Living in a Glass House: Challenges to Ethics Committees and Consultation Services in Rural and Small Community Hospitals

By Gail A. Van Norman, MD

PART I IN A SERIES ON ETHICS COMMITTEE LIABILITY CONSIDERATIONS

Almost 50 years ago, Justice C.J. Hughes opined in In the Matter of Karen Ann Quinlan that a committee of ethics experts would be helpful in solving ethical medical dilemmas, thereby keeping intensely personal medical decisions out of the courts. Ethics committees emerged, who attempted to address several basic needs:

  1. the need to resolve professional and patient conflicts without resorting to the courts,
  2. the need for an authority on ethics to clarify moral ambiguities in healthcare decisions, and
  3. the need to bring an unbiased, scholarly approach to ethical medical decision-making.

Ethics consultation is an invaluable resource to patients, families, surrogate decision-makers, and healthcare professionals. Although now well established as a standard in healthcare delivery, ethics committees still struggle to find footing in healthcare institutions in rural settings. 
 
Establishing a credible ethics committee can be challenging for small community hospitals, where well-trained and vetted clinical ethicists are scarce, and funding and administrative resources may be limited. Rural ethics committees are more vulnerable to attrition and resource “re-allocation” than their urban counterparts. Rural institutions and practitioners are also more likely to believe that ethics services may not be particularly useful.2 As a result, the development of ethics committees and ethics consultation services in rural hospitals has lagged significantly behind that of those in larger communities. 

A significant problem is that clinicians and hospital administrators frequently believe that “ethics” is merely a matter of consensus among well-meaning healthcare workers, and fail to grasp that ethics consultation requires serious expertise. Indeed, many administrators and practitioners are hard-pressed to even describe exactly what a hospital ethics committee is for, other than perhaps the reduction of the likelihood that an institution will be sued, or worse, criminally prosecuted for disastrous medical thinking. In order to address problems of quality in healthcare ethics consultation, and to aid institutions that wish to establish ethics services, the American Society of Bioethics and Humanities published a list of core competencies and skills that are essential for the individuals and committees who provide them.1 As with any medical specialty, these requirements are rigorous and demanding, and call for significant continuing study and training. The detailed description of competencies included in the report involves: 

  • Advanced knowledge of ethical reasoning and skill in ethical analysis
  •  Advanced knowledge of ethical concepts
  • Basic knowledge of ethics-related healthcare law
  • Advanced skills in building ethical consensus

Proper ethical decision-making involves rational, deliberative, unbiased, and compassionate thinking by a multidisciplinary group of professionals who are well-schooled in ethical theory, not just casually acquainted with it. In other words, you can’t just wing it. As with all healthcare decision-making, it requires lifelong dedication to learning and growing in the understanding of medical ethics—and institutions should be prepared to provide significant committee support, such as funding (to compensate professional time dedicated to meetings and consults) and administrative help. Such support can often be beyond the means of a small hospital in a rural setting.

Ethical questions that arise in rural settings overlap with, but are not identical to, those faced in urban settings. Specific characteristics of smaller communities intensify ethical dilemmas. A number of factors have been identified and studied that make ethical problem-solving more difficult and present often-unrecognized barriers to good clinical ethical problem-solving. People in rural healthcare settings are more likely to know each other, depend on each other, and share complex relationships outside of the work setting. There are challenges around conflicting roles; altered therapeutic boundaries between caregivers, patients, and families; preservation of patient confidentiality; heightened cultural dimensions in healthcare; “generalist” care and multidisciplinary team issues; the limited resources for consultation and clinical ethics; and the greater stresses experienced in general by rural caregivers. Discussion of ethical issues may seem risky or unwise, raising feelings of disloyalty and betrayal and leading to loss of professional support and referrals. Rural physicians and nurses admit to being profoundly hesitant to recognize and report errors or to question a colleague’s decisions, even when those decisions appear to be deeply flawed. In one study, rural physicians described their situation as “living in a glass house” where “everybody knows everybody,” and described feeling pressure to “not rock the boat.” Seventy-six percent of rural physicians in a large  , multi-state study   had never referred a case to an ethics committee at any time during their training or career. Most identified their ethics resources as spouses or peers, prayer, the Ten Commandments, or their own consciences—all “resources” that are by nature heavily biased, potentially culturally insensitive, and at times personally conflicted.3,4  

Imagine, for example, the nurse in a small rural hospital—which represents the only potential healthcare employment within a reasonable distance—who has observed or believes that there has been an ethical or legal violation in the care of a patient by the hospital chief of staff, who also happens to be a wealthy and prominent member of the community. What should they do? As one nurse stated, “You tend to lose your job if you take aggressive steps, so you have to be prepared if you want to be here until you retire.”2 But the problems that make ethics consultation more challenging in rural settings are the very reasons that educated, balanced, and fully grounded ethics consultation and ethics committees are critical. And it does require a committee rather than individual approach, lest ethics consultation become simply another fiefdom for strong-willed and opinionated individuals whose biases then go unchallenged. Ethics committees are designed to deliver what one author calls “moral courage through a collective voice,” rather than enhance individual power inequities that would discourage ethical decision-making.5 

One proposed solution to the problems limiting the establishment of appropriate ethics committees in rural communities is to encourage multiple institutions to work together to create a multi-institutional ethics committee (MIHEC). MIHECs can harness more ethics expertise, incorporate more individuals who then broaden cultural, religious, and community perspectives, and share an economy of cost to support the formal education and administrative needs of its members. MIHECs are less bound by the specific social and professional relationships of any one institution, thus avoiding some of the pitfalls of ethics consultation that remains siloed inside the walls of one community, while still permitting each institution to contribute its own unique perspective to ethical cases. Removing the operations of the ethics committee from the sole influence of a single individual or institution also increases public understanding and trust in the committee’s function.

Recent developments have made MIHECs easier to implement, as telehealth methods and usage increased during the COVID pandemic. As practitioners have become both more facile and comfortable with technologically aided “virtual” consultations and meetings, the ability of ethics committees to serve institutions that are separated over great distances has increased. Today, the terms tele-ethics and virtual ethics are increasingly common.6 

Ethics committees, when properly trained and institutionally supported, provide an invaluable service in enhancing patient care and safety, as well as a sense of support to staff. Establishing a committee with proper education and training, funding, and support should be a top priority for any rural healthcare institution. With the aid of multi-institutional resources and the technology of telehealth, there are no longer any excuses for failing to deliver on this crucial aspect of ethical and appropriate patient care. 

 

Resources

  1. American Society for Bioethics and Humanities. “Core competencies for healthcare ethics consultation: A report of the American Society for Bioethics and Humanities.” (Second ed.) Chicago IL. 2011.
  2. Cook A, Hoas H. “Where the rubber hits the road.” Healthcare Ethics Committee Forum. 2000; 12:331-40.
  3. Cook A. “Ethics and rural healthcare: What really happens? What might help?” National Rural Bioethics Project, University of Montana. Am J Bioethics 2008; 8:52-6.
  4. Cook AF, Hoas H. “From good intentions to good actions: A patient safety manual for rural healthcare settings.” University of Montana, Missoula MT. 2007. Available at: https://scholarworks.umt.edu/cgi/viewcontent.cgi?article=1014&context=psych_pubs. Accessed May 14, 2023.
  5. Aultman J. “Moral courage through a collective voice.” Am J Bioethics 2008; 8:67-9.
  6. Pope T. “Multi-institutional ethics committees for rural hospitals, and urban ones too.”  Am J Bioethics 8:69-71.
  7. Crowden A. “Distinct rural ethics.” Am J Bioethics 2008; 8:65-4.

Dr. Van Norman is Professor Emeritus of the Department of Anesthesiology and Pain Medicine, and past Adjunct Professor of Bioethics, at the University of Washington. She has chaired the American Society of Anesthesiologists’ Committee on Ethics, and has served and provided ethics consultations on the ethics committees of the University of Washington and within the Franciscan Healthcare System.