University of Connecticut
Improving Hospital Ethics Committees (HECs): Educating Across the Health Professions
Concern that further expansion of the scope and complexity of modern medicine might soon overwhelm decision making about patients has led to the widespread introduction of Hospital Ethics Committees (HECs). The membership of such committees is generally made up of doctors, nurses, lawyers, hospital administrators, risk managers, social workers, philosophers, and clergy, with the medical professionals predominating. While the members of these committees are on the whole well equipped to understand the technological issues associated with complex treatment decisions, few have had any training in moral philosophy (ethics), health law, or associated disciplines. This project had as its goal the development, piloting and evaluation of a week-long ethics and health law curriculum for members of HECs.
The curriculum focused on three areas of concern to HECs: committee structure and procedures, techniques for case analysis, and topical issues. Three sessions were devoted to committee mandate, authority and operating practices; six to relevant moral, ethical and legal issues and their application; and six to illustrations of their application in particular matters that commonly come to HEC attention. Ultimately these 15 core sessions were merged into an intensive one-week seminar that also included attention to sources of literature relevant to core issues and the means of assessing them.
The seminar was offered three times between April 1988 and February 1989 in different parts of the country to groups of about 15 each, a total of 47 in all. One seminar included only new HEC members; another, members with 1-3 years' experience; and the third, veteran members. Each seminar group was representative of the mix of professional backgrounds typical of HECs. All three seminars were taught by the co-project directors, project faculty, and legal preceptors recruited locally.
This is the only program to offer systematic training in bioethical and legal issues to HEC members. Given that nearly two-thirds of the nation's acute care hospitals have appointed healthcare ethics committees, this sort of training is of utmost importance to large numbers of people.
The project directors have further initiated a periodical, Hospital Ethics Committee Forum, (now HealthCare Ethics Committee Forum) which appears six times a year. HEC Forum displays the work of HEC members and includes HEC members on its editorial advisory board.
Separation of the original 47 participants into seminars based on level of experience allowed a good estimate of the kind of person for whom the seminar would be of most value. The primary means of assessment was a pre-test/post-test technique in which identical questions were posed at the beginning and end of the seminar. The test included sections on HEC procedure, formulation of questions that should be raised in relation to a particularly challenging hypothetical case, and journals and books that might be consulted in dealing with the case.
The pre-test revealed marked differences among participants with differing levels of experience on both the test as a whole and most subsections of the test. By the end of the seminar, 73 percent of the new members had improved their score, and the average gain for the group was 11.5 points out of 100. By contrast, only 44 percent of the one-to-three year members and 50 percent of those with longer tenures improved their scores. The mean score of the group made up of new members improved only slightly, while the mean of the most experienced group actually declined. The decline seems to have more to do with chance and test conditions than with an actual decline in knowledge, and none of the declines was statistically significant.
These results suggest that the seminar increased knowledge only of the new members and particularly in the area of HEC organization and functioning. However, participant ratings and comments on the seminar as a learning experience were uniformly high for all three groups of participants. Indeed, 71 percent of the most experienced group gave the seminar "very high" ratings. The sessions on specific analytic techniques seem to have been the most appreciated. Thus even the more experienced HEC members appear to have gained a good deal, even if some of that gain was not measured by the principal assessment instrument.
Other than years of HEC experience, the only variable on which participant learning and response differed was professional background. Even here, while lawyers did notably better and social workers somewhat less well than other groups on the post-test, members of other professional categories were clustered within a seven-point range. Gender, place of employment (hospital or non-hospital), age and committee role (chair or member) resulted in quite insignificant differences.
The project identified a special subgroup with particular learning needs and devised a curriculum and pedagogy to address those needs, apparently with measurable success. Beyond the seminars themselves, the project has led to the completion of 45 participant papers on HEC procedures and bioethical issues, and the founding of HEC Forum for HEC members.
Major Insights and Lessons Learned
The curriculum appears most successful in bringing new members of HECs up to the functioning level of more experienced ones. However, participant response suggests that the experience is intellectually stimulating even for the more veteran participants.
State laws and other regulations mandating HECs have resulted in an increase in such groups since the project was completed. Building on the documented success of this project, the project directors (as co-editors of HEC Forum) will disseminate its ethics curriculum nationwide to HECs, supported by a new three-year grant from FIPSE. The project includes expanding the numbers of present faculty in health-care ethics and health law by conducting one in-service training program, and educating members of HECs at 60 sites using the curriculum modules and materials developed in the initial project. At mid-decade the project directors plan to convene a conference of U.S. HEC network leaders, who are dedicated to the continuing bioethics/health law education of HECs.
Information about the journal, HealthCare Ethics Committee Forum, and about future educational opportunities growing out of the project is available from:
Stuart F. Spicker
Center for Ethics, Medicine and Public Issues
Baylor College of Medicine
1 Baylor Plaza
Houston, TX 77030