Chapter 4: Healthcare Ethics Committee

how do i contact the ethics committee or request an ethics consultation?

Check with your hospital to identify the pager number to reach the ethics consultant. There should be an individual at each hospital that carries a pager for responding to ethics consultations.

Ethics Committees and Consultation (website)

Most hospitals are now required to have an ethics committee, and many in the Seattle area provide an ethics consultation service. In the United States some ethics committees have expanded their functions and become more comprehensive ethics programs. This topic page will discuss the role and activities of these groups.

Committee Functions (section 4)

-The functions of ethics committees are multifaceted and include development of policy and procedure guidelines to assist in resolving ethical dilemmas; staff and community education; conflict resolution; case reviews, support, and consultation; and political advocacy. The degree to which an ethics committee serves each of these functions varies in different healthcare organizations.

Partial Reasoning

-bias for or against a person -based on one's relationship with that person

last slide on powerpoint

-consensus building occurs when people reason together

Expanding Role of the Ethics Committee

- Typically, hospital ethics committees concern themselves with biomedical issues as they relate to end-of-life issues; unfortunately, they often fail to address external decisions that affect internal operations -The role of an organization's ethics committee is evolving into more than a group of individuals who periodically gather together to meet a regulatory requirement and address advance directives and end-of-life issues. The organizational ethics committee has an ever-expanding role. This expanded role involves addressing external issues that affect internal operations (e.g., managed care, malpractice insurance, and complicated Health Insurance Portability and Accountability Act regulations that often increase legal and other financial costs). Ethics committees need to review their functions periodically and redefine themselves. -ethics committee is health care's sleeping giant because of its potential to bring about change, its mission must not be limited to end-of-life issues -vision must not be restricted to issues internal to the organization but must include external matters that affect internal operations -Failure to increase the good of others when one is knowingly in a position to do so is morally wrong. Preventative medicine and active public health interventions exemplify this conviction. After methods of treating yellow fever and smallpox were discovered, for example, it was universally agreed that positive steps ought to be taken to establish programs to protect public health. The wide variety of ethical issues in which an ethics committee can be involved is somewhat formidable. Although an ethics committee cannot address every issue that one could conceivably imagine, the ethics committee should periodically reevaluate its scope of activities and effectiveness in addressing ethical issues. Some of the internal and external issues facing an organization's ethics committee are listed here.

Policy: Consultation and Conflict Resolution

-Ethics consultations are helpful in resolving uncertainty and disagreements over healthcare dilemmas. -Ethics committees often provide consultation services for patients, families, and caregivers struggling with difficult treatment decisions and end-of-life dilemmas. Always mindful of its basic orientation toward the patient's best interests, the committee provides options and suggestions for resolution of conflict in actual cases. Consultation with an ethics committee is not mandatory but is conducted at the request of a physician, patient, family member, or other caregiver. -The ethics committee strives to provide viable alternatives that will lead to the optimal resolution of dilemmas confronting the continuing care of the patient. It is important to remember that an ethics committee functions in an advisory capacity and should not be considered a substitute proxy for the patient. -A representative of the ethics committee is often able to intervene, when requested, in resolving ethical dilemmas. On occasion it may be necessary to request the assistance of one or more additional members of the ethics committee. An on-call roster is generally helpful when a consultation is necessary during evening, night, and weekend hours. Ethics committee members of the hospital staff generally provide on-call services.

Ethics Committee Policy Statement (s. 4)

-Kennedy Health System ensures that all adult patients will be provided the opportunity to learn about and/or make a valid advance directive to indicate their decisions about life-prolonging treatment, and/or to appoint a proxy to speak for them, should they lose their decision-making capacity or the ability to communicate choices. -Advance directives can protect a patient's rights and wishes in the event the patient becomes physically or mentally unable to make healthcare decisions. Providers honor a patient's advance directive as long as it does not violate State and Federal laws. The existence or lack of an advance directive does not determine an individual's access to care, treatment and services. -A valid advance directive is followed regardless of the patient's race, religion, national origin, sex, sexual preferences, handicap, diagnosis, ability to pay and source of payment. No patient will be discriminated against with regard to the provision of care or based on whether the patient has executed an advance directive. -Information for patients, community and associates regarding their rights to make healthcare decisions, options and a summary of the hospital's advance directive policy shall be provided by Kennedy Health System (Appendix A) in the KHS Patient Guide, and website. -The provisions of a valid advance directive (See Appendix B) will be followed. -If a healthcare professional, because of personal conviction, declines to participate in withholding or withdrawing of life sustaining treatments, as outlined in a patient's advance directive, then Kennedy Health System's "Exclusion from Patient Care Policy" (see Human Resource Manual) should be followed. If necessary, the provider must cooperate with appropriate and timely reassignment of care to a willing provider. -When conflicts about compliance with an advance directive arise, associates, physicians, and students are strongly encouraged to contact the system's Medical Ethics Advisory Committee (M.E.A.C.) for further guidance.[2]

Conflict Resolution (section 2)

-ethics committee members should be carefully vetted as to their skills -. Members of the ethics committee should complete a mandatory orientation that includes training and coaching. They should participate in continuing education programs. Committee members are expected to be active participants in committee activities. Self-study interest in the law and ethics should prove helpful. Those members of the committee who participate in consultative services involving patient care dilemmas should have appropriate medical, legal, and ethics training.

Limited Resources affect decisions

-reaching agreement may mean -sacrificing one's personal values

Healthcare Ethics committee

-s an advisory body whose purpose is to facilitate discussion and consultation on ethical issues arising in the patient care setting. The goal of the ethics committee is to improve patient care and outcomes through recognition of the needs, interests, and rights of each patient and participants in the delivery of each patient's care. -address legal and ethical issues that arise during the course of a patient's care and treatment. They serve as a resource for patients, families, and staff. They offer objective counsel when dealing with difficult healthcare issues. Ethics committees provide both educational and consultative services to patients, families, and caregivers. They enhance but do not replace important patient/family-physician relationships; nevertheless, they afford support for decisions made within those relationships. The numerous ethical questions facing health professionals involve the entire lifespan, from the right to be born to the right to die. Ethics committees concern themselves with issues of morality, patient autonomy, legislation, and states' interests. -first emerged in 1960s in the US: attention was focused on ethics committees as a result of the 1976 landmark Quinlan case: parents of Karen Ann Quinlan been in a coma for a year

The underlying goals of traditional ethics committees are:

-to promote the rights of patients -to promote shared decision making between patients (or their surrogates if decisionally incapacitated) and their clinicians -to promote fair policies and procedures that maximize the likelihood of achieving good, patient-centered outcomes -to enhance the ethical environment for health care professionals in health care institutions. Ethics committees or select members often help resolve ethical conflicts and answer ethical questions through the provision of consultations. More recently, some ethics committees, particularly those affiliated with academic institutions and large health care systems, have expanded their traditional functions to become more comprehensive ethics programs. They address both clinical and organizational ethics issues. Ethics programs may provide ethics consultations in response to non-clinical ethics questions, identify and remedy systems-level factors that induce or exacerbate ethical problems and/or impede their resolution (often using quality improvement methods), and promote a positive ethics culture throughout the institution. Thus, the additional goals of expanded ethics programs include: -integrating ethics throughout the health care institution from the bedside to the boardroom, -ensuring that systems and processes contribute to/do not interfere with ethical practices, and -promoting ethical leadership behaviors, such as explaining the values that underlie decisions, stressing the importance of ethics, and promoting transparency in decision making

Policy and Procedure Development (s.4)

-valuable resource for assisting in the development of hospital policies and procedures pertinent to addressing ethical dilemmas (consultation procedures, confidentiality of information, staff and community education, annual review of the committee's activities and effectiveness

Circular Reasoning

-when a person sees no need for deliberation -"I have already made up my mine- don't confuse me with the facts"

Reasoning Powerpoint

1 slide: -Reasoning involves: -capacity for logical inference -conduct inquiry, evaluate, criticize, deliberate, and solve problems -reach an understanding of self and others

Family Members must be identified, and the following questions considered when making decisions: (s4)

1. Do family memebrs understand the patient's wishes? 2. Is the family in agreement with the patient's wishes? 3. Does the patient have an advance directive? 4. Has the patient appointed an agent? 5. Are there any religious proscriptions? 6. Are there any financial concerns? 7. Are there any legal concerns that need to be addressed (applicable state statues and case law)? - When an ethics committee is engaged in the consulting process, its recommendations should be offered as suggestions, imposing no obligation for acceptance on the part of the patient, family, surrogate decision maker, organization, its governing body, medical staff, attending physicians, or other persons. FIGURE 4-1 presents an ethics consultation form for documenting an ethics committee consultation.

Chapter Review

1. Ethics committee serves as a resource for patients, families, and staff, offering an objective counsel when dealing with difficult healthcare dilemmas. 2. Ethics committee should be structured to include a wide range of community leaders in positions of political stature, respect, and diversity. 3. The goals of the ethics committee are to: -promote the rights of patients -promote shared decision making between patients and clinicians -assist the patient and family in coming to consensus when faced with ethical dilemmas 4. the functions of ethics committees are multifaceted and include: - -policy and procedure development -staff and community education -consultation and conflict resolution -a resource tool in resolving the ethical dilemmas -patients and family should be encouraged to partcipate in addressing ethical dilemmas 5. Decision making is difficult when there are: -a variety of value beliefs held by patients, family members, and caregivers -alternative choices that offer both good and bad outcomes -limited resources 6. The resolution of ethical dilemmas is perplexing task. Ethics committee members must be prepared to understand the challenge by actively participated in the decision-making process without bias

When conducting a formal consultation, ethics committees should: (s4)

1. Identify the ethical dilemma (e.g., reasons why the consult was requested) 2. Be sure that the appropriate "consultation request" form has been completed 3. Identify relevant facts: -diagnosis and prognosis -patient goals and wishes -regulatory and legal issues -professional standards and codes of ethics -institutional policies and values 4. Identify stakeholders 5. identify moral issues -human dignity -common good -justice -beneficence -respect for autonomy -informed consent -medical futility 6. Identify legal issues 7. Consider alternative options 8. conduct consultation 9. review, discuss, and provide reasoning for recommendations made 10. review and follow up 11. endure committee discussions includes family members 12. Query family members as to their hopes and expectations 13. document consultations

Forms of Reasoning

1. Partial Reasoning 2. Circular Reasoing

Decisions concerning patient care must take into considerations the patient's: (s4)

1. Personal assessment of the quality of life 2. Current expressed choices 3. Advance directives 4. Competency to make decisions 5. Ability to process information rationally to compare risks, benefits, and alternatives to treatment 6. Ability to articulate major factors in decisions and reasons for them and ability to communicate The patient must have all the information necessary to allow a reasonable person to make a prudent decision on his or her own behalf. The patient's choice must be voluntary and free from coercion by family, physicians, or others.

Decision-Making Process

1. Process of deciding: what is the right thing to do 2. Dilemmas occur when there are alternative choices 3. Variety of value beliefs: patient, family members, caregivers

Committee Goals (section 3)

1. Provide a forum for review and discussion of ethical and moral issues relative to patient care. 2. Provide information to patients as to the functioning of the ethics committee and how to access the committee at the time of admission. This information is generally provided in patient handbooks and/or informational brochures. The electronic media available through patient room televisions is also helpful in educating patients as to their rights and responsibilities including the process for requesting a consultation. 3. Serve as support and resource for hospital staff, families, and patients. 4. Provide consultation, as requested, when there are conflicts in care options. 5. Provide assistance in clarifying situations that are ethical, legal, or religious in nature that extend beyond the scope of daily practice. 6. Clarify issues and discuss alternatives to ethical dilemmas. 7. Promote patient rights 8. Assist the patient and family in coming to consensus with the options that best meet the patient's care needs. 9. Review cases for educational purposes 10. enhance the ethical tenor of both the hospital and healthcare professionals

Autonomy and Law Collide (s5)

Advance directive statutes can impede the purpose and effective functioning of hospital ethics committees. For example, as described below, the Texas Advance Directives Act places the ethics committee in an untenable position: on the one hand, it is designed to assist patients in making end-of-life decisions, while at the same time, if the ethics committee disagrees with the patient-family decision for continuation of life support systems, it can supersede and overrule their decision, effectively trampling on the patient's rights. The decision to remove life support here is effectively based on quality of life and financial considerations. In effect, it would seem the law, here as described, changes the function of the ethics committee from one of consultative support for patients to that of enforcer of state statutes. -In summary, the Texas law appears to take the ethics committee to a new level from a consultative-advisory role by requiring it to be the final arbiter between life and death, thus expanding the role of the ethics committee from playing a consultative role when addressing end-of life decisions to that of the ultimate decision maker. -Although an ethics committee's serves in an advisory capacity, its value to an organization has yet to be fully realized.

External Ethical Issues (S5)

Among the external issues the committee may look at are questions such as: 1. Does the ethics committee have a role in addressing questionable reimbursement schemes? 2. Should an ethics committee have its own letterhead? What value would this serve? 3. What role, if any, should an ethics committee play in the following scenario?

what is the difference between an ethics committee and an ethics consultant?

An ethics consultant is an expert in ethics who provides ethics consultations and may also serve as an educator to the committee or program. In some health care institutions an ethics consultant provides ethics expertise to workgroups that are addressing systems issues and have the need to better understand the ethics and preferred practices from an ethics perspective. Sometimes in lieu of having an ethics consultant address ethics questions or concerns, the ethics committee will develop a subcommittee to handle these functions. The decision to have an ethics consultant versus a subcommittee rests with the available resources and the expertise of the committee members. In general, the strengths of having an ethics consultant is that she is a recognized expert, and the logistics of having someone perform a consultation is straight forward. The weaknesses are that clinicians can rely on this outside person for the answers to their questions and not develop their own expertise, and only one voice/perspective gets expressed. The major strength of having subcommittees or a consultation service (having 2-3 people per month) perform consultations is that this structure incorporates a diversity of views. The major weakness is the logistical difficulty of having more than one person respond to a consult request. Regardless of the ethics consultant versus subcommittee structure, peer-review of ethics consultations should routinely occur at a subsequent ethics committee meeting to ensure quality.

Policy: Annual Review of Ethics Committee Activities

An overall review of the ethics committee's activities will be conducted on an annual basis to determine the effectiveness of the committee and if it is accomplishing its stated goals. This review may take the form of a self-study or external review, preferably by a qualified ethicist.

Policy: Confidentially of Information (s4)

Ethics committee information shall be considered confidential and shall not be used in any way except as provided by hospital policy and required by law. Any information or case study developed for use by the committee shall not be required to become part of a patient's medical record. Committee members shall not make entries in a patient's medical record unless required by law and/or hospital policy.

Who becomes a member of an ethics committee or program?

Ethics committee members usually represent major clinical services and other stakeholders in health care delivery. Thus, it is not uncommon for committee members to include clinicians (physicians and nurses) from medicine, surgery, and psychiatry, social workers, chaplains, and community representatives. These committees may also have a quality improvement manager, an individual responsible for the education program at the facility, a lawyer, and at least one individual with advanced training in ethics. This latter representative can come from a number of disciplines, including philosophy, law, medicine, theology, and anthropology. All members of the ethics committee take responsibility for learning techniques of ethical analysis (see Bioethics Tools) and the arguments surrounding most of the ethically charged issues in clinical practice. Some ethics committees allow guests. These can include health sciences students, philosophy graduate students, physician trainees, facilitators, and patient representatives. Guests need to maintain the confidentiality of the information discussed at the meetings, often signing oaths to that effect. In order to integrate ethics throughout the institution and effect cultural change, ethics programs may include senior leaders in disparate services, such as fiscal, human resources, patient safety, quality improvement, and compliance and business integrity. At some institutions a special ethics council is formed to address ethical issues across the institution, providing a more integrated approach to addressing ethical issues.

Internal Ethical Issues: (s4)

Ethics committees face a variety of internal issues, including: 1. Dilemma of blind trials: who gets the placebo when the investigational drug looks very promising? 2. Informed consent: Are patients adequately informed as to risks, benefits, and alternative procedures that may be equally effective, knowing that one procedure may have greater risk or be more damaging than another (e.g., lumpectomy versus a radical mastectomy)? 3. What is the physician's responsibility for informing the patient of his or her education, training, qualifications, and skill in treating a medical condition or performing an invasive procedure? 4. What is the role of the ethics committee when the medical staff is reluctant or fails to take timely action, knowing that one of its members practices questionable medicine? 5. Should a hospital's medical staff practice evidence-based medicine or follow its own best judgment? 6. To what extent should the organization participate in and/or support genetic research? 7. How should the ethics committee address confidentiality issues? 8. To what extent should medical information be shared with the patient's family? 9. To what extent should the organization's leadership control the scope of issues that the ethics committee addresses? 10. What are the demarcation lines as to what information should or should not be provided to the patient when mistakes are made relative to his or her care?

Policy: requests for Consultations (s4)

Ethics consultations are available to caregivers, patients, or family members who request an ethics consult. Ethics consultations are available 24 hours a day by calling the hospital ethics hotline. Consultations shall be requested on a form prepared by the ethics committee and reviewed and approved by the hospital's administration, legal counsel, and board of directors.

What does an ethics committee or program do?

Historically, ethics committees involve individuals from diverse backgrounds who support health care institutions with three major functions: providing clinical ethics consultation, developing and/or revising policies pertaining to clinical ethics and hospital policy (e.g., advance directives, withholding and withdrawing life-sustaining treatments, informed consent, organ procurement), and facilitating education about topical issues in clinical ethics.

Committee Structure (section 2)

Hospital-based ethics committee: composed of a multidisciplinary group of individuals composed of representatives form the hospital (administrator, chaplain, nurse, physician, patient advocate, and community (clergy, legal counsel, ethicist) -include those in positions of corporate and political stature, respect, and diversity. Appointment and rotation of new members to the ethics committee should be staggered in order to maintain continuity and stability.

Requests for Committee Consultations (s4)

Requests for ethics consultations often involve clarification of issues regarding decision-making capacity, informed consent, advance directives, and withdrawal of treatment. Consultations should be conducted in a timely manner considering the following information: -Who requested the consultation? -What are the issues? -Is there is a problem that needs referral to another service? -What specifically is being requested of the ethics committee (e.g., clarification of the problem or mediation)? -When conducting a consultation, all patient records must be reviewed and discussed with the attending physician, family members, and other caregivers involved in the patient's treatment. If an issue can be resolved easily, a designated member of the ethics committee should be able to consult on the case without the need for a full committee meeting. If the problem is unusual, problematic, or delicate, or has important legal ramifications, a full committee meeting may be necessary. Others who can be invited to an ethics committee case review, as appropriate, include the patient, if competent; relatives; agent or surrogate decision maker; and caregivers. Evaluation of a case consultation should take the following into consideration: 1.Patient's current medical and mental status, diagnosis, and prognosis 2.Patient's mental status and ability to make decisions, understand the information that is necessary to make a decision, and clearly understand the consequences of his or her choice 3. Benefits and burdens of recommended treatment, or alternative treatments 4.Life expectancy, treated and untreated 5. Views of caregivers and consultants 6. Pain and suffering 7. Quality-of-life issues 8. Financial burden on family (e.g., if the patient is in a comatose state with no hope of recovery, should the spouse deplete his or her finances to maintain the spouse on a respirator?)

Ethics Committee Serves as Guardian (s4)

The Kentucky Supreme Court ruled in Woods v. Commonwealth [3] that Kentucky's Living Will Directive, which allows a court-appointed guardian or other designated surrogate to remove a patient's life support systems, is constitutional. The patient in this case, Matthew Woods, had been placed on a ventilator after having a heart attack. It was generally agreed that he would never regain consciousness and would die in 2 to 10 years. After a recommendation of the hospital ethics committee, Woods's guardian at the time asked for approval to remove Woods's life support. The Kentucky Supreme Court affirmed an appeals court decision, holding that: (1) "If there is no guardian," but the family, physicians, and ethics committee all agree with the surrogate, there is no need to appoint a guardian; (2) "If there is a guardian" and all parties agree, there is no need for judicial approval; (3) "If there is disagreement," the parties may petition the courts. Withdrawal of life support from a patient is prohibited absent clear and convincing evidence that the patient is permanently unconscious or in a persistent vegetative state and that withdrawing life support is in the patient's best interest. Ethical and Legal Issues

what will the ethics consultant do if I page her or him?

The consultant will usually ask you to specify the nature of the perceived ethical problem, and the question that you would like answered. She will meet with you and the other people involved in the situation. In clinical consultations she will review the medical record and meet with the patient (or surrogate decision maker) and family members. Often the consultant will arrange an interdisciplinary meeting to review the specifics of the case and to facilitate communication across disciplines or between clinicians and the patient (and/or the family). The consultant will write a note and attempt to answer the proposed question(s). In the Seattle area, the recommendations may be anchored to the 4 box analysis of relevant case information, utilization of principles of clinical ethics, rigorous analysis of similar and dissimilar cases, and supporting arguments and data from the literature. If definitive recommendations cannot be made because there is disagreement among the ethics consult team, a clear explication of the ethics standards (e.g., laws, consensus statements, policies), and analytic arguments (i.e., claims and counterclaims, such as reliance on established codes, consideration of short- and long-term consequences, analysis of comparable features of the case) will be presented in the consultant's note. If several ethically permissible options exist, the consultant will present them in a note including their justifications.

Policy: Education (s4)

The ethics committee typically provides education on current ethical concepts and issues to committee members, staff, and the community at large. Some community hospitals provide ethics education to the staff at ambulatory care facilities, home health agencies, long-term care facilities, and physicians' offices. Such education helps reduce the need for emergent end-of-life consultations in acute-care settings. The ethics committee provides resources for educational purposes to support staff in the development of the appropriate competencies for addressing ethical, legal, and spiritual issues, for example, those common to end-of-life issues (e.g., surrogate decision making, the patient's refusal to accept recommended medical treatment, family conflict). Educational programs on ethical issues are developed for ethics committee members and staff on such topics as moral theories and principles, as well as common ethical dilemmas that occur as they relate to such services common to emergency departments and critical care units. Community education often includes such topics as how to prepare and execute an advance directive.

Resolution of Ethical Dilemmas (s6)

The resolution of ethical dilemmas is a perplexing task at best, especially when two opposite answers both have elements of right and wrong—good and bad, regardless of the ultimate decision made. Finding compromise is no easy task when ethical principles, values, and morals are in conflict and vary from individual to individual. This is no easy task for members of an ethics committee, especially when the mix of opinions of caregivers, family members, and the healthcare entity's mission of healing collide. Although decision making can be much easier when the patient has executed end-of-life directives, ethics committees often do not have this luxury, thus creating a need for ethics committees to help guide others in making difficult care decisions. With outcomes that often result in the decision maker reflecting back and doubting his or her own decisions, it is important that each committee member reflect on the following thoughts prior to participating in an ethics consultation: -I will accept the patient's wishes, if known. -I will accept the dialogue of committee members with varying beliefs, expectations, and values, knowing some will undoubtedly challenge my own sense of right and wrong. -I will help the ethics committee seek a morally acceptable resolution to an ethical dilemma. -I will not be too fearful to seek clarification of issues and ask questions. -I will contribute to making consultations meaningful and not argumentative. -My compassion will outweigh my need to be right. -The ultimate decision is not mine to make. -I will provide guidance, consultation, and education. -An ethical dilemma can arise when, for example, the principles of autonomy and beneficence conflict with one another. The following cases illustrate how one's right to make his or her decisions can conflict with the principle of doing good and not harm.

Making Better Decisions (s7)

The study of the ethical and legal issues that arise in a wide variety of patient care settings can be somewhat challenging. However, the rewards in the study of ethics and the law will help the caregiver make better decisions regardless of the setting in which patient care is rendered. The following are some helpful guidelines to follow when faced with ethical dilemmas: -Be aware of how everyday life is full of ethical decisions and that numerous ethical issues can arise when caring for patients. -Help guide others to make choices. -Ask your patient how you might help him or her. -Be aware of why you think the way you do. Do not impose your beliefs on others. -Ask yourself whether you agree with the things you do. If the answer is no, ask yourself how you should change. -When you are not sure what to do, the wise thing to do is to talk it over with another person, someone whose opinion you trust. -Do not sacrifice happiness for devotion to others. -Do not lie to avoid hurting someone's feelings.

under what circumstances should i call the ethics consultant/service?

You should consider asking for a case consultation when two conditions are met: 1. you perceive that there is an ethical problem in the care of patients, and 2. health care providers have not been able to establish a resolution that is agreed upon by the patient/surrogate and the clinicians caring for the patient -While a communication breakdown is often a factor in ethics consultation, an ethical dilemma occurs when two courses of action may both be ethically defensible. These dilemmas are often due to a conflict between principles (e.g., autonomy, beneficence, justice) or between principles and outcomes. -At most hospitals, anyone may request an ethics consultation including the patient or family. Please check the hospital's policies to learn how to request an ethics consultation. -You should consider asking for an ethics consultation even when patient care is not the central issue if you believe that there is a lack of clarity about an ethics policy or concept that would benefit from education. The following are examples: -a question about professionalism, -a general question about patient privacy or confidentiality, and -a question about ethical practices in the workplace, human resources, resource allocation, or the business practices of the institution.