Consider this recently unsolicited comment: “I really need to be on the ethics committee. I’m not shy about telling folks what is right and what is wrong.” For F. Keith Stirewalt, PA, MBA, MDiv, a remark like that is worrisome.
“I fear those with monocular lenses coming onto the committee, seeing the world only through their personal perspective,” says Stirewalt, chaplain for clinical engagement at Wake Forest Baptist Medical Center in Winston-Salem, NC. Ethics committees thrive on the diverse perspectives of patient advocates, attorneys, chaplains, and hospital leaders. “Administrators are often forgotten, or seen as the ‘enemy,’” Stirewalt observes. Stirewalt provides a few examples of diversity in ethics committees:
- A university-based elder law attorney can address the legalities of a situation;
- Chaplains can emphasize the need to respect diversities of faith in patients, visitors, and staff;
- An academic philosopher may be the only one bold enough to ask, “Why?” when everyone seems to agree on a particular course;
- A neonatologist can explain why a policy for adult patients is not appropriate for pediatrics;
- Nurses can point out why a process sounds good in theory, but will not work in clinical practice.
The answer, says Stirewalt, “is to be purposeful in the recruitment of people with these various lenses. Who is missing at the table? We need to go get them.” Recruiting individuals who would benefit the committee is not always easy. One obvious obstacle is lack of compensation. “Participation in ethics comes at the cost of time, paid for in the shifting of professional duties and by less time and energy with our families,” Stirewalt laments.
Diversity on the ethics committee “doesn’t just happen. It has to be intentional,” says Robyn M. Axel-Adams, M.Div, BCC, manager and senior affiliate faculty at the Charles Warren Fairbanks Center for Medical Ethics.
A respiratory therapist, music therapist, dentist, and quality control expert can add insight that a committee would never have thought of before. “Chaplains and social workers help us to view the patient in a holistic way,” Axel-Adams adds.
In one case, a frail, elderly woman was unconscious, and slowly dying. Her daughter insisted she remain a full code, even though it was potentially inappropriate, and no one wanted to perform CPR on the woman. “The chaplain was able to ascertain that the patient’s religious conviction was that the more she suffered, the more grace God released into the world,” Axel-Adams recalls.
This belief was a primary reason she stayed in an abusive relationship and would now remain a full code. “The staff was challenged with this theology, but respected her values and kept her a full code,” Axel-Adams reports.
Diverse ethics committee members can bring previously unexplored options to light. A recent case involved a woman who had resided at a long-term acute care hospital, and was now refusing to eat. She struggled with cognitive impairment, and could not express why she was not eating.
A dental professor, and member of the ethics committee, voiced concerns about a dental issue. She asked if the patient recently underwent a dental examination to see if there were any intraoral conditions that might be contributing to her refusal to eat. “We were all taken aback that we had not thought of the obvious,” Axel-Adams says.
Ethics-related policies affect the entire hospital community. “Thus, having representation from a variety of disciplines will help ensure many voices are heard and respected,” Axel-Adams adds.
Stirewalt favors an application process for anyone interested in joining the ethics committee. During this process, it is important to ask these three questions:
- Why do you think you would like to be on the ethics committee?
- How do you feel your experience and knowledge will assist the committee?
- What are your hesitations about joining the ethics committee?
People do not necessarily need extensive education in bioethics to participate on an ethics committee. “It is true — ethics committees need folks with formal bioethics training,” Stirewalt admits. However, he says the basics, the ethical principles of autonomy, beneficence, nonmaleficence, and justice, can be taught to newbies.
“In the end, committees need competent, reflective listeners who are not afraid to speak up when they perceive the risk of injustice,” Stirewalt offers.
Also, it is important to eliminate those who are interested for the wrong reasons. Members must be willing and able to wrestle with difficult issues, not just hear about conflicts, inappropriate surrogates, and unusual end-of-life cases. “There is a fine line between voyeurism and contribution on an ethics committee,” Axel-Adams stresses.
Interdisciplinary composition is “what makes ethics committees so valuable,” says Peter Clark, PhD, professor and director of the Institute of Clinical Bioethics at Saint Joseph’s University in Philadelphia. Clark shares a few observations about the makeup of ethics committees:
- Nurses and physicians comprise about half of all members;
- Many committee members are women;
- Most committees include an administrator and a chaplain (or at least someone trained in pastoral care);
- Most committees include lawyers, board members, or risk managers;
- Most committees lack at least one person from a racial or ethnic minority. “Achieving ethnic and racial diversity remains a challenge,” Clark says. Recruiting representatives from different ethnic and racial backgrounds could help facilities identify and eliminate disparities in care, Clark adds.
- Few committees include nutritionists, occupational or physical therapists, or psychologists. Clark suggests including psychiatrists or psychologists would be helpful because an ethics committee often addresses issues surrounding a patient’s competency to make medical decisions.
For issues around wound care, Clark says occupational and physical therapists are especially beneficial. Their opinions on pain management could be valuable. Additionally, since feeding tube issues are yet another key subject for ethics committees, a nutritionist could help address those needs for elderly patients.
Clark says ethics committees should include at least representatives from social work, nursing, clinical ethics, pastoral care, respiratory care, law, psychiatry/psychology, and dietetics and nutrition. There also should be at least one community representative. “The committee should also try to be diverse culturally and racially, especially in the appointment of the community member,” Clark adds.