Institutional agendas and ethics committees.

Institutional ethics committees serve the needs of patients. They also help doctors and nurses, providing collegial assistance in resolving ethical dilemmas. But what account should ethics committees take of the institution's interests? Institutions have interests of their own. In part, this is due to the multiplicity of tasks and goals to which a complex organization devotes itself. Success in some of these hinges on the disposition of others, and the problematical cases and policy quesdons that come before the ethics committee are likely to have wider effects within the institution. Keeping Mr.jones alive in the I.C.U. may have the effect of denying intensive care to Ms. Smith. The continued operation of the genetic counseling service may depend on the kind of hospital policy on late-term abortions the committee advises the administration to adopt. The institution as a whole, regarded simply as the aggregate of these particular activities, could be harmed by disadvantageous trade-offs in these and similar instances. A hospital, however, is more than a collection of individual services. It is a community resource, with a history and a social position, responsive to public expectations and pressure. It is an employer and spender, the largest one in many towns. It is a doctovs workshop"' in which physicians pursue both healing and entrepreneurship. It may be a cash cow in its own fight paying dividends to bondholders or profits to shareholders. And it may be, in the view of its employees, patients, and the public, a moral agent, whose moral character is determined and expressed in the way it sets its policies and handles its problem cases. Ethics committees must decide whether to take these institutional interests into account. The answers they reach will determine whether ethics committees view themselves as pan of a management team or as an independent agency working at times in tension with the overall direction of the hospital. A pufist' might reason that any ethics committee worthy of the name should disregard institutional interests, since its job is to determine "what is right," rather than "what is feasible." Giving some weight to institutional concerns, in this view, would deliberately skew the results of moral judgment toward expediency; better to deliver a purely ethical judgment and let the hospital administration weigh this against other relevant considerations. If Mr. jones ought to remain in the I.C.U., morally speaking, let the financial officer decide whether the hospital can afford to pay for his care; if Ms. Smith should be allowed to die at home, hospital management can deal with the referring physician. The purist'view calls for a division of labor. For the administrator, in this view, "what is right' is one of several considerations that must be taken into account in decisionmaking. It is up to the ethics committee to clarify this consideration for the actual decisionmaker, whether this is the patient, doctor, or administrator. The committee, in performing this limited function, is not and ought not be making the final decision. This should be made by the person or persons with overall authority over the case. It will represent the best choice, everything considered. The administrator, however, can contest this "Purist"'view on plausible grounds. It presents a false picture of the role of ethics in decisionmaking, for "what is righte' is not just one consideration among many, but what ought to be done, everything considered. The conscientious administrator thinks about ethics just as much as the patient, doctor, and ethics committee. The difference among them is in the scope of their decisions, that is, in the range of considerations each must take into account, given his or her role.2 The administrator must consider such issues as financing and community attitudes because doing so is a part of the administrators responsibility, and because the administrator's authority covers not only the case or policy choice before the ethics committee, but the full range of cases and policies in the institution. …