ETHICS COMMITTEES IN SOUTHERN BAPTIST-RELATED HOSPITALS:

SURVEY RESULTS AND ANALYSIS

By Raymond E. Higgins II, Ph.D., and Steve W. Lemke, Ph.D.(1)


Introduction

        What is the current status and function of ethics committees in Southern Baptist-related hospitals? The answers to this question are important for at least three reasons. First, there is an increasing number of and a growing public interest in the complex ethical issues which arise in the medical setting. Second, hospitals which are sponsored by Christian denominations base their mission on the Christian moral tradition. Southern Baptists represent a particular embodiment of that larger moral tradition. Third, Southern Baptist-related hospitals are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In order for such hospitals to maintain their accreditation, they must have in place a process for addressing and resolving ethical issues which arise in their institutions. Recent government regulations regarding end-of-life issues have heightened the value of ethics committees to a hospital.

        In this article we describe and analyze the results of our study of ethics committees in Southern Baptist-related hospitals, and evaluate our survey results within the context of the hospital ethics committee movement in the United States. The process for conducting our survey went through several stages. A written survey was mailed in September of 1991 to the chief executive officer of twenty-one hospitals. The surveys were completed by a variety of hospital personnel, and all twenty-one hospitals returned the survey. A follow-up telephone survey was conducted during the summer of 1993. Additional information was collected through the spring of 1994. The hospitals which we surveyed exist in nine states: Alabama (2), Kentucky (2), Mississippi (1), Missouri (1), North Carolina (1), South Carolina (2), Tennessee (3), Texas (8), and Virginia (1). The survey posed questions regarding the status, membership, structure, and function of ethics committees.

Existence of HECs

        Of the twenty-one hospitals queried, fourteen had an ethics committee, two were in the process of forming a committee, and five hospitals did not have an ethics committee. The first ethics committee was formed in 1984. Seven hospitals formed committees during the 1980s; five formed committees during the 1990s; two were forming committees during the summer of 1993; and two hospitals gave no starting date. Ethics committees are thus a recent phenomenon in Baptist hospitals.

        The first ethics committee in the United States was formed in the early 1960's. Referred to as a "treatment committee," this primitive ethics committee in Seattle, Washington addressed the issue of which chronic kidney disease patients should receive hemodialysis treatment.(2) The real stimuli for creating ethics committees occurred on three occasions: the decision of the New Jersey Supreme Court in the Karen Quinlan case (1976); the recommendation of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1983), and the implementation of the so-called Baby Doe regulations (1984-85).(3) Recent formal incentives include the Patient Self-Determination Act of 1991 and the requirement by the Joint Commission on Accreditation of Healthcare Organizations for those hospitals which receive federal funds.

        There has been a dramatic increase in the recognition of the need for HEC's over the last decade. A 1983 survey of 602 randomly selected U. S. hospitals revealed that ethics committees exist in only approximately 1 percent of the hospitals. No hospital with fewer than two hundred beds had a committee.(4) As of March 1988, an estimated 60 percent of medium and large hospitals had ethics committees.(5)

Naming HECs

        Our survey collected the following names for the ethics committee: Ethics Committee (4), Institutional Ethics Committee (2), Hospital Ethics Committee (2), Medical Staff Ethics Committee (1), Bioethics Committee (1), Medical Center Ethics Committee (1), Medical Ethics Committee (1), Committee for Religious and Moral Issues (1), and Committee for Special Services and Functions (1).

        The title of the committee should describe the focus of the committee; ethics and bioethics are the common terms. The title should also describe the constituency of the committee. The terms "institutional" and "hospital" signify more organizational inclusiveness than terms like "medical staff."

Meeting Schedule of HECs

        The frequency of committee meetings varied widely among the hospitals. Five full committees or subcommittees met monthly, and two met every other month. Eight met on a case-by-case basis as special needs arose. Several hospitals which had regularly scheduled meetings permitted called meetings for special issues. One committee reported that it had not met for two years.

        In order for the ethics committee to be effective within the institution, it should hold a formal meeting once a month. Ethics committees which hold formal meeting less frequently than once per month are usually not very powerful or influential within the institution. Such committees are often not recognized as having a positive contribution on the work of the institution. They often do not know exactly what their agenda is or should be. The committee members are not able to work together frequently enough to get to know each other and to form a cohesive and intentional group which plays an important ethics role within the organization. Even when there are no specific case consultations to consider, committees can meet profitably by reviewing existing policies and protocols, studying new laws impacting the hospital, and discussing case studies.

Membership on HECs

        The roles represented on the ethics committees included physician, nurse, administrator, chaplain, attorney, social worker, community representative, minister, patient advocate, ethicist, psychologist, quality assurance representative, hospital board member, librarian, and specialist (see Figures 1 and 2). All 14 hospitals with committees had physicians on the committee; the number of physicians a ratio of physicians to other professionals on the committee varied. Five committees had at least one minister on the committee, and eleven committees had at least one chaplain on the committee. Five committees had an ethicist on the committee. One hospital did not include any nurses on the committee.

        In order for the Ethics Committee to be effective within the institution, all significant roles within the institution must be represented on the committee. Omitting a particular role should alert the members to institutional and committee dynamics which need to be analyzed. Because of the nature of the power structures in hospitals, physicians will need to play a significant role in the formation and process of the committee. However, ethics committee can expand their perspectives by including representatives from the other major departments within the hospital.

        Representatives from outside the institution can make a valuable contribution as well to HECs. Well-informed members of the community can provide a fresh perspective from outside the institutional flowchart. Ethicists and philosophers from nearby educational institutions are one underutilized resource for ethics committees.

Figure 1: PROFESSIONS REPRESENTED ON ETHICS COMMITTEES

COMMITTEE MEMBERSHIP

BY PROFESSION

Voting

Members

Nonvoting

Members

Chairperson*

Physicians

12

0

10

Nurses

9

2

0

Administration

8

2

0

Chaplains

8

1

0

Attorneys

8

1

0

Social Workers

7

1

0

Community
Representatives

7

0

0

Ministers

4

0

0

Patient Advocates

3

0

0

Ethicists

3

0

1

Psychologist

1

0

0

Quality Assurance
Representative

1

0

0

Hospital Board Member

1

0

0

Librarian

1

0

0

Specialists

**

0

0

* One hospital rotated the chairperson.

** Specialists were added to the committee to address a specific issue.


        While Figure 1 represents the membership status of all the hospital ethics committees polled, Figure 2 reflects the make-up of individual hospital committees as reported by the hospitals. The hospitals are numbered, and the make-up of each hospital's committee is listed below.***

Figure 2: MEMBERSHIP ON INDIVIDUAL HOSPITAL ETHICS COMMITTEES

COMMITTEE MEMBERSHIP
BY PROFESSION



#1



#2



#3



#4



#5



#6



#7



#8



#9



#10



#11



#12

Physicians

1

6

23

1

1

4

7

1

8

2

14

15

Nurses

1

3

9

1

1

2

1

4

1

4

1

Administration

1

1

3

1

1

2

3

1

2

1

Chaplains

1

1

1

1

3

1

1

1

1

1*

Attorneys

1

1

1

1

1

1

1

1

2

Social Workers

1

1

1

1

1

1

2

1

Community
Representatives


1


2


1*


1


1


3

Ministers

3

1

1

1

Patient
Advocates


1


1

Ethicists

1

3

Psychologist

1

Quality
Assurance
Representative


1

Hospital
Board Member


3

Librarian

1

Specialists

**


* In some cases, a minister doubled as a community representative or a chaplain.

** The committee would bring in all people appropriate to a particular issue.

*** In some cases, the surveys were returned with check marks instead of a number by each profession. It is possible that in some of these cases there were more than one member in each profession, but this chart assumes one for each profession.

Participation on HECs

        One important aspect of participation concerns the profession of the chairperson. Our survey revealed that the chairperson of the ethics committee tended to be a physician (14), in two cases was an administrator, in one case the chairperson had degrees in medicine and ethics, and in one case the chairpersonship rotated (see Figure 1).

        In order for the ethics committee to be effective within the institution, the chairperson must be highly interested in and trained in both ethics and leadership. Having co-chairpersons of the committee often insures that the committee is less prone to authoritarian leadership and limited perspectives. Rotating the co-chairpersons can be effective if it does not undercut the continuity of the committee.

        A second important aspect of participation concerns which committee members are authorized to vote. Our survey revealed that seven committees allowed all members to vote (see Figure 1). Three committees indicated that they had voting and non-voting members. Physicians were never non-voting members. In one case only the physicians had voting privileges. The reasons for excluding certain roles from voting privileges should be discussed openly. Allowing all committee members to vote maximizes the contribution and sense of ownership that each member brings to the committee.

Organizational Placement of HECs

        What was the relationship of the ethics committee to the organizational structure of the hospital? Nine hospitals placed the ethics committee under the medical staff; two placed it under hospital administration; one placed it under the hospital's governing board; and two did not provide an answer. Organizational placement of the ethics committee indicates to whom the committee is responsible, who has the most influence over the committee, and what the committee will be able to address and accomplish.

Mission and Purpose of HECs

        The hospitals had varied perspectives of the mission or purposes of their ethics committees. The primary purposes were educating the medical staff in ethical issues, and providing non-binding consultation for the medical staff on ethical issues. Other purposes included educating the community in medical issues, developing and writing policies and protocols, advising families in decision making, and advocating patient rights (see Figure 3).

        Effective Ethics Committees have a clearly identified mission statement which is compatible with the nature of that particular medical center. The three central purposes of an ethics committee are education (both institutional and community), consultation, and institutional policy. HEC's can also be a vehicle for broadening an institution's vision to address concern for patients rights and the needs of the community, as well as enhancing the community's understanding of heath care.(6)

Figure 3: MISSION AND PURPOSES OF ETHICS COMMITTEES


MISSION/PURPOSES

1st Choice

2nd Choice

3rd Choice

4th
Choice

5th Choice

6th Choice

Educating the community
in medical issues


1


1


1


3

Educating medical staff

5

1

1

1

Providing non-binding
consultation for medical staff


3


2


2


1

Developing and writing
policies and/or protocols


2


2


1


2

Advising families in
decision making


2


1


2


1


1

Advocating patient rights

2

1

1

2

1


* One hospital did not rank the purposes in order of importance, but checked educating medical staff, providing non-binding consultation for medical staff, and advocating patient rights as its three purposes. Another hospital chose all six suggested purposes as having equal emphasis, and added a seventh emphasis of providing theological resources for constituents, medical personnel, patients, and families. A third hospital added a seventh purpose of advising medical staff and administration regarding patient care issues, medical experimentation issues, and the life-support policies of the hospital.

Benefits of HECs

        The chief benefits of ethics committees were to facilitate decision making in difficult cases and to educate institutional staff regarding ethical dilemmas. Other benefits included developing institutional policies, providing legal protection for the institution, and educating the community regarding ethical issues in health care (see Figure 4).

        Effective ethics committees will understand the needs, values, and issues within their own institution and design the ethics committee in such a way that it is able to address those needs, values, and issues in light of its own nature and resources.

        Figure 4: BENEFITS OF ETHICS COMMITTEES TO THE HOSPITALS


CHIEF BENEFITS

1st
Choice

2nd Choice

3rd
Choice

4th Choice

5th
Choice

Provide legal protection
for the institution


1


1


1


1


1

Develop institutional policies

2

4

1

2

Facilitate decision making
in difficult cases


4


2


3


1

Educate institutional staff
regarding ethical dilemmas


5


1


3

Educate community regarding
ethical issues in health care


2


2


2


* One hospital ranked all five as top priorities. Another hospital reported no benefits because the committee had not been meeting.

Functions of HECs

        The major function of most of the committees dealt with termination of life issues. Most committees (9) had developed protocols and policies on termination of life support and ten committees had consulted on a such a case. Committees also concerned themselves with the issue of living wills and advanced directives with nine committees developing policies and protocols and nine committees consulting on such cases. A third issue committees worked on concerned heroic measures taken for patients. Six committees engaged in policy development and eleven committees consulted on cases. Other issues which received policy consideration and case consultation included termination of pregnancy, allocation of health care resources, in vitro fertilization program, definition of death, Do Not Resuscitate policy; conflict between physician and family, and implementation of the Patient Self-Determination Act (see Figure 5).

Figure 5: MAJOR FUNCTIONS OF ETHICS COMMITTEES


MAJOR FUNCTIONS
OF THE COMMITTEE

Committees
developed policies or protocols

Committees consulted on a specific case

Termination of life support

8

8

Termination of pregnancy

2

1

Allocation of health care resources

1

Living wills/advanced directives

8

6

Heroic measures taken for patients

6

8

In-vitro fertilization program

1

Definitions (brain death, etc.)

1

1

Do not resuscitate policy

2

1

Implementation of Patient
Self-determination Act


1

Problems in HECs

        The hospitals encountered a number of problems in seeking to achieve their ethics committee objectives. Obstacles included confusion of goals (4), lack of leadership (4), lack of physician support (4), schedule conflicts (2), lack of authority to act (2), inadequate representation (1), lack of administrative support (1), lack of consensus (1), lack of time to accomplish desired goals (1), failure of physicians to understand the need to meet (1), and retrospective rather than concurrent case review. One hospital reported no major problems hindering its committee's work.

        Many of these problems are not unique to ethics committees. Other insitutional committees struggle with the same challenges. Effective ethics committee are aware of their problems, discuss them as a committee, and develop strategies to minimize the problems.

Training for HECs

        How were the committees trained? The training the committees received included attending conferences (9), in-house workshops (7), securing materials from other ethics committees (7), consultation with an ethicist (7), reading literature (3), and consultation with hospital chaplain (1). Six of the hospitals expressed an interest in continuing education for an already existing ethics committee. Four hospitals were interested in assistance in starting an ethics committee. One hospital had conducted workshops for other institutions and was interested in a collaborative effort to train committees.

        Committee members need training in how to reflect on medical ethics issues. Ethics committees can obtain advice and training from several resources. One resources is to communicate with the members of other ethics committees in the immediate area. Committees outside one's immediate area may be contacted in dealing with specific issues or based on the reputation of that particular committee. Another source is to secure the services of an ethics consultant. Many of these consultants and organizations can be located in The Directory of Bioethics Organizations. Baptist-related hospitals may secure consultants on ethical issues from nearby Baptist institutions of higher learning.

Conclusion

        Our survey provides the first attempt at collecting data on the status and operation of ethics committees in Southern Baptist-related hospitals. The data reveals that these ethics committees encounter many of the same kinds of issues as other ethics committees. Patterns which exist in the general hospital ethics committee movement are noticeable in Southern Baptist-related hospitals. As we track the evolution of ethics committees over the next decade, this survey should be supplemented with the collection of additional information and the continuation of more specific analysis of ethics committees.

Endnotes

1.     Raymond E. Higgins II is pastor of the Second Baptist Church in Little Rock, Arkansas, and
        formerly served as Assistant Professor of Christian Ethics at Southwestern Baptist Theological
        Seminary. Steve Lemke is Provost and Professor of Philosophy and Ethics at New Orleans
        Baptist Theological Seminary, and was formerly Associate Professor of Philosophy of Religion
        at Southwestern Baptist Theological Seminary. Both Higgins and Lemke have served as members
        of hospital ethics committees, and both have served as hospital chaplains in a Clinical Pastoral
        Education program in a Southern Baptist-related hospital.

2.     Judith Wilson Ross, Handbook for Hospital Ethics Committees (Chicago: American Hospital
        Publishing, Inc., 1986),
         5-6.

3.     Carl L. Middleton and Laurence O'Connell, Ethics Committees: A Practical Approach (St. Louis:
        The Catholic Health Association of the United States, 1986), 1.

4.    Stuart J. Younger, et al. "A National Survey of Hospital Ethics Committees," Critical Care Medicine
        11 (November 1983):902-905.

5.    Ruth Macklin and Robin B. Kupfer, Hospital Ethics Committees: Manual for a Training Program 
        (New York: Albert Einstein College of Medicine, 1988), 6.

6.    American Hospital Association Technical Panel on Biomedical Ethics, Values in Conflict:  Resolving
        Ethical Issues in Health Care (Chicago: American Hospital Association, 1994), 5-17.

Back to Ethics papers

Back to Steve Lemke home page