Ethics decisions are among the hardest hospital staff need to make. Thomas Barwick/Stone via Getty Images
Many states have imposed sweeping restrictions that all but ban abortion since the June 2022 Supreme Court ruling that overturned the 50-year-old constitutional right to the procedure. These laws have created new obstacles for pregnant patients facing life-threatening complications like severe fetal anomalies, cancer diagnoses and ectopic pregnancies – when a fertilized egg implants outside the uterus.
Some media reports about these challenging cases mention the involvement of hospital ethics committees.
Stat, for example, a medical news website, reported that one OB-GYN had to wait for an ethics committee to determine whether she could terminate her patient’s ectopic pregnancy under the narrow, vague exceptions to Missouri’s abortion ban. In Texas, a patient told reporters that a hospital refused to abort her life-threatening pregnancy until a doctor on an ethics committee advocated on her behalf. And a patient in Oklahoma told NPR that an ethics committee declined to meet with her husband after doctors refused to terminate her dangerous pregnancy.
Abortion debates have put the ethics of medical decision-making in the spotlight, but ethics committees’ roles are often misunderstood. As trained bioethicists who have practiced and researched clinical ethics consulation, we aim to clarify how ethics services work in U.S. hospitals.
Basics of hospital ethics
Ethics have been part of medical practice throughout history, with principles like those in the Hippocratic oath guiding decision-making since the 5th century B.C.E.
Specialized hospital ethics committees originally formed in the 1960s to address decisions about the use of revolutionary therapies like mechanical ventilators, which could keep patients alive even if they would never regain consciousness or leave the hospital.
Today, accredited U.S. hospitals are required to provide ethics services, and most use ethics committees to help meet this requirement. Their functions include developing ethics-related policies and providing ethics education to staff. For example, ethics committees have contributed to hospital policies about what to do if a child’s parent opposes blood transfusions for religious reasons and triage policies for allocating scarce resources during the COVID-19 pandemic.
Another key service is clinical ethics consultation: advising staff, patients or families about how to navigate ethical issues related to a specific patient’s clinical care. Usually these requests are handled by a subcommittee or an individual ethics consultant – and, increasingly, hospitals are hiring staff with specialized training in medical ethics.
Patients’ families can request a consultation with ethicists to help think through challenging decisions.
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Apart from ethicists, committee members may also include physicians, nurses, social workers, chaplains, lawyers and administrators. Sometimes they include volunteers who represent the views and experiences of local communities. Member selection, funding and other organizational features vary by hospital.
Recommendations, not rulings
Ethics consultations about specific patients often address concerns about patients who cannot make their own medical decisions, such as if they are in a coma and it is unclear who should make decisions on their behalf. Requests for consultation also can occur when a medical team and a patient disagree about the goals of care: for example, whether applying a do-not-resuscitate order is in the best interests of a severely ill patient.
One essential aspect of ethics committees’ and consultants’ work is that their input is advisory, not binding. They help identify the range of ethically acceptable options, based on medical information from health care providers and on patients’ goals and values.
But even when ethics consultations result in a clear recommendation, neither patients nor health care providers are obligated to follow consultants’ advice. In other words, ethics consultants are not decision-makers, but they do contribute to a decision-making process.
When medicine says yes, but the law says no
Some media reports, however, have suggested that hospital ethics committees are acting as final arbiters, determining whether doctors can help end life-threatening pregnancies in states with severe abortion restrictions.
Yet none of these states currently has laws suggesting that ethics committees must play a role in those decisions. The question of whether an abortion is medically necessary or legally acceptable is one that doctors or lawyers would make, not ethicists.
Other recent reporting on hospital ethicists’ experiences suggests a different reality. New state laws threaten doctors with fines or imprisonment for providing abortions that are considered standard medical care for patients facing serious risks to their health. Some of these doctors are seeking guidance from ethics experts about how to meet their ethical and professional obligations under these difficult circumstances.
Ethics consultants in states with restrictive abortion laws can help health care providers work through difficult questions. For example, how can providers communicate honestly and respectfully with patients about their health needs when they might risk prosecution for recommending abortion? How should providers navigate ambiguities in the law in order to protect their patients’ health and well-being? When might the severe health risks to a patient morally justify providing an abortion, even if there are unresolved concerns about legal liability?
Even if the law prevents doctors from providing treatment their patients need, talking with an ethics consultant can help ease their moral distress about being unable to do what’s best for their patient.
In fact, one study showed that only one-third of clinical ethics consultations wound up changing a patient’s treatment plan. However, consultations left three-quarters of clinicians feeling more confident about enacting a plan of care. Input from ethicists can help doctors confirm that their plan of care is appropriate or help them clarify their own values.
Getting help
Most hospitals allow anyone directly involved in a patient’s care to request clinical ethics consultation services, including patients and their families.
Yet available data suggests that very few patients and families do. For example, a review of a hospital with a high volume of ethics consultation requests showed that only 4% came from patients or their families. However, the majority of patients and families who interact with ethics services say the process helped them understand their situation, figure out difficult decisions or feel morally supported.
Ethics consultations can help patients and caregivers clarify their own values.
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Access to high-quality health care is deeply unequal in the United States, and the same is true for ethics consultations. Nearly all teaching hospitals, religiously affiliated hospitals and hospitals with over 200 patient beds have ethics consultation services. But roughly 1 in 5 small hospitals, rural hospitals and nonteaching hospitals do not.
Many hospitals have other services, such as “ethics hotlines” where people can report legal and compliance issues, but these are not the same as ethics committees or ethics consultants. Patients seeking support in making care decisions should ask for the hospital’s clinical ethics consultation service to connect with the right resource.
Ethicists do not make decisions for others, but they can support clinicians and patients through dilemmas and distress.
The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.
