Anyone who has been paying attention to healthcare issues realizes that as treatment options have expanded, so have our ethical dilemmas. Partly in response to such dilemmas, almost all hospitals in the U.S. have created institutional ethics committees. These hospital ethics committees are often formally charged by their institution to provide education, to help develop policy, and to provide ethics consultation services. Drawing from the twenty-seven-year history of the Montefiore Medical Center Bioethics Committee and Consultation Service, Linda Post, Jeffrey Blustein, and Nance Dubler have written a Handbook for Health Care Ethics Committees. And it truly is.
Thick with useful information, this multifaceted handbook relays dispatches from the health care front. Part I offers an eight chapter curriculum that draws upon the Montefiore experience to address both procedural questions and substantive questions that arise in healthcare ethics. For their theoretical framework, the authors adopt a principles-based approach based on the now classic work of Tom Beauchamp and James Childress (Principles of Biomedical Ethics). They also affirm a complementary casuistry approach, suggesting that committees "compile a library of cases that can serve as analytic models "(137).
Following a brief introduction to ethics committees (Chapter 1), Chapters 2 through 7 address moral conflicts in the clinical setting, covering both clinical matters and the therapeutic relation. The authors begin with the issue of decision making and capacity (Chapter 2) and then look more carefully at the consent process in Chapter 3. With respect to the issue of decision making and decisional capacity in adult patients, they are honest as representative health care professionals. "The fact is," they admit, "we only question the capacity of people who do not agree with us" (29). And in their discussion of informed consent and refusal, they reaffirm consent as a collaborative process and not a mere signature or event.
Informed consent and collaborative decision making depend upon honesty and truth telling, the subject of Chapter 4. Looking closely at issues regarding disclosure and confidentiality, our authors conclude that, "although the obligation of truth telling is not an absolute, it is something that requires a compelling reason to disregard" (53). The discussion of issues related to the decision making of children and adolescents in Chapter 5 is a fine start; however, it would be enhanced with an examination of the related concept of the assent of minors.
Beginning with Chapter 6, End-of-Life Issues, the book moves beyond procedural questions about who ought to make decisions to the more substantive question about what those decisions ought to be. For most hospital ethics committees, end-of-life decisions make up the bulk of their agenda. Mindful of the conflicting obligations that often arise between respecting patient autonomy and patient well-being, the authors urge care givers and ethics committees to focus on the goals of care. Otherwise, they proffer, a technological imperative can easily dominate the therapeutic relationship, encouraging both families and care givers to defer to interventions because they are available rather than clinically indicated.
Part I also includes several topics rarely explored in bioethics texts: palliation, justice, access to care, and organizational ethics. As backdrop for their discussion, the authors acknowledge that in the clinical setting a dialectic between cure and care often emerges. In response, they affirm that, "The therapeutic continuum seeks a balance of curative and palliative care that responds to the patient's changing condition" (109). Pursuing this topic, Chapter 7 focuses on palliation and the clinical and ethical mandate to reduce suffering.
Chapter 8 broadens the scope of ethical inquiry to include questions of social justice and the distribution of health care. Although the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) changed the title of its standards chapter from Patients Rights to Patient Rights and Organizational Ethics in 1995, most works on bioethics have ignored the topic of organizational ethics. Boldly entering this newer terrain of organizational ethics, the authors urge ethics committees to move beyond the care giver-patient relationship and take on the wider responsibilities of monitoring and guiding institutional decisions that can affect patient care. They see organizational ethics as "an intermediate level of analysis between the narrower set of clinical concerns and the broader societal policy issues" where "the organization itself is seen as having obligations to adhere to certain norms of ethical behavior" (129-30).
In Part II, ethical theory meets clinical reality. Chapter 9 focuses on the use of health care ethics committees for prospective case consultations. It analyzes three different models of ethics consultation: the use of an individual ethics consultant, an ethics committee, and an ethics consultation team, the most common approach that is used by almost two-thirds of hospitals in the United States. In their discussion of the actual consultation process, they compare and contrast their own practice, the Montefiore Medical Center Model of bioethics mediation, with the five steps model of the CASES (Clarify, Assemble, Synthesize, Explain, Support) approach to clinical ethics consultation developed by the National Center for Ethics in Health Care in use at VHA facilities. Commenting on the unique mediation approach practiced at Montefiore, they conclude that, "Over the years, we came to realize that, rather than providing ethics directives or even analysis, what we were doing was some from of alternative dispute resolution or mediation" (150). The Montefore model acknowledges that process is often part of the product. However, while bioethics mediation may unmask resolve communication problems disguised as ethical dilemmas, it may encounter difficulties with genuine ethical dilemmas that may require the ethical substance and perspective of bioethics consultations. Part II concludes (Chapter 10) with representative clinical cases that are most likely to generate an ethics consultation or a meeting of the hospital ethics committee. Each case not only contains cogent analysis, but several offer as well sample chart notes that might be entered on the medical record. Such examples will be helpful to many hospital ethics committees.
Part III of the Handbook focuses on the educational function of a hospital ethics committee, and the committee's need for materials for its own education. Samples of working documents for the committee's own edification, a white paper ("Allocating Critical Care Resources") and a memorandum ("Justice and Access to Unreimbursed Therapies") are provided. Two other documents, "Guidelines for Transferring Patients Between Services" and a "Decision-Making Protocol For The Patient Alone" are also included to illustrate draft strategies to enhance clinical and organizational processes.
A third function assigned to most hospital ethics committee is the review of institutional policies and procedures. Part IV offers examples of such documents from several health care institutions around the country. Included are such policies as "Access to Bioethics Consultation," "Advance Directives," "Determination of Brain Death," "Do-Not-resuscitate (DNR) Orders," and "Foregoing Life-Extending Treatment." Not only are these examples well chosen, since they reflect key policy issues, but they are helpfully annotated as well. This chapter alone will be a valuable resource to committees, since it will allow them to compare how different institutions address similar issues.
The Montefiore Medical Center Code of Ethics makes up Part V. Although many health care institutions have already committed to the JCAHO-mandated compliance code, the folks at Montefiore offer a normative challenge. Their "code sets the bar at a higher level - the ethical obligations of the institution as health care provider - and establishes the desired rather than the required standard of behavior" (279).
Another unique contribution of the Handbook is the inclusion in Part VI of selected legal cases in bioethics. The authors are quick to disclaim any legal prowess, but they rightfully acknowledge the importance of the legal and statutory context within which ethical decision making occurs. Their overview contains both classic cases and more recent legal decisions. For example, the discussion of "Reproductive Rights," briefly references both the classic Griswold v. Connecticut in 1965 and Bowers v. Hardwick in 1986, as well as Lawrence and Garner v. Texas which overturned Bowers in 2003.
Always mindful that they are providing a handbook and not a text book, the authors conclude the Handbook with another unique offering: a transcript of a mock ethics committee meeting. Here clinical reality meets committee deliberation in a retrospective case analysis of professional obligation to provide patient care when there is thought to be a risk to the provider and an examination of an institutional DNR policy. This sample ethics committee meeting illustrates in more practical terms how a mix of ethical analysis, narrative, and guided deliberation can respond to the dilemmas that arise in clinical and organizational settings.
With its blend of the elements of principles-based ethics, context, and narrative, the Handbook for Health Care Ethics Committees can help patients, families, and health care professionals make decisions that have clinical and ethical validity. The authors have indeed met their goal and provided a needed resource that, "Would help your committee be a knowledgeable, skillful, and effective ethics resource for your institution"(12).
© 2007 Larry D. Hultgren
Larry Hultgren describes himself as follows:
A.B. Grinnell College majoring in Philosophy and Religion; Ph.D. Vanderbilt University in Philosophy. Currently Professor of Philosophy at Virginia Wesleyan College, Norfolk, VA. Since I am at a liberal arts college, my teaching runs the gamut of philosophy offerings. I am especially interested in interdisciplinary pursuits, and I direct the college's Social Ecology Program and our innovative PORTfolio Project, which attempts to bring the liberal arts to life for our students by connecting the classroom with real world experiences. I also serve on the Bioethics Committee of the Children's Hospital of the King's Daughters in Norfolk, VA, and serve on the Board of Directors of the Bioethics Network of Southeast Virginia.