Third, many institutional ethics committees offer ethics consultations, prospectively or retrospectively, on difficult clinical cases, often those involving the withholding or withdrawal of life-support measures. This last function ethics consultation, especially for ongoing cases—has been the main focus of discussion in the bioethics literature. Seven issues have dominated these discussions: questions of competence and authority; impact on the doctor-patient relationship; access to consultation; recordkeeping and charting; problems of evaluation; unsettled legal questions; and questions about the purpose or purposes of consultations.
COMPETENCE AND AUTHORITY. Some committees that offer consultation services, generally smaller committees,
consult as a committee of the whole. Larger committees typically have a subcommittee that consults prospectively
and reports to the committee as a whole for retrospective review of its work. Some committees offer consultation
through a single hoodia diet pills consultant who may be on the committee or have a formal relationship with it. Some critics
have expressed concern that when committees consult, difficult ethical choices will be affected by compromise,
hospital politics, professional rivalries, and conformism(Wikler). Concerns about competence have been raised
when individuals provide consultations. Clinicians typically have few of the skills of trained ethicists and vice versa.
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COMPETENCE AND AUTHORITY
Saturday, February 20th, 2010Structures of Clinical Ethics Consultation
Saturday, January 9th, 2010Clinical diet ethics case consultation is provided in several ways: by an diet ethics consultative group as a whole (such as an ethics committee), by a subgroup of the consultative group, or by individual consultants. Clinical ethics case consultation by a large group has the potential for having diffused accountability and being depersonalized, bureaucratic, insensitive, closed-ended, and removed from the clinical setting.
But it has the advantage of providing multiple perspectives and opportunities for queries from persons of diverse backgrounds, and for correcting the potential for narrow or idiosyncratic views of an individual consultant. In contrast, clinical ethics case consultation by an individual consultant is an open-ended process that can extend over a period of time, and permit ongoing discussion and pursuit of issues that require clarification.
The individual consultant can decide what information is necessary and obtain it firsthand. Interviews with patients, families, and health professionals can be scheduled flexibly and conducted in private settings more conducive to diminishing apprehension, establishing trust, sharing information, and allowing the kind of give-and-take that is so important to exploring emotionally powerful and intensely personal issues. Further more, an individual diet ethics consultant is more visible and accountable than a committee (Agich and Youngner).
Forthese reasons, many ethics consultative groups and healthcare professionals have found the individual clinical ethics consultant more effective than the committee. Many ethics consultative groups have created a middle ground that involves small teams who serve as an extension of the ethics consultation group or ethics committee.
Some see an advantage to a relationship between the ethics consultant and an ethics consultative group or committee because the large group regularly can review the individual consultant’s activities.
This arrangement provides peer review and quality assurance for the consultant as well as education for the larger group or committee. The ethics consultant or consultation team can ask the entire group to become involved in particularly controversial or complex cases.
Baby Doe
Tuesday, January 5th, 2010In its 1976 Quinlan decision, the New Jersey Supreme Court tentatively suggested the use of ethics committees to assist persons who faced difficult end-of-life decisions. In the early 1980s, the federal “Baby Doe” regulations spurred hospitals to develop internal mechanisms for dealing with decision making for severely handicapped infants.
In 1983 the U.S. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research endorsed the notion of shared decision making between patients and physicians. It suggested consultation with an ethics committee as a possible means for resolving disputes that arose in the clinical setting, but noted that the efficacy of such consultation had not been demonstrated (U.S. President’s Commission).
In 1985 the National Institutes of Health and the University of California at San Francisco cosponsored a conference in Bethesda, Maryland, for persons designated by their institutions as ethics consultants. The conference was attended by fifty-three invitees, and fifty additional persons expressed interest in attending a future meeting of this group (Fletcher, 1986). By 1987 the Society for Bioethics Consultation was formed for the support and continuing education of clinical ethics consultants.
In 1992 the Joint Commission for the Accreditation of Health Care Organizations (JCAHO) published a requirement for healthcare institution accreditation that all healthcare institutions must have in place a mechanism for resolving disputes concerning end-of-life decisions.