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Society's Choices: Social and Ethical Decision Making in Biomedicine Institutional Ethics Committees: Local Perspectives on Ethical Issues in Medicine ELIZABETH HEITMAN, Ph.D. Assistant Professor, University of Texas School of Public Health THE HISTORICAL DEVELOPMENT OF INSTITUTIONAL ETHICS COMMITTEES Institutional ethics committees (IECs) have evolved over the past two decades in the United States and Canada as health care professionals, hospital administrators, regulatory agencies and legal authorities, and patients and their families have struggled to make good decisions about applying resuscitative and life-sustaining technologies. Much of the history of the IEC parallels the development of medical ethics as an academic and, more particularly, clinical discipline. However, the practical nature of clinical ethics and constraints of law and institutional policy have also led IECs to a theory and practice distinct from academic ethics. The first public call1 for an advisory body on clinical ethics2 came in 1971 from the Catholic Hospital Association of Canada (CHAC) and the Canadian Catholic bishops.3 Their Medico-Moral Guide (1), a handbook on the application of the Roman Catholic teachings known as the Ethical and Religious Directives for Catholic Hospitals, recommended that Catholic institutions establish special committees to: (a) educate the hospital community on the moral dimensions of life-sustaining technologies; (b) provide a forum for interdisciplinary dialogue on their appropriate use; (c) make institutional policy on the application of the CHAC's guidelines in treatment; and (d) serve as a legislative watchdog for Catholic interests. The first mention of such committees in the United States appeared in a 1975 article on the highly publicized nontreatment of a newborn with Down's Syndrome at Johns Hopkins Hospital (2). Physician Karen Teel
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Society's Choices: Social and Ethical Decision Making in Biomedicine observed that doctors often hesitated to make difficult medical decisions because of the perceived threat of legal action against them. She suggested that an institutional sharing of responsibility for morally charged treatment decisions might make it easier for physicians to take appropriate action. Teel recommended that multidisciplinary committees analyze treatment options for deformed infants in light of their legal, ethical, and social aspects, and support physicians in their implementation. In 1976 the New Jersey Supreme Court cited Teel's work in its ruling In re Quinlan (3). Although the Court assumed jurisdiction over the issue of surrogate decision making and awarded Karen Ann Quinlan's father guardianship for the express purpose of consenting to the withdrawal of her ventilator, it contended that the court was not the proper site for such decisions. Instead, it declared that the authority of an incompetent patient's guardian included decisions to limit or refuse life support, and that such decisions should be made in consultation with an "ethics committee," as described by Teel, or a "reasonable counterpart." The Court understood the committee's role more in terms of assessing the patient's prognosis than resolving the ethical dilemmas of treatment, and mistakenly assumed from Teel's comments that hospitals commonly had such committees. The state then issued guidelines for such prognostic bodies, consisting of physicians from varied specialties, and for their role in decisions to withdraw life support (4). In 1977, the Hastings Center held a conference on the actual and potential roles and responsibilities of IECs. Participants' experience of the roles and constitution of such bodies differed, but they generally agreed that multidisciplinary committees, well versed in the ethical issues of medicine, could serve in a valuable advisory capacity to physicians and families confronted with difficult treatment decisions (5). In 1983, the President's Commission for the Study of Ethical Issues in Medicine and Biomedical and Behavioral Research issued its report on the ethical, medical, and legal issues in decisions to forego life-sustaining treatment (6). The report focused on the creation of procedures for such decisions, and examined the role of public and private organizations in establishing and governing the process. The Commission recommended that hospitals formulate specific policies on withholding and withdrawing life support for competent and incompetent adults, and children and infants. In evaluating procedures for surrogate decision making, they rejected the practice of seeking formal judicial review as too cumbersome, too adversarial, too expensive, too public, and too harmful to the process of patient care (6, 159). They concluded that institutions should establish institutional procedures to "promote effective decision making for incapacitated individuals" (6, 160), including neonates (6, 227); one such procedure was review by a hospital ethics committee (6, 439-442).
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Society's Choices: Social and Ethical Decision Making in Biomedicine As envisioned in a model bill included in the report (6, 439-442), institutional ethics committees could serve to: (a) confirm the patient's diagnosis and prognosis; (b) provide a forum for discussing the social and ethical issues that a particular case might raise; (c) educate staff on the identification and resolution of ethical problems; (d) formulate institutional policy and procedural guidelines on decision making; (e) review treatment decisions made for specific patients by doctors and surrogates; and (f) mediate conflict over patient care between health care professionals, patients, family members, and the institution. They recommended a multidisciplinary committee that would be available to staff and patients and their families, and that would operate formally, keeping minutes and placing consultation records in patients' charts. The Commission's survey of hospitals found that few had established formal institutional structures, and those that had reported them to have widely divergent functions and composition (6, 443-457). While the Commission concluded that IECs offered an appropriately sensitive, rapid, and private approach to safeguarding the interests of incompetent patients, it cautioned that there needed to be more study of their use and outcomes before their adoption could be recommended, much less required. It further suggested that both the American Hospital Association (AHA) and the Joint Commission on the Accreditation of Hospitals (JCAH) examine the formation and varied functions of IECs. In 1983, when the federal government established guidelines equating nontreatment of severely impaired newborns with discrimination against the handicapped, known as the Baby Doe rules (7), both the AHA and the American Academy of Pediatrics (AAP) challenged the regulations on the grounds that local ethics review would be more valuable than federal oversight. The AHA, AAP, and American Medical Association (AMA) filed suit to have the rules invalidated, and later that year, the AAP issued guidelines for the establishment of multidisciplinary "infant bioethics committees" to review the proposed nontreatment of severely impaired infants using a best-interests standard that recognized the limits of technological intervention (8). When the regulations were overturned in early 1984, a judgment subsequently affirmed by the U.S. Supreme Court (9), Congress attempted "compromise legislation" that made the withholding of "medically indicated" treatment a form of child abuse or neglect (10). An essential part of this legislation was the requirement that hospitals with neonatal intensive care units (NICUs) have a multidisciplinary Infant Care Review Committee (ICRC) to assist in the determination of appropriate intervention for affected infants, in keeping with the AAP guidelines. Also in 1984, the AMA (11) and AHA (12) each called for the formation of voluntary ethics committees in hospitals and other inpatient institutions to "consider and assist
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Society's Choices: Social and Ethical Decision Making in Biomedicine in resolving unusual, complicated ethical problems" in such areas as quality of life, terminal illness, and the use of limited resources (11). The AHA suggested that the IEC could serve to establish policies on withdrawing and withholding treatment at the end of life; to educate staff, patients, and the public on the medico-moral aspects of caring for terminally ill and/or severely deformed infants; and to provide consultation to doctors, other health professionals, patients, and families in situations where the use of medical technology created ethical conflict (12). In 1987, the state of Maryland enacted legislation requiring hospitals to establish IECs to advise caregivers, patients, and family members on ethical aspects of the treatment of terminal illness (13). The law also suggested that committees review and formulate institutional policy on the use of life support as well as conduct educational programs for hospital staff and patients and their families on ethical issues in medical decision making. The Act specified standards for the IEC's composition, as well as a variety of procedural aspects, including that it: (a) notify all patients of its existence and their right to seek an advisory opinion; (b) consult all caregivers, the patient, and the patient's family in its deliberations; (c) and keep written, but confidential, records and place its formal recommendation in the patient's chart. The Act also freed the IEC from legal liability for recommendations given in good faith. In 1990, the U.S. Supreme Court affirmed Missouri's right to impose a strict standard of evidence of patients' wishes regarding withholding and withdrawing treatment (14), ruling in the case of Nancy Cruzan, a permanently unconscious woman whose family sought to discontinue her tubal feeding. As Cruzan was unfolding, Missouri Senator John Danforth, intent on preventing the need for court intervention in treatment decisions, proposed legislation to require hospitals and other inpatient institutions to inform patients about their state's law on the use of life-sustaining treatment, and to ask patients upon admission whether they had an advance directive. The initial version of the federal Patient Self-Determination Act (PSDA) called for the creation of IECs to educate caregivers, patients, and the public about advance directives, and to consult on difficult treatment decisions. This provision was dropped in the final version of the bill (15), however, because of widespread concern that IECs were relatively new and their effectiveness unknown (16). While the federal government ultimately did not mandate the creation of ethics committees, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO, formerly JCAH) did so in late 1990 in its 1992 Accreditation Manual for Hospitals (AMH) (17). JCAHO's new accreditation standards on patient rights included a requirement for a "mechanism (s) for the consideration of ethical issues in the care of patients and to provide education to caregivers and patients on ethical issues in health
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Society's Choices: Social and Ethical Decision Making in Biomedicine care" (17, 156). As of January 1, 1992, these standards require U.S. hospitals to have an IEC or a similar body or process as a condition for accreditation and eligibility for Medicare payments. There has been tremendous growth in the numbers of IECs in the last decade, although their actual prevalence has been difficult to assess. In 1982, the President's Commission survey of 602 hospitals found that only 3% had an IEC or other organizational body that might be involved in medical decision making; all were in hospitals with over 200 beds (6, 439- 457). A 1983 national survey by the AHA's National Society for Patient Representatives found that 26% of hospitals responding had an IEC; by 1985 that number had grown to 60% (18). The most likely hospitals in the survey to have an IEC were large, teaching hospitals; surprisingly, the number of nonteaching hospitals with an IEC dropped almost 10% in the two years between the surveys. In a study of the effects of Maryland's 1987 law requiring IECs two years after the Act's passage, 55 of the 63 hospitals surveyed responded that they had an IEC, compared with 14 of 18 in the District of Columbia and 29 of 114 in Virginia (19). Hospitals with fewer than 250 beds were not likely to have an IEC, and many of the administrators of hospitals in the District of Columbia and Virginia commented that they did not perceive a need for such a committee. Although considerable time has passed since JCAHO's patient rights standards were proposed, there are still hospitals with no formal mechanism in place, particularly small private hospitals and those in rural areas. Despite an extensive literature in clinical and hospital ethics and the availability of several handbooks on IECs (20-25), many hospital administrators are unsure of what is required of them or where to turn for information. Even in hospitals with established IECs, committee members may be uncertain about the committee's purpose, as well as their own roles and the adequacy of their knowledge in ethics, law, or medicine (19; 26; 27). This uncertainty, coupled with the fact that JCAHO instituted the requirement for IECs at the same time as a host of other changes, suggests that hospitals that create IECs primarily to conform to the AMH's standards are unlikely to have active committees for some time to come (19). ROLES OF THE IEC As described above, the IEC has three typical roles, which are complementary and mutually sustaining: (a) the recommendation or creation of policy on ethical issues in patient care; (b) the education of hospital staff, patients, family members, and the community on ethical issues and the philosophy and policies of the institution; and (c) the consideration of and consultation on ethical issues in patient care generally and questions about the treatment of specific patients. Not every IEC is involved in all of these
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Society's Choices: Social and Ethical Decision Making in Biomedicine activities, and some have additional responsibilities. JCAHO standards require only that committees provide education on ethical issues and a forum for their discussion (17). Policy Much of the uncertainty that surrounds difficult treatment decisions can be prevented with well-written, comprehensive institutional policies governing the areas where conflict is most likely. Since IECs were first conceived, their primary responsibility in the area of policy has been to define institutional guidelines and procedures for the withholding and withdrawing of resuscitative and life-sustaining treatment, as recommended by the President's Commission. Although they do not stipulate that the IEC be responsible for making policy,JCAHO's standards on patient rights (17) also outline requirements for institutional policy in several areas where the IEC may have considerable interest, and where its advice or leadership may be valuable (28): The objectives, procedures, and jurisdiction of the IEC; Resuscitative services and the use of do-not-resuscitate (DNR) orders; Informed decision making and informed consent; Advance directives and their implementation, and withholding and withdrawing life-sustaining treatment generally; Surrogate decision making for incompetent patients, including infants, children, and the unconscious; Assessment and management of pain; Transfer of patients to other facilities; and Respect for patients' religious and cultural preferences. The IEC should be sufficiently familiar with existing policies and procedural guidelines and state and federal law, to clarify, rather than complicate, the standards of clinical practice. Education It takes an educated committee to write good policy and provide meaningful consultation, educated caregivers to carry out policies and recommended courses of action, and educated patients and families to appreciate the institution's policies and make meaningful personal choices. While the necessary scope of IEC members' background in medicine and ethics is controversial, they certainly need a foundation in clinical ethical theory and practice, medical law relevant to issues of treatment at the end of life, and the process and techniques of mediation (22-27; 29-31). Education
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Society's Choices: Social and Ethical Decision Making in Biomedicine in clinical ethics, as in medicine, is an ongoing process, as new issues may arise that require committees to reevaluate "settled" questions (30). Turnover of committee membership implies a need for introductory materials for new members and ongoing committee education to ensure that the members have a common framework, without which the committee risks inconsistency in policymaking and consultation. Physicians and hospital staff need ongoing education on the institution's policies and relevant law on such issues as DNR orders, advance directives, withholding and withdrawing treatment, and surrogate decision making. These elements are frequently omitted from the orientation of new personnel, and where physicians practice in more than one facility differing policies among institutions can lead to confusion and conflict. Routine medical staff education is also essential in teaching hospitals where house staff and faculty trained in other states may incorrectly assume that laws and policies are national. Many younger health professionals have some education in ethics; however, caregivers need continuing ethics education to avoid the well-intentioned application of theories and laws that have been modified or superseded (23). Finally, staff members must learn how to contact the IEC to clarify questions of policy or law or to request consultation. Under the PSDA and the JCAHO standards, hospitals and other inpatient institutions are required to provide education to patients, their family members, and the community on their rights to make certain treatment decisions, including the right to formulate advance directives, and on the institution's mechanism for resolving conflict over treatment. Such education should involve meaningful discussion of the goals and real limits of medical intervention (32), so that lay people truly understand the nature of the decisions that they are called to make. Lastly, patients and their families need information about the IEC, its purpose, and how to use it; unfortunately, even in hospitals with well-established committees, most patients and family members still know nothing about the IEC (19; 33; 34), Consultation Consultation is the IEC's most controversial role, as some physicians question the need for ethics consultation. Where consultation does take place it assumes numerous forms (29; 34-41). There remains no real consensus on some important aspects of consultation, even after almost a decade of discussion and experience. The primary issues include: Who may seek consultation? The President's Commission and JCAHO call for the IEC to be available to all members of the institutional community, including physicians, nurses, allied health professionals, patients, family members, and potentially even outsiders. However, some IECs that oper-
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Society's Choices: Social and Ethical Decision Making in Biomedicine ate on a conservative interpretation of the AMA guidelines (11) limit consultation to physicians; the JCAHO standard on universal access to consultation will likely meet with resistance in such hospitals. In some facilities, this limitation has led to the creation of parallel "nursing ethics committees," where nurses seeking advice or interpretation of policy may get an answer directly; often their issues involve conflict with physicians (42). Clinical ethicists typically advocate broad access to a central IEC, concerned that nursing committees marginalize nurses and compartmentalize institutional issues along disciplinary lines. Who may attend meetings, participate in discussion of cases, and attend a consultation? Closely related to the issue of who may seek consultation is whether meetings and case discussion are open only to members or to the hospital at large (40; 43). The openness of regular business meetings is typically less a problem than is the open discussion of cases where both the patient's confidential information and the caregivers' insecurities may be exposed. Many committees hold open business meetings, particularly in teaching hospitals. Some IECs permit anyone to attend a consultation who is involved in the relevant patient's care, but hold formal deliberation privately. Others hold closed business meetings and case review, admitting nonmembers only by invitation. Some critics have argued that too many committees exclude even the patient and their surrogates, denying them due process (34; 35) and violating confidentiality (29; 35; 40; 44). IECs need to distinguish between concern for protecting confidentiality and the risk averse desire for secrecy before the question of openness can be resolved. How formal a consultation is necessary for different levels of advice? A number of levels of consultation are possible, from the quick telephone call to confirm the meaning of a policy, to the bedside consultation by an ethics consultant or IEC subcommittee, to the convening of the entire IEC for formal presentations and extensive discussion. The level of formality varies with the information needed, the patient's condition, and the complexity of the issue, including the duration of the controversy and the roles of the caregivers and family members involved (41). Most clinical ethicists now agree that, except in straightforward cases of defining policies, the consulting ethicist or a representative of the IEC should see the patient (33-36; 38; 39). For some this visit is intended to confirm the patient's diagnosis and "gather ... a clinical database" (39); for others it is to talk with the patient and the family firsthand about the issues (34; 35). Much, and by some accounts most, of the apparent conflict that prompts a call for ethics consultation is the result of poor communication (22, 241-243; 31). Consequently, the best type of consultation may depend on the severity of the miscommunication or the format most likely to resolve the particular communication problem. A formal meeting of the entire committee can seem adversarial to some patients or family mem-
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Society's Choices: Social and Ethical Decision Making in Biomedicine bers, who may feel threatened or inadequate before a large group of "hospital authorities"; physicians may also become anxious in a setting that looks too much like a peer review hearing (40). However, a full committee consultation may be quite effective when communication is the real problem, as the committee's need for a complete picture also affords the principals an opportunity to hear others' perspectives. Although the IEC can promote comprehensive communication among caregivers, the patient, and family members, an IEC consultation is neither the only nor the best format for achieving such results; multidisciplinary family conferences can be equally effective in many instances. Who is told of the IEC's recommendation? How? When? The IEC's recommendation will vary in its specificity and formality in part according to the format of the consultation. Clearly the person requesting the consultation should be informed of the IEC's recommendation, as should the other principals, including the patient and attending physician (33-35). At some point, too, others involved in the patient's care will need to be informed of any changes in the treatment, and their rationale. The question of how and by whom the information should be relayed is tied into: What documentation should be kept, and where? The President's Commission and most other bodies with guidelines on the conduct of IECs call for a consultation record to be put in the patient's chart in much the same way that other consultations generate chart notes; additional copies of the recommendation could be provided to the attending physician, patient, or person seeking the consultation, as needed. This format works very well in many institutions. However, many hospital attorneys and many more physicians are leery of formal records, worried that a patient who is the subject of an IEC consultation is likely to become the focus of litigation (23; 27; 44). Some fear that a formal IEC note-or even a mention of the IEC's involvement in the patient's chart might heighten a malpractice attorney's curiosity about any physician wrongdoing; in some hospitals, the consultation notes are kept only in the IEC's files, ostensibly to protect them from discovery. The committee's chair or another member confers with the attending physician and the patient or family to relate, and if necessary interpret, the IEC's opinion; the physician is then responsible for writing orders that reflect treatment plans in light of the recommendation. Unfortunately, this practice offers physicians none of the benefits of the "institutional sharing of responsibility," and may confuse other staff who must rely on word-of-mouth information to learn about the IEC's perspective. Moreover, in the few cases where litigation is pursued, the absence of an IEC record in the chart may generate interest in "undiscoverable" material that otherwise might be left alone. What if the attending physician disagrees with the IEC's recommendation?
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Society's Choices: Social and Ethical Decision Making in Biomedicine Most IECs consider even their formal opinions to be advisory only, and as with other clinical consultations, the physician is free to follow all, part, or none of the IEC's advice. Although IEC recommendations are typically the product of a consensus in which the physician has participated, doctors are suspicious of formal consultation because they fear that the IEC will ''rule" against them, and that disagreeing with the IEC will create a risk of litigation (23; 27; 44; 45). Some have argued that, in practice, even informal recommendations may function as binding decisions (46). Where the IEC is not able to resolve a conflict between doctor and patient or family, the IEC typically informs the patient or family that they may seek another physician, and reminds the physician of the professional (and in some states legal) duty to facilitate a transfer should the patient or surrogate decision maker request it.4 What if the patient or family disagrees? Including the patient or family in discussion and planning of treatment typically prevents conflict, and the communication that the IEC facilitates often results in compromise and consensus that includes patients' or family members' views. Often the question involves conflict among family members that may have nothing to do with the patient's care; here it is more important to determine who has decision-making authority than to achieve consensus. If a patient or family member with decision-making authority disagrees with the IEC's recommendation and the attending physician's advice, the patient may request to be transferred to another physician or hospital, and the physician should facilitate the transfer, if possible. Increasingly, such situations have involved family members' requests for treatment that physicians and IECs contend are unduly burdensome for the patient, inappropriate to the goals of treatment, or "futile" (34; 47- 49). Many hospitals claim to follow the guidelines of the Society of Critical Care Medicine (34; 48), which state that the attending physician is under no obligation to provide treatment that "has no chance of achieving benefit" (50). However, determinations of medical futility have become quite controversial in light of two court rulings that appear to have given patients a right to "futile" treatment that the physician and hospital sought to discontinue (51; 52). This question is likely to remain unresolved for some time, as the clinical issues converge with the social debate on the right to health care and the value of life in any form (32; 33; 48; 49). ADMINISTRATIVE ASPECTS Despite its broad mandate, the IEC is a hospital committee with the same administrative considerations as other committees, many of which are shaped more by the general practices and culture of the institution than by the IEC's formal charge. Several of the proposed guidelines for
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Society's Choices: Social and Ethical Decision Making in Biomedicine IECs attempt to define administrative structures and processes (11; 20-25). JCAHO's standards are exceptionally open, in keeping with its Principles of Quality Improvement, which are intended to support institutions' efforts to tailor guidelines to their own needs (17). Some basic administrative questions to be resolved at the institutional level include: Should the IEC be under the jurisdiction of the medical staff, administration, or governing board? A number of aspects of the committee's structure and function may be influenced by its place in the hospital's administrative structure. The IEC's authority, accountability, leadership, membership, and length of terms may all be defined by its location in the institutional hierarchy. The AMA recommends that the IEC work under the Medical Executive Committee, primarily to ensure that physicians have a prominent voice in policy (11), but some would argue that such IECs might not have the independence necessary to question physicians' practice (29). Others place the committee under the administration, as administrators are typically responsible for what may be perceived as the risk-management and policy aspects of the committee's work. However, such placement may marginalize the committee in clinical practice if physicians do not have a sense of ownership (29). Placement under the governing board can give the IEC the authority and political freedom to work effectively throughout the institution, but requires strong committee leadership, and a self-critical sense of purpose among the members. The IEC's budget and the availability of support staff, meeting rooms, and other essentials may also be defined by its relationship to particular offices. These considerations are especially important in smaller hospitals, and where staff and facilities are overburdened owing to financial constraints. The maintenance, availability, and discoverability of the IEC's records may also be affected by its placement in the hospital's administrative structure (22; 23; 27; 29; 45). The IEC's minutes and case reports might be safeguarded like quality assurance materials if the IEC is an administrative committee; records might come under peer review protection if the IEC is a medical staff committee. However, neither of these assumptions has been tested, and there is no consensus of legal opinion about the protection of IEC documents or the potential testimony of IEC members in litigation. Moreover, preoccupation with secrecy is not consistent with the publicly projected image of the IEC as a means of ensuring the accountability of health care professionals and institutions in decision making. Who should chair the IEC? Leadership is crucial to the proper functioning of any group, especially one that has a potentially controversial role. The head of the IEC must have the respect of the hospital community for the committee to be effective (22; 23; 29). Some guidelines suggest that the chair have a highly visible position of authority within the hospital; elsewhere, experience suggests that a chair's high profile may limit the
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Society's Choices: Social and Ethical Decision Making in Biomedicine From the beginning, physicians have been skeptical about the value of an IEC, and have been worried that the committee would be looking constantly over doctors' shoulders, telling them how to practice medicine (22; 29). While some of this initial hesitance has abated, especially among younger doctors, some physicians are unwilling to serve on what they perceive will be a meddlesome committee, or are fearful of the political consequences of appearing to sit in judgment of their peers (29). Others do not want to participate in a multidisciplinary IEC because they are unaccustomed to working with nonphysicians, or they may object to the implication that others can adequately assess the ethical dilemmas that doctors face. However, some IECs have found that critics of the committee can become its champions if they are invited to share their opinions as members. Nurses of various specialties, including floor nursing, critical care, and administration. Nurses are especially important because of their experience in carrying out treatment orders in controversial situations and their appreciation of the more personal responses of patients and families to serious illness. Moreover, they often recognize the political issues at stake in both policy and practice, and know how to negotiate them. In most institutions, nurses are eager to take part in the IEC, and it may be difficult to determine who among a number of qualified candidates should serve. Some nurses hope that the IEC will provide an opportunity to redress injustices that nurses have suffered in the past; but just as physicians must work with others, nurses must be willing to work with doctors. Social workers, patient representatives, and discharge planners, valuable because they are often called upon to handle the problems of "difficult" patients, whose "trouble making" may be the result of conflicting ethical or socio cultural values. They typically know both how to recognize the sources of conflict among caregivers, patients, and family members and often how to present options to resolve the conflict. Social workers and discharge planners can be central to the strategic aspects of an IEC's consultation, as they know what options are possible and how to use community resources to support patients' and families wishes for care that cannot be provided in the hospital. Physical and respiratory therapists, seldom included in lists of prospective members, but whose familiarity with the care of the chronically ill and comatose, as well as knowledge of the stresses and rewards of rehabilitation, make them invaluable to some committees. They, like nurses, typically implement treatment orders for patients likely to fall under IEC policies, and they see the long-term consequences of critical care. They can be helpful in case consultation because they often give social and emotional support to patients and families, and their teaching skills often enable them to communicate complex medical concepts to lay people.
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Society's Choices: Social and Ethical Decision Making in Biomedicine Clergy, whether hospital chaplains or clergy from the community, who can assist the IEC in appreciating the religious meaning that both health professionals and lay people may find in illness and medical care, and in identifying symbolic issues that can complicate decision making. Clergy can offer reassurance and reinterpretation of religious teachings to patients, family members, and staff who mistakenly fear that their intended actions are prohibited within certain religious traditions. Many clergy are trained in moral analysis, and although the perspective of their particular denomination may not be immediately applicable, their ability to identify central ethical themes and questions can be quite useful to the consultative process. Community-based clergy can be particularly helpful when they are familiar with the values, experiences, and daily life of the hospital's patient population. Hospital administrators, who are often responsible for drafting and implementing hospital policy that may affect the IEC. As committee members they may both facilitate the IEC's work in policy and learn lessons from the IEC's experience that will make hospital policy more appropriate to clinical needs. The presence of the hospital's CEO or other upper management on the IEC can also lend authority to its work. Administrators, like physicians, however, must appreciate the necessary collegial nature of the IEC and its deliberation, and refrain from imposing top-down decisions based on business criteria. Community representatives, including former patients or their family members who can provide important insight into the lay person's perspective on medical issues, and represent the committee and the hospital outside the institution. In case consultation they may be able to translate the language of health professionals into words and ideas more familiar to patients, and offer reassurance that the conflict over care is not a medical conspiracy. Community representatives are typically the most difficult for IECs to recruit and retain, often not because community members are unwilling to serve, but because the professional staff does not know whom to recruit. To identify potential community members, the IEC must know its patient population and what characteristics might be representative. Where community members are not effective representatives of the hospital's patient population, patients and their families may perceive the IEC to be simply another way in which the hospital protects its self-interest (29; 33). Attorneys and ethicists, who may be found on the IECs of larger, urban hospitals, especially university-affiliated institutions with a program in medical ethics or medical humanities. Many of the country's first IECs were started in collaboration with faculty from such programs. Some university affiliated hospitals now have clinical ethics programs that offer ethics consultation services, as part of or independent of the IEC. Attorneys and
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Society's Choices: Social and Ethical Decision Making in Biomedicine 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-
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Society's Choices: Social and Ethical Decision Making in Biomedicine ticularly in the areas of policy and consultation. Some networks have worked on standardized forms for DNR and supportive care orders, and others have defined community standards for withdrawing treatment; even informally, networks provide a means of establishing community standards for IECs by informing members about the operations and activities of other committees against which they may measure their own work. Some networks coordinate public educational efforts; others provide committee education or review difficult cases. With the implementation of health reform, such administrative umbrellas are likely to be increasingly important in facilitating the integration of IECs within health alliances, and safeguarding the ethical quality of care from the potential negative consequences of managed competition. ISSUES ON THE HORIZON As many new IECs become established, others are entering their second decade. The future of ethics committees will be difficult to predict, as much remains unknown about them currently. Some issues on the horizon include the development of IECs in long-term care facilities; the liability of IECs and their members for their consultation; the role of IECs in cost containment; and the need for formal evaluation of IECs and their varied roles. IECs in Long-Term-Care Facilities Although nursing homes and other long-term care facilities are subject to the PSDA and required to meet JCAHO standards in order to receive Medicare payments, there has been little study of IECs in such institutions. Some research and anecdotal evidence suggests that many do not inform patients or their families about their right to an advance directive or their options for treatment, and few have established IECs (58-61). For many hospital IECs, nursing homes and other long-term care facilities are a source of ethical problems, as their residents are repeatedly hospitalized for the treatment of strokes, infections, and fractures from which they will neither recover nor die. Most patients come from such facilities to the hospital unable to make their own decisions, and many have no available family member or other surrogate decision maker (59; 61). However, hospitals often discharge patients to long-term care rather than face difficult questions of appropriate intervention in the treatment of comatose or otherwise incompetent patients whose quality of life is limited. Typically there is little communication between hospitals and long-term care institutions over advance directives, DNR orders, and the goals of treatment, which itself may contribute to ethical conflict in such patients'
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Society's Choices: Social and Ethical Decision Making in Biomedicine care. IECs in nursing homes will be increasingly important in the coming years, as the population ages and hospitals and health policymakers reevaluate the use of acute care facilities and life-sustaining interventions. Long-term care facilities present many of the same institutional challenges as hospitals in terms of education in clinical ethics and policymaking; their higher turnover and typically less well-trained personnel make ongoing education and clear policies even more important. The prevalence of incapacitated patients means that surrogate decision making may be the norm, and the low rate of reimbursement for physician visits may make doctors less willing to spend time with patients and their families for advance planning. The role for IECs in long-term care facilities must be one aspect of a comprehensive assessment of the care of the elderly and severely disabled under health care reform. IECs' Liability for Malpractice and Other Legal Action Ethics committees were first suggested as a forum for resolving the conflicts that might lead to a court's intervention; both the New Jersey Supreme Court and Congress anticipated that IECs would help to keep medical decisions out of the courtroom (3; 16). Good policies should prevent hospitals and physicians from needing a court's opinion in all but extreme cases, and IEC consultation should reduce the risk of malpractice litigation against physicians as evidence that "due care" was used in decision making (29). Moreover, most malpractice suits stem from poor communication between patient and from physician, and patients' or families' perceptions that their opinions did not count (62). By actively including patients and their families in controversial decisions, taking their views seriously, and mediating conflict, IECs should prevent the resentment that typically leads to suit. There remains the possibility, however, that IECs themselves could become the target of litigation, either from a patient or family member who is dissatisfied with the consultative process or advisory opinion, or from a physician sued after relying on an IEC's recommendation. While Maryland law makes ethics committees immune from legal action, IECs in other states have no such protection (63). In 1986, an IEC in California was sued by Elizabeth Bouvia for its role in supporting a physician's decision to force-feed her through a nasogastric tube (64). That conflict was ultimately resolved without going to trial, and there have been no such suits since. However, there are a number of gray areas in which an IEC might recommend action that could be considered to violate the patient's legal rights: the discontinuation of "futile" life-sustaining treatment against a surrogate's wishes is a likely possibility. Where the IEC makes binding rulings or "optional" recommendations that are not really optional (46), a
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Society's Choices: Social and Ethical Decision Making in Biomedicine physician sued for following the IEC's advice might seek damages from the committee or its individual members. In either situation, the IEC would need to demonstrate the duty of care that ethics committees have to patients, and establish that it had not breached that duty. In a case of a recommendation on a controversial issue, it would have to show how it arrived at the conclusion, and that it followed the standard of practice that similar bodies would accept in reaching a conclusion. Individual members would need to show that they had the knowledge and exercised the skill and judgment of a reasonable member of an IEC in deliberating and reaching a recommendation. Records supporting the ICE's position would be crucial, as would evidence that documented the process. Because there are no well-established standards for IECs, including criteria for membership and appropriate process, a committee under public scrutiny might find it difficult to prove that it met a standard of care. Moreover, as some committees keep only minimal records, documenting the decision-making process could be even more troublesome. In the unlikely, but equally possible, case that an IEC came under criminal investigation for such crimes as conspiracy to commit murder or child or elder abuse, the existence of formal measures and the availability of records would be even more important. While IECs will likely always face some risk of legal action, clear professional and institutional standards for their constitution and operation would reduce that risk. IECs and Cost Containment For many caregivers, questions of appropriate intervention become ethical questions when the patient cannot pay for care. In a recent nonfiction book portraying the work of an IEC in a large urban hospital, economic issues lie behind every treatment decision (65). Although the IEC never discusses the cost of care, the book is laced with descriptions of caregivers and other institutional bodies considering the financial impact of the intensive care and technological intervention provided to indigent patients. Ethics committees have typically focused as a matter of principle on serving the patient's best interests. They have sought to remain above the debate about cost containment and allocation of resources. Increasingly, the inequalities of access to care, the inequalities of care once accessed, and the high cost of many lifesaving interventions-some in short supply-are likely to force IECs into the discussion of costs, especially in light of health care reform. The question of how IECs should participate in the discussion and how they should use financial information in their consideration of patient care and policy remains unanswered (65- 68). IECs should know what role their individual institutions expect them
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Society's Choices: Social and Ethical Decision Making in Biomedicine to play in the hospital's larger agenda, and ensure that the ethical criteria for its policies and practices are not subverted by other interests. The IEC can promote the hospital's healing mission where others serve the bottom line, and it can examine head-on the issue of cost containment in selective policy and case review, providing the institution with a clear understanding of the difference between ethics and economics. On a societal level, IECs and ethics committee networks can consider the Canadian Catholic bishops' suggestion that they observe and respond to governmental efforts to address health care (1), safeguarding the interests of patients and caregivers in the process of health care reform by sharing with policymakers their ethical expertise and practical experience. Measuring the Effects of IECs In the more than ten years that professional organizations and licensing and accrediting bodies have recommended or required the establishment of IECs, a number of manuals have offered guidelines on their self assessment, and there have been many calls for substantive evaluation of their effects (5; 6; 16; 21-23; 31; 43; 53; 70-73). To date, assessment has been confined to a few academic articles, workshops at professional meetings, and the informal shoptalk of clinical ethicists. Given the limited degree to which any technology is evaluated before its widespread diffusion into clinical practice (72), and the limited funds available for health services research, this uncritical adoption of IECs is not surprising. Assessment of the effects of IECs is also complicated by the fact that these committees are intended to serve a variety of purposes, not all of which have been clearly defined even among practicing clinical ethicists. Establishing what is meant by "success," the standards by which IECs should be measured, and the rationale for these definitions is essential before meaningful assessment can take place (53; 69; 70; 72). As JCAHO surveyors gain experience with IECs in their varied formats, it is likely that the AMH will set more specific standards and assessment criteria for their composition and function. The establishment of formal standards should not be left to JCAHO alone, however, but should involve the ethicists, clinicians, and policymakers whose work has led to the growth of clinical ethical theory and the rise of active IECs, and the individual committees themselves. Anecdotal evidence suggests that IECs have been successful at the widely claimed goal of limiting court intervention in treatment decisions. It is less clear whether this effect is truly due to the IECs' mediating capacities, their occasional tendency to function as risk-management committees, the effectiveness of staff and patient education on ethical issues, or a growing social consensus about appropriate treatment at the end of life.
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Society's Choices: Social and Ethical Decision Making in Biomedicine Each of these questions is worthy of study, and should provide valuable insight into the future direction of IECs. NOTES 1. Some discussions of the development of IECs find important parallels to institutional review boards (IRBs) governing biomedical research with human subjects and/or Seattle's dialysis allocation committee of the 1960s. Like the IRB, hospital ethics committees are intended to safeguard patients' interests and right to informed consent; like Seattle's ''God Committee," IECs may deliberate on the appropriate use of advanced life-sustaining treatment. However, neither of these bodies is truly similar to the IEC. Its mandate has been much broader than that of the other structures, and was derived primarily from the need to define whether and how to end treatment that physicians might construe as being in the patient's interests. 2. For simplicity, all such institutional structures and processes will be referred to here as IECs. 3. Clinical ethics has developed as a field in Canada in parallel with the United States; although under somewhat different guidelines, IECs serve much the same purposes there as here. 4. In a some instances, however, patients and families will not seek transfer and doctors do not seek to remove themselves from the patient's case. Although this phenomenon has not been explored, it appears to be more common in community hospitals and where the physician and patient have had a long-term relationship. For patients, families, and doctors faced with a life-threatening situation, conflict in a familiar relationship may be preferable to the anxiety and unknown outcome of change. REFERENCES 1. Catholic Health Association of Canada. Medico-Moral Guide. Ottawa, ON: CHAC, 1971. 2. Teel, K. "The physician's dilemma: A doctor's view: What the law should be." Baylor Law Review, 1975, 27, 6, 8-9. 3. In re Quinlan, 70 N.J. 10, 355 A. 2d 647, cert. denied, 429 U.S. 922 (1976). 4. New Jersey Health Department. "Guidelines for health care facilities to implement procedures concerning care of comatose, non-cognitive patients," 1976. Cited in E.J. Leadem, "Guidelines for health care facilities to implement procedures concerning care of comatose, non-cognitive patients - A perspective," Hospital Progress, 1977, 58 (March), 9-10. 5. Levine, C. "Hospital ethics committees: A guarded prognosis." Hastings Center Report, 1977, 7 (June), 25-27. 6. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment: Ethical, Medical, and Legal Issues in Treatment Decisions. Washington, DC: U.S. Government Printing Office, 1983. 7. "Nondiscrimination on the basis of handicap: Procedures and guidelines relating to health care for handicapped infants." Federal Register, Jan. 12, 1984, 49, 1622-1654. 8. American Academy of Pediatrics, Infant Bioethics Taskforce and Consultants. "Guidelines for infant bioethics committees." Pediatrics, 1984, 74, 306-310. 9. United States v. University Hospital, 729 F. 2d 144 (CA2) (1984), and Bowen v. American Hospital Association et al., 476 U.S. Supreme Court 610 (1986). 10. Child Abuse Prevention and Treatment Act, 42 U.S.C., Section 5101-05 (1984).
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Society's Choices: Social and Ethical Decision Making in Biomedicine 11. Judicial Council, American Medical Association. "Guidelines for ethics committees in health care institutions." Journal of the American Medical Association, 1985, 253, 2698-2699. 12. American Hospital Association. Guidelines: Hospital Committees on Biomedical Ethics. Chicago, IL: AHA, 1984. 13. Patient Care Advisory Committee Act of 1987, Maryland Health Gen. Code Ann. 19- 370-19374. 14. Cruzan v. Director of Missouri Department of Health, U.S. Supreme Court 58 LW 4916, 1990. 15. The Patient Self-Determination Act, Omnibus Budget Reconciliation Act of 1990, P.L. 101-508, Nov. 5, 1990. 16. McCloskey, E.L. "The Patient Self-Determination Act." Kennedy Institute of Ethics Journal, 1991, 1, 163-169. 17. Joint Commission on Accreditation of Healthcare Organizations. Accreditation Manual for Hospitals. Oak Park, IL:JCAHO, 1992. 18. Anonymous. "Ethics committees double since '83: Survey." Hospitals, 1985, 59 (Nov. 1), 60-61. 19. Hoffman, D.E. "Does legislating hospital ethics committees make a difference? A study of hospital ethics committees in Maryland, the District of Columbia, and Virginia." Law, Medicine, and Health Care, 1991, 19, 105-119. 20. Cranford, R.E., and Dudera, A.E., eds. Institutional Ethics Committees and Health Care Decision Making . Ann Arbor, MI: Health Administration Press, 1984. 21. Craig, R.P., Middleton, C.L., and O'Connell, L.J. Ethics committees: A Practical approach. St. Louis, MO: Catholic Health Association, 1986. 22. Hosford, B. Bioethics Committees: The Health Care Provider's Guide. Rockville, MD: Aspen Systems Corporation. 1986. 23. Ross,J.W., Bayley, C., Michel, V., and Pugh, D. Handbook for Hospital Ethics Committees. Chicago, IL: American Hospital Publishing, Inc., 1986. 24. The Hastings Center. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying. Bloomington, IN: Indiana University Press, 1987. 25. Macklin, R., and Kupfer, R.B. Hospital Ethics Committees: Manual for A Training Program Bronx, NY: Albert Einstein College of Medicine, 1988. 26. Ross, J.W. "What do ethics committee members want?" Ethical Currents, 1991, 3, 7-8. 27. Cohen, M., Schwartz, R., Hartz, J., and Shapiro, R. "Everything you always wanted to ask a lawyer about ethics committees." Cambridge Quarterly of Healthcare Ethics, 1992, 1, 33-39. 28. Heitman, E. "Meeting the JCAHO Standards on Patient Rights: A proactive role for the institutional ethics committee or clinical ethicist." Trends in Health Care, Law, and Ethics, 1993 8(4), 8-12. 29. Fost, N., and Cranford, R.E. "Hospital ethics committees: Administrative aspects." Journal of the American Medical Association, 1985, 253, 2687-2692. 30. Bayley, C., and Cranford, E.E. "Techniques for committee self-education and institution-wide education", in R.E. Cranford and A.E. Dudera (eds.), Institutional Ethics Committees and Health Care Decision Making. Ann Arbor, MI: Health Administration Press, 1984, 139-156. 31. West, M.B., and Gibson, J.M. "Facilitating medical ethics case review: What ethics committees can learn from mediation and facilitation techniques." Cambridge Quarterly of Healthcare Ethics, 1992, 1, 63-74. 32. Brennan, T.A. "Physicians and futile care: Ethics committees to slow the momentum." Law, Medicine, and Health Care, 1992, 20, 336-339. 33. Youngner, S.J., Coulton, C., Juknialis, B.W., and Jackson, D.L. "Patients' attitudes toward hospital ethics committees." in R.E. Cranford and A.E. Dudera (eds.), Institutional Ethics Committees and Health Care Decision Making. Ann Arbor, MI: Health Administration Press, 1984, 73-84.
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Society's Choices: Social and Ethical Decision Making in Biomedicine 34. Wolf, S.M. "Toward a theory of due process." Law, Medicine, and Health Care, 1992, 20, 278-290. 35. Fletcher, J.C. "Ethics committees and due process." Law, Medicine, and Health Care, 1992,20,291-293. 36. Cohen, C.B. "Avoiding 'Cloudcuckooland' in ethics committee case review: Matching models to issues and concerns." Law, Medicine, and Health Care, 1992, 20, 294-299. 37. Singer, P., Pellegrino, E., and Seigler, M. "Ethics committees and consultants." Journal of Clinical Ethics, 1990, 1, 263-267. 38. Lowey, E.H. "Ethics consultation and ethics committees." Hospital Ethics Committee Forum, 1990, 2, 351-359. 39. LaPuma, J., and Schiedermayer, D.L. "Must the ethics consultant see the patient." Journal of Clinical Ethics, 1990, 1, 56-59. 40. Agich, G., and Youngner, S. "For experts only? Access to hospital ethics committees." Hastings Center Report, 1991, 21 (Jan./Feb.), 17-24. 41. Ross, J.W. "Why cases sometimes go wrong." Hastings Center Report, 1989, 19 Jan./ Feb.), 22-23. 42. Edwards, B.J., and Haddad, A.M. "Establishing a nursing bioethics committee." Journal of Nursing Administration, 1988, 18 (March), 30-33. 43. Lo, B. "Behind closed doors: Promises and pitfalls of ethics committees." New England Journal of Medicine, 1987, 317, 46-50. 44. Veatch, R.M. "Advice and consent." Hastings Center Report, 1989, 19 (Jan./Feb.), 20-22. 45. Capron, A.M. "Legal perspectives on institutional ethics committees." In B. Weinstein (ed.), Ethics in the Hospital Setting, Morgantown, WV: West Virginia University Press, 1985, 66- 84. 46. Ritchie, K. "When it's not really optional." Hastings Center Report, 1988, 18 (Aug./ Sept.), 25-26. 47. Smith, D.G. "Committee consultation to override family wishes-Commentary," Hastings Center Report, 1989, 19 (Sept./Oct.), 24-25. 48. Rie, M.A. "The limits of a wish." Hastings Center Report, 1991, 21 (July/Aug.), 24-27. 49. Callahan, D. "Medical futility: The-problem-without-a-name." Hastings Center Report, 1991, 21 (July/Aug.), 30-35. 50. Society for Critical Care Medicine. "Consensus report on the ethics of foregoing life sustaining treatments in the critically ill." Critical Care Medicine, 1990, 18, 1435-1439. 51. In re Helga Wanglie, 4th Judicial District (Dist. Ct., Probate Ct. Div.) PX-91-283, Minnesota, Hennepin County. 52. In re Baby K, Civil Action No. 93-68-1 (July 1, 1993). Discussed in L. Greenhouse, "Hospital appeals decision ordering treatment for baby missing a brain." New York Times, Sept. 24, 1993, A8. 53. Scheirton, L.S. "Determinants of hospital ethics committee success." HEC Forum, 1992, 4, 342-359. 54. Mitchell, S.M., and Swartz, M.S. "Is there a place for lawyers on ethics committees? A view from inside." Hastings Center Report, 1990, 20 (March/April), 32-33. 55. Schuyve, P.M. "A systems perspective on individual competence in ethics consultation." Newsletter of the Society for Bioethics Consultation, 1993, Winter, 1, 4-6. 56. Fletcher, J.C. "Training program in ethics consultation: The time is now." Newsletter of the Society for Bioethics Consultation, 1992, Spring, 1, 6. 57. Kushner, T. "Networks across America." Hastings Center Report, 1988, 18 (Feb./March), 14. 58. Brown, B.A., Miles, S.H., and Aroskar, M.A. "The prevalence and design of ethics committees in nursing homes." Journal of the American Geriatric Society, 1987, 35, 1028-1033. 59. Glasser, G., Zweibel, N.R., and Cassell, C.K. "The ethics committee in the nursing home: Results of a national survey." Journal of the American Geriatric Society, 1987, 36, 150-156.
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Society's Choices: Social and Ethical Decision Making in Biomedicine 60. Zweibel, N.R., and Cassell, C.K. "Ethics committees in nursing homes: Applying the hospital experience." Hastings Center Report, 1988, 18 (Aug./Sept.), 23-24. 61. Eubanks, P. "Nursing homes seek advance directives." Hospitals, 1990, 64 (22), 52-54. 62. Press, I. "The predisposition to file claims: The patient's perspective." Law, Medicine, and Health Care, 1984, 12, 53-62. 63. Merritt, A.L. "Assessing the risk of legal liability for ethics committees." Hastings Center Report, 1988, 18 (Feb./March), 13-14. 64. Bouvia v. Glenchur, L.A. Superior Court, C583828, Oct. 7, 1986. 65. Belkin, L. First, Do No Harm. New York: Simon Schuster, 1992. 66. Wikler, D. "Institutional agendas and ethics committees." Hastings Center Report, 1989, 19 (Sept./Oct.), 21-23. 67. Brock, D. "Ethics committees and cost containment." Hastings Center Report, 1990, 20 (March/April), 29-31. 68. Cohen, C.B. "Ethics committees as corporate and public policy advocates." Hastings Center Report, 1990, 20 (Sept./Oct.), 36-37. 69. Povar, G.J. "Evaluating ethics committees: What do we mean by success?" Maryland Law Review, 1991, 50, 904-919. 70. Keffer, M.J., and Keffer, J.L. "U.S. ethics committees: Perceived vs. actual roles." Hospital Ethics Committee Forum, 1991, 3, 227-230. 71. van Allen, E., Moldow, D.G., and Cranford, R. "Evaluating ethics committees." Hastings Center Report, 1989, 19 (Sept./Oct.), 23-24. 72. Rosner, F. "Hospital medical ethics committees: A review of their development."Journal of the American Medical Association, 1985, 253, 2693-2697. 73. Greer, A.L. "The state of the art versus the state of the science: The diffusion of new medical technologies into practice." International Journal of Technology Assessment in Health Care, 1988, 4, 5-26.
Representative terms from entire chapter: