Ethics Committees As Corporate and Public Policy Advocates
New roles will open to ethics committees in the 1990s in the face of dramatic changes in the structure of the health care system and range of patient care choices. As vertically integrated corporations take over the for-profit sector, an ethos of profit maximization and value-blind competition will affect options available to patients in both the for-profit and non-profit sectors. Moreover, if current trends continue, local and federal governments will enact new laws and regulations restricting the kinds of care available not only to the poor, but to those better off, in attempts to decrease growth in their budgetary allocations to health care. The cost containment policies of corporate superstructures and government bodies will adversely constrain the health care choices of patients and create barriers against shared decisionmaking by patients and caregivers. Ethics committees, in response, will find themselves morally impelled to move into the corporate and public policy arenas to advocate a recovery of our fundamental vision of the connection between human dignity, individual need, and the common good.
Should ethics committees engage in public discussion of ethical issues affecting patient care? Is it wise for them to address directors of corporate conglomerates, visit congresspeople, submit briefs to courts on these issues? If so, should they speak out on positions taken at their home institutions or present their own?
Mature ethics committees will be increasingly called upon to engage in advocacy outside the walls of their institutions in the next decade if they are to fulfill their mission within those very walls. The institutions they serve are not just a collection of miscellaneous health care services, but agents of care and healing with a special trust, a fiduciary responsibility, that most other market-oriented institutions do not share. To meet this responsibility, health care institutions must give high priority to the interests of their patients.
As the interests of some patients are adversely affected by policies that lead to skimming and dumping, mandated care by protocol, and triage by wallet, ethics committees, the "conscience" of their institutions, will have to speak out. They cannot meet their charge of eliciting, developing, and upholding a value structure for their institutions if they remain silent about extra-institutional policies that work to the detriment of patients. Committees with experience at in-house education will be especially well geared to serve as advocates in the corporate and public forums, for they will have well-developed ideas, information, and arguments to provide to policy makers. (Of course, they will have an obligation to check with the in-house body to which they report about possible legal restrictions on their promotion of particular legislation.)
Ethics committees are already beginning to move outside their institutions as their members enter the halls of Congress to acquaint legislators with the Patient Self-Determination Act. They are venturing into courtrooms to provide advisory opinions about difficult patient care cases, meeting in regional networks to exchange methods for resolving common problems, and sitting at corporate boardroom tables to assist in health care planning, financing, and delivery.
Some will argue that this is a terrible mistake. Ethics committees should function as ethical tabula rasas, bringing no preconceptions or biases to their deliberations. Since their members often have different ethical convictions, none has a claim on the absolute truth. The role of these committees, on this view, is to facilitate the development of fair decision-making processes, not to espouse substantive positions. Committees cannot take a stance on policy matters without compromising their integrity as impartial adjudicators and should …