The vast majority of hospitals have ethics committees. Yet these committees vary in terms of their effectiveness, leading some ethicists to conclude it is time for a new approach.
“The field has matured and professionalized so much since the inception of ethics committees. It’s reasonable to experiment and try new things. We can have thriving ethics programs using new approaches,” says Hilary Mabel, JD, HEC-C, core faculty and healthcare ethicist at Emory University Center for Ethics.
Mabel has worked with multiple ethics committees, some high-functioning, and others less so. “We started to question, ‘Should we be doing clinical ethics this way? Are we doing it this way just because this is the way it’s always been done? Would another way be better?’” says Mabel.
One approach is the professional clinical ethicist (PCE)-primary model, which Mabel and co-authors describe in a recent paper.1 The model dissolves the traditional ethics committee and places primary responsibility for ethics work on PCEs. “In place of ethics committees, new structures can be created to allow former ethics committee members and other hospital staff to collaborate with ethicists and engage in meaningful ethics work,” says Mabel.
One form of this model was implemented at Wellstar, Mabel’s previous institution, in 2022. At Wellstar, ethics committees were discontinued. In their place, the ethics program initiated these approaches:
• a regular ethics grand rounds series for systemwide education;
• an ethics liaison network for highly engaged staff seeking advanced education and camaraderie;
• an ethics advisory group to weigh in on strategic directions and other goals.
Mabel expects that more ethics programs will consider the PCE-primary model as time goes on. “Talking about the PCE-primary model helps soften the taboo of deviating from the traditional ethics model,” says Mabel. “If first movers find success with it, other programs may increasingly consider innovating their programs as well.”
Implementing the PCE-primary model poses multiple challenges, however. It is likely to result in significant pushback from longstanding members of the ethics committee. “You have to develop a thoughtful plan for what you are going to replace ethics committees with — for what comes next,” advises Mabel. “Patience, adaptability, and creativity are important.” Since everyone in healthcare is familiar with ethics committees, it’s necessary to get people comfortable with the idea of a different model. “You have to be clear in your vision. Getting buy-in from hospital leadership is essential for a transition process, as well,” says Mabel.
There is a risk of losing valued, experienced ethics committee members. Some will choose to discontinue collaborating with the ethics program under the new model. “For folks who see the ethics committee as part of their professional identity, there may be hurt feelings,” says Mabel. “There is a need to retain these folks in the next iteration of your ethics program and maintain those strong relationships.”
Healthcare providers with an interest in ethics sometimes want to know, “What does the ethics committee do?” “The purpose was hard to define,” recalls Joshua Crites, PhD, a staff ethicist, regional ethicist, and co-director of the Cleveland Fellowship in Advanced Bioethics at Cleveland Clinic.
Crites and colleagues were concerned that the ethics committee was not as productive as it could be, even though there were many invested members. “You’ve got a group of interested people. They come to the meeting, and they hear about cases and get some self-education. But the output from that is sometimes limited, because they may not have the time or expertise to deliver that education outside of the committee itself,” explains Crites.
Some healthcare providers wanted to become ethics committee members, but their schedule would not permit them to attend meetings. Typically, ethics committee meetings were held at 7 a.m. or 12 p.m. “Clinical nurses, in particular, have difficulty getting to those meetings and getting coverage for their patients. They sometimes have work restrictions where they can’t do things on days when they are not working,” says Crites. The same issue came up with members of the community, many of whom were at work during the committee meeting times.
To address these issues, and make the ethics program overall more effective, Crites and colleagues made some changes. Professional clinical ethicists still are the ones who do the actual bedside consultation work. However, ethicists dissolved ethics committees at Cleveland Clinic Ohio hospitals and replaced those with a new model. “A structured, tiered network allows healthcare professionals to incorporate a passion for, and commitment to, ethics into their professional development. With the new model, we provide a clearer set of expectations, and we teach those expectations in ways that we couldn’t as a committee,” reports Crites.
The network for healthcare professionals also has a community-based counterpart. “We have a parallel group of people from the community who function alongside us,” explains Crites. Without some of the structural limitations of a committee model, greater representation of communities and higher community member engagement is possible.
The new ethics model also is more efficient. Previously, Crites and colleagues had to go to 13 different ethics committees within the health system to obtain input if a policy needed updating. Some of the committees met only quarterly, delaying review and input. Many policies, such as the system’s do-not-resuscitate policy, required specialized knowledge rather than input from all committee members. “Relatively few members had expertise in policy work,” explains Crites. Similarly, contributing to ethics initiatives (such as quality improvement of the Ethics Consultation Service) was limited by the committee structure. “You’ve got only a couple people with the time and interest to engage in those kinds of things,” explains Crites.
Now, PCEs can draw on a group of people throughout the healthcare system and the community to form goal-driven and time-limited task groups. When a policy comes up for review, or an organizational issue would benefit from ethics guidance, ethicists query the network for volunteers.
The new model provides standardized core education for members, known as “ethics ambassadors.” Members obtain professional growth and development, as opposed to just being an attendee at a committee. “That’s really the idea here — to create a network of people who are more fulfilled in their jobs because they understand some of the ethics issues that are at play. They are able to help their colleagues in a way they were not previously,” says Crites.
All participants are expected to be able to identify ethics issues on their units. For example, an ethics ambassador may hear a colleague say that the family is struggling to identify what is important to the patient. If so, the ethics ambassador would identify the need to clarify patient values and ensure goal-concordant care. “That’s something that we can empower all healthcare professionals to do directly,” says Crites. In other cases, the issue is a clinical problem, not an ethics problem. “It helps orient everyone involved to come to a solution, if you know what framework to apply to solve the problem,” says Crites.
Ethics ambassadors also are expected to recognize when they need support from a professional clinical ethicist. “We are not asking people to become ethicists or do ethics work. We are endeavoring to empower them to do the work that they know how to do a little better. They are able to more confidently approach some of the ethical aspects of their care that they see every day,” explains Crites.
An ethics ambassador might say, “It sounds like not everybody is on board with the plan of care. Let’s talk about that.” “Sometimes it comes as a surprise when you are moving forward and one person is not OK,” says Crites. Ethics ambassadors routinely ask questions such as: “Have we talked to all the right people? Do they know what the plan is? Do they support the plan? How can we support them?”
“If we can get 10 more people in every hospital asking those kinds of questions, that is the benefit of having a more diverse group of healthcare professionals involved in ethics work,” says Crites.
Ethics is interwoven into everyday patient care, as opposed to being restricted to monthly or quarterly meetings. “This makes ethics hyper-local at the bedside and accessible to caregivers in a way that an ethics committee can’t,” concludes Crites.
REFERENCE
- Mabel H, Crites JS, Cunningham TV, Potter J. Reimagining thriving ethics programs without ethics committees. Am J Bioeth 2023; Nov 14:1-16. doi: 10.1080/15265161.2023.2276172. [Online ahead of print].
The vast majority of hospitals have ethics committees. Yet these committees vary in terms of their effectiveness, leading some ethicists to conclude it is time for a new approach.
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