Ethics Committee Structures

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• Ethics Committee Structures
• Decision Making Models
• Philip Boyle, Ph.D.
• Vice President, Ethics
• www.CHE.ORG/ETHICS

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Goals for todays conversation

• House keeping review of course
• Expectations
• Different ethics mechanisms
• The Next Generation
• Nature of ethics
• Evaluation of ethics functioning
• Nature of ethical decision making
• Values-based decision-making process

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Etiquette

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Case of Mrs. White

• 82 year old
• Found unconscious at home
• Placed on vent
• 3 days later awake
• Take me off vent, I want coffee
• Listen to my son
• MD refuses
• Ethics consultation provide info on state law

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Nature of ethics consultation?

• How would you describe the actions?
• Recommending?
• Consultation?
• Mandating?
• What do these verbs connote? Are any antithetical
  to the nature of ethics?
• What is the authority of the EC?

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Nature of ethics

• Goal
• Compliance
• Ethics is good business/practice
• Doing good, avoid evil
• Human flourishing
• Facilitating the decision maker to make a good
  decision

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Ethics MechanismsBefore and After

• Beforein the beginning
• Largely grass roots
• Not hard wired to administration
• Focused on patients rights
• Philosophical discussion of hard cases
• Dispute resolution forums

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Process

• Scope of jurisdiction and authority
• What authority do they have?
• What is the authority of the education?
• What is the authority of the consultation?
• What is there authority on policy review?
• Are there any functions that the committee will
  never accept?
• Could some other existent committee better handle
  this request? Are we duplicating functions?
• Who calls the committee into being?
• To whom does the committee report?
• The nature of ethics committeessafe place for
  unsafe ideas
• Confidentiality
• Functional consensus

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Functions

• Education
• Will only certain groups be targeted?
• What formats will be best for the various groups?
• What is the expected outcome for education?
  Changed behavior? Provision of guidelines?
  Standards of practice?
• In a pluralistic society, where there is little
  agreement on ethical issues, what information can
  be presented?
• How does education avoid appearance of mandating?

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Functions

• Policy
• Should the policy come from the ethics committee
  or from another group?
• Should the committee merely review policy, or
  help develop it? What is the extent of the
  authority given to the committee in policy
  making? What are the pros and cons?

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Functions

• Case consultation
• At what point in an ethics committee's
  functioning should it provide case consultation?
• Should it provide prospective and retrospective
  consultation?
• Should the consultation be binding? What if the
  entire committee agrees but the person asking for
  the consultation disagrees?
• Who can ask for a consultation?
• Who decides whether the consultation comes before
  the committee?
• Should there be an ad hoc subcommittee on call to
  consider ethical problems that arise?
• Should the subcommittee follow standard pattern
  of consultation?
• Shall the consultations be noted in the chart?

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Functions

• Advocacy
• To what extent should community education efforts
  advocate one position or another?
• Should the committee become involved with
  political advocacy for the passage of a bill?

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• Who should have access to the ethics committee?
• Physicians only?
• Nurses after they have exhausted existing
  channels?
• All staff?
• Patients? Family?
• Community members?

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• How will people know about the committee and
  access it?
• Through the chairperson only?
• Through any member of the committee?
• Through department heads?
• By request of physicians or administration, or
  merely by asking to be put on the agenda?

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Priorities

• Priorities What substantive issues are most
  important to the institution? Long range planning
• How broad shall the committee cast its nets?
• Should it consider social issues i.e., rationing?
• Should the committee consider business ethics?
• How much time will be allotted to diversions from
  designated goals to talk about issues such as
  procedure?
• What are our priority functions?
• What are our priority substantive issues?
• What is our 1 and 3 year plan?
• How will and when will we evaluate them?

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AfterEthics Mechanisms The Next Generation

• Integrating Healthcare Ethics into Healthcare
  Operations
• Holding Ethics Mechanisms Accountable
• Ethics Mechanisms Going from Good to Great
• Ethics as Mission Reflection A Spirituality at
  Work

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Notable successes

• Self education
• First responders
• Ethics Champions
• Safe-place for unsafe ideas
• Identifiable institutional response
• Participative collaborative

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Notable failures?

• Limited to clinical ethics
• Lack of demonstrable value/effectiveness
• Good intentions value
• Stuck on hard cases
• Doing ethics talking about ethics
• Volunteers amateurs
• Consistency in action
• Dispute resolution forums with no power or
  training in arbitration

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How can we respond to the record?

• Improving? Refining?
• New slant on consultations e.g., organizational
  ethics?
• Enhance policy development for management tool?
• New pedagogy to shape professionals or new sexy
  topics e.g., face transplants?

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Experience/ History

• Disillusionment
• Are ECs making a demonstrable difference in pt
  care?
• Quasi-legal protection of pt rights
• Operating dispute resolution forums with little
  power of training in arbitration

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How can we respond to the record?

• The Next Generation
• Proactive agent of system change
• Better integrated
• Upstream
• Improved Pt care
• Adds value contributes to quality
• Integrated Mission Reflection

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What does this mean practically?

• Mission Vision
• May be articulated, often not
• Source of conflict
• Clear mission vision
• Catalyst facilitator for systemic change
• Not principle vehicle for change

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What does this mean functionally?

• Ethics Resource Service (ERS)
• Clinical Consultation Group
• Facilitates Cases
• Educational Forums
• Healthcare Ethics Committee (HEC)
• Integrates ethics into quality
• Operationally minded
• Measures outcomes, hold accountable

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Membership

• Selecting qualified members, not location
• Core education
• Trained in conflict resolution
• Escape appearance of volunteers
• Long-range training

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Modes Methods of Operation

• Focus is operations, not philosophical discourse
• Skill-set operational accomplishment
• How to get things done
• How to bring about change
• How to facilitate org development

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Ethics Resource Service

• 1. Provide competent informational
  decision-making support
• Consultation mechanism
• Core knowledge
• Dispute resolution
• 2. Advise HEC on recurring issues
• Systemic/structural solutions

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Total Quality ImprovementOperationally
Integrating Ethics

• Trending
• Values-based Decision-making Process
• Indicators/Trigger Mechanisms
• Committee self-evaluation

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Why use it?

• Consistent evidence of supporting Mission
• Evidence of Participation and Respect for Persons
• Evidence that the Spirit has guided
• Checks Balances
• Fosters habit of moral reasoning

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When to use it?

• Formally
• Decision that affect significant interests and
  populations
• Opening Closing Services
• Significant HR issues
• Development of Strategic management tools
• Informallyall moral decisions

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Phase I Preparation

• Number of persons/groups impacted
• Does it affect a department or the institution?
• Duration of the impact
• Does the impact last a few years or the span of
  the ministry?
• Depth or weight of impact
• Does the question affect the entire ministry or
  a portion of it?
• Closeness to Core Values
• Does the question directly jeopardize a value?
• Degree of complexity
• Past commitments
• Does the question positively or negatively affect
  past commitments?
• Relationship to strategic direction

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Whose interests are affected?

• Based on the nature of the issue, what other
  individuals or groups need to be part of the
  process?
• What is the nature and frequency of the
  connection between the groups and the question?
• What departments will be affected?
• What departments might have insight?
• What other entities will be affected by the
  decision?
• Who would have insights to the Mission and
  tradition as it applies to this decision?

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Phase II Decision Making

• Pray, reflect, identify question, and clarify
  authority of decision-making group.
• Prayer and reflection are necessary because the
  group believes that it is Gods spirit that is
  guiding and perfecting the many decision-making
  talents brought to the table. A spirit of
  prayerful reflection centers the group on the
  fact that they are continuing the healing,
  transforming ministry of Jesus.
• Identification of the question is essential
  because each decision maker will perceive and
  state the question differently. If the question
  is inaccurately identified at the outset of
  decision making, or not agreed upon, then the
  ensuing process will be counterproductive.
• The decision-making group should be clear about
  its scope of authority. Do they have the ultimate
  decision-making authority, or are they a
  consultative group that provides information to
  the ultimate decision maker(s)?

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Phase II Decision Making

• 2. Determine primary and secondary communities of
  concern and their interests.
• While there may be a large community of concern,
  not everyone in that community has the same
  interests. The decision-making group should
  assess the manner and degree to which a
  sub-community will be affected positively and/or
  negatively.
• The decision-making group should consider how
  those who are poor and vulnerable will be
  affected by the decision.

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Phase II Decision Making

• 4. Identify key moral commitments and values, as
  well as conflicts among them.
• Identify the question in terms of trade-offs
  between one or more values. For example, consider
  your decision in terms of human dignity and
  identify the dignity trade-offs in the various
  options that you are weighing.
• Identify the major consequences of this dignity
  trade-off in terms of individuals and groups in
  terms of long- and short-term burdens and
  benefits or in terms of money, morale and
  relationships, etc.

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Phase II Decision Making

• 5. Establish priorities among commitments and
  values.
• The moral commitments and values that deserve
  priority will flow from consideration of
  strategic goals/objectives, core values,
  historical commitments, the broader religious
  tradition, and special circumstances.
• List each priority and provide the rationale for
  why it is a priority.

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Phase II Decision Making

• 6. Develop options that support the priorities.
• Identify options that promote the moral
  commitments and values deserving priority.
• Examine carefully the major options and evaluate
  the positive and negative consequences of these
  options on the identified priorities.
• Consider not only the burdens and benefits of the
  preferred option but all of the options.
• Do any of the options preserve and protect a
  majority of the identified priorities?

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Phase II Decision Making

• 7. In silence reflect and then listen to
  viewpoints.
• To ensure that the Spirit has guided the
  discussion and to promote the voice of any
  reservations or opposition, a quiet time of
  reflection should be offered during which group
  members consider the discussion in light of the
  faith tradition and personal conviction.
• Consider the following reflective questions
• Have I listened to the facts and appreciated the
  viewpoints of others?
• Have I opened myself to the workings of the
  Spirit?
• Have I sought the good of the entire ministry and
  then the particular good of others?
• Has input been elicited from all decision makers?
  

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Phase II Decision Making

• 8. Gain consensus on decision.
• Invite all members to express which option should
  be pursued and why. Discussion should be held
  until every member has had an opportunity to
  voice an opinion.
• At the conclusion of the participatory decision
  making, estimate if a consensus exists, and if
  not, identify the points of disagreement and
  allow for additional conversation for
  clarification.
• If a consensus is reached, identify the values
  that will suffer because of the choice. Discuss
  how to mitigate the harms.

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Phase III Follow Through

• Assign accountabilities to specific persons for
  each component to be realized.
• Build a plan for monitoring and reporting with
  measurable outcomes.
• Build a communication plan for community of
  concern with key messages and methods.
• Build a plan that connects to the larger meaning
  and purpose.

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Conclusions

• One needs to first clarify the nature of ethics
• Then focus on the nature of facilitation
• Core knowledge
• Competencies for facilitation
• Proper use of values-based decision making