H E C FORUM, Vol 1, pp. 63-76, 1969. 0956-2737/89 $3.00+.00 Printed in the USA. All fights reserved. Copyright O 1989 Maxwell Pergamon Macmillan pie

F U T U R E F I J N C I ~ O N S O F H O S P I T A L

E T H I C S C O b l M I ' I T E E S

KENNETH V. ISERSON, M.D., M.B.A.

FLOYD B. GOFFIN, M.D.

Ft. JAMES J. MARKHAM

Hospital Ethics Committees (HEC) have a relatively short history. Yet, there is already a modicum of uniformity in the activities that these committees perform. One of the earliest proposals for the formation of HECs was the 1971 Medico-Moral Guide of the Canadian bishops. The tasks outlined for the proposed medical-moral committees in Catholic hospitals were to: (a) assume responsibility for educating the total hospital community concerning the developing medical-moral trends in effective health care; (b) provide a forum for interdisciplinary dialogue; (c) provide a basis for unified direction and interpretation of the Ethical and Religious Directives for Catholic Health Care Facilities, published in 1971 by the U.S. Conference of Catholic Bishops; (d) serve as a channel of communication "from the front line of experience to the rear line of policy making"; and (e) serve as a legislative watchdog (1, p. 269).

Soon thereafter, in 1973, the Massachusetts General Hospital Critical Care Committee created a multidisciplinary ad hoe subcommittee to study and to recommend treatment both for the hopelessly ill patient as well as the appropriate utilization of limited critical care facilities (1).

In 1977, Montefiore Medical Center in New York City formed a bioethics committee. Its purpose was to serve as an educational, policy-making, and guideline-writing body. However, the committee was not seen as being very successful by its leadership (1).

After the Quinlan decision there was a significant increase in the prevalence of institutional ethics committees (IEC). Recently, there have been some attempts to legislate the functions of HECs. In Maryland's statute, the Patient Care Advisory Committee is required to be "involved in cases involving life-threatening conditions" (2, Sect. 19- 373). But the remainder of the legislative charge to these committees is broad, and includes "medical decision-making" and "withholding of

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medical treatment, n including specifically the education of hospital personnel, patients, and families; and the review and recommendation of institutional policies and guidelines concerning the withholding of medical treatment (2, Sect. 19-373).

This suggests that some legislatures subscribe to the assertion made by proponents of ethics committees, that "they will satisfy the need for a more systematic and principled approach to the contemporary dilemmas of medical-ethical decisionmaking within our hospitals and long-term care facilities ~ (3, pp. 40-41).

WHAT ARE ETHICS COMMITTEES ACTUALLY DOING?

Currently, IECs, which may serve the entire institution or a special unit, such as a neonatal intensive care nursery or a cardiac intensive care unit (4), are primarily located in hospitals. They usually have four main functions. First, they coordinate education on bioethical issues (for the committee members, hospital physicians and staff, patients, families, and local hospital community) about the ethical dimensions of clinical care. Second, they assist in the development of institutional mandatory or suggested policies or guidelines dealing with bioethical issues (policies and guidelines for health care professionals regarding decision-making processes in problematic cases and for resource allocation issues). Third, they review and analyze, prospectively and retrospectively, clinical cases, and offer advice and conclusions to those directly involved, most often concerning the treatment or non-treatment of patients who lack decision-making capacities. Most often the committees do not act as the primary decisionmakers. Rather, they serve in an informative and advisory capacity, supporting the primary decision-making role of the patient-family-physician triad, especially for urgent decisions about withholding, withdrawing, or continuing life-sustaining medical care (5), (6), (3), (7). Finally, they counsel hospital staff, patients, and families on ethical issues. This is often done by providing forums for discussion among hospital and local medical professionals and for airing and resolving disagreements among staff, patients, and families about clinical care decisions, and acting as a source of support as these difficult decisions are made. In essence, then, the function of the HEC is to consider and assist in resolving unusual, complicated ethical problems (8).

However, the experience of many suggests that substantive ethical analysis does not typically have a primary role in HEC discussions of concrete cases. Since conflict is the essential element in issues brought before ethics committees (9), it is thought that clarifying the facts and fostering communication comprise upwards of 80 to 90 percent of their

The Future Functions of HEC's 65

work (1), (9), (4), (11), (12), (13), (3), (7), (14), (15). These activities also occur in Canadian HECs (16). Similarly, a

survey of long-term care facilities in Minnesota reveals that their HECs have primary functions of policy development (97.5%), education (82.5%), resident care consultation (45.5%), and retrospective case review (47.5%) (17).

Current HEC functions, therefore, closely parallel those of a model bill proposed in 1983 by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research to establish HECs. The suggested scope of authority of such committees would be to: (a) review treatment decisions made on behalf of terminally ill, competent patients who request committee review; (b) review medical decisions having ethical implications; (c) provide counselling; (d) establish guidelines; and (e) educate (6).

EVALUATING THE INDIVIDUAL HEC

There are a number of questions to be considered before deciding to expand, or indeed even to initiate a HEC. [See Table I]

"If an institutional ethics committee is to function effectively within a health care setting, it will have to be conscious of its legitimation, of its claim to be taken seriously by virtue of having the appropriate skill and authority to deal with the tasks at hand. [This is] closely related to the question of to whom the committee is accountable. If the committee is accountable to physicians on a hospital staff, then the committee will take on the ethics agenda of that medical staff. It will be viewed as legitimate to the extent that the physicians are convinced that it is really helping the medical staff make decisions based on its ethical framework. On the other hand, if the committee is accountable to patients, then it will turn to patients for its legitimation. Other committees might see themselves as accountable to the administration of the hospital, the board of trustees, or the broader community that has created the hospital, whether that be a city government or a church" (3, pp. 39, 41).

TABLE I: SELF-EVALUATION QUESTIONS FOR ETHICS COMMITYEES

. Who is the public being served by this committee? Can this be described merely through the use of an institution's catchment area?

2. What are the limits (geographic, functional, administrative,

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legal, ethical) of this service? Is this determined by the institution? The committee? The authorizing body for the committee? The community? An ethics network (formal or informal)?

Why was the committee initiated? Why is it still in existence? Why should it continue?

. What are the reasons to expand the functions? Is it because there is truly a need for this added function? Or is it simply a "good idea"?

5. Does this function really need ethical expertise?

6. Does this new function truly complement current committee activities, or is it only administratively "politically" easier then establishing a new group to carry out the function?

FUTURE FUNCTIONS

In reality, the term "ethics committee" is frequently used to refer to bodies that review decisions concerning foregoing life-sustaining treatment, although they may evolve into committees that are consulted on a much wider range of decisions that have an "ethical" component within hospitals. A few already go beyond ethical issues, and this tendency has been construed by some as a problem (3).

Several of the new functions that a HEC can perform include: (a) identifying conflicting interests, rights, and duties and aiding in the reconciliation of competing goals--including the utilization of scarce or limited health care resources; (b) supporting families, patients, and staff; (c) resolving disputes among staff members and between staff, patients, and patients' families over non-treatment decisions; (d) helping to protect the health care professionals, patients, patients' families, and institutions from lawsuits--acting as an ethics/risk management team; (e) confirming medical prognosis; (f) reviewing physicians' judgments and competence; (g) acting for the community/society by trying to determine how to maximize social utility or promote a just distribution of social resources; (h) enforcing institutional ethical policies; (i) conducting ethics-related research; and (j) incorporating the pre-hospital arena, e.g., emergency medical system and clinics, into the ethical milieu (8), (18), (13), (16), (19).

The Future Functions of HEC's 67

SPECIFIC ADDITIONAL FUNCTIONS

DEFINING 'DISTRIBUTIVE JUSTICE'

Assessing the *technological imperative * b y prospectively reviewing decisions to adopt new technologies may be one of the most important areas into which HECs may move. It may only be a matter of time before HECs find themselves important figures in the debate over the allocation of scarce health and medical resources. They deal almost exclusively with patients who are critically ill and who have little hope of regaining even a semblance of health--typical of patients during their last year of life. This is precisely when the greatest medical costs occur. The HEC may become a powerful voice in determining the extent to which considerations of cost will influence medical care decisions (10).

The most difficult moral problems arise when patients and their physicians seek access to therapies judged only marginally useful. Conflicts can arise between administrators with broad institutional responsibilities and clinicians committed to particular patients. It is not clear if HECs can or should attempt to resolve such conflicts (1).

The Belmont Report included an explicit appeal to distributive justice norms (20), (21). Some HECs exist for the express purpose of dealing with social justice issues, that are defined as *the equitable distribution of goods and the recognition of rights so that each individual has the opportunity to fulfill his or her human dignity and contribute to the common good ~ (6). "'Social justice' refers to questions not only of respect for individual patients (their safety, autonomy, and general well-being), but [also] of fairness to patients in relation to other patients and to society. It has to do with the allocation of scarce resources, the fair distribution of benefits and burdens and the rights of members of a human community to participate in decisions that affect their lives. It concerns primarily the structures and processes that allow the just distribution of power, the protection of human rights, and security for the weak and vulnerable" (21).

In 1978, it was reported that a committee to address social justice issues was established at the New Britain, [Connecticut] General Hospital; the 1983 Catholic Health Association review of member hospitals indicated that 70 of approximately 400 (18%) had committees for ethical concerns related to social justice (21).

As hospitals themselves have become moral agents with a responsibility beyond providing a setting for one-on-one medical care, there has been a growing interest in the need for HECs to address social justice questions. To some extent, this task goes beyond present

68 ICV. Iserson, F.B. Goffin, J.]. Markham

expectations of HECs, whose task is to aid a patient, physician, or family in making an ethical decision regarding treatment or non- treatment. It also goes beyond the current understanding of an institutional review board's (IRB) task to review and approve proposed research on human subjects (21).

REVIEW THE ETHICS OF INSTITUTIONAL RESEARCH

IRBs are widespread and generally accepted as useful by the biomedical community and the lay public. Their mission is generally uncontroversial and based upon 1974 U.S. federal legislation (Public Law 93-348), that governs federally-funded research. They have a clear mission and they have the authority to make decisions. Internationally, IRBs were given impetus with adoption of the revised Helsinki Declaration in 1975, and were adopted under a variety of legal and other provisions and titles (1), (22). Unlike IRBs, HECs which deal with ethical dilemmas arising in the course of non-experimental therapy, are nowhere required by law (10). However, many HECs currently deal exclusively with reviewing clinical research applications and therefore are in essence IRBs, even though they use the term 'ethics' in their title (1) (22).

The Belmont Report proposed three basic ethical principles as being relevant to IRBs: respect for persons (autonomy); beneficence; and justice (distributive justice) (20). Most IRBs consider informed consent and risk/benefit assessment as the two major concerns that they should deal with in examining research proposals (22).

There are at least two examples of committees that have simultaneously and successfu!ly taken on both the functions of the HEC and the IRB. One is at a children's hospital in Switzerland, and the other is at a U.S. institution for the mentally retarded (1), (23).

HECs, like some IRBs, attempt to resolve complex ethical dilemmas through the use of members of local, hospital-based, multidiciplinary committees. Aside from the legal requirements, HECs differ from IRBs in several important ways: (a) the issues confronting HECs carry more emotional weight, often involving the life or death of an identifiable person; Co) HEC cases will not arrive neatly packaged and on a scheduled basis; and (c) the uncertainties involved will require more effective leadership to ensure the efficient presentation of important data and the dispassionate discussion of highly charged issues.

One of the reasons that it might be difficult for a single committee to fulfill both functions is that in many institutions the IRB is among the busiest of committees, involving a great deal of work for its members. A HEC could become equally busy, however (5).

The Future Functions of HEC's 69

MONITORING THE ADMINISTRATIVE DECISIONS OF THE HOSPITAL

Perhaps the primary role of HECs is to foster an ethical milieu within the hospital. At all levels within modern institutions there is a growing awareness of urgent and complex problems whose resolutions are beyond the capabilities of individuals acting alone. As legal and regulatory constraints on institutional activities increase, administrators will expect legitimate and effective internal groups to develop policies and to monitor individual situations (24).

Frederick Abrams, M.D., (Director of the Center for Applied Biomedical Ethics at Rose Medical Center, in Denver), predicts a fundamental attitude change toward the role of ethics committees. ~I think that because of the trend toward the commercialization of medicine, ethics committees may start to act as the conscience of the hospital. ~ He continues: [this will ensure that] ~the primary thrust of the hospital is still care and not profit ~ (25).

The majority of HECs function as a subcommittee of either the Medical Staff Committee or the Administration/Hospital Committee. These are the two most powerful institutional forces in hospitals (24). This placement, in addition to the committee members' expertise and interest in clinical medical ethics, may unfortunately encourage the members to act as the moral watchdog of the hospital. Nevertheless, justification for the presence of HECs is based upon the ~ideal observer theory," which states that ethically correct decisions should be sought by an observer whose qualities include omniscience, disinterest, and dispassion. Since no individual can possess these virtues, the HEC, through its broad membership, can more easily and effectively improve the decision-making process (5).

However, George Annas, an attorney, maintains that the review mechanisms hospitals have created in the past were established primarily to protect the institution. To expect HECs to depart from this tradition by being altruistically concerned only with patient welfare is naive. The prepaid health care provider setting is tailor.made for HECs because of its potential for major conflicts with patients' rights. But when your doctor or hospital is also your insurer, there may be a tremendous incentive to limit treatment because the physician's income will be affected by his or her decisions (10).

Hospital administrators have already suggested that HECs should have as one of their tasks the recommendation of policies concerning the extent of non-reimbursed care (26). Others have suggested that HECs should be given the authority to initiate judicial review in ambiguous cases (10).

70 K.V. Iserson, F.B. Goffin, J.J. Markham

Some ethicists believe that HECs may provide the necessary responsive forum for resolving the dilemma of whether, or to what extent, cost should be a consideration in health care decisionmaking (3). However, even in hospitals with functioning HECs, the financial aspects of medical care are rarely, if ever, overtly discussed (1).

ACTIVELY EDUCATING THE COMMUNITY, LEGISLATURE, AND THE COURTS

An important role for HECs is to serve "...as a link between societal values and the actual developments occurring in the institutions that care for and treat particular patients whose cases manifest these dilemmas" (3).

Ronald Cranford, M.D., Co-chairman of the Biomedical Ethics Committee at Hennepin County Medical Center in Minneapolis, Minnesota, predicts that "we will see more interaction between ethics committees and state legislatures". He points to the Tomes decision as a landmark case in that direction because "three ethics committees submitted written opinions to the probate court and played an important role in helping to form the opinion of the Supreme Court" (25).

CONSULTING SERVICE

There are a number of possible scenarios through which an expanded scope of HEC activities could be accomplished. One method is through either hiring or appointing ethicists to the hospital staff (27). These individuals could be, as they are in some institutions, self- supporting.

The ethicist could work either through the same mechanisms currently available, or develop into the realm of private consultations. In this role, he or she would provide professional advice or services regarding matters pertaining to medical ethics, either to the HEC, patients, clinicians, families, or administrators. This service is certainly needed, as demonstrated by the fact that HECs that already provide consultation services have experienced a sizable increase in the number of requests received (24).

However, the activities of the ethics consultant will differ from those of a clinical consultant in an important way--the ethicist retreats after the consultation; under no circumstances would an ethics consultation be followed by the ethicist becoming the primary caregiver or assuming ongoing responsibility for the clinical management of a case (27).

Still to be answered is the question of whether formal hospital

The Future Functions of HEC's 71

staff appointments for non-physician ethicists is workable. Most hospital ethicists currently have academic appointments in local medical schools, and their consultative activity is carried out from that base. Are hospital administrators, medical staffs, and boards of directors prepared to make changes in their bylaws to accommodate ethicists? Also, how many ethicists are prepared to be on call on weekends or after hours to do what they term "beeper ethics" (27)?

At least two institutions have already developed fee scales for ethics consultants and implemented a protocol similar to that used for clinical consultants. But so far no hospital has completely analyzed the procedural problems, such as how to document an ethics consultation in a patient's record, and the procedures for determining and obtaining remuneration for such consultation (27).

A major question remains: Who will pay for the consultation? The Health Care Financing Administration is currently studying the possibility of having reimbursements go to the primary physician, who will then be responsible for paying other consultants. Questions rarely asked are, who is currently paying for the services--albeit covertly? Would overtly paying for ethicists increase the use of their services, decrease it or, in fact, corrupt the system [27]?

PROBLEMS WITH THE EFFECTIVENESS OF THE CURRENT ROLE

Although HECs already have a broad set of functions, it is unclear whether they are as effective as they might be. The lack of adequate time routinely plagues HECs in at least two ways: (1) by the unfortunate curtailment of committe~e discussions, and (2) by failing to provide sufficient time to properly educate committee members and hospital staff. Committee members also complain about the lack of financial resources to promote HEC activities, to provide administrative and clerical help, and to support visits by outside speakers (24).

It is known that many cases in which clinicians could benefit from a sympathetic and skilled ethicist never reach the committees (27). Most health care providers are neither prepared to address ethical issues nor emotionally comfortable discussing them, even if they have had an undergraduate or professional school course in ethics (19). They are often confused by the gap between what is taught about medical ethics and what goes on in the clerkships and residency programs (28). Staff physicians are often reluctant to bring cases to the HEC, since they see it as a loss of control and do not want committees "looking over their shoulders" and asking "Why?" (24)

The most pervasive and frustrating difficulty encountered by HECs is the distorted perceptions and suspicions about committee

72 ~ V . Iserson, F.B. Goffin, J.J. Markham

activities on the part of administration and staff. Administration's resistance to change often is expressed by, nwhat we have now works f ine n (24) .

The ninternal life * of HECs also limits their effectiveness. Pressures on HECs to reach consensus may lead them to make recommendations that are ethically questionable. Agreement, or even consensus, does not confer infallibility. In some circumstances HECs may inadvertently pressure members to reach a consensus, to avoid controversial issues, to underestimate risks and objections, to fail to consider alternatives, or to search for additional information. In other words, committees may not serve their intended functions to include consideration of diverse viewpoints and arguments. Such undesirable qualities of committee discussions, which have been labeled "groupthink, * may lead to grave errors in judgment (18).

PROBLEMS WITH AN EXPANDED HEC ROLE

But while a HEC may choose to address any of the issues that are within its general mandate, for the most part, time is so short that most ethics committees choose to narrow their functions by addressing themselves exclusively to bioethical and clinical care problems. In some cases, there may be more work than one committee can perform--such as problems of critically ill newborns, dialysis units, ICUs, etc. This may require the development of permanent subcommittees or separate committees, even though they may have overlapping memberships (29). Other problems, although they involve important ethical issues, may be better dealt with by other hospital committees (30).

Along with added responsibilities will certainly go an increased cost. At the present time, very little of an institution's resources are spent supporting the HEC. With an increased workload, there can only be a finite amount of increased time commitment from the HEC members. There may be a legitimate need for a number of full-time members. There also may be a legitimate need for a full-time, in- residence philosopher.

HEC functions may of course be expanded or contracted over time. However, the committee members and the entire hospital staff should have a clear understanding of the committee's present role (19). There is a danger that the HEC's functions might expand the hospital bureaucracy and add to its cost without making a significant contribution (4). Since the most common committee members are physicians (though not usually constituting a majority), it is not clear that an HEC includes the expertise necessary to make it competent for decisionmaking related to other areas and functions (18).

To avoid a denigration, or a least a lessening of importance of

The Future Functions of HEC's 73

the HEC's current functions, each institution establishing such a committee should decide which of these functions its HEC should perform. One important question might be: Is there some other committee already established to perform that function or one that might be better suited to it? (4) Alexander Capron, an attorney and professor of law, has pointed out that the function least likely to be performed by another committee in the hospital is consultation on individual cases (4).

There is also the potential for conflicts among the various committee functions. It has been suggested that allocation, clinical care, and patient advocacy issues might all require separate HECs because the underlying principles of each differ substantially (29). Also, if committees take on not only these roles, but also the role of being the agent for the hospital in seeking judicial review, this would lead to a breach in the confidentiality implicit in the activities of the committee (13).

RELATIONSHIP BETWEEN LAW, ETHICS, AND THE "BUSINESS" OF MEDICINE

The distinction between the HECs, law, and the "business' of medicine is already becoming hazy. Future added functions may further blur these distinctions. Physicians have recently begun looking to HECs for a "current standard of medical practice," a kind of legal approval, before taking definite steps such as withdrawing life-support equipment (24).

Norman Fost, M.D., suggests the "most dramatic change will be mandatory committees" which he believes will "come about as a result of pressure from legislatures, the enactment of federal regulations, or possibly through changes in the accreditation process" (25).

One hospital administrator has already suggested that the HEC be used as a "public relations tool" to justify unpopular decisions to discontinue unprofitable services.

"By integrating value analysis with more traditional management tasks, the challenges of service closure can be converted into opportunities to demonstrate how your institution has met or exceeded its ethical obligations .... An administrator who foresees the possibility of downsizing should lobby for an ethics committee .... He should suggest that an ethics committee have as one if its tasks the recommendation of policy concerning the extent of non- reimbursed care which is appropriate for this hospital in these circumstances and this time .... Questions will be

74 K,V. Iserson, F.B. Goffin, J.J. Markham

asked about why the committee is needed. Argue for it on a variety of issues besides resource allocation .... These ethics committees can be of help to administrators who know how to use them to generate support for unpleasant but necessary management decisions" (26).

While this may be an extreme statement, there is no doubt that some HECs have been co-opted in precisely this way. Others have suggested that HECs should be established to minimize liability by having such committees approve or disapprove all medical-ethical decisions regarding withdrawal of life-support equipment and "no-code" orders (4). At a small number of long-term care institutions, the HECs function as utilization review committees. This leads to a direct conflict. Ethics review is centered on the patient's needs and wishes, while utilization review exists to protect the hospital's or even society's interests by conserving costs and resources (17).

Some ethicists have argued strongly that HECs should not serve as professional ethics review boards, i.e., as substitutes for legal or judicial review, or as decisionmakers in biomedical ethics' dilemmas. This stems in part from the fear that HECs may replace the traditional loci of decisionmaking on these issues, and in part from a feeling that they are inadequate to do so (11). If HECs are to be considered alternatives to the courts, it should be understood that, in the legal sense, they are procedurally weak. They usually fail to notify parties of the proceedings, do not allow them to provide evidence, do not ensure representation for patients, do not notify all parties of the decision and the reasons for it, and do not have a mechanism for review or appeal of prior decisions (18).

There is no doubt that as the lines of authority become more blurred, because HECs intentionally absorb other functions or have them thrust upon them, the dangers of inadequacy, insufficiency, and ignorance of HECs will loom large on the horizon.

BENEFITS OF EXPANDING THE HEC'S ROLE

It should be recognized that there are a number of potential benefits if the scope of a HEC's functions are expanded. Concerning those functions that would be performed in any case, having the HEC take on the task lessens the potential for a duplication of effort. This is undoubtedly true of HEC functions whose performance requires expertise in ethics. By asking the HEC to deal with these concerns, it can be assured that they will at least be dealt with by individuals with sincere interest and expertise in ethical analysis. Also, by increasing the functions of the HEC it will commensurately increase the expertise

The Future Functions of HEC's 75

of the committee's members. "Ethical leadership is, of course, particularly perilous. It is called

for only in dangerous times, and it demands a peculiar sort of courage, the ability to hold to ideals and values tenaciously in face of threats to material well-being" (28). And, while the future of HECs is virtually guaranteed, how they shape their own future and how they expand their current functions are surely in need of careful and continuous scrutiny.

REFERENCES

1. Rosner, F.: "Hospital Medical Ethics Committees: A Review of Their Development", Journal of the American Medical Association, 1985;253: 2693-97.

2. Annotated Code of Maryland Part IX: Patient Care Advisory Committee--Sections 19-370 to 19-374. Effective July 1, 1987.

3. Veatch, R.M.: 'qlae Ethics of Institutional Ethics Committees", in Cranford, R.E., Doudera, A.E. (eds.), Institutional Ethics Committees and Health Care Decision Making, Health Administration Press, Ann Arbor, Michigan, 1984, pp. 35-50.

4. ~ n e , C.: "Questions and (Some Very Tentative) Answers about Hospital Ethics Committees". The Hastings Center Report, 1984;14: 9-12.

5. Fost, N., Cranford RE: "Hospital Ethics Committees", Journal of the American Medical Association, 1985;253: 2687-92.

6. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, Deciding to Forego Life-Sustaining Treatment, Appendix F. U.S. Government Printing Office, 1983;439-57.

7. "Committee on Ethics and Medical-Legal Affairs: Institutional Ethics Committee's [sic]: Roles, Responsibilities, and Benefits for Physicians", Minnesota Medicine, 1985;68: 607-12.

8. "AMA Judicial Council: Guidelines for Ethics Committees in Health Care Institutions", Journal of the American Medical Association, 1985; 253: 2698-99.

9. Murray, T.H.: "Where Are the Ethics in Ethics Committees?" The Hastings Center Report, 1988; 18: 12-13.

10. Randal J: "Are Ethics Committees Alive and Well?" The Hastings Center Report, 1983;13: 10-12.

11. American Hospital Association: Values in Conflict" Resolving Ethical Issues in Hospital Care, AHA, Chicago, IL, pp. 34-35.

12. Craig, R.P., Middleton, C.L, O'connell, Laurence J.: Ethics Committees: A Practical Approach, Catholic Health Association, St. Louis, Missouri, 1986.

13. Weinstein, B.D. (ed.): Ethics in the Hospital Setting: Proceedings of the West Virginia Conference on Hospital Ethics Committees, (Sept 14-15, 1984), University of West Virginia Press, Morgantown, West Virginia, 1985.

14. Kliegman, R.M., Mahowald, M.B, Youngner, S.J.: "In Our Best Interests: Experience and Workings of an Ethics Review Committee", Journal of Pediatrics 1986;108: 178-88.

15. Van Allen, E., Miles, S.: "Ethics Committees in Minnesota Hospitals", Minnesota Medicine, 1987;70:. 77-80.

16. Avard, D., Greiner, G., Langstaff, J.: "Hospital Ethics Committees: Sur,,ey Reveals Characteristics"~ Dimensions in Health Service, 1985;62: 24-26.

17. Brown, B.A., Miles, S.H., Aroskar, M.A.: "I'he Prevalence and Design of Ethics Committees in Nursing Homes", Journal of the American Geriatric Socie~, 1987;35: 1028-33.

18. Lo, B.: "Behind Closed Doors: Promises and Pitfalls of Ethics Committees", New

76 ICV. Iserson, F.B. Goffin, JJ. Markham

England Journal of Medicine, 1987;317: 46-50. 19. Robertson, J.A.: "Ethics Committees in Hospitals: Alternative Structures and

Responsibilities", Quali~, Review Bulletin, 1984;10: 6-10. 20. National Commission for the Protection of Human Subjects of Biomedical and

Behavioral Research. The Belmont Report Ethical Principles and Guidelines for the Protection of Human Subjects of Research. pp 2-4. DHEW Publication No. (OS) 78-0012, Washington, D.C., 1978.

21. Farley, M.A.: "Institutional Ethics Committees as Social Justice Advocates", Health Progress, 1984;65: 32-35, 56.

22. Gutteridge, F., Zbigniew, B., Curran, W. and Dunne, J.: "The Structure and Functioning of Ethical Review Committees", $ocial Science and Medicine, 1982;16: 1791-1800.

23. Treadway, J.T., Bossi, R.B.: "An Ethical Review Board: Its Structure, Function and Province", Mental Retardation, 1977; 15: 28-29.

24. Kushner, T., Gibson, J.M.: "Institutional Ethics Committees Speak for Themselves", in Cranford, R.E,, Doudera, A.E.: Institutional Ethics Committees and Health Care Decision Making, Health Administration Press, Ann Arbor, Michigan, 1984, pp. 96-105.

25. Mannisto, M.M.: "Orchestrating an Ethics Committee: Who Should Be On It, Where Does It Best Fit"? Trustee, 1985 (April): 17-20.

26. Summers, J.W.: "Closing Unprofitable Services: Ethical Issues and Management Responses, "Hospital Health Services Administration, 1985;30: 8-28.

27. Purtilo, R.B.: "Ethics Consultations in the Hospital", New England Journal of Medicine, 1984;311: 983-86.

28. Jonsen, A.R.: "Leadership in Meeting Ethical Challenges", Journal of Medical Education, 1987;62: 95-99.

29. Veatch, R.: "Hospital Ethics Committees: Is there a role"? The Hastings Center Report, 1977;7: 22-5.

30. Ross, J.W., et al.: Handbook for Hospital Ethics Committees, American Hospital Publishing Co, Chicago, Illinois, 1986.