HEC Forum (2006) 18 (4): 368-369. DOI 10.1007/s10730-006-9015-0

© Springer 2006

Ethics Committees: Beyond Benign Neglect

Jonathan D. Moreno

It’s time for a candid assessment of where ethics committees have been and where they need to go. If we select the Quinlan case as a crucial date, it’s now about 30 years since the beginning of the ethics committee movement. The Quinlan court famously identified a preferable alternative to legal review of such tragedies as “ethics” committees, though from their description it seems they were really talking about prognosis committees. Semantic niceties notwithstanding, in the increasingly litigious environment of the later 1970s, hospitals that found themselves playing host to life-extending technologies with no obvious brakes in sight were interested in just about any option that might avoid the type of scenario that played out in northern New Jersey. By the early 1980s the President’s Commission on Ethical Issues in Medicine estimated that most larger hospitals had ethics committees. At about that time, regulators began insisting that institutions have some mechanism for addressing the ethical issues that might arise in patient care. In the later 1980s there was even speculation that the federal agency in charge of Medicare might create a DRG (diagnosis-related group) for ethics consultation, thus legitimizing hospital charges for this purpose and creating a revenue stream for a new profession. Yet by the mid-1990s John Fletcher was expressing repeated concern about ethics committees’ “failure to thrive” and searching for ways to address this problem. By then the theory that every hospital would have to have an ethics consultant as a crucial adjunct to the ethics committee had fallen before certain hard realities: the new dominance of managed care and the disincentive of for-profit management to pay the salary of an in-house beeper ethicist who could easily turn into a liability. Ethics committees staffed by well-meaning volunteers were not always welcomed, and rarely compensated, but because they didn’t seem to do much harm, and because some kind of ethics mechanism is required by regulatory authorities, they _____________________________________________________________________________________ Jonathan Moreno, Ph.D., Center for Biomedical Ethics, University of Virginia, Box 800758, Charlottesville, VA 22908; email: [email protected].

HEC Forum (2006) 18 (4): 368-369.

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were tolerated. Uncountable numbers of expensive professional hours have been donated by many talented and dedicated people to ethics committee work over the past thirty years. But failure to thrive is the stepchild of benign neglect. All this left many committees pretty much on their own. Some of them have managed to scare up more work than others, but that seems mostly a function of the esteem in which members are held by their colleagues or the opportunities of some clinician committee members to identify problematic cases in the course of their work. Virtually unheard of now is any serious commitment by many ethics committees to function as internal resources for systematic ethics education among the staff in general, though in the 1980s this was frequently touted as perhaps an even more important function of the committees than case review. I would be happy to be proved wrong in this laconic assessment of the ethics committee landscape, and there are surely exceptions. I am sure that some of the readers of this issue operate in a very different environment from the one I have sketched. Yet their committees are likely to be exceptions that prove the rule. Paradoxically, health care institutions with healthy professional environments are the places that need ethics committees the least. One key to the beginning of a correction of failure to thrive lies in addressing ethical issues in healthcare organizations as a systemic challenge, requiring a comprehensive approach. However analysis of systemic problems can’t be dealt with simply by adding another committee to continue with business as usual. The organization’s moral climate must be addressed by developing mechanisms to define and oversee its existence and growth, with the ethics committee as one action arm. If the organization as a whole isn’t committed to this effort no ethics entity can rise above benign neglect; if it is then the committee’s success is virtually assured and it can grow and thrive in the future healthcare organization. A similar insight, that a comprehensive approach to ethics is needed, now guides institutional review boards, as research institutions are seeing that the locus of responsibility is the human research participant protections program, with the institutional review board as only one element. We know that addressing ethical issues in health care organizations is a systemic challenge, but without some kind of impetus, the evidence is that we will ignore those issues that need addressing. I believe this approach or one similar must be initiated by accrediting bodies, in order to move ethics committees beyond benign neglect.