The Observer, March 21, 2008
Volume XL, Issue 21
The modern day bioethics "committee:" not a committee at all
The notion of the "bioethics committee" – a group of ethicists and representatives from various disciplines sitting around a table reviewing and passing judgment on cases – is to a great degree a holdover from the beginnings of modern bioethics. When medicine started to recognize the significance of ethical dilemmas, committees were indeed formed to answer some of these difficult questions and provide courses of action. For instance, the controversial Patient Admissions Committee of the Seattle Artificial Kidney Center, which during the 1940s sought to allocate the new and scarce medical resource of hemodialysis, seems to be the image that we think of with respect to a "bioethics committee."
Today, at many hospitals and especially so at academic institutions, the landscape is far different. Ethics consultation services provided by on-call clinical ethicists are prevalent and have, in the words of one such clinical ethicist, reigned in the image of a "God squad" of ethicists sitting at a round table passing down rulings. Instead, in image and practice, the consultation services offer mediation, not mandates.
Any concerned witness, typically physicians, nurses, patients, and families, but also hospital staff and even passersby uninvolved with the case but having witnessed something of concern, can summon consultation services. In an effort to offer mediation, ethicists speak with all parties involved and seek to serve as facilitators of discussion, providing instead of a decree, a set of ethical options for practitioners, patients, and families to consider.
Such services have made access to academic ethical conversation far more widespread. They also come with a slew of new and interesting challenges. Among the most obvious and important are issues of simple logistics. It is not enough to offer an ethics consultation service; those to whom it is relevant must know about its existence for it to make any measurable impact.
Physicians and nurses are easier to reach – it is after all, offered in their workplace – but patients and families can be far harder to inform. Some hospitals include ethics consultations listed as a service in the standard patient informational pamphlet provided upon admission. At what rate, however, are people being admitted to a hospital actually able to make it through and internalize such pamphlets?
Medicine has maintained an extremely hierarchical system such that, despite the ability for "anybody" to request an ethics consultation as the system is designed, there are severe professional risks for medical students, residents, and fellows, for instance, to request a consult in a situation in which they are objecting to the handling of a case by an attending physician. It is not a stretch to see this as a compelling deterrent to taking advantage of the service.
As an academic discipline, modern clinical ethics is extremely decentralized. While some formal guidelines exist from various professional and governmental bodies, the practice of clinical ethics is based on a collection of the scholarly literature, not legislation, written by opinionated and often disagreeing contributors. The result is a system of individual clinical ethicists, with both their own opinions and diverse scholarly sources, trying to advance a practice that ideally, would have the same case under the same circumstances at two different hospitals on either side of the country decided with the same result. The reality is that the individual ethicists, their own opinions, and the literature they are able to find and choose to put weight in all impact individual cases.
In the face of, and indeed as a result of, all of these challenges and many others, the relatively new field of clinical medical ethics is, in the words of that same ethicist, "a vibrant but un-formalized system." With the obvious goal of actually improving the delivery of clinical care, the result is that perhaps the greatest challenge for this entire endeavor is, seemingly simple: to find a method for measuring its true impact on the practice of medicine.
George L. Anesi is a first-year medical student and a bioethics graduate student. He can be contacted at george.anesi@case.edu.
