Flagler ethics committee focuses on self-training

Approach relies on case "work-ups"

Flagler Hospital - St. Augustine on Florida's east coast may offer practices or lessons for other mid-size to smaller community hospitals.

After serving on the ethics committee for Flagler Hospital – St. Augustine, FL, for several years, Michael C. Sanders, MD, a solo practitioner, was asked to chair that committee for the hospital about five years ago at this mid-size hospital.

"And I said, 'Only if I can run it the way it needs to be run," Sanders tells Medical Ethics Advisor.

Since then, he has recruited 16 members for the hospital ethics committee, about half of whom are physicians, with other members including an attorney, a minister, staff nurses, social workers, community members, and two members trained in bioethics.

The previous structure for the committee comprised about five or six members, who routinely focused on the facts of a particular case before sharing opinions on that case.

"There was no formal ethics training, nor was there any evaluation," Sanders recalls. "So, one of the things that I said we needed to do was not only have an ethics committee, but when they were appointed, it had to be for a minimum of five years; otherwise, you get someone trained, and they rotate off and you've lost [that training and knowledge]."

As a training/education tool, Sanders selected a book titled "Clinical Ethics," which includes an ethical case workup for each case that comes before the committee. The workup was originally called the "four boxes method." In the last volume, it was referred to as the "four topics method," he says, noting that this process "essentially breaks every case down to the medical indications, patient preferences, quality of life, and contextual features."

Sometimes, different members of the ethics committee are charged with working up a particular topic, and then they meet as a committee.

"If it's a pressing case, we may do it at the same meeting," Sanders says, noting that while the committee has discussed bringing in outside speakers on ethics topics, it generally fares much better by working through the four topics methodology from the book.

Also, each formal, documented case is filed in the medical staff office for "the committee itself to refer back to when there may be a similar case or similar problems. We're building, really, a case file of the problems that we've encountered," he explains.

Another accomplishment by the committee is the development of an operating manual for the ethics committee itself, i.e., its policies and procedures.

"We [formalized] not only the way in which we go through these cases, but we really established an institutional policy . . . for Flagler Hospital," he says. The manual is between 120-130 pages.

Once the institutional ethics policy was developed, the ethics committee presented it to the medical staff, who approved it. At that point, the policy was put online, so hospital employees can reference it, when needed.

"We simply use that as reference, and nurses in the hospital, physicians in the hospital, ancillary staff can refer to that manual and know, how do I get a referral, and what do we do, what is it that you are looking for, how does it work, what kinds of things we should bring to the ethics committee, and what does the ethics committee really do," Sanders explains.

Sanders emphasizes that by presenting cases in general staff meetings, he is able to educate the staff about what the ethics committee does, "so people know how the system works [and that] we're not just sitting in a room and saying, 'Well, that sounds like a good idea.' "But we actually go back to published literature from the 1700s on ethical reasoning and try to have people understand, one, what are the principles of bioethics, what is the principle of double-effect, and how does that happen, because it comes up very frequently in medicine," he says.

Simple cases, complicated questions

Sander notes that he disagrees with any suggestion that smaller hospitals — Flagler Hospital – St. Augustine has about 300 beds — lack the complex cases that a larger, urban hospital might have.

"I would disagree with the logic," he says. "I've certainly heard that before, but most of the time, the ethical issues and dilemmas are not necessarily associated with complicated cases. So, I would suggest that even small, community hospitals of 100 beds or less are going to run into the same problems we do."

Sometimes, he says, complicated medical cases can actually be quite simple from an ethical perspective.

Sanders provides an example of a man who had tried to commit suicide presenting to a small emergency department (ED). The ED physician inserted a nasogastric tube to pump that patient's stomach, but the patient began objecting, saying, "No, I don't want this done."

"How do you approach that? That problem can exist in any size hospital, and it's a problem that needs to be dealt with immediately, which is why we have an emergency consultation service for the hospital, so that if something happens, we can do the consults immediately," Sanders says.

Emergency consults conducted

When there is an emergency situation, members of the ethics committee respond, if an ethics consult is needed. That group typically includes Sanders, as the chair, or the vice chair, as well as two or three other members of the ethics committee.

"We'll go to the emergency room; we'll gather the facts; we'll talk to the attending; we'll talk to the patient or the family and try to put the case together and decide whether or not this really is an ethical problem, if it needs a full committee review — and if it does, we'll hold a meeting right then," Sanders explains.

Otherwise, if it turns out to be a misunderstanding, Sanders or the vice chair and the rest of the team explain what they think the problems are — and why this particular case does not present an ethical issue.

"If that's acceptable to the patient or the family or the physician, then the team that's gone to do the [emergency consult] will write up this problem, and at the regular committee meeting, they will present the case," Sanders says.

Continuous learning is critical

Learning from previous experiences is the most important aspect, says Sanders, describing himself as "an Edward Deming guy."

Deming in the 1950s developed Continuous Quality Improvement, a business process approach he took to Japan after it was shunned in the United States, and "the rest is history," as Sanders says.


  1. Jonsen A, Siegler M, Winslade W."Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine."


Michael C. Sanders, MD, Solo Physician Practice and Chair of the Flagler Hospital – St. Augustine Ethics Committee. St. Augustine, FL. E-mail: mikesandersmd@bellsouth.net.