**1. Introduction**

Decision-making in health can often be complex, as doctors face daily ethical dilemmas in their professional practice. It is essential to make correct decisions to achieve the patient's best interest, respecting their autonomy, dignity, and values; this can be achieved with the support and contribution of the HCECs. Currently, the provision of health services generates constant tension between doctors and patients. This can be explained in terms of the technological development in health that has extended the limits of life, which has generated conflictive situations in which the doctor's criteria are not enough to comply with bioethical principles. Therefore, the need to implement HCECs in hospitals with high technology has spread worldwide for several decades. Its mission is to provide advice – when ethical dilemmas arise from medical care- and guide decision-making – always trying to achieve the best for each patient [1, 2].

Medicine has always been characterized by basing its actions on the principles of Beneficence and Non-Maleficence. In recent decades, respect for autonomy has also emerged, considered an inalienable right. Advances in medical knowledge and the enhancement of bioethical principles have made it possible to improve patient care. Still, they have also led to situations in which the individualistic or paternalistic approach is insufficient to decide. At the institutional level, the existence of the HCECs is justified by the conflicts that arise between the bioethical principles, most often between the autonomy of the patient and the beneficence/non-maleficence that the doctor seeks. The HCECs seek, through pluralism and deliberation, to find the best possible alternative in each case.

#### **1.1 Definition of HCECs**

The HCECs are organizations structured at the hospital level, whose priority is to support health professionals toward ethical conflicts arising from medical care, seeking the benefit of all those involved. For Crico et al. [3], HCECs are teams of people defined by a hospital or healthcare institution and assigned to consider, debate, study, take action, or report on ethical issues that emerge in patient care. In Ecuador, Article 20 of Ministerial Agreement 4889 [4] defines the Committee on Health Ethics (CEA by its Spanish acronym) as a multidisciplinary deliberation body, at the service of professionals, users, and management teams of health facilities, created to analyses and advise on ethical issues that develop in health care practice.

#### **1.2 Historical background**

The first CEA in history was the "Seattle Committee," established in 1962 in the United States to decide which patients were eligible for hemodialysis treatment, developed by the physician Scribner. This first committee was widely criticized and was nicknamed the "Committee of Death" because its criteria for selecting patients were nonmedical, giving greater importance to aspects such as social status or income level. This form of decision-making is at odds with the principles advocated by Bioethics and today with the focus on medical judgment in assigning treatment [5].

In 1968, the Harvard Medical School, in response to the need for an "ad hoc" ethics committee to examine the definition of brain death, produced a special report containing a set of criteria for identifying what they called "an irreversible coma." This committee produced a special report containing a set of criteria for the identification of what they called "an irreversible coma." The need for a committee arose from medical concerns about defining brain death, seeking to provide a reliable diagnosis of irreversibility in mechanically ventilated patients, and implementing transplantation programs, which emerged in the 1960s. It is evident that this historical milestone caused physicians to become aware of the ethical dilemmas they may face, and these required not only scientific knowledge but also moral knowledge to be addressed [6].

A paradigmatic case, which reinforced the need for CEAs, was that of young Karen Ann Quinlan. Karen was a 21-year-old American who suffered permanent brain damage and was left in a vegetative state after alcohol and benzodiazepine intoxication, so she was placed on a mechanical ventilator. In 1976, Quinlan's parents filed a lawsuit to have her right to be disconnected from the ventilator that kept her alive recognized, arguing that her condition was irreversible. Following the New Jersey court order, Karen was progressively weaned off the ventilator but continued to breathe spontaneously until she died in 1981 of nosocomial pneumonia. From this case onwards, greater importance was given to CEAs and their functions [7].

With Van Rensselaer Potter's publications on Bioethics and the Karen Quinlan case, in the 1980s CEAs were present in 60% of US hospitals, then in the 1990s, the number rose to 90%. Today in this country, almost every hospital has a CEA. Such bodies have become the primary mechanism for addressing ethical issues in patient care [8].

In Spain, the first CEA was established at the Hospital San Juan de Dios in 1974. In the 1990s, Circular 3/1995 was issued for the creation and accreditation of CEAs in

*Analysis and Reflections on the Current Situation of the Health Care Ethics Committees (HCECs) DOI: http://dx.doi.org/10.5772/intechopen.112339*

the INSALUD system (National Health Institute). Initially, the CEAs were voluntary, but they are now mandatory [9].

In Latin America, Argentina was the pioneer in the creation of CEAs. In 1996, a national law was enacted, determining that, in each hospital of the public health system, there must be a CEA with advisory functions. In Colombia, progress has been significant. Although there is little legislation on CEAs, Resolution 13,437 of 1991, by which CEAs are constituted, is known; Decree 1757 of 1994, which expanded the functions of CEAs by assigning them administrative and quality control roles in the provision of health services, which elevated the committees to the category of guaranteeing social participation in the activities that are developed within the institutions of the social security health system [9, 10].

In the case of Ecuador, there have been regulations for the creation and formation of CEAs and CEISH (Ethics Committee for Research on Human Subjects) since 2014; however, few hospitals have these committees, which highlights the importance of this study.

#### **1.3 Role of the CEAs**

The main role of the CEA is to discuss individual dilemmas or moral conflicts in clinical practice, to seek the best decision-making in each case, and to educate healthcare personnel on bioethical issues. Among the objectives of a CEA are to make recommendations on ethical conflicts that may arise in the context of everyday medical care, to improve the quality of care, and to seek the protection of all those involved in an ethical dilemma. In addition, to promote bioethics training for committee members as well as the staff of the institution. Consultation with CEAs achieves important benefits for healthcare personnel, such as consensual decision-making, strengthened moral competence, and improved medical care [2, 11, 12].

The aim of consulting a CEA is to identify and resolve existing and potential ethical problems related to health care, to improve the patient-physician relationship, to ensure the well-being of the patient, and to resolve conflicts between health care personnel, patients and their families, i.e., CEAs seek not only the benefit of the patient or their families but also the benefit of the health care personnel. In some countries, the role of CEASs is also to evaluate and supervise clinical trials involving human subjects, although this is a function that corresponds to the Human Research Ethics Committees, which is why it is necessary to carry out training on CEAs and raise awareness of their institutional contribution [13].

Medical staff, patients, family members, legal surrogates, and other healthcare personnel should have access to CEA counseling, which is why information about the availability and process of counseling should be widely disseminated. Although hospital-based ethics consultancy is the most common, the possibility of consultancy in the outpatient setting should be recognized and supported at the institutional level [14].

CEAs usually have scheduled meetings, often once a month, to discuss cases or plan future training. The physician usually consults the committee because he/she wishes to clarify doubts and obtain recommendations on sensitive issues, such as discontinuation of nonbeneficial treatments. It should be mentioned that anyone involved in the care of a patient can request consultation with the CEA, fulfilling its advisory role. This allows the patient's relatives or caregivers to reduce their moral distress and find adequate support in the CEAS [15].

Per Moon [16], CEAs in the United States promote the practice of ethics through a variety of activities, including continuing education on bioethical issues for health professionals, review of hospital policy, and consultation on clinical cases that present dilemmas in their approach. Raoofi et al. [11] mention that the functions of the CEAs in Iran are to solve problems that arise during health care in hospitals, to increase healthcare personnel's awareness of conflicting situations and participation in decision-making, to foster communication and to educate on bioethical issues.

Galván et al. [17] mention in their work that in Spain, the function of the CEA is to advise patients and health personnel in ethical conflicts that arise in medical practice; however, problems in the structure or in the way they work limit their true scope. Carillo et al. [9] indicate in their work that in Colombia CEAs are available to both physicians and patients, and their functions are to advise on ethical conflicts and education.

Current regulations in Ecuador state that second and third-level hospitals, due to the complexity of their services, must have a CEA, which allows professionals with ethical doubts to seek advice and counseling. The recommendations of the CEA are not binding, i.e., in the end, medical judgment will prevail, but they demonstrate commitment to the patient to exercise proper professional practice [4].
