Prompted by a recommendation of the two Christian hospital associations in Germany, the Neu-Mariahilf Hospital in Goettingen set up a health ethics committee in autumn 1998. It is the committee's task to give support to staff members, patients and their relatives in individual cases where ethical dilemmas arise. The following article descibes the committee's work by means of three cases.
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Health ethics committees in Germany
In March 1997 the two Christian hospital associations, the Katholischer Krankenhausverband Deutschland, and the Deutscher Evangelischer Krankenhausverband, recommended that every hospital within the associations establish a health ethics committee (Klinisches Ethik-Komitee).1 These are quite distinct from the institutional review boards, which examine research proposals, and which have been in existence in Germany for about twenty-five years.
One of the factors which has led to this development is the clear gulf between what is medically feasible and what can be afforded. This gulf leads to conflicts for health professionals who wish to do the best they can for each individual patient but are not always able to do so. Health ethics committees, it is hoped, will provide a forum for open and free discussion, thus giving support to health professionals in coming to a decision as to how best to resolve ethical conflicts.
These committees will not only focus on issues arising from the limitations on resources. They will provide doctors, nurses and other health professionals with an opportunity to discuss any ethical problem which arises in their practice. Furthermore, the committees will be available to patients.
In addition to being a forum for discussion these committees may also give specific advice. On some issues a vote may be taken on which course of action is thought to be best. The committee's advice, however, will only be one factor in coming to a decision. In the end, the decision will remain with the health professional.2
The health ethics committee at the Neu-Mariahilf hospital in Goettingen
The Neu-Mariahilf hospital in Goettingen was one of the first to take up the recommendation of the two Christian Hospital Associations; it established a health ethics committee in the course of putting into practice the hospital's new mission statement.3 The establishment of the committee was supported by the Academy for Ethics in Medicine as regards content and organisation.4
Members of the ethics committee include an ethicist (as the chairman), a teacher of religious education, a jurist, a citizen, three physicians, two nurses, a teacher of nursing care, the managing director of the hospital and the matron (as spiritual adviser and representative of the supporting order). The individual members were appointed by the board of directors for two years. It is not their task to represent the interests of the profession. Rather they should play a part in the forming of a joint opinion through their own personalities, and on the basis of their professional experience and professional competence.
Along with consultation in situations of ethical conflict, the committee offers discussion evenings, which take place every three months. The individual events are announced publicly in the hospital. Everyone interested in the topic, whether they are staff, patients or relatives, may participate.
The introduction of the ethics committee was prepared carefully. After the first preliminary talks, an in-house series of events on various ethical topics (for example, informed consent, withdrawal of treatment, dealing with dying people and their relatives) was held during the autumn of 1997. A booklet with articles on the individual events was distributed free of charge among interested staff members. The concept of the committee was presented in January 1998, in the course of a public information day on the various projects involved in the realisation of the hospital's mission statement. Staff members were encouraged to take an active part in four preparatory seminars in order to work out the standing orders of the committee and to rehearse and try out how it might work, by means of case examples. In June 1998, the standing orders were passed and the members selected. After the first session in July, the members of the committee introduced themselves to the staff and took up work in September.
In the following, the work of the health ethics committee at Neu-Mariahilf hospital is to be delineated with three examples. The first example describes an initiative which developed from the first public discussion evening organised by the ethics committee, the other two show clearly the ways in which the committee tries to support people in situations of ethical conflict.
Case 1: Handling stillborn children with dignity
In Germany, about 4,000 children are stillborn each year. If their birthweight is less than 500 g they do not have to be buried. As a rule, the bodies of these stillborn children are burned as hazardous waste.
Because of reports in the media, in summer 1998 1998, according to which the cinders of burnt miscarriages were used in road construction, the committee organised a discussion evening with staff members of the obstetrics department and parents concerned in order to talk about how to handle stillborn children with dignity and how to support their parents. As a result, the following initiative was launched, which in the meantime has been joined by the other two obstetrics clinics in Goettingen.
The bodies of stillborn children under 500 g are no longer disposed of as hazardous waste but are collected in the pathology department. Up to three times a year, the bodies are transferred to a coffin and buried in an anonymous burial ground in the municipal cemetery. The parents may learn the site of the burial ground on request. The obstetrics clinics agreed to pay for the burial and are supported in this by an annual collection in the parishes of Goettingen. Several days after the burial an ecumenical memorial service takes place. By means of a reply card, which they receive together with information about further possibilities for consultation and support when being discharged, the parents can make known their wish to be invited to the memorial service.
An additional result of the discussion evening is a new mode of expression at the hospital's obstetrics department. The discussion showed that some specialist terms in obstetrics, especially in connection with miscarriage and stillbirth, sometimes sound unfeeling and cold to the ears of parents concerned. Sensitised by this, staff members of the department have since tried to avoid such terms, both among themselves, and while talking to parents.
Case 2: Withdrawal of treatment in the final stage of a cancer disease
At the beginning of 1999, the ethics committee was asked by staff members of the intensive care unit to give its opinion on the question of withdrawal of treatment in patients in the final stage of cancer. A few days earlier, a patient had died in the intensive care unit who, on the eve of his death had received intensive medical treatment to prolong his life, although it had been clear that because of his disease he would die within the next few days.
In the preliminary talk between the committee's chairman and members of the nursing staff it became clear that the nursing staff were not so much interested in an evaluation of the case itself, as in the committee's position on the problem in principle, taking the case as a starting point. This could then serve as guidance in future cases. Three questions were crystallised as being very important in the course of the talk: how important is the patient's will concerning decisions on withdrawal of treatment and forgoing treatment? Who is to be included in the decision making process? How should the decision be documented?
After this preliminary talk, which clarified both the question and the committee's task, the inquiry was discussed at the committee's next meeting.5 The proposers were informed personally about the result of the discussion by the chairman. Furthermore, the result was set down in a written statement, that may be seen by everyone in the hospital.6
In its statement the ethics committee first refers to the new principles relating to medical terminal care published by the German Medical Association,7 according to which the patient's will and the discussion with medical and nursing staff are crucial to the question of withdrawal of treatment. Going beyond these professional guidelines, the committee stressed the necessity of documenting in the medical record the consent reached in the discourse between medical and nursing staff. This should be carried out, especially in case of end-of-life decisions, by the senior physician of the respective department by means of a clear entry in the patient's notes.
Furthermore, the ethics committee saw a need for discussion and further vocational training on this topic. Therefore it subsequently organised a public discussion evening on the topic of medical advance directives, and in-service training on the ethical and legal aspects of medical terminal care. Both offers were very well received by the staff.
Case 3: Operations with an increased risk for the patient
Another inquiry was made about a patient who, because of unbearable pain in the vertebral column, wished for an operation to alleviate pain. The attending physician was prepared to perform the operation although drastically increased risks for the patient were involved. When, after the operation the feared complications occurred, some staff members shook their heads or made critical or reproachful remarks. In this situation the physician asked the ethics committee to give its opinion.
The committee held the view that the therapy wish of a patient may be complied with even if an increased risk for the patient is involved. This requires, however, the patient to be sufficiently informed about these risks and that there are no less risky alternative treatments available. In this case, the patient had been clearly aware of the increased risk, particularly as the operation had initially been refused by the attending anaesthetist. Also, an alternative analgesic drug therapy in maximum dosage had been suggested and tried out. As this therapy attempt failed, gaining no satisfactory alleviation of pain for the patient, the operation on the vertebral column was performed as a last resort.
With regard to the negative reactions of the staff, the ethics committee considered whether the decision in favour of the operation had been sufficiently discussed with the staff members involved. Possibly, many of the staff knew only little of the patient's urgent wish for an operation even at the risk of dying, and therefore after the operation reacted by shaking their heads. This could probably have been avoided by more communication and transparency with regard to medical therapeutic decision making.
Between October 1998 and June 2000, the ethics committee was asked by staff members (physicians or nurses from different wards) to give its opinion in seven cases. In one case, the proposers were referred to the managing director of the hospital as the problem involved was more of an organisational nature. All inquiries concerned cases that had happened only a short time earlier and had left those involved feeling uneasy. As even talks with colleagues did not result in satisfactory answers, those concerned turned to the ethics committee, hoping to find perspectives and guidance for their future actions. With the proposers' assent, some of the questions included in the inquiries were taken up as topics for the public discussion evenings. In this way the ethics committee tried to promote the general discourse of ethical issues, seeking for it to become a matter of hospital routine.
In summary, one can say that in the two years of its existence the ethics committee has proved worthwhile in dealing with questions and problems arising from the discrepancy, often very painful for hospital staff, between the ethical guidelines formulated in the mission statement and striven for by the staff, and the realities of the hospital. One should, however, take care not to measure success and failure of an ethics committee by quantitative criteria, for example by the number of inquiries. Rather, the success or failure of the committee rests on whether, through its various activities (ethics consultation, public discussion evenings, further vocational training for staff etc) it has contributed to a greater awareness and more open discussion of ethical problems in the hospital.
Alfred Simon, Dr phil, is Executive Director of the Academy for Ethics in Medicine, Goettingen, Germany.
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