Ethics Committees: A Hospital Standard?

The presence of ethics committees in hospitals has become increasingly common since the 1980s, with nearly every hospital in the US now having a hospital ethics committee (HEC) or an ethics consultation service. HECs are bodies established by hospitals or healthcare institutions to address ethical issues that arise in patient care, such as informed consent, end-of-life cases, and conflicts between personal values and recommended treatments. They are intended to empower patients, families, and healthcare professionals to make sound decisions that respect the values and interests of all involved. While the Americas and Europe have been the most prominent in establishing HECs, many countries in the Eastern Mediterranean and South-East Asia are only beginning to introduce them.

History of ethics committees in hospitals

The emergence of hospital ethics committees (HECs) in the US and other countries can be traced back to the late 20th century, particularly the 1980s and 1990s. During this period, rapid advances in medical technologies and treatments, such as organ transplantation and kidney dialysis, raised complex ethical questions and value clashes that society and the medical community were ill-prepared to address.

In the US, the establishment of HECs was influenced by several notable cases and legislative changes. The 1976 New Jersey Supreme Court decision in the Karen Quinlan case highlighted the importance of ethics committees for end-of-life cases. The Baby Doe Law in 1984 addressed discrimination against critically ill newborns, and the 1991 Patient Self-Determination Act mandated that healthcare organizations receiving Medicare or Medicaid payments ensure compliance with advance healthcare directives. The 1990s also saw an increase in public discussions and legislative changes surrounding ethical issues, such as the Cruzan decision, which further emphasized the need for HECs.

The development of HECs in Western countries, including the US, began around 1985. During this time, review committees were formed to address specific ethical issues, such as abortion and dialysis treatment, where the demand for resources exceeded supply. These early committees introduced community representatives into the decision-making process, marking the beginnings of HECs in the field of bioethics.

Over the past 30 years, HECs have gained prominence and are now well-established in many countries, particularly in the Americas and European regions. These committees provide ethics consultations, assist in policy development, and promote ethical decision-making that respects the values, concerns, and interests of all stakeholders. HECs have become increasingly important as medical advancements and diverse moral and religious values have made healthcare decision-making more complex.

While HECs are prevalent in developed countries, many countries in the Eastern Mediterranean and South-East Asia regions are still in the early stages of establishing these committees in their hospitals. The establishment of HECs in these regions may be influenced by the guidance and experiences of countries with more established HECs.

Functions of ethics committees

The functions of ethics committees in hospitals have evolved since the 1960s, when the rapid advancement of medical technologies presented ethical questions that society was unprepared to answer. Today, ethics committees continue to address ethical challenges in medicine and are characterised by their role in considering, debating, studying, taking action on, and reporting on ethical issues that arise in patient care.

One of the most important functions of hospital ethics committees is to provide ethics consultations to the hospital community. They are often sought when a physician and patient/family cannot agree on a treatment decision. A member of the ethics committee with formal training in bioethics will evaluate the case and present their findings to the committee. The entire committee will then discuss the case and make a recommendation, which the physician and patient/family will then consider.

Ethics committees also play a role in ethical formation, providing education and guidance to the hospital community. They develop ethics education programs and assist in ethics-related educational programming and policy development within their institutions. This includes developing and revising policies pertaining to clinical ethics, such as advance directives, DNR and Comfort Care Policies, withholding and withdrawing life-sustaining treatments, informed consent, and organ procurement.

Additionally, ethics committees serve as advisors and educators, respecting the rights and privacy of all participants and maintaining the confidentiality of information disclosed during discussions. They facilitate sound decision-making that respects the values, concerns, and interests of all stakeholders.

In some cases, ethics committees may also be involved in risk management activities, interpreting and implementing relevant laws, regulations, and statutes, as well as setting priorities for the use of limited resources. However, there is less clarity around this function, and it is not always available for emergency consultations.

Ethical challenges faced by clinicians

Hospital ethics committees (HECs) have become increasingly common in hospitals worldwide since the 1980s. They are established to help clinicians deal with ethical challenges in their clinical practice and to advise and educate patients, physicians, and other healthcare professionals.

Healthcare professionals face a wide range of ethical challenges in their day-to-day work. These challenges can be broadly categorized into four types: confidentiality, decision-making, communication, and professional duty. For example, clinical geneticists often face the ethical dilemma of deciding how much clinically significant and hereditary information to disclose to patients. Clinicians must also navigate the complex dynamics of patient autonomy, particularly in situations where parents or guardians make treatment decisions for minor patients.

The rapid advancement of medical technology has introduced new ethical dilemmas, such as those surrounding kidney dialysis technology in the 1960s, where the demand for dialysis machines outpaced the supply, leading to difficult rationing decisions. Similarly, the development of assisted reproduction technologies has raised ethical considerations for patients seeking these treatments, who may be psychologically vulnerable due to repeated frustrations in their attempts to have children.

Ethical challenges can also arise from medication and tool shortages, particularly in rural areas. This can result in moral conflicts when patients do not receive the medication they need due to limited supply. Furthermore, insurance companies' involvement in medical care can create ethical dilemmas, such as when insurance dictates or delays surgeries.

Healthcare professionals often experience stress and self-doubt when facing tough moral decisions. To navigate these challenges, they may seek guidance from experienced doctors or join online communities to explore diverse opinions and learn from shared experiences.

Patient rights and consent

The presence of ethics committees in hospitals has become increasingly important due to the emergence of complex ethical issues in medicine and advancements in medical technology. While it is unclear if every hospital has an ethics committee, they are well-established in many countries, particularly in the Americas and Europe. These committees play a crucial role in addressing ethical challenges that arise in clinical practice, promoting ethical decision-making, and protecting patient rights.

Patient rights refer to the legal and ethical entitlements that individuals have when receiving medical care. These rights are protected by laws and policies and they ensure that patients are treated with respect, dignity, and autonomy. One of the most fundamental patient rights is the right to informed consent.

Informed consent is a process that involves providing patients with the information they need to make voluntary and well-considered decisions about their medical care. This includes disclosing details about the patient's health status, recommended treatments, procedures, or interventions, along with associated risks, benefits, alternatives, and potential consequences. Healthcare providers are responsible for ensuring that patients understand this information and addressing any language or comprehension barriers.

Patients have the right to ask questions, seek clarification, and make decisions about their care based on the information provided. They can also refuse or withdraw consent at any time, even after initial agreement. This right to change one's mind about consent is essential for upholding patient autonomy and ensuring that individuals are not pressured into treatments or procedures they do not fully understand or agree with.

In certain situations, such as when a patient's capacity is impaired, a surrogate or designated representative may be involved in the informed consent process. This representative is expected to act in the patient's best interests and make decisions aligned with the patient's values and preferences. In the case of minor patients, parents or guardians are responsible for safeguarding their children's health and well-being while also respecting their maturing autonomy.

Informed consent serves ethical and legal purposes by safeguarding patient rights, fostering transparency, and promoting trust between healthcare professionals and patients. It also protects clinicians by documenting that patients were adequately informed, reducing their legal liability. Overall, the process of informed consent ensures that patients are active participants in their healthcare journey, making decisions that align with their personal values, beliefs, and preferences.

Ethics committees in different countries

The role of hospital ethics committees (HECs) is to help clinicians deal with ethical challenges in their clinical practice. HECs promote shared decision-making between patients/surrogates and clinicians, enhancing the ethical tenor of healthcare professionals and institutions. They also promote fair policies and procedures that maximise the likelihood of achieving good, patient-centred outcomes. HECs are well-established in many countries, particularly in the Americas, Europe, and South Korea, and are becoming more prominent in the Eastern Mediterranean and South-East Asia.

In the United States, several laws and mandates have been passed since the 1980s, requiring healthcare organisations and hospitals to establish ethics committees. These include the 1984 Baby Doe Law, the 1991 Patient Self-Determination Act, and the 1992 mandate by the Joint Commission on the Accreditation of Healthcare Organisations.

In Italy, the establishment and organisation of ethics committees differ from the rest of the EU. Italy has the highest number of national, local, and regional ethics committees compared to other EU member states. However, Italy ranks low in the number of NIH-registered trials per capita, possibly due to cumbersome administrative procedures and a lack of harmonisation of procedures.

In Israel, ethics committees are mainly active in the field of medical research, and academic staff generally have the freedom to conduct research without seeking approval. On the other hand, ethics committees in the USA and New Zealand are perceived as more cautious, with more stringent recruitment procedures and detailed instructions on conducting research to minimise harm to participants.

In China and India, ethics committees require a minimum of seven members and a maximum of 12–15 members, while most other countries recommend a minimum of five members. It is mandatory that at least one member is autonomous and independent of the institution, and at least one member is from the non-scientific community.

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