Niemim, Orr and Culver 19

Ethics Committees in S d Hospitals*

Denbe A. N h i r a , Robert D. Orr and Charles M. Culver

AB!3TRKT: Ethics committees at small hospitals confront most of the same ethical dilemmas present at large hospitals, but must usually deal with them with fewer resources and less access to recognized eprtise. Nonetheless small hospital committees can function effectively in the areas of education, policy deliberation, and case consultation. The deuelopment of ethics committees at two small Vermont hospitals is described, noting some of the pmb- lems associated with smallness and making suggestions about how to surmount them.

Institutional Ethics Committees (IECs) are’ a natural response to recent dilemmas in health care which have arisen from the increased use of technology and from an ever-more apparent limitation of resources. These committees, interdisciplinary in make-up, confront and try to resolve a variety of ethical problems that occur in modern hospitals. Individual IECs vary somewhat in their composition and process, but most eventu- ally attempt to serve three important functions: (1) education of hospital personnel; (2) review of those hospital policies which contain an ethical component; and (3) consultation with clinicians about individual cases (President’s Commission, 1983).

As the usefulness of IECs has become more widely appreciated (Cran- ford & Doudera, 1984) the number of hospitals with such committees has correspondingly increased. Precise numbers are unavailable, but it is clear that the majority of IECs are currently located in large hospitals, often those with university affiliations; only a small minority are located in hospitals with fewer than 100 beds (Anonymous, 1985). The literature on IECs similarly reflects the experience and needs of larger institutions, and mostly fails to address the somewhat different problems faced by smaller hospitals in developing Committees. In the text that follows, we examine the role and problems of IECs at small hospitals, noting in particular some of the experiences in two small hospitals in Vermont.

The Problems of IECs in Smal l Hospitals The moral dilemmas of modern medicine are not confined to large

institutions. Issues surrounding sophisticated technology (e.g., organ trans- plantation; in vitro fertilization) are not available at community hospitals, but issues involving the quality of life, treatment of incompetent patients, withdrawal of life support, including feeding tubes, occur in all hospital settings.

* Requests for M e r information should be sent Ux Denlse A. Niemlia, M.D., P.O. Box 501, Derby Line, Vermont 05830. THE JOURNAL OF RURAL HEALTH

JANUARY, 1989 VOLUME 5. NUMBER 1

20 me Journal of Rural Health

What an IEC brings to these common ethical dilemmas is a structured methodology for critically examining the issues, and elucidating and mor- ally evaluating the various options open to health care providers. It pro- vides a forum where conflicting values underlying policies, procedures and treatment decisions can be discussed, disputed, negotiated and, hope- fully, resolved in a manner respecting the integrity, rights and responsi- bilities of all concerned parties. It functions as an arena for arriving at a consensus that can transcend local prejudice.

Practitioners at small hospitals, no less than their counterparts at larger ones, must sometimes face the unpleasant situation of being caught in the middle of family disputes concerning treatment alternatives for both competent and incompetent patients. They must come to terms with decisions to limit treatment, to write or not to write do-not-resuscitate orders, to provide or withhold full disclosure about prognosis. They must contend with ever broadening treatment options, ever increasing de- mands for patient autonomy, and ever present risks of liability. Under these circumstances, they face decisions that are not strictly medical and for which their clinical training is often inadequate; decisions that arise in the context of the physician-patient relationship but are enacted in the social environment of the hospital; decisions that are subject to the public scrutiny of the institution as well as the private reflection of personal morality.

How rural physicians approach and arrive at these decisions is not independent of their environment. Their choices of certain courses of action as morally justifiable have been shown to be influenced by such factors as the physical distance to specialists and referral centers, and the interrelationship between private and professional roles in a small com- munity (Purtilo & Sorrell, 1986; Purtilo, 1987). The difficulty of maintain- ing confidentiality in a relatively closed social setting, and problems of limited resources also affect their options.

The significance of these factors cannot be overlooked when intro- ducing the concept of an IEC into a small institution. At each stage of the Committee’s development, from the identification of leaders, through the formulation of a common base of knowledge, and the expansion of the group’s expertise into policy-making and consultation, there will be pit- falls related to institutional size and location. While individual institutions must develop their own solutions, there are common strategies that can be utilized to address these problems, as we believe our experiences show.

Experience with IFXs at ’Ibvo Smafl Hospitah h Vermont

Vermont is a state whose population is largely rural and whose inpatient health care needs are supplied primarily by small hospitals. Of 16 acute care institutions, 12 have fewer than or just over 100 beds. Two

Niemira. Orr and Culvw 21

of these, North Country Hospital in Newport and Brattleboro Memorial Hospital in Brattleboro, have had functioning ethics committees for more than three years. Both IECs are now committed to serving all three functions of education, policy review and consultation. The circumstances leading to the formation of the committees and the method of their development were different in the two institutions; they reflect two dis- tinct approaches to the establishment of IECs in small hospitals. Yet the structures that have evolved are more striking in their similarities than in their differences.

Brattleboro. Brattleboro Memorial Hospital (BMH) is a 60-bed facil- ity located in a town of 12,000 near the southern border of Vermont. It has a service population of 35,000 and a traveling distance of one hour to its tertiary care referral center at Hanover, New Hampshire. Its active medical staff consists of 33 physicians, 16 of them primary care doctors and 17 specialists.

Newport North Country Hospital (NCH) is an 80-bed facility located in Newport, a town of 6,000 on the northeastern border of the state. It has a service population of 25,000 and traveling distance of close to two hours to either of its two tertiary referral centers in Burlington, Vermont, or Hanover, New Hampshire. Its active medical staff consists of 20 physi- cians, equally divided between primary care and specialty practice with five additional university specialists providing part-time consultation.

Background and Resources. By nature of its location on the Cana- dian border and its distance from referral centers, the Newport hospital is more geographically isolated than the one in Brattleboro. In addition, its service population is considered to have the lowest income in the state and is spread over the greatest distance, making it more typically rural.

Physician mix is similar between the two institutions as is age (both staffs are relatively young) and level of training. Each hospital has a medical library and a part-time librarian. Each also has in-house continu- ing medical education sessions for its medical staffs on a regular basis; weekly at Brattleboro, monthly at Newport. Each institution has access to continuing education networks such as the network for Continuing Medi- cal Education through lending collections, and in-house video hardware available for staff use. Neither hospital has an ethicist available for more than very sporadic consultation. Both institutions have access to the re- sources available at the Dartmouth-Hitchcock Medical Center which in- clude informal consultation, conferences, speakers and information. Both institutions have IEC chairpersons who have been actively involved in medical ethics outside of their institution and have been pursuing possi- bilities for regional networking both through Dartmouth-Hitchcock and the Vermont State Medical Society (VSMS).

22 Tbe Journal of Rural Health

Initiation of the IEC Each hospital began their IECs in 1984. Brattleboro Memorial Hospi-

tal began deliberately. A three member subcommittee of the hospital’s Patient Care Committee presented a formal proposal to the medical staff, outlining a three year phased-in approach to an IEC, with clearly defined tasks suggested for each phase. Year one was to focus on education, year two on review of hospital policy, and year three on establishing a formal committee with consultative functions. Guidelines were provided for ex- panding the committee as each new function was added, and it was stipulated that the committee would be reviewed and reconfiied at the end of each phase by the entire medical staff.

The IEC at North Country Hospital began quite differently. A discus- sion of proposed Baby Doe regulations (Federal Register, 1984) at the monthly medical staff meeting generated a motion from the incoming Chief of Staff to establish an IEC. The motion carried and an IEC was created on the spot with an exactly defined membership and the respon- sibility to report to the medical staff, but with no specific mandate for its scope or type of activity.

Thus, from the outset, different styles were evident at the two institu- tions. The initial approach in Brattleboro was highly structured and cen- tered on planning and drafting a proposal that would be acceptable to the hospital’s physicians. The approach in Newport was very loosely organized, essentially reflecting a consensus on a particular day that this was an idea whose time had come and whose concrete expression would be shaped by the forces of time and institutional need.

Each approach has advantages and disadvantages. The structured approach is more orderly and probably more efficient during the early growth of a committee. There is an agenda to follow and both committee members and medical staff know roughly what to expect as time goes on. However, as the committee develops and unanticipated hospital needs arise, there may be little flexibility to alter the structure or advance the timetable even when that might be desirable.

The unstructured approach adopted in Newport is potentially ineffi- cient during the committee’s early stages, especially if the committee tries to do too many things too quickly. There may be uncertainty on the part of both committee members and hospital staff about the proper scope of the committee’s role. However if the committee can attain some cohesion and some institutional credibility as it develops, it can adapt reasonably quickly to hospital needs.

Despite their differences in approach, both IECs were clearly seen as instruments of their medical staffs and responsible to them. The Brattle- boro medical staff retained control by requiring its approval before the IEC could embark on each additional task; the Newport medical staff by limiting the terms and precisely determining the membership of the com- mittee. By assuming responsibility for its IEC, each medical staff was able to endorse it actively and overcome any significant resistance by individ-

Niemim, Orr and C u l w 23

ual staff members. Whde ths relationship to the medical staff runs the risk of co-opting the independence of the IEC, we do not believe this has happened at either institution.

Developing the IECs The IEC in Brattleboro developed just as outlined in its initial pro-

posal. During its first year, the committee sponsored five educational sessions for the medical and nursing staffs of the hospital. Topics ranged from moral theory and decisions to forego life-sustaining treatment, to the what, why and how of IECs; these were presented both by committee members and by resource people from outside the institution. In addi- tion, a resource bibliography was compiled for all committee members and some members deepened their education by attending regional and national conferences on medical ethical issues.

During the second year the committee focused on policy review, updating the do-not-resuscitate, limited therapy, and informed consent policies of the hospital. In addition, new hospital policies were written on the care of handicapped newborns and the determination of death. This activity required further committee self-education, to examine the litera- ture and to understand the moral principles underlying these areas of policy concern.

The IEC in Newport developed in a less structured manner. Part of the first year was spent defining the group’s purpose and scope of activity. Having agreed to pursue the three task model of an IEC, the committee in Newport began the first two tasks, education and policy review, simultaneously, but deferred the consultative task until the com- mittee felt more knowledgeable. Like its counterpart in Brattleboro, the committee reviewed the hospital’s do-not-resuscitate and informed con- sent policies; its work at formulation of new policies, however, came in response to concerns of the local Jehovah’s Witness community. Similarly, its educational efforts were directed to specific issues raised by members of the hospital community, frequently the ICU nurses. Formal moral the- ory was presented only in the analysis of particular clinical dilemmas, never the other way around. In addition, efforts were made to involve the local community in the committee’s educational mission by sponsor- ing a public forum on life support and advance directives.

The committee in Newport was also concerned, from the beginning, with establishing links outside the institution. It conducted, in 1985, a survey of small hospital IECs in northern New England (i.e., Vermont, New Hampshire and Maine), and shortly followed this by inviting repre- sentatives of these small hospitals to a conference to discuss the possibil- ity of regional networking of IECs.

The network was envisioned as a mechanism to facilitate the devel- opment of IECs at institutions where there were none, and to promote continuing education among hospitals that did have an IEC in place. The

24 The Journal of Rural Health

conference was poorly attended (though probably valuable for the few who came); we surmise that the problems of time, lack of local leader- ship, and what we knew to be quite disparate levels of interest in hospi- tals across the region meant that local networks were not yet an idea whose time had come. The concept has not been abandoned, however, as we explain below.

Present Status of the IECs By the end of their third year, both hospitals had IECs offering

consultative services. The Brattleboro committee had 11 regular members: three physicians, three nurses, one administrator, one trustee, one social worker, one member of the clergy, one community member and four consultants who are called on an ad hoc basis: a lawyer, an ethicist, a psychiatrist, and a representative of the handicapped. The committee in Newport had nine members: four physicians, one nurse, one administra- tor, one member of the clergy, one lawyer and one lay person. Both committees meet regularly. The Brattleboro committee has expanded the scope of its activities to include all four area nursing homes and, at appropriate times, the administrators of those homes sit as consultant members on the IEC. Both committees seem very much to have the support of their medical staffs who use them for initiation and review of relevant policies as well as for case consultation. In their first year of consultation, Brattleboro did seven consults and Newport did five.

mture Role To what degree the consultative service will continue to be utilized

remains to be seen. In all probability this will be a slowly growing process and not without difficulties. Neither IEC currently allows for a consultation to be brought without the approval of the attending physi- cian, but it is quite likely that nurses, family members and others may attempt to gain independent access to the committee as its presence becomes known. Managing such a situation will require tact and credibil- ity as well as expertise.

The formation of a regional network has continued to be a priority of the Chairpersons at both hospitals. Their initial efforts in 1985-86 faltered because of the lack of both financial resources and an organiza- tional structure which could link up with potential educational resources at Dartmouth-Hitchcock Medical Center. However, activities by two Ver- mont state organizations since 1986 have created circumstances which may make a network possible in the near future. In 1986 the Vermont State Medical Society’s Committee on Medical Ethics made an active com- mitment to encourage the formation of IECs at hospitals throughout the state by sponsoring a resolution at the Society’s annual meeting endorsing their establishment. The Society also mounted an educational campaign

Niemira, Orr and Culver 25

by enclosing a series of ethics inserts in the Society’s monthly newsletter. The series consisted of twelve short summaries of ethical principles and problems, accompanied by brief bibliographies and presented in a format that could be collected and compiled in a looseleaf binder. The Ad Hoc Committee’s current educational effort is the development of a series of suggested guidelines regarding the establishment of hospital policy in several areas, including do-not-resuscitate and limited therapy orders. These are to be sent to hospital administrators and medical staff officers through- out the state, who will be encouraged to participate in an on-going dialogue with the Ad Hoc Committee.

Coinciding temporally with the Medical Society’s efforts was a state- wide grassroots ethics education project sponsored by the Vermont Health Policy Corporation, a quasi-public health planning agency (Friedman, 1988). Funded by a grant from the Robert Wood Johnson Foundation, the Taking Steps program, as it was called, identified and trained a cohort of some 30 discussion leaders, many of them members of the health care community. These trained discussion leaders then held public forums on ethical issues in health care decision making in their local communities, using a slide-tape presentation as a focal point. This 13 minute slide tape contains a segment on IECs, highlighting the experience at the Newport hospital. While the original Talung Steps grant has ended, the program continues through a number of local satellite groups as well as through the Vermont Ethics Network (VEN), an organization composed of repre- sentatives of community and statewide organizations concerned with bi- oethical issues. While the primary focus of VEN is on community bioeth- ics, it also has a specific commitment to provide education and technical assistance to groups developing organized ethics activities within health care institutions.

These two agencies, the Vermont State Medical Society and the Ver- mont Health Policy Corporation, have created a climate of ethical aware- ness in Vermont. They have identified and trained interested health care providers. They have provided central organizational support to ongoing efforts.

In 1988 the Vermont State Medical Society’s Committee on Medical Ethics sponsored a one day conference on hospital ethics committees. This conference was well attended by committee members and potential committee members from throughout the state who expressed an interest in developing a regional network to share experiences and resources. With the continued commitment of this organization and the educational support of Dartmouth-Hitchcock and the Vermont Ethics Network, a state- wide network of hospital ethics committees is likely to become a reality in the near future.

Analyihg the IEC Experience In examining the experience of establishing a functioning and cred-

ible IEC at these two hospitals, we believe three stages of internal com-

26 The Journal of Rum1 Health

mittee development and maturation can be identified: (1) the emergence of “local experts”; (2) the development of a committee-wide common base of knowledge; and (3) the expansion of the scope of activity into hospital-wide education, policy development and consultation.

The Emergence of “Local Experts” Small hospitals in general, and rural small hospitals in particular, have

more limited resources than their larger, more urban counterparts. Their medical staffs are smaller. This means that individual staff members fre- quently serve on more than one hospital committee. They have limited time for additional commitments not in their area of clinical expertise. The small size also influences the relationships among staff members. They are usually less formal and less compartmentalized than in larger settings. When staff size is less than twenty, it is hard to avoid knowing, frequently encountering, and personally relating, positively or negatively, to most of one’s colleagues. Referral opportunities within the institution are usually limited. In such a setting, staff conflict can acquire the dynam- ics of a family feud rather than a disagreement among colleagues, be- cause the buffer afforded by larger numbers and greater space is lacking.

Introducing a concept such as an IEC - considered by some as controversial, not essential to good patient care, and not mandated by any federal or accreditation agencies - into such a small interpersonal space may be difficult. The problem may be compounded when the hospital and the community lack the resources to obtain an ethicist with recognized training to aid the committee. A former equal among equals must now become the “local expert”, usually without formal training.

If the medical staff from the outset sees the IEC as a probable benefit, the emergence of a local expert or experts may be a more natural and easily accepted phenomenon. This person may be the one who initiated the formation of the IEC (as in Brattleboro), or the one who is nominated to and assumes the role of Chairperson (as in Newport). In either case, this person must be committed to acquiring the necessary knowledge and expertise by whatever means are available and practical: independent study; seminars and workshops by such organizations as the Hastings Center, the Kennedy Institute, or the American Society of Law and Medicine; and/or training sessions by visiting consultants. Acquiring expertise in this manner is difficult and problematic, but is the only means currently available for independent practitioners at small hospitals. Whether the local expert is a physician, a nurse, or other professional is probably less important than his or her ability to motivate and stimulate the development of other committee members, and his or her political ability to promote the committee’s respect by the rest of the hospital community.

As regulatory agencies such as Medicare/Medicaid and the Joint Commission on Accreditation of Hospitals (The Joint Commission, 1987)

Niemim, Orr and C u l w 27

require hospital policies on ethically related issues such as organ dona- tion and do-not-resuscitate orders, these issues will be raised and dis- cussed in all institutions. In the course of these discussions, individuals with a special interest in ethics may identlfy themselves. With the support of their colleagues and the institution, these persons could develop into “local experts”. In addition, the Joint Commission on Accreditation of Hospitals policy mandates a mechanism for conflict resolution over do- not-resuscitate orders. Consideration of establishing an IEC would seem a natural part of this discussion, since many medical staffs would consider an ethics committee of peers to be a more desirable mechanism than an administrative review panel.

Development of a Common Base of Knowledge One or more local experts provides the nucleus for an IEC, but for

an IEC to function adequately it needs multidisciplinary input, a certain level of expertise, and a common body of shared knowledge. As others have noted: “In the past few years, a body of knowledge has developed regarding the nature of ethical decision making in the clinical setting. Committee members need to be exposed to definitions, ethical principles and methodologies for approaching an ethical dilemma” (Bayley & Cran- ford, 1986, p. 194). The IECs shared knowledge should include such matters as knowing the necessary components of a valid consent or refusal, understanding when a patient is fully competent to consent or refuse, knowing when it is morally justified to deceive a patient or to breach confidentiality, and knowing when it is morally justified to take an action which allows a patient to die. Knowledge in these areas should include not only relevant concepts and decision-making procedures, but also, if consultation is to be carried out, some facility in those interper- sonal skills necessary to inject ethical advice into someone else’s ongoing clinical case.

While the local expert may become the leader in developing and updating this body of shared knowledge, it is unreasonable to expect a professional with full-time responsibilities elsewhere to shoulder this bur- den alone. Therefore all committee members must share a commitment to continue their self-education, both separately and collectively.

This becomes significant in deciding about the composition of the IEC. While a variety of rationales have been suggested for selecting IEC members (Cranford & Jackson, 1984; Ferguson, 19841, a small hospital must take a pragmatic approach: it cannot afford much dead wood. It must have members who are interested, have something to contribute, and are willing to participate in a common effort that reaches beyond a sophisticated version of local custom. Those selected must be flexible and able to examine, but on rare occasion abandon, their intuitive ethics. There should be a commitment to exploring and sometimes even encour- aging aferences of opinion, so that premature closure on issues can be

28 Tbe Journal of Rural Health

avoided. Selecting such a group is often a trial and error process. There- fore, any IEC should have a mechanism to allow for the withdrawal or termination of the rare members who negatively impede the group’s function. Such a situation can be terribly complex in a small institution and community and may be made easier by planning for the possibility. Limited terms of service, with a renewal option, is one such mechanism; however any limitation of service should reflect the length of time needed to develop expertise so that turnover time does not coincide with training time.

Small hospitals may choose to start with small committees and ex- pand them, as both Brattleboro and Newport have done. New constitu- encies added to the committee can then represent experienced rather than fantasied needs. New members also provide fresh input into a committee; they should be encouraged to be vocal and questioning as they learn, to give older members the opportunity to review and reflect on their common body of knowledge.

All IECs should include physicians and nurses, and probably at least one hospital administrator. Input from clergy can be very valuable. How- ever, the distinction between ethical principles and religious codes must be clearly maintained, and the clergy committee member should be sensi- tive to the pluralism of religious faiths and not espouse the specific tenets of his or her particular denomination. If such a clergy person is not available in the community, the committee would do better to function without clerical input than to become embroiled in religious doctrinal disputes. The local area clergy association may aid in the selection of a person with broadminded views.

It is also helpful, and sometimes necessary, to have legal input into the committee. It is obtuse to make moral decisions and be ignorant of the legal context in which one is operating. However, law and ethics, while related, are different. The committee lawyer should not believe that legal liability is the only or even a terribly important factor in choosing morally appropriate courses of action. For flus reason, it is sometimes desirable to use an attorney who is not the hospital counsel. It is impor- tant that the lawyer advising the IEC become familiar with the literature on the legal aspects of ethics consultation.

Members of a small hospital IEC should maintain a basic medical ethcs competency which reflects current moral and legal thinking, as reflected in the rapidly expanding literature. Achieving this for individuals whose major commitments lie elsewhere is difficult. As more small hospi- tals struggle with this problem, basic bibliographies and case analyses may come to be shared. Networking among reasonably contiguous insti- tutions might be established so that some members from each IEC can occasionally meet together, perhaps with an outside consultant, to discuss their successes and failures. In some cases a regional newsletter might be useful to keep abreast of current national and local developments.

Niemim, Orr and C u l w 29

The Expansion hto Hospital-wide Education, Policy Development and Consultation

As the committee extends its educational efforts to the hospital at large, it encounters the practical question of what issues need to be addressed and how this activity should be undertaken. There can be, especially at first, a thin line between confronting the issues and affront- ing the practitioners. How and when an issue is introduced may be just as critical as the issue itself, and while ethics should not be sacrificed to expediency, neither should it be sacrificed to poor timing. Starting off slowly, with relatively non-controversial issues (for example, the defmi- tion and criteria of death) that are well-prepared and well-presented builds the foundation necessary to tackle more controversial issues later.

The transition of the IECs role from purely educational to policy review and development can come about through a predetermined time- table as in Brattleboro or by natural evolution as in Newport. In either case policy deliberation is an almost predictable extension of the commit- tee’s educational function, made more likely by the recent impetus from outside agencies for hospitals to review their do-not-resuscitate and other policies. To ignore ongoing institutional policy review about ethically related issues, after IEC members have acheved a reasonable level of competence, is to undermine one purpose of most IECs: to serve as a forum for the discussion of ethical issues within the institution. To con- tribute to the ongoing discussion, if only by providing information, is to become part of the policy development process.

It is the IECs proposal of new policy, however, that changes the committee’s role within the institution, even when it has been asked to take this step by the hospital itself. To function most effectively as an initiator of policy change, the committee must have a measure of credibil- ity through its previous educational efforts. It must also appreciate the current philosophical stance of the institution and its staff, and the degree of change, if any, the committee may be asking them to adopt. Policy changes which reflect a shlft in stance from medical paternalism toward patient autonomy may be welcomed by some but resisted by others. The committee should not naively anticipate that all its efforts will be quickly welcomed and accepted. Clearly outlining its policy initiating intentions and soliciting widespread input from the beginning may help diffuse or at least idenhfy potential conflict early. This may be especially helpful when the committee is considering such potentially controversial matters as a limited therapy policy (regarding the withholding of various kinds of life support). Ascertaining, for example, the medical staffs viewpoints on the withholding or withdrawing of artificial feeding and hydration, as well as its acceptance of an optional IEC review function for troublesome cases in this area, may initiate a discussion which will place the issue in the context of a dialogue and not a confrontation when the IEC distrib- utes its preliminary and final drafts on the subject. Change which is presented in a positive and non-threatening way, and which invites dis-

30 The Journal of Rural Health

cussion, is more likely to be accepted than that which is perceived as legislating institutional morality from the pulpit. What is at stake and what may ultimately be the determining factor is the IECs credibility within the institution. Do the physicians trust it, does the administration trust it, do the nursing and support staff trust it as an arbiter of ethical values?

Whether this trust is developed depends on many factors: the context in which the IEC was established; the quality of its educational efforts; the persistence and persuasiveness of its presence; and the perceived independence of its control by one or another institutional faction. With- out credibility the IEC cannot move on to the next phase of develop- ment, case consultation.

Case consultation is a large step in a new direction. Although the consultative role of an IEC is almost always defined as “optionaVoptiona1” (i.e., it is optional to ask for a consultation and optional whether to follow any recommendations that might ensue), it is also true that a unequivocal committee opinion may carry great weight in a particular clinical situation (Robertson, 1984). Committees must be soberly aware of that fact. They must realize that, even when invited, they are entering territory that some consider private between physician and patient. There may be those who would never willingly invite them in. Committees should be honest with themselves and their hospitals about their ability to provide timely consultations, as well as their ability to provide expert ethical opinion in particular cases.

If our current experience with ethics consultations can be general- ized, the most frequent cases to come before small hospital IECs (as well as large) involve issues concerning withdrawal of life support. Most of these cases, luckily, do not raise conceptually arcane problems and should be within the expertise of mature small hospital IECs. For those cases where the ethical issues are more complex, there should be a mechanism in place to obtain advice from an ethicist or an IEC at a referral center. To be guarded against is the temptation to give up without trying, and the temptation to jump into case consultation too soon.

Conclusion An IEC at a small hospital must confront most of the same ethical

dilemmas present at large institutions. It must deal with them in an environment which has fewer resources, less access to recognized exper- tise, and less of a buffer zone to dilute personality tensions which may arise. It may be more dependent on the approval of its medical staff, yet must achieve an independence from that staff to safeguard its integrity. It will probably evolve at a slower rate than its larger counterparts, and can benefit from the support of both horizontal (with similar size institutions) and vertical (with academic centers) networks. We have emphasized the obstacles in establishing an IEC at a small hospital because we have encountered them ourselves, and we believe they should be more man-

Niemim, Orr and C u l w 31

ageable if anticipated. We have not found the obstacles insurmountable. We also believe there may be two advantages that small hospital

IECs, once established, have over their larger counterparts. One is in the area of community relations: many small hospital IECs have begun to conduct community education sessions on such topics as Living Wills, durable powers of attorney, and terminal care. These sessions are excel- lent vehcles for public education and for strengthening hospital-commu- nity relations. In fact, they may be co-sponsored by the IEC and one or more community organizations. Large hospital IECs can conduct s d a r sessions, but the target community is often more scattered and less easily identified.

Another advantage is internal: IECs are usually more conspicuous in small hospitals than in large ones. For one thing, the IECs membership simply comprises a higher percentage of the professional staff at a 50-bed than at a 500-bed hospital. But it is also true that changes are more readily noticed in small communities than,in large. Thus, to the extent that a small hospital’s IEC elaborates and introduces new perspectives on clinical practice, these changes may, if the committee is credible, more quickly and pervasively affect practice patterns than at a large institution.

The forces that have spawned the development of the IECs - tech- nological advances, consumer advocacy, limited resources - are not likely to abate in the forseeable future. They pose dilemmas not contem- plated in the past and force us to reexamine our concepts - even our definitions of such basic matters as life and death. Whether we practice at small or large institutions, we cannot escape the impact of these forces. Whether we address them in an active or reactive way is ours to deter- mine. The history of IECs consists of the recent recognition by groups of people in different institutions of the need to develop a mechanism to address actively the ethical dilemmas of modern medicine. Large institu- tions are at one stage of this histoT, small institutions at another. Small institutions can learn from the experience of larger ones, but must adapt the models developed there to meet their own needs and resources. State and county medical societies can facilitate this process by providing s u p port and expertise. Finally, those of us in small institutions who have developed IECs must find ways to link up and share our experiences.

REFERlmm

Anonymous (1985). Ethics committees double since ’83: Survey. ffosoitak. 59, 60,64. Bayley, C. & Cranford, R.E. (1986). Ethics committees: What we have learned. In E.

Friedman (Ed.), Making Choices: Ethical Issues of Health Can? Profkssionak (pp. 19% 133). Chicago: American Hospital Publishing, Inc.

Cranford, R.E. & Doudera, A. E. (1984). The emergence of institutional ethics committees. Law, Medicine and Health an?, 12, 13-19.

Cranford, R.E. & Jackson, D.L. (1984). Neurologists and the hospital ethics committee. Seminars in Neurology, 4, 15-22.

Federal Register (1984). 49, 1622-54.

32 m e Journal of Rural Health

Ferguson, C. G. (1984). Medical ethics committees - the decision is yours. Dimensions in

Friedman, E. (1988). Ethics as a community project. Health Care Forum, 7. The Joint Commission on Accreditation of Hospitals (1988). AMW88: Accreditation Manual

for Ho.pitals. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and

Behavioral Research (1983). Deciding to Forego Life-Sustaining Treatment. Washing- ton, D.C.: Government Printing Office.

Purtilo, R.B. (1987). Rural health care: The forgotten quarter of medical ethics. Second Opinion, G, 11-33.

Purtilo, R.B. & Sorrell, J. (1986). The ethical dilemmas of a rural physician. Hustings Center Repor?, 6, 24-28.

Robertson, J. A. (1984). Ethics committees in hospitals. Alternative structures and responsibility.

Health Service, 61, 36-41.

Quarierly Reyiew Bulletin, 10, 6-10,

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April 30 to May 3,1989 Reno, Nevada

For additional information and details:

NRHA National cOnft?n?nce 301 East h o u r Blvd., Suite 420

Kansas cily, Missouri 641 11