Alfred Simon, PhD;
Director of the Academy of Ethics in Medicine, Göttingen, Germany
E-mail: [email protected]Internet: http://www.aem-online.de/
Ethics consultations are becoming increasingly important in German hospitals. For example, hospitals must offer such consultations to qualify for KTQ certification (Co-operation for Transparency and Quality) or receive a proCum certificate. Some 200 German hospitals and healthcare providers already offer ethics consultation services. Recently, the Central Ethics Committee of the German Medical Association issued a statement welcoming this development as a practical and appropriate contribution to better patient care and calling on all healthcare institutions to establish these structures. Clearly, ethics consultation is in vogue but is it more than just a trend?
Roles and Models for Ethics Consultation
Ethics consultation in the hospital setting may be understood as a service provided by an individual or group for the purpose of supporting patients, relatives, patient advocates, hospital staff and other actors to address uncertainty or conflicts which arise when dealing with value-related issues. The consultation is intended to assist the person who has sought advice to better identify and understand the value conflict or uncertainty. In addition, it is intended to make a contribution towards finding a practical solution to the conflict or uncertainty. This can take several forms, ranging from advice on a single issue, to the production of ethical guidelines (recommending specific courses of action in the hospital) to the provision of ethics training and education.
A series of models has been developed for ethics consultation. The clinical ethics consultant intervenes to provide guidance and mediation in the decision-making process where difficult conflicts arise in arriving at a decision. The advantage of this consultation model is that intervention takes place in a timely fashion and in situ, with the result that all parties have an input into the process. Its main disadvantage is that outcomes are predicated to a large extent on the personality of the consultant, who must possess significant ethical, communications and organisational skills. The clinical ethics committee is composed of representatives from the various departments, for example, medicine, nursing, administration, social work, chaplaincy, ethics, law, patient advocates etc. Members are appointed by hospital management for a fixed term of normally two to three years. A request for intervention is made to the committee and the consultation generally takes place outside the ward setting. The advantage of this model is that the interdisciplinary and inter-professional character of the committee allows it to tap into and exploit a wide range of skills and experiences as part of the consultation process. The main shortcoming of the model is its lack of flexibility and the committee’s distance from events, i.e. from the ward.
In light of these advantages and disadvantages, it makes sense to combine the two models. Some German hospitals have established ethics committees to draft guidelines and co-ordinate training and education, while leaving the case consultations to two or three members of the committee or specially trained moderators who carry out their work on the wards. The ethics committee and ethics consultants co-operate closely, with the committee receiving ongoing briefings on questions and problems arising in the hospital.
Potential for Ethics Consultations to Improve the Decision-Making Culture
The practice of offering ethics consultations can contribute in a variety of ways to improving a hospital’s approach to addressing ethical conflict and uncertainty, as I would like to illustrate using the following example. A 75 year old woman has been unconscious and is being ventilated on a hospital’s intensive care ward four days after suffering a stroke. The patient’s son asks for the ventilator to be switched off, citing the contents of her living will, in which she declines all forms of treatment in the event that she suffers irreversible serious brain damage. Opinion differs among members of the team in the intensive care unit about how to respond to this request and their views also vary on whether it is legally permitted to switch off the ventilator. Faced with these circumstances, the ward team turns to the hospital’s ethics committee and a case consultation is held on the ward.
A key first step in the consultation process is to bring together everyone involved in the case with a view to creating a space within which a common approach to decision-making can be found. The second step is to develop a structure for the decision-making process. In this context, it has been shown that it is preferable to first ensure everyone involved is apprised of the facts (e.g. assessment of the prognosis, clarification of the legal situation, identification of different courses of action), before proceeding to an evaluation of the case and an assessment of the different options available. The latter process includes consideration of medical-ethical principles such as autonomy, the right to care and patient dignity. Where possible, a joint decision on how to proceed should be taken at the end of this discussion. The third key contribution of the consultation lies in the facilitator or mediator role performed by the consultant. As ethics consultants are not directly involved in the case, they are able to act as neutral arbiters and their competence in the areas of ethics and communications means they can help clarify moral concepts and shape a moral consensus.
In the case I have outlined, the final decision on how to proceed could take the following form. All those involved in the process agree that the patient’s living will must be taken seriously. Clarification is provided and it emerges that, under German law, switching off a ventilator is considered a form of admissible, passive euthanasia. It emerges from discussions with the patient’s son that the overriding concern of his mother in making a living will was to exclude the possibility that, in the event of losing consciousness, she would be kept alive for a prolonged period. The medical team forms the view that a sufficiently reliable prognosis will not be possible for several days. Based on these facts, it is decided to continue ventilation for a further week – insofar as no complications arise – after which the patient’s son and the medical director will make a further decision. If it becomes clear during the consultation that staff lack knowledge or are uncertain about particular issues, for example, they are unable to differentiate between active and passive euthanasia or are unsure of whether living wills are binding, the consultant may ask for training courses or guidelines to be provided on the issue.
Given the complexity of the ethical decisions taken in hospital, it is necessary to develop a common approach to decision-making, which enhances rather than replaces the responsibility of the individual. Ethics consultations offer a form of structural and methodological support for joint decision-making processes. Ethics consultants must have appropriate qualifications if consultations are to be successful and effective. Moreover, members of staff and management at the hospital or institution must be willing to engage in the ethics consultation process and must be supported in doing so. While certification is a valid reason for introducing a framework for ethics consultations, this should not be a hospital’s sole or primary motivation. Whether ethics consultations deliver sustained improvements in the decisionmaking culture in hospitals or are little more than a passing trend will largely depend on the approach adopted by individual institutions.
For further information (in German) refer to: “Ethics Consultations in the Hospital”, by the Academy of Ethics in Medicine in Göttingen, Germany: www.ethikkomitee.de