The unpalatable truth about ethics committees
BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4179 (Published 14 October 2009) Cite this as: BMJ 2009;339:b4179
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Dear Sir
Maybe the reason that ethics review bodies are not used is that they
are not seen as particularly useful1. Medical Ethicists justify their role
by making claims that knowledge of ethics will help with making difficult
decisions. However there are also clinical (what is possible and what is
likely to happen) and legal (what society allows you to do) aspects of
making difficult decisions. Ethical aspects are often only part of the
consideration which goes into making hard decisions. Furthermore I know of
no evidence that clinicians make different decisions if they have
knowledge of ethics than those who have not had any ethical instruction.
My anecdotal experience of teaching on ethics courses is that clinicians
make the same decisions at the start of the course and the end of the
course. The difference being that at the end of the course they have a
slightly different language to describe the problem. So before we are all
subjected to an obscure dialogue on Greek ancients in the name of ethics
teaching let’s see some evidence that this knowledge actually makes a
difference.
Yours
Dr. Simon Hatcher
Senior Lecturer in Psychiatry, The University of
Auckland s.hatcher@auckland.ac.nz
1. Sokol, D. The unpalatable truth about ethics committees. BMJ 2009;
339:b4179 (17 October)
Competing interests:
None declared
Competing interests: No competing interests
It is suggested that readers make a distinction between the
conclusions of our questionnaire survey published in the Postgraduate
Medical Journal1, and the opinions expressed by Sokol in his column2. In
that study we set out to explore the case consultation activities of CECs
via the views of the committees’ chairpersons. Although Sokol was a co-
author of the Postgraduate Medical Journal article, his opinions as a BMJ
columnist and CEC member should not be seen as, and confused with, the
conclusions of the questionnaire study.
Lucassen et al.3 reported that the Southampton CEC was not included
in the study published in the Postgraduate Medical Journal1. All CECs on
the Ethox website were contacted by email. We sent out an invitation
email to all committees listed on 27th March 2008, with a reminder on 8th
April 2008. As responses were anonymous, it was not possible to tell
which CECs replied. It is strange that Lucassen et al. reported that they
never received the questionnaire of Whitehead et al.1, not least since
Lucassen was the contact for the Southampton CEC. Our records show that
the survey was sent to Lucassen at the e-mail address shown on the Ethox
website. This non-receipt is unfortunate as their response would have
enriched the data and increased our response rate. It would not, however,
have altered our fundamental conclusion regarding the minimal case
consultation activity of CECs in the United Kingdom.
Louw4 commented that our sample of the UK CECs was “no-doubt skewed”
as it was small. We received responses from 30 CECs out of the 70
initially contacted, giving a response rate of 43%. Although we were
disappointed with this response rate, it is suggested that this compares
favourably with other surveys sent by email. In our paper we discussed
the limitations of our survey including that it may be prone to biases in
respect of the respondents. We have no idea if our sample was
representative. Louw has no evidence, only conjecture, to suggest the
sample was skewed. He went on to imply that the questionnaire survey was
“bad science”, presumably once again because of his conjecture that the
sample was “no-doubt skewed”. Louw does not substantiate his claims and
is confused as to what constitutes “bad science”. We reported our
findings based on those questionnaires returned in our national study,
analysed by a professional medical statistician and following a
comprehensive peer-review process. “Bad science” would have been the
irresponsible act of not reporting our findings because a proportion of
CECs did not wish to respond, or as has subsequently been claimed they did
not receive the questionnaire.
In the interests of good science and useful debate, we encourage
responders to comment on the original Postgraduate Medical Journal article
and Sokol’s BMJ column separately using the rapid response procedures on
the respective journal websites. Otherwise, there is potential to mislead
other readers.
Jessica Whitehead, Final year medical student.
Philip Sedgwick, Senior Lecturer in Medical Statistics.
Daniel Sokol, Honorary Senior Lecturer in Medical Ethics.
Deborah Bowman, Senior Lecturer in Medical Ethics and Law.
1. Whitehead JM, Sokol DK, Bowman D, Sedgwick P. Consultation
activities of Clinical Ethics Committees in the United Kingdom: an
empirical study and wake-up call. Postgrad. Med. J. 2009;85:451-454.
2. Sokol D. The unpalatable truth about ethics committees BMJ.
2009;339:b4179.
3. Lucassen A, Fenwick A, Woodcock T, Wheeler R. Unpalatable
conjecture maybe... BMJ. 19 October 2009.
4. Louw S, Rudd P, Slowther A, Larcher V, Watson A. The truth is an
unpalatable concept. BMJ. 24 October 2009.
Competing interests:
Whitehead, Sokol, Bowman and Sedgwick were authors of the original article published in the Postgraduate Medical Journal.
Competing interests: No competing interests
Daniel Sokol’s article “The Unpalatable Truth about Ethics
Committees”(1) contains some interesting thoughts about Clinical Ethics
Groups (CEGs), but I wonder what his real point is? His remarks read a
little like a customer’s letter of complaint to a company about one
specific problem (the low number of live cases considered by Ethics
Committees in his limited survey in 2009), which then becomes a series of
“,and another thing” “and another thing” grumbles.
A major concern of Sokol’s seems to be that clinicians are not using
CEGs as much as he thinks they should because they are seen as
intimidating and lacking in real ethical expertise. However, how much
should clinicians use formal referrals to a CEG? This is an unanswered
question, and what Sokol sees as insufficient referral, may simply reflect
significant expertise on the part of clinicians in considering and solving
ethical problems themselves. In his Nicomachean Ethics, Aristotle
repeatedly gives the example of a physician’s approach to medical decision
making as the paragon of the right method to use in ethical decision
making.
Undoubtedly CEGs across the U.K. vary in their size, composition and
precise methods, but certainly they will share the key functions of our
own Trust’s Clinical Ethics Advisory Group (CEAG) which was established in
January, 2001.
The two key functions of our Group are:-
a. to comment and advise on the ethical implications of policies and
guidelines that are developed within the trust and,
b. to advise clinicians on the broad ethical dimensions of clinical
problems.
Our group consists of a number of health care professionals and has had
different non-clinical ethicists since its inception. In terms of ethical
expertise, of the health care professionals in our group of around 25
members, three practicing clinicians have an MA in Health care Law, MA in
Ethics of Health Care, and MA in Law and Medical Ethics respectively. One
nurse is a PhD student in Ethics and Sociology. The director of the
University’s undergraduate course in Medical Ethics has always been a
member and, in addition, over the past eight years we have had as members
a clinician with a PhD in philosophy, a former nurse with a PhD in Ethics
and a non clinical PhD ethicist. The remainder of the membership consists
of a wide range of health care workers with a demonstrable interest in the
ethical issues inextricably linked to their practice. This seems to me to
represent an almost ideal mix of talents for a clinical ethics advisory
group.
We discuss around eight live cases per year, brought to us by health
care workers from within the Trust, and which are felt to require debate
and reflection to assist in the resolution of an apparent ethical dilemma.
In addition we offer an urgent ethical consult service, and are often
involved in exploring the ethical underpinning of policies and guidelines.
Although Sokol mentions two centers in the USA with very high numbers of
consultations, his paper in the Postgraduate Medical Journal(2) shows
that average USA practice accords very much with current UK practice.
Do we need – or want – an ethicist with a dect phone able to be
summoned to a patient’s bedside whenever an apparent ethical problem
arises? I think there is a real risk that going down this path could harm
physicians’ skills in moral thinking – an essential part of medical
practice, in the way that phlebotomists have blunted doctors’ skills in
venous access. “Call the ethics man” is a poor substitute for thinking
through and resolving a problem. I believe that we provide ethics support
that is “accessible, professional and non-threatening.” However, such
ethical support is relatively new and evolving; there are undoubtedly
aspects of practice that will improve, and I agree with Sokol that these
will probably include better advertising of our existence and enhanced
training of clinician ethicists. Fortunately, the UK Clinical Ethics
Network exists, in part, to further these objectives.
Dr Charles McKnight
Competing interest - Charles McKnight is a consultant anaesthetist
and deputy chair of the Newcastle upon Tyne Hospitals NHS Foundation Trust
Clinical Ethics Advisory Group.
(1) BMJ 2009;339:b4179
(2) Postgrad Med J 2009;85:451-454
Competing interests:
Vice Chair of the Newcastle upon Tyne Hospitals NHS Foundation Trust Clinical Ethics Advisory Group
Competing interests: No competing interests
We are grateful to Daniel Sokol for introducing this important
discussion regarding clinical ethics committees (CECs). Although his study
is limited by the relatively low response rate (less than 50%) it is
important to take seriously the points he makes regarding the possible
under-use of CECs, lack of financial support, the difficulty in providing
an acute response to ethical dilemmas, the potential for inadequate
training and the possibility (not substantiated by research) that they may
be intimidating to use. We do not, however, agree that CECs in principle
are “ill suited to resolving individual ethical problems of clinicians at
the coal face” as he suggests.
CECs, as Dr. Sokol points out, are unlikely to be the only way to
provide ethics consultation in health care settings. Other forms of ethics
support may include the employment of an ethicist to provide regular
ethics support to teams, providing training in ethical issues to clinical
staff and rapid response systems including face to face, telephone and E
mail consultations. A well functioning CEC can have an important role in
facilitating and co-ordinating these other activities as well as providing
a regular forum for clinicians and mangers to bring cases or policies for
more considered discussion. A key strength of the CEC is it’s multi-
disciplinary composition, including, ideally, a patient and carer
representative alongside clinicians from different areas, ethicists and
lawyers, thus providing a balanced perspective. Members need to be
selected carefully, using an interview process, in order to ensure members
with the appropriate skills and experience who can work together as a
group and create a context that is accessible, useful, and not
intimidating to clinicians and other referrers. Our own committee in
Oxford (which incidentally has on average 9 cases referred a year) values
the perspective of carers and patients and is continually evolving as we
seek to improve our methods of case deliberation; it has had very
favourable responses from clinicians and others using it, although we are
aware of the need for more formal audit of the process. CECs are a
relatively recent innovation and there is a crucial need for critical
reflection, audit, and research to clarify the role, process and success
of CECs and thus to constantly improve their practice.
Finally, we agree that support from Trust management, including
financial support, is essential, in order to facilitate adequate time for
the contribution of members, training, communication and administration.
Without the back-up of management, committees will struggle to even
advertise themselves, let alone provide high quality ethics support. Sound
ethical decision-making is a sign of a healthy well functioning Trust.
Trusts need to feel reassured that ethical dilemmas are being resolved
safely and effectively; CECs, when they are securely grounded in the
organisation, can play a part in providing the support to achieve this.
Competing interests:
I am a chair of a clinical ethics committee
Competing interests: No competing interests
Daniel Sokol’s approach is more moderate in his response. But he
appears to stand by his view (BMJ 2009;339:b4179) that Clinical Ethics
Committees (CECs) “alone … are not the answer to the day to day dilemmas
faced by clinicians.” Of course they are not. But nor is what he
proposes.
Quite apart from the acknowledged low response rate in the Sokol
study, his quantitative findings seem disconnected from his conclusions.
The number of CECs that are “moribund” is, by his own data, quite small.
A low referral rate does not justify the claim, quoted by Sokol from his
earlier work, that “clinicians are not using them.”
Clinicians are using our CEC. It is approaching its fourth birthday
having endured two rounds of organisational change, battled for
credibility and funding, relied entirely on the goodwill & capability
of the officers’ secretaries, met in dingy rooms on dark evenings and
occasionally sat twiddling its thumbs and wondering why no one has made
referrals. It has a broad range of experience and expertise including a
handful of postgraduate degrees. That breadth and plurality, if well
used, makes for vigorous debate and produces advice that is far more
robust than a single expert ever can, avoiding domination by a single view
or approach. It has engaged, sometimes quickly via email subcommittees
and sometimes contemplatively in a quarterly full meeting, with
experienced clinicians struggling with real dilemmas. In the last two
months they have included potentially headline-hitting controversies. The
CEC has never claimed to have easy answers but has consistently helped
those clinicians to find a way through the mire. We have a sheaf of
‘thank-goodness-for-the-CEC’ emails to show for it and increasing demand
from disciplines who have not used us before. Far from just showing how
well we've done, this demonstrates the usefulness and stability of a model
of clinical ethics support that Sokol would replace with a different
approach.
Are there dilemmas that don’t get referred? Are there colleagues who
don’t even know we exist? Of course there are. Are there people who are
too intimidated to refer? Yes, although in our case it’s not because
we’re scary but because they fear conflict within their team if they go
outside the chain of command. I don’t think we’ll have arrived until we
get referrals from GP practice staff worried about confidentiality at the
reception window. But there is a reason that British CECs have low demand
and don’t need to offer emergency advice. Most clinicians are good at
integrating the ethical into their clinical decision-making, have access
to authoritative published guidance, and only occasionally need help. I
don’t often need a plumber, but when I need one I’m really glad to find
one.
Putting 24/7 ethics consultation into hospitals is like having the
plumber living in your house. You’ll get him to turn the taps on and off
for you. Eventually there’ll be health and safety rules banning you from
touching them. This is the unhappy reality in a culture that insists on
ethical review of every hard decision, a culture that as reported above
exists in only a minority of hospitals even in the US. The real ethical
decision makers where I work are the clinicians, and the CEC is glad not
to have deskilled them but to be in support when it’s needed. What is the
answer to clinicians’ ethical dilemmas? It lies in better training,
clearer guidance, and fewer organisational barriers to reflection on hard
choices and to doing their best with their patients. All CECs need to
keep improving. But the only ones who would gain from Sokol’s proposals
are the ethicists.
Competing interests:
I chair a CEC.
Competing interests: No competing interests
I did not set out to exaggerate the issues when writing the
column on clinical ethics committees. I did not intend to
provoke or offend. I decided, after much soul-searching, to
point out what seems to me like an elephant in the room . I
say ‘after much soul-searching’ because I know that hundreds
of people devote a lot of time to CECs and that others have
spent years setting up, running and promoting CECs. I was
aware of the potential damage that the piece could cause to
some already fragile CECs, perhaps struggling to justify
their existence or with low morale among its troops, and to
the egos of those who have a more positive outlook on the
work of CECs. I regret if I have upset them. The article
was not an attack on any individual but on the sole
committee model itself, and if the model is failing in other
parts of the world, this only supports the point.
We were open about the limitations of our study in the
recent PMJ article, the main one being the relatively low
response rate of 43%. I do not think, however, that this
means we should ignore the results. We should stop
pretending all is well with CECs. Some, including Dr
Lucassen’s, are doubtless busy and successful. Many more
are struggling to get any active cases and may go for months
without a single case. Some are moribund and are, to be
blunt, a waste of everybody’s time. In the last week, I
have received many e-mails from individual CEC members,
understandably reluctant to post their comments publicly,
telling me that this needed to be said. One response is to
rubbish the article and to claim in a letter circulated to
CECs around the country that it demonstrates ‘lack of
understanding about the reality of some committees and of
providing ethics support in the UK’ but I doubt that such a
dismissive approach will help improve matters. If a
clinical ethics committee has no elephant, then wonderful.
They should share the secrets of their success with others.
If it has, then committee members should discuss ways to
push it out of the room. Ignoring it will no longer do.
Competing interests:
I am the author of the
article
Competing interests: No competing interests
In his commentary on clinical ethics committees Sokol makes several
claims about clinical ethics committees, not all substantiated by evidence
(it is not clear how he knows CECs are intimidating as his survey was of
CECs not the users of CECs). He also makes a somewhat unflattering
comparison of clinical ethics support in the UK (caricatured as under
used, under trained committees) with the United States (characterised as
bioethics centres with trained ethicists providing individual case
consultation). However the truth about ethics consultation services in the
US is more complex. In a survey conducted by Fox et al(1) of a random
sample of 600 hospitals in the US 81% had an ethics consultation service
(ECS). The median number of consultations performed in the previous year
was three, with 22% of services performing no consultations. Fewer than 4%
of those people performing consultation were in the category that included
ethicist or philosopher and only 5% had completed a fellowship programme
or graduate degree in bioethics. As Fox and her co authors observe there
is a marked contrast between the majority of those doing clinical ethics
in hospitals (mainly clinicians) and those writing about ethics
consultation in the ethics literature (mainly ethicists).
Thus, Sokol uses a sample (n=2) of US hospital groups with unusually
high usage of ethicist consultations (clearly outliers compared to Fox’s
systematic data) and concludes that by comparison the UK CEC model is
“ill suited” and “ too clumsy”. In our view Sokol is mistaken in using
his small (no-doubt skewed) sample of UK CECs to draw his comparisons with
an even smaller sample of US hospitals. The truth is that bad science
will not lead to better ethics. It is disappointing to note that Sokol’s
criticism of the quality of clinical ethical consultations in the UK
threatens to undermine sustained efforts to develop accountable ethics
support services for clinicians in the much less well endowed NHS health
economy. He is right, though, that for UK CECs to thrive, formal
financial support is required: for systematic training, expert support and
research on their functionality.
The UK Clinical Ethics Network (UKCEN) has responded to an
independent consultation process led by the RCP on Clinical Ethics
Committees (2)by developing a Core Competencies document (in press) – the
process included wide consultation with practicing clinicians and
professional ethicists. Thus UKCEN aims to establish a minimum standard
for membership of a CEC for the short-term and also clearly sets out the
pathway for enhancing the quality of ethics competencies for the future –
a blend of pragmatic realism and idealism. No comparable set of standards
has been published in the UK; UKCEN is currently planning to develop
training materials to match these competency standards.
Even if Sokol’s belief that ethics case consultation should be done
only by trained ethicists (leaving the policy advice to committees) is
correct, it is clear that in the UK, and also the US, this is unlikely to
become a reality in the foreseeable future. The truth may be more
multifaceted. There is a documented need for clinical ethics support in
the UK (3) which includes raising awareness of ethical issues, education
of health professionals and advice in individual cases. Resources to
provide this support are scarce - so we should be focussing on how we can
deliver an effective service with the resources we have and can develop,
including (but not exclusively) the establishment of clinical ethics
committees.
At a more fundamental, academic, level, there is a need for research
to test the hypothesis that clinical ethics support in any form adds value
to the quality of patient care. The evidence for this is currently
lacking; so, before we attempt to state the ‘truth’ about what the service
should look like, we should do the research to test our hypothesis.
Stephen Louw, Chair: UK Clinical Ethics Network
Peter Rudd, Vice-chair: UK Clinical Ethics Network
Alan Watson, past Chair: UK Clinical Ethics Network
Anne Slowther: Communications secretary, UK Clinical Ethics Network
Victor Larcher: Member, UK Clinical Ethics Network Board
1. Fox E, Myers S, Pearlman RA. Ethics consultation in United States
Hospitals: A National Survey. American Journalof Bioethics. 2007;7(2):13-
25
2. Shickle, D, Smith S, Stamp M, Watson A, Woolfson J. Ethics in
practice: Background and recommendations for enhanced support. Report of
a Working Party, Royal College of Physicians. June 2005.
3. Slowther A, Bunch C, Woolnough B, Hope T. Clinical ethics support
services in the UK: an investigation of the current provision of ethics
support to health professionals in the UK. Journal of Medical Ethics.
2001;27suppl I:i2-i8
Competing interests:
All authors are members or officers of the UK Clinical Ethics Network and members of clinical ethics comittees.
Anne Slowther is a consultant clinical ethicist at University Hospitals Coventry and Warwick NHS Trust and has received charitable funding to evaluate clinical ethics committees.
Vic Larcher is consultant clinical ethicist at Great Ormond Street Hospital NHS Trust and a member of the Royal College of Paediatrics and Child Health ethics advisory committee
Competing interests: No competing interests
I read Daniel Sokol’s editorial with great interest. I have so far
been a member of two clinical ethics committees and although I hope that
we are helpful to the clinicians that do refer cases to the committee, my
experience generally tallies with Dr.Sokol’s survey results, namely that
given the wealth of ethically thorny clinical scenarios that clinicians
talk about, there is a surprising dearth of cases actually being referred
for discussion. I would suggest, however, that this does not mean that
clinical ethics committees are not useful. The mere act of setting up and
maintaining a clinical ethics committee within an organisation requires
some level of acknowledgement from the executive board that clinical
ethics is an important issue in the delivery of clinical care; the
importance of this alone in today’s increasingly business-like medical
healthcare environment should not be underestimated. Furthermore, by
having a clinical ethics committee, the committee would necessarily report
to clinical governance committees and ultimately to the executive board,
which again keeps clinical ethics on the agenda. Furthermore, the
healthcare professionals who are members of the clinical ethics committees
hear and learn from other members, notably lay members and users and
carers, and maintain their enthusiasm for clinical ethics, which must
inevitably inform their own clinical practice. Replacing a clinical ethics
committee with a professional hospital ethicist who is seen as ‘the
expert’ in clinical ethics may be disempowering to clinicians who are
interested in ethics, by discouraging them from developing their own
expertise. And finally, clinical ethics committees, with their wide
representation, can play a very useful role in considering particularly
thorny cases as well as critiquing the ethical aspects of policy documents
for healthcare organisations, providing and integrating a variety of
perspectives in a way that a single individual’s opinion cannot.
For all these reasons, I would suggest that having clinical ethics
committees may themselves be worthwhile. What the challenge should be is
how to provide clinical ethics consultation and support to healthcare
professionals and the patients and carers they try to help. It may be that
as Daniel suggests the monthly committee model, though more affordable
(because almost all members give their time for free) than a dedicated
hospital ethicist post, is more intimidating and less responsive to a
clinician under pressure and unsure of what to do than an ethics
consultant who can come to the bedside. Different ways of delivering
ethics advice and consultation should be explored, and the best model for
the United Kingdom should be determined using good evidence. It may be,
for example, that clinical ethics committees, with their wide
representation, are best used to scrutinise trust policies and previous
decisions, while hospital ethicists should be employed to provide rapid
and accessible bedside consultations. The NHS should not expect to get
clinical ethics for free, any more than they would expect to get other
services and consultation for free.
Competing interests:
I am a member of a clinical ethics committee
Competing interests: No competing interests
We assume that Sokol has set out to exaggerate issues to obtain a
reaction, and we are happy to supply one. The ‘ethics man’ points out that
clinical ethics committees (CECs) differ in both their make-up, level of
training and amount of ethics cases/ policy issues deliberated upon. This,
we assert, is an advantage. Heaven forbid that CECs go the same way as
research ethics committees- who in their bid to harmonise responses, have
become process driven and bureaucratic and spend much less time on real
ethical issues than on form filling and defensive stances towards
research.
Where does the notion that CECs alone should be the answer “to the
day to day dilemmas faced by clinicians” come from? This is not a model
that CECs themselves want, or aspire to. Rather, we believe that there
should be a range of clinical ethics support mechanisms within Trusts,
including educational activities which help clinical teams work together,
of which CECs are just one. CECs provide support to clinicians who
otherwise may not have the knowledge or time to consider the ethical
issues of a case in detail. The mere existence of a CEC provides staff
development activities; members can take their experience of thinking
about ethical issues – whether though cases bought to the committee,
discussion of current issues (such as rationing of ICU beds in a pandemic
flu basis) or developing policy – back into their practice and work with
others. Indeed the existence of CECs could be said to protect clinicians
struggling with a dilemma from the idiosyncrasies of individual opinions
or from the expense of seeking legal advice.
Our committee in Southampton has been in existence since 2001; meets
monthly and discusses between 1 and 4 clinical cases per month with acute
case consultation in between. We have clear terms of reference, interview
for members but strangely never received Sokol’s questionnaire. Sokol uses
a less than 50% response rate of a subset of CECs from an unknown
questionnaire to conclude that ‘CECs can be intimidating’ ‘not terribly
approachable’ and ‘ill suited to resolving the individual ethical problems
of clinicians at the coalface’. We would be interested to know how these
‘truths’ popped out of the questionnaire. We acknowledge that not all
clinicians use us, or indeed may be aware of our existence, but we provide
one element of clinical ethics support within our Trust. Sokol’s
unpalatable truth strikes us as pure and mischievous conjecture.
Competing interests:
None declared
Competing interests: No competing interests
Ethics support: a Darwinian work in progress?
Sokol’s article makes some valid points about the need for developing
a clinical ethics service and the means to provide it, but in so doing his
criticism of clinical ethics committees (CECs) risks compromising what
many hope to achieve in terms of developing clinical ethics support. As he
acknowledges, his views are both anecdotal and based on a survey in which
less than 50% of UK CECs responded. Although the US experience presumably
reflects a similar need for ethical support it has been driven by a “top
down” approach and its usage is perhaps more patchy than Sokol’s article
would lead us to believe (1).
At the risk of also being anecdotal, I have been involved in the
development planning and delivery of a clinical ethics service at a major
children’s hospital over the last 15 years and freely acknowledge the
pivotal role that the CEC played in this. Our early experience has been
recorded in detail elsewhere (2,3) but the development of a forum for the
discussion of ethical issues led in turn to retrospective case analysis
and thence to review of “hot” cases. The latter range from the high
profile withdrawing life sustaining treatment case to what should be done
in regard to non-payment of fees for non NHS biochemical testing. The
Committee itself has always contained a high proportion of individuals
with postgraduate qualifications in ethics and has also included
philosophers and lawyers. We select members in accordance with the
principles set out in the document produced by the UK Clinical Ethics
Network (UKCEN) that sets out core competencies for the provision of
clinical ethics support and how they may be acquired, maintained and
assessed (4).
Ultimately in 2005 the Trust appointed a clinician (with a
postgraduate degree in ethics and law) on 3PA basis (12 hours per week) to
provide the level of service that might be achieved by a single full time
ethicist in the US (40+ formal cases, >50 “informal”, plus >100
hours postgraduate teaching p.a.). We continue to use individual case
consultation by ethicist, rapid response by 3 members of the CEC and full
CEC meetings to discuss cases. The CEC has reviewed cases using
established models for ethical review e.g. Nijmegen, Parker and has
compared models as an educational exercise. Effective administrative
assistance has been crucial in growing the service. The presence of a
committee was, in retrospect, essential to this evolutionary process.
The point of describing our experience is merely this:-
I suspect that for many institutions, especially those who do not
have funding or access to a university department of ethics, CECs may form
the basis of a future clinical ethics service. UKCEN have outlined
elsewhere (not alas in the BMJ) the core competencies needed to develop
such support (4). I freely acknowledge that there are other valid means
of providing clinical ethics support. However in the current financial
climate it would be unrealistic to expect many Trusts to provide Sokol’s
ideal mixed model solution, even though we ourselves have essentially done
so. If we do wish to cultivate ethical review then ethics committees,
established appropriately, would seem a reasonable starting point;
throwing out the baby with the bath water would not.
References
1). Fox E, Myers S, Pearlman RA. Ethics consultation in United States
Hospitals: A National Survey. American Journal of Bioethics. 2007;7(2):13-
25
2). Hope, T., Bunch, C., Meslin, E., Larcher, V.F., Rayner , C.
Hospital Ethics Committees in the United Kingdom.
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3). Larcher, V.F., Lask, B., McCarthy, J.M.
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4). Larcher V, Slowther A, Watson A
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Competing interests:
Vic Larcher is consultant in Paediatrics and Clinical Ethics at Great Ormond Street Hospital NHS Trust London and chairs the trust’s Clinical Ethics Committee
Conflicting interests
Dr Larcher is a chair of the Trust’s clinical ethics committee and chair of the RCPCH Ethics Advisory Committee. He is a member of the Board of Trustees of the UK Clinical Ethics Network
Competing interests: No competing interests