Editorials

Clinical ethics committees

They can change clinical practice but need evaluation

Research ethics committees, both local and for multicentre research, are now well established in the United Kingdom. Clinical ethics committees, which deal with issues that arise in clinical practice, are a more recent phenomenon. Earlier this year people from 14 clinical ethics committees within the United Kingdom met to compare their experiencesat a time when the pressure for such committees, or other mechanisms for dealing with the ethics of everyday practice, is growing.

The first clinical ethics committees in the United Kingdom developed for a variety of local reasons. Some were an institutional response to one or two problem cases. Others developed because a few clinicians were particularly concerned with, and interested in, the ethical aspects of clinical practice. Now that medical ethics is part of the core of medical education,¹ and with the high profile of medical ethics in the media, clinicians are increasingly aware of the ethical dimensions of practice. The medical profession is also under mounting pressure to ensure high standards of ethical practice. Inevitably, this will mean developing clear processes for determining and assessing those ethical standards. Clinical ethics committees at the level of NHS trusts, health authorities,² and primary care groups are likely to play an important part. Professional bodies will want such processes to be in place; the courts may consider them a part of due process; and clinical governance will need to include ethics within its remit.

Most published data on clinical ethics committees (often called healthcare ethics committees) come from the United States, where such committees have existed since the early 1980s. The Joint Commission on Accreditation of Healthcare Organisations requires hospitals to have a mechanism for addressing ethical issues in providing patient care, and it recommends a multidisciplinary ethics committee.³ Nursing homes and long term care institutions also have developed committees in the United States.⁴

Clinical ethics committees in the United States typically perform one or more of three functions⁵: (a) individual case consultations in response to requests from clinicians or occasionally from patients or their families; (b) providing ethical input into hospital policies and developing guidelines; and (c) education of health professionals within the institution. In practice, case consultation is more likely to be carried out by individual ethicists or increasingly by small multidisciplinary teams which may include ethics committee members as part of the team.⁶

Clinical ethics committees, and other ethics support services, are developing in Europe and Australia. In the Netherlands clinical ethics committees are usually combined with research ethics committees, and in Australia many research ethics committees report that they also provide ethics advice on clinical issues.⁷ In Germany the Christian association of hospitals (representing about a third of all German hospitals) has recommended that all hospitals in the association should have a clinical ethics committee.⁸

There are few published data on United Kingdom clinical ethics committees, though hospital committees have been described in London, Oxford,⁹ and Nottingham¹⁰ and more recently in a small NHS trust including a general practitioner hospital and community services.¹¹ We are currently studying the position of clinical ethics support services in the United Kingdom. Preliminary results suggest there are at least 20 committees throughout the United Kingdom and several NHS trusts are considering establishing a committee in the near future. United Kingdom committees usually report directly to the trust board, or are a subcommittee of another hospital committee. Most are in acute trusts, although there are a few in community trusts and at least one in an ambulance trust.

Established committees tend to follow the North American model. Case consultation is less developed than in the United States, and most committees in the United Kingdom see ethical input into policy and guidelines as their main function. Indeed, American experience suggests that a model other than a committee is required for case consultation, and some committees in the United Kingdom are looking at this.

Clinical ethics committees can change clinical practice through policy development and case consultation, and indirectly through education and raising awareness of ethical issues throughout the trust. But evaluation is needed to determine whether these committees are influencing clinical practice. There have been no rigorous studies in the United States evaluating healthcare ethics committees and ethics consultation,¹² possibly because of the disparate nature of these services. If these committees are to develop effectively, they will need to communicate closely with each other to share experience and to establish the basis for systematic evaluation and research.

Anne-Marie Slowther, Nuffield Trust research fellow. 
Tony Hope, director and reader in medicine. 

Oxford Centre for Ethics and Communication in Health Care Practice, University of Oxford, Oxford OX73 7LF (anne-marie.slowther{at}ethox.ox.ac.uk)