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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:
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:
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:
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.
Financial Disclosure: Physician Editor Arthur R. Derse, MD, JD, Nurse Planner Susan Solverson, RN, BSN, CMSRN, Editor Jonathan Springston, Editor Jill Drachenberg, Editorial Group Manager Leslie Coplin, Accreditations Manager Amy M. Johnson, MSN, RN, CPN, and Author Stacey Kusterbeck report no consultant, stockholder, speakers’ bureau, research, or other financial relationships with companies having ties to this field of study.