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Orlando, Fla. -- Nearly all hospitals have ethics committees to help resolve dilemmas facing physicians, patients and families, especially regarding end-of-life care. Yet surveys have found the typical ethics consultation service handles only three cases a year.

When should ethics services be consulted? Who should sit on ethics committees? Should they tell doctors and patients what to do, or just offer advice?

These were some of the questions delegates debated at the AMA Council on Ethical and Judicial Affairs' open forum during the Interim Meeting in November.

Richard Pieters Jr., MD, an alternate delegate for the Massachusetts Medical Society, said the ethics consultations should be a function of the medical staff. "I have a great deal of concern about the idea of the profession losing control of ethics committees to trained ethicists," said Dr. Pieters, a radiation oncologist. "It is important that the committee include people from specialties who have an interest in the patients but who may not have had ethics training."

Other delegates complained that ethics services too often operate in secrecy and avoid cases that could pose challenges for the organization.

"How do you make an ethics panel stick to its job and solve the problems brought to them?" asked Stephen L. Brotherton, MD, a delegate for the Texas Medical Assn. "Physicians should get regular reports on what [ethics committees] are doing and how they're dealing with different cases. Ethics belongs to the whole community. It's not the committee's job to cover the hospital's butt."

Conflict with midlevel relationships

Delegates reacted passionately to another question explored at the forum -- can physicians manage the potential conflict of interest that arises when employed by nonphysicians they are responsible for supervising?

Nurse practitioners and physician assistants are increasingly setting up independent practices and hiring doctors to provide legally required supervision. Can doctors supervise the midlevel health professionals who are paying them?

"I'm amazed that we even have to think about whether this is ethical or not," said Michael E. Greene, MD, an alternate delegate for the Medical Assn. of Georgia. "To put doctors in the ... employee role of those they are supervising is ludicrous."

Dr. Greene, a family physician, said the situation poses an untenable conflict for doctors. "Yes, in a perfect world, my ethics say, 'We shouldn't do this or that,' but then they say, 'Thanks very much. You're no longer employed here.' "

Michael A. Williams, MD, a delegate for the American Academy of Neurology, said the relationship can be handled professionally.

"There is a lot of temptation to frame this as a scope-of-practice issue and a financial issue," said Dr. Williams, an employed physician who supervises a physician assistant. "But the physician responsibility in any kind of relationship is the same."

Sham supervisory relationships formed to skirt the law are obviously wrong, Dr. Williams said. But he argued it would be difficult for CEJA "to make the case across the board" that it is ethically impermissible for doctors to supervise midlevels who employ them.

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