Intended for healthcare professionals

Education And Debate

Ethics and the structures of health care in the European countries in transition: hospital ethics committees in Croatia

BMJ 2005; 331 doi: (Published 21 July 2005) Cite this as: BMJ 2005;331:227
  1. Ana Borovečki, research assistant (abor{at},
  2. Stjepan Orešković, professor of medical sociology1,
  3. Henk ten Have, professor of medical ethics2
  1. 1 Andrija Štampar School of Public Health, Medical School, University of Zagreb, 10 000 Zagreb, Croatia
  2. 2 University Medical Centre, Radboud University Nijmegen, the Netherlands, Postbus 9101, 6500 HB Nijmegen, Netherlands
  1. Correspondence to: A Borovečki

    Hospital ethics committees are a recent phenomenon in countries in transition. Croatia's example shows they are staffed mainly by older doctors with no specialist knowledge of ethical issues. The importance of professional relationships and the educational function of ethics committees have been ignored


    Healthcare structures, organisations, and institutions have ethical characteristics that are about relationships. These groups are composed of individuals and groups of people with moral obligations. Healthcare structures embody particular organisational cultures that, good or bad, affect people and reflect values. Also, healthcare structures have certain purposes, and they can be evaluated and held accountable whether or not they fulfill their purposes, particularly those affecting and effecting health care. For these reasons, healthcare structures have ethical attributes, and ethical analysis of the healthcare system could be performed.1

    We use hospitals ethics committees in Croatia to explore the issues connected with structural ethics in healthcare institutions in the countries in transition, and we present it as an example that applies also to other countries in transition. We chose hospital ethics committees because we believe that such an analysis can explain structural ethics issues in a healthcare system.

    Hospitals and structural ethics

    Hospitals are healthcare structures made of intricate webs of relationships between people. They have attributes relevant to ethics: they promote values embodied in medical ethics, reinforcing certain kinds of behavior and discouraging transgressions. Hospitals create and promote ethical cultures within their walls. Hospitals have purposes: they protect the wellbeing of patients, foster their healing process, and help patients and their families to cope with disease. On the basis of these purposes, hospitals have responsibilities towards patients and their families. Observing how hospital ethics committees function makes it possible to “read” a hospital. Hospitals and hospital ethics committees are part of the patchwork of a healthcare system, as are the other institutions and organisations. Thus by observing the work of hospital ethics committees one can tell a lot about the ethical climate of the healthcare system itself.

    Embedded Image

    Ethics comes to Croatia's former healthcare factories

    European countries in transition, ethics, and healthcare structures

    Countries in transition in central, eastern, and southeastern Europe have a similar path of development and historical background.2 The healthcare structures in countries in transition were regarded as health factories. The number of beds, the number of patients processed, the level of technical sophistication in these healthcare factories were most important in evaluations of their work. Little if any attention was paid to the age, personal characteristics, religious beliefs, and gender differences of patients or to ethical problems that arose in the process of providing health care. The bureaucratic approach in health care was omnipresent. Unfortunately, the legacy of such an approach can still be seen in healthcare structures in the countries in transition. Thus the process of institutionalisation of bioethics is regarded by some authors as especially important to European societies in transition. The development of hospital ethics committees, especially, could encourage the development of ethical professional behaviour and the creation of important networks within a specific country.3 However, if institutionalisation is carefully implemented, it can produce scepticism and bureaucratic behaviour.4

    History of ethics committees in Croatia

    1970s: First steps towards bioethics institutionalisation (hospital drug commission, institutional review boards) for international multicentre trials

    1990s: Ethics committees formed in medical schools, medical associations

    First legal requirements for ethics committees in healthcare institution (Law on Health Protection): committees must combine the functions of institutional review boards and hospital ethics committees; they are to have five members, of whom two are not from the medical field

    2001: Formation of the National Bioethics Committee for the Medicine of the Government of the Republic of Croatia (20 members; issues recommendations, guidelines, and reports on various ethical issues)

    Committees are found in scientific institutes and the schools of dentistry, veterinary medicine, and pharmacy, along with National Bioethics Committee and committees in healthcare institutions, medical schools, and professional regulatory bodies

    Croatian ethics committes and healthcare structures

    Ethics committees in Croatia are a relatively new phenomenon (box).

    In 2002 and 2003, the National Bioethics Committee for Medicine conducted a study of ethics committees in Croatia, asking about the number of members, structure of membership, issues discussed during meetings, number of meetings so far, standing orders, working guidelines, and documents related to their work. The survey had a response rate of 82% and showed a highly formal and legalistic approach to the formation of ethics committee.5 Those findings prompted us to further analyse the situation, especially regarding ethics committees in hospitals in Croatia, because we felt that analysing the work of hospital ethics committees would provide information about structural ethics issues within a healthcare system.

    Survey and results

    We sent a questionnaire to 241 members of hospital ethics committees. Their names were obtained from the 2002-3 survey of the National Bioethics Committee. The questionnaire had four parts: data on age, sex and occupation, number of members in the committee, educational practices, frequency of meetings, issues dealt with in everyday practice; a 42 question self-evaluation questionnaire (assessed on a Likert scale); 23 questions testing knowledge of ethical issues; and 19 “bioethics consensus statements” (agreement measured on a Likert scale).

    The survey had a response rate of 61% (74 men, 73 women); mean age of the respondents was 51; 73% of respondents were doctors. The survey showed that the structure and the composition of hospital ethics committees followed the legal requirements. Most committees were formed after 1997, when the legal provisions for ethics committees in Croatia were introduced. The number of members and their occupation was an exact replica of the structure of the committees required by the law: three doctors and two members from other professions, of whom lawyers and theologians were the most likely candidates.

    The main task of ethics committees in hospitals was an analysis of research protocols, thus neglecting the other functions important for a hospital ethics committee: education, case analysis, and development of guidelines. The level of knowledge of the members was average, but not sufficient for the complicated tasks that they were supposed to perform in their everyday work. Their views on the doctor-patient relationship and bioethical dilemmas showed a high level of paternalism and overprotectiveness of their patients. These results may be due to the fact that most of those who participated in our survey were 50 years and older and had no formal education in the field of bioethics.

    A bureaucratic approach

    The legalistic approach to the formation of ethics committees, as in the Croatian case, is not uncommon, and transforms ethics committees into bureaucratic bodies.4 Hospital ethics committees exist only to fulfill the legal requirement. This is a drawback in developing a healthcare institution or a healthcare system with ethical standards.

    This top down approach is common in countries in transition,6 where the development of civil society has been constrained by a former totalitarian government. Those societies feel more at ease when the regulatory frameworks in all areas as well as in health care are implemented by the state. This is to be expected in healthcare systems which were monitored and regulated by the government in a highly bureaucratic manner with no sensitivity to the reality of the everyday work of healthcare professionals. In such a climate, healthcare professionals were usually required to conform to bureaucratic requirements, thus putting their judgment in conflict with the requirements of the system.7

    The top down approach and highly legalistic framework has created confusion about the tasks of ethics committees in hospitals. Although the committees combine the functions of institutional review boards and hospital ethics committees, they have made the analysis of research protocols their main function. This is also not uncommon, since in other countries in transition institutional review boards have been present for many years in one form or another because of multicentre trials.8 Thus members of ethics committees have considerable knowledge from this field. However, this jeopardises the other, more important, functions of an ethics committee in hospital: education about ethical issues, development of guidelines, and analysis of cases that raise ethical questions.9 10

    This lack of recognition of the broad range of functions of a hospital ethics committee, especially the educational function, can be seen in the insufficient level of knowledge of the committees' members. This draws attention to the need for developing bioethics education on all levels in the countries in transition; efforts to improve the level of knowledge have been made in Lithuania, Estonia, Latvia, Poland, Slovenia, Czech Republic, Slovak Republic, Hungary, Romania, Bulgaria, and Croatia.3 6

    Another trait is a strong paternalistic tendency, especially among older healthcare staff who have a more traditional view on the doctor-patient relationship and medical ethics.6 This is reflected in the work of ethics committees, which are often made up of older doctors, as in the Croatian case—probably because the experience of older doctors is equated with their competence in medical ethics. Here we find a traditional approach to medical ethics: older, more experienced doctors are thought to be competent enough to converse about ethical issues just because they have considerable experience to draw their knowledge from.


    The work of ethics committees in Croatia can be viewed as one of satisfying norms and requirements within a healthcare system. However, healthcare systems are also about people and relationships, and when that is ignored it can create a lot of strain on both providers and users, creating unresolved issues and tensions as well as ethical problems. Healthcare organisations should be based on webs of relationships and interactions between people, promoting ethical values, trying to foster patients' best interests, and having responsibilities.

    Summary points

    In European countries in transition, like Croatia, the healthcare system has a bureaucratic climate and approach

    Ethics committees in such a climate are bureaucratically constituted entities whose functions consist mainly of analysing research protocols

    Members of hospital ethics committees have insufficient knowledge of ethical issues and a paternalistic approach

    Ignoring people and relationships can strain both providers and users, creating unresolved issues and tensions and ethical problems.


    • We thank Darko Hren for help with statistical analysis and the National Bioethics Committee for Medicine of the Government of the Republic of Croatia for permission to use its data and help with sending out the questionnaires.

    • Contributors AB planned and conducted the study, composed the questionnaire, collected and analysed data, and prepared the manuscript. HtH and SO planned the study and revised the questionnaire. AB, HtH, and SO prepared the manuscript. AB is guarantor.

    • Competing interests None declared.


    1. 1.
    2. 2.
    3. 3.
    4. 4.
    5. 5.
    6. 6.
    7. 7.
    8. 8.
    9. 9.
    10. 10.
    View Abstract