THE ROLE OF ETHICS COMMITTEES

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THE ROLE OF ETHICS COMMITTEES

• Janet Farrell
• Thailand Accreditation Consultant

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CONTEXT

• Large teaching university hospital-
• Ethics committee studies the ethical implications
  of research projects and approves these.
• Moderate size and small hospitals-
• Professional ethical situations
• All hospitals-
• Ethical dilemmas

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What is an Ethical Dilemma?

• Definition
• Ethics the study of moral standards and moral
  judgment.
• Dilemma
• Any situation requiring a choice between
  unpleasant alternatives.
• Any serious problem that is difficult to solve.

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Sample ethical dilemmas

• Workshop exercise

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Principles of ethical decision-making

• Some principles that are relevant to health care
  
• Autonomy
• Beneficence
• Nonmaleficence
• The common good
• Double effect
• Informed consent
• Proportionate and disproportionate
• Integrity and totality

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Why we use the ethical principles?

• Biases
• Definition
• Partiality
• Slanting in one direction

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Why we use the ethical principles?

• We must set aside our individual biases and make
  decisions using the ethical principles.
• Not all principle can be applied to all dilemmas.

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Principle of Autonomy

• Capacity for self determination
• Implies that the patient should be free from
  coercion in deciding to act. Others are obliged
  to respect the decision and to tell the truth.
• Informed consent.

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Principle of Autonomy

• This can be overridden by competing moral
  considerations.
• Choices endanger public health
• Potentially harm others
• Require a scare resource.

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Principle of Beneficence

• Traditionally understood as the first principle
  of morality.
• Do good and avoid evil.

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Principle of Nonmaleficence

• first do no harm
• Doing no evil
• Often considered a normal result of beneficence.
  
• If one cannot cause good without causing harm,
  then one should not act at all.

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Principle of Double effect

• An action has two effects intended as good, and
  yet there is an unintended yet foreseen evil
  effect.
• Used in conflict situations where avoiding harm
  would required no action.
• Used when the best actions may have some harmful
  results.

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Principle of Double effect

• One need not abstain from the good action that
  has foreseeable bad effects, depending on the
  moral criteria
• It must be a good action (within your heart)
• Direct intention is to avoid the harmful effects.
• Beneficial effects must not be achieved by means
  of the foreseen harmful effects
• The benefit must be equal to or greater than the
  foreseen harmful effects.

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Principle of Common Good

• Conditions in society that allow individuals to
  achieve human and spiritual growth.
• There are three elements
• Respect for persons
• Social welfare
• Peace and security.

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Principle of Informed Consent

• The right of a competent individual to advance
  their own welfare.
• There are four requirements
• Adequate disclosure of information
• Patient freedom of choice
• Understanding of the patient
• Capacity for decision-making.

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Principle of Proportionate and Disproportionate
Means

• Proportionate means there is a hope of benefit
• Disproportionate means there is no hope of
  benefit.
• It arises from the general obligation to save
  life.
• It guides individuals in weighing of benefits and
  burdens.
• When medical treatment constitutes disproportion,
  is when one is no longer obliged to undergo the
  treatment.

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Principle of Integrity and Totality

• Integrity refers to each persons duty to
  preserve a view of the whole person.
• Totality refers to the whole body and spiritual
  nature of human life.
• These dictate the well being of the whole person.

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Functioning of the ethics committee in dealing
with ethical dilemmas

• First educate the members of the ethics committee
  regarding the ethical principles.
• To educate and provide support to the teams of
  the hospital in making decisions that are
  consistent with the patients values and goals.
• Development or have input into ethical policies
  e.g. CPR, restraints, research. etc.
• Make recommendations (not decisions) that add
  substantive guidance to the decision making
  process.

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Method of supporting teams

• Join the hospital teams to provide expertise and
  a recommendation.
• Clearly articulate the rational as to why one
  course of action is permissible or preferable
  within the ethical perspective and the clinical
  circumstances of the particular case.
• Some members to be available on short notice
• Keep minutes of activities

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Steps to be taken to guide the processStep 1

• Identify the right questions
• Why was the consultant called?
• What are the right questions to be asked?

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Step 2. Identify the Facts

• Patient diagnosis and prognosis
• Patient values and goals
• Legal issues and laws
• Professional standards and ethics
• Hospital policies and values

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Step 3. Identify stakeholders

• Who is affected by the decision to act?
• Who is MOST affected by a particular decision?

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Step 4. Identify Relevant Moral/Ethical
Principles

• Beneficence, autonomy, informed consent, common
  good, double effect etc.

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Step 5. Consider Alternate Options

• Are the identified goals of treatment appropriate
  considering the patients clinical situation?
• Are there other options than to treat or not
  treat?

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Step 6.Arrive at and Justify the Recommendation.

• Get the people involved to take turns expressing
  different points of view.
• Summarize points of agreement.
• Debate and discuss points of agreement until a
  decision is reached that everyone can live with.
• Allow some to opt out if necessary.
• Consider if the intended results are consistent
  with relevant moral/ethical norms.

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Step 7. Review and Follow-up

• Were all parties comfortable with the decision
• Were people with expertise consulted.
• Was informed consent obtained before
  implementation.
• Were appropriate steps taken in a timely manner?

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CONCLUSION

• Ethical dilemmas will never leave us.
• Ethics committees can and should provide support
  to the PCTs to try to deal with these difficult
  problems