Ethics Committee Structures

&

Decision Making Models

Philip Boyle, Ph.D.

Vice President, Ethics

www.CHE.ORG/ETHICS

Goals for today’s 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

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

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?

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

Ethics Mechanisms:Before and After

Before—in the beginning

• Largely grass roots

• Not hard wired to administration

• Focused on patients’ rights

• Philosophical discussion of hard cases

• Dispute resolution forums

ProcessScope 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 committees—“safe place for unsafe ideas”

– Confidentiality – Functional consensus

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?

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?

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?

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?

• Who should have access to the ethics committee?– Physicians only?– Nurses after they have exhausted existing

channels?– All staff?– Patients? Family?– Community members?

• 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?

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?

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

Notable successes• Self education• First responders• Ethics Champions • Safe-place for

unsafe ideas• Identifiable

institutional response

• Participative & collaborative

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

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?

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

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

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

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

MembershipSelecting qualified

members, not locationCore education

Trained in conflict resolution

Escape appearance of volunteers

Long-range training

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

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

Total Quality ImprovementOperationally Integrating Ethics

• Trending

• Values-based Decision-making Process

• Indicators/Trigger Mechanisms

• Committee self-evaluation

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

When to use it?Formally

• Decision that affect significant interests and populations

• Opening Closing Services

• Significant HR issues

• Development of Strategic management tools

Informally—all moral decisions

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

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?

Phase II: Decision Making1. Pray, reflect, identify question, and clarify authority of

decision-making group.

• Prayer and reflection are necessary because the group believes that it is God’s 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)?

Phase II: Decision Making2. 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.

Phase II: Decision Making4. 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.

Phase II: Decision Making5. 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.

Phase II: Decision Making6. 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?

Phase II: Decision Making7. 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?

Phase II: Decision Making8. 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.

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.

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