relating to the handling of social and ethical issues that arise from developments in biomedicine. The committee nevertheless recommends that formal studies of the optimum roles, use, and outcomes of HECs be undertaken by such groups as the Office of Technology Assessment, Institute of Medicine, and foundations interested in health care issues.

As has been described in this report, HECs were originally proposed as a mechanism for sharing responsibility for morally charged treatment decisions by hospital staff, patients, and their families. However, a tension exists between the HEC as a forum for professionals and as a vehicle for fostering the rights and interests of patients and their families (Wolf, 1991, 1992). HECs constitute one way in which medical decision making has been democratized by being opened to input from nonphysicians (e.g., nurses, administrators, clergy, and family members).

The Joint Commission on the Accreditation of Health Care Organizations (JCAHO) requires that hospitals have a HEC or a similar body or process as a condition for U.S. hospital accreditation (which is tied, in turn, to eligibility to receive Medicare payments). The JCAHO also requires accredited hospitals to provide education on ethical issues to staff, patients, and families. It has been suggested, but not required, that HECs assume additional roles such as developing patient rights standards; formulating and/or reviewing institutional policy and procedural guidelines on decision making for medical care; reviewing diagnoses, prognoses, and treatment decisions made for specific patients by doctors and surrogates; and mediating conflicts that might arise over treatment decisions. Although HECs seem to be potentially useful bodies to help patients, families, surrogates, and other decision makers deal with ethical and social issues, it is unclear at present how many HECs exist, how they function, and what the outcomes are of the various ways in which they can operate.

The committee believes that HECs or similar committees operating across health plans could help patients and health care professionals deal with social and ethical issues that arise from developments in biomedicine. Little is known about the range and characteristics of effectiveness of these committees; this knowledge needs to be expanded. This sort of knowledge will aid in the design and evaluation of similar ethics committees that may accompany health care reform.

Institutional Review Boards

As discussed elsewhere in this report, the committee believes that past experience with IRBs has been important and salutary, but that the present structure and role of IRBs should be evaluated and, if necessary, modified.



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