San Diego Bioethics Commission

The San Diego Bioethics Commission, chaired by Lynette Cederquist MD (USCD) and Paula Goodman-Crews LCSW (Kaiser Permanente), was developed within the San Diego County Medical Society (SDCMS) with a vision of bringing together San Diego County's medical community to develop standards in bioethics practices. Very few communities have organized such an effort! At this point in time, there is only one other bioethics commission in California of which we are aware, the Southern California Bioethics Consortium, based in Los Angeles.

So far, our commission has representation from UCSD, Kaiser Permanente, Sharp Grossmont, Sharp Coronado, the VHA (Veterans Health Administration), Rady Children's Hospital, Sharp Grossmont, Sharp Mission Park, Edgemoor, Navy Medical Center, San Diego Hospice, Silverado Hospice, Scripps La Jolla, and Palomar Medical Center. The first issue the commission has tackled is "non-beneficial treatment," also referred to as "medical futility." This is an issue that every hospital and every ethics committee wrestles with on a regular basis.

In a recent review of UCSD's ethics consultations, close to 50 percent of consults were requested because of conflicts surrounding perceptions of medical futility or medically ineffective treatment. This has been identified by all of the commission's participants as a major source of conflict, especially intractable cases that are not remediated by ethics facilitation. The nearly universal consensus has been that when faced with cases where physicians have determined treatment is non-beneficial, but the patient or surrogate continues to insist on treatment, most physicians continue treatment. Physicians tend to default to continuation of treatment even if their institution's policies support withdrawal of non-beneficial treatment. We believe that by developing a community standard to guide policy, each individual institution's policies and practices will be better enforced.

When we reviewed the policies from the hospitals represented, we found significant variations. In an attempt to help develop a "model policy" that will be identified as San Diego County's community standard, we have developed a work group to craft such a policy. We are drawing from current policies, as well as looking at policies from other institutions within California, as well as the Texas legislation that offers legal immunity to physicians and institutions who withdraw treatment considered to be non-beneficial.

Effective policies that address medical futility or non-beneficial treatment, in general, contain three major components:

1. A definition of medical futility/non-beneficial treatment. The commission is still in the process of creating a definition. Of note, the inability of the medical community to achieve consensus on a proper definition has been a major barrier in the development of a standard.
2. A process for conflict resolution. This portion of the policy will outline the steps that should be followed when conflicts arise. The hope is that with careful deliberation by all parties involved, including the ethics consultation service, the majority of conflicts can be resolved using a model of mediation.
3. The "bottom line": What should be done in intractable cases when the conflict cannot be resolved? This is the component that varies the most widely. Some San Diego County policies explicitly state that the disputed treatment can be unilaterally discontinued and will not be offered at that institution. Other policies are silent on this issue, while others advise referring the case to hospital administration, or in one policy, to the courts. The nature and scope of Bioethics Committee role and function also requires further scrutiny, as some hospitals consign moral agency and decisional authority to the committee, while others do not. This vital "bottom line" I believe will be the most critical component.

We believe we are making great headway but still have much work ahead of us. We are very excited about the enthusiastic participation by all of the members of the Bioethics Commission and workgroup. Each individual has volunteered their own time out of a sense of commitment to their institutions, an effort that is to be commended! In the coming months, we will be working to contact other hospital ethics committees that are not yet involved to solicit involvement and input into this vital process. If you have not heard from us and would like to be involved, please contact us.