Of the 2,433 hospitals, 472 responded (response rate 19.4%). Of the 472 respondents, 328 (69.5%) were members of their ethics committees. Table 1 shows the demographic features.
As shown in Figure 1, the 382 hospitals of the 472 hospitals (80.9%) had an HEC, and 12 reported that they were preparing to establish it.
Among these 394 hospitals, 155 (39.3%) reported operating an HEC as an independent organization within the hospital, 33 (8.4%) reported operating it under the REC, and 19 (4.8%) reported operating it under other departments. The 394 hospitals were asked additional questions on the organizational structure and the actual activities of their HECs.
Reason for establishing an HEC
As shown in Figure 2, the main reason was the evaluation of hospital functions by the JQ. The smaller-bed-number group (20 – 99 beds) had higher percentage of the JQ evaluation than the larger-bed-number group (100 – 499 beds or ≥ 500 beds). On the other hand, the larger-bed-number group (≥ 500 beds) was more likely to choose the reason that requests from hospital staff members compared with the smaller-bed-number group (100 – 499 beds or 20 – 99 beds).
General information on HECs
The average number of HEC members was nine. By profession, the median values for HEC members were as follows: three medical doctors, two nurses, two clerical staff, and one individual who was not a hospital staff member (e.g., lawyer, university professor, or representative of the patients’ association).
Roles of hospital ethics committees
The HECs clarified that they engaged in multiple roles. In all, 840 multiple-choice answers were provided by 394 hospitals. The HECs of 288 out of 394 hospitals (73.1%) engaged in clinical ethics consultations, those of 279 (70.8%) engaged in formulating/updating ethical guidelines, those of 212 (53.8%) engaged in delivering in-service education, and those of 61 (15.5%) provided other services, such as a research ethics board, clinical trials, and organ transplants.
A total of 239 hospitals with HECs reported actually conducting clinical ethics consultations, and an additional 49 hospitals reported offering clinical ethics consultations but indicated that they had not performed these consultations as on the date of the survey. The average number of clinical ethics consultation requests in the 239 hospitals was 4.4 cases per year.
Methods of clinical ethics consultations
Various types of clients request clinical ethics consultations. We obtained 779 multiple choice answers from the 239 hospitals. The most frequent types of clients were heads of medical sections (222, 28.5%), other medical staff (197, 25.3%), doctors-in-training (92, 11.8%), patients (59, 7.6%), patients’ families (59, 7.6%), and others (150, 19.2%).
The methods of information collection regarding problems were investigated through an MCQ. Of the 551 multiple answers from the 394 hospitals that reported an existing or developing HEC, the most popular methods were interviews with the staff (173, 31.4%), medical records (141, 25.6%), and consultation forms (127, 23.0%). Conversely, interviews with patients and/or their families were adopted by 70 respondents (12.7%), and physical examinations by 40 respondents (7.3%).
Figure 3 describes how 239 hospitals operated a clinical ethics consultation. We also asked an open question about how hospitals operate their HECs. We obtained written answers from 25 employees who answered “none of above.” In the 25 answers, the most common way to operate the HEC was reported as altering the number of consultants depending on the cases (13 hospitals). On the other hand, eight hospitals reported that they adopted a small-team consultation and an individual consultant on a case-by-case basis.
Of the 223 hospitals that reported using discussions and other methods in the previous question, 201 (90.1%) held discussions to arrive at unanimous conclusions. However, other hospitals did not have face-to-face discussions. They reported that the administrators summarized the opinions of HEC members by email or returned all opinions to the clients.
Records of clinical ethics consultations
We asked the 239 HEC-operating hospitals how the clinical ethics consultation records were maintained in the department through an MCQ. We obtained 262 responses. Among them, 135 (51.5%) reported that they maintained simple records alone, while 101 hospitals (38.5%) reported that they maintained detailed records that included information on the discussion, the course of discussion, and outcomes. The remaining hospitals did not maintain any records in their departments.
We also asked the 239 hospitals about documenting consults in patient’s medical records. While only 59 (24.7%) of the 239 hospitals reported recording the consultation outcomes in patients’ medical records, 104 hospitals, the majority (43.5%), responded that recording the contents of the consultation in the medical records depended on the nature of each case, and 76 hospitals (31.8%) did not create any records. Hospitals in the small-bed-number category were more likely to record the consultation in patients’ medical records (16 of 32 hospitals, 50.0%) than the medium-bed-number category hospitals (32 of 166 hospitals, 19.3%); however, there was no statistical significance. In all, 163 hospitals made note of some details in their medical records. We found that medical doctors were responsible for this task in 108 hospitals (53.2% of the 203 responses), and nurses wrote them in 65 hospitals (32.0%). There were no significant differences between each bed-number group.
Enforceability of the HEC recommendations
Of the 239 hospitals, 85 hospitals (36.5%) reported that the clients must comply with the final decisions of its clinical ethics consultation. On the other hand, 148 (63.5%) regarded the decisions of its clinical ethics consultation as recommendations. There were no differences based on the number of beds.
Our inquiry into the follow-up process after the consultation found that 85 hospitals followed up on the outcome of a consultation. The reported follow-up methods were obligatory reporting of detailed accounts (25 of the 142 answers, 16.9%), obligatory reporting depending on the case (69 responses, 48.6%), and tracking subsequent progress (39 responses, 27.5%). The remaining nine responses indicated a choice of other methods.
The person with the ultimate responsibility for consultation cases was the hospital director in 149 responses, which was almost half of the 339 responses.
Reasons for not requesting clinical ethics consultations
As we mentioned previously, the 394 hospitals of the 472 hospitals had an HEC (Figure 1). But 153 hospitals had never executed clinical ethics consultations. We asked them why they did not undertake any clinical ethics consultations with the three MCQs and the open question (Table 2). We obtained the answers from 50 hospitals and 22 free-form descriptions. We conducted a text analysis on the contents. The results revealed six categories shown in Table 2.
In response to the request for self-evaluation of their HEC, 90 (19.1%) of the 472 respondents reported sufficient, 270 (57.2%) reported insufficient, and 112 (23.4%) responded that they did not know.
There were three principal reasons for considering their HECs sufficient. First, a system for scrutiny was already in place as a result of multidisciplinary external resources. Second, they assessed subjectively that their HECs worked effectively. Third, their HECs were functioning sufficiently because they had a few consultations each year.
We got 187 responses of the 270 hospitals considered their HECs as insufficient. The most-reported reason was inadequate system/response capabilities (100 respondents, 53.5%), followed by the lack of staff knowledge/interest (35 respondents, 18.7%). The third most-reported reason, provided by nine people (4.8%), was the limited number of consultations.
The reasons for choosing the option “I do not know” included the following: First, they did not have enough knowledge to evaluate whether their HECs were sufficient. Second, it was difficult to draw comparisons with other institutions. Finally, they had no experience with clinical ethics consultations.
The open descriptions revealed the difficulties encountered in conducting and administering clinical ethics consultations. Therefore, we categorized and counted the opinions from the open-ended questionnaires. We obtained 211 responses from 106 hospitals in all. The most-reported problem (62 responses) was “how to disseminate information about the existing clinical ethics consultation system,” followed by “how to provide a platform for fair discussions” (53 responses), and “how to identify latent ethical problems” (48 responses).