Bioethics in a Liberal Society: The Political Framework of Bioethics Decision Making

7. Conclusion: Health Care Ethics Committees and Consultants in a Liberal Framework

7 CONCLUSION Health Care Ethics Committees and Consultants in a Liberal Framework Throughout, i have focused on the implications of a liberal political and social context for bioethics decision making. Protecting an individual’s right to frame the values that guide her life is, as we have seen, a fundamental concern of our liberal society. Now I will examine how the concern to respect patient autonomy has given rise to the development of health care ethics committees and consultants, and how these developments can be understood in a liberal context. In most areas of social life, protection of individual autonomy is accomplished through a “hands-off” approach coupled with the principle of tolerance . Remember that we cannot be said to tolerate values with which we agree; rather, tolerance is necessary only for values we do not ourselves share. To tolerate these values, we need not accept them, but we must recognize the right of others to adopt them. This protects our right to adopt certain values with which others may disagree. In health care practice, it protects a patient’s right to adopt values with which a health care provider or others may not agree. A hands-off approach does not always suffice to protect individual autonomy . Alan Montefiore (1975, 7) offers an example of two children involved in a dispute: one is older, stronger, and more resourceful. If the children are left to their own devices, the interests of the younger, weaker child are likely to be subverted. That is, without intervention to “level the playing field,” the older child’s wishes will prevail. In a clinical setting, patients are vulnerable. They are by definition sick, often weak, and largely dependent on others, particularly those who provide care. Because patients are vulnerable and because remaining neutral would likely result (in cases where value differences exist between patient and health care provider) in the provider’s values prevailing , it is important to provide mechanisms to protect the standing of the patient’s values and to ensure that these are recognized in those areas where they should be protected. To fill this role, health care ethics committees and consultants were developed. The Role of Health Care Ethics Committees Health care ethics committees have developed along with our society’s increased awareness of individual rights in a variety of arenas. The growth of bioethics in general began as our society reflected on a wide array of civil rights reforms needed to bring our political systems in line with our liberal ideology (and, in health care, with an increased emphasis on patient autonomy ). Over the past twenty-five years, ethics committees have been advocated by the courts (In re Quinlan, 70 NJ 10,355 A2d 647, cert. denied, 429 US 922 [1976]), supported by a report of the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1983, 5), and even required by laws and regulations in several states (Leeman et al. 1997). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires that hospitals provide some mechanism for addressing ethical conflict. As recently as the early 1980s fewer than 1 percent of hospitals had formal ethics committees, whereas surveys conducted in the early 1990s suggested that as many as 85 percent of hospitals have one (Ross et al. 1993, ix). The functions of health care ethics committees are generally threefold: education, policy development, and case consultation (ibid., 5–6). The education function normally consists in the provision of in-service or continuing education sessions, grand rounds, or monthly forums in which hospital staff members learn about ethical issues that arise in clinical care. Topics include advance directives, surrogate decision making, and the withdrawal of life support . Education is an important first step in protecting patients’ rights. Awareness of how a patient’s values might influence care is often difficult, and education designed to make health care providers sensitive to this is essential. Conclusion 116 Ethics committees are also commonly charged with developing and reviewing institutional policy. Typically, the committee will review policies for consistency with respect to patients’ rights and will recommend changes to better reflect this concern. Areas in which health care ethics committees might review institutional policies include do-not-resuscitate (DNR) orders, informed consent, advance directives, brain death and organ donation, and a myriad of other areas. As the practice of...