Hospital ethics committees
Gonzalo Herranz, department of Bioethics, University of Navarra.
Session professor, probably at the School of Medicine of the Austral University.
Buenos Aires, November 8 (?), 1999.
grade publishing houseUnlike other meticulously written interventions in these pages, this is a schematic text, intended to serve as a script for a session professor, we believe, with a view to the establishment of an Ethics committee at the Austral Hospital, which began its work shortly thereafter. Nevertheless, the text is crystal clear and offers no difficulties of interpretation.
How to control the quality of the Committees and to improve it.
2. Expansion of the subject matter
3. The professionalization of ethics
4. Audit of the function of the cis
Greetings
Medicine has become more complicated:
-
technology, which makes it necessary to seriously consider the economic aspects and management, to control the expense, to ration services.
-
assertion of patients' rights that give rise to demands that may seem improper to the physician.
-
ethical plurality, which creates a diversity of values.
-
demand for respect for the individual and idiosyncratic nature of each person.
-
developments (abortion, euthanasia, end-of-life decisions) that clash with accepted morality.
-
increasingly complex interprofessional relations.
Many of these problems cannot be solved by knowing more medicine, as they are of an ethical nature.
Consequently, physicians, nurses and sensitive conscience managers are faced with many conflicts that are difficult to solve. One would have to devote many hours to study and reflection. And, before making a final decision, prudence impels one to seek the opinion and committee of others.
To facilitate the study, reflection and committee on ethical conflicts, the Ethics Committees (EC) were created as an effort to institutionalize the whole process.
Over the last 20 years, hospitals have been creating them, testing possibilities, each hospital looking for the EC that best suits its character and needs. There is now a tendency to create networks of HCCs. But there will always be a factor of its own: the HEC.
It is a great fortune that when a hospital starts up, it can do so with such an important organism and that one can help in some way to ensure that it is born strong.
It takes two years for the child to get going: patience, optimism and understanding are needed, both in the members of committee and in those who will benefit from it financial aid.
The first two years are very important, because:
a. It needs to be set up as committee: issue, qualifications and background of members, structure, rules of procedure, procedure for access, deliberation and resolution systems, conference proceedings, publication of documents. All of that is already well rehearsed. It is easy to solve. Many different solutions and regulations can be found in books, magazines and on the internet.
b. He needs, above all, to educate himself, to learn to study and decide on the ethical problems that are sent to him at enquiry. He must learn to relate, to communicate with the hospital. To gain the intellectual and moral prestige that gives him moral authority, since he has no other.
c. It needs to review the work done (self-audit) to see if it has deviated from its goals, if it has given up its independence and has taken a submissive or rebellious attitude, not fair, in front of the different levels: patients, management, faculty.
d. Above all, it must take care of its internal independence: listen to everyone, not allowing any of its members to become passive; study hard; not allow itself to be dragged down by laziness or violent zeal; respect freedom, feel uncertainty.
These things said, there are many others that could be addressed:
About people. We should talk about issue, credentials, representativeness, character, hard work, availability, ability to work as a team. Of the humility of seeing that very good things that one has prepared with a lot of effort and skill do not receive approval or applause. People are the capital of the SC. The hospital itself has to make a strong commitment, to dedicate to this task first-rate people, but with the proper virtues.
On the mode of operation. Need for a secretary. An EC can function without a President, but not without a Secretary. It is the engine: conference proceedings and convocations, file and report active, agenda and assessment of urgency/waiting. Sessions of fixed duration: punctuality of starting and ending. Making the most of the time.
Agreements: speaker submits minutes of resolution, discussion, perfects, accepts. Rarely need for a vote. Right to present an individual vote: majority opinion, minority opinions.
Sessions. Periodicity. Matters of dubious legitimacy: extraordinary sessions, emergency sessions. Alternatives: permanent of three, consultant ad casum, with subsequent information. Designate groups of work for special topics. Fixed points: approve certificate, execution of agreements, self-education program, next session with designation of speakers.
Functions: Education hospital ethics, essay of statements and guidelines, consultancy service of cases and problems.
Responsibility and accountability. To whom they are accountable. Self-criticism, external audit.
Accessibility: who can consult. Performance of official document. Rooting of the recommendations accepted by the board Directive or the board Facultative.
Doubtful areas: institutional criticism on issues of management, disciplinary function, monitoring of the internship of human rights, of informed consent, of the hospital's friendly internal ecology, whether it deals only with major problems (life/death, for example) or also everyday ethics.
How to control the quality of the Committees and to improve it.
Need for terms of reference letter, to have their functions well described: established in writing and publicly defined.
They guarantee a clean process, and take responsibility for their opinions.
They establish who can present cases and raise issues, how the speakers are adjudicated, the study schedule, who is entitled to receive the documentation, who participates in the final essay of the resolution.
The committee analyzes its "products": proposals, educational function.
It establishes what is to be given to each new member so that he/she will soon, in how much time (months, a year) become an active agent of committee.
Each member studies continuously, communicates in informative-educational sessions.
Friendly system of recommendations for improvement in discussion and agreement reaching skills.
It is also possible to fall into the temptation of the new millenarianism and start talking about the future, to speculate about what awaits us.
The future of the HECs depends on the present, on how the HEC members do it. A B responsibility.
What is going to happen? There is no crystal ball.
There are reasons for concern. Medical ethics is not degree program, it is not implemented in a serious, attractive way. It does not seem that, for the moment, it is going to become specialization program. Young people are not very attracted.
Many universities do not respond: There is no place in the plans of programs of study and no promising prospects in hospitals. Utopian or dilettante stuff. At best, a second occupation.
It does not give much prestige to be from the HEC, at least among molecular biologists, neogeneticists: a macroethics thing, which does not compromise anything, but not the daily ethics of the hospital.
You have to move to the head of the pack: that's where the future begins.
Futurology is dangerous business. But it is inevitable, at some point, to wonder what is going to happen? To find the answer, explore a few fields.
Five points, to make the intervention sufficient and bearable.
1. The imperfect future: inventory of delays, debts.
2. The broadening of the subject matter: the expansive landscape of some of the frontrunners.
3. The professionalization of ethics: changes in mentality and status.
4. auditing the role of the cis: time for accountability.
5. The remote future: let your imagination run wild.
Really, can we talk, discuss, about the future?
The HECs in Spain are somewhat underdeveloped. Many lead a nominal existence.
All of them have a lot of work to do.
Many HECs have not yet started: their future lies in redeeming lost time. We have seen this in Dolores Espejo's communication.
The irremediable capacity of legal norms to take things for granted, when they do not even exist. Obsession to create and authorize. But withdrawal total of the subsequent responsibility: we are not in a culture of accreditation, certification, inspection, homologation.
It is easy to authorize, but no one follows up, unless catastrophes arise. Assisted Human Reproduction Law.
The first future is to catch up.
Getting to the starting line means growing in: hours of basic study, exploration of the bibliography, training in the art of discussion, internal Education techniques of committee.
It means creating a favorable environment in the hospital, getting the necessary messages across to everyone. It means to give validity, to gain respect, to corner with a humble but persistent effort the skepticism and rejection of so many colleagues towards institutional ethics.
Demonstrate with facts that the HEC is worth: produce convincing and rational guidelines.
Draft the hospital's ethics guide , not all at once, but little by little, putting together the puzzle with pieces that gradually fit together.
Winning the communication battle: making the HEC known and respected by hospital managers and physicians, by nurses and assistants, by patients and their families. Paper, copier, administrative assistant.
Schedule sessions to explain the ethical implications of legislation, contracts, economic and social policy of the hospital.
Educate consultants, physicians and nurses not to instrumentalize ethics by mixing it with disputes over power or knowledge.
2. Expansion of the subject matter
HECs now basically work on informed consent issues, end-of-life issues, treatment refusal decisions.
Suppose that, in a hospital, the HEC functions exemplarily. The HEC's victory may be pyrrhic. As legislation and "bioethical jurisprudence" are created; as criteria for action, guidelines and standards accumulate; as the action of HECs permeates the hospital, HECs become less and less necessary.
He always needs to broaden the field in which he exercises his expert function. Broadening the subject matter is essential to get out of the routine, the repetitive casuistry, the boredom that occurs after a few years of dealing with easy subjects and not attacking the hard ones.
The future lies in not shying away from strong, complex, thorny issues. The HEC is the ethical conscience of the hospital.
Many think that the HEC is there to advocate on issues of autonomy and patients' rights. They flee, like the devil, from getting involved in other issues.
There is a tendency not to enter into conflict: HSCs in cotton wool, like a weak creature. HSCs in persistent vegetative state. Decorative HECs. But an HEC worthy of the name has to get involved in the human relations of some physicians with others, of managers with those they manage, of the ethical implications of the hospital's economic policy.
Iserson KV, Golfin FB, Markham JJ. The future functions of hospital ethics committees. HEC Forum 1989;1(2):63-76. listed what people had said about future functions of HECs. From setting out to eliminate discrimination, abuse of power, favoritism and ostracism (hierarchical, economic, promotional, research), conflicts of interest, disputes between physicians and among all, acting as a lightning rod against bad judgments internship, functioning as a prognostic committee , reviewing the skill and good judgment of physicians, promote the social utility of the hospital, making research empirical medical ethics, going out to outpatient clinics and emergency departments to enlighten them. Obviously excessive things.
It has to analyze data: length of stay, internal ecology of respect for persons (rooms, privacy), judging on amounts of fees, and costs of interventions as part of informed consent, ethical aspects of the professional degree program , human rights of physicians, protection of minorities or weak, of dissidents.
Denounce political nepotism, immovable gurus, refractory or tyrannical directors. Justice and ethics.
A few of these new features deserve a comment:
a. To proclaim and practice the human rights of patients.
b. Rights of physicians and staff non-physician.
c. Prevention of the repetition of errors. The Córdoba episode.
d. Strong subject matter. We are facing a future of hard issues. The role of money, the freedom to prescribe, the strength of clinical protocols, the standards of prescribable drugs. There is no doubt that many guidelines are informed by rationality and flexibility. But bureaucrats believe that everything can be fixed with circulars and lists: the ethos must be changed: this is the role of the HECs.
This is the programmed future, which calls for responsibility, a lot of energy. But surely the HECs or their alternative modes will be here for many decades to come.
3. The professionalization of ethics: consultant of ethics
A lot diary. Not something for amateurs, nor for free time. A cry from the few HEC members who have taken the task seriously: it is not a part-time occupation. It is serious, professional. You have to attend to the sessions, you have to study and participate in the debates, you have to be speaker of some issues. Time.
So much knowledge and so much dedication that we talk about professionalization.
But with professionalization, won't routine, comfort and conformism follow? And won't HECs be puppets of the management?
To leave general medicine, Anatomy pathology, psychiatry or legal medicine is to risk subject. Today it is no longer easy to retrain. If the thing fails... It would be serious if there is no professional medical ethics degree program .
Professionalization can also mean not risk, but job security.
Professionalization reasons.
For decision facilitation/rapidity
General trend: from single models to diverse formats. Coexistence models: between all and one, one and all situations (Singer, Pellegrino, Siegler, Fletcher):
-
from committee by collective decision
-
from committee speaker /member of committee
-
from committee post facto
-
of consultant individual. The Committee/Consultants dilemma is now openly posed, topic of today and tomorrow.
Academic maturation: the second generation. From self-anointed to professionals.
Dedication, degree program: masters and certification.
The empire of total quality: from internal auditing to the public accreditation function.
4. Auditing HECs. Time for accountability
Internal audits. Voluntary external audits. The obligation to render accounts. What is done, qualitatively and quantitatively. What quality, homogeneity, on procedure, in terms of reference letter. It is necessary to develop the instruments of measurement, of intellectual quality, of presentation, of respect, of acceptability, of satisfaction. We need research. Ways to improve quality and performance.
The research done until recently was of very poor quality: empirical, uncontrolled, descriptive.
It is necessary to study the knots:
Institutional unity/identity: divorce between ethicists and executives. The complex relationship between HECs and management.
Ethicality, which is based on and in accordance with the norms (legal, deontological, international, national, institutional), relationship with programs of study.
Effective conflict resolution. Consultations with committees that make things more complicated, that bring things to a standstill, that pit one against the other. Or that are not executed, are not accepted. Or they are accepted by only one of the parties in conflict. Committees that sew without thread, because nobody follows them.
The educational function. Dissemination of knowledge, attitudes, skills. That they read and learn the roles, that they change their posture towards ethics and committees (from mockery and skepticism to respect and appreciation or even conversion), that they go to enquiry, that they know how to consult.
The public function. Judicial immunity of physicians who follow the opinion of the HEC, in 15 States of the USA. Judges ask HECs for their expert opinion. What is sometimes asked of the Central Deontology Commission, will be asked of the HECs.
Inez de Beaufort. Those were the days: looking back at the future. J med ethics 1996;22:356-359.
There will be committees. Yes, but there will not be committee meetings. There will be conferences at network, video conferences.
The Internet will have grown to unmanageable dimensions, superabundance: we will have access to all legislation, to all cases, to all real problems, to all fictitious scenarios.
There will be practically no new situations, because there will be applicable software: diagrams, algorithms, decision trees. There will be applied modules for problem solving, pluggable artificial intelligence programs to synthesize answers: to choose utilitarian, naturalistic solution.
Nobody will have to go to Library Services anymore: bioethicsline with a system for reading the entire bibliography bioethics, with selective search and filtering systems for materials, with synthesis and electronic consensus programs. Many companies will make abstracting programs: it will no longer be necessary to read originals: everything will be digested and extracted.
Role of exemplarity. HECs must make institutional ethics friendly, not hateful.
Vaccine against bitterness, resignation.
The future is open.