Case for Discussion : When
to Ask for Help
The first prominent ethics committee in the United States was put
in place at the University of Washington to help clinicians determine
which people should receive hemodialysis. Hemodialysis was new and
experimental at the time, and the University could care for only
limited numbers of patients. A committee was put in place to select
which people would get the treatment. In many cases, these decisions
meant life or death, and not surprisingly, the committee soon became
known as “the God committee.” The committee was quickly
criticized because it tended to value some people (married) over
others (unmarried). In a sense, the problem of allocating hemodialysis
was not solved until the U.S. government began in the 1970s to finance
the treatment for anyone who needed it.
The principal accrediting agency for health care organizations
in the United States (Joint Commission for the Accreditation of
Healthcare Organizations; JCAHCO) now requires that hospitals and
other institutions have some mechanism in place to resolve ethical
conflicts. Healthcare institutions meet that requirement in a variety
of ways, relying mostly on ethics committees and ethics consultants.
Ethics committees are local committees of specific healthcare institutions.
They are usually composed of physicians, nurses, ethicists, and
other healthcare professionals. The may review policy and evaluate
cases. Ethics consultants are usually health care professionals
or academics familiar with healthcare who respond immediately to
questions from clinicians about particular cases or policy. Usually,
the consultants respond to questions related to the direct clinical
care of patients.
to top of page]
Although JCAHO requires that institutions have some mechanisms
for resolving ethical difficulties, it does not set out specific
ways in which health care institutions must meet that goal. Ethics
committees are usually staffed by volunteers from a variety of clinical
and academic backgrounds: medicine, social work, theology, nursing,
and so on.
The specific responsibilities of a committee vary from place to
place. Some committees meet weekly, for example, to discuss patient
care problems that arise. Others meet less frequently and review
institutional policies and procedures. There can be extreme variability
in the activities and scope of committees.
Successful committees are those that have a reliable membership
and the attention of the hospital administration.
In its work, an ethics committee may review institutional policies
dealing with transplantation, the determination of death, patients
who refuse care, and so on. As it does its work, the ethics committee
must, of course, interact with any other administrative units having
responsibility in these areas as well. It is not usually the case
that ethics committees have the power to establish policy, but they
can advise and offer recommendations as they see fit.
Perhaps the single most important activity of an ethics committee
is its discussions. These discussions focus on live concerns in
the institution, whether that means the care of patient with a peculiar
set of circumstances or responding to a complaint from a staff member
that a particular policy is ineffective or counterproductive.
Most medical students will not interact with ethics committees,
but they may witness an ethics consultation in the course of their
to top of page]
Some institutions make ethics consultants available to help physicians
and health professionals sort through individual problems that come
up in patient care. For example, a physician may call upon an ethics
consultant to clarify exactly how hospital policy applies to a particular
patient. Or a physician may call an ethics consult in order to get
help in resolving a family dispute about medical care for an elderly
parent. Brothers and sisters may vehemently disagree about whether
to continue treatment or not. In other words, ethics consultants
are sometimes called for educational purposes and sometimes called
for their skills in conflict resolution. Ethics consultants can
come from a variety of backgrounds including medicine, nursing,
philosophy, social work, and so on. A major professional organization
has defined the skills ethics consultants ought to have, but it
does not require that consultants all come from the same backgrounds.
The individual responsibilities of consultants will vary by medical
In general, the ethics consultant may work alone or in conjunction
with the institution’s ethics committee. When working alone,
the consultant responds to requests coming directly from professionals
involved with patients (or sometimes from patients themselves).
By contrast, ethics committees meet on a regular basis to discuss
patient care issues in general and to review institutional policies.
Of course, because they meet on a set schedule, committees cannot
be as flexible in responding to concerns that arise in the course
of patient care. However, committees can often bring a great deal
of depth to consideration of particular problems. They are often
better than individuals at discussing and designing policy recommendations.
In virtually every instance, when an ethics consult is called,
the consultant will meet with the relevant parties and sometimes
the patient and the family. This may occur in an informal interaction
or may involve several in-depth meetings. Depending on how the ethics
procedure is set up at an individual institution, the ethics consultant
may seek advice from the larger ethics committee. Either way, the
consultant will try to analyze the problem at hand in terms of existing
policy, relevant laws, and core ethical principles. The ethics consultant
may write a note of recommendation in the patient’s record.
It remains up to the attending physician, of course, to accept and
act on the recommendation or not. It should be mentioned, however,
that the force of the consultant’s recommendation remains
a matter of debate. Some commentators see little value in seeking
ethics advice that does not have to be followed.
Not everyone at each medical institution can initiate an ethics
consult. In some cases, it is possible for medical students to initiate
an ethics consult. Policies vary but are usually designed to accommodate
a broad range of input.
to top of page]
Case for Discussion : When to Ask for Help
Ginger Vernor is a medical student who is rotating through her medicine
clerkship at a time when there are a large number of cardiac patients
on the floor of the hospital. One patient is Mrs. Lynne Shawson, 54,
who has a variety of symptoms related to AIDS, but it appears that
congestive heart failure is her most serious problem. In fact, the
attending physician believes that Mrs. Shawson will not survive this
hospitalization. He expects her to die within a week. Mrs. Shawson
has no relatives except another sister who is, in fact, in another
hospital across town, in virtually the same condition. The sisters
had lived a great deal of their lives together, and that life included
a lot of alcohol and drugs and very poor medical care.
A social worker has learned that Mrs. Shawson’s sister is not
competent to make decisions about her own health, let alone any one
else’s. The social worker cannot find any other relative, though
she has found a friend who lives in her building. The friend she does
not know Mrs. Shawson very well and does not want to get involved
in making any kind of medical decisions. The attending physician believes
that Mrs. Sharav should receive no major medical interventions because
she is so close to death.
Ms. Vernor wonders whether she or the attending physician should call
an ethics consultant in order to decide what kind of care this dying
woman should get. Because she is so inexperienced about these matters,
she hesitates to ask the attending physician whether this would be
a good idea.
- Would it be appropriate to call an ethics consult in regard
to the medical care of Mrs. Sharav?
- How should Ms. Vernor make her thoughts on this matter known
to the attending physician? Would it be appropriate for her to call
the ethics consultant without first talking to the attending physician?
- How might an ethics consultant go about trying to respond to
Ms. Vernor’s concerns?
[return to top of