PART TWO IN A SERIES ON THE USE OF ETHICS COMMITTEES
The following article is Part Two in a series sharing best practices around the formation and use of ethics committees within the hospital care setting.
An ethics consultation service allows clinicians, patients, and families to access ethical expertise in fraught clinical situations. Over 85% of U.S. general hospitals provide for clinical ethics consultations that employ a variety of approaches in providing this service.1 Each approach has advantages and disadvantages, and the best model for a particular hospital depends upon a variety of factors, including the availability of content experts in bioethics, the number and complexity of requests for ethics consultation, and the organizational support provided for the service. Here I will outline three different models of ethics consultation, emphasizing the strengths and weaknesses of each and identifying the circumstances in which one model might be preferable to another.
Single Consultant
The most straightforward model of ethics consultation involves a single consultant who is asked to review and weigh in on a particular case. This model is familiar to clinicians, as it is analogous to how other consultations—say for subspecialty input or procedural assistance—are conducted. That said, it is currently employed in less than 20% of organizations.1 In a single-consultant system, an individual ethics consultant is kept “on call” for consultations as they arise. The consultant reviews each case, meets with appropriate members of the medical team and the patient and/or their family, reviews relevant literature as appropriate, and reports back to those requesting consultation, generally with a written note outlining an ethical assessment and recommendations as appropriate.
The single-consultant model has several advantages. First, such consultations are efficient, allowing for ethical concerns to be promptly addressed without the bureaucracy and prolonged timeline sometimes associated with gathering a team together. Second, the personal nature of the consultations can help facilitate education and ongoing communication between the consultant and the medical team. Finally, engaging with a single person may be less stressful to patients and families than meeting with groups of people, as would be required by the two other models described below.
The advisability and success of the single-consultant model, however, depends on several factors. Most importantly, individual ethics consultants should possess specific ethics expertise and be formally trained to provide ethics consultation. Currently in the U.S., fewer than 10% of consultants providing ethics consultations (including within the other models discussed below) have completed advanced training, such as a fellowship or graduate degree, in bioethics. Almost half of the individuals who perform ethics consultations have no formal training at all and have not been supervised as a consultant, leading to a lack of consistency in opinions or standards of quality.1 Recognizing the need to improve competency in ethics consultation, the American Society for Bioethics and Humanities (HCEC) has developed a certification program for healthcare ethics consulting.2 Admittedly, the ASBH program is not without its detractors,3 but it does represent a start in establishing minimum competencies for ethics consultants.
Full Committee
In roughly 20% of organizations, a full ethics committee takes on the role of ethics consultant and meets to discuss cases as they arise.1 This approach generally includes representatives from the medical team as well as the patient and/or their family, all of whom attend a meeting of the committee focused on a particular case. Typically, an ethics committee will be made up of a diverse group of individuals that might include clinicians, social workers, lawyers, spiritual care providers, members of the public, and ideally, at least one individual with advanced training in ethics.
This model has the advantage of including a group of individuals with a variety of backgrounds, clinical experience, and ethical expertise, who work together to analyze the ethical issues arising in a case. This allows for the debate and weighing of various arguments and claims, with the goal of reaching a consensus regarding recommendations. The group approach can help make up for a paucity of clinical expertise in individual committee members, and can also help overcome the tacit biases or fixed opinions that an individual ethics consultant might bring with them.
The biggest disadvantage of the full-committee model is inefficiency. Not only is it generally quite challenging to get a large group of busy people together in a timely fashion, but the process of the consult itself also tends to be cumbersome. Eliciting the relevant details of a clinical case, arriving at pertinent ethical questions, and reaching a consensus all tend to be much more time-consuming operations when performed by a group. The process can also be intimidating to the clinicians and, particularly, the patients and families who find themselves in front of a large group of people to discuss matters that are not only ethically but almost always also emotionally fraught.
Hybrid
The most popular model of ethics consultation currently in use in the United States1 has features of both single-consultant and full-committee approaches. This hybrid, or small-group, approach typically combines a point-person—who receives the initial request and completes the basic gathering of background information—and a small number of individuals, generally a subset of ethics committee members, who gather to discuss the case and make recommendations. Not surprisingly, this approach tends to split the difference between the other two models in terms of advantages and disadvantages.
One advantage of having a single person—with at least some experience in doing consultations and a basic level of expertise—doing the initial intake is that simple questions may be efficiently answered, and issues that are best dealt with by others—for example, risk management—can be referred without requiring a full meeting of consultants. Getting a convenient sample of ethics committee members together can usually be done expeditiously, avoiding delays in providing support and guidance. Furthermore, this model’s utilization of multiple individuals to discuss cases again helps overcome the personal biases of individual consultants.
Disadvantages of the hybrid model include the possibility that the small group may not have the expertise necessary to best address the case at hand. Especially in organizations that may only have one or two members formally trained in bioethics, the assessment and decisions of a small sample of individuals might be quite different from that of the entire group. Small groups can be more easily dominated by a single voice.
Conclusion
In the end, the model that works best for a particular organization is likely to be determined by the size and availability of ethical expertise at that organization. Hospitals with relatively few beds, few or no individuals with expertise in clinical ethics, and few cases requiring ethics consultation will generally be well-served by the full-committee approach. (Very small hospitals may want to reach an agreement with larger, supporting organizations to have them provide ethics consultation on an as-needed basis.) The single-consultant model tends to work best in large, particularly academic, organizations where there are both a significant number of consultations and group of well-trained ethicists who are able to share call. Since individuals will be asked to take call and respond promptly to requests for consultation, they should be reimbursed in some fashion by the organization for their service. For the many organizations that fall somewhere in the middle, a version of a hybrid model that balances efficiency with quality is likely to be best.
Regardless of the model employed, all ethics consultation services should have a system to review the cases and recommendations subsequently. For instance, having the full ethics committee regularly review consultations performed by individual or small groups provides not only provides quality control, but will improve the consistency of future ethics consultation.
References:
1. Fox E, Danis M, Tarzian AJ, and Duke CC. “Ethics Consultation in U.S. Hospitals: A National Follow-up Study.” Amer J Bioethics 22:4-18 (2022).
2. HCEC Certification Commission. “Healthcare Ethics Consultant-Certified Program.” Accessed on 1/22/24 at: https://asbh.org/certification/hcec-certification.
3. Siegler M. “The ASBH Approach to Certify Clinical Ethics Consultants is Both Premature and Inadequate.” J Clin Ethics 30(2): 109-116 (2019).
Mark R. Tonelli, M.D.
Professor of Medicine
Adjunct Professor of Bioethics and Humanities
University of Washington