Wednesday, April 16, 2008

Ethics Committees: Where Have All the Consults Gone?

I have finally turned over my responsibilities as Chair of my hospital's Ethics Committee. It's about time. I've been Chair ever since the Committee was formed, and there needs to be turnover.

Reflecting on my chairmanship has me thinking about how ethics committees work, and what they do with their time. I'm also watching to see what others have to say about this. Two staff members of the Center for Practical Bioethics are planning to look into this, but they're just getting started.

It does appear that the functions of ethics committees have changed. They originally came to be for clinical consultation - to help clinical staff and families sort out conflicts over appropriate goals and means of care - but there's some evidence that the number of consultations has gone down. Some have begun to wonder why.

I don't have my own research on this, but I have noted a couple of things. First, there is the apparent ascendancy of the patient's autonomy over other principles of clinical ethics. I have written before of the "Georgetown Mantra," the principles that have most shaped clinical ethics in this generation: autonomy, non-maleficence, beneficence, and justice. In theory they should arguably be considered equally in any ethics discussion. In practice, however, autonomy has come to be not only first but also foremost. If clinical staff have some sense that they know what the patient would want, they tend not to think any further. Indeed, all too often they seem to believe there is nothing more to be thought about, as though the patient had a right to whatever the patient wanted regardless of the clinician's best professional judgment of what might harm or benefit the patient. The availability of Health Care Treatment Directives and of Durable Powers of Attorney for Healthcare, with their legal imprimatur, has contributed to this, of course. Whatever the reasons, autonomy has largely trumped other principles.

As a result, I think, when the patient's wishes seem clear, even if only in the minds of surrogates, almost no one questions them. They may, of course, agree with the patient's wishes. Even if they disagree, clinicians may think they can't question them, or that questioning them would be more trouble than it's worth. In either case, believing the matter settled, they don't think about consulting the ethics committee. Granted, there are probably still some clinicians who think consulting the ethics committee may be more trouble than it's worth. I suspect the belief that there's nothing more to talk about is a more pervasive problem.

A second issue is the growth of an "alternate provider." Many of the early questions brought to ethics committees were about care at the end of life: helping clinicians communicate hard news to families, or to build consensus with families about appropriate goals for treatment. My experience is that clinicians have a rather narrow perspective about where ethical issues might arise. They seem to see them in end of life issues when they don't see them anywhere else.
But more and more, palliative care committees are addressing those issues. Issues of communication, and even differences between clinicians and families, are addressed less as relational and ethical issues, and more as functional and procedural issues. This is, I think, comforting to clinicians. They fear having nothing to offer, nothing to do. A palliative care program, even if it's no more than an order set and a checklist, feels more controlled, more predictable, than the interpersonal openness of an ethics screening. Again, clinicians think of the ethics committee when they're not sure what to do. Give them a set of procedures to follow, and they don't feel the need.

Now, I'm aware that not all institutions have official palliative care programs, or even checklists. At the same time, this has been a frequent topic in journal articles, conferences, and other continuing education. The information is out there; and, empowered with information, clinicians don't feel the need for the consultation.

So, these are two of my thoughts about why ethics committees are doing fewer ethics consults. And it's not necessarily bad. Respect for the patient's autonomy and palliative care resources are both good things. At the same time, either one might seem to give a simple answer to situations that can in fact be quite complex. If these resources make ethical consultation necessary less often, that's all well and good. If, on the other hand, they lead us to skip over clinical and family issues that need more time and care and exploration, no one involved is truly well served; and that's my concern.

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