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Educational Resources: Appendices

Appendix A13

An example of a proposal to a trust board for the setting up of a clinical ethics committee

Graham Behr, Jo Emmanuel and Jon Ruddock, Central and North West London Mental Health NHS Trust

Introduction

Public expectations of health care, and public criticism of health care professionals has increased over the past few years. The demand for greater public accountability in health care decision making means that health care professionals will need to justify both the clinical and ethical reasons for their decisions both to their patients and to society. Judicial involvement in medical decision making has also increased, often in cases where competing moral values need to be weighed against each other.

Much of the debate about how best to help mentally ill clients centres on the degree to which clinicians should intervene paternalistically (i.e. make choices on people’s behalf) to safeguard the best interests of those clients who may have a reduced ability to make treatment decisions. The Mental Health Act 1983, associated commentaries and Code of Practice provide a framework to help clinicians faced with these decisions. However there are many facets of the care of people with mental illness that are not covered by the above mentioned guides, which present ethical dilemmas.

Furthermore some of the most difficult treatment decisions involve withholding or withdrawing treatment from people who want treatment but for whom clinicians feel treatment is conferring no good or may even have unwanted or unhelpful effects. In some cases clients and clinicians can agree together that ‘not treating’ is the best option. However, in a substantial number where agreement cannot be reached there is a risk of suicidal or violent behaviour. Clinicians, and also their managers, are anxious in the current political climate to minimise the likelihood of a resulting ‘serious untoward incident’ occurring.

Professionals also face decisions about withdrawing treatment when the patient is so threatening or violent that the treatment required can not be given without compromising the safety of the clinicians or other service users. This creates difficult management decisions within the Trust, and has led to differences of opinion between clinicians and managers.

These are the kinds of examples in every day mental health practice which require principles to guide us rather than purely senior opinion or group consensus.

The transition from a model of ethical paternalism to one of respect for autonomy and clinician/client partnership means that clinicians have to reassess the value systems used in their clinical decision making. Policies which guide the actions of clinicians must similarly be based on sound ethical principles.

In addition, the introduction of medical ethics into the undergraduate curriculum for medical students means that clinical teachers need to have an understanding of medical ethics, as applied to psychiatric practice.

Within this framework of raised ethical awareness and demand for public accountability, how can individual health professionals and Trusts ensure high ethical standards in all aspects of patient care? Some guidance already exists at a national level through DoH and GMC, but local resources need to be developed to provide support that is both responsive and relevant to local circumstances.

The way in which many Trusts deal with this challenge is by invoking the assistance of a Clinical Ethics Committee (CEC). The proposal for the development of a CEC in CNWL, recently highlighted in the NHS Clinical Governance Support Team Accelerated Service Improvement Program Evaluation Report (2002), arose from work undertaken following the Protected Time Initiative, held in North Westminster in 2001.

The national governing body of clinical ethics committees, ETHOX is not aware of any Mental Health Trust which has yet developed a dedicated CEC. It is our view that in a Trust the size of CNWL, the volume and complexity of clinical issues merits this.

Remit of a CEC

The CNWL CEC will have as its primary remit, the support of decision making by clinicians within an ethical framework. It may also extend its role to providing support for Trust policy development and education for Trust employees

1. Clinical management
CECs do not have the same executive decision making powers as Research Ethics Committees. Rather their function is to enable the professionals involved in any given decision to look at the situation from many viewpoints, and as such make better informed and considered decisions about their own cases. The responsibility for the decision remains with the clinicians bringing the case for consideration. There is no onus on a clinician to discuss cases in the CEC; it is available as a facility to be used at clinicians’ discretion. It is recommended that a decision to bring a case be agreed by the relevant team though any member of the team may initiate this.

2. Input into policy development
Some examples of this (which might be pertinent to a Mental Health Trust) are: Advance directives, rights and duties of relatives, confidentiality, consent to participate in undergraduate education, withholding and withdrawing of treatment, use of restraining techniques, possession of illicit drugs, the abuse of the service by members of the public.

3. Education
We would wish to assist in the education of clinicians and students. Initially this may take place by the involvement of clinicians who sit on the committee and those who bring cases as well as by dissemination of the summarised debates of the committee.

Structure

Membership of Clinical Ethics Committee

Members should have:

  • Interest in the subject of medical ethics
  • An ability to work in a group
  • A commitment to the group
  • Some personal experience which would be useful to the group (clinical / service user / lawyer etc)

The committee will comprise:

  • Professional ethicist
  • Legal professional
  • Clergyman
  • Service user
  • Non-executive member of the Trust Board
  • Administrator
  • Four other Trust clinicians
  • Chair
  • Core group (three Trust employees) to initiate and drive the process

The non-executive member of the Trust Board will be appointed by the Board.

The chair and the core group will be responsible for recruiting the other members of the committee and reviewing that membership on an annual basis.

All members of the CEC will be legally indemnified from prosecution by the Trust.

The role and responsibility of the chair

The chair will be recruited and appointed by the Chief Executive and will not be a Trust employee or member of the Board. This will reduce the likelihood of conflict of interest arising.

The chair is likely to become the ‘public face’ of the committee and, as such it is crucial that they have broad acceptability to clinicians bringing cases.

The role of the chair would have particular requirements:

  • To summarise ethical debate
  • To clarify strands of argument
  • To separate administration/managerial discussion from clinical discussion
  • To ensure the discussion’s primary focus is on ethical considerations
  • To frame conclusions in a way which is helpful to clinicians

The chair has the right to co-opt additional members to provide specialist expertise.

Accountability and reporting of proceedings

  • The CEC will be constituted as a subcommittee of the CNWL Clinical Governance committee.
  • The discussions of each meeting will be summarised and anonymised so that :
    • They may be tabled at meetings of the clinical governance committee
    • They may be accessed by clinicians as an educational tool
  • The detail of the discussion will remain privy to the participants. The committee would divulge information to management only when there was a clear breach of the law
  • An audit tool is currently being designed to determine the usefulness to clinicians of the committee.
  • The CEC will continue to link with ETHOX, other CECs and other relevant organizations. In this way, the committee will continue to learn about ways of working which best support clinical decision-making.

Resource Implications

There are four areas with resource requirements:

1. Administration
Administration is required for: accurate minute-taking, telephone and email liaison with group members, clinicians and outside organizations, maintenance of a database, arranging training and education, carrying out audit, dissemination of information Trust-wide, input into Intranet etc.. It is expected that 4 sessions per week are required.

2. Education and Training
Although some members will have training in medical ethics, a basic level of knowledge for all members will assist the effectiveness of the CEC. This might best take the form of an annual training day, with initial training upon the commencement of the committee. Costs would involve the trainer/facilitator of such days. Access to key literature may also involve a small cost.

3. Honorarium payment to members
The chair will receive an honorary payment.

Trust employees would be expected to participate in this committee voluntarily. However, whilst our sense is that we are unlikely to have to pay for the services of other participants at this time, such payment may be required in the future.

4. Sundries
To include coffee facilities, possible remuneration of transport costs for any unemployed members, and other minor expenses as they arise.

Copyright of Appendix A13 is held by Central and North West London Mental Health NHS Trust

Graham Behr, Jo Emmanuel, Jon Ruddock
Central and North West London Mental Health NHS Trust