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CECs in Estonia - first steps on a long way

I Background

Estonia regained its independence 15 years ago and started to develop its society following Western standards. This change of direction meant that the Oath of the Soviet Physician was abandoned and the debate over ethical issues in medicine, especially regarding autonomy of the patient, broadened. However, the first ethical committees in Estonia, established in 1990, were set up not because of the need for ethical guidance in clinical setting but to carry out clinical trials in accordance with western standards. The first clinical ethics committee was established by the Tallinn Childrens’ Hospital in 1997 and was shortly followed by the clinical ethics committee of the University Clinics of Tartu. So far, these are the only two clinical ethics committees in Estonia. The population of Estonia is about 1.4 million and there are approximately 10 major hospitals in Estonia. Currently, there is no law requiring establishment of a clinical ethics committee for each hospital and there is very little legal basis for these committees. Another question is, of course, whether the activities of clinical ethics committees should be regulated by law at all.

II Composition

Both the clinical ethics committee in Tallinn and in Tartu have a quite fluid membership. and members are mainly appointed by the Board of the hospital upon proposal of the chairman of the committee. Membership is not fixed but varies according to problems under discussion. To a large extent, members of ethics committees are physicians working in the same hospital but committees may also include nurses, lay persons, lawyers, priests and members of the hospital administration. The total number of members varies from 7 to 15. Given the small size of the population, some individuals are members of both clinical ethics committees but there is no overlap of membership with research ethics committees.

III Function

Clinical ethics committees in Estonia fulfil similar tasks as the respective bodies in Western Europe. Questions where input from the clinical ethics committee is sought include allocation of scarce resources, confidentiality, rights and duties of relatives, informed consent documents, DNR policy and policies regarding severely handicapped newborns etc. Committees meet on a regular basis and committee process aims at consensus decision-making. Retrospective case studies make up much of their work.

IV Challenges

The greatest challenge that the clinical ethics committees in Estonia face is related to determination of their position. A lot of work needs to be done to raise the profile of clinical ethics committees. This point is closely related to the second challenge which has to do with separation of law and ethics. Medical practice has recently undergone extensive legal regulation and thus the focus of physicians is currently on legal rather than ethical issues. Such a situation is understandable if one bears in mind that the principles of informed consent, professional liability etc. were introduced into Estonian law only in recent years, and with great reluctance on the part of physicians who were accustomed to the concept of a community beneficence ethic that had governed soviet medicine. Thirdly, reorganisation of Estonian health care and its financing system is still in progress and the lack of a stable environment certainly hampers the activities of clinical ethics committees in Estonia. However, it can be expected that in the future clinical ethics committees will be an integral part of the modern hospital environment in Estonia.

Ants Nomper
Lecturer in Medical Law
University of Tartu