Organization- or System-Level Strategies

The discussion in the preceding section focuses on the resolution of disputes at the individual level but also points to the need for organizational- and system-level responses to prevent or resolve conflicts. If distrust related to ethnic or religious differences appears to be at the heart of some disputes, are there organizational or community sources of distrust or misunderstandings that should be investigated and responded to by health care organizations and their communities? If misunderstanding of facts or terminology is a consistent problem, can training programs and protocols be created to help clinicians communicate more successfully or might public education programs be helpful?

Ethics Committees

Ethics committees and similar groups constitute a system-level effort to assist in the resolution of disputes about clinical care (see, e.g, Fletcher, 1991; AAP, 1994b, 2001d; AMA, 1984, 1994b; Dugan, 2001). They developed as hospitals struggled with the increasingly difficult questions that advances in medical technology have created. In 1983, the President’s Commission endorsed the creation of hospital ethics committees. Such committees are now part of the institutional fabric of most American hospitals. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) accepts such committees as one approach to meeting certain of its requirements, for example, having a “functioning process to address ethical issues” (JCAHO, 1998, Standard RI.1). A number of organizations have set forth guidelines for the creation, composition, and operation of ethics committees. Box 8.1 presents the recommendations of the AAP.

To a considerable degree, ethics committees have focused on articulating processes and providing consultative resources for resolving disputes without necessarily establishing guidelines or rules to address the substance of such disputes. For example, committee consultants may be useful in identifying when a persistent conflict in values may be best handled by transferring responsibility for a child’s care to another physician or trying to arrange for the child’s transfer to another institution. More generally, they may set forth processes for attempting to determine when a dispute is grounded in misunderstanding of facts or terminology and when it is grounded in true differences in values about the goals of care or the benefits of treatments. Box 8.2 summarizes the elements of such a process.

Ethics committees may also propose and try to develop professional consensus on institutional policies for specific issues such as DNR orders. In addition, committees usually have an educational role in teaching other

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