Willing, but waiting: Hospital ethics committees
■ Consultation services are widespread, but many doctors hesitate to ask for ethics help. Questions about ethicists' training and performance persist.
Since their rise more than three decades ago, hospital ethics committees have sought to help physicians, patients and their families resolve ethical disagreements and navigate the treacherous terrain that so often accompanies medical care at the end of life.
The role of these committees was cemented in 1992 when the Joint Commission mandated that health care organizations come up with some way of addressing ethical concerns. Ninety-five percent of general hospitals surveyed in 1999 and 2000 offered ethics consultation or were starting up a consult service.
Yet at the median, these services handled only three cases in the previous year, according to the survey of more than 500 general hospitals whose results were published in February 2007 in The American Journal of Bioethics.
The use of ethics consultation services varies widely from hospital to hospital, but physician experts and ethicists agree that they frequently are underused. That leads, they say, to increased medical costs and ugly disputes among physicians, patients and families.
Physicians' reluctance to seek aid when dilemmas arise is partly grounded in the notion that a call for help is equivalent to hauling in the "ethics police." But the problem, experts say, goes far deeper.
Too often, ethics consultants lack the resources, training and mediation skills necessary to resolve disputes and address dilemmas in a timely and effective manner. In addition, the journal article pointed out that fewer than half of consultants have any formal training, and only one in 20 has a bioethics certification or graduate degree.
Moreover, the evidence that ethics consultation actually improves patient outcomes is thin. Many experts are at a loss on how even to go about measuring its impact.
"If ethics committees were a drug," said Howard Brody, MD, PhD, director of the University of Texas Medical Branch's Institute for Medical Humanities, "they would not be approved."
A big reason that doctors don't ask for ethics advice more often is their perception of the ethics consultants' role, according to Lainie Friedman Ross, MD, PhD, associate director of the University of Chicago's MacLean Center for Clinical Ethics.
"Rarely do ethicists tell you -- the physician -- what to do, but rather they help you think about options and ways to negotiate compromise," Dr. Ross said via e-mail.
Richard E. Thompson, MD, is a retired neonatologist and author of So You're on the Ethics Committee? A Primer and Practical Guidebook. He said many physicians worry that ethics committees are out to undermine their ethical responsibility to the patient.
"The physician thinks, 'I've got this license, and it says that I'm supposed to be making the decisions, and now I've got these nurses and preachers and social workers who want to make these decisions.' It's a feeling of displacement," Dr. Thompson said.
"It might look to a physician like, 'Someone's trying to tell me I did something wrong.' If the committee takes that approach, shame on them. That's not the idea at all."
Indeed, an American Society of Bioethics and Humanities position paper published in 2000 dubs "authoritarian" an approach that puts the "emphasis on consultants as the primary moral decision-makers." The ASBH, the organization that represents clinical bioethicists, says consultants should gather the facts, clarify the ethical issues and "help to identify a range of morally acceptable options" in the context of a given case.
Arthur L. Caplan, PhD, director of the University of Pennsylvania's Center for Bioethics, said physicians also fear that asking for ethics advice will grab the attention of hospital lawyers.
"Doctors remain very wary of engaging the law, and too many ethics committees and consult teams operate under the aegis or with the review of risk management at their institution," Dr. Caplan said in an e-mail.
There also is an element of pride that makes physicians shy away from asking for help, said Douglas S. Diekema, MD, MPH, a pediatric emergency physician and ethics consultant at Children's Hospital and Regional Medical Center in Seattle.
"Bioethics, in the eyes of most clinicians, is something they all do, in a way that they wouldn't say they all do cardiology or pulmonary medicine," said Dr. Diekema, director of education at the Treuman Katz Center for Pediatric Bioethics. "Then it's hard to ask for a consult, because they're admitting they don't know how to do it."
It is also difficult for physicians to know when a case presents an ethical dilemma, said Dr. Brody, a retired family physician who has spent decades serving on ethics committees.
"Bioethicists are extremely good if you come to us wearing a sandwich board that says, 'I am an ethical issue.' Then we can give you good advice based on rules, cases, ethics, with all the footnotes," Dr. Brody said. "But if what you want to know is how to see what's an ethical problem, something that happens in the clinical work flow and doesn't have 'ethics' printed at the top of the page, then I'm not sure we know how to teach that."
Pay and performance
The principal question many doctors have about ethics consultations is whether they are worth the trouble. A March 2004 Journal of General Internal Medicine study did find that 72% of nearly 350 internists believed they learned something from an ethics consult they experienced, and 86% said they likely would ask for help again.
But a significant minority of doctors surveyed had reservations about using ethics consultation, saying the process is too time-consuming and could worsen the situation.
Only 18% of consultants receive extra pay for their ethics duties, and experts say too many ethics committees are bare-bones efforts to satisfy the Joint Commission mandate. That lack of funding is largely to blame for consultants who are undertrained, pressed for time and not evaluated in a meaningful way.
The AMA has policy saying doctors should be paid for clinical ethics consults. AMA policy also says all hospitals should provide and finance access to consultations, which should follow explicit procedural and structural standards.
It is a challenge to set standards for ethics consultation, experts say, because it is unclear how to determine which approaches work best.
"We're sort of groping in the dark in the sense that we don't have a lot of data to tell us one way or the other what's a successful consult," said Kayhan Parsi, PhD, an ethics consultant and graduate program director of the Loyola University Chicago Stritch School of Medicine's Neiswanger Institute for Bioethics and Health Policy.
Testing consultants' performance is daunting, Dr. Brody said, because "it assumes you have a yardstick of what counts as a successful resolution, and that's demanding certainty over things where we on the ethics committee don't claim to have any certainty."
Nonetheless, some researchers have tried. In one randomized controlled trial studying seven intensive care units, the cases of more than 550 patients receiving life-sustaining treatment were identified as posing some physician or family dispute over the aggressiveness of care, palliative care or futile care. Attending physicians for half the patients were offered an ethics consult, and no action was taken for the control group.
The results, published in the Sept. 3, 2003, Journal of the American Medical Association, showed no difference in mortality, but the intervention group did experience slightly shorter stays in the hospital and the ICU, and less time on the ventilator. Eighty-seven percent of doctors, nurses, patients and families said the consults were helpful.
"Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU," concluded lead author Lawrence J. Schneiderman, MD, and his colleagues.
A similar project is under way at the Albany Medical Center ICU in New York. The program will study the effect on length of stay of a multidisciplinary effort combining the work of ethics consultants, pastors and social workers.
Perhaps the largest effort to standardize and measure the work of ethics consultants is happening as part of the Dept. of Veterans Affairs' IntegratedEthics Initiative. The VA began the initiative in May 2007. By September of this year, it will record electronically all consultations and their outcomes.
The VA has developed a 63-page primer and two-hour instructional video for its consultants. Ethics coaches will visit VA medical centers to train consultants on consistently following a step-by-step process when handling cases. They will be expected to evaluate their own performance and skills, and physicians and other health professionals will be surveyed for their feedback, said Ellen Fox, MD, director of the VA's National Center for Ethics in Health Care.
"It is concerning to me that almost 20 years after the Joint Commission mandate, there still are not widely agreed-upon standards for quality," she said. "That's why in the VA we've issued these standards and will hold people accountable for meeting them."
Dr. Fox, lead author of the study in The American Journal of Bioethics, said proof of ethics committees' effectiveness is still largely anecdotal.
"The way to ensure that ethics consultation is utilized at an appropriate level is to ensure that the quality of ethics consultation is very high," she said. "Our strategy is to prove the value of it on the ground."