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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