Who Speaks For The Others?

Large and small hospitals may not advertise the fact that they have biomedical ethics committees, but they do. If  a patient's family asks "can Dad's case be reviewed by a biomedical ethics committee?" the answer may be "yes, but, we don't think that's necessary" or it may affirm the availability, willingness to meet and consider Dad's case, and the experience and expertise of the committee in formulating recommendations. Or sometimes, review of Dad's case is suggested by a hospital staff person or physician, familiar with Dad's case who also understands the issues Dad's medical and social condition present and seeks help.

This blog isn't about Dad, the subject of  biomedical ethics committee attention.  This blog is about the focus of the committee on Dad which excludes consideration of the impact of its decision and recommendations on  other individuals and communities which the institution serves.(biomedical ethics committee opinions are commonly in the form of recommendations to the doctors, staff and family, and those recommendations reflect consideration of Dad's medical and social issues, discussion with the family, review of hospital and medical staff policies and procedures, consideration of standards of care and sometimes consideration of applicable law). The review is targeted on Dad and his immediate survivors.

A simple example:  the committee recommends that Dad, who is terminal, receive full resuscitation efforts because that is what Dad's family says they want and their customs demand. Dad dies. One minute after the team begins Dad's resuscitation, a young patient suddenly and unexpectedly experiences cardiac arrest which would respond to competent resuscitation if the resuscitation team weren't occupied with Dad's fruitless resuscitation.  Dad is declared dead, the young patient receives less than optimal resuscitation and survives in a vegetative state. The decision about Dad directly impaired the care another patient received, but the biomedical ethics committee focused only on Dad. No one represented the interests of the potential "others" at the biomedical ethics conference table. When a family aggressively demands services which cannot alter the outcome of care, they may not appreciate or care about the effect of the satisfaction of that demand on the hospital's ability to provide appropriate care to other patients. But this sensitive issue is not often raised in committee deliberations and discussions.

When antibiotics are provided with knowledge that they will not affect the patient's outcome, the appearance of antibiotic resistant bacteria become a threat to all of the patients and communities that the hospital serves. The national cumulative effect of antibiotic resistant bacteria means widespread unnecessary suffering from infections which will not respond to "standard" antibiotics, a huge expenditure for tests and treatments, and preventable mortality. When, with biomedical ethics committee recommendation, an intensive care unit breathing tube is inserted with no expectation that the comatose patient will awaken or ever be weaned, that bed, those staff people, that equipment and the opportunity to care for someone who is highly likely to recover, may be irretrievable.

My suggestion is straightforward. In each biomedical ethics committee case review, one person be appointed to speak for the interests of the "others" - the patients whose lives and care may be impacted by the recommendations for a decision to be made about "Dad." Committee recommendations may not change, but the process will be more honest and inclusive..