Clinical ethics committees
BMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7262.649 (Published 16 September 2000) Cite this as: BMJ 2000;321:649All rapid responses
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I am sceptical about the value of these institutions for the follwing
reasons.
1. A hospital ethicist or ethical committee can serve as a "hand-
washing devise", allowing the ward staff to let others take the
responsibility for hard decisions: "The ethicists said it was OK. What
do you want of me?"
2. The existence of ethicists and their committees can be an excuse
for ward staff not to read biomedical ethics literature themselves, and
not to think deeply about bioethical questions.
3. Ethicists and the ethics committees who are hired or appointed by
hospital or national health service or sick fund management may naturally
be selected to serve the interests of management. This can run from not
interfering with experimentation which management wants to pursue, to
liberal DNR policies to save resources.
4. There is no reason in the world why every hospital in a country,
or every ward within a hospital, should have the same policy about DNR and
other ethically-sensitive issues. With due respect to Kantians, life and
death are too complicated for ethical uniformity, let alone
universalization. Hospital ethicists and ethics committees can tend to
push for uniform policies for an entire hospital, discouraging creative,
sensitive case-by case thinking by the ward staff involved.
As a philosopher-bioethicist (not a physician) in a medical school, I
deplore efforts by my colleagues to ensure us and our students employment
by encouraging the institutions of clinical ethics committees and hospital
clinical ethicists. Instead I think our function should be educational,
helping present and future physicians and nurses to learn to think deeply,
systematically and for themselves, about life, death and their ethics.
Rather than passing the responsibility on to others, they should make
ethics decisions ward decisions: not to be made, of course, by
individuals (even the most distinguished professors) but in ward staff
meetings including the nurses, the social workers and -- lest we forget --
the patient and family whenever possible.
Competing interests: No competing interests
Clinical ethics committees and due process
Slowther and Hope suggest that clinical ethics committees (CECs) will
likely play important roles in the future, given that the "medical
profession is under mounting pressure to ensure high standards of ethical
practice; the courts may consider them as part of due process; and
clinical governance will need to include clinical ethics within its
remit".(1)
While CECs might be called upon to ensure high ethical standards,
they will likely face greater public pressure to ensure that these
standards also apply to their own practices, especially regarding issues
about due process. It has been noted that CECs operate behind closed doors
and rarely provide reasons or justification for the decisions they
make.(2) The view that CECs are part of a culture of secrecy and
paternalism and lack meaningful procedural rights was hotly debated in the
United States where CECs have been provocatively referred to as a "due
process wasteland".(3)
This debate will likely be rekindled. Why? The public trend for
greater transparency and accountability in medical decisions is gaining
momentum, as are human right concerns about some medical practices. This
trend may put many patients on a collision course with professional bodies
that resist public scrutiny and accountability. Given the current climate
of concerns about industry pressures, conflict of interests, and self-
regulating professions,patients will likely expect CECs to provide open
access to and full explanations for their decisions. They will want to
know who sits on CECs and whose interests are being represented.
Will the courts turn to CECs as part of due process? Before this can
occur with any degree of public confidence, clinical ethics committees
must demonstrate that their own moral house is in order. They need to show
that the moral landscape in which they operate is not a "due process
wasteland" but rather a fertile ground for human rights to flourish.
Mark Wilson
1. Hope,T, Slowther AM. Clinical ethics committees, BMJ 2000;321:649-
650. 16 September)
2. Bernard, L. Behind Closed Doors, Promises and Pitfalls of Ethics
Committees. N EnglJ Med1987;317:46-50.
3.Wolf S. Ethics Committees and Due Process:Nesting Rights in a
Community of Caring. Maryland Law Review 50:1991, 798-858.
Competing interests: No competing interests