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Quality Control for Hospitals' Clinical Ethics Services: Proposed Standards

Published online by Cambridge University Press:  29 July 2009

Cavin P. Leeman ,
John C. Fletcher ,
Edward M. Spencer  and
Sigrid Fry-Revere
Cavin P. Leeman
Affiliation:
Clinical Professor of Psychiatry, and Faculty Associate in the Division of Humanities in Medicine at State University of New York, Health Science Center at Brooklyn.
John C. Fletcher
Affiliation:
Emily Davie and Joseph S. Kornfeld Professor of Biomedical Ethics at the University of Virginia's School of Medicine and Director of the University's Center for Biomedical Ethics.
Edward M. Spencer
Affiliation:
Director of Outreach Programs at the University of Virginia's Center for Biomedical Ethics and a member of the Ethics Consultation Service of the University of Virginia Medical Center.
Sigrid Fry-Revere
Affiliation:
An independent bioethics consultant and educator based in Washington, D.C.
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Extract

Hospital ethics committees have become widespread over the last 25 years, stimulated by the Quinlan decision of the New Jersey Supreme Court, the report of a President's Commission, and most recently by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which now man dates that each hospital seeking accreditation have a functioning process for the consideration of ethical issues in patient care. Laws and regulations in several states require that hospitals establish ethics committees, and some states stipulate that certain types of cases and disputes be taken to such committees. At least one state grants legal immunity to those who implement recommendations of an ethics committee.

Type
Special Section: Healthcare Ethics Committees and Consultants: The State of the Art
Information
Cambridge Quarterly of Healthcare Ethics , Volume 6 , Issue 3 , Summer 1997 , pp. 257 - 268
Copyright
Copyright © Cambridge University Press 1997

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References

Notes

1. Fletcher, JC, Hoffmann, DE. Ethics committees: time to experiment with standards. Annals of Internal Medicine 1994;120:335–8.CrossRefGoogle ScholarPubMed

2. In re Quinlan, 70 NJ 10,355 A2d 647, cert. denied, 429 US 922 (1976).

3. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forgo life-sustaining treatment. Washington: US Government Printing Office, 1983:5.Google ScholarPubMed

4. Joint Commission on Accreditation of Healthcare Organizations. 1995 Accreditation Manual for Hospitals. Oakbrook Terrace, Illinois: Joint Commission on Accreditation of Healthcare Organizations, 1994.Google ScholarPubMed

5. See, for example, Maryland Health-General. Code Sec. 19–370 (1990 & Supp. 1992) and New Jersey Administrative Code Title 8, Sec. 486–5.1 (March 16, 1992).

6. See, for example, Arizona Revised Statutes Annotated, Sec. 36–3231; Maryland Health General Code Annotated, Sec. 5–606(b); New York Public Health Law Art. 29–B, L., 1987, ch. 818, as amended, 1991.

7. Hawaii Revised Statutes Annotated. Sec. 663–1.7 (1988, Supp. 1990, & Supp. 1992).

8. See note 1. Fletcher, , Hoffmann, 1994.Google Scholar

9. Lo, B. Behind closed doors: promises and pitfalls of ethics committees. New England Journal of Medicine 1987;317:47–50.CrossRefGoogle ScholarPubMed

10. Wolf, SM. Ethics committees and due process: nesting rights in a community of caring. Maryland Law Review 1991;50:798–858.Google Scholar

11. Fry-Revere, S. Some suggestions for holding bioethics committees and consultants accountable. Cambridge Quarterly of Healthcare Ethics 1993;2:449–55.CrossRefGoogle ScholarPubMed

12. See note 1. Fletcher, , Hoffmann, 1994.Google Scholar

13. Fletcher, JC, Spencer, EM. Bioethics Services in Healthcare Organizations: Introduction to Clinical Ethics. Frederick, Maryland: University Publishing Group, 1995.Google Scholar

14. Super. Ct. Civ. Action No. 922–4820, Suffolk Co., Mass., Verdict, 21 April 1995.

15. Capron, AM. Abandoning a waning life. Hastings Center Report 1995;25(4):24–6.CrossRefGoogle ScholarPubMed

16. In the matter of Baby K. 832F. Supp. 1022 (E.D. Va. 1993).

17. Annas, GJ. Asking the courts to set the standard of emergency care: the case of Baby K. New England Journal of Medicine 1994;330:1542–5.CrossRefGoogle ScholarPubMed

18. See note 1. Fletcher, , Hoffmann, 1994.Google Scholar

19. See, for example, Hoffmann, DE. Regulating ethics committees: is it time? Maryland Law Review 1991;50:746–97.Google Scholar

20. Fry-Revere, S. The Accountability of Bioethics Committees and Consultants. Frederick, Maryland: University Publishing Group, 1992.Google ScholarPubMed

21. Also see note 1. Fletcher, , Hoffmann, 1994.Google Scholar

22. Also see Note 11. Fry-Revere, 1993.Google Scholar

23. Fletcher, JC, Spencer, EM, Fry-Revere, S, Leeman, CP. Recommendations for Guidelines on Procedures and Process and on Education and Training to Strengthen Bioethics Services in Virginia. Charlottesville, Virginia: University of Virginia, Virginia Bioethics Network, 1995.Google Scholar

24. Schyve, P. Critiques and new directions. Bioethics Matters. Charlottesville, Virginia: University of Virginia, Center for Biomedical Ethics, 1995;4(4):insert i–iv.Google Scholar

25. Since legislative and accreditational interest so far has been directed mainly to clinical ethics services in hospitals, this paper focuses primarily on hospitals' clinical ethics services; however, the principles espoused can readily be adapted to nursing homes and other healthcare institutions and organizations.

26. The last sentence is crucial to the integrity of an ethics consultation service. This issue will be discussed further in relation to Standard III.

27. Many institutions, but not all, have found it useful to include representation from the clergy, the legal profession (although generally not the hospital counsel), and hospital administration. Administrative participation is especially important if the scope of the ethics program is defined so as to include issues of institutional and business ethics, as recommended by Schyve. See note 24. Schyve, 1995;4(4):insert i–iv.Google Scholar

28. See note 10. Wolfe, 1991.Google Scholar

29. There are different views on this issue. In some hospitals, particularly those teaching hospitals in which consultations are done by persons who already are allowed general access to patients' charts, specific permission to review the chart is not required. The overriding principle is that patients' privacy and confidentiality, already maintained only tenuously in modern medicine, should not be further compromised by ethics consultation. Also see Siegler, M. Confidentiality in medicine: a decrepit concept. New England Journal of Medicine 1982;307:1518–21.CrossRefGoogle ScholarPubMed

30. Whether the names, specific aspects of the case, and information in the chart are made available to the ethics consultant(s) as a part of this informal process depends on the nature of the inquiry, on the culture of the particular hospital, and on who is doing the consultation. Also see note 29.

31. The authors are aware that the members of many, perhaps most, currently functioning ethics committees have not achieved the level of education suggested by these examples. Although these committees do much good work, they cannot provide an optimal level of service to their institutions. Nor can they be relied on to deal effectively with crises.

32. Psychological and psychiatric skills often are underemphasized in training programs in clinical ethics in spite of their critical importance. See Leeman, CP. Ethics consultation masking psychiatric issues in medicine. Archives of Internal Medicine 1995;155:1715–7.CrossRefGoogle Scholar

33. This standard presupposes a choice by an institution to use an educational approach involving courses and teachers as a means to fulfill parts or all of Standards VI through IX. We remind the reader that such an approach is only one option among several.

34. See Note 1. Fletcher, , Hoffmann, 1994:336.Google Scholar