H E CFORUM, Vol 3, No. 1, pp. 19-22, 1991. 0956-2737/91 $3.00+.00 Printed in the USA. All rights reserved. Copyright © 1991 Pergamon Press pie

POINT AND COUNTERPOINT: SHOULD THE ETHICS COMM1TI'EE VISIT

THE PATIENT?

NO: HEC MEMBERS SHOULD NOT VISIT THE PATIENT

KENNETH V. ISERSON, M.D., M.B.A., (F.A.C.E.P.)

The purpose of ethics committees is to reduce the likelihood of moral tragedy by subjecting moral dilemmas to systematic, rational analysis (1). The primary consideration of ethics committees is the patient. Yet saying this does not necessarily mean that the patient and commit tee must interact. A broad range of possibilities exists in the interaction of commit tees and patients -- from no contact to the patient 's presence during all commit tee deliberations (2) (3).

There is obviously a difference between the rare instance when a patient requests, or can participate in commit tee deliberations, and the usual situation in which the patient, at least for the present, does not have this capacity. I submit that it is inappropriate, if not destructive to the commit tee process and its successfully reasoned deliberations, to have the members visit such incapacitated patients. The reasons fall into three categories: psychological, administrative, and ethical/legal.

Psychological

The typical, and perhaps ideal, commit tee structure includes a significant proport ion of non-clinicians, who may be averse to and disoriented by seeing the bells and whistles of an ICU -- and even more so upon viewing the condition of a patient in such a unit. Routine medical situations and devices, such as an intracranial bolt, tracheal or nasogastric tube, orthopedic external fixation device, or thoracic or urinary catheter may so daunt those not familiar with them that clear thinking and subsequent recommendat ions may be affected.

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This is not to say that committee members, at a time other than during a consultation, should not view the various clinical settings in the institution so as to understand better the "bedside medical culture" (4).

Even those within the healing professions who, because of their duties, are not routinely exposed to intensive care procedures and patients may be shocked upon exposure to the patient. Intensivists themselves are not immune, since "psychological pressures on the physician in caring for terminally ill patients conspire against his impartiality" (5).

One justification for the existence of ethics committees is as an "ideal observer," whose "ethically correct decisions should be approvable by an observer whose qualities include omniscience, disinterest, and dispassion" (6). Introducing the extraneous factors of unfamiliar medical surroundings, sights, and smells to the committee members would seem to negate the possibility of disinterest and dispassion being present. (Omniscience is unobtainable by the committee members with whom I am familiar.)

The reactions to the patient visit by the committee members, either at the bedside or subsequently, may further distance the medical staff from the committee and the committee's activities. "The physician must remember that he has only one client -- the patient. He is the advocate of the patient -- not the family, nor the welfare agency, nor the kindly clergyman, squeamish at the sight of [a] tracheostomy" (5).

Nearly all committee members are struggling for expertise in the field of bioethics. To complicate matters with the shock of an intimidating medical experience would be counterproductive. The clinical "data" achieved by a bedside visit very often would lead to flawed information, which in turn could lead to flaws in reasoning and recommendations. While seeing the reality of the patient's condition may theoretically be part of providing a complete picture, it is unlikely that most members would ever come away from the experience with a disposition to extend the patient's life. If that is the committee's considered opinion in any case, nothing is lost. But if this is a situation where the agony of seeing the patient's current condition unduly influences members, then it would be an avoidable moral tragedy.

Administrative

Administrative considerations also play a role, albeit small. In some institutions it is difficult to obtain active participation on the committees, especially among non-physicians. When asked, many intelligent individuals state that they did not pursue a career in medicine because they "cannot stand the sight of blood and gore."

Point and Counterpoint: NO 21

Requiring this type of brutalizing experience of non-medical committee members would only exacerbate this fear as well as make it more difficult to attract and retain good non-medical members.

An increasingly common scenario in ethics committees is to have 3-5-person subgroups of the committee do the consultations (7). The danger here is that if patient visits were required during consults, subgroups might be fashioned in such a manner so that only those comfortable with hospital practice and patient care would be included. The physicians' power within the committee would be magnified, diminishing the consideration of diverse viewpoints and arguments, and leading to what has been called "groupthink" (8). This would also diminish the benefits to the committee, including the linking of medical and non-medical values (9), gained by the diverse background of the individuals involved. It would also serve to promote an already bankrupt concept -- that medical ethics is the special province of physicians.

Gathering relevant information about each case is vital to delivering a balanced and reasonable recommendation to the clinician. This is true both of consultant and committee consultations. Nurses, social workers, family, physicians, consultants, clergy, and other interested parties in the case can and should be available to clarify their perspectives on the issues involved and often work out differences of interpretation with each other. Case records should be reviewed if appropriate. This need not, though, be done at the bedside. "Decisions regarding termination of care are fundamentally ethical, not medical. Sound judgments will obviously depend on accurate medical information -- good ethics starts with good facts -- but the crucial question is usually an ethical one..." (3).

The only direct purpose for bedside evaluation of the patient is either to speak with the patient, if he or she has decision-making capacity (in which case most consultation should be moot), or to reevaluate the medical examination (an inappropriate role for committee members unless called on specifically and separately in their roles as medical specialists). To enter into the role of medical consultant, as has been suggested as a partial role for individual ethics consultants, (4) diffuses and confuses the committee's role and puts an additional block between the patient and the attending clinician. It may also engender animosity between the medical staff and the committee.

Ethical/Legal

Two main issues in this category pertain to the committee visiting the incapacitated patient. The first question is whether the

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patient i s adequately represented without a bedside visit. This is absurd. Committee performance requires that adequate information be obtained before decisions are reached. At least one member of the committee, if not the entire committee, specifically must act as an advocate for the patient (1). This, of course, is in addition to the patient's family, clergy, and personal health care workers who are often present. One need only ask whether judges, who actually make final decisions rather than recommendations in such cases, go to the bedside.

The second question is whether patient autonomy is being maintained. Assuming as we have that the patient does not have decision-making capacity, is his or her right to make personal decisions about health care helped in any way by a bedside visit? Or rather, will considerations of prior wishes or reasoned substituted judgement be more judicious without the visit? If the end result of committee deliberations is to be patient-centered and rational, then committee members should avoid seeing most of those patients for whom life or death decisions must be made.

REFERENCES

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9.

Cross AW, Churchill LR. Pediatric ethics committees: Learning from our experience. Journal of Pediatrics. 1986; 108:242-3. Stidham GL, Christensen KT, Burke GF. The role of patients/family members in the hospital ethics committee's review and deliberations. H E C Fon~m. 1990; 2:3-17. Fost N, Cranford RE. Hospital ethics committees: Administrative aspects. Journal o f the American Medical Association. 1985; 253:2687-92. La Puma J, Schiedermayer DL. Must the ethics consultant see the patient? Jout?lal o f Clinical Ethics. 1990; 1:56-9. Epstein FH. Responsibility of the physician in the preservation of life. Archives o f btternal Medichle. 1970; 139:919-20. Fost N+ Ethical problems in pediatrics. Current Problems hi Pediatrics. 1976; 6:1- 31. Kushner T, Spicker SF. HECs and consultation. H E C Forum. 1990; 2:71-3. Lo B. Promises and pitfalls of ethics committees. New England Journal of Medichle. 1987; 317:46-50. Churchill LR. The role of the stranger: The ethicist in professional education. Hastings Center Report. 1978; 8:13-15.