The following is a summary of an address by Morris Litton, Senior Legal Counsel, Intermountain Health Care, October 13, 1994 to the Humanists of Utah.

The forming of a moral community from a bioethics community is made necessary because, in our society, advancement of medical technology has changed life. And it has also changed death. It has changed life in that many of us have experienced life or know of someone who would have been deprived of life a generation ago. Many of us have also known or heard about what medical technology can do to keep bodily functions going after sapience, or awareness, has disappeared.

The record is of a person who lived on a ventilator in a comatose state for over thirty years. An example of this condition is the Nancy Krusan case of Missouri, who drove off the road into a ditch and was found face down. She was without oxygen about nine to thirteen minutes. She was revived and breathed on her own but was in a persistent vegetative state; she had no cognizance. Reviewing this case, the Supreme Court cited expert testimony saying that Nancy was not in a terminal condition because she could be sustained in that condition for thirty years.

Older people as well as others are horrified at the possibility that they might face a prolonged death or a sustained dying period hooked up to machines to keep them alive after they are no longer sapient. They have nightmares of spending their life savings and their children's inheritance or causing their families financial hardship at their insistence during that time. There is also the fear that government regulators or health care providers, who are supposed to be advocates, will cut their lives short because they are old, or sick, or no longer sufficiently productive. They worry that they will be prohibited access to modern medical technology.

As response to these concerns, several movements have begun in the United States and the world at large. The most popular is that related to advanced directives, such as Living Wills and Medical Treatment Plans. This is in partial response to the advancement of medical technology and the feeling that we are somehow being deprived of the right to make decisions regarding our own care. Another movement is Death With Dignity which promotes self determination both in terms of time and means of death. A third, perhaps a less radical and less publicized movement, is Bioethics.

(A video was presented by Mr. Litton which portrayed the anguish experienced by a typical family facing ethical decisions after being swept into the health care system by misfortune. A discussion then followed about how a Bioethics Committee functions and how it responds to the ethical needs not only of the patient but also the family members.)

A Bioethics Committee, or Interdisciplinary Ethical Committee (IEC), is a group of individuals who are brought together not to make decisions but to engage in an evaluation to recommend ethical alternatives to dilemmas that arise in health care. This Committee does its best work when functioning as a moral community. The following is from a handout:

Ethical Dilemmas are a matter of legitimate differences of opinion among people around a moral choice; the very existence of an ethical dilemma implies that more than one perception of value is involved. Ethical reflection is a process for resolving conflicting moral visions and claims, not simply a matter of applying clinical competence or technical expertise. Thus, it is believed that the best way to resolve such dilemmas is in a forum that is interdisciplinary and involves representatives from all clinical units as well as representatives from the community the institution serves.

The differing viewpoints provided by such a multidisciplinary approach ensure that every option is explored. With fresh minds working together, a "synergy" develops that helps everyone rank and weigh his or her values to single out those that are most critical to the issues in the balance, helping to ensure the most thoughtful decisions possible.

As a moral community, a well-functioning IEC [Interdisciplinary Ethical Committee] provides a new model, a new modus operandi, for resolving tensions, values and conflicts through a sense of collaboration and mutuality.

When the family asks the Physician how to make a decision, they are invited to be a part of a Bioethics Committee, or an IEC, to deliberate all the medical, ethical, and personal concerns involving the patient's care. The Committee would include all the physicians involved with the patient, the nurses, the care personnel, representatives of the care facility, and the family members. The outside world would be shut out, the door literally closed so a sense of security and confidentiality would prevail. There would be great effort to form a close relationship within the group. Everyone would be able to speak and everyone would be heard. Someone will be conducting the Committee meeting but no one should be afraid to speak out, even to the Physician.

The following handout, read as the "IHC Home Health Bioethics Committee Opening Statement", explains how this Committee functions:

Welcome to all of you who have given of your time and yourselves to this important process of ethical deliberations. Before we begin by introducing ourselves, let us remember that we all come to this process in the spirit of good will and with the best interests of the patient as our individual and collective goal.

It is important that we remind ourselves that what is heard in this room is confidential and not to be discussed outside of this group.

• We advocate and support patient-centered decision making, and encourage the consideration of all information related to the patient's care.
• We support and acknowledge each participant as a colleague, recognizing our unique perspectives and contributions. We consider every individual's contribution to be of importance.
• We encourage participants to speak freely, openly, and frankly and to listen thoughtfully and respectfully.
• We are not a decision or policy making committee. Our purpose is to make recommendations that may enable ethical decisions to be made.

Guidelines have been established to help the Committee make their recommendations. They are as follows:

1. Decisions on treatment or on terminating, limiting, or withholding life sustaining procedures shall regularly be made, when feasible, within the patient, the family, and the professional staff relationship. In such decisions, the best interest of the patient is always to be the primary consideration.
2. Bioethical disputes between any members of the professional care team including physicians, any member of the medical team and family, or among the family members regarding a patient, should be referred to the Committee for consultation.
3. The obligation to do no harm dictates that treatment which is no longer in the patient's best interest be discontinued; but when there is substantial doubt, continuing treatment or life support is favored.
4. Parents or legal guardians, along with the competent patient, have the role of primary decision makers concerning any treatment for the patient. Such decisions should be based upon the reasonable medical judgment of the patient's attending physicians.

Thus, the purpose of the Committee is to make ethical recommendations, not decisions, about the care of the patient. All concerns of everyone in the group will be discussed and evaluated. The group does not jump to conclusions but goes through a process to identify the problem, to present diagnosis and prognosis, and to understand the problems of the family. What are the ideal pictures: who is the number one to be effected, what are the burdens and benefits; who else will be burdened or benefited. The process allows everyone an opportunity to learn and be involved. Everyone has a chance to see how they feel about what has been discussed and then the family can make a thoughtful decision.

A Bioethics Committee, working as a Moral Community, can work to resolve ethical conflicts. It guarantees (1) that similar cases are treated in the same manner; (2) that practitioners attend to all aspects of the case that should be considered; (3) that the quality of a Committee's work from case to case is consistent; (4) and that it amplifies members' capacity to learn from their experience and develop a transmissible knowledge base.

--Bob Green and Willa Mae Helmick