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History Of Dartmouth Hitchcock Medical Center's Ethics Committee

By Laura Stephenson Carter

Dartmouth-Hitchcock Medical Center (DHMC) has one of the oldest hospital ethics committees in the United States. It was created in 1983 and since 1994 has been led by James Bernat, M.D., a neurologist and an internationally recognized medical ethicist.

The committee grew out of ethics initiatives that began at Dartmouth in the 1970s with the work of a Dartmouth philosophy professor, Bernard Gert; a Dartmouth Medical School (DMS) psychiatrist, Dr. Charles Culver; and others. Medical ethics was taught—by Culver and Gert—at Dartmouth Medical School (DMS) as early as 1971. In the 1980s, Dartmouth and DMS became a hotbed of ethics programs, with faculty writing scholarly articles on ethics as well as offering workshops and conferences. Even Dartmouth's other professional schools—the Tuck School of Business and the Thayer School of Engineering—began including ethics training in their curriculums. In 1982, the Institute for the Study of Applied and Professional Ethics was established at Dartmouth, with Culver and Gert as codirectors.

When DHMC's Ethics Advisory Committee was formed in 1983, "there was a lot of resistance to ethics committees [because] they were new," says Gert. The Hospital's trustees resisted the idea, but DHMC medical director Dr. Louis Matthews wanted one anyway. So he set up the committee to advise him on broad policies and to be available for other health-care providers to consult on specific cases; he appointed Culver as its chair. Its other members included a philosopher (Gert), a lawyer, nurses, hospital administrators, other physicians, and a hospital chaplain. Today the DHMC Ethics Committee has nearly 30 members and now includes—in addition to the types of positions on the early committee—social workers; a representative from the Dartmouth-affiliated VA Medical Center in White River Junction, Vt.; a DMS student; a DHMC resident; and a member of the general public.

"In the beginning we were very active and proselytizing," says Gert. He and Culver wrote papers together, gave presentations, taught courses, and ran an ethics consultation service that gave advice in situations where providers, patients, and families didn't always agree on treatment options—especially in end-of-life cases. "I never did anything that looked like philosophy. I just pointed out things that follow from the philosophy," Gert says. "Most of the time what I did in

the ethics committee was to reassure people that they had done what was acceptable." Gert retired from the committee a few years ago, since he now spends only part of the year teaching at Dartmouth and part teaching in North Carolina.

In the meantime, Culver was gaining a national reputation as a medical ethics expert and even had the nickname "Captain Ethics." In a 1987 article, the Wall Street Journal called him "a pioneer practitioner [in] medical ethics counseling." The paper said he handled most of the requests himself because he was the most available and experienced member of the committee; occasionally consulted other committee members by phone; "rehashes two or three of the most important cases at his committee's monthly meetings;" and sometimes calls "the group into emergency session on what looks like a precedent-setting issue—for example, the first time a doctor sought to withdraw food and water from a terminally ill patient."

The committee also sponsored regional and national educational seminars on medical ethics, lobbied for legislation aimed at improving ethical patient care (including New Hampshire's Terminal Care Document and the Durable Power of Attorney for Health Care acts), and helped community hospitals in New Hampshire and Vermont establish their own ethics committees. Culver and Gert also wrote a textbook on medical ethics as well as several journal articles.

Culver left DHMC abruptly in 1992, under a cloud. Ironically, he was perceived as engaging in unethical behavior—he had become romantically involved with a former patient (a woman he had treated several years earlier). At the time, the American Psychiatric Association (APA) had a code banning psychiatrists from having sex with current patients, but they soon adopted a policy banning sexual relationships between psychiatrists and former patients, too.

The next decade brought changes as the committee was reshaped under the leadership of James Bernat, a neurologist. After Culver left DHMC in 1992, another psychiatrist, Dr. Charles Solow, chaired the committee for two years. Then Bernat took over in 1994. Bernat had been chief of neurology at VA Medical Center in White River Junction, Vt. He and the Reverend William Nelson had been guiding medical ethics efforts there and had established and codirected a regional ethics center, which was selected as the VA's national ethics

center in 1991 (it was relocated to Washington, D.C. in 2002).

At DHMC, Bernat created and still directs DHMC's Clinical Ethics Program, which integrates educational, clinical, research, administrative, and community outreach activities. Bernat also established and chairs the New Hampshire-Vermont Hospital Ethics Committee Network, which includes ethics committee members from nearly 40 hospitals. The network meets twice a year at DHMC for educational programs.

Bernat has become a nationally respected expert on medical ethics and has written numerous books and journal articles. He also served on and chaired the ethics committee of the American Academy of Neurology for many years. Members of the national media often call on him to comment on thorny issues such brain death. His expertise landed him a spot on task forces convened in 1997 and 2006 to advise the Vatican on how death should be defined.

Bernat made national news in 2008 for criticizing—in an editorial in the New England Journal of Medicine—a case in which hearts were harvested from infant organ donors only 75 seconds after their hearts stopped beating. The technique is controversial because the waiting time recommended by the Institute of Medicine is five minutes, unless the patient is brain dead. These babies were not, although they did have severe brain damage. Bernat predicted that when leaders in relevant fields reach consensus, they will conclude that harvesting after just 75 seconds is too hasty. He was asked later in 2008 to chair a committee organized by the Health Resources and Service Administration Division of Transplantation (part of the U.S. Department of Health and Human Services) that will draft practice guidelines for organ donation after cardiocirculatory death.

Bernat continues to provide thoughtful commentary on bioethical issues as well as thoughtful leadership of the DHMC Ethics Committee. Today, the DHMC committee consults on cases in which the correct course of treatment isn't clear. It also educates DHMC caregivers about bioethics, develops ethics policies, coordinates the New Hampshire-Vermont Ethics Network, collaborates with Dartmouth's Committee for the Protection of Human Subjects, and occasionally lobbies on ethics-related legislation.

To learn about how the DHMC Bioethics Committee grapples with ethical dilemmas, see "On the Other Hand."

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