Analysis and Reflections on the Current Situation of the Health Care Ethics Committees (HCECs)

Abstract

Health Care Ethics Committees (HCECs) advise health personnel and patients in making morally difficult decisions. This work aims to analyze in a general way the current situation of the HCECs. The methodology used was a literature review. A low level of knowledge about HCECs was found, and internal and external conflicts were identified for their development. As they are beneficial organisms in hospitals, their role in facing current ethical dilemmas in health care is highlighted.

1. Introduction

Decision-making in health can often be complex, as doctors face daily ethical dilemmas in their professional practice. It is essential to make correct decisions to achieve the patient’s best interest, respecting their autonomy, dignity, and values; this can be achieved with the support and contribution of the HCECs. Currently, the provision of health services generates constant tension between doctors and patients. This can be explained in terms of the technological development in health that has extended the limits of life, which has generated conflictive situations in which the doctor’s criteria are not enough to comply with bioethical principles. Therefore, the need to implement HCECs in hospitals with high technology has spread worldwide for several decades. Its mission is to provide advice – when ethical dilemmas arise from medical care- and guide decision-making – always trying to achieve the best for each patient [1, 2].

Medicine has always been characterized by basing its actions on the principles of Beneficence and Non-Maleficence. In recent decades, respect for autonomy has also emerged, considered an inalienable right. Advances in medical knowledge and the enhancement of bioethical principles have made it possible to improve patient care. Still, they have also led to situations in which the individualistic or paternalistic approach is insufficient to decide. At the institutional level, the existence of the HCECs is justified by the conflicts that arise between the bioethical principles, most often between the autonomy of the patient and the beneficence/non-maleficence that the doctor seeks. The HCECs seek, through pluralism and deliberation, to find the best possible alternative in each case.

1.1 Definition of HCECs

The HCECs are organizations structured at the hospital level, whose priority is to support health professionals toward ethical conflicts arising from medical care, seeking the benefit of all those involved. For Crico et al. [3], HCECs are teams of people defined by a hospital or healthcare institution and assigned to consider, debate, study, take action, or report on ethical issues that emerge in patient care. In Ecuador, Article 20 of Ministerial Agreement 4889 [4] defines the Committee on Health Ethics (CEA by its Spanish acronym) as a multidisciplinary deliberation body, at the service of professionals, users, and management teams of health facilities, created to analyses and advise on ethical issues that develop in health care practice.

1.2 Historical background

The first CEA in history was the “Seattle Committee,” established in 1962 in the United States to decide which patients were eligible for hemodialysis treatment, developed by the physician Scribner. This first committee was widely criticized and was nicknamed the “Committee of Death” because its criteria for selecting patients were nonmedical, giving greater importance to aspects such as social status or income level. This form of decision-making is at odds with the principles advocated by Bioethics and today with the focus on medical judgment in assigning treatment [5].

In 1968, the Harvard Medical School, in response to the need for an “ad hoc” ethics committee to examine the definition of brain death, produced a special report containing a set of criteria for identifying what they called “an irreversible coma.” This committee produced a special report containing a set of criteria for the identification of what they called “an irreversible coma.” The need for a committee arose from medical concerns about defining brain death, seeking to provide a reliable diagnosis of irreversibility in mechanically ventilated patients, and implementing transplantation programs, which emerged in the 1960s. It is evident that this historical milestone caused physicians to become aware of the ethical dilemmas they may face, and these required not only scientific knowledge but also moral knowledge to be addressed [6].

A paradigmatic case, which reinforced the need for CEAs, was that of young Karen Ann Quinlan. Karen was a 21-year-old American who suffered permanent brain damage and was left in a vegetative state after alcohol and benzodiazepine intoxication, so she was placed on a mechanical ventilator. In 1976, Quinlan’s parents filed a lawsuit to have her right to be disconnected from the ventilator that kept her alive recognized, arguing that her condition was irreversible. Following the New Jersey court order, Karen was progressively weaned off the ventilator but continued to breathe spontaneously until she died in 1981 of nosocomial pneumonia. From this case onwards, greater importance was given to CEAs and their functions [7].

With Van Rensselaer Potter’s publications on Bioethics and the Karen Quinlan case, in the 1980s CEAs were present in 60% of US hospitals, then in the 1990s, the number rose to 90%. Today in this country, almost every hospital has a CEA. Such bodies have become the primary mechanism for addressing ethical issues in patient care [8].

In Spain, the first CEA was established at the Hospital San Juan de Dios in 1974. In the 1990s, Circular 3/1995 was issued for the creation and accreditation of CEAs in the INSALUD system (National Health Institute). Initially, the CEAs were voluntary, but they are now mandatory [9].

In Latin America, Argentina was the pioneer in the creation of CEAs. In 1996, a national law was enacted, determining that, in each hospital of the public health system, there must be a CEA with advisory functions. In Colombia, progress has been significant. Although there is little legislation on CEAs, Resolution 13,437 of 1991, by which CEAs are constituted, is known; Decree 1757 of 1994, which expanded the functions of CEAs by assigning them administrative and quality control roles in the provision of health services, which elevated the committees to the category of guaranteeing social participation in the activities that are developed within the institutions of the social security health system [9, 10].

In the case of Ecuador, there have been regulations for the creation and formation of CEAs and CEISH (Ethics Committee for Research on Human Subjects) since 2014; however, few hospitals have these committees, which highlights the importance of this study.

1.3 Role of the CEAs

The main role of the CEA is to discuss individual dilemmas or moral conflicts in clinical practice, to seek the best decision-making in each case, and to educate healthcare personnel on bioethical issues. Among the objectives of a CEA are to make recommendations on ethical conflicts that may arise in the context of everyday medical care, to improve the quality of care, and to seek the protection of all those involved in an ethical dilemma. In addition, to promote bioethics training for committee members as well as the staff of the institution. Consultation with CEAs achieves important benefits for healthcare personnel, such as consensual decision-making, strengthened moral competence, and improved medical care [2, 11, 12].

The aim of consulting a CEA is to identify and resolve existing and potential ethical problems related to health care, to improve the patient-physician relationship, to ensure the well-being of the patient, and to resolve conflicts between health care personnel, patients and their families, i.e., CEAs seek not only the benefit of the patient or their families but also the benefit of the health care personnel. In some countries, the role of CEASs is also to evaluate and supervise clinical trials involving human subjects, although this is a function that corresponds to the Human Research Ethics Committees, which is why it is necessary to carry out training on CEAs and raise awareness of their institutional contribution [13].

Medical staff, patients, family members, legal surrogates, and other healthcare personnel should have access to CEA counseling, which is why information about the availability and process of counseling should be widely disseminated. Although hospital-based ethics consultancy is the most common, the possibility of consultancy in the outpatient setting should be recognized and supported at the institutional level [14].

CEAs usually have scheduled meetings, often once a month, to discuss cases or plan future training. The physician usually consults the committee because he/she wishes to clarify doubts and obtain recommendations on sensitive issues, such as discontinuation of nonbeneficial treatments. It should be mentioned that anyone involved in the care of a patient can request consultation with the CEA, fulfilling its advisory role. This allows the patient’s relatives or caregivers to reduce their moral distress and find adequate support in the CEAS [15].

Per Moon [16], CEAs in the United States promote the practice of ethics through a variety of activities, including continuing education on bioethical issues for health professionals, review of hospital policy, and consultation on clinical cases that present dilemmas in their approach. Raoofi et al. [11] mention that the functions of the CEAs in Iran are to solve problems that arise during health care in hospitals, to increase healthcare personnel’s awareness of conflicting situations and participation in decision-making, to foster communication and to educate on bioethical issues.

Galván et al. [17] mention in their work that in Spain, the function of the CEA is to advise patients and health personnel in ethical conflicts that arise in medical practice; however, problems in the structure or in the way they work limit their true scope. Carillo et al. [9] indicate in their work that in Colombia CEAs are available to both physicians and patients, and their functions are to advise on ethical conflicts and education.

Current regulations in Ecuador state that second and third-level hospitals, due to the complexity of their services, must have a CEA, which allows professionals with ethical doubts to seek advice and counseling. The recommendations of the CEA are not binding, i.e., in the end, medical judgment will prevail, but they demonstrate commitment to the patient to exercise proper professional practice [4].

2. Methodology

A literature review was used, as full articles were consulted in databases such as PubMed, Web of Science, SciELO, Scopus, and Google Scholar. To search, the following health descriptors were used in Spanish: “Hospital Ethics Committees,” “Institutional Ethics Committees,” “Clinical Ethics Committees,” “Knowledge,” “Objectives,” “Development,” “Functions,” “Benefits,” and “Challenges.”

Articles were selected from the last 5 years, published in English or Spanish, that addressed general aspects of the HCECs for analysis. Fifty-one articles were thoroughly evaluated, 39 were discarded, and 21 papers containing the main aspects were chosen for reflective analysis of the HCECs.

3. Results and discussion

Zurzycka et al. [2], in their work, analyzed the information available on the WEBSITE of accredited hospitals in Poland. From 227 hospitals, only 56 confirmed having an HCEC. Most of them expressed how they could request their services and their functions. Raoofi et al. [11] interviewed 19 members of Iran’s hospital HCECs about the main challenges they have faced in their roles; the most common barriers to the proper functioning of the committees were lack of support from the authorities, lack of knowledge in Bioethics, and poor communication.

An important characteristic of the CEA is its multidisciplinary composition. Jansen et al. [15] in Australia, when analyzing a hospital committee for 24 months, found that it was made up of various professionals in different areas, mostly physicians (45% of the total). Carrillo et al. [9] found that in Colombia, CEASs were composed of both professionals and representatives of civil society. Zurzycka et al. [2], when reviewing the websites of hospitals with accredited CEAs in Poland, found that no hospital specified who the committee members were. Scherer et al. [12], when interviewing members of a CEA and physicians in a hospital in Germany, found the need for more staff to achieve a multidisciplinary approach, such as nurses or psychologists.

Baker et al. [8], by exposing a series of cases in an emergency room in the United States, which generated critical ethical dilemmas, emphasize the need for these services to have a trained person in Bioethics or a member of an HCEC who can be consulted through digital media, for a better approach to this type of situation. In Germany, Scherer et al. [12] interviewed 28 people among HCECs and healthcare personnel members on the main challenges of the proper functioning of the committees. Lack of communication and hierarchical asymmetry were identified as situations that hinder the work of these bodies.

Głusiec [18], in Poland, investigated the frequency of priests’ participation in ethical dilemmas that the HCEC must resolve. The few requests were surprising, considering that it is a Catholic country. The main topics on which the help was requested were the limitation of therapeutic effort and termination of pregnancy. Something that should be mentioned is that most of the priests consulted acknowledged not having adequate knowledge of these issues, so the support of doctors was required for a better understanding. Crico et al. [3], in a systematic review, identified that both physicians and members of HCECs considered the presence of these organizations in hospitals practical since less satisfaction was identified among physicians concerning the service offered by the HCECs, possibly due to their critical stance toward the decisions adopted by the committees.

Gradinarova and Zlatanova [14] compared the level of knowledge about HCECs, among doctors and patients in Bulgaria. The vast majority of physicians and patients were unaware of the existence of these organisms. Those who knew about the HCECs reported that hospitals lacked more information about their functions. Jansen et al. [15] evaluated the role of HCEC in the pediatric area of a hospital in Australia. There was great satisfaction with the role played; the pediatricians who came to this body mostly expressed that this organization was beneficial and would recommend it to their colleagues.

Moodley et al. [19] analyzed the reality of HCECs in African countries, interviewing 20 physicians and bioethicists. These organisms were found to be nonexistent; there was a greater need for ethical consultation during the pandemic and, therefore, the need for HCECs. As for the level of knowledge, this was very low. Pons Valls et al. [20] investigated the level of expertise about HCECs in a hospital in Spain. A high level of knowledge was found about its existence and functions, while the knowledge recorded was low on how to address it. Most recognized that when faced with an ethical dilemma in their work, they would go to these organizations.

Ferreira et al. [13] analyzed the level of development of HCECs in Paraguay. They found that, out of 130 hospitals, only 28 had an ethics committee, and only four identified as HCEC, reflecting the need to boost state policies to promote their further development. Ávila et al. [21], in Mexico, explored the level of knowledge, in traumatology and orthopedics residents, about Bioethics, which turned out to be low, and about HCECs and their functions, which turned out to be in the majority. However, it is surprising that most would never have encountered this body due to an ethical dilemma.

Among the main challenges faced by CEAs in their proper functioning, the work by Raoofi et al. [11] is one of the most comprehensive because it identifies external, internal, and committee factors, especially highlighting the lack of management support as an impediment to achieving real impact. Scherer et a. [12] describe lack of communication and hierarchical asymmetry as the main challenges to committee functioning. Moodley et al. [18] cite a lack of knowledge and resources as challenges to achieving functional CEAs. Galván et al. [17] state that the bureaucracy of the committee impedes good work, which Carrillo et al. Pitshelauri [1] highlights the following factors for the good functioning and development of CEAs: good institutional attitude toward care, professional interests, patient demands, and social development, and a consensus decision-making model based on cooperation and recognition of plurality.

In relation to the topics consulted Zurzycka et al. [2] found that very few committees published this information in Poland, Głusiec [20], when interviewing Catholic priests, found that the main topics consulted to the CEA were on Limitation of Therapeutic Effort (LTE) and contraception. Moodley et al. [18] found that the main topics consulted in Africa were LET, futile treatments, Informed Consent in children, and patient complaints. Carillo et al. [9] found that the main topics consulted were LET, Organ Transplantation, and Brain Death in Colombia. In general, consultations with CEASs are related to conflicts regarding the Start or End of Life, poor doctor–patient relationship, and analysis of the benefit or futility of certain treatments, especially in critical areas.

4. Conclusions

HCECs are required in all hospitals that provide highly complex services. In today’s medicine, ethical conflicts are constantly presented, and an organ that can advise the health professional in decision-making is required. Even though HCECs have developed exponentially since the eighties, this has not been uniform because they are nonexistent in low-income countries, which violates bioethical principles in healthcare. However, it is interesting to confirm that knowledge of their functions in developed countries is still scarce, which means that the HCECs do not have a real impact.

Despite having regulations for their formation and execution, HCECs present numerous challenges regarding the performance of their functions. This invites the development of new strategies to promote optimal functioning. Several topics are consulted at the HCEC; this requires a multidisciplinary approach in which its members can deliberate and recommend the best decisions. More significant support is required from the authorities to fulfill this goal, which unfortunately is not the case due to the little importance given to ethics in the healthcare field.

The role of HCECs needs to be strengthened. Precisely, this work highlights the need for moral knowledge as a weapon to improve health care. It is recommended to combine certainty with prudence to achieve the best in favor of the patient. It is also necessary to remember that the primary objective of the HCECs is to achieve the patient’s well-being and respect their rights, which must be shared by healthcare personnel and society in general.