Most hospitals have some type of ethics committee in place, but how effective they are varies widely, says Mathew David Pauley, JD, MA, MDR, a regional ethicist at Kaiser Permanente Northern California in Oakland.
Pauley provides oversight to 21 medical centers with 17 ethics committees. “There is some disparity in how they operate. But the general model is that we have co-chairs who are not ethics professionals. They are the standard well-meaning, ethics-interested person,” Pauley observes. These are some common issues Pauley has seen arise:
• Ethics committees can become bloated. Ethics committees may become so popular that they end up with too many members — as many as 42 in one case. With this many people in the mix, the meetings became more of a social club.
“We have found that the golden number is around 16. The more beyond 16 members, the less efficient the committee becomes,” Pauley reports.
• Members may not know what role to play. “We have seen the failure to thrive issue,” Pauley notes.
A job description on what is expected of a committee member can help prevent this lack of clarity. In Pauley’s former role as an ethicist and co-chair of an ethics committee, he was handling 90% of that medical center’s consults. “Only a few consults required more than a single-ethicist approach. I was also doing so many consults that they all could not be discussed in retrospective review,” Pauley recalls.
Using the current co-chair model, some members also handle consults, although they are largely untrained as clinical ethicists. Members were included in the hospital’s committee on triage decisions. This gave them the appropriate training to become involved should the need for scarce resource allocation ever arise. “But in the general day-to-day, the members are there as a reminder to bring their background and specialty to the conversation,” Pauley adds.
• Some members are happy to be on the committee, then never show up again. People may be well-intentioned, but just do not have the time to commit. An attendance policy can be helpful.
Ethicists can ask the member if there is something he or she can to do encourage their attendance. Ideally, says Pauley, “we give them the option to step down rather than get kicked off.”
• Certain members report conflicts of interest. Risk managers, lawyers, utilization managers, and discharge planners are not the typical people one would expect to see on an ethics committee. These individuals can offer valuable insights, but they also may be carrying conflicts of interest. “These are areas that we may want to have higher levels of scrutiny about their participation,” Pauley offers.
This can be tricky if an individual’s appointment on the committee comes from hospital higher-ups. Ideally, the committee selects its own members, all of whom are participating for the right reasons. Members should be there to ensure ethical care is provided, as opposed to keeping the committee in check.
Pauley has seen it work both ways. On one committee, a hospital risk manager came forward to join because she cared about ethics issues. Every time there was even the hint of a potential conflict, she brought it to the committee’s attention proactively. On other occasions, hospital administrators joined the committee, but seemed to express little interest or awareness of ethics. That can be an indication of an ulterior motive. “There have been times when risk management is there to prevent risk,” Pauley cautions.
• Committees may lack representation from all relevant areas. Those who needs ethics consults often (the ICU, hospital-based services, hospitalists, nursing, social workers, and chaplains) usually are well-represented. There may be other important specialty services left out.
If a hospital is well-known for its neurosurgery, a neurosurgeon probably should be on the committee. This can result in some push-back from hospital leaders concerned about cost. Administrators question why they should pay a neurosurgeon for several hours of time for something other than neurosurgery. “The ethics committee can get very pricey from that point of view,” Pauley shares.
One solution is for specialists to bill at a different, lower rate of reimbursement for their time spent on ethics committee work than for their clinical work. Another option is to obtain input from specialists as needed, instead of enlisting them as official committee members. For instance, a neurosurgeon would be the designated “go-to” person whenever an issue involving neurosurgery arises.
• There are committees that meet for hours, but do not achieve much. If there are not tangible results or activities that benefit the whole organization, hospital administrators are going to question the value of the ethics committee. “If the ethics committee is in a silo only talking to itself, and not providing any sort of benefit, the administration may question why they are paying people a lot of money to sit in a room and talk to themselves,” Pauley cautions.
Agenda-focused committees, which provide education to various hospital departments or review policies, can avoid this negative perception. Building a good relationship with hospital administrators is helpful in more ways than one. It helps convey the value of the ethics committee.
It also helps when “outlier” cases come up. Ethicists may be faced with people threatening legal action regarding conflicts over brain death or non-beneficial treatments. “Administrators do have the ability to speak with more authority and commit the hospital in a way that ethics may not be able to,” Pauley says.