the Pulse,” available from http://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2007.html, gives a national average nursing vacancy rate of 8.1%.

7. For a detailed discussion of how these features create the need for ethics consultation in healthcare today see Aulisio, MP. Meeting the need: Ethics consultation in health care today. In: Aulisio MP, Arnold RM, Youngner SJ, eds. Ethics Consultation: From Theory to Practice. Baltimore, MD: Johns Hopkins University Press; 2003:1–22.

8. The data collected by Fox et al. (see note 1, 2007) when extrapolated and divided by the total number of American Hospital Association general hospitals yield a rough average of about seven consults a year (36,000 consults divided by 5,072 hospitals). By this metric, Metro was average. If one takes into account (1) that the number of consults performed in federal hospitals and in Council of Teaching Hospitals exceeded by a factor of 4 or more the number performed elsewhere, even when corrected for bed size and (2) that Metro would have been in the largest category for bed size, then Metro's seven consults per year during this period was probably well below average.

9. See, for example, Ross JW. Case consultation: The committee or the clinical consultant? HEC Forum 1990;2(5):289–98, and, more recently, Rubin SB, Zoloth L. Clinical ethics and the road less taken: Mapping the future by tracking the past. Journal of Law, Medicine & Ethics 2004;32(2):218–25, 190.

10. See Aulisio MP, Arnold RM, Youngner SJ. Health care ethics consultation: Nature, goals, and competencies. Annals of Internal Medicine 2000;133(1):59–69; Rushton C, Youngner, SJ, Skeel J. Models for ethics consultation: Individual, team or committee. In: Aulisio MP, Arnold RM, Youngner SJ, eds. Ethics Consultation: From Theory to Practice. Baltimore, MD: Johns Hopkins University Press; 2003.

11. This is one example of what The SHHV-SBC Task Force on Standards for Bioethics Consultation (Core Competencies for Ethics Consultation: The Report of the American Society for Bioethics and Humanities. Glenview, IL: American Society for Bioethics and Humanities; 1998:5–6) characterized as an “authoritarian” approach to ethics consultation. Such an approach emphasizes the ethics consultant(s) as a substantive moral expert who supplants or displaces primary decisionmakers.

12. As ethics consultation emerged in hospitals in the 1980s, worries that ethics consultation was a form of policing and would intrude on the doctor–patient relationship were common. The provocatively titled editorial by M. Siegler and P.A. Singer “Clinical Ethics Consultation: Godsend or God Squad? (American Journal of Medicine 1988;85(6):759-760) addresses this concern. For an illuminating and detailed discussion of these concerns, see Rothman DJ. Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision Making. New York: Basic Books; 1991.

13. The small team model now appears to be the dominant model for ethics consultation (68%) in U.S. general hospitals, as opposed to full committee (23%) or individual (9%) consult models (see note 1, Fox et al. 2007).

14. Others, such as Walter Davis (Failure to thrive or refusal to adapt? Missing links in the evolution from ethics committee to ethics program. HEC Forum 2006;18(4):291–7), have identified flexibility as a key component of successful consult services, as a “one size fits all approach” does not comport with the array of cases that may be brought to ethics consultation.

15. We do not take on issues that are primarily organizational ethics issues, though ethical issues that arise in patient-care-related consults or policies that cover patient care can, of course, be relevant for organizational ethics discussions (and vice versa) as both the cases of “Mr. H” and “Mrs. V” discussed later suggest.

16. See note 11, The SHHV-SBC Task Force on Standards for Bioethics Consultation 1998:9–10.

17. Identifying whether an issue may be appropriate for ethics consultation can, of course, be rather difficult initially. At the outset, we err on the side of inclusion while screening out requests that are obviously inappropriate for ethics consultation (e.g., a purely legal question, a request for a second medical opinion, or complaint about poor service that might be more appropriate for an ombudsman).

18. It is important to underscore here that informal consults are not the same as so-called curbside consults that are discussed in the literature and that we do not include in our numbers.

19. See, for example, Schneiderman LJ, Gilmer T, Teetzel HD, Dugan DO, Blustein J, Cranford R, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized controlled trial. JAMA 2003;290(9):1166–72. Even among internists, end-of-life issues appear to be the single largest category of cases that lead to ethics consultation, as reported by DuVal G, Clarridge B, Gensler G, Danis M. A national survey of U.S. internists' experiences with ethical dilemmas and ethics consultation. Journal of General Internal Medicine 2004;19(3):251–8.

20. For a detailed discussion of some of the potential benefits of the “outsider” view of ethics consultation, see Aulisio MP, Chaitin E, Arnold RM. Ethics and palliative care consultation in the intensive care unit. Critical Care Clinics 2004;20(3):505–23.

21. See note 11. It should be noted that ethics consultation as moral policing and what it characterizes as an “authoritarian” approach to ethics consultation is flatly rejected by the SHHV-SBC Task Force on Standards for Bioethics Consultation see note 11, 1998:3–7.

22. Davies L, Hudson LD. Why don't physicians use ethics consultation? Journal of Clinical Ethics 1999;10:116–25; Orlowski JP, Hein S, Christensen JA, Meinke R, Sincich T. Why doctors use or do not use ethics consultation. Medical Ethics 2006;32:499–502. These authors suggest that this view remains relatively common among physicians.

23. See note 10, Aulisio et al. 2000. See note 11, SHHV-SBC Task Force on Standards for Bioethics Consultation 1998:3—7. See note 7, Aulisio 2003:1–22.

24. As indicated in note 22, this remains a concern among some clinicians. Interestingly, even though worries about ethics consultation as “moral policing” may have long ago been put to rest in the ethics consultation literature, vestiges of this view periodically resurface in the academic literature. For a nice recent discussion of the latter with respect to statements about the goals of ethics consultation, see Smith ML, Weise KL. The goals of ethics consultation: Rejecting the role of “ethics police.” American Journal of Bioethics 2007;7(2):42–4.

25. It is important to note that the subcommittee reported to the ethics committee, which itself is appointed by the Chief of Staff (COS), which appointments are approved by the Medical Executive Committee (MEC). As such, the ethics committee in all of its activities is accountable to the COS and the MEC. The guidelines developed for dealing with chronically nonadherent patients are purely voluntary and are used for educational purposes and in ethics consultations, in which they may be of assistance.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
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