Functions of an Ethics Program

An Introduction to Doing Medical Ethics
Michael A. Gillette, Ph.D.

As already noted, hospital ethics programs have developed in institutions across the country. Most commonly these programs involve ethics committees which are composed of individuals who represent a broadly based cross section of perspectives. The function of ethics committees is restricted to three basic areas.

The first priority of an ethics program is educational. This aspect of committee business falls into two specific sub-categories. First, ethics committees must spend time becoming better educated themselves regarding medical ethics. The process of training committee members to carry out the functions of the committee can be time consuming. Second, ethics committees have provided a framework for broader educational initiatives for all staff at a given facility. Ethics committees should provide a variety of educational opportunities including structured seminars, panel-discussions, printed materials and informal consideration of issues. These educational programs should be designed to raise awareness of ethical issues in the facility and to improve the skills required by staff to deal effectively with those problems.

The second area of ethics committee involvement has been case consultation. When an ethical issue is identified by staff, it may be brought before the committee and discussed in a cross-disciplinary manner. A well structured consultative effort is capable of fostering a clear exchange of ideas which often resolves conflict of opinion. When conflict cannot be eliminated, the committee is capable of developing a rationally defensible solution to disagreement.

The third aspect of committee work is policy development and review. Ethics committees do not set policy, but they do comment on proposed policy and develop model policies when ethical issues are involved. This service allows the ethics committee to add one more voice to the procedure of policy development and to help identify possible considerations and implications that otherwise might go unnoticed.

The following list is indicative of some of the sorts of issues that benefit from ethics committee involvement. This list is suggestive of the broad range of ethical issues that arise in developmental disabilities medicine, but is in no way exhaustive.

Sample Topics of Case Consultations (partial list)

• Removal of life-support from a brain dead minor over parental objections
• Withholding of blood transfusions at the end of life
• Disagreement with family regarding gastrostomy
• Withdrawal of antibiotic therapy at the end of life
• Maintaining restraints on a client who pulls her NG tube
• Disagreement regarding intubation of an end-stage AIDS patient. MD wants to restrict care, family wants everything possible to be done
• A client who wishes to smoke but suffers from COPD
• A medically uncomplicated client who wishes to smoke
• Refusal of care on the basis that the care is costly and unlikely to produce appreciable benefit for an uninsured and suicidal patient
• Forcible discharge of a patient from an MH facility
• A client who requests tubal ligation
• Staff desire to refuse dialysis from an HIV positive individual on the basis risk to other patients and providers in the unit
• The use of Depo-Provera to produce amenorrhea
• DNR review for a client
• End of life decisions for an incapacitated patient without family or close friends
• Restriction on diet of a mildly overweight client in an MR facility
• Placement in the community of an at-risk client with Pica
• Refusal of AKA (Above the Knee Amputation) by a family for a client
• Disagreement regarding the aggressiveness of care that is appropriate for a seriously ill neonate
• Parental wish to lie to a client regarding siblings
• Disagreement between family members regarding appropriate care for their elderly mother
• The use of monetary incentives to produce medical compliance for a patient with a mental illness
• Hormonal treatments to reduce libido
• Sexual activity between consenting clients in an MR facility
• DNR (Do Not Resuscitate Order) in a group home
• Detention of a patient in the hospital who is suicidal but does not suffer from mental illness
• Adult client refusing mastectomy
• Community supported client who wants to be left alone
• Protective isolation for an immune suppressed client
• Brittle diabetic client who wants her own apartment
• Parental desire to upgrade diet of a client at risk for choking
  

Examples of Policy Work

• Ethical Issues of Medical Informatics
• DNR Policy for an MR facility with a hospital
• DNR Policy for an MR facility without a hospital
• Extraordinary Care Policy for an MR facility with a hospital
• Extraordinary Care Policy for an MR facility without a hospital
• Policy governing access by outside observers
• DNR Policy for a group home
• Policy on Physician Assisted Suicide and Euthanasia
• Sexuality Policy for an MR facility
• HIV Policy for a community services board