Clinical ethics committes

Question 1

Describe types of ethics committees

Answer 1

In and around healthcare:
- Research Ethics Committees (RECs, IRBs, REB), human / non-human animal.
- National Ethics Committees or Commissions (USA Presidents Commission, UK Nuffield Bioethics, Ireland, Australia- was once for purpose, largely replaced by NHMRC)
- Organizational Ethics Committees (BMA, GMC, AMA?) - do not consult, but think about general ethical questions in medical practice
- Institutional Ethics Committees (Input into Policy)
- Clinical Ethics Committees (Input into Practice)

Some overlap, particularly in relation to last two or three.

Question 2

Describe the types of members

Answer 2

Contemporary composition: Scientific or professional expertise, Lay (or non-experts), Ethical Expertise not recognized. Should it be? Secular/ theological? Patient (or population) Representatives.

Question 3

Describe research ethics committees and criticism

Answer 3

Purpose: To prospectively review the ethical dimension of proposed, thereby preventing unethical research. Part of ‘Research Governance’: A bureaucratic hurdle, a matter of paperwork Primarily procedural and administrative Standardized Applications (forms) Sometimes applicants may attend meeting to answer questions, often not. Notionally, RECs either approve or reject. Usually they ‘request’ changes. Often matters of detail re consent forms, sometimes methodological. Rarely are the issues raised matters of actual ethics… Further Criticism: Unclear if these bodies can or do prevent unethical research. Developed for Biomedical Research, arguably inappropriate for critical social sciences, particularly more qualitative research. Universities using RECs to manage reputational risk (Hedgecoe)

Question 4

Describe ethics consultants

Answer 4

Consultants: Experts in Ethics or Competent, Accredited (or credentialed) Professionals?
1. Ethical Expertise ≠ Moral Authority
2. Ethical Expertise may not be all that useful in practice. Applying for ethical approval from a REC: specialists in ethics or in the logic of a bureaucracy? ASBH: ‘Core Competencies for Healthcare Ethics Consultation’ include analytic skills, as well as:
- Facilitate formal meetings
- Communications skills (listen well, empathic)
- Elicit views of others
- Promote communication on the part of others
- Mediate, negotiate ^[between patients and doctors, doctors on call and care team, team and hospital etc.] and advocate.

ASBH publish a ‘Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants’

Question 5

Describe the work of a CEC

Answer 5

1. Case Consultation
2. Review of Institutional Policy
   
   • existing or as part of development
3. Organizing Educational Activities
   
   • regular / irregular
   • addressing current issues
   • addressing professionals in general or targeting a particular group; or specialism.
   • following up on a particular case

Question 6

Describe the purpose of CEC case consultation

Answer 6

Purpose:
- to obtain needed help in deciding what to do
- to identify a practical way of doing what had already been decided should be done
- to implement a practical solution
- to obtain reassurance that the correct decision was being made
- to seek consensus [or support/ cover]
- to organize educational activities

Who benefits? Who refers? Who participates?
- Patients
- Medical Professionals - usually as insurance
- Healthcare Professionals
- The Institution/ managers
- Lawyers
- Ethicists (secular and theological)
- Lay/ Patient representatives (esp. in relation to specific patient identities)

Question 7

Describe how case consults work

Answer 7

Institutional buy-in is often essential Meetings: On a regular or ad hoc (‘emergency’ or ‘responsive’) basis? The point of first contact? Committee Chair? An administrator? A dedicated individual? (A quasi-consultant?) Merely answering telephone calls or a proactive engagement with staff and promotion of the CEC? A structured or unstructured approach? Written or oral presentation of case? The Four Box Method: Medical indications; patient preferences; quality of life; and contextual features.

Question 8

Describe the benefits of a CEC discussion

Answer 8

CECs provide a forum for reflective practice. Allows for a focused discussion of the ethical dimension of cases. Enables the contributions of a range of individuals to be heard. A matter of advising, not of determining. Not a court of appeal or a decision-making body. Not a space in which to rehearse arguments that have failed to convince colleagues. A form of peer review or supervision.

Question 9

Describe the relationship between CECs and the Law

Answer 9

Not the same thing Although their recommendations will be influential, they do not (and should not) have the force of law. Legal advice is another matter.

Question 10

Describe the notion of confidentiality in CECs

Answer 10

The presence of non-medical members raises issues of confidentiality. To some extent, these can be addressed by training and the signing of confidentiality agreements. However, given the nature of the work, such measures are, perhaps, more symbolic than real.