Journal international de bioEthique, 2008, vol. 19, n° 1-2

Chapitre 12

CLINICAL BIOETHICS COMMITTEES: A BRAZILIAN EXPERIENCE

Jose Roberto GOLDIMI, Marcia M. RAYMUNDO2, Marcia SANTANA FERNANDES3, Maria Helena ITAQUI LOPES4, Delio Jose KIPPERS, Carlos Fernando FRANCISCONI6 1. Biologist, PhD. Researcher in charge of the Bioethics and Science Ethics Research Laboratory of the Hospital de Clfnicas de Porto Alegre, Professor at the Medical Schools of Pontiffcia Universidade Catdlica do Rio Grande do Sul and at Universidade Federal do Rio Grande do Sul. 2. Biologist, PhD, Researcher at the Bioethics and Science Ethics Research Laboratory of the Hospital de Clfnicas de Porto Alegre. 3. Lawyer, Doctor in Law, Researcher at the Bioethics and Ethics Laboratory of the Hospital de Clfnicas de Porto Alegre. Professor at the Law School of Centro UniRitter. 4. Physician, PhD, Professor and Vice-Director of the Medical School of Pontiffcia Universidade Catdlica do Rio Grande do Sul. 5. Physician, PhD. Professor of the Medical School of Pontiffcia Universidade Catdlica do RioGrande do Sul. 6. Physician, PhD. Professor at the Medical Schools of Pontiffcia Universidade Catdlica do Rio Grande do Sul and of the Universidade Federal do Rio Grande do Sul. Coordinator of the Programa de Atencao aos Problemas de Bioetica of the Hospital de Clfnicas de Porto Alegre. 181

INTRODUCTION Clinical Bioethics is based on the concept that Medicine is a moral commitment, whose reference relies on its physician-patient relationship. This moral relationship between physician and patient generates co-responsibilities and establishes the context in which shared decisions occur [1]. However, problems of different types may arise in the patient care scenario and require decisions that many times make the physician search for counseling, in order to make the best possible solution for the dilemma in question. The scientific and technological evolution has caused frequent situations with conflicts of moral values between health professionals and patients, many times involving their families. In order to try to solve problems of this nature, two types of resources are employed. The first one is of personal aspect, in which the individual reflects morally on his/her act and comes to a conclusion regarding the best decision to make. For this purpose, cognitive resources are used, which consist in an awareness of the elements that make up bioethics reflection and the values that are part of his/her personality, created along the lifetime as a result of the experiences acquired from his/her family, school, religion and culture of his/her environment. The decision based solely on "good sense" should be avoided. Many times, "good sense", which is a rational analysis of facts and alternatives, is confused with "common sense", which represents the average thought uncritically accepted. The second resource is to have the support of a Clinical Bioethics Committee, in order to reflect and evaluate questions and moral dilemmas resulting from the practice and procedures performed within the institutions' range, sharing them with other professionals and community representatives [2]. HISTORY Hospital Bioethics or Ethics Committees were originated in the United States, in the 1960s, when discussions arose on performing hemodialysis in chronic renal patients, since there was a high number of patients and insufficient equipment. The first committee was created from such resource allocation dilemma, composed of laypersons only, and whose purpose was to establish criteria for resource allocation. As it made decisions that involved the survival of patients, this commission was named "Divine Committee" by the lay opinions [3]. The first suggestion for the creation of a Hospital Ethics Committee, published in a scientific periodical, was made by Pediatrician Karen Teel in 1975, in order to enable a dialog between professionals in individual clinical situations, as a way to share responsibilities [4]. The treatment provided to Karen Ann Quinlan started a judicial dispute between her parents and her assistant physician. The patient lived in a permanent vegetative condition, due to an unexplained cause, and her family wanted the artificial breather to be removed. The physician refused to do that, saying that this resource was necessary to her survival and that the patient did not fulfill the brain death criteria [5]. The sentence of New Jersey Supreme Court in 1976 established that the Ethics Committee of St. Clair Hospital should define the patient's prognosis and ensure that she would never be able to regain a "sapient cognitive state". The judge mistakenly presumed that this hospital already had a Clinical Bioethics Committee, just as most of the other North American hospitals that could evaluate such a situation. As there was no Committee, the Hospital management created one especially to study the case. As a result, it was recommended to remove the breather from the patient [4]. After this fact, the patient still lived for nine years. Also in 1976, Massachusetts General Hospital created a subcommittee of the Clinical Care Committee, in order to revise 15 cases of patients with cancer, without apparent possibility of being cured [6]. The results

of such revisions, published by the Committee members, caused significant repercussion in the medical area [7]. Later, Baby Doe's case in 1982 made a Northern American State government recommend the creation of committees to revise the pediatric care, which caused an increase in the number of Hospital Ethics Committees. Baby Doe's case involved a judicial dispute between the parents of a newborn baby with multiple malformations, who did not authorize a surgery required for the baby's survival, and the surgeon, who insisted on his indication [5]. In July 1987, a new law was in force in the Northern American State of Maryland making the creation of counseling committees mandatory in hospitals, in order to support the decision-making process in cases of health risk diseases. In 1990, this law was extended to include nursing homes [6]. It should be noted that this was the first North American law that made the creation of Clinical Bioethics Committees mandatory in hospitals. In 1994, the American Hospital Association (AHA) suggested that hospitals should create clinical ethics committees. The North American Presidential Commission was not giving such recommendations anymore, only requesting hospitals to have ethics education, consultancy and revision programs in place for difficult cases, which is today's attitude adopted by the North American Hospital Registry Commission [8]. In Brazil, there is no legislation or guideline that regulates the creation or operation of Bioethics Committees. The Hospital de Clinicas de Porto Alegre (HCPA) was the first to implement in 1993 its Support Program to Bioethics Problems (Programa de Apoio aos Problemas de Bioetica). The Hospital Sao Lucas at Pontificia Universidade Catolica do Rio Grande do Sul created its Bioethics Committee in 1995. I as a way to share responsibilities [4]. The treatment provided to Karen Ann Quinlan started a judicial dispute between her parents and her assistant physician. The patient lived in a permanent vegetative condition, due to an unexplained cause, and her family wanted the artificial breather to be removed. The physician refused to do that, saying that this resource was necessary to her survival and that the patient did not fulfill the brain death criteria [5]. The sentence of New Jersey Supreme Court in 1976 established that the Ethics Committee of St. Clair Hospital should define the patient's prognosis and ensure that she would never be able to regain a "sapient cognitive state". The judge mistakenly presumed that this hospital already had a Clinical Bioethics Committee, just as most of the other North American hospitals that could evaluate such a situation. As there was no Committee, the Hospital management created one especially to study the case. As a result, it was recommended to remove the breather from the patient [4]. After this fact, the patient still lived for nine years. Also in 1976, Massachusetts General Hospital created a subcommittee of the Clinical Care Committee, in order to revise 15 cases of patients with cancer, without apparent possibility of being cured [6]. The results of such revisions, published by the Committee members, caused significant repercussion in the medical area [7]. Later, Baby Doe's case in 1982 made a Northern American State government recommend the creation of committees to revise the pediatric care, which caused an increase in the number of Hospital Ethics Committees. Baby Doe's case involved a judicial dispute between the parents of a newborn baby with multiple malformations, who did not authorize a surgery required for the baby's survival, and the surgeon, who insisted on his indication [5]. In July 1987, a new law was in force in the Northern American State of Maryland making the creation of counseling committees mandatory in hospitals, in order to support the decision-making process in cases of health risk diseases. In 1990, this law was extended to include nursing homes [6]. It should be noted that this was the first North American law that made the creation of Clinical Bioethics Committees mandatory in hospitals. In 1994, the American Hospital Association (AHA) suggested that hospitals should create clinical ethics committees. The North American Presidential Commission was not giving such

recommendations anymore, only requesting hospitals to have ethics education, consultancy and revision programs in place for difficult cases, which is today's attitude adopted by the North American Hospital Registry Commission [8]. In Brazil, there is no legislation or guideline that regulates the creation or operation of Bioethics Committees. The Hospital de Clinicas de Porto Alegre (HCPA) was the first to implement in 1993 its Support Program to Bioethics Problems (Programa de Apoio aos Problemas de Bioetca). The Hospital Sao Lucas at Pontificia Universidade Catolica do Rio Grande do Sul created its Bioethics Committee in 1995. THE ROLE OF BIOETHICS COMMITTEES The purpd&e of a bioethics consultancy is to improve the standard of patient care, providing the professional in charge of the patient care with an opportunity of better decision making in case of a moral dilemma. A Bioethics Committee can be defined as an interdisciplinary board of people, whose objective is to teach, study, provide consultancy services and suggest institutional norms on ethical issues [9]. Specialists in Ethics have assumed an important role in patient care. The authority of the Clinical Ethics specialist has been the subject of great discussions. On the one hand, the Ethics consultant is seen as a specialist in moral theory, a technical consultant similar to a medical specialist, with skills, experience and techniques to solve complex moral dilemmas. On the other hand, the specialist can be seen as a mediator, a communication facilitator, with the function of clarifying the moral position of the others involved and finding a discussion space where the different opinions can be addressed, understood and solved [10]. In pluralist societies, the Bioethics Committees search for solutions to ethical dilemmas based on defensible moral norms. For this reason, they need people with, besides knowledge, characteristics such as moral sensitivity and balance, and who are not controversial and dogmatic. According to Andy Clarck, a specialist in Ethics, this consultant should be a highly competent person to promote a cooperative moral debate [10]. For this role, the bioethics consultant is expected to have conditions of gathering all information required to understand the case in question and, at the same time, expand the communication between the parties. It is not difficult to see, especially at university hospitals, a patient with several medical teams taking care of his/her case simultaneously and the professionals never talk to share their decisions. These meetings enable to identify areas of possible scientific and ethical discrepancies. In this sense, the objectives of each person participating in the patient care process should be clear and defined [10]. It is not necessary to have the group composed of Bioethics specialists only. What is expected from the group members is the moral reflection capability. The Committee leaders are responsible for motivating the group members to improve their skills in the Clinical Bioethics field, by providing selected bibliographical material and, preferably, significant to the individual's field of competence, and organize their arguments gradually, less intuitively and more based on facts, doctrines and paradigmatic cases within the Bioethics field. THE EXPERIENCE OF THE HOSPITAL SAO LUCAS CLINICAL BIOETHICS COMMITTEE The Clinical Bioethics Committee of the Hospital Sao Lucas at PUCRS was created in 1997. Its objectives were established in Article 4 of its Internal Bylaw: a) educate both internal and external communities regarding the moral dimension of health professionals practice; b) support, as a consulting board, all health professionals, patients and representatives who have moral conflicts to be solved or assist and/or provide clarifications in a difficult decision-making case, from the moral viewpoint;

c) propose norms, routines and guidelines to the Institution's central administration related to the protection of patients, health professionals and community members [11]. The Clinical Bioethics Committee of PUCRS is composed of 17 members, there being 1 external member that represents the community and 16 other institutional members, including six physicians, a nurse, a social worker, a psychologist, a bioethics specialist, a lawyer and representatives from: the Hospital Administration, from the Catholic Church, from the Medical Ethics Commission and the University's Research Ethics Committee. All members of the Clinical Bioethics Committee have previous Bioethics education. The Clinical Bioethics Committee of PUCRS meets monthly and provides on-demand consults requested by involved parties. From 1997 to 2006, 82 consults were addressed, 15 of which requested by the Institution itself in order to obtain advice on specific subjects in the Bioethics area. The clinical consults were requested by 14 different areas of the Hospital, especially from Internal Medical, Intensive Care Unit, Special Care Unit, Geriatrics, Gynecology and Obstetrics. The main themes addressed by these consults were: limits of treatment; best treatment choice; blood transfusions in Jehovah Witness patients, HIV diagnosis disclosure to partners and information protection on aggression threats to third parties [11]. Among the institution's demands for consults from the Clinical Bioethics Committee, the most highlighted was related to patients' privacy preservation, particularly regarding their medical records. Annually, Pontificia Universidade Catolica do Rio Grande do Sul offers three qualification and improvement activities in Bioethics area: a Basic Course for beginners, a Winter Course for professionals and an Advanced Course to discuss specific issues. These activities are used as an Ethics and Bioethics continuing education program. THE EXPERIENCE OF THE HOSPITAL DE CLINICAS DE PORTO ALEGRE CLINICAL BIOETHICS COMMITTEE The Support Program to Bioethics Problems (Programa de Apoio aos Problemas de Bioetica) of the Hospital de Clinicas de Porto Alegre was created in 1993 with the purpose of reflecting on the moral dilemmas resulting from the practice and procedures performed in this hospital. Today, the Clinical Bioethics Committee of the HCPA is composed of 18 members: six physicians of different specialties - gastroenterologist, nephrologist, pediatrician, psychiatrist, gynecologist and obstetrician, surgeon and coroner - a nurse, two biologists, a social worker, a hospital administrator, a psychologist, a nutritionist and two lawyers, and also two community representatives and a philosopher - the three latter without relationship with the institution [12]. In November 1993, the first group of professionals associated with the Program decided that it was necessary a period dedicated to studies and reflections. Only after a ten-month period of study, the group felt able to provide the consultancy services requested by the hospital community. The Clinical Bioethics Committee of the HCPA usually meets once a month to discuss the most difficult cases addressed during the consults and recommend guidelines to the Hospital Administration. Between November 1994 and October 2007, 937 consults were addressed, which can be done on-demand basis or in systematic activities. Specific on-demand consults can be provided mainly to the hospital wards themselves, or

in other areas of the HCPA Medical Services or in the Bioethics and Science Ethics Research Laboratory. Systematic consults are scheduled in advance with groups of health professionals who have recurring problems which, this way, can be addressed in a proactive manner. Such proactive consults may be provided in areas of the HCPA Services or in other rooms that allow the professionals to interact [12]. In order to provide the on-demand consults, also known as ward bioethics' consults, the Clinical Bioethics Committee of the HCPA has a board composed of five consultants available to provide the services. All consultants have postgraduate studies in Bioethics. Ward consults are preferably provided by two consultants, in order to avoid a single approach to the problem in question. All consult requests are answered in less than 24 hours. On-demand consultancy services were mostly requested by assistant physicians, as well as other health professionals, patients, patients' families, members of the Hospital Administration or religious communities. Such consults were requested by 58 different areas of the HCPA, especially by Pediatrics, Internal Medicine, Psychiatry, Gynecology and Obstetrics, Oncology and Hematology. The main issues addressed by such consults were: the patients' privacy; HIV diagnosis disclosure to partners; late onset genetic diseases; end of-life decisions; medically assisted reproduction; transsexual surgeries and blood transfusions in Jehovah Witness patients. Proactive consults were performed in several areas of the HCPA. Clinical Pediatric wards, Pediatric Surgery and Rheumatology services have already received proactive consults. Nowadays, two areas have proactive consults systematically: the Pediatric Intensive Care Unit and the Gender Identity Disorder Program (PROTIG). The PROTIG consults are held monthly and their objective is to discuss issues related to transsexual surgical indications, gender disorders diagnosis, patients privacy and name change in patients' civil registrations. In the Pediatric Intensive Care Unit, a 13 beds unit, the proactive consults are held weekly, always on Wednesday mornings, to discuss bioethical aspects involved in inpatients health care. The weekly discussion allows for the supervision of the evolution of long length of stay patients and for the prevention of either present or possible ethical issues. If required, the team of these areas may request on-demand consult to discuss situations that cannot await a new meeting. The most frequent themes were: end-of-life decisions, recommendations of procedures, family support and child abuse. The institution's demands for Clinical Bioethics' consults were related to the Hospital's need to reflect on some themes in order to propose actions to optimize its own operation. The most relevant themes were: patients' privacy; patient records confidentiality; electronic medical records privacy protection; nondiscrimination of patients, particularly in situations of isolation for infection control purposes; rights and obligations of visitors and patients' companions; physical and moral aggression to hospital employees. The Clinical Bioethics Committee members are encouraged to keep themselves updated on relevant themes, mainly with the bibliographical material and other educational activities that are available, such as the access to Bioethics disciplines that have regularly offered since 1996, through the UFRGS Medicine Post-graduation Program. Since 1997, classes on privacy and confidentiality have been offered in the HCPA to the Hospital's employees. These courses are directed at professionals working in those various areas where they are in direct or indirect contact with the patients, such as: secretaries of inpatients and outpatients units, professionals related to patients' printed/written or electronic records, to billing,

elevator operators, receptionists, security guards, nutrition delivery area, technician-level and superior level professionals of the Clinical Pathology laboratories, as well as those involved in those different activities related to human resources management. In 1997, over 1,200 employees were qualified in more than 40 courses. In 1999, Bioethics actions were included in the integration activities to new employees. In 2006 and 2007, new groups were formed to resume discussions on these themes. Forty-five courses were offered to over 1,400 employees. The instructors of these courses are associated with the Clinical Bioethics Committee or the Research Laboratory of Bioethics and Ethics in Science. Since 1996 a one-week Introductory Course of Bioethics has been offered annually to the community. Over 2,000 people, such as: graduate and postgraduate students, patient relatives, members of religious groups involved in the health area, health professionals, journalists and community members, have participated in these courses. For professionals who want to improve their qualification in Clinical Bioethics, the Research Laboratory of Bioethics and Ethics in Science of the HCPA offers, a Bioethics Committees fellowship, as a continuing education activity, of six-month duration. This course enables professionals from other institutions to implement and develop similar activities in other places. The Bioethics and Science Ethics Internet site (www.bioetica.ufrgs.br), maintained by the Interinstitutional Research Group in Bioethics, which is located in the Bioethics and Science Ethics Research Laboratory offers texts, slides, audio and video presentations on relevant themes of Clinical Bioethics. This site has been visited by over 840,000 people from different countries since 1997. Many educational and health care institutions use the site materials as reference. COMPARING BRAZILIAN EXPERIENCES TO OTHER COUNTRIES' EXPERIENCES In bioethical literature, little data on the operation of Clinical Bioethics Committees, both in Brazil and in other countries, are available. However, it is possible to establish some comparisons regarding the way Bioethics' consults are provided, the annual volume of consults and the type of competence related to the Clinical Bioethics Committee, as well as possible legal outcomes from this operation. Regarding the way the consults have been provided, both the Clinical Bioethics Committee of the Hospital Sao Lucas, since 1997, and the Clinical Bioethics Committee of the Hospital de Clinicas, since 1994, have offered on demand consultancy services. In England, this type of activity was proposed by the Institutional Clinical Ethics Committee of John Hunter Hospital, Newcastle, in 1999. They created an Acute Clinical Ethics Service (ACES) to address a need perceived from ethics consultancy services performed in the hospital [13]. Proactive consults, which have been performed in the Hospital de Clinicas since 1997 in the Pediatric Intensive Care Unit, were also described by other authors in 1998, and provided to adult patients in the same clinical situation [ 141. Regarding the volume of consults provided, there are some data from different countries. In Norway, a study conducted in 2004 involving 28 hospitals reported that the Committees held around nine meetings a year and had few cases to evaluate [15]. For instance, the National Hospital of Norway provided 31 bioethics consults in 7 years (1996-2002), which resulted in the average of 4.4 consults/year [16]. In New Zealand, at the Auckland Hospital, few cases have been submitted to the Bioethics Committee, although the physicians appreciate the activity [17]. In Israel, a study conducted in several hospitals reported that each Committee had an average of two consults/year [18]. In England, the average reported was four consults/year [19]. In the United States, two studies offer some data. The first one studied 113 North American Catholic Hospital Committees, with the average of five consults/year [20]. The second study, involving 600 hospitals, reported an average of three consults/year [21]. The Clinical Bioethics Committee of the Hospital Sao Lucas provides an average of 8.2 consults/year, while the Hospital de Clinicas de Porto Alegre an average of 72 consults/year. One of the factors that may partially justify the averages in

these two Brazilian hospitals is the credibility of the Ethics and Bioethics activities developed in both institutions. In the case of the Clinical Bioethics Committee of the Hospital de Clinicas de Porto Alegre, the higher number of consults provided can be credited to proactive consults, which is offered as a regular and continuous activity. The denomination of Hospital Ethics Committees is ambiguous. This denomination could be used to describe a Research Ethics Committee, a Clinical Bioethics Committee and even a Medical Ethics Committee. Due to this ambiguity, is difficult to characterize the legal implications to their members [22]. In Belgium, where this situation has occurred, a proposal was made to clarify the attributions to the Committees: dividing them in two - one for research and one for clinical issues [23]. It already works likes that in Brazil. The deliberative aspect of the Research Ethics Committees, granted by Resolution 196/96 of the Conselho Nacional de Saude (Brazilian National Health Council), guarantees powers to approve or refuse research projects submitted to them. It causes a legal responsibility to their members that act as representatives to protect the best interests of the society. The Medical Ethics Committee exists in any Brazilian hospital, as a formal recommendation of Federal Council of Medicine. The Medical Ethics Committee deliberates formally in malpractice cases and other professional issues. On the other hand, Clinical Bioethics Committees do not have any legislation or guidelines giving them either deliberative or consultative attributions. The Ethics Committee do Soroka Medical Center was created in BeerSheva/Israel in 1998, with executive and deliberative aspect, as it evaluates, and then approves or not, the proposals of treatment interruption and information revelation [24]. In this situation, the members of this Committee assume direct responsibilities for the service provided. Both Brazilian Clinical Bioethics Committees, at Hospital de Clinicas and at the Hospital Sao Lucas, have only had a counseling function, since they were created, in 1993 and 1997, respectively. This way, the members of these Committees should be exempted from this responsibility, as they do not make decisions, but only help professionals and patients in their decision-making process. CONCLUSION Health professionals should conciliate, in addition to scientific and technological knowledge, a solid ethical foundation in their professional practice. We support the idea that a competent professional is the one who gathers scientific, technological and ethical qualifications [25]. The function of the Clinical Bioethics Committees is to help professionals, patients and their representatives in situations whose decision becomes difficult. This way, by exchanging ideas and opinions, clarifying facts and circumstances, using cases as reference and theoretical approaches of Principles, Human Rights, Virtue Ethics and Alterity, adapted to the situation and by considering the systems of beliefs and affectivity aspects as inherent to human beings, alternatives may arise, and its consequences, enabling to make the decision for the best possible solution at the moment [26]. Clinical Bioethics Committees are an important element to humanize activities performed in health institutions, both in their institutional aspects and in the personal level of professionals, patients and their families. BIBLIOGRAPHY [I] Siegler M. "The doctor patient accommodation: a critical event in clinical medicine". Arch Intern Med 1982; 142:1899-902. [2] Goldim JR, Francisconi CF. "Os comites de etica hospitalar". Revista de MedicinaATM 1995;15(1):327-34. [3] Childress IF. "Who shall live when not all can live?". In: Edwards RB, Graber GC. Bioethics. Chicago: Harcourt, 1988, p. 745-55. [4] Teel K. "The physician's dilemma, a doctor's view: what the law should be".

Baylor Law Review 1975;27:6-9. [5] Rothman D. Strangers at the bedside. New York: Basic Books, 1991, p. 168-84.[6] McCarrick PM. "Ethics committees in hospitals". Kennedy Institute of Ethics Journal 1992;2(3):285-306. [7] Clinical Care Committee. "Optimum care for hopelessly ill patients". N Engl J Med1976;295(7):362-4. [8] de Blois J, Norris P, O'Rourke K. A primer for health care ethics. Washington: Georgetown, 1995, p. 151. [9] Tealdi JC, Mainetti JA. "Hospital ethics committee". In: Connor SS, Fuenzalida Puelma HL. Bioethics: issues and perspectives. Washington D.C.: Pan American Health Organization, 1990, p. 52-8. Scientific publications, n. 527. [10] Francisconi CF, Goldim JR, Lopes MU. "0 papel dos Comites de Bioetica na humanizacao da assistencia a sadde". Bioetica 2002;10(2):147-157. [dissertacao de mestrado]. [11] Borges GJC. Os comites de Bioetica e possiveis vias de comunicacao e acesso a (criminal). Porto Alegre: PPG em Ciencias Criminais/PUCRS, 2007 I [12] Goldim JR, Francisconi CF, Raymundo MM, Salgueiro JB. Bioethics Committees: a brazilian hospital's experience. European Association of Centres of Medical Ethics (EACME) 21" Annual Conference Book of Abstracts. Zurich: Institute of Biomedical Ethics, 2007, p. 34. [13] Gill AW, Saul P, McPhee J, Kerridge I. "Acute clinical ethics consultation: the practicalities". Med J Aust 2004 Aug 16;181(4):204-6. [14] Dowdy MD, Robertson C, Bander JA. "A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay". Crit Care Med 1998 Feb;26(2):252-9. [15] Pedersen R, Forde R. "What are the clinical ethics committees doing?". Trdsskr NorLaegeforen 2005;125(22):3127-9. [16] Forde R, Vandvik 1H. "Clinical ethics, information, and communication: review of 31 cases from a clinical ethics committee". JMed Ethics 2005 Feb;31(2):73-7. [17] Pinnock R, Crosthwaite J. "The Auckland Hospital Ethics Committee: the first 7 years". N Z Med J 2004 Nov 5;117(1205):U1152. [18] Wenger NS, Golan 0, Shalev C, Glick S. "Hospital ethics committees in Israel: structure, function and heterogeneity in the setting of statutory ethics committees". J Med Ethics 2002 Jun;28(3):177-82. [19]Thornton JG, Lilford RJ. "Clinical ethics committee". BMJ1995Sep 9;311(7006):667-9. [20] Bernt F, Clark P, Starrs J, Talone P. "Ethics committees in Catholic hospitals. A new study assesses their role, impact, and future in CHA-member hospitals". Health Prog 2006 Mar-Apr;87(2):18-25. [21] Fox E, Myers S, Pearlman RA. "Ethics consultation in United States hospitals: a national survey". Am J Bioeth 2007 Feb;7(2):13-25. [22] Hendrick J. "Legal aspects of clinical ethics committees". J Med Ethics 2001Apr;27 Suppl 1:i50-3.

[23] Meulenbergs T, Vermylen J, Schotsmans PT. "The current state of clinical ethics and healthcare ethics committees in Belgium". J Med Ethics 2005 Jun;31(6):318-21. [24] Frenkel DA. "The role of the ethics committee in hospital practice". Med Law 2003;22(4):627-33. [25] Francisconi CF. "The efficient gastroenterologist". Ital J Gastroenterol Hepatol 1997;29:289-92. [26] Goldim JR. "Bio6tica: origens e complexidade". Revista HCPA 2006;26:86-92.

1 Journal international de bioethique, 2008, vet. 19, n" 1-2

Chapitre 12

CLINICAL BIOETHICSCOMMITTEES: A BRAZILIAN

EXPERIENCE

Jose Roberto GOLDIMI, Marcia M. RAYMUND02

,

Marcia SANTANA FERNANDES3,

Maria Helena ITAQUI LOPES', Delio Jose KIPPER5,

Carlos Fernando FRANCISCONI6

1. Biologist, PhD. Researcher in charge of the Bioethics and Science Ethics Research Laboratoryof the Hospital de Clfnicas de Porto Alegre, Professor at the Medical Schools of PontiffciaUniversidade Cat61ica do Rio Grande do Sui and at Universidade Federal do Rio Grande do SuI.

2. Biologist, PhD, Researcher at the Bioethics and Science Ethics Research Laboratory of theHospital de Clfnicas de Porto Alegre.

3. Lawyer, Doctor in Law, Researcher at the Bioethics and Ethics Laboratory of the Hospital deClinicas de Porto Alegre. Professor at the Law School of Centro UniRitter.

4. Physician, PhD, Professor and Vice-Director of the Medical School of Pontiffcia UniversidadeCat6lica do Rio Grande do SuI.

5. Physician, PhD. Professor of the Medical School of Pontiffcia Universidade Cat6lica do RioGrande do Sui.

6. Physician, PhD. Professor at the Medical Schools of Pontiffcia Universidade Catolica do RioGrande do Sui and of the Universidade Federal do Rio Grande do SuI. Coordinator of thePrograma de Atencao aos Problemas de Bioetica of the Hospital de CHnicas de Porto Alegre.

181

INTRODUCTION

Clinical Bioethics is based on the concept that Medicine is a moralcommitment, whose reference relies on its physician-patient relationship. Thismoral relationship between physician and patient generates co-responsibilitiesand estahlishes the context in which shared decisions occur [I]. However,problems of different types may arise in the patient care scenario and requiredecisions that many times make the physician search for counseling, in order tomake the best possible solution for the dilemma in question. The scientific andtechnological evolution has caused frequent situations with conflicts of moralvalues between health professionals and patients, many times involving theirfamilies. In order to try to solve problems of this nature, two types of resourcesare employed. The first one is of personal aspect, in which the individual reflectsmorally on his/her act and comes to a conclusion regarding the best decision tomake. For this purpose, cognitive resources are used, which consist in anawareness of the elements that make up bioethics reflection and the values thatare part of his/her personality, created along the lifetime as a result of theexperiences acquired from hislher family, school, religion and culture of hislherenvironment. The decision based solely on "good sense" should be avoided.Many times, "good sense", which is a rational analysis of facts and alternatives,is confused with "common sense", which represents the average thoughtuncritically accepted. The second resource is to have the support of a ClinicalBioethics Committee, in order to reflect and evaluate questions and moraldilemmas resulting from the practice and procedures performed within theinstitutions' range, sharing them with other professionals and communityrepresentatives [2].

HISTORY

Hospital Bioethics or Ethics Committees were originated in the United States,in the 1960s, when discussions arose on performing hemodialysis in chronic renalpatients, since there was a high number of patients and insufficient equipment.The first committee was created from such resource allocation dilemma,composed of laypersons only, and whose purpose was to establish criteria forresource allocation. As it made decisions that involved the survival of patients,this commission was named "Divine Committee" by the lay opinions [3].

The first suggestion for the creation of a Hospital Ethics Committee,published in a scientific periodical, was made by Pediatrician Karen Teel in 1975,in order to enable a dialog between professionals in individual clinical situations,

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as a way to share responsibilities [4]. The treatment provided to Karen AnnQuinlan started a judicial dispute between her parents and her assistantphysician. The patient lived in a permanent vegetative condition, due to anunexplained cause, and her family wanted the artificial breather to be removed.The physician refused to do that, saying that this resource was necessary to hersurvival and that the patient did not fulfill the brain death criteria [5]. Thesentence of New Jersey Supreme Court in 1976 established that the EthicsCommittee of St. Clair Hospital should define the patient's prognosis and ensurethat she would never be able to regain a "sapient cognitive state". The judgemistakenly presumed that this hospital already had a Clinical BioethicsCommittee, just as most of the other North American hospitals that couldevaluate such a situation. As there was no Committee, the Hospital managementcreated one especially to study the case. As a result, it was recommended toremove the breather from the patient [4]. After this fact, the patient still lived fornine years. Also in 1976, Massachusetts General Hospital created asubcommittee of the Clinical Care Committee, in order to revise 15 cases ofpatients with cancer, without apparent possibility of being cured [6]. The resultsof such revisions, published by the Committee members, caused significantrepercussion in the medical area [7]. Later, Baby Doe's case in 1982 made aNorthern American State government recommend the creation of committees torevise the pediatric care, which caused an increase in the number of HospitalEthics Committees. Baby Doe's case involved a judicial dispute between theparents of a newborn baby with multiple malformations, who did not authorize asurgery required for the baby's survival, and the surgeon, who insisted on hisindication [5]. In July 1987, a new law was in force in the Northern AmericanState of Maryland making the creation of counseling committees mandatory inhospitals, in order to support the decision-making process in cases of health riskdiseases. In 1990, this law was extended to include nursing homes [6]. It shouldbe noted that this was the first North American law that made the creation ofClinical Bioethics Committees mandatory in hospitals. In 1994, the AmericanHospital Association (AHA) suggested that hospitals should create clinical ethicscommittees. The North American Presidential Commission was not giving suchrecommendations anymore, only requesting hospitals to have ethics education,consultancy and revision programs in place for difficult cases, which is today'sattitude adopted by the North American Hospital Registry Commission [8]. InBrazil, there is no legislation or guideline that regulates the creation or operationof Bioethics Committees. The Hospital de Clinicas de Porto Alegre (HCPA) wasthe first to implement in 1993 its Support Program to Bioethics Problems(Programa de Apoio aos Problemas de Bioeticat, The Hospital Sao Lucas atPontificia Universidade Catolica do Rio Grande do Sui created its BioethicsCommittee in 1995.

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as a way to share responsibilities [4]. The treatment provided to Karen AnnQuinlan started a judicial dispute between her parents and her assistantphysician. The patient lived in a permanent vegetative condition, due to anunexplained cause, and her family wanted the artificial breather to be removed.The physician refused to do that, saying that this resource was necessary to hersurvival and that the patient did not fulfill the brain death criteria [5]. Thesentence of New Jersey Supreme Court in 1976 established that the EthicsCommittee of St. Clair Hospital should define the patient's prognosis and ensurethat she would never be able to regain a "sapient cognitive state". The judgemistakenly presumed that this hospital already had a Clinical BioethicsCommittee, just as most of the other North American hospitals that couldevaluate such a situation. As there was no Committee, the Hospital managementcreated one especially to study the case. As a result, it was recommended toremove the breather from the patient [4]. After this fact, the patient still lived fornine years. Also in 1976, Massachusetts General Hospital created asubcommittee of the Clinical Care Committee, in order to revise 15 cases ofpatients with cancer, without apparent possibility of being cured [6]. The resultsof such revisions, published by the Committee members, caused significantrepercussion in the medical area [7]. Later, Baby Doe's case in 1982 made aNorthern American State government recommend the creation of committees torevise the pediatric care, which caused an increase in the number of HospitalEthics Committees. Baby Doe's case involved a judicial dispute between theparents of a newborn baby with multiple malformations, who did not authorize asurgery required for the baby's survival, and the surgeon, who insisted on hisindication [5]. In July 1987, a new law was in force in the Northern AmericanState of Maryland making the creation of counseling committees mandatory inhospitals, in order to support the decision-making process in cases of health riskdiseases. In 1990, this law was extended to include nursing homes [6]. It shouldbe noted that this was the first North American law that made the creation ofClinical Bioethics Committees mandatory in hospitals. In 1994, the AmericanHospital Association (AHA) suggested that hospitals should create clinical ethicscommittees. The North American Presidential Commission was not giving suchrecommendations anymore, only requesting hospitals to have ethics education,consultancy and revision programs in place for difficult cases, which is today'sattitude adopted by the North American Hospital Registry Commission [8]. InBrazil, there is no legislation or guideline that regulates the creation or operationof Bioethics Committees. The Hospital de Clinicas de Porto Alegre (HCPA) wasthe first to implement in 1993 its Support Program to Bioethics Problems(Programa de Apoio aos Problemas de Bioeticay. The Hospital Sao Lucas atPontificia Universidade Catolica do Rio Grande do SuI created its BioethicsCommittee in 1995.

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THE ROLE OF BIOETHICS COMMITTEES

The purpose of a bioethics consultancy is to improve the standard of patientcare, providing the professional in charge of the patient care with auopportunity of better decision making in case of a moral dilemma. A BioethicsCommittee can be defined as an interdisciplinary board of people, whoseobjective is to teach, study, provide consultancy services and suggestinstitutional norms on ethical issues [9]. Specialists in Ethics have assumed animportant role in patient care. The authority of the Clinical Ethics specialist hasbeen the subject of great discussions. On the one hand, the Ethics consultant isseen as a specialist in moral theory, a technical consultant similar to a medicalspecialist, with skills, experience and techniques to solve complex moraldilemmas. On the other hand, the specialist can be seen as a mediator, acommunication facilitator, with the function of clarifying the moral position ofthe others involved and finding a discussion space where the different opinionscan be addressed, understood and solved [10]. In pluralist societies, theBioethics Committees search for solutions to ethical dilemmas based ondefensible moral norms. For this reason, they need people with, besidesknowledge, characteristics such as moral sensitivity and balance, and who arenot controversial and dogmatic. According to Andy Clarck, a specialist inEthics, this consultant should be a highly competent person to promote acooperative moral debate [10]. For this role, the bioethics consultant isexpected to have conditions of gathering all information required to understandthe case in question and, at the same time, expand the communication betweenthe parties. It is not difficult to see, especially at university hospitals, a patientwith several medical teams taking care of hislher case simultaneously and theprofessionals never talk to share their decisions. These meetings enable toidentify areas of possible scientific and ethical discrepancies. In this sense, theobjectives of each person participating in the patient care process should beclear and defined [10]. It is not necessary to have the group composed ofBioethics specialists only. What is expected from the group members is themoral reflection capability. The Committee leaders are responsible formotivating the group members to improve their skills in the Clinical Bioethicsfield, by providing selected bibliographical material and, preferably, significantto the individual's field of competence, and organize their arguments gradually,less intuitively and more based on facts, doctrines and paradigmatic caseswithin the Bioethics field.

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THE EXPERIENCE OF THE HOSPITAL SAO LUCASCLINICAL BIOETHICS COMMITTEE

The Clinical Bioethics Committee of the Hospital Sao Lucas at PUCRS wascreated in 1997.lts objectives were established in Article 4 of its Internal Bylaw:

a) educate both internal and external communities regarding the moraldimension of health professionals practice;

b) support, as a consulting board, all health professionals, patients andrepresentatives who have moral conflicts to be solved or assist and/orprovide clarifications in a difficult decision-making case, from the moralviewpoint;

c) propose norms, routines and guidelines to the Institution's centraladministration related to the protection of patients, health professionalsand community members [11].

The Clinical Bioethics Committee of PUCRS is composed of 17 members,there being 1 external member that represents the community and 16 otherinstitutional members, including six physicians, a nurse, a social worker, apsychologist, a bioethics specialist, a lawyer and representatives from: theHospital Administration, from the Catholic Church, from the Medical EthicsCommission and the University's Research Ethics Committee. All members ofthe Clinical Bioethics Committee have previous Bioethics education.

The Clinical Bioethics Committee of PUCRS meets monthly and provideson-demand consults requested by involved parties. From 1997 to 2006, 82consults were addressed, 15 of which requested by the Institution itself in orderto obtain advice on specific subjects in the Bioethics area.

The clinical consults were requested by 14 different areas of the Hospital,especially from Internal Medical, Intensive Care Unit, Special Care Unit,Geriatrics, Gynecology and Obstetrics. The main themes addressed by theseconsults were: limits of treatment; best treatment choice; blood transfusions inJehovah Witness patients, HIV diagnosis disclosure to partners and informationprotection on aggression threats to third parties [11].

Among the institution's demands for consults from the Clinical BioethicsCommittee, the most highlighted was related to patients' privacy preservation,particularly regarding their medical records.

Annually, Pontiffcia Universidade Catolica do Rio Grande do SuI offers threequalification and improvement activities in Bioethics area: a Basic Course for

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beginners, a Winter Course for professionals and an Advanced Course to discussspecific issues. These activities are used as an Ethics and Bioethics continuingeducation program.

THE EXPERIENCE OF THE HOSPITAL DE CLINICASDE PORTO ALEGRE CLINICAL BIOETHICSCOMMITTEE

The Support Program to Bioethics Problems (Programa de Apoio aosProblemas de Bioetica) of the Hospital de Clinicas de Porto Alegre was createdin 1993 with the purpose of reflecting on the moral dilemmas resulting from thepractice and procedures performed in this hospital. Today, the Clinical BioethicsCommittee of the HCPA is composed of 18 members: six physicians of differentspecialties - gastroenterologist, nephrologist, pediatrician, psychiatrist,gynecologist and obstetrician, surgeon and coroner - a nurse, two biologists, asocial worker, a hospital administrator, a psychologist, a nutritionist and twolawyers, and also two community representatives and a philosopher - the threelatter without relationship with the institution [12].

In November 1993, the first group of professionals associated with theProgram decided that it was necessary a period dedicated to studies andreflections. Only after a ten-month period of study, the group felt able to providethe consultancy services requested by the hospital community.

The Clinical Bioethics Committee of the HCPA usually meets once a monthto discuss the most difficult cases addressed during the consults and recommendguidelines to the Hospital Administration. Between November 1994 and October2007, 937 consults were addressed, which can be done on-demand basis or insystematic activities. Specific on-demand consults can be provided mainly to thehospital wards themselves, or in other areas of the HCPA Medical Services or inthe Bioethics and Science Ethics Research Laboratory. Systematic consults arescheduled in advance with groups of health professionals who have recurringproblems which, this way, can be addressed in a proactive manner. Such proactiveconsults may be provided in areas of the HCPA Services or in other rooms thatallow the professionals to interact [12].

In order to provide the on-demand consults, also known as ward bioethics'consults, the Clinical Bioethics Committee of the HCPA has a board composed offive consultants available to provide the services. All consultants havepostgraduate studies in Bioethics. Ward consults are preferably provided by two

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consultants, in order to avoid a single approach to the problem in question. Allconsult requests are answered in less than 24 hours.

On-demand consultancy services were mostly requested by assistantphysicians, as well as other health professionals, patients, patients' families,members of the Hospital Administration or religious communities. Such consultswere requested by 58 different areas of the HCPA, especially by Pediatrics,Internal Medicine, Psychiatry, Gynecology and Obstetrics, Oncology andHematology. The main issues addressed by such consults were: the patients'privacy; HIV diagnosis disclosure to partners; late onset genetic diseases; end­of-life decisions; medically assisted reproduction; transsexual surgeries andblood transfusions in Jehovah Witness patients.

Proactive consults were performed in several areas of the HCPA. ClinicalPediatric wards, Pediatric Surgery and Rheumatology services have alreadyreceived proactive consults. Nowadays, two areas have proactive consultssystematically: the Pediatric Intensive Care Unit and the Gender IdentityDisorder Program (PROTIG).

The PROTIG consults are held monthly and their objective is to discussissues related to transsexual surgical indications, gender disorders diagnosis,patients privacy and name change in patients' civil registrations.

In the Pediatric Intensive Care Unit, a 13 beds unit, the proactive consults areheld weekly, always on Wednesday mornings, to discuss bioethical aspectsinvolved in inpatients health care. The weekly discussion allows for thesupervision of the evolution of long length of stay patients and for the preventionof either present or possible ethical issues. If required, the team of these areasmay request on-demand consult to discuss situations that cannot await a newmeeting. The most frequent themes were: end-of-life decisions,recommendations of procedures, family support and child abuse.

The institution's demands for Clinical Bioethics' consults were related to theHospital's need to reflect on some themes in order to propose actions to optimizeits own operation. The most relevant themes were: patients' privacy; patientrecords confidentiality; electronic medical records privacy protection; non­discrimination of patients, particularly in situations of isolation for infectioncontrol purposes; rights and obligations of visitors and patients' companions;physical and moral aggression to hospital employees.

The Clinical Bioethics Committee members are encouraged to keepthemselves updated on relevant themes, mainly with the bibliographical materialand other educational activities that are available, such as the access to Bioethics

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disciplines that have regularly offered since 1996, through the UFRGS MedicinePost-graduation Program.

Since 1997, classes on privacy and confidentiality have been offered in theHCPA to the Hospital's employees. These courses are directed at professionalsworking in those various areas where they are in direct or indirect contact withthe patients, such as: secretaries of inpatients and outpatients units, professionalsrelated to patients' printed/written or electronic records, to billing, elevatoroperators, receptionists, security guards, nutrition delivery area, technician-leveland superior level professionals of the Clinical Pathology laboratories, as well asthose involved in those different activities related to human resourcesmanagement. In 1997, over 1,200 employees were qualified in more than 40courses. In 1999, Bioethics actions were included in the integration activities tonew employees. In 2006 and 2007, new groups were formed to resumediscussions on these themes. Forty-five courses were offered to over 1,400employees. The instructors of these courses are associated with the ClinicalBioethics Committee or the Research Laboratory of Bioethics and Ethics inScience.

Since 1996 a one-week Introductory Course of Bioethics has been offeredannually to the community. Over 2,000 people, such as: graduate andpostgraduate students, patient relatives, members of religious groups involved inthe health area, health professionals, journalists and community members, haveparticipated in these courses.

For professionals who want to improve their qualification in ClinicalBioethics, the Research Laboratory of Bioethics and Ethics in Science of theHCPA offers, a Bioethics Committees fellowship, as a continuing educationactivity, of six-month duration. This course enables professionals from otherinstitutions to implement and develop similar activities in other places.

The Bioethics and Science Ethics Internet site (www.bioetica.ufrgs.br).maintained by the Interinstitutional Research Group in Bioethics, which islocated in the Bioethics and Science Ethics Research Laboratory offers texts,slides, audio and video presentations on relevant themes of Clinical Bioethics.This site has been visited by over 840,000 people from different countries since1997. Many educational and health care institutions use the site materials asreference.

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COMPARING BRAZILIAN EXPERIENCES TO OTHERCOUNTRIES' EXPERIENCES

In bioethical literature, little data on the operation of Clinical BioethicsCommittees, both in Brazil and in other countries, are available. However, it ispossible to establish some comparisons regarding the way Bioethics' consults areprovided, the annual volume of consults and the type of competence related tothe Clinical Bioethics Committee, as weIl as possible legal outcomes from thisoperation.

Regarding the way the consults have been provided, both the ClinicalBioethics Committee of the Hospital Sao Lucas, since 1997, and the ClinicalBioethics Committee of the Hospital de Clinicas, since 1994, have offered on­demand consultancy services. In England, this type of activity was proposed bythe Institutional Clinical Ethics Committee of John Hunter Hospital, Newcastle,in 1999. They created an Acute Clinical Ethics Service (ACES) to address a needperceived from ethics consultancy services performed in the hospital [13].

Proactive consults, which have been performed in the Hospital de Clinicassince 1997 in the Pediatric Intensive Care Unit, were also described by otherauthors in 1998, and provided to adult patients in the same clinical situation [14].

Regarding the volume of consults provided, there are some data fromdifferent countries. In Norway, a study conducted in 2004 involving 28 hospitalsreported that the Committees held around nine meetings a year and had few casesto evaluate [15]. For instance, the National Hospital of Norway provided 31bioethics consults in 7 years (1996-2002), which resulted in the average of 4.4consults/year [16]. In New Zealand, at the Auckland Hospital, few cases havebeen submitted to the Bioethics Committee, although the physicians appreciatethe activity [17]. In Israel, a study conducted in several hospitals reported thateach Committee had an average of two consults/year [18]. In England, theaverage reported was four consults/year [19]. In the United States, two studiesoffer some data. The first one studied 113 North American Catholic HospitalCommittees, with the average of five consults/year [20]. The second study,involving 600 hospitals, reported an average of three consults/year [21].

The Clinical Bioethics Committee of the Hospital Sao Lucas provides anaverage of 8.2 consults/year, while the Hospital de Clinicas de Porto Alegre anaverage of 72 consults/year. One of the factors that may partially justify theaverages in these two Brazilian hospitals is the credibili ty of the Ethics andBioethics activities developed in both institutions. In the case of the ClinicalBioethics Committee of the Hospital de Clinicas de Porto Alegre, the higher

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number of consults provided can be credited to proactive consults, which isoffered as a regular and continuous activity.

The denomination of Hospital Ethics Committees is ambiguous. Thisdenomination could be used to describe a Research Ethics Committee, a ClinicalBioethics Committee and even a Medical Ethics Committee. Due to thisambiguity, is difficult to characterize the legal implications to their members [22].In Belgium, where this situation has occurred, a proposal was made to clarify theattributions to the Committees: dividing them in two - one for research and onefor clinical issues [23].

It already works likes that in Brazil. The deliberative aspect of the ResearchEthics Committees, granted by Resolution 196/96 of the Conselho Nacional deSaude (Brazilian National Health Council), guarantees powers to approve orrefuse research projects submitted to them. It causes a legal responsibility to theirmembers that act as representatives to protect the best interests of the society. TheMedical Ethics Committee exists in any Brazilian hospital, as a formalrecommendation of Federal Council of Medicine. The Medical Ethics Committeedeliberates formally in malpractice cases and other professional issues. On theother hand, Clinical Bioethics Committees do not have any legislation orguidelines giving them either deliberative or consultative attributions.

The Ethics Committee do Soroka Medical Center was created in Beer­ShevalIsrael in 1998, with executive and deliberative aspect, as it evaluates, andthen approves or not, the proposals of treatment interruption and informationrevelation [24]. In this situation, the members of this Committee assume directresponsibilities for the service provided.

Both Brazilian Clinical Bioethics Committees, at Hospital de Clinicas and atthe Hospital Sao Lucas, have only had a counseling function, since they werecreated, in 1993 and 1997, respectively. This way, the members of theseCommittees should be exempted from this responsibility, as they do not makedecisions, but only help professionals and patients in their decision-makingprocess.

CONCLUSION

Health professionals should conciliate, in addition to scientific andtechnological knowledge, a solid ethical foundation in their professional practice.We support the idea that a competent professional is the one who gathersscientific, technological and ethical qualifications [25]. The function of theClinical Bioethics Committees is to help professionals, patients and their

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representatives in situations whose decision becomes difficult. This way, byexchanging ideas and opinions, clarifying facts and circumstances, using casesas reference and theoretical approaches of Principles, Human Rights, VirtueEthics and Alterity, adapted to the situation and by considering the systems ofbeliefs and affectivity aspects as inherent to human beings, alternatives mayarise, and its consequences, enabling to make the decision for the best possiblesolution at the moment [26]. Clinical Bioethics Committees are an importantelement to humanize activities performed in health institutions, both in theirinstitutional aspects and in the personal level of professionals, patients and theirfamilies.

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[3] Childress JP. "Who shall live when not all can live?". In: Edwards RB, Graber GC.Bioethics. Chicago: Harcourt, 1988, p. 745-55.

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[18] Wenger NS, Golan 0, Sha1ev C, Glick S. "Hospital ethics committees in Israel:structure, function and heterogeneity in the setting of statutory ethics committees".J Med Ethics 2002 Jun;28(3):I77-82.

[19] Thornton JG, Lilford RJ. "Clinical ethics committee". BMJ 1995 Sep9;311(7006):667-9.

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[22] Hendrick 1. "Legal aspects of clinical ethics committees". J Med Ethics 2001Apr;27 Suppl l:i50-3.

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