© 2006 National Rural Health Association 193 Summer 2006

. . . . . Commentary . . . . .

Where Is the Evidence: A Need to Assess Rural Ethics Committee Models William Nelson , PhD 1

Ethics committees are an important resource for health care providers and administrators in addressing ethical confl icts. 1-4 Even though ethics committees have evolved over the past 2 decades, 5-10 there is a generally

accepted purpose, structure, and set of functions framing the traditional ethics committee. The basic functions include ethics education, institutional policy review and development, and case consultation. The focus of these activities is primarily clinical, with some committees also addressing organizational ethics confl icts. Even though ethics committees vary in effectiveness, structure, and function, they tend to have multidisciplinary professionals, 2,11 defi ned functions and processes, regular meetings, members participating in meetings, consultation services, ethics education, and a formally trained ethics expert available to advise and/or educate members.

Ethics Committees in Rural Settings Unlike their large urban counterparts, small rural

health care facilities are less likely to have ethics committees. Survey data from 117 hospital administrators from 6 western states indicated that only 42% of the hospitals had created ethics committees or other formal models for providing ethics services. 12 Physician and nurse surveys indicated that only 29% and 22%, respectively, have access to ethics resources. 13 In another survey noted by Cook and Hoas 14 of 600 randomly selected rural physicians from Montana, Wyoming, and North Dakota, only 29% reported access to any ethics-related resources and 75% of the physicians had never referred a case to an ethics committee.

Obstacles for Implementing the Traditional Ethics Committees

Where they do exist, some ethics committees in rural facilities encounter obstacles in functioning similar to a traditional committee, including:

• Lack of multidisciplinary and available professionals — small rural hospitals tend to have limited services and diversity of health care professionals, such as

mental health professionals, which reduces the possibility of having a multidisciplinary committee. 15,16

• Lack of regular meetings — ethics committees in rural facilities are less likely than urban committees to meet regularly.

• Members ’ lack of ethics knowledge and skills — many members of rural ethics committees lack ethics training, 3,17 and few rural ethics case consultants possess the recommended knowledge and skills for performing consultations. 2,11,18

• Limited opportunities for relevant ethics training — rural facilities have limited budgets, which impacts the fi nancial support for training committee members. 3,11,14,19,20

• Effectiveness of training content and material — rural committee members report that training, textbooks, and journals rarely focus on ethics confl icts occurring within rural contexts. 21,22

• Lack of regulatory requirement for an ethics “ mechanism ” — rural hospitals are less likely than larger urban facilities to be reviewed by the Joint Commission on Accreditation of Healthcare Organizations. 12

• Rural familiarity — the traditional ethics case consultation process raises challenges rarely seen in urban facilities because of interwoven values and overlapping relationships among patients, clinicians, and ethics consultants in rural settings. 3,4,12,23-25

1 Departments of Psychiatry and Community and Family Medicine,

Dartmouth Medical School, Hanover, NH.

The author expresses his appreciation to Gili Lushkov, MS, and

Paula Schnurr, PhD, for providing helpful reviews and suggestions

to this manuscript. This manuscript was supported by the

Veterans Health Administration Rural Health Initiatives, White River

Junction, Vermont. The views expressed in this article do not

necessarily represent the views of the Department of Veterans

Affairs or of the US government. For further information, contact:

William Nelson, PhD, Dartmouth Medical School, Strasenburgh

Hall, Hanover, NH 03755; e-mail william.a.nelson@dartmouth.edu .

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The Journal of Rural Health 194 Vol. 22, No. 3

Promoting Effective Rural Ethics Committees

What should be the rural facility ’ s mechanism to meet the need for competent and effective resources to address ethics confl icts? Even though there never will be a universal ethics resource model because of the diversity of rural settings, various rural-attuned models should be considered. One approach is to implement local strategies to systemically overcome the obstacles to using a traditional committee model. 17 Niemira 3,17 suggests the development of a local ethics expert to guide the activities and competency of the ethics committee. This strategy may be effective where there is institutional support for an identifi ed ethics leader who is willing to help train and support the committee members.

Rural ethics committees could be linked and supported by statewide ethics networks. Unfortunately, even if rural committee members attend network training, they frequently feel out of place because network leaders, presenters, and many participants tend to be from large academic facilities in urban areas and are unfamiliar with the confl icts encountered in rural settings. State networks can potentially enhance rural ethics committee members ’ knowledge and skills, but these networks rarely foster ongoing linkage between autonomous local committees. 20,26 Where state networks recognize rural issues, however, they could be a useful support to the rural committee members.

Another response to meeting the need for an effective ethics mechanism is to recognize that the traditional model may not be feasible in small rural facilities. 3 Since rural facilities have limited fi nancial resources and rural ethics expertise 27 and few multidisciplinary professionals, other committee models may need to be considered.

Another option, building upon proposals by Niemira, 20 Rauh and Bushy, 19 and Cook and Hoas (1999) 1 for linking rural ethics committees, is a multifacility ethics committee (MFEC). The MFEC would provide several of the basic functions of the traditional model while overcoming many of the obstacles that limit the effectiveness of rural committees. 12,28 The MFEC model is particularly plausible and is being developed where there is an existing network of facilities. The model has the potential to be effi cient and effective by sharing ethics expertise and fi nancial support and by reducing duplication of efforts.

Each facility participating in an MFEC would identify 1 or 2 professionals to serve on the committee. The membership criteria would be a willingness to participate in regular meetings, a commitment to

develop their ethics knowledge and skills, being a respected member of their local facility ’ s staff, and dedicated time. An MFEC ’ s members would select the committee ’ s chair or cochairs. Each participating facility would provide fi nancial support for its representative(s) and modest support for the MFEC ’ s general operation. The support could be pooled without overly taxing any individual facility. Because of geographical distances between facilities, regular meetings could be conducted by conference calling or, where available, videoconferencing.

An MFEC would foster ethical practices at member facilities through 2 functions. First, education activities would focus on promoting the knowledge and skills of MFEC members as well as supporting members ’ efforts to facilitate ethics training at their local facilities. Lack of ethics expertise is a concern. 12,14,17,24 However, since members come from multiple facilities, the probability of some MFEC members having ethics training increases. Since membership criteria include a willingness to seek increased competency in health care ethics, members ’ expertise should evolve.

The second and primary function would involve a shift from the traditional model of reacting to indivi dual cases to a proactive review of organizational practices. The MFEC would (1) identify and prioritize common, recurring ethical confl icts at MFEC member facilities, such as confi dentially, dual or overlapping clinician-patient relationships, and confl icting roles; 23,25,26,29 (2) study the confl ict(s); (3) review the ethically grounded alternatives to the confl ict; and (4) select the appropriate response and draft a document, such as a procedure guideline or suggested policy or education plan. The document would be shared with the local facility for review and potential implemen tation. Where implemented, the MFEC member(s) could track the proposed response to the ethics issue to assess its impact on preventing or resolving the confl ict. Such a process could promote consistent, reasoned ethical practices while not burdening any one facility.

The model could provide a third function, case consultation, after the MFEC gained respect, expertise, and appreciation.

The briefl y described MFEC model, like other rural ethics committee models, must be carefully planned, implemented, and assessed to determine its effectiveness in helping clinical and administrative staff respond to ethical confl icts.

Conclusion Rural health care professionals recognize the need

for effective mechanisms to address the ever-growing

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Nelson 195 Summer 2006

litany of ethical challenges. 3,19,20,28 The traditional ethics committee model is well established, especially in the large urban facilities. The obstacles to implementing the traditional model in rural settings suggest that the model may not be culturally attuned to this context. Therefore, alternative models should be considered. In some situations, a multifacility model has the potential to be effi cient and effective by sharing ethics expertise and fi nancial support and by reducing duplication of efforts. This model, like other models, should be formally evaluated to provide evidence for broader dissemination in rural health care facilities. 30,31

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