Mary Lynn Dell, M.D., M.T.S., Th.M.
Many of us in medical practice sometimes feel beleaguered by meetings, institutional requirements, and organizational demands that take time and energy away from patient care and other professional and personal interests. A chance to serve our patients, healthcare organization, engage interesting material, learn from a multidisciplinary team, and represent our specialty at its best – all at the same time – can be very fulfilling for child and adolescent psychiatrists. Service on an institutional ethics committee (IEC) is one such unique opportunity.
While ethics committees existed in some academic medical centers and larger hospitals as early as the 1960’s, they have become common since 1992. In that year, the Joint Commission on Accreditation of Healthcare Organizations mandated that hospitals institute a method for considering ethical issues in medical settings. For many reasons, IECs have become the predominate venue for addressing matters of ethical significance in healthcare.
In general, the work of IECs falls into four categories. The best known task is consultation on individual cases. Consultations may be initiated by patients, families, or any member of the hospital staff with a concern about the care or treatment of a particular patient. A second area regards policies in the institution, including researching, writing, and incorporating relevant ethical considerations into new and existing position statements and procedures. Representative policy areas include informed consent, resuscitation, organ donation, fertility, brain death, and medical errors. The educational mission of IECs flows naturally from its policy responsibilities. IECs work with staff to provide information and training in support of ethically sound care of patients and families. Finally, IECs are charged to provide ethical reflection and input into the larger healthcare organization’s mission, goals, and priorities.
Child and adolescent psychiatry is by nature a collegial specialty that respects and works well with other disciplines. Thus, child and adolescent psychiatrists bring a natural and comfortable spirit of collaboration and appreciation of others who serve on IECs. Ethics committees are by design multidisciplinary. Medicine, nursing, legal counsel, custodial services, chaplaincy, administration, and respiratory, physical, and occupational therapies are represented. Most IECs include a current or former patient, parents of current or former patients, and representatives of the community at large. Unlike typical multidisciplinary teams, however, all members have equal standing on the committee, though the weight of various individual’s input will vary with the nature and content of the case or issue at hand. Some physicians, especially, are initially uncomfortable with the more egalitarian nature of IECs, and child and adolescent psychiatrists can model the healthy balance of medical authority and responsibility with interest in and respect for the wealth of knowledge, experience, and expertise non-physician members bring to the discussion table.
Child and adolescent psychiatrists will also find themselves at ease with many elements that factor into situations referred to IECs. Essentially, ethics consults are requested in the face of ambiguity and lack of consensus by significant individuals in a patient’s life (medical caregivers, family, even the patient herself). While ambiguity and disagreement may be purely of an ethical or philosophical nature, other issues such as poor communication and misunderstandings between patient and care providers, cultural and religious concerns, and the emotional effects of extreme stress can affect how well families and care providers are able to work together and agree on decisions in the best interests of patients. By the very nature of our training and experience, child and adolescent psychiatrists can discern communication issues masquerading as or contributing to ethical dilemmas and recommend strategies for working through misunderstandings. We are well versed in child development, parenting, and family dynamics in acute, chronic, and terminal illnesses, dying, and death; as well as elements of mood, anxiety, and cognitive disorders that might be affecting patients and families, if only temporarily. We are better trained than many committee members in cultural elements that may surface in ethics cases, especially cultural differences in parenting, family structure and authority, living arrangements, health care beliefs and practices, and religion and spirituality. Our psychiatric expertise in decision making capacity, emotional and cognitive development, and adolescent and adult maturation are particularly relevant to issues of informed consent and guardianship that arise in IEC consultations. Certainly our clinical skills of listening and reframing issues, problems, and potential solutions can be invaluable not only in consultations, but in IEC meeting discussions as well.
What is required of IEC members?
Committees usually meet once a month, typically from 1-2 hours. Some IECs ask members to take turns responding to ethics consultations, often in small teams of 2-3 people, reviewing the chart, talking to the involved parties, and making preliminary recommendations to the medical team or parties involved in the consultation. In major cases, the front-line consultant or team may request input from the entire IEC, if available, in a timely manner, but in more clear-cut or less controversial situations may report their activities to the larger IEC at the next regular meeting. Members may be asked to volunteer a few or several hours per year for ethics education efforts throughout the hospital or organization. Occasionally, members may be asked to be in smaller groups that review policies or to study a select issue on behalf of the larger IEC.
What are the benefits of IEC service?
I have served on ethics committees in three children’s medical centers and in two national professional organizations. All of these committees were filled to capacity and even had waiting lists of those wanting to serve. The issues are intriguing, and IECs provide a unique combination of intellectual stimulation and multidisciplinary collegiality in a moral community. It is a good way to keep up with medical developments outside of our field, teach others valuable points about child and family development and mental health in a case-based fashion, and demonstrate the many contributions that child and adolescent psychiatry can make to patient care. Additional perks can include continuing medical education hours and credit toward mandatory committee membership that is more enjoyable that other hospital standing committee assignments you might draw!
Where should you start?
Most IEC meetings are open for any interested parties to attend, so go a few times as an observer. Speak with sitting members about the issues they are addressing, the committee’s mission, goals, and current projects, and their perspectives about IEC service. Ask if you can observe or sit in on a consult. Learn about the committee’s composition, history, and influences on the larger institution. Supplement this with basic independent reading in ethics, especially in areas related to your own clinical work. This will help you decide if IEC membership is for you – now or in the future.
Child and adolescent psychiatrists have much to contribute to the mission of IECs. I recommend that you explore the possibility of offering your insights and expertise as an IEC member. You will learn a great deal, be enriched by the perspectives of individuals from other disciplines and walks of life, and find its work to be some of the most challenging and rewarding of your professional life.
Dr. Dell is a member of the AACAP Ethics Committee and serves on the psychiatry faculty at Case Western Reserve University and Rainbow Babies and Children’s Hospital in Cleveland, Ohio. Her clinical and academic interests include pediatric psychosomatic medicine, bioethics, medical education, and religion and spirituality in medicine and psychiatry. Dr. Dell can be reached at Mary.Dell@UHhospitals.org.