Contributor Post Created with Sketch. Hospital Ethics Committees and Death Panels

 

Remember how people were afraid that based on the Affordable Care Act, “death panels” would be making life and death decisions for their patients? The fact is that at least in hospitals, these panels have existed since the 1970s, in the form of ethics committees. I must say after researching these committees, I’m even more confused and ambivalent about their roles and decisions.

Listening to talk radio in my car, I learned about this issue and how it became a hot topic in Texas. One of the most publicized cases was the case of David Chris Dunn, 46 years old and a former deputy sheriff for Harris County, Texas. He was transferred to Houston Methodist on October 12, 2015. He had a mass on his pancreas which affected his other organs and was in renal failure. The family was told he would die that night, but he didn’t. Over time the medical team met to discuss Dunn’s condition; he wasn’t improving.

One day, J. Richard Cheney, the chairman of the hospital Bioethics Committee entered the room. Dunn’s mother, Evelyn Kelly, woke up to learn that the committee had decided to remove all of Dunn’s life-support machines. Kelly refused to let them take these steps. The committee met again, approved of the doctor’s decision to end medical care. The only option Evelyn Kelly had was to try to get her son transferred to another hospital. She was not surprised to discover that no one would take him.

Meanwhile, Kelly contacted an organization called Texas Right to Life:

Within a few hours, longtime Houston lawyer and former state representative Joe Nixon was in Dunn’s hospital room shaking hands with Kelly.

‘I really thought he’d be unconscious, a vegetable, the way they usually are,’ Nixon says now. When he saw that Dunn’s eyes were open, Nixon started asking him questions. One of the lawyers pulled out a phone and began to film.

‘Chris? Look at me! Is it okay if I hired some lawyers?’ Kelly said insistently, leaning over the hospital bed and waving her hands. Dunn gave a slight nod.

‘Chris, do you want to stay alive? Do you want me to fight for your life?’ Nixon asked using his full courtroom voice.

Dunn pulled his palms together, as if in prayer, and nodded his head.

Joe Nixon filed for a temporary restraining order to stop the hospital from withdrawing life-sustaining treatment and to give the family more time, and a judge approved it. Chris Dunn died on December 23 before the hospital withdrew care. Evelyn Kelly is suing the hospital on behalf of her son’s estate.

Diana Wray, the writer from the Houston Press, describes the situation this way:

Chris Dunn didn’t have health insurance, and he had never filled out advance directives or even talked to his mother and siblings about what they should do if he ever got really sick.

It wouldn’t have changed anything anyway — not once his doctors decided to convene a hospital ethics committee.

In Texas it doesn’t matter what instructions you’ve previously given or what your relatives say: If you’re in critical condition, you’re dependent on machines to survive and hospital officials decide it’s time to pull the plug, you will die. And it’s completely legal.

After hearing this story, I wanted to know more about ethics committees in hospitals and whether calling them death panels is fair. I came away with more questions than I had answered. The issues of life and death are extremely complex to address. Unfortunately, little seems to have been done to clarify how, when, why and for whom these decisions can or should be made. Here is what I have learned:

  • Many hospitals across the country have ethics committees of some sort.
  • Membership for these committees varies widely, including but not limited to medical professionals, bioethicists, social workers, nurses, clergy, and hospital board members.
  • The size of these committees varies from hospital to hospital.
  • Each hospital decides the size of these committees and when they should be called.
  • No national or even state rules have been established for decision-making.
  • The degree to which costs are or should be a factor in making decisions varies.

The list of uncertainties is endless.

A study from the University of Maryland cited above concluded the following:

The role and legal status of ethics committees in the United States remains amorphous. Committees, for the most part, remain unregulated and disagreements exist in the field as to whether regulation is appropriate. Despite the lack of homogeneity in committee function and operation and the inconsistent quality in committee performance, a number of state legislatures have given HCECs [health care ethics committees] legal authority to make health care decisions for patients lacking health care decision making capacity and/or available surrogates.

While threats of malpractice may lead to improvements in ethics committee performance, in a number of jurisdictions ethics committees have been protected by statute from liability. In addition, suits have been rare and there are no published judicial opinions that have articulated standards for ethics committee process. As a result, committees continue to operate with minimum oversight and without legal standards.

I don’t want to point fingers at any one group, because there are many parties who have contributed to this controversial and difficult ethical conundrum. I don’t have answers since every case is different in multiple ways, but I don’t think we can put off these issues indefinitely. As medicine becomes more sophisticated, lives are prolonged for those who are critically injured or aged, we need to try to address these ethical issues of life and death.

What are your thoughts?

There are 14 comments.

  1. CB Toder aka Mama Toad Member
    CB Toder aka Mama Toad Joined in the first year of Ricochet Ricochet Charter Member

    Excellent essay, Susan. Truly outstanding.

    I believe that it is these types of edge-of-life decisions, both at the end and at the beginning of life, that caused New York State to drive Catholic hospitals out of business across the state, many of them, like Benedictine Hospital in my county and St. Francis Hospital in Poughkeepsie (which was formed because Vassar Hospital would not admit Jewish doctors, and the doctors of Poughkeepsie petitioned the Archbishop of New York to find some sisters to come and open a hospital, and now is part of Westchester Medical Center’s large conglomerate), being forced to sell their assets to hospitals that perform abortions and make the decision to turn off Deputy Sheriff Dunn’s life support. 

    It is terrifying to me.

    Thank you for this essay.

    • #1
    • May 18, 2018, at 2:29 PM PDT
    • 8 likes
  2. Susan Quinn Contributor
    Susan Quinn

    It is frightening, @cbtoderakamamatoad. Who gets to play G-d? I’m scared, because the answer is not clear. And many of us are approaching the time when we may be faced with these decisions. We have advanced directives, but will that matter? I do know that I don’t want machines keeping me alive. That lack of clarity seemed to affect this case.

     

     

    • #2
    • May 18, 2018, at 2:54 PM PDT
    • 6 likes
  3. RushBabe49 Thatcher

    The answer is NOT “more regulation” or “national standards or guidelines”. The answer is more public and local attention to these issues. Public outcry can keep the medical profession honest without the government getting involved and making things worse. Publicity on the issue can also make people more aware of the “advance directive” issue. Our local clinic offers free classes to all patients about how to draw up all the necessary papers. I’m betting that most big hospital systems also offer this kind of education.

    • #3
    • May 18, 2018, at 3:18 PM PDT
    • 5 likes
  4. Susan Quinn Contributor
    Susan Quinn

    RushBabe49 (View Comment):

    The answer is NOT “more regulation” or “national standards or guidelines”. The answer is more public and local attention to these issues. Public outcry can keep the medical profession honest without the government getting involved and making things worse. Publicity on the issue can also make people more aware of the “advance directive” issue. Our local clinic offers free classes to all patients about how to draw up all the necessary papers. I’m betting that most big hospital systems also offer this kind of education.

    @rushbabe49, you offer great strategies, but none of them will solve the issues. If you read the OP the issues are much biggèr than your suggestions. 

    • #4
    • May 18, 2018, at 3:25 PM PDT
    • 3 likes
  5. Susan Quinn Contributor
    Susan Quinn

    BTW, I’m not in favor of regulations, mainly because I have no idea what to include. But also, there are no criteria, and no expectations to develop them. Do we really doctors deciding when it’s time for us to die?

     

    • #5
    • May 18, 2018, at 3:34 PM PDT
    • 4 likes
  6. TheRightNurse Member

    Susan Quinn (View Comment):

    BTW, I’m not in favor of regulations, mainly because I have no idea what to include. But also, there are no criteria, and no expectations to develop them. Do we really doctors deciding when it’s time for us to die?

     

    In many ways, that is better than letting a larger government body determine it. Ethics boards are often intimately familiar with cases, both pros, cons, pains and costs. They are often confronted with family and serious family issues (like keeping people who are physically liquefying on supportive measures to spite other family) that don’t serve the patient.

    Be very wary of equating ethics boards with death panels. One is interested in the individual and is local and the other is neither. They are not the same and your argument that if effect they are is not just offensive and wrong, but it causes a panic about the wrong thing. We should worry less about the ethics board of the local hospital and more about the Medical Use Officers of the state and insurance companies.

    • #6
    • May 18, 2018, at 6:33 PM PDT
    • 7 likes
  7. Phil Turmel Coolidge

    When it’s somebody else’s money, there must be some agreed way to say no. Chris Dunn was uninsured. Charity spent on him is charity not spent on someone potentially more deserving, or many someones.

    Life is sacred from conception to natural death. Anything beyond basic care and sustenance is morally optional.

    • #7
    • May 19, 2018, at 9:26 AM PDT
    • 3 likes
  8. MarciN Member

    Phil Turmel (View Comment):

    When it’s somebody else’s money, there must be some agreed way to say no. Chris Dunn was uninsured. Charity spent on him is charity not spent on someone potentially more deserving, or many someones.

    Life is sacred from conception to natural death. Anything beyond basic care and sustenance is morally optional.

    From what I read, being uninsured was a temporary problem he had. He had had many good-paying well-insured jobs up to this year. He had paid into the system. And probably would again.

    Insurance works over a long time period. That’s true for all of us.

    • #8
    • May 19, 2018, at 12:45 PM PDT
    • 2 likes
  9. Rodin Member

    I am ambivalent about these committees as well. I have two cases close to home this year that are relevant:

    1. My 87 year old father-in-law fought stomach cancer for 5 years until the “Tumor Board” determined there were no additional treatments that were likely to meaningfully deter the disease’s further progression. No doubt the Board’s decision was appropriate. I was amazed at what my father-in-law was willing to put up with over that period of time. I am uncertain as to whether his was a wise choice, but I am certain that I was not the one experiencing the pain or desire for continued living in that state.
    2. I have a close acquaintance who is 91 years old and has recently been diagnosed with a form of throat cancer. Given his age and other health issues he is an extremely poor risk for surgery. He was a surgeon and he would not have done surgery on someone in his condition. There are treatments available that will help his condition and possibly prolong his life. But not all of those treatments may be available to him — or at least from at least one institution that has declined to offer it to him. At his age and health problems it is totally rational to believe that certain treatments or not his longevity could be the same. He is my friend and I want him to be comfortable and enjoy his remaining life as much as possible. But I cannot gainsay a decision to deny him a certain treatment if it is a limited resource and there are other demands for it.

    The challenge of our time is the same as it has always been. Everything with scarcity must be rationed (allocated) on some basis. As a free marketer I believe that using prices to make allocations is as good and fair a method as can be devised (assuming there are no artificial barriers to the acquisition of wealth). Failing personal wealth we are in an age in which charitable appeals can be broadly and democratically made ( e.g. GoFundMe and the like). So price rationing continues to be as fair a system as we can construct.

    Medical ethics boards and the like short-circuit price rationing to deny treatment at any cost. We would likely support a medical board denying the 5th liver to a billionaire with uncontrolled alcoholism. But there are many other cases where we just have to wonder: Is it right?

    • #9
    • May 19, 2018, at 1:35 PM PDT
    • 2 likes
  10. Susan Quinn Contributor
    Susan Quinn

    TheRightNurse (View Comment):
    Be very wary of equating ethics boards with death panels. One is interested in the individual and is local and the other is neither. They are not the same and your argument that if effect they are is not just offensive and wrong, but it causes a panic about the wrong thing. We should worry less about the ethics board of the local hospital and more about the Medical Use Officers of the state and insurance companies.

    Thank you for weighing in, @therightnurse. You are correct; ethics committees and governmental “death panels” are not the same. I’m glad your experience has been a positive one with these committees, but they are human and if they don’t have clear criteria for making their decisions in life-and-death situations, I’m the one who is wary of their decisions. In other stories in the article I cited, the ethics committee made decisions that I’m not saying were wrong, but could be questioned. So to be clear, I’m not in favor of committees or panels affiliated with the government or insurance companies. But I’m not ready to accept without questions the ethics committees in hospitals. As I described in my OP, quoting a study:

    While threats of malpractice may lead to improvements in ethics committee performance, in a number of jurisdictions ethics committees have been protected by statute from liability. In addition, suits have been rare and there are no published judicial opinions that have articulated standards for ethics committee process. As a result, committees continue to operate with minimum oversight and without legal standards.

    I just happened to hear a story today of a fellow who was in a coma, and because he was in kidney failure (and had Type 1 diabetes), the hospital recommended taking him off life support. His parents refused, transferred him to a different hospital and he came out of the coma and lived.

    • #10
    • May 19, 2018, at 3:07 PM PDT
    • 2 likes
  11. Susan Quinn Contributor
    Susan Quinn

    Phil Turmel (View Comment):

    When it’s somebody else’s money, there must be some agreed way to say no. Chris Dunn was uninsured. Charity spent on him is charity not spent on someone potentially more deserving, or many someones.

    Life is sacred from conception to natural death. Anything beyond basic care and sustenance is morally optional.

    It’s really difficult, isn’t it @philturmel? I could never serve on this type of committee and hold someone’s life in my hand. I’m glad at least that there are those who do.

    • #11
    • May 19, 2018, at 3:08 PM PDT
    • 1 like
  12. Susan Quinn Contributor
    Susan Quinn

    MarciN (View Comment):

    Phil Turmel (View Comment):

    When it’s somebody else’s money, there must be some agreed way to say no. Chris Dunn was uninsured. Charity spent on him is charity not spent on someone potentially more deserving, or many someones.

    Life is sacred from conception to natural death. Anything beyond basic care and sustenance is morally optional.

    From what I read, being uninsured was a temporary problem he had. He had had many good-paying well-insured jobs up to this year. He had paid into the system. And probably would again.

    Insurance works over a long time period. That’s true for all of us.

    You are correct, @marcin, although only the current insurer gives a rip. But that’s an interesting way to look at these decisions: is our current condition temporary or long-term?

    • #12
    • May 19, 2018, at 3:11 PM PDT
    • 2 likes
  13. TheRightNurse Member

    Susan Quinn (View Comment):

    Thank you for weighing in, @therightnurse. You are correct; ethics committees and governmental “death panels” are not the same. I’m glad your experience has been a positive one with these committees, but they are human and if they don’t have clear criteria for making their decisions in life-and-death situations, I’m the one who is wary of their decisions. In other stories in the article I cited, the ethics committee made decisions that I’m not saying were wrong, but could be questioned. So to be clear, I’m not in favor of committees or panels affiliated with the government or insurance companies. But I’m not ready to accept without questions the ethics committees in hospitals. As I described in my In addition, suits have been rare and there are no published judicial opinions that have articulated standards for ethics committee process. As a result, committees continue to operate with minimum oversight and without legal standards.

    Yes. And they do not make legal decisions. The government doesn’t get to decide what my Presbyterian hospital’s ethics board does or decides. There are no legal standards because there is no precedent or right for the government to determine what they are or how they act. Ethics boards are consulted in difficult cases and determine the hospital’s position.

    That’s what they do.

    They do not need to be accepted without question. Plenty of people will transfer to another hospital or choose their own route of care. Ethics boards are not legal entities and could theoretically go with “because I said so”. No one is legally bound to obey.

    • #13
    • May 19, 2018, at 4:27 PM PDT
    • 3 likes
  14. Susan Quinn Contributor
    Susan Quinn

    TheRightNurse (View Comment):
    They do not need to be accepted without question. Plenty of people will transfer to another hospital or choose their own route of care. Ethics boards are not legal entities and could theoretically go with “because I said so”. No one is legally bound to obey.

    Thanks, again, TRN. I just hope that people realize they can make a different decision when they don’t agree. Many people elevate those in the medical professions and take their advice as gospel; that’s not necessarily the fault of the profession, but is a cultural standard that has been in place for a long time. Fortunately many people also realize they are responsible, as are their families, for being well-informed and for making wise decisions for themselves. 

    • #14
    • May 19, 2018, at 5:13 PM PDT
    • 3 likes