The guidelines issued by UNESCO in 2005 recommended to establish four types of bioethics committees [1]:

• policy-making and /or advisory bioethics committees

• health professional association bioethics committees

• hospital ethics committees (HEC)

• bioethics committees for experimental research.

At present, there are only two research bioethics committees in Poland established pursuant to the Health Professions Act and the directive of the Minister of Health [2, 3]. Hence, the question arises whether it is necessary to extend the Polish system of ethics committees with HECs.

THE TASKS OF HECS IN THE LIGHT OF INTERNATIONAL DOCUMENTS

According to the UNESCO guidelines, the tasks of HECs include:

• protection of patients` rights to decide about themselves and protection of their well-being,

• protection against legal responsibility of an institution which appointed HEC [1].

The first task is to guarantee the patients the right to consent to the treatment suggested or otherwise. As far as individuals with legal and actual competence are concerned, in the vast majority of cases no help of the HEC is needed to follow this rule. However, an increasingly high number of similar cases concern patients who are unconscious and unable to make legally bound decisions. In such cases, HECs are advisors and may substantiate the decisions made by institutions providing a patient with care to settle the conflicts between the rules of medical management and law regulations or between the will and wishes of a patient and claims of other parties, e.g. family members.

The Israel regulations concerning HEC tasks are different. The Regulation on Patient Rights issued in 1996 defines four key tasks of HECs [4]:

• confirmation of need to treat patients against their will in life-threatening situations if HEC recognizes that:

◉    the patient was earlier adequately informed about the health condition and the need of treatment,

◉    the treatment proposed will substantially improve the patient`s status,

◉    there are grounds to suppose that after treatment the patient will be inclined to accept the management undertaken;

• they allow to withhold the information, which should be revealed during the procedure of conscious consent to treatment if HEC recognizes that the disclosure of information might seriously harm the physical or mental health of the patient,

• they allow to reveal the medical information against the patient`s will to protect public health or health of other people,

• they allow the access to medical records to carry out the inspection, including evaluation of the quality of work of an institution taking care of the patient. 

Analysis of the regulations cited indicates that the tasks of HECs in Israel are defined in a quite detailed way and that subjects of HEC tasks are mainly patients with legal and actual competence.

The USA is the country with the longest HEC experience. For this reason, the American tasks of HECs are extremely broad. According to the Ethics Manual published by the American College of Physicians, HECs:

• contribute to the achievement of therapeutic goals by helping to solve conflicts in honest and comprehensive discussions carried out in the atmosphere of due respect,

• help the institutions to shape the policy and practical actions in accordance with the highest ethical standards,

• facilitate the individuals to solve current and future moral dilemmas through education in the filed of medical ethics [5].

In the USA, the practice shows that some HECs are also involved in the settlement of financial litigations [6].

In Great Britain, HECs deal with [7]:

• preparation of the local recommendations for an institution appointing the committee based on national and professional codes and guidelines,

• ethical education for physicians and other medical professionals employed in a given institution,

• ethical consultancy in individual clinical cases if requested by a physician.

Not all British HECs carry out the full range of duties. Ethical consultancy concerns, among other things, the autonomy of patients unable to give their consent, violation of confidentiality of data, conflicts within the medical team concerning the optimal therapy, “health tourism”, withholding resuscitation or patient`s refusal to be treated [7].

PATIENTS’ RIGHTS AND TASKS OF POLISH HECS

The Act on Patients’ Rights and the Ombudsman of Patients’ Rights amended in 2009 lists the following rights of a patient to: [8]

• be provided with health services,

• obtain information and keep them private,

• give consent for health services provided,

• respect his/her privacy and dignity,

• have access to medical records,

• object the physician’s opinion or ruling,

• respect for private and family life,

• pastoral counselling,

• deposit valuable belongings.

Hence, Polish HECs may have to deal with the issues concerning the patient`s right to medical services, information, consent or otherwise to medical services. In cases of the right to object the opinion or ruling of the physician, the legislator appointed the Medical Council attached to the Ombudsman of Patient`s Rights, which is to settle such objections; therefore, most likely, HECs will not be involved in opinion giving in such arguments.

HECS AND POLISH REALITIES

In Poland, there are no regulations regarding HECs. They are not included in the Act on Patient`s Rights and the Ombudsman of Patient`s Rights [8]. The Polish legislator recognizes, however, the need for independent ethics committees in the health care system, which is visible in the Act on retrieval, storage and transplantation of cells, tissue and organs [9]. The Act appointed the Ethics Committee under the National Transplantation Council, whose key task is to give opinions concerning the legitimacy and admissibility of living donation of cells, tissues and organs to a person who is not a close relative, sibling, adopted child, or spouse (article 13 section 1)[9]. The procedure in question is carried out irrespectively of the required consent of the district court. This is a typical example of tasks that may be dealt with by HECs. Since HECs are lacking, the legislator entitled the Ethics Committee appointed at the national level. It is worth stressing that ethical dilemmas accompanying organ transplantations and qualification for medical procedures of limited availability, which in the 60ties of the XXth century was dialysis therapy, made the USA physicians create the first HECs [10].  From the historical point of view, Poland follows the USA way yet at present we are just commencing the whole process.

Despite the lack of legal regulations, a few HECs were established in Poland. In addition to the HEC attached to the Teaching Children Hospital in Krakow-Prokocim, since 2006, the Advisory Committee of Clinical Ethics under the Children’s Memorial Health Institute has been functioning [11, 12]. The model of HECs accepted in Poland is in accordance with those in force in other countries [4, 5, 6, 13]. However, the term HEC is misleading, as all health care institutions should be authorized to create HECs, including centres for chronically ill patients. 

WHY ARE THERE SO FEW HECS IN POLAND?

The lack of HECs in the Polish system of health care results from numerous factors, the key of which include the paternalistic model of Polish medicine, lack of legal regulations or patterns of action and sources of financing.

Much misunderstood paternalism of patient-doctor relationships leads to conflicts. HECs may and should undertake the advisory role in ethical arguments. Unfortunately, the lack of legal regulations and eligibility for HECs favours contestation of their role and authority. Financial limitations discourage independent establishment of HECs. The role of managers of Polish hospitals may prove to be essential for this initiative. It is up to them and their decisions that such committees are established. They decree the financial means for organizing the HEC structures and ensuring their efficient performance. The attitude of Polish physicians to the idea of HEC formation remains a great unknown.

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WHERE ARE HECS ESPECIALLY NEEDED?

The understanding of the need for HECs depends on the degree of complexity of ethical problems which the medical personnel of a given hospital faces. There is reason that the two already functioning HECs were created in large children hospitals. The issues related to withdrawal of futile therapy or decisions concerning optimal care may lead to arguments between the parties (parents, medical personnel). Similar ethical dilemmas accompany the work of anaesthesiologists, transplantologists and other specialists taking care of critically ill patients. Teaching departments undertake treatment in most difficult cases. In such situations, HECs may facilitate the patients, their families and physicians to choose the optimal solutions.

CAN BIOETHICS COMMITTEES ACT AS HECS?

In some countries, the opinions concerning projects of medical experiments are given by the same institutions [14, 15]. The operational scheme of Polish HECs and the one in force– of Polish bioethics committees, differ. In the majority of countries, HECs emerge attached to hospitals whereas bioethics committees in Poland are attached to medical universities, medical research institutions and regional medical councils [3]. Thus, bioethics committees have hindered access to the parties of an argument compared to HECs which should act locally. The results of the questionnaire about Polish bioethics committees indicate that some of them are overburdened with duties [16]. The idea of combined duties of both committees, as in Belgium, is also widely criticised [14].  In the Polish Children’s Memorial Health Institute there are also two independent committees. Therefore, the combination of both types of committees seems pointless.

From the perspective of availability of qualified candidates for HECs, the issues in question looks slightly different. Those with suitable qualifications and skills are few. The members of the Polish bioethics committees have skills, knowledge and experience that may be useful for HEC activities. Therefore, it should be considered whether some members of bioethics committees should not be proposed to participate in HECs. The group particularly valuable for any HEC includes scientific-didactic workers of medical ethics departments at medical universities. Since, due to flawed Polish legal regulations, such workers practically cannot sit on bioethics committees, they may be proposed to work in HECs [3]. 

CONCLUSION

The level of ethical awareness of the medical personnel and abilities to settle the arguments in an amicable way and according to valid professional and ethical standards, which emerge during the provision of health care, define the quality of this care. By educating the physicians and other medical professionals and acting as counsellors in contentious issues, HECs help in providing the patients with the care of the highest quality. Hence, further discussion should focus on optimal forms and methods of their activities rather than the legitimacy of establishing HECs.

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REFERENCES

1.    United Nations Educational, Scientific and Cultural Organization, Division of Ethics of Science and Technology: Guide No. 1. Establishing Bioethics Committees. Paris  2005: 20.

2.    Ustawa z dnia 5 grudnia 1996 r. o zawodach lekarza i lekarza dentysty. Dz. U. 2008; nr 136, poz. 857 (z późniejszymi zmianami).

3.    Rozporządzenie Ministra Zdrowia i Opieki Społecznej z 11 maja 1999 r. w sprawie szczegółowych zasad powoływania i finansowania oraz trybu działania komisji bioetycznych. Dz. U. 1999; nr 47, poz. 480.

4.    Wenger NS, Golan O, Shalev C, Glick S:  Hospital ethics committees in Israel: structure, function and heterogeneity in the setting of statutory ethics committees. J Med Ethics 2002; 3: 177-182.

5.    Snyder L, Leffler C: Ethics manual. Ann Intern Med 2005; 142: 560-582. 

6.    Bernt F, Clark P, Starrs J, Talone P: Ethics Committees in Catholic Hospitals. Health Progress 2006; 2: 18-25.

7.    Slowther A, Johnston C, Goodall J, Hope T: A practical guide for clinical ethics support. The Ethox Centre, University of Oxford 2004: A1-A14.

8.    Ustawa z dnia 6 listopada 2008 r. o prawach pacjenta i Rzeczniku Praw Pacjenta. Dz. U. 2009; nr 52,
poz. 417.

9.    Ustawa z dnia 1 lipca 2005 r. o pobieraniu, przechowywaniu i przeszczepianiu komórek, tkanek i narządów. Dz. U. 2005; nr 169, poz. 1411.

10.    Jonsen A: The birth of bioethics. Oxford University Press, New York, Oxford, 1998: 211-217.

11.    Kornas S: Czy w polskich szpitalach potrzebne są komitety etyczne? Medycyna Praktyczna 2009; 2: 145-148.

12.    Komitet Doradczy Etyki Klinicznej przy Instytucie Pomniku Centrum Zdrowia Dziecka w Warszawie. http://www.czd.waw.pl/index1.php?id=781&keyword=komitet

13.    McGee G, Spanogle JP, Caplan AL, Penny D, Aasch DA: Successes and failures of Hospital Ethics Committees: a national survey of ethics committee chairs. Cambridge Quarterly of Healthcare Ethics 2002; 1: 87-93.

14.    Meulenbergs T, Vermylen J, Schotsmans PT: The current state of clinical ethics and healthcare ethics committees in Belgium. J Med Ethics 2005; 6: 318-321.

15.    Borovecki A, Ten Have H. Oresković S: Ethics and the structures of health care in the European countries in transition: hospital ethics committees in Croatia. BMJ 2005; 331: 227-229.

16.    Czarkowski M, Różanowski K: Polish Research Ethics Committees in the European Union system of assessing medical experiments. Sci Eng Ethics 2009; 2: 201-12.

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Address:

*Marek Czarkowski
Katedra i Klinika Chorób Wewnętrznych
i Endokrynologii
Warszawskiego Uniwersytetu Medycznego
ul. Banacha 1A, 02-097 Warszawa
tel.: 0-22 599-29 70, 0-601 269 204
fax: 0-22 599-19 75
e-mail: mczark@gmail.com

Received: 26.09.2009
Accepted: 20.11.2009