The hospital ethics committee. Health care's moral conscience or white elephant?

Early in their formation, ethics committees enjoyed a considerable and reassuring consensus regarding their functions. It was generally agreed that these were three: case review or consultation, policy or guideline development, and education in the field of bioethics. It seemed to be assumed, moreover, that whatever else these committees might do by way of generalized policies or educational reflections on the problems of bioethics, first and perhaps foremost they would labor amid the messy and complicating details of individual cases. In fact, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research actually worried that the case review function would be over-utilized. Ironically, just the opposite has occurred: case review is what these committees are now least likely to do or to be known for doing. [1] It is this irony that motivates my suggestion that the time has come for a serious reconsideration of the hospital ethics committee. The Decline in Case Review The factors that have contributed to the shift away from case review as the committee's central task fall into at least three loosely defined categories: political, psychological, and cultural or intellectual. As a political matter, case reviews by committees may be problematic because they tend, de facto, to infringe upon the authority (and prerogatives) of attending physicians. We might wonder, however, whether the authority of the attending physician is an ethical authority. That is, are there purely or mostly ethical reasons for the physician to be the final arbiter of treatment decisions in the management of individual cases? Or is this authority mostly a matter of the social statute of physicians in comparison to other health care professionals (or to the public at large)? It is not, in any case, self-evident that this authority is an ethical authority in need of preservation by an ethics committee. Mark Siegler has argued: Most troubling of all, [institutional ethics committees] may remove or at least attenuate the decision-making authority of the physician who is responsible--medically, morally, and legally--for the patient's care. Some physicians may abdicate their medical responsibility by delegating difficult clinical-ethical decisions, an intrinsic part of medical practice, to such committees. In contrast to individual physicians, committees lack specific medical knowledge, have not been trained in the ethic of caring, have little responsibility for decisions, and have not been sanctioned by the patient to make such decisions. Thus, to delegate decision making to the IEC may be unethical for physicians and hospitals. [2] The argument here is, however, less than compelling. Surely the moral responsibility that Siegler assigns to the physician does not exist because of some explicit, special agreement between physician and patient, wherein the patient specifically gets the physician to assume this kind of responsibility. It is a responsibility that attends one's work and role as a health care professional. Since physicians are not the only health care professionals involved in patient care, they are not the only ones with a moral responsibility for that care. Thus, Siegler would have to provide a special warrant for assigning the physician the kind of authority he is concerned to preserve; without such warrant, the authority, like the responsibility, may legitimately be shared. Otherwise, the committee's possible infringement of the physician's authority is simply a matter of (health care) politics. A second category of factors contributing to the decline of case reviews might be loosely termed psychological. Here we have all those tensions that attend sitting in judgment on morally problematic situations--tensions that can easily explain why many committees see their role as providing non-judgmental emotional support, in the style of group therapy. …