H E C FORUM 1994; 6(3):157-162.

© 1994 Kluwer Academic Publishers. Printed in the Netherlands.

REVIEW ARTICI.F~

H E A L T H CARE ETHICS COMMITTEES: THE NEXT GENERATION,

J.W. ROSS, M.A., J.W. GLASER, S.T.D., D. RASINSKI-GREGORY, J.D., M.D.,

J.M. GIBSON, Ph.D., C. BAYLEY, M.A., CHICAGO, IL, AMERICAN HOSPITAL ASSOCIATION,

1993 (xiii+ 188 pp.), individuals $45.00; members of AHA $34.00

GILES R. SCOFIELD, J.D.

A good book is like a good movie. You enjoyed it so much that you hope they make another. Yet you also wonder whether the sequel can and will live up to the well deserved reputation of its predecessor. Many health care professionals, hospital administrators, and ethics committee members derived great satisfaction from A Handbook for Hospital Ethics Committees (1), whose principal author was Judith Wilson Ross. The Handbook remains a useful guide, based on solid scholarship and practical wisdom.

Thus, when I heard that Ms. Ross and her colleagues were putting together another book on healthcare ethics committees (HEC), I hoped it would be as good as the first, but wondered how it could be. After all, one of the problems plaguing bioethics is that it has become middle-aged. Many of the articles written today read like articles written ten years ago, and the :most common complaint I hear from those who attend conferences on healthcare ethics is that there seems to be little that is new or useful discussed at them.

From my own work with HECs, I know that many members wonder what their mission should be, now that they have dealt with the Patient Self-Determination Act and the Joint Commission's requirements for accredited healthcare organizations. In short, the field needs a breath of fresh air. Would Ross and company provide it again?

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When I learned that the book had been published, I called the AHA to obtain a copy. It arrived just as I left for the Rocky Mountains, where I was to spend two days with an HEC. So, I took advantage of the time flying from White Plains to Denver and read it cover to cover. When I arrived at the hospital, I immediately recommended the book to the chair of the HEC, who told me that she had just finished reading it herself and that she was going to have her hospital library purchase a copy for each member of her committee. Now I recommend it to every HEC I work with, often finding that the committee has already received its own copy, or that a committee member was about to mention the new book to me. The word is spreading: The sequel is every bit as good as the original.

Why is this book so good, so useful, so essential? In large measure because it reflects the collective efforts of individuals who do not just write and think about ethics and ethics committees; they "do" ethics, serve as members of HECs, and have actually met patients, family members, nurses, and physicians who have struggled with difficult dilemmas. Thus, while The Next Generation reflects sound scholarship, it is also grounded in clinical reality. It recognizes that members of HECs are human beings, and that patients and families express their emotions; they often cry. Finally, this book recognizes that, for all the fascination and excitement that fill the world of ethical deliberation, much of what needs to be done is mundane, tedious, detailed work.

So if you want to know how abstract, rational agents behave when facing a dilemma, how Parfitian notions of personal identity appear to make nonsense of surrogate decision-making, or what medical futility is all about, this book will not help you. If, on the other hand, you work with patients who are struggling to reconcile what they think with how they feel about dying, with an ethics committee consisting of people who did not get invited to The Symposium, and with a hospital administration that wants to do something (but not too much) about ethics, then purchase this book. If you do, you will get a user-friendly synopsis of what ethics and HECs have been doing for the past thirty years. You'll also find some tangible advice on such questions as how to run a meeting (Chapter 4), how an HEC may conduct an evaluation and self-assessment (Chapter 8), and how to think about a former chairperson's role (pp. 152-54). So, if you serve on or work with a HEC that is struggling with its identity and even experiencing a loss of morale (pp. x-xi), this book is for you.

Health Care Ethics Committees addresses the gritty, mundane, sometimes tedious, yet always essential details that go with being part of

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a good HEC. For example, each of us has attended a successful and a useless HEC meeting. Yet have we ever thought about what distinguishes the former from the latter; or done so in a constructive way that would enable us to improve the quality of how an HEC functions? This book tries to do just that. The Next Generation outlines what is and should be expected of an ethics committee chairperson, whose primary role is to ensure that: [1] the meeting runs smoothly, [2] the agenda is covered; [3] broad participation is elicited from the members; [4] discussions are not dominated by a single individual or group; [5] there is some recognized forward motion, however slight; and [6] the meeting has closure (p. 33).

If you serve on a HEC that seems to be going nowhere, or that is always dominated by the same people, these words of wisdom may be more important to you than someone's view of the impending collapse of the whole-brain definition of death. If you're thinking of whom to select or whether you wish to be picked as the next chair of a HEC, advice such as this will help you more than will a detailed knowledge of the Belmont Report. There's more where this comes from. Thinking about having a lawyer on your committee? Look at pp. 133-35. The problem with the lawyer member is that most committees feel the need to have one, but all dread what that experience will be like. This is because committees fear that they will be stuck with an attorney who approaches every questions in terms of the institution's liability, or who will bring every meeting to a halt by saying, "That's all well and good, but we can't do it." What HECs need are attorneys who are able to participate appropriately, i.e., by noting what the law requires while allowing for what the law permits. In most cases, the law permits a much wider range of choices than some attorneys suggest, but the HEC wants the benefit of sound legal assistance and will usually select an attorney who can provide something more than a bottom-line, conservative opinion.

Beyond this, Health Care Ethics Committees is full of helpful advice on how to "consult" (pp. 91-112), and what sorts of topics HEC members should know something about (pp. 45-67). In short, it addresses the sorts of issues and questions that most committees deal with.

Are there any weaknesses with this book? Well, a thorough reviewer surely must find something to quibble about, for two reasons: [1] to prove that he/she actually read the book, and [2] to prove that he/she is every bit as smart as (if not smarter than) the authors. All right! I do not agree with how the authors define the tasks of ethics consultants and clinical ethicists (pp. 145-49). In their view, the clinical ethicist provides clinical

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ethics consultation, whereas the ethics consultant educates from afar but does not consult clinically. The field does seem fairly muddied about who is supposed to be doing what, where, when, and how. But I think the authors may be cutting the cheese a bit fine here. Most people will have difficulty believing that clinical ethicists are not ethics consultants, even though they consult on ethics in the clinical setting; they will have an even tougher time seeing how anyone who is not clinically consulted on ethical issues can be called an "ethics consultant." However, where ethics consultation is concerned, I have been known to be mistaken (2, p. 444), so take my concern with a grain of salt.

More to the point, this book notes that healthcare ethics has become more critical outside the acute care setting. The authors mention nursing homes and home care as examples, but neglect to mention the rehabilitation hospital, where ethical questions can and do arise with greater uncertainty and ambiguity than one finds elsewhere. Nor do they address the looming issue of how attitudes and beliefs about persons with disabilities influence decisions about what to do to or for such persons (3). But in a book so full of useful information, such gaps as these are not so serious.

So, what should you do? Buy the book, read it, and then put it aside. That's right, put it away. Why? Because the one thing that you should not do with this book is treat it as some canonical text. My sense of The Next Generation is not that its authors want or. expect HEC members to memorize it, but that they hope that anyone who reads it will take its message to heart.

I say this because the authors sprinkle the book with topics that cannot be reduced to rules and guidelines. For example, in their discussion of HECs as communities of "respect and trust," they note how important it is to integrate unconditional positive regard and empathic understanding into the committee's work. Even though we can know when such virtues are absent, does anyone know how to guarantee that they are present? You can read the Hastings Center's Guidelines repeatedly and still not know how to demonstrate unconditional positive regard for someone, or sense what it means to have empathic understanding. What the authors seem to be saying is this. HEC members need to be concerned with what they know and do not know. More than that, they need to be sensitive to what they do with the knowledge they possess, and especially that there are limits to what they know. This means that HEC members -- as well as anyone who "does" ethics -- need to be attentive to how they approach

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ethics, ethical dilemmas, and the individuals who find themselves at an impasse that is morally, emotionally, personally, and professionally troubling.

The best way to convey what this book is about is to close this review with a quote that captures its essence:

Health care is filled with uncertainty. It should be no surprise that its ethical issues also are characterized by uncertainty. In support of the art of health care, ethics committees can offer the art of ethical reflection as presented in long and sometimes frustrating conversations in which commitment to clear and honest communication, appreciation of the virtues of common sense, and abiding respect for the values of others will stand them in good stead. The richness of the conversation about ethical issues is what draws most people to ethics committees. By realizing that the diversity of the conversation is an inherent part of ethical analysis, committees may find greater confidence in their work and cease looking for an expertise that would not help them if they had it (p.26).

If these words have meaning for you, then you will find Health Care Ethics Committees: The Next Generation to be a source of wisdom, practical sense, and warmth. Isn't that what ethics and ethics committees are all about?

REFERENCES

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2.

Ross JW, et al. Handbook for Hospital Ethics Committees. Chicago, IL: American Hospital Publishing, Inc.; 1986. Self DJ. Is ethics consultation dangerous? Cambridge Quarterly of Healthcare Ethics. 1993; 2(4):442-45.

162 J.W. Ross, J.W. Glaser, D. Rasinski-Gregory, J.M. Gibson, C. Bayley

. Gething L. Judgments by health professionals of personal characteristics of people with a visible physical disability. Social Science and Medicine. 1992; 34:809-15.