Sci Eng Ethics DOI 10.1007/s11948-014-9609-x ORIGINAL PAPER

Hospital Ethics Committees in Poland Marek Czarkowski • Katarzyna Kaczmarczyk Beata Szyman´ska



Received: 8 May 2014 / Accepted: 10 September 2014 Ó Springer Science+Business Media Dordrecht 2014

Abstract According to UNESCO guidelines, one of the four forms of bioethics committees in medicine are the Hospital Ethics Committees (HECs). The purpose of this study was to evaluate how the above guidelines are implemented in real practice. There were 111 hospitals selected out of 176 Polish clinical hospitals and hospitals accredited by Center of Monitoring Quality in Health System. The study was conducted by the survey method. There were 56 (50 %) hospitals that responded to the survey. The number of HECs members fluctuated between 3 and 16 members, where usually 5 (22 % of HECs) members were part of the board committee. The composition of the HECs for professions other than physicians was diverse and non-standardized (nurses—in 86 % of HECs, clergy—42 %, lawyers— 38 %, psychologists—28 %, hospital management—23 %, rehab staff—7 %, patient representatives—3 %, ethicists—2 %). Only 55 % of HECs had a professional set of standards. 98 % of HECs had specific tasks. 62 % of HECs were asked for their expertise, and 55 % prepared \6.88 % of the opinions were related to interpersonal relations between hospital personnel, patients and their families with emphasis on the interactions between superiors and their inferiors or hospital staff and patients and their families. Only 12 % of the opinions were reported by the respondents as related to ethical dilemmas. In conclusion, few Polish hospitals have HECs, and the structure, services and workload are not always adequate. To ensure a reliable operation of HECs requires the development of relevant legislation, standard operating procedures and well trained members.

M. Czarkowski (&)  K. Kaczmarczyk  B. Szyman´ska Department of Endocrinology and Internal Medicine, Medical University of Warsaw, ul. Banacha 1a, 02-097 Warsaw, Poland e-mail: [email protected] M. Czarkowski Center of Bioethics of the Supreme Medical Council, ul. Sobieskiego 110, 00-764 Warsaw, Poland

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Keywords Hospital ethics committees  Polish  Clinical ethics committees  Clinical ethics support

Introduction Hospital Ethics Committees (HECs) are designed to help to educate and advise health care professionals, patients and families and the institutions about ethical issues arising from clinical practice and patient care (Florida Bioethics Network 2011; Slowther et al. 2004a, b). The reasoning behind initiating HECs is to emphasize official standpoints of the representatives of diverse environments. For example, the Universal Declaration on Bioethics and Human Rights, that was unanimously approved during the 33rd General UNESCO Conference, supports the actions of the HECs. According to Article 19 of the Declaration, independent, multidisciplinary and pluralist ethics committees should be established, promoted and supported at the appropriate level in order to provide guidance on ethical problems in the clinical setting (UNESCO 2006). The Pontifical Council for Pastoral Assistance to Health Care Workers has similar point of view on this issue and supports establishing HECs. The authors of that document state that healthcare workers, especially doctors, cannot be left alone and overloaded with the entire responsibility of more and more complex and complicated clinical cases (Pontifical Council for Pastoral Assistance to Health Care Workers 1995). The USA has the greatest amount of experience with utilizing ethics committees, which dates back to the 80 s, of the 20th century (Rosner 1985). HECs have existed in Europe, mainly in Great Britain for many years (Slowther et al. 2004a, b). However, there are three models of ethics consultations: individual consultant, a small team of individuals, and a full HEC (American Academy of Pediatrics 2001; Fox et al. 2007). In Europe, ethics consultations are usually provided by HECs (Førde and Pedersen 2011; Slowther et al. 2012). In 2008, the act regarding accreditation in healthcare was approved in Poland (Act on accreditation in healthcare 2009a). The goal of the accreditation was to evaluate hospitals’ standards of healthcare delivery and functioning of the hospitals. According to the act, the accreditation standards needed to be developed. The standards were prepared by the Center for Health Care Quality Monitoring (CHCQM), which is part of Health Administration. CHCQM received the status of WHO Collaborating Center for Development of Quality and Safety in Health Systems. The accreditation standards were published in 2009. One of the standards was regarding the techniques for resolving ethical issues (ZO-8). According to the standards, every hospital should elect a group of individuals that has gained trust among the employees (HEC), and could serve other employees and patients with advice on ethical issues (Center for Health Care Quality Monitoring 2009). The accreditation standards stated that the information about HEC has to be provided within the accredited hospital. There were no other regulations regarding HECs. There are no laws regulating HECs in Poland. This study was conducted in order to evaluate how the tasks mentioned above were carried out in clinical practice, in one the newest European Union member states.

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Materials and Methods The purpose of the study was to analyze the activity of HECs in Poland. During the research, there were 913 general hospitals in Poland (Central Statistical Office 2013). For the purpose of the study, two groups of hospitals were selected which were accredited with CHCQM during the time the study was conducted (121 hospitals), along with clinical hospitals which were located next to medical schools or scientific research institutions and did not possess those accreditations (51 hospitals). Altogether, 176 hospitals were chosen. All of the hospitals were contacted and it was determined that HECs operated in 111 of them (10 of the hospitals were not able to be contacted). A survey was sent to the 111 pre-selected hospitals (98 accredited hospitals and 13 clinical hospitals without accreditation). Of the hospitals which held the accreditation, not all of them were responsible for having HECs, since as stated in the obligatory regulations of the 221 accreditation standards (Center for Health Care Quality Monitoring 2009), in order to receive accreditation, one must obtain only 75 % of the points (Regulation of the Minister of Health 2009). The study did not allow the determination of the actual number of active HECs in Poland. First of all, there is no law regulating the registration of HECs. Secondly, not every HEC accredited hospital responded to the survey. Lastly, the survey did not include the small hospitals. The questionnaire was prepared based on earlier published works related to ethics consultations (Gaudine et al. 2010; Slowther et al. 2001) and only contained questions related to facts. The questionnaire was refined through three interviews with selected members or chairs of HECs. Their suggestions were considered when the final draft of the survey was prepared. The survey contained questions about the start date, the structure and the number of members, whether it had an official set of regulations, duties and their nature, the number of consultations and their themes, member’s rewards, people who could ask for support, the limitations and the reasons why HEC’s were initiated. The questionnaire included both multiple choice questions as well as open ended questions regarding the type of tasks that HECs handles, consultation’s topics, and the limitations that interfered with the capacity of HECs. The survey was prepared by a website called SurveyMonkey (https://www.surveymonkey.com/). Additionally, the opportunity to use traditional survey methods of paper and pencil was provided. The questionnaires were mailed to the Center of Bioethics of the Supreme Medical Council after completion.

Results Of the 111 hospitals, 56 (50.5 %) responded. Only 13 out of 54 (24 %) hospitals have HECs that were established before 2010. The HECs did not have a common naming system. There were different names used, such as: advise committee for clinical ethics, ethical dilemmas committee, hospital’s ethical committee, hospital’s ethics committee, ethical team, ethical committee, ethical-medical team, and ethical team for geriatrics.

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Fig. 1 Proportion of HECs with number of all included members

The Structure of HECs The number of HECs members fluctuated between 3 and 16 members (Fig. 1), usually 5 (22 % HECs) members made up of the committee. The number of members who were physicians usually did not exceed 3 people in the committee (79 % HECs). There were only 2 HECs (4 %) identified in which all of the board members were composed solely of medical doctors. Besides the physicians in Polish HECs, there were also: nurses (in 86 % of HECs), clergy (in 42 % of HECs), lawyers (in 38 % of HECs) and psychologists (in 28 % of HECs). The administrative hospital staff, such as directors, unit managers and other assistive personnel were found in 23 % of HECs. The members of other professions were rarely part of HECs—rehab staff (in 7 % of HECs), ethicists (in 2 % of HECs), patient’s rights representatives (in 3 % of HECs). The percentage of HECs members representing specific profession are shown in the Fig. 2. The Method of Working Only 55 % of the HECs had an official set of regulations, while 98 % had specific duties. The duties of HECs included: solving ethical issues related to patient care (88 % of HECs) and education in medical ethics (47 % of HECs). The Workload for HECs 62 % of the HECs (33 out of 53) were asked to express their opinions. 55 % of HECs (29 out of 53) answered \6 times. Of the HECs who exchanged these opinions, only 12 % were related to a difficult medical decision, such as weaning from the ventilator and extubation at the end of life, futile treatment and

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Fig. 2 Percentage of HECs with at least one member in this category (N = 56)

discontinuation of medical treatment, and palliative care consultations. 88 % of opinions focused on conflicts among the hospital employees or between the hospital employees, patients and their families or other persons (for example: robberies, tobacco use among hospital employees, division of the responsibilities of different workers responsible for assistance with the healing process, allowing the provocation of hospital staff, rude behavior of supervisor towards his subordinates or hospital personnel towards patients, damage to the reputation of the hospital or workers). Besides the well-defined themes in regards to consultation, the survey also contained answer choices such as: non-ethical behavior of the hospital personnel or conflicts between superiors and inferiors or between hospital personnel and patients and/or patients’ family members in the hospital environment. HECs’ Operational Methods 91 % of HECs (49 out of 54) has specific regulations regarding who can use their services, that being: physicians (100 %), patients (88 %), patient’s families (79 %) and others, in that: assistive medical staff and non-medical hospital personnel (91 %). Usually, members of HECs were not paid. Only in 4 % of the HECs (2 out of 55) members were paid for their attendance in the HECs sessions. The Limitations that Affect the HECs’ Activity 74 % of the HECs state that there are no limitations that would affect their activity. The remaining 26 % stated that the main limitation is the lack of laws regulating their activity (78 %) and difficulties related to the organizing and maintaining the

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activity of the committee (43 %). 14 % of the surveys stated that there were no ethical issues noted. The main reason behind creating the HECs were hospital’s accreditation requirements (74 %).

Discussion Polish hospitals are going through a transformation in terms of the structure and ownership, that may have an influence on the number of active HECs. For example, in 2011, there were 856 hospitals and in 2012 the number of hospitals increased to 913 (Central Statistical Office 2012, 2013). Supposedly, the actual number of HECs does not differ a lot from the number presented in this study. It is based on the following: the majority of HECs were founded because it was one of the accreditation requirements (accreditation requirement is the reason why 74 % of HECs that participated in the survey were created and almost the same percentage of HECs was established in 2010 and later, when the accreditation standards were established in Polish hospitals). Since accreditation was the major reason for establishing HECs, they were more or less only created in the hospitals that were applying for accreditation. All hospitals that have accreditation were included in the study. A second group that the study targeted were clinical hospitals. Clinical hospitals are famous for the promotion of health and wellness. Thus, HECs are most likely to be established by the hospitals that are located next to medical schools or scientific research institutions. The best piece of evidence for that is the fact that the first HEC was created by a clinical hospital (Czarkowski 2011). In conclusion, these methods allowed us to localize the majority of the active HECs. The number of received answers (50.5 %) facilitates the establishment of credible data about HEC’s structure and mechanism of action. A diverse background of the HEC members provides their credibility and validity. Thus, the members of HECs should not only have medical education but also ethical, paralegal, cultural and religious knowledge (Florida Bioethics Network 2011; Slowther et al. 2004a, b). It is essential that there are members involved who are not affiliated with the institution selecting HECs (Florida Bioethics Network 2011). This is crucial in providing the independence and freedom of the functioning of HECs. Thus, HECs should consist of at least a few members from different backgrounds. Recommendation #4 points out that the number of members of HECs should be at least six members (a physician, a nurse, an administrator, a clergy person, a social worker and an individual who is not involved in patient care and who is not a member of the clergy or clinical health care provider or attorney) (Florida Bioethics Network 2011). Usually, there were five board members in the committee; however there were committees that had more than five board members (Fig. 1). These numbers within Polish HECs do not differ much from the average number of individuals who performed ethics consultations in the USA (Fox et al. 2007). The numbers included in HECs in Great Britain, is however greater, as more often, the commissions were composed of 16 members (Slowther et al. 2012). Theoretically, HECs had five board members or more who should fulfill their duty, under the condition that the number of members will be adjusted to each task

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and based on every task’s severity. Among HECs that participated in the survey, members who were not medical professionals were underrepresented, such as attorneys, clergy, ethicists and psychologists. It was likely caused by confidentiality issues (as the survey did not contain a question regarding this topic). Running ethical consultations requires accessing confidential information about patients by members of HECs. Polish law does not allow sharing patient-sensitive information with HECs (art. 26) (The Act on patient’s rights 2009b). Moreover the accreditation standard ZO-8 concerning ethical issues does not recommend that HECs have members who are not medical professionals (Center for Health Care Quality Monitoring 2009). It is worth remembering, that a large portion of older doctors (who are entitled to be appointed to HECs) never had any formal education regarding ethics, and detailed rules for appointing members to HECs were never clearly specified. In other European countries, such as Norway, psychologist, attorney and/or clergy are not members of every HEC, however the Norwegian HEC’s structure is more diverse, e.g. there are ethicists involved more frequently than in Polish HECs (Førde and Pedersen 2011). Perhaps, it is related to the fact that these institutions were founded earlier than in Poland—the first HEC was initiated 18 years ago. It was then possible to make corrections to the composition of HECs. It is also important to realize, that the formation of HECs is supported by the University of Oslo, and that there are specified rules and recommendations (Førde and Pedersen 2011; Pedersen et al. 2008). In many countries, such as Great Britain, HECs were created despite the lack of laws and regulations (Campbell 2001). However, there were some guidelines that facilitated the accomplishing of the HECs’ duties (Slowther et al. 2004a, b). In Poland, besides a few articles in the medical literature, no other supporting guidelines were found (Czarkowski 2010a, b). In a situation where there are no official laws, it is crucial to have a set of unofficial (internal) rules that regulate HECs’ tasks. 98 % of HECs had specific tasks but only 55 % of HECs had official regulations. It is very common that HECs that lack an official set of standards also do not have standardized pathways which help solve ethical issues in a similar way, though not necessarily have the same view about particular moral dilemmas (Orr and Shelton 2009). Solving ethical issues related to patient care was rated most frequently by the survey responders, and education was a secondary task in almost half of HECs. The most important question that emerged during this research was whether HECs were consulted regarding ethical issues or moral dilemmas. There is no doubt that in comparison to countries such as the USA or Great Britain, the workload of Polish HECs is smaller. Only 62 % of survey responders were dealing with an ethical dilemma, where 55 % of survey responders expressed their opinions \6 times. The percent of Polish HECs, which did not have any questions or opinions asked of them was six times higher than HECs in Great Britain, and almost twice as high as HECs in the USA (Fox et al. 2007; Slowther et al. 2012). Both the British and the US HECs provided more consultations regarding ethics (Fox et al. 2007; Slowther et al. 2012). The results of the survey do not provide an answer to this question—why is the workload of Polish HECs lower than that of Great Britain and/ or the USA? There may be several reasons. The most important reason is the

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significantly less experience of taking advantage of the assistance provided by HECs in Poland in comparison to other countries. The results of studies that comparatively evaluate the activity of HECs in the first years of their creation as well as later years, indicate that with time, the role and the importance of HECs grows in the medical field (Førde and Pedersen 2011; Gaudine et al. 2010; Pedersen et al. 2008; Slowther et al. 2001, 2012). Another cause of the low-activity of HECs was the lack of knowledge about the existence of HECs and their services in the community. Therefore, the activity of non-governmental institutions, such as the Polish Chamber of Physicians and Dentists, the Polish Bioethics Society and the Conference of Presidents of Medical Societies are very important. All of these institutions support the formation of HECs (Supreme Medical Council 2009; Polish Bioethics Society 2009; Conference of Presidents of Medical Societies 2009). HECs are known by different names, which contributes to decreased access. This supports the argument that a standardized system of nomenclature should be implemented as soon as possible. Similarly to other countries, the nature of ethical conflicts varied. Part of them has to do with non-healthcare related topics, and decisions, which are difficult to make from an ethical point of view. The results of the survey do not allow for a determination of how often there were consultations on issues directly associated with the ethical dilemmas of modern medical care. There definitely can be 12 % of opinions considered related to difficult medical decisions while 88 % of the opinions focused on conflicts among hospital employees or between the hospital employees and patients or other people, and only several surveys contained precise descriptions of what the conflict was in regards to. In many of the examples, there were issues likely to be unrelated to solving ethically difficult decisions in terms of treatment, though in others vaguely defined ‘‘conflicts between superiors and inferiors,’’ or ‘‘conflicts between medical doctors and patients in the hospital environment’’, it is likely that the disputes had something to do with ethical aspects of treatment and the healing process. It is the legal-ethical realities in which Polish doctors work and which exist for Polish patients. According to Articles 32 and 34 in regards to physicians and dentists, patients have the right to autonomy, and patients need to give consent for performing any medical exams and treatments (Act on professions of physician and dentist 1997). However, a doctor or dentist must provide medical care in all cases where delays of care could cause harm or death—art. 30 (Act on professions of physician and dentist 1997). Thus, these laws limit the possibility of discontinuation of futile treatment. Also, regardless of the patient’s medical condition, stopping artificial feeding and hydration is prohibited. Furthermore, there is no written documentation of advanced directives, in which patients clearly specify how medical decisions are to be made when they are unable to make them, or to authorize a representative who will make decisions for them (La Puma et al. 1991). Family members are not allowed to make any medical decisions for the adult patient who is not capable of doing it himself/herself—art. 34 (Act on professions of physician and dentist 1997). If an adult patient is not capable of making his/her own decisions, only the court, or a proxy elected by the court, is legally entitled to give consent for treatment—art. 34 (Act on professions of physician and dentist 1997).

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For example, if a doctor would like to perform an operation or use a diagnostic tool, which could endanger or cause harm to the patient, consent must be obtained, even if the medical doctor believes the intervention is in the patient’s best interest. Only in cases of emergency can a physician make medical decisions for the patient, who does not have the capacity to make the decision himself (Act on professions and physician and dentist 1997). The above mentioned, indicates that the way to deal with a sick individual who lacks capacity, is either prohibited by law, requires permission from the court, or is left for the doctor to decide. The low awareness of consumers about HECs is most likely caused by the limitations of access to them by doctors, patients, their families as well as assistive medical personnel, despite the fact that HECs were found in response to a clinical need for a formal mechanism to address some of the ethical conflicts and uncertainties that arise in contemporary health-care settings (Aulisio and Arnold 2008). Therefore, access to HECs should be quite broad, if not universal. All members of the health care team, as well as patients and family members should be able to obtain a consultation if needed (American Academy of Pediatrics 2001; Aulisio et al. 2000; Florida Bioethics Network 2011; Slowther et al. 2004a, b). The results of the survey do not support these principles. All Polish HECs allowed medical doctors to request a consultation. The rest of the medical personnel, the patients and their family were allowed to use HEC’s services in only specific Polish HECs. While it is true that not all HECs in the USA allow every individual to request a consultation, these restrictions are much smaller than those in Polish HECs (Fox et al. 2007). Polish HECs should not restrict patients and their families, as well as other people involved in the care, access to consultations. HEC staff should be trained appropriately and held responsible for establishing proper rules and regulations. In order to function properly, HECs need to have sufficient financial support. The majority of members of HECs do not receive any financial remuneration. This contributes to limiting HECs from getting members that are not part of the medical team. This fact needs to be included in the analysis of reasons why non-medical staff are underrepresented in Polish HECs. All members of HECs, and especially those who are not hospital employees (for example lawyers, ethicists), must attend committee meetings, and also provide some of their personal time for preparing for work and in forming opinions. That is why they might not agree to work for free. In the USA, in as many as 16 % of hospitals, salary support was provided specifically for ethics consultations (Fox et al. 2007). Running HEC offices and meetings and preparing expert advice requires financial support (Schick and Moore 1998). Currently, HECs in Poland are not overwhelmed by work and some do not run any cases. If the activity of HECs was expanded, to include the protection of patients’ rights, increased financial support would be needed. Meanwhile, the majority of Polish hospitals are facing financial difficulties (Sagan et al. 2011). Unfortunately, there is only a small chance that the financial administration of hospitals will be able to find the financial means to support HEC services, especially when they do not have a legal structure (Czarkowski 2010a, b). Although the majority of active HECs state that there are no difficulties that would limit their services (74 %), it has to be noted that they did have very few cases or did not have any cases at all. Suppose

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then, that the remaining few HECs, that have pending cases, point out difficulties in organizing and sustaining their services due to the lack of rules and standards.

Conclusion Few Polish hospitals have HECs. Its structure, services and workload are not always adequate. In order to provide quality services by HECs, the development of relevant legislation, standard operating procedures and well trained members need to be implemented.

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According to UNESCO guidelines, one of the four forms of bioethics committees in medicine are the Hospital Ethics Committees (HECs). The purpose of th...
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