Health Care Ethics Consultation. Individual Consultant or Committee Model?: Pros and Cons

The American Society for Bioethics and Humanities is to be congratulated on its updating of competency standards for ethics consultations (Tarzian and ASBH Core Competencies Update Task Force 2013). These will be of great assistance to ethics committees all over the world, given that quality assessment for this service has had extremely limited implementation in many countries.

The report defines “ethics consultation” as a service that can be provided by one person or by a group. In other words, consultation can be made individually by an individual consultant or by several people together in what is traditionally known as an ethics committee. Both models are analyzed by Tarzian and colleagues from the perspective of skill competencies requiered in order to carry out this advisory function. However, it would also be very useful to consider their respective advantages and drawbacks, taking into account the repercussion that these models have in facilitating ethics consultation in health care delivery and in the quality of service.

The individual consultant model, more common in the United States, offers greater ease of access and more speed and flexibility for the consultation process. For a health care professional considering making a request for assistance for an ethical problem, it is more practical to turn to a consultant, who can be located and contacted in the space of a few hours, than to think of attending a committee meeting that is held intermittently. Intuitively, this can be likened to a clinical referral situation in which assistance is requested from another specialist: Initiating a consultation process with a colleague who can provide a response within a short period of time is not the same as waiting for a diagnostic session to be held in which the team can discuss the case. However, gains in speed and flexibility can have an adverse effect on the quality of the response, which theoretically would come with greater guarantees when it is the result of the deliberation of a committee that provides a wealth of different perspectives, something that is difficult for an individual consultant to achieve.

Another advantage of the individual consultant is the low exposure of the case in question to public scrutiny. This may be more highly valued by professionals making the consultation, given that despite the strict confidentiality to which committee members are subject, there is a certain hesitance to undergo what can be viewed as a public examination when it comes to explaining the prior professional actions taken in the case. In European countries where the committee is the prevalent model for holding ethics consultations, this is one of the reasons for the scarcity of consultations, owing to the fear professionals have of being ridiculed in cases where their problem may be interpreted as elementary of lacking in substance, reflecting a possible lack of training.

For many patients and their families, it would be more convenient to request advice from a personal consultant than from a committee of strangers who may prove to be intimidating. However, there may also be cases where advice with a range of alternatives and different levels of moral sensitivity is preferred, for which a committee would always be seen as a better option.

When faced with doubts in “ordinary” cases in their daily activity, professionals commonly will hold informal consultations in corridors with colleagues whose advice is seen as trustworthy, and, if possible, turn to an ethics committee member in such a way that the consultation will not be recorded as authentic part of the committee's advisory activity, when it actually does fall under this definition. Perhaps more importance should be given to this category of informal consultations and recording them, in order to place a value on this task that quietly contributes to the quality of health care delivered by the institution. It would also serve to raise the self-esteem of some committees whose members often receive these kinds of informal consultations that are subsequently not included in reports on their activity, while complaining they receive few “officially” presented cases.

Another reason favoring individual consultants is the possibility that they can be chosen at will by professionals, adding a degree of trust that enhances interaction in order to obtain the necessary information for a response that is more rapid and complete, unlike committee procedures, which are seen as slower and more rigid, qualities that dissuade professionals from consulting them.

It is true, however, that the cases formally received by committees tend to involve remarkably complex ethical problems, where the response provided by an individual consultant would be at a disadvantage, at least from the theoretical perspective of the moral deliberation preceding clinical decision making (Gracia 2001). The diverse profiles of the members on a committee, with different kinds of health care professionals and even patients, guarantee multiple approaches and opinions, which enrich the ethical deliberation of the group and the final response. Although this is advantageous, it should pointed out that there is also a disadvantage on occasions when consensus is not reached (Adams 2009).

It is a fact that doctors have difficulty writing up cases in full detail, including lists of circumstances, conflicting values, and so on, which are prerequisites for presenting problems to a committee. However, it is a common occurrence that a committee member will act as a “fairy godmother” by helping to prepare the consultation, transforming an informal, verbal, face-to-face consultation and following guidelines that many committees normally provide in order to clarify the professional's ideas and facilitate the presentation of the case. Additionally, a private conversation with a consultant enables the questions to be broadened or made more specific as answers are given, and allows interaction to take place if the circumstances of the case vary. In comparison, consultations made directly to a committee present a certain rigidity and often require additional clarifications.

It is interesting to point out the experiences where this personal encounter with a committee member acting as an actual consultant in a “pre-consulation” may help to resolve the original doubts, simply as a result of bringing order the ideas that were in disarray owing to the emotional dimension of the problem under consideration.

While it is stressed that the response given by a committee is only orientative and does not replace the decision made by the professional in charge of a case, a number of doctors fear legal reprisals if they act contrary to the opinion of a group of experts reflected in a document annexed to the medical records. These reports are taken into account in the courts of law of a number of countries (Couceiro and Beca 2006; Montano 2007)—together with the remainder of the information and clinical documentation—when there are no specific regulations or legal precedents governing the matter before the court. There has been criticism in the United Kingdom of the negative influence committees have on patient relations owing to the legal implications of their resolutions (Fulford 2000). This should be taken into consideration when giving information on the pros and cons of consulting a committee or an individual consultant.

A number of committees routinely bring together all the parties involved in a consultation (patients, family, and professionals), which is often not effective and may even be harmful, as pointed out in the report of the American Society for Bioethics and Humanities. This is less likely to occur with individual consultants, as they can arrange separate meetings with the different parties, which are probably more appropriate for patients and their families. Nevertheless, this advantage can be maintained if a committee has consultants among its members who can carry out this task.

A clear advantage of committees is the varied qualifications of their members, which are complementary and can make up for the lack of training in different aspects of some of their members. On the contrary, an individual consultant may have a good background in ethics and clinical experience, but may lack legal training.

In the light of the different advantages and drawbacks of both models, it is important to assess the preferences and needs of the health care professionals, patients, and families seeking ethical consultations (Altisent, Buil, and Delgado-Marroquín 2012). A number of authors (La Puma and Schiedermayer 1994), have spent years defending the need for both figures, given their shared synergies and complementarity.

It would be worthwhile to take full advantage of both models without causing antagonism: making the most of the potential deliberational wealth of ethics committees and providing them with the necessary flexibility so that some of their members are trained to act as individual consultants when required, or as “fairy godmothers” by facilitating the presentation of consultations to the committee. In any case, the evaluation of the standards of competency and quality proposed for health care ethics consultation should be present, even for informal consultations, with the appropriate modifications. Nevertheless, it would be suitable to incorporate as a quality criterion information on the pros and cons of both models for consulting professionals so that people choose the model that is best adapted to their needs.

Acknowledgments

Funding was provided by Instituto de Salud Carlos III. PI 05/2590, PI 09/1735.