Dilemmas of ethics committees’ effectiveness: a management and team theory contribution

Introduction

The Royal College of Physicians (2007) proposed that if ethics committees (ECs) are to be effective they must provide, and be seen to provide, support to health professionals dealing with difficult ethical issues, as well as others affected by such cases.

Dilemmas underlying much of the work published about ECs relate to questions such as: if hospital and clinical ethics committees (HECs and CECs) were designated to support health-care management decisions, why do they often fail to provide the service required of them, effectively and efficiently? What are the obstacles standing in the way of ECs’ success? How can ECs’ functioning be improved, to aid health professionals, patients and other beneficiaries? ECs in general, and HECs and CECs in particular, have been studied and researched, in the various countries in which they operate, for the purpose of enhancing their effectiveness. ^1–6 This issue has been approached in the literature through concepts such as ‘missions’, ‘expectations’ and ‘factors for success’.

Beleveld et al. ² suggest that there are two possible main missions of HECs: to help with the ethical concerns of clinicians and to assuage managers’ concerns, such as restoring public confidence or reducing litigation claims from patients. Related to the mission of helping with clinicians’ ethical concerns, they outlined nine missions that HECs may assume, recognizing that these are not mutually exclusive or exhaustive: (a) respecting the patient's interest; (b) education; (c) consensus forming; (d) therapeutic (confidence raising); (e) conflict or dispute resolution; (f) towards participation; (g) towards local democracy; (h) ethical procedural; and (i) ethical substantive.

McLean ³ points out that ‘the expectations of patients and their families – and, indeed, of wider society – are that decisions about patient care, resources and therapeutic regimes should be soundly based on appropriate ethicolegal, as well as scientific, principle’.

Schick-Critelli and Moore ⁵ identified four key factors for success of ECs: (a) support from the administration; (b) committee composition; (c) committee leadership; and (d) committee structure, function and process. Since then an intensive search has been taking place regarding the identification of more specific factors that determine ECs’ effectiveness. ^1,4 Issues regarding the make-up and constitution of these committees, the level of their education and expertise in bioethical dilemmas and their formal status in the health-care organizations in which they operate, as well as the procedures according to which they operate, the frequency of their meetings and the atmosphere and quality of communication among committee members in those meetings, have all been put forward as critical determinants of the level of effectiveness of ECs.

ECs in general are not decision-making bodies but rather advisory ones. That is, their ‘raison d’être’ is the contribution of an ethical dimension to a range of individual, clinical and organizational decisions within health-care organizations. These may include providing a recommendation on a course of action but may also consist of highlighting particular ethical considerations or perspectives that an individual or group can take into consideration when making their decision/s. ECs can be seen as part of the wider decision-making team (the multidisciplinary clinical team for individual patient decisions or the relevant organizational committee for policy decisions). It contributes to or facilitates the decision but is not responsible for all aspects of it. Although committees are rarely forums for making and implementing decisions, their goals are to eventually affect decision-making and implementation, in specific ethical directions.

This paper argues that HECs’ and CECs’ effectiveness is not merely about recommending as to how a specific factor (doctor, department, unit or health-care organization) should act regarding a particular ethical dilemma, but also about what will actually be carried out in practice. In other words, it is about ECs making a difference and monitoring changes.

The following discussion constitutes the potential contribution of team and project management theory and practice to the inquiry into the crucial factors that determine ECs’ effectiveness to carry out their missions. It proceeds to shed some light on the appropriate steps and general approach needed to be taken, to enhance ECs’ effectiveness in a variety of cultural and political frameworks.

A contribution from organizational theory and practice

A major field of study within management theory is that of teamwork, and the management of decision-making processes within teams. Organizational theory is primarily about organizations, organizational units and structures, and dilemmas faced by executives, managers and workers within organizations. Its boundaries attempt to include notions that are beyond the limits of any specific kind of organization or organizational structure. Team theory limits itself to issues that have a direct implication to teamwork, team processes and the difficulties encountered within them. Effectiveness is a primary and central issue within those scopes of knowhow. Health-care organizations constitute a major domain within both these areas of knowledge. ECs, their goals and objectives, their structure and working procedures, their association with the managements, organizational units, patients and other factors and sectors, for the benefit of whom they exist, would, therefore, be a direct concern for organizational and team experts.

In order to render legitimacy to the theoretical and conceptual ‘loan’ from this field, to the specific issues brought up in this paper, it will hereby also be argued that a committee is a team assigned to achieve particular objectives. On the basis of this argument, the diagnostic tools for studying the functioning of teams will be applied to ECs, to help shed some light on the factors that render them, as the literature reveals, ^1–6 more often than not, insufficiently effective, to this day.

Daft ⁷ proposed the following characteristics of a team: (a) two or more people are required in order to constitute a team, (b) people in a team have regular interaction and (c) people in a team share a common performance goal. In teams, people have complementary skills and work together to achieve a shared purpose. They hold themselves mutually accountable for its accomplishment. ^8,9 Teamwork is, therefore, all about a group of people having a common ‘raison d’être’, and attempting to get goals materialized and achieved. Pineda and Lerner ¹⁰ defined a project team as a collection of individuals who are interdependent in the tasks they perform and who share responsibility for outcomes.

Committees, in general, are groups of functionaries, formally nominated, to perform particular tasks and/or achieve a specific requirement. Committee members attempt to achieve clear objectives and goals, towards a previously decided-upon mission. A committee comprises several individuals, who, together, are expected to accomplish this mission. A committee is undoubtedly, according to these specifications, a working or project team. An EC is, therefore, from here on, to be considered a team, in every sense of the word.

Many have questioned, researched and discussed the issue of effective and efficient decision-making and decision-implementation in teams in general, and in teams within health-care organizations, in particular. ^11–16

Committees in general, including ECs, are groups of functionaries, formally nominated, to perform particular tasks and/or stand up to specific requirements. Committee members attempt to achieve clear objectives and goals, towards a previously decided-upon mission. An EC is, thus, a standard working and project team, according to various definitions provided in this field. ^7,10 This argument renders legitimacy to the previous theoretical and conceptual ‘loan’ from this field, for the benefit of ECs.

It has been shown, within a variety of organizations, that when different stakeholders, from different functional areas or organizations, are involved in a working team, such as an EC, contradictory interests, assumptions, expectations, knowledge and perceptions may seriously jeopardize team processes. ¹⁷

Adizes ¹² views the management of any team, project or decision, as an overall process of maximizing two objectives: the quality of decisions taken and the efficiency of their implementation. In the case of ECs, ‘decisions’ refer to the committee's future recommedations; ‘implementation’ refers to the eventual processes of turning those decisions into the desirable outcomes. A set of two tools is recommended to promote those two managerial objectives: ^11,18,19 the ‘capi’ model and the revised decision-square model (RDSM). When managing committee decisions and projects, one should make sure, in advance, that the decision (or set of decisions) one is taking is a qualitative, suitable and workable one. In order to ensure both the quality of the decisions to be taken and the smooth process of their application, regarding the solution to a problem or the promotion of a project or organizational change, the ‘capi’ model (illustrated in Figure 1) recommends that team and project managers investigate three potentially hazardous factors, prior to implementation:

The factor of ‘authority’: The ‘capi’ model ‘advises’ its users to verify, in advance, whether the project manager has, in fact, the full authority to act independently upon decisions, taken within the project.

OPEN IN VIEWER

Figure 1

The ‘capi’ model

It is the coalition (‘c’ in the model) of the three factors – ‘authority’ (‘a’), ‘power of cooperation’ (‘p’) and ‘influence’ (‘p’), and the preliminary analysis of the decision-situation with the aid of this combination, that enables one to be sure, to the maximum of one's potential abilities, of the ultimate results of one's doings. For an EC's set of recommendations to have a chance of affecting and diverting health-care decisions as well as their eventual outcomes, representatives of all the three above factors are required to mean it.

The RDSM is a tool that ensures efficient follow-up and a high level of control over project and decision implementation processes. It collapses all the possible variety of decision aspects into four categories that constitute the four sides of a square. ¹⁸ Those decision aspects include not only the goals, a detailed operative description of the final project/decision results, a detailed implementation timetable, resources and processes for their attainment, and the distribution of assignments among committee members, but also dates for future follow-up meetings of the team/committee, and the nominated project/decision coordinator. Figure 2 presents a detailed RDSM. OPEN IN VIEWER

The RDSM states that the more thoroughly, clearly and unequivocally one ‘seals’ (i.e. specifies in detail) all decision aspects, one has a better chance of efficient implementation. It recommends to ‘seal’ a decision-square (usually more than one, i.e. a square per each topic or aspect of the overall issue or project aspect), before the end of every team meeting, which takes place as part of the project. This tool touches on extremely basic issues, such as tying all loose ends, ensuring clear and unequivocal communications within teams, setting follow-up meetings and dates, etc. Its contribution for managers is in emphasizing the obvious (such as scheduling enough follow-up meetings, to ensure that quality and timetables will be maintained), which is sometimes neglected or taken for granted, thus hindering, or even totally jeopardizing efficient implementation.

The significance of these two models for future ECs’ work is elaborated in the following.

Criteria for effective ECs

A variety of obstacles, apparently, stand in the way of the effective proceeding of ECs; many of which have been researched and discussed in the literature. Examples are provided in the literature in McLean's ³ work, in that of Pedersen et al. ²⁰ and in others’. A comprehensive understanding of the nature of such obstacles is thus essential to be able to search for specific strategies and techniques to overcome them.

Shetach ¹⁸ reported on an extensive long-term observation into obstacles, interfering with team decisions and team performance. She came up with five categories of obstacles that cover the full spectrum of such interferences, in the attainment of effective and efficient teamwork results. She proceeded to present the critical factors by which to construct a working team, in order to ensure its eventual effective functioning.

It is to be argued, in the following, on the basis of the above work, ^10,17,18 that in order to maximize ECs’ effectiveness, these committees should be constructed and managed to stand up to five major criteria:

Their mission should be clarified and agreed upon, with patients’, health-care personnel's, and organizations’ interests primarily considered;

These criteria constitute a set of propositions regarding the relationships between five critical EC characteristics and their effective products, in terms of committee-stakeholders’ satisfaction. Existing policy documents for ECs, such as core competency documents, partly cover these. But are they actually fully implemented in ECs work? As will be argued in the following, effective EC work can be maximized on condition that all five criteria are applied simultaneously.

These five are elaborated, one by one, in the following five sections:

(1) Mission clarification

Is the committee's mission clarified and agreed upon, regarding each particular case, by all its members; and are patients’ and health-care personnel's, as well as the health-care organizations’ interests primarily considered?

Due to the interdisciplinary nature of these committees and the contradictory preliminary interests of their participants (e.g. low-cost decisions preferred by managements versus. quality and possibly expensive alternative solutions preferred by patients and their representatives), each factor within it would naturally view ‘effectiveness’ and ‘success’ of committee sessions in different terms. Differing goals and objectives tend to hinder the development of constructive discussion processes, failing to lead to mutually agreed-upon recommendations and decisions.

A preliminary prediscussion stage, within each meeting, spent in dealing openly with viable goals and objectives for each case or topic, is rarely attempted, on the common assumption that the declared goals are common knowledge and that underlying interests are irrelevant or non-discussable. Teams tend to rush into the actual topics under hand, rather than ‘waste time’ on controversial issues that may hinder their ‘progress’. Under such circumstances interests of patients, their families and those of medical personnel are not necessarily prioritized.

Thus, it is absolutely essential for effective teams to work their way through decision-making processes, only after a clear, mutually agreed-upon mission and specific goals have been reached among its members. ¹⁸

(2) Authority

Is the committee provided with the appropriate authority, to carry out its missions (which are, in most cases, to provide quality recommendations as well as to ensure that they will be considered and that the final decisions will eventually be applicable)?

In order for the recommendations and decisions, taken within the committee, to have validity – to actually influence medical considerations and procedures – they should be taken, and thus backed up, by the same people, who are formally authorized to see those decisions through ^10,17 (see above description of ‘capi’ model).

Two conditions are, therefore, required, in order to obtain ECs’ validity:

(a) An EC should include, as an active member, the executive, within that health-care organization, who is the ‘figure of authority’, ¹⁷ regarding the implementation of the committee's decisions, or the consideration of its recommendation. Many CECs deliberately decide to keep their committee separate from hospital management to allow freedom of discussion. It is hereby argued that ‘freedom of discussion’ is a high price to pay for the recommendations eventually being doubted, invalidated, rejected or plainly ignored. The committee should therefore include those individuals among its members, in those specific sessions where ‘their’ cases or issues are on the agenda. For example, the EC's figure of authority could be the hospital's medical executive, if the particular issue, dealt in the committee at the time, refers to more than one department in that hospital; or it can be the departmental manager, whose department brought forth the particular case, on the committee's agenda.

If both these conditions do not prevail, the committee's decisions risk having a mere recommendation status, thus missing their designated ethical objective. Evidence for these practices can be observed daily, as part of decision-making processes handled within organizations. As for their recommendations – those may risk having limited effect on the particular system – which is expected to consider carrying them out. Participants holding on to positions of authority within their organizations will render the committees’ decisions (conclusions) more likely to materialize, and the overall weight of the committee within the organization (i.e. hospital) more meaningful and central, over time. This argument may be directly related to some of the deficiencies in ECs’ functioning, reported in the literature. ^3,20

The crucial question, which is brought up here, and which has apparently not yet been directly considered by researchers and writers, in this field is whether a particular EC has, in addition to having a decision-making authority, a decision-implementation authority, i.e. an authority to follow its decisions through. This issue also has a direct impact on the following dilemma.

(3) Composition of members

Is the committee manned by a suitable composition of members, representing the relevant expert professions, as well as the factors that are expected to carry out the committee's decisions/recommendations?

In order for a committee to have both a qualitative decision-making potential and an efficient decision-implementation mandate, the composition of its members is a crucial factor. ECs are composed of members from a large range of professions. These may include administrators, bioethicists, clergy or pastoral care workers, community representatives, direct care nurses, hospital board members, nurses in management or education positions and even pharmacists. The presence of patients or their representatives in ECs is a disputed issue. McLean ³ writes: ‘The input of patients, and awareness of the patient's values, will need to be at the heart of the resolution of an ethical issue. Some committees may come to the conclusion that there are circumstances in which it is appropriate for a case to be referred by a patient, or for a patient to be present to participate in the discussion’. The differences among ECs and the disputes over this issue highlight the following dilemmas: Whose participation is, in fact, necessary for achieving effective committee products? Is there a specific technique to determine the appropriate committee composition?

It is hereby argued that there can be no universal format for CE member composition. The appropriate composition should be adapted to the specific issue discussed in the committee, as well as the overall conditions that prevail in that system, at that particular time. If, for example, a particular procedure is recommended by a certain EC, it is absolutely essential that the medical personnel who should exercise it, the hospital administration, who must authorize it, the patient, who must undergo it, and/or his representatives, and probably a few more factors (clergymen, lawyers, psychologists, social workers, therapists, etc.), who must give their consent – should all be part of the process of arriving at this recommendation. Otherwise, the recommendation may not suit one or more of the above, and/or one or more of the above will refuse to cooperate with its implementation.

If effectiveness is measured by the quality of the recommendations and decisions taken, and by the level of efficiency of their implementation, then the rationale for member composition could well be that of maximizing those two objectives. The ‘capi’ model ¹⁷ (see model description above) can serve as a potential formula for determining the precise composition of members for any given EC, regarding any particular sitting or discussion or issue to be dealt with, at any particular point in time. It is hereby advised that ECs have a wide reservoir of potential members, from a variety of relevant professions, all in positions of authority within their organizational units, who could be called on a committee's session or set of sessions, according to varying ‘capi’ requirements.

(4) Regulations and working procedures

Does the committee function along a suitable set of regulations and working procedures? Does the decision making process within the committee enable all members to share their goals, dilemmas and interests, and to, eventually, arrive at mutually satisfactory recommendations and decisions?

Quality of the dynamics and discussion processes within committees have often been mentioned as critical in determining EC effectiveness. ^2,3 Decision-making processes, practised throughout committee meetings, need to be monitored along effective and efficient techniques of directing meetings. Decisions and recommendations arrived at should be based on ethical reasoning, knowhow and expertise of each and every team member. The discussion processes should lead to mutually agreed-upon conclusions, to ensure the cooperation of all members in the consequent follow-up and implementation of the committee's ‘products’ – each member within his own domain.

(5) Follow-up and control

Does the committee employ an efficient method for follow-up and control over the consequences of their recommendations, and over the implementation process of their decisions?

In order to ensure that recommendations are dealt with and decisions are followed through, efficient follow-up procedures are required. The vast majority of decisions that are eventually inefficiently applied or altogether immaterialized are subject, in many cases, to inefficient processes of follow-up and control. The RDSM ²⁰ can be easily adopted for use in any EC, to guarantee that their decisions and recommendations are followed through, and eventually applied successfully (see model description above).

Summary and implications

Organizational and team theories attempt to cross professional boundaries, as well as boundaries of organizational and political settings, cultures, etc. They try to deal with the differences and variations at all organizational, team and situational levels, considering the commonalities of human settings, which are designated to promote goals. The ‘capi’ tool (see above) attempts to provide managers and team/committee members with the specific means to determine the situational characteristics of each organizational setting, a committee in our case, enabling one to accord manning, structures and working procedures to the specific requirement and goals of each committee process.

The crucial issue, when discussing ultimate EC effectiveness, should not be limited to investigating how ECs, in particular settings, constitution and working procedures, might improve their decision-making capabilities. The issue should rather focus on their effective results in both taking quality ethical decisions and, eventually, rendering them efficiently implemented.

An example is appropriate to clarify this point: Let us assume that an EC has managed to arrive at a satisfactory set of decisions, as far as all its members are concerned, regarding a suitable medical procedure to be followed through, for the benefit of a particular patient, his family, the medical and nursing staff and the medical institution concerned. It is argued here that this result is hardly sufficient to render efficiency. It is yet critical to ensure that those decisions will, in fact, eventually, be carried out as recommended. Otherwise, have not the efforts of all factors concerned, and all participators, been in vain?

The five conditions, presented above, when combined together, guarantee an increasingly effective and efficient EC. It is hereby argued that ECs, which are not led by medical figures of authority within the institution, which do not include representatives of all prevailing interests, and whose meetings are not managed efficiently, are unlikely to arrive at relevant and suitable decisions, which are likewise likely to be implemented. And last of all, efficient follow-up techniques are required to guarantee that the recommendations and decisions arrived at by those committees, will, eventually, be put to practice.

Each particular EC, within each specific setting, organization, country, culture, etc., is hereby encouraged to be diagnosed along those five criteria, and to be modified accordingly, to enhance its effectiveness and maximize its efficiency. The construction of those committees, as well as the working procedures that may render them effective, should be flexible and made adaptable to the specific issue or process or case, which is dealt by that committee, at the time.

Conclusions

Researchers and writers within the field of ECs have studied clinical and hospital ECs’ effectiveness mainly in terms of their abilities to affect various health-care decision-making processes. They have apparently not yet focused on ECs’ effectiveness, in light of their decision-implementation potential – their ability to influence the final outcomes of their recommendations. It is argued here that the ultimate criteria for effectiveness are the specific results obtained, within the actual operating ground, and the extent of positive change acquired, in light of the previously set missions and objectives, rather than the recommendations and decisions arrived at, within the committee's meeting room. ECs’ effectiveness is not merely, for example, about recommending as to how a specific factor (doctor, department, unit or health-care organization) should act, regarding a particular ethical dilemma, but also about what will actually be carried out in practice, as a result of the committee's work, i.e. about making a difference and monitoring changes.

Thus, an attempt to adopt a few notions from the team theory has been, hereby, made. Five specific conditions for ECs’ success are brought forth. It is argued that when all these five are applied and practised together, an increased effectiveness and efficiency of ECs could be guaranteed.

In order for ECs to have any influence at all, they should be constructed so as not to be bypassed and ignored. The dynamics of decision-making and decision-implementation processes are hereby advised to be seriously considered, to ensure ECs’ effectiveness. Organizational ‘politics’ – conflicting interests and struggles over power-based issues, among the various sectors, professions and individuals within organizations, as well as overall organizational processes leading to the final desirable outcomes – should all be taken into consideration as part of EC overall planning and management.

Thus, the following conclusions are reached here:

The specific constitution of the committee members should vary according to the particular mission addressed at each and every meeting or series of meetings;