Children, Ethics, and Modern Medicine

10. The Politics and Ethics of a Hospital Ethics Committee

DELIBERATIVE AND NONDELIBERATIVE PROCEDURES Discussions at Baylin about whether to accept organ donations from strangers involved a case consult that never expanded into a proposal for a formal policy requiring the hospital administration’s approval. Guidelines for screening donors were circulated to a working group of ethicists and surgeons for feedback, but nothing official came of those conversations . That process contrasts with the work of crafting ethical policy, for which the Ethics Advisory Committee (EAC) served as the hospital’s main deliberative body. To fulfill the goal of forming policy, the EAC met monthly to discuss case consults and broader issues that were relevant to the hospital as a whole, and it is to that work that I want to direct attention here.1 Composed of physicians and nurses from different services, chaplains, family members, legal counsel, ethicists, and outside observers, Baylin’s EAC—like other hospital ethics committees—served several functions: 1. To educate hospital staff about moral and legal standards in medicine. Hospitals must learn to be ethical—not once, but on an ongoing basis. Staff turnover, new cases, and changes in biomedicine all contribute to the need for continuing education. 2. To review case consults brought to their attention by the hospital’s staff to determine whether formal policy is needed. Committees must serve as the hospital ’s casuists, settling cases of conscience and representing the moral voice of the institution. 3. To informally advise and support health care providers who confront moral issues in the treatment of patients and families. Individuals have crises of conscience even (perhaps especially) when institutions do not. 4. To craft official hospital policy regarding the provision of care. Such policy may include do not resuscitate (DNR) orders, futility policy, or inTEN The Politics and Ethics of a Hospital Ethics Committee The Politics and Ethics of a Hospital Ethics Committee | 221 formed consent, drawing on developments and arguments in contemporary bioethics. 5. To institutionalize a hospital’s commitment to moral standards by providing an official venue for the discussion of ethical issues. In that capacity, ethics committees serve to dispose members of the institution to deliberate about ethical issues and to seek reasonable and workable solutions. Committees are thus facilitators of virtue—the virtue of practical reasoning— producing occasions for moral deliberation about health care policy and practice. In this chapter, I want to focus on the last two items here—forming official policy and disposing institutional members to deliberate about policy —keeping in mind that these two functions might be distinct in theory but not in practice. Specifically, I am concerned with how a hospital committee monitors itself in its attempt to craft ethical policy. I want to consider ethical questions that surround the procedures of committee decision making. When forming policy, is it possible for ethics committees to behave ethically? Are there standards of practice that should govern how a committee comports itself? Note that we are not focusing on the professional norms that characterize the goods of medical practice, norms that should infuse the ethos of hospitals and the first-order, day-by-day deliberations of personnel and committees: beneficence, nonmaleficence, autonomy, or fairness in resource allocation.2 Instead, I want to inquire in a second-order way into the ethics of crafting ethical policy in an institutional setting, drawing on ideas that might ground those first-order norms but exceed them in their implications for administrators who must fashion policy in institutional contexts. It is tempting to think that the process of crafting policy is problem-free, that orchestrating policy deliberations is either morally neutral or that those responsible for orchestrating such deliberations are agents of virtue, needing no moral standards. But we know that neither of these assumptions is true: There are better and worse ways of producing policy, and those who can be trusted as virtuous leaders are trustworthy in part because they satisfy moral norms such as respect for persons. Those whom we do not trust we suspect of acting “politically”; they rely on procedures that may be effective and prudential, but they fail to respect persons by providing reasons to justify their actions. Proceeding in this second-order way, I will assume that forming official policy and disposing institutional members to deliberate about policy cannot avoid certain practices that we call “political.” That is, forming policy may require an ethics committee not only to respect persons by providing reasons for their actions, but also to negotiate, caucus, vote, and compromise for the sake of...