ethicists have analytic skills and knowledge of tradition and contemporary standards that can strengthen the IEC's confidence and effectiveness. The place of lawyers and ethicists on the IEC has been debated, however, and many hospitals have no opportunity to include experienced professionals in health law or clinical ethics in their committees.

Lawyers and theoretical ethicists, with no clinical experience may misunderstand the issues and mislead the IEC with information and perspectives that, while technically correct, are inappropriately applied (22; 27; 54). Hospitals with an attorney on retainer are often hesitant to pay to have legal counsel attend committee meetings, and few non university hospitals contract for an ethicist's ongoing professional services. Small hospitals in large for-profit chains may work primarily with lawyers at a corporate headquarters who know little about the specific institution. Attorneys who see their single role as protecting the hospital from liability may encourage the IEC to become a risk-management committee; ethicists who see themselves as the patient's only advocate may put off the very caregivers who most need consultation; both may hamper the effectiveness of the IEC in consultation and the creation of policy.

Some handbooks written by clinical ethicists concede that there is no need for a staff ethicist on many IECs, but note that committees should attempt to include professional ethicists among their educational speakers (22; 23). However, the continued growth of this discipline and the educational opportunities in clinical ethics will almost certainly increase the prominence of clinical ethicists in the hospital setting.

Since the publication of its patient rights standards, JCAHO has taken interest in the makeup of IECs, and has begun to consider standards for IEC membership and ethics consultation (55). JCAHO's interest comes at a time when there is already a spirited discussion among clinical ethicists about the value of professional certification (56). Ethicists themselves are far from agreed on whether clinical ethics consultation is a profession, and if so what level of education, training, and expertise should be expected of its members. JCAHO is interested in the practice and credentials of clinical ethicists, but is particularly concerned about the quality of IECs in small and rural hospitals where ethicists are virtually nonexistent and few caregivers are likely to be proficient in clinical ethics. JCAHO is currently observing the creation of ethics committee networks in Virginia, with the hope that similar affiliations elsewhere could serve as cooperative regional ethics committees for institutions unable to create IECs individually (E.M. Spencer, personal communication).

Over the past several years, a number of local and statewide IEC networks have evolved across the country (57). Typically networks develop as members of newly formed IECs seek advice from other institutions, par-