Modern medical knowledge, diversity of lifestyles, and broad moral and religious values in modern societies have made medical involvement and healthcare decision-making processes more complicated.
The economic pressure being experienced by healthcare systems requiring well-thought-out allocation of meagre resources demands that decisions be made in a well-informed manner. Implications of any decision made in medicine have been raised through public political and medico-legal discussions about patient independence and autonomy to make self-determining decisions. Social, cultural and religious norms cannot be ignored in decision-making. To house all these factors, hospital ethics committees (HEC) are a crucial component of healthcare.
The committee is a multidisciplinary team that helps patients, families and clinicians address value disagreement or uncertainty arising during healthcare provision. In the committee are clinicians, non-clinicians (for example, counsellors) and community representatives. They should have basic training in medical ethics, so that they can offer guidance on the best way forward when there is no consensus among those concerned in a patient’s care. The committee considers the various factors that play a role in the provision of care as well as all the stakeholders.
The HEC is not a decision-making body. Decision-making authority rests with the patient, and their family and caregivers. The primary responsibility of HECs is to facilitate proper understanding of the situation in question, piece the pieces together, and thus come up with the best way forward in the given situation. Situations where there are disagreements on the way forward can be referred to as ethical dilemmas.
An ethical dilemma occurs when one is choosing between alternatives, none of which is absolutely right or wrong. Mostly, conflicts arise based on differences in values, problems in communication, or due to the severe stress of critical illness. An ethics consultation can be helpful in these situations.
Ethical dilemmas may be experienced by patients, family and healthcare providers in situations such as; admission to critical care areas like the high dependency unit, intensive care unit and end-of-life care, and beginning-of-life decisions. They also arise when there are pickles on maintenance of confidentiality and privacy, and informed consent in interventions/examination.
The family’s and/or caregiver’s role in medical decision-making can also present an ethical dilemma, as there is need to agree on who makes decision when a patient is not in a capacity to do so, or where there is refusal of recommended treatment, and in conflicts about organ donation, among other cases.
Hospital ethics committees help resolve the conflicting interests by mediating the discussion of differences of opinion (on treatment) among family members; supporting a patient or family member in making decisions about what type of care the patient should receive or the goals of that care; and facilitating ethical decision-making by physicians and the healthcare team.
The committee can also educate patients, families, and staff on hospital policies affecting patient care, such as resuscitation or life-saving treatments; work with patients, families, and staff to help include personal values, religious, and cultural traditions in decision-making, and address questions about a patient or the next of kin’s ability to make decisions about treatment.
The HEC can be consulted by the patient, family member(s), caregivers, a community member who is a stakeholder in the patient’s care and well-being, and any member of the treating team including the doctors, nurses and allied healthcare providers. The hospital administration can also consult the HEC.
The committee assists the hospital in developing policies and practices that conform to the highest ethical standards, and offers ethical education to staff and the community. Where such a committee is not available, an individual with some knowledge on medical ethics can be consulted for guidance.
The biggest challenge in establishing these crucial components of quality healthcare is paucity of education in medical ethics coupled with lack of proper national, institutional infrastructure, policies and guidelines on establishing the same.
Dr Weru is a palliative physician and the chairperson of the hospital ethics committee at the Aga Khan University Hospital, Nairobi