Our earlier observations
Ten years ago we outlined three key functions of ethics committees and consultants: education, institutional policy development, and case consultation.
With regard to ethics consultation, we argued that:
• The central goal is to improve patient care and patient outcomes
• The ethics consultant must be ethically and clinically competent, although not necessarily a physician
• The consultant's recommendations are suggestions that the referring physician may choose to accept or reject
We highlighted three key dangers of ethics consultations and committees:
• Abrogation of moral decision making by the referring physician
• Usurpation of moral decision making by the ethics consultant
• Diffusion of responsibility within the ethics committee
We outlined four models of ethics case consultation:
• Pure committee model (no ethics consultations, just committee work)
• Committee member as consultant (a committee member performs consultations but these are not systematically reviewed by the ethics committee)
• Post-facto committee review (the committee reviews the consultations after they have been performed)
• Pure consultation model (no ethics committee, just an ethics consultation service)
Finally, we highlighted the limited evidence base on which ethics committees and consultation services had been developed, and called for the effectiveness of these programmes to be evaluated.
The key development in the last decade was the American Society for Bioethics and Humanities' report on 'Core Competencies for Health Care Ethics Consultation.' Co-chaired by Robert Arnold and Stuart Youngner, the report described core competencies for ethics consultation in health care, but rejected accreditation of programmes or certification of individuals or groups to do ethics consultation [18
The 1990s also saw the clinical ethics movement called into question by two amusing but incisive articles. In 1997, in "When we were philosopher kings," published in The New Republic
, Ruth Shalit took clinical ethics to task for its lack of educational standards, its lack of evidence of effectiveness, for its "attitude of superior virtue", for confusing the empirical and theoretical, and for "the matter of ethics-for-hire [19
In the same year, a Lancet editorial concluded:
"...the ethics industry needs to be rooted in clinical practice and not in armchair moral philosophy. Debate on ethical matters is as much an integral part of everyday doctoring as choosing the best treatment for patients. Departments of ethics that are divorced from the medical profession, wallowing in theory and speculation, are quaintly redundant [20
There are important truths in these criticisms, which call for heightened humility, self-questioning, and evaluation on the part of clinical ethicists.
Clinical ethics also entered the field of quality improvement: the Tavistock Group described a set of principles that facilitate a team approach to care [9
]; Joanne Lynn led a quality improvement collaboration on end-of-life care through the Institute for Health Care Improvement in Boston, USA [21
]; and Joan Teno developed a toolkit to measure quality of end-of-life care [22
Another important development has been an increasing focus on conflict resolution in clinical ethics, particularly in the areas of end-of-life care and cultural difference. This focus is likely to increase over the next decade.
In our view, the most exciting prospects for ethics committees and consultants involve integrating them into the quality improvement culture of health care organisations. For example, we hope clinical ethicists will develop report cards for health care organisations on the quality of end-of-life care. The approach of the Picker Institute in Boston, USA, to care through the patient's eyes represents an important hint of future possibilities. We hope clinical ethicists will spend time with patients, understand their concerns, and feed these back to clinical teams and senior management to harness the opportunities for improvement. A decade ago, Rabbi Julia Neuberger, now Chief Executive of the King's Fund in London, did just that with bone marrow transplant and other cancer patients at Beth Israel Hospital in Boston (Neuberger J, personal communication). Unfortunately, this important line of clinical ethics has not yet been further developed.
A second key challenge relates to organisational accountability. How should we respond if a board member of a health care organisation asks, "Is this an ethical organisation?" In response to this simple but critical question, we should be able to describe an accountability framework of policies, processes, and practices, and provide empirical data with respect to certain indicators. Sadly, we are nowhere near being able to provide a comprehensive answer to this question. The US Joint Commission on Accreditation of Health Care Organisations has recommended that some mechanism for institutional ethical accountability be developed. However, there are at present no standards to encompass the wide ambit of clinical, managerial, and academic activities one would want to examine in a comprehensive "ethics audit" in response to the Board member's deceptively simple question. In short, what is needed is an accountability framework or ethics infrastructure for health care organisations?
Third, it is increasingly recognised that the capital assets of health care organisations involve not just buildings and equipment but also the people who work in the organisation. Although clinical ethics takes seriously the need for education of health professionals, and has at times used modern methods of continuing education, it has not looked upon its task as one of strengthening capacity both by hiring ethicists and by building the skills of health workers throughout the organisation. For example, one can identify few systematic efforts in health care organisations that aim to develop the skills of health workers to address pressing clinical problems such as medical error, end of life care, and the like. Ideally, health care organisations will have: a workforce able to address common ethical issues without the assistance of a clinical ethicist; and systematic strategies of capacity building and measures of capacity, with respect to clinical ethics.
A fourth challenge is further work on organizational ethics, which is in the earliest stages of conceptual and methodological formation. Organisational ethics is an exercise in collective accountability. It has to do with persons acting together on behalf of some institutional goal. It is concerned with defining an ethically defensible mission, implementing that mission, and allocating responsibility at all levels of institutional life for preserving the fidelity to the mission. Hospitals are examples of institutions acting as moral agents, fulfilling the promise to serve the needs of the sick in the community. What is the source of this obligation and how is it distributed at all levels from trustees, administrators, professional staff and non-professionals? How are conflicts of obligations resolved? Should organisational and clinical ethics committees be separate, institutionally related in some way, or combined? What is the role of professional organisations? And do they have ethical responsibilities over and above the welfare and self-interests of the professionals they represent? These are some of the questions organisational ethics must address.
Finally, although important improvements have occurred in clinical ethics processes, the goal of improved clinical outcomes has not been achieved. We find this conclusion disappointing, and urge our colleagues in clinical ethics to redouble efforts to demonstrate improvements in patient outcomes related to clinical ethics activities.