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In recent years, ethics committees have become increasingly influential in resolving conflicts involving end-of-life decision making. When disagreements arise among physicians, patients and families in the clinical setting, ethics committees often can find creative ways to settle disputes without resort to the judicial system.

Ethics committees as they exist today evolved from professional committees that met in the past to draft policies related to abortion, organ transplantation and medical research. The Quinlan decision, by recommending the use of ethics committees rather than court intervention, helped to establish their legitimacy. More recently, in 1995, the Joint Commission on Accreditation of Health Care Organizations a (JCAHO) required health care facilities to "establish and implement a code of ethical behavior," a demand that served as further impetus for health care facilities to create ethics committees. More and more institutions are employing them to strong effect, and success rates often are high.

Some observers are concerned that a growing reliance on ethics committees may have the potential to undermine patients' ability to participate in end-of-life decisions. In this article Choices examines how one ethics committee operates and suggests issues to bear in mind if you become involved in a situation that goes before an ethics committee.

The Ethics Committee of Harbor Hospital Center

Shahid Aziz, MD, FACPE, who chairs ethics committee of Harbor Hospital Center in Baltimore says his committee's three main functions are to draft policy, to educate staff and to provide emergency consultation when requested by patients, families or staff. "Our ongoing work includes seminars and lectures for physicians and ethics rounds in the intensive care unit. We try to sensitize staff and keep them thinking about ethical issues on a regular basis. We also draft policies for the hospital about issues such as patients' rights and the withdrawal or withholding of treatment," explains Dr. Aziz. "Finally, we sometimes are called upon to provide a recommendation when a conflict arises or when a physician or family member is unsure of the legal or ethical issues involved in a decision."

Upon receiving a request for emergency consultation, Dr. Aziz must convene at least four members of the committee within four hours. The attending physician and the family are present at the meeting. "We begin by familiarizing ourselves with the case. We hear the physician describe the patient's clinical condition and we hear the family share their views of the situation . We then establish important facts such as who the legal decision maker is. This initial review of the case allows family members to express their concerns, and a solution often can be found. We choose not to have a hospital attorney present because we want to be sure that both the physician and the family feel free to discuss their view of the case openly. At times we ask the family and physician to leave so we can discuss the case privately before offering a recommendation. In the end, the decision must be made between the physician and the family, who may choose to accept or reject what we suggest."

Dr. Aziz believes that involving the family in the committee meetings is fundamental to the success of the Harbor Hospital committee in resolving conflicts. "We believe it is crucial to involve family members. Being open with the family and helping them understand the medical and ethical issues at hand is an important step toward settling disputes. Sometimes it helps to share difficult choices I have made, not just as physician working with patients, but as a family member caring for my own relatives at the end of life. It helps other families to know that I have faced similar choices with my own family."

The Harbor Hospital benefits from an ethics committee that makes family involvement a priority and a chairman dedicated to fulfilling that commitment. However, not all ethics committees are as successful as Harbor Hospital's at resolving disputes. Choice In Dying staff members receive calls from families who are having difficulty with ethics committees' processes.

Cautions

The stated purpose of ethics committees varies widely among facilities and often is the subject of debate. Most experts agree that the educational role of ethics committees is positive, but some question how deeply ethics committees should be involved in ongoing cases, even as negotiators. "Conflict resolution by ethics committees sounds benign enough on the surface, but it is not without its pitfalls," says Giles R. Scofield, professor of health law at Pace University Law School. "Although these committees theoretically are neutral, it is important to remember that they are created and maintained by the institution in which they serve. Committees generally are chaired by physicians and other established professionals within the facility; occasionally a hospital attorney also will participate. Although committees claim that their recommendations are nonbinding, they have an authority-in-fact that is undeniable. It can be very difficult for a family or even a physician bringing the case before the committee to act against a committee's recommendation."

Although non-judicial dispute resolution can be an efficient alternative to lengthy and costly legal proceedings, such efficiency may come at the expense of a fair and impartial proceeding. "Meetings might be secretive and held without recorded minutes. Family members might be excluded from discussions," Professor Scofield points out. "A poorly run committee threatens to become, quite literally, a form of secret law."

Whatever the nature of the ethics committee in your hospital, it helps to be prepared. "People who call Choice In Dying counseling line report both good and bad experiences with hospital ethics committees," says Anna Moretti, RN, JD, Director of Legal and Educational Programs at CID. "We try to help families who are planning to approach an ethics committee become familiar with the ethical and legal issues at hand. It can be daunting for some families to deal with a committee, but many report a positive experience. We hope that, as ethics committees educate physicians and other hospital staff about how to honor the right of patients and families to participate in decisions, the need for direct intervention of a committee in conflict resolution will lessen."