H E C FORUM © 1993 Kluwer Academic Publishers.

1993; 5(2):89-99. Printed in the Netherlands.

THE NURSE'S ROLE ON THE

HEALTHCARE ETHICS COMMITTEE

F E L I C I A A. M I E D E M A , R.N., B.S.N.

Though content, process, and function of ethics committees have been

thoroughly described and vigorously debated in the literature, virtually all
of the literature states that ethics committees should be multidisciplinary,
specifically including nurses. The Joint Commission on Accreditation of
Healthcare Organizations, in its revised standards for Nursing Care states:
"Nursing staff members will have a defined mechanism for addressing
ethical issues in patient care"(1). Supporting text states: "When the
hospital has an ethics committee or other defined structures for addressing
ethical issues in patient care, nursing staff members participate."
However, despite consensus that nurses should participate in institutional
ethics committees, very little is known about the role of nurses that are
members of healthcare ethics committees (HEC).

Review o f Statistical Data

What little data exist reflect an increasing involvement by nurses in

HECs. Youngner surveyed hospital ethics committees in 1982, and
reported that fewer than half of the ethics committees had a nurse
member (2). At that time, 50% of responding committees indicated that
nurses were allowed to attend meetings; however, only 31% of committees
allowed nurses to request meetings. In a 1989 survey of California
children's hospitals, virtually all of the HECs reported having at least one
nurse member, although 54% reported that their nurse members had only
nursing management responsibilities (3). Another survey of midwest
hospitals performed the same year mirrored these results, reporting an
average of 2.2 nurse members per ethics committee and reporting that
69% of these nurses were in management or administrative roles (4).
Perhaps the most comprehensive recent study of ethics committees
was performed by the University of Maryland (5). This study looked at
ethics committees in Maryland (where ethics committees are mandated by

89
90 F.A. Miedema

law), the District of Columbia, and Virginia. This study reported that
98% of ethics committees included at least one nurse member, with an
average of 3 nurses per committee. As these data clearly indicate, nurses
do participate in HECs, yet there is little discussion in any of these studies
or elsewhere about what the nurse's role on the committee is, or should
be.

Justification for Interdisciplinary Membership

In order to describe the unique role that nurse members of ethics

committees may have, we need to ask why the membership of ethics
committees is varied in the first place. Why aren't ethics committees
comprised solely of physician members? Or hospital administrators? Or
attorneys? Much of the literature on ethics committees cites the unique
perspective of individuals with varied backgrounds as the justification for
xiaried membership. What is this perspective other than a particular point
of view. However, for our purposes we will refine this definition to mean
a valued point of view. Ethics committees include community members,
pharmacists, hospice volunteers, even risk managers because of this valued
perspective. Their expertise, knowledge, and perspective all contribute to
what we claim are more fully informed, more broadly represented, and
consequently more ethical decisions.
As correct as this is, I would argue that there are deeper, more
important reasons why ethics committees seek varied membership. Some
authors have argued that ethics committees propose to diffuse
responsibility by spreading decisionmaking among a group of people.
Siegler has argued that the most troubling aspect of ethics committees is
that they "may remove or at least attenuate the decision-making authority
of the physician who is responsible - medically, morally, and legally - for
the patient's care" (6, p. 22)(7, pp. 38-39) While it may be true that
decisions reached by consensus are easier to feel good about, this alone
cannot serve to justify seeking wide interdisciplinary representation in
ethics committees. However, Siegler's concern may lead us to the real
reason that ethics committees seek varied membership, as well as why
more and more health care professionals are encouraging the
establishment of ethics committees in their institutions.
It is doubtful today that members of our society view physicians as
uniquely accountable for the health care delivered to a particular patient.
Certainly few non-physician health care professionals believe that the
 The Nurse's Role on the HEC 91

physician is ultimately accountable for the patient's care. Health care

institutions and non-physician health care professionals are frequently
included in malpractice suits, and large settlements are often sought from
institutions rather than individual physicians. This suggests that
accountability from a medical, legal and social viewpoint is a shared
accountability. As for moral accountability, individuals are accountable for
their own actions, even when their actions are performed within the
context of a role which is subordinate to other individuals. Thus, no
individual member of the health care team can be ultimately accountable
for the actions of the many individuals that comprise the team.
Today's health care professionals see the delivery of health care as a
shared moral responsibility. Ethics committees value the perspectives of
members whose political, social, and legal responsibilities may differ
greatly because health care professionals are aware that moral
accountability is a shared responsibility. Though individuals have distinct
roles within the institution, moral accountability for one's own actions
does not vary with role.

The Notion of Equality

The issue of equality deserves further attention as it relates to the

members of ethics committees. Ross has stated in Handbook for Hospital
Ethics Committees that "the ethics committee must function as a group of
equals and members should be chosen for their ability to accept that
equality" (8, p. 38). Her comments are echoed in much of the literature
which describe ethics committees as "safe havens" and "open forums."
This claim concerning equality between members is cogent only if equality
refers to a sense of moral accountability. However, it would be a
potential mistake to assume that HEC members could be viewed as true
equals within the political structure of an institution. It would seem that
such equality would require the abandonment of individual roles outside
the committee, as physicians, nurses, social workers, attorneys and
philosophers. Yet these are the very roles which contribute to expertise
o n the committee.
The very nature of the political and organizational hierarchy within
any health care institution impinges upon equality. Without established
hierarchies, it would be impossible to work, communicate, or make
decisions efficiently. Hierarchies are necessary within the health care
institution. We accept our position within the hierarchy, and use the
92 F.A. Miedema

structure to accomplish our goals.

Physicians are, at least traditionally, in high-status positions within this
hierarchy. Their reporting structure may vary depending upon whether
they work within a group practice, an HMO, or in private practice, but
only rarely do they report to the institutional administration in the way
that nurses usually do.
Though nurses and physicians in many settings are working more
collaboratively, it remains a fact that physicians provide the "orders" which,
at least in the acute care environment, define the treatments, medications,
and care that the nurse offers the patient. Even the word "orders"
denotes an inequality from which we cannot escape. It seems unlikely
that political and social rules that govern behavior within the hierarchy of
the institution could be disregarded, even temporarily, during HEC
meetings.
If health care professionals, and particularly HEC members, view the
institutional political hierarchy as directly related to moral accountability,
HECs will not function optimally.

Nursing F_~pertise

With this background, let us examine the specific expertise and moral
responsibilities of the nurse and attempt to validate the presence of nurses
on HECs by clarifying the role that they play (or can play) on these
committees.
Nursing has had a long history of identity crisis, compounded by issues
brought to light by the feminist movement, technological advances,
inconsistent educational requirements, and claims of professional
autonomy. Nursing has struggled long and hard to identify itself as a
profession, possessing a unique expertise that is distinct from both medical
science and motherhood.
During the last decade, several nursing theorists have identified the
concept of caring as the essence of nursing (9). There is no doubt that
caring, as a concept, has had a profound influence on nursing philosophy,
education, and research. A recent proliferation of literature on the topic
of caring has led many to conclude that nursing has perhaps finally
identified its unique contribution to health care.
Though I shall not here attempt to explore the concept of caring in
great detail, a few key concepts may help more clearly to describe the
unique role of the nurse within the health care structure. First, care is
 The Nurse's Role on the HEC 93

differentiated from the more medical concept of cure, in that nursing

views the patient as a composite of intellect, spirit, experience and body,
whereas cure focuses upon particular systems, disease processes, and
pathologic findings. The concept of caring sees illness as a subjective
human experience rather than a quantifiable deviation from the norm, and
seeks to support and capitalize upon each patient's unique methods of
adaptation. Caring includes the notion of helping, and most nurses see
themselves as "helpers," whether the help delivered be in the form of
physical assistance or advocacy. Finally, caring as a concept is firmly
rooted in concepts about relationships and intimacy. Nurses, by virtue of
their sustained and often intimate contact with patients, have the
opportunity to enter into a unique relationship with patients. Nurses are
often allowed to be witness to or participate in relationships that patients
have with others. And nurses are often the bridge between the patient,
significant others, other members of the health care team, and even the
health care system itself.
Caring is certainly not limited to nursing, nor do other health
professions exclude caring from their core values. As well, nurses
certainly engage in many activities focused upon cure, and physicians do
care. However, it may be safe to say that caring as a concept comes
closer to defining nursing than it does other health professions. If the
central definition of nursing differs from that of other health professions,
it follows that the values held by members of the nursing profession may
also differ from values held by other health professionals. Value conflicts
give rise to ethical dilemmas. Hence the importance of assuring that the
values of nurses are articulated and represented in the process of
resolving ethical dilemmas.
So far I have argued that there should be nursing presence on the
HECs, that issues of equality within the hospital hierarchy must receive
further exploration, that health care is a shared moral responsibility, that
nurses possess specific competencies, and that caring is a concept that may
help us define the nurse's perspective.
Let us turn to the specific functions of HECs in order to identify
those functions that nurses may be particularly well suited to carry out.
There seems to be a consensus that there are at least three major
functions of HECs: education, policy development, and case
review/consultation. Specific tasks of the ethics committee, then, should
be assigned to those members with the specific skills and expertise to
perform those tasks. Nurse members of the committee, however, are most
94 F.A. Miedema

skilled in the areas of advocacy, communication, and education.

Nurses are usually perceived as expert patient advocates. In addition,
nurses are also the strongest advocates for other nurses. Nurse HEC
members are best able to identify, articulate, and support the autonomy
and interests of the patient, and they are often best able to express
questions and viewpoints of patients and families, because of their
experience in maintaining close and sustained contact with patients and
families. Nurses also have a keen ability to discern when patients and
families do not understand certain aspects of the situation fully, even
when the patient or family dutifully indicates an understanding. Nurses
have in-depth knowledge of institutional operations and unit routines that
may assist patients and families. Nurses who are involved in the care of
the patient will often be more comfortable expressing their concerns to
other nurses; Thus nurse ethics committee members will be able
accurately to represent the concerns of the nursing staff.
Nurses, largely because of their central position in the health care
team, but also because of their training and skill in addressing issues
sensitively, are excellent communication facilitators. The nurse is often
the one health team member who is familiar with all the players in the
case. The nurse may be best able to alert the HEC to factors that may
not have been identified by others. For instance, since nurses are often
the first to identify conflicts of interest or dysfunctional communication
patterns, and are typically viewed as non-threatening people, they often
hear the views of patients, families, and even physicians who are nervous
or uncomfortable about sharing their opinions with others. Patients and
their families often report feeling intimidated by their physician, and worry
that their questions may appear stupid, or that they will be perceived as
"bad" or "uncooperative" patients, parents, or family members.
Finally, nurses are trained educators. Nurse members of the HEC can
present information on ethical issues to other nurses as well, using
established forums, such as nursing grand rounds, or establishing new
programs, such as monthly unit "ethics rounds." Nurse members should
be available to nurses who wish to discuss a particular case or issue in
order to determine its suitability for committee referral. One way to use
nurses' expertise in education and communication is in the development
of joint nurse/physician communication workshops. In this forum, nurses
and physicians meet together to discuss issues that impact upon the
nurse/physician relationship. Such a forum can generate significant
improvement in the ways nurses and physicians understand each other and
 The Nurse's Role on the HEC 95

work together in collaborative relationships.

Education, Policy Formation, Case Review/Comultation

The implementation of the Patient Self-Determination Act

demonstrates one education and policy formation challenge that HECs
have encountered. The PSDA requires all hospitals, HMO's, home health
agencies, nursing homes, and hospices to notify patients on admission of
their rights to participate in health care decisions, including the right to
refuse treatment. In addition, the Act requires that these institutions
provide all patients with information about state-recognized advance
directives, and educate their staff and community on advance directives.
In the months prior to December, 1991, when the Act became effective,
institutions across the country scrambled to meet the requirements of the
Act. In many institutions this responsibility fell to the HEC.
In my own institution, the HEC had that responsibility. In order to
educate patients, written educational material was needed. This material
had to be written legibly in large type, and provide not merely legal
information but practical information that each patient could relate to
his/her own circumstances. Media information, such as videotapes or
audiotapes was thought to be useful as well. There were logistic details
concerning how to obtain or produce such material, and how and when
to make it available. Oral information was seen as the most important
route of education; the consistency of this information, whether delivered
by physicians, nurses, or social workers had to be assured. Identifiable
and accessible resource people were needed to answer questions or help
address unusual circumstances. And, finally, the HEC planned to evaluate
the educational program provided to patients to determine whether they
understood the information, and whether this resulted in patient action.
Throughout the process, it was recognized that the HEC nurses who
participated were best suited to represent both the patient's and the
nurse's point of view. It was the nurses who alerted the task force to the
small print about to be used in the brochure that many patients would
find unreadable. While the HEC's initial educational focus had been the
physicians (a group for whom education concerning advance directives was
vital), the rmrses were able to point out that patients more often ask
nurses questions, since their physician is present only for a short time each
day. Given this information, the task force recommended revising the
educational focus to include the entire nursing staff. Nurse members had
96 F.A. Miedema

the knowledge of unit routines that was required to realize that the
proposed 4:00 p.m. time slot for showing an in-house television program
on advance directives would conflict with patient assessments that occur
at that time. Their recommendation to change the time of showing to
change-of- shift time (when patients' treatments are less frequently being
provided), has undoubtedly resulted in more patients being able to view
the program. And, finally, nurse members were able to convey some of
the practical concerns regarding the policy as it was being created.
As the HEC performs case reviews, certain tasks must be completed,
regardless of the methods a particular committee chooses in conducting
reviews. Information on the case as well as well as information relevant
to identifying alternatives for action must be obtained, the viewpoints of
key players must be identified and heard, and, most importantly,
negotiation and communication must be enhanced. These tasks may be
divided, shared, or rotated among members of the HEC, but it is clear
that some members, rather than others, are better suited to perform
certain tasks. For example, medical information is best gathered and
understood by members with knowledge of medical terminology and
documentation, whereas negotiation efforts require excellent
communication skills and knowledge of small group dynamics.
While many effective models for case review have been noted, I would
like to describe a model that takes advantage of the nurse's expertise in
case consultation. In this model, ethics consultation on particular cases
is not performed by the entire ethics committee (i.e., is not a review), but
rather is undertaken by a physician/nurse team who go to the bedside to
initiate the process. It is in conducting case consultation that the nurses
involved in the situation share important concerns, and where it is just as
important that members of their own profession are able to hear these
concerns and translate them, either to the consultation team or to the
entire HEC.
An illustration here should clarify what I mean by "translate."
Recently I participated in an ethics consultation in which the physician
ethicist and I were asked to assist in determining whether a "No
emergency CPR" or "DNR" order was appropriate for a terminally ill
patient who lacked decision-making capacity, had no available surrogate
decisionmakers, and had not completed a written advance directive. We
went together to see this patient, who had advanced carcinoma of the
lung, was unresponsive, and ventilator dependent.
The patient was located on a medical respiratory unit in our hospital,
 The Nurse's Role on the HEC 97

which is a non-monitored, non-critical care unit. The nurse caring for the
patient informed us that the patient's blood pressure had been very
unstable for the past several hours, and that his apical pulse rate had
dropped into the 40's at times. She was maintaining a near constant vigil
at the bedside, despite the fact that she had several other patients for
whom she was responsible.
After assessing the patient's medical history and current condition, and
discussing the situation by telephone with the patient's attending, we
recommended that a NO CPR order be written, since CPR held virtually
no possibility of benefit for this patient. The patient's attending physician
agreed, and stated that he would write the order and corresponding
progress note when he next arrived at the hospital, which would be a
couple of hours later. My physician colleague was satisfied with this, and
felt that the consultation was completed, until I pointed out to him that,
from the nurse's perspective two hours may be a significant interval. The
nurse caring for this patient would need to maintain continuous
assessment of this patient, anticipating that cardiac arrest was likely, until
she was legally authorized not to administer CPR. Once a "NO CPR"
order was written, she would be free to focus more of her energy on the
patient's comfort, and less on his hemodynamic instability. In addition,
this would free her to spend some time providing comfort to her other
patients. Since in our institution "NO CPR" orders must be written by a
physician, we recontacted the attending physician, who agreed to allow my
physician colleague to write the order.
This case was rather unproblematic as it did not raise a complex
ethical dilemma, but it does illustrate the differences in the way that
nurses and physicians may perceive a particular issue, such as time
management. It is a commonplace that disagreements often occur not
because parties truly disagree, but because they are unable to "translate"
the viewpoint of the other into a process that is understandable to them.
In other words, they are unable to place themselves in the shoes of the
other. We've found that team consultations performed in this manner
promote not only the expression of individual viewpoints, but assist health
professionals to translate these viewpoints so that they become mutually
understandable.

Concluding Word

At this point it should be clear that more nurses should become

98 F.A. Miedema

actively involved in HECs. The number of nurses on the HEC should at

least equal the number of physician members, since nurses usually far
outnumber physicians and comprise the largest single group of health
professionals. The nurse members should be selected for their ability to
represent the viewpoints of many nurses, including staff nurses, and the
HEC should specifically turn to its nurse members, who have the expertise
and skill in the areas of advocacy, communication, and especially patient
education, and apply these skills to each of the HEC's functions: self-
education, policy formation, case review, and case consultation.

NOTE

An abbreviated version of this essay was presented at the Third

Annual Intermountain Medical Ethics Conference, sponsored by LDS
Hospital and the University of Utah School of Medicine, March 13, 1992;
and at the 1st Annual Chicago Conference on Ethics in Healthcare
Institutions, August 19-21, 1992.

REFERENCES

. Joint Commission on Accreditation of Healthcare Organizations.

Accreditation Manual for Hospitals. Oakbrook Terrace, IL; 1991.
2. Youngner S, Jackson D, Coulton C, et aL A national survey of
hospital ethics committees. Critical Care Medicine. 1983;
11:902-905.
. Levine-Ariff J. Institutional ethics committees: A survey of
children's hospitals. Issues in Comprehensive Pediatric Nursing.
1989; 12:447-61.
. Oddi L, Cassidy V. Participation and perception of nurse members
in the hospital ethics committee. Western Journal of Nursing
Research. 1990;12:307-17.
. Hoffmann D. Does legislating hospital ethics committees make a
difference? A study of hospital ethics committees in Maryland, the
District of Columbia, and Virginia. Law, Medicine and Health
Care. 1991;19:105-19.
. Siegler M. Ethics committees: Decisions by bureaucracy. Hastings
Center Report. June 1986;16(3):22-24.
7. Spicker SF. In defense of IECs [letter] Hastings Center Report
Feb.1987;17(1):38-39.
 The Nurse's Role on the HEC 99

, Ross JW. et al. Handbook for Hospital Ethics Committees.

American Hospital Publishing, Inc. Chicago, IL; 1986.
9. Morse J, Solberg S, Neander W. et al. Concepts of caring and
caring as a concept. Advances in Nursing Science. 1990;13:1-
14.