AMA Journal of Ethics®
May 2016, Volume 18, Number 5: 546-553
HISTORY OF MEDICINE
Why Did Hospital Ethics Committees Emerge in the US?
Mark P. Aulisio, PhD
Ethics committees are the primary mechanism for dealing with ethical issues in hospitals
in the United States today [1-3]. Present in nearly every US hospital, ethics committees
were virtually nonexistent in the 1960s and ’70s and, as recently as the early 1980s,
were present in only 1 percent of US hospitals . By the late 1980s, however, ethics
committee presence had expanded to over 60 percent of US hospitals —a figure that
jumped to over 90 percent by the late 1990s , when ethics consultation services (a
standard function of ethics committees) were present in all US hospitals with 400 beds
or more, federal hospitals, and hospitals that are members of the Council of Teaching
Why did ethics committees come to be present in nearly all US hospitals in the span of a
few short decades, beginning in the 1970s? To answer this question, I will (1) consider
the historical emergence of ethics committees in the US, highlighting just a few of the
landmark events that contributed to their rise; and (2) glean from these events key
underlying features of the need that ethics committees arose to address.
The “God Committee” (1962)
In order to understand the rise of ethics committees in the US, we need to reach back to
at least the 1960s when Belding Scribner, at Swedish Hospital in Seattle, made possible
dialysis as we know it by building on the work of the Dutch physician Willem Kolff. In the
1940s, Kolff had created the first dialysis machine by modifying an automobile fuel
pump to circulate blood outside of the body to be filtered through a series of tubes and
then returned back to the body. The problem with Kolff’s device was that each artery and
vein could be used only once, giving patients a limited number of opportunities for
dialysis. Scribner developed a permanent indwelling shunt with a shut-off valve that
allowed for repeated dialyzing through the same sites, thus extending patients’ lives
indefinitely . Over time, Scribner recognized this benefit and convinced hospital
administrators to establish 17 outpatient dialysis slots in a long-term “Artificial Kidney
Center” . As word of Scribner’s breakthrough spread, the number of candidates for
dialysis at Swedish Hospital grew dramatically, far outstripping the Artificial Kidney
Center’s capacity to provide dialysis for all of them. The stunning success raised a
profound ethical question: How should candidates for dialysis be chosen ?
AMA Journal of Ethics®, May 2016
To address this question, Scribner appointed an “Admissions and Policy Committee” that
was composed of lay people whom he considered to be representative of the community
(e.g., a minister, housewife, lawyer, banker, labor leader, and state government official)
and a surgeon and charged it with formulating nonmedical criteria for the selection of
dialysis candidates . The group considered a candidate’s age, sex, occupation, marital
status, education, dependents, income and net worth, past performance and future
potential, and references [7, 9]. Scribner’s account of the committee at a major media
convention to raise awareness about the dialysis breakthrough became the focus of a
front-page article in the New York Times, precipitating a firestorm of controversy. The
criteria adopted by the committee soon came to be viewed pejoratively as passing
judgment on candidates’ “social worth,” and the committee itself was infamously
dubbed the “Seattle God Committee” .
How should candidates for dialysis be selected? To Scribner’s credit, he realized that,
aside from a few obvious medical exclusion criteria, there was no strictly medical or
scientific answer to this question . Indeed, Scribner saw that any answer to the
question would be fundamentally value-laden or value-dependent in a way that the
question of who needed dialysis was not. While the God Committee was not the first
ethics committee as we now conceive of such committees, we can see in the impetus for
its creation many key features of the need that ethics committees later emerged to
address: technology creating options that formerly seemed unthinkable, value-laden
questions that go well beyond what medical science can address, a pluralistic context in
which not all involved share the same values, and the need for decisions to be made in a
relatively short timeframe.
In re Quinlan (1976)
A host of other very public controversies in the 1960s through the early ’70s helped
make health professionals, the general public, and policymakers alike aware of the need
for some way to address ethical issues in biomedicine [12-14]. Nevertheless, there is
arguably no case that more poignantly illustrated that need than the tragedy of Karen
Quinlan . On April 15th, 1975, 21-year-old Karen Quinlan was found unconscious
and nonresponsive by friends not long after they helped her to bed. Ms. Quinlan, who
suffered from a drug overdose, was transported to Newton Memorial Hospital, placed on
a respirator, and later transferred to St. Clare’s Hospital in Denville, New Jersey, where
she remained in a vegetative state, fed through a nasogastric tube. After months of
hoping against hope, Karen’s parents, Joseph and Julia Quinlan, in consultation with
family and their parish priest, came to accept that their daughter was not going to regain
consciousness and therefore to believe that she would not want to be kept alive on the
respirator. When the Quinlans requested that their daughter be taken off the respirator
and allowed to die, hospital administrators and the physicians responsible for her care
refused the request on the grounds that to do so would be euthanasia—in their eyes, a
form of murder. To be fair, we need to acknowledge that this position was no different
from that of the American Medical Association (AMA) at the time and that withdrawing
(as opposed to withholding) life-sustaining respirator support was far from standard
Appealing to the constitutional right to privacy, the New Jersey Supreme Court ultimately
supported the Quinlans’ right to have respirator support withdrawn on their daughter’s
behalf. Karen Quinlan’s plight, however, shook the general public in a way that would be
hard to overstate. As the philosopher Gregory Pence eloquently put it, together the
“invasive feeding tube and the respirator...would come to symbolize an oppressive
medical technology, unnaturally prolonging dying” . Like the God Committee, the
Quinlan case highlights many of the features of the need that ethics committees
emerged to address: technological developments creating options that formerly seemed
unthinkable, value-laden questions and decisions that go beyond what medicine or
science itself can address, the fact that not all involved share the same values, and the
time-pressured need for decisions. Unlike the God Committee, however, the Quinlan
case had very broad resonance, as nearly anyone could easily imagine him- or herself in
the same position as Joseph, Julia, or Karen Quinlan. The New Jersey Supreme Court,
apparently motivated in part by the fear of a torrent of cases that would grind the judicial
system to a halt, suggested that “ethics committees” (meaning, albeit, mostly physician-
dominated prognosis committees) might play an advisory role in such cases as an
alternative to the courts .
From Doe Regulations to Ethics Committees (1980-’86)
After Quinlan, additional events spurred the development of ethics committees. The early
’80s witnessed the divide between pro-life and pro-choice views after Roe v. Wade 
extend into a debate around withholding or withdrawing treatment for severely impaired
newborns, resulting in the Baby Doe regulations , which required aggressive care for
newborns unless such care:
would merely prolong dying, not be effective in ameliorating or correcting
all of the infant’s life-threatening conditions, or otherwise be futile in
terms of the survival of the infant .
By the end of 1984, the American Academy of Pediatrics  and the American Hospital
Association  issued statements supporting the use of interdisciplinary ethics
committees as an alternative to governmental investigation in such cases, and the
President’s Commission for the Study of Ethical Problems in Medicine and Biomedical
and Behavioral Research endorsed the establishment and use of ethics committees in
hospital settings in its influential report, Deciding to Forego Life-Sustaining Treatment: A
Report on the Ethical, Medical, and Legal Issues in Treatment Decisions . Two years later,
the AMA Council on Ethical and Judicial Affairs also supported their use as a way of
addressing ethical issues that emerge in clinical settings . In this context , the
AMA Journal of Ethics®, May 2016
dramatic growth of ethics committees from around 1 percent in the early 80s to over 60
percent of US hospitals by the late 1980s is both remarkable, because of the short
timeframe, and understandable, given the growing recognition of the need [4, 5].
The Cruzan Case (1990)
We conclude with the case of Nancy Cruzan, a Missouri woman who had been injured in
a car accident in 1983 at the age of 24 and remained in a permanent vegetative state
seven years later. Unlike Karen Quinlan, who was kept alive by both a respirator and a
feeding tube, Nancy Cruzan was kept alive only by a feeding tube—an example of
technological developments creating new dilemmas that, as we have discussed
throughout, ethics committees arose to address. Nancy Cruzan’s parents, Joe and Joyce
Cruzan, requested that the feeding tube be withdrawn and that she be allowed to die, on
the grounds that Nancy would not have wanted it . Opposed by the State of
Missouri—in the type of value-laden conflict characteristic of these cases emerging in a
pluralistic context—the case made its way to the US Supreme Court and was finally
decided in 1990 in the Cruzans’ favor. The legal issue in the initial case was whether the
State of Missouri had the right to set the evidentiary standard regarding the wishes of an
incompetent patient to have a treatment withdrawn. Missouri had set a “clear and
convincing evidence” standard and argued that Joe and Joyce Cruzan had failed to meet it
in offering only vague recollections of their daughter’s wishes . The Supreme Court’s
subsequent decision, however, recognized that competent patients have a constitutional
liberty interest, i.e., a constitutional liberty-based right, to be free of unwanted medical
More than 25 years later, it is easy to forget that the State of Missouri actually won the
case, in a decision that was roundly criticized by many bioethicists at the time . In the
immediate aftermath, the significance of the decision in furthering patients’ rights was
much harder to see because the Supreme Court majority opinion favored Missouri and,
therefore, ostensibly left Nancy imprisoned by medical technology. Interestingly, not
long after its victory, the State of Missouri claimed to have discovered additional
evidence of Nancy Cruzan’s wishes (allegedly, people came forward who knew her by her
married name, Nancy Davis, and provided additional evidence of her wishes not be kept
alive in these circumstances as Karen Quinlan had been) and moved to have the feeding
tube withdrawn .
Given the State of Missouri’s victory, why was the Cruzan case a major victory for
patients’ rights, and how did it contribute to the rise of ethics committees? As noted
above, Cruzan recognized that a competent patient has a constitutional right to be free of
unwanted medical interventions . Once competent, but now incompetent, patients,
then, also must have such a right, raising the question of how that right might be
respected. In her concurring opinion, Justice Sandra Day O’Connor emphasized that the
task of crafting protections for the liberty interests of such patients is entrusted to the
“laboratory of the states” . Public outcry during and after the Cruzan case led directly
to the passage of the Patient Self-Determination Act (PSDA) of 1991, which underscored
patients’ rights to direct their care by mandating, among other things, that patients be
informed of such rights and offered information about advance directives [29, 30].
For our purposes here, the final push in the emergence of ethics committees in the US
came in 1992, when the Joint Commission on the Accreditation of Healthcare
Organizations (JCAHO) changed its recommendation that hospitals have some
“mechanism” for dealing with ethical issues in clinical care to a requirement . It would
appear to be no mere coincidence that the process for initiating this change came on the
heels of the very public discussion of the Cruzan decision and the passage of the PSDA.
Not surprisingly, the 1990s saw the presence of ethics committees in US hospitals jump
from 60 percent to over 90 percent by the end of the decade .
These three cases—the God Committee, Quinlan, and Cruzan—all feature the
technological developments, value-laden questions, clashes between values in a
pluralistic context, and relative time-pressure for decision making that I argue
characterize the need that ethics committees came into existence to address—a need
that seems unlikely to abate in the foreseeable future.
1. Ethics committees typically have a threefold function of education, policy
formation or review, and consultation. Aulisio MP. Clinical ethics. I. Development,
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4. Youngner SJ, Jackson DL, Coulton C, Juknialis BW, Smith EM. A national survey of
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MA: McGraw-Hill; 2000.
8. During the early and mid-twentieth century, medical science was experiencing a
historically unprecedented series of technological advances that created options
AMA Journal of Ethics®, May 2016
for medical care and challenges for decision making that were almost
unthinkable in earlier times. These advances included successes with antibiotics
(e.g., penicillin in the ’40s), vaccinations (e.g., polio in the ’50s), transplantations
(e.g., kidney, liver, heart in ’50s and ’60s) and a variety of medical devices (e.g.,
“iron lung” in the ’20s and ’30s). Advancing medical technology played an
important role in the rise of ethics committees [1, 3].
9. Winslow GR. Triage and Justice: The Ethics of Rationing Life-Saving Medical
Resources. Berkeley, CA: University of California Press; 1982:13.
10. This ethical dilemma was thrust into public spotlight when Scribner himself tried
to raise awareness about his breakthrough and the great need it had created by
taking one of his patients with him to address a large media convention in
Atlantic City, New Jersey. There he discussed not only the innovation of the
permanent indwelling shunt, but also that demand for dialysis was vastly beyond
what his center could possibly meet. Given this, it is not surprising that those
present pressed him to discuss how candidates for dialysis were selected, and he
obliged. Alexander S. They decide who lives, who dies: medical miracle puts a
burden on a small committee. Life. 1962;53(19):102-104, 106, 108,110, 115,
117-118, 123-124, 127.
11. Winslow, 13-15.
12. The furor over the “God Committee” had barely subsided when successes in
organ transplantation evoked similarly difficult, value-laden questions about the
procurement and distribution of the scarce resource of solid organs. Jonsen AR. A
Short History of Medical Ethics. New York, NY: Oxford University Press; 2000.
13. In 1967, Christiaan Barnard, a South African surgeon, successfully transplanted a
beating heart from a patient with “irreversibly fatal brain damage” into another
patient. Barnard’s shocking and unsettling “success” sent ripples through the
biomedical community, raising questions about what was thought to be a solid
scientific concept—“death.” Just a year later, Harvard Medical School issued a
statement supporting a new type of death, “brain death”—a notion that,
although widely accepted in practice, remains controversial in the academic
literature even today. Rodríguez-Arias D, Tortosa JC, Burant CJ, Aubert P, Aulisio
MP, Youngner SJ. One or two types of death? Attitudes of health professionals
towards brain death and donation after circulatory death in three countries. Med
Health Care Philos. 2013;16(3):457-467.
14. In 1972, the New York Times expose of the Tuskegee Syphilis Study—a US Public
Health Service research project regarding the progression of untreated syphilis in
African American men who were deceptively enrolled, subjected to painful and
invasive study procedures, and followed for over 40 years—shocked the public
and served as an example of biomedicine being used as an instrument of racism
and injustice . Heller J. Syphilis victims in US study went untreated for 40
years. New York Times. July 26, 1972:1, 8. The landmark US Supreme court case
of Roe v. Wade in 1973 forced the public to see again just how profoundly
considerations beyond medical science impacted clinical decision making, with
concepts like “personhood,” “viability,” and “privacy” lying at the heart the
15. Jonsen AR. The Birth of Bioethics. New York, NY: Oxford University Press;
16. Pence, 31.
17. In re Quinlan 70 NJ 10, 355 A2d 647 (1976).
18. Roe v Wade, 410 US 113 (1973).
19. Wolf SM. Ethics committees in the courts. Hastings Cent Rep. 1986;16(3):12-15.
20. Services and treatment for disabled infants, 45 CFR sec 1340.15 (1985). Cited in:
Jonsen, 2000, 113.
21. Strain JE. The American Academy of Pediatrics comments on the “Baby Doe II”
regulations. N Engl J Med. 1983;309(7):443-444.
22. American Hospital Association. Guidelines: hospital committees on biomedical
ethics. January 27, 1984.
23. President’s Commission for the Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research. Deciding to Forego Life-Sustaining Treatment:
A Report on the Ethical, Medical, and Legal Issues in Treatment Decisions.
Washington, DC: President’s Commission for the Study of Ethical Problems in
Medicine and Biomedical and Behavioral Research; 1983.
24. Judicial Council of the American Medical Association. Guidelines for ethics
committees in health care institutions. JAMA. 1985;253(18):2698-2699.
25. The decade also saw the California case of Elizabeth Bouvia, a 28-year-old
cerebral palsy patient who won the right not to be medically force-fed against
her wishes. Bouvia v Superior Court, 179 Cal App 3d 1127, 1135-1136 (1986).
26. Cruzan v Director, Missouri Department of Health, 497 US 269-285 (1990).
27. Annas GJ. Nancy Cruzan and the right to die. N Engl J Med. 1990;323(10):670-673.
28. Cruzan v Director, 292.
29. Aulisio MP. Advance directives and the physician-patient relationship: a
surprising metamorphosis? In: Lack P, Biller-Andorno N, Brauer S, eds. Advance
Directives. Dordrecht, The Netherlands: Springer Netherlands; 2014:127-132.
30. Aulisio MP. “So what do you want us to do?” Patients’ rights, unintended
consequences, and the surrogate’s role. In: Youngner SJ, Arnold RM, eds. The
Oxford Handbook of Ethics at the End of Life. Oxford, UK: Oxford University Press. In
31. Joint Commission on Accreditation of Healthcare Organizations. Patient rights.
Accreditation Manual for Hospitals, 1992. Oakbrook Terrace, IL: Joint Commission
on Accreditation of Healthcare Organizations; 1993:1-16.
Aulisio MP, Arnold RM. Role of the ethics committee: helping to address value conflicts
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AMA Journal of Ethics®, May 2016
Fletcher JC. The bioethics movement and hospital ethics committees. MD Law Rev.
Fost N, Cranford RE. Hospital ethics committees. Administrative aspects. JAMA.
Mark P. Aulisio, PhD, is the Susan E. Watson Professor and chair of the Department of
Bioethics at Case Western Reserve University School of Medicine and director of the
Center for Biomedical Ethics at the MetroHealth System in Cleveland, Ohio. Professor
Aulisio’s scholarly interests in clinical bioethics include ethics committees and
consultation, ethics and professionalism, end-of-life decision making, and the principle
of double effect.
Related in the AMA Journal of Ethics
Hospital Ethics Committees, Consultants, and Courts, May 2016
The Evolution of Surrogates’ Right to Terminate Life-Sustaining Treatment, September
God Panels and the History of Hemodialysis in America: A Cautionary Tale, November
Legal Constraints on Pursuit of a “Good Death,” December 2013
Medical Futility: Legal and Ethical Analysis, May 2007
End-of-Life Care and the Goals of Medicine, June 2007
The Appropriate Use of Increasingly Sophisticated Life-Sustaining Technology, December
Helping Surrogate Decision Makers in the Face of Uncertainty, August 2004
The Use of Informed Assent in Withholding Cardiopulmonary Resuscitation in the ICU,
Deciding for Others: Limitations of Advance Directives, Substituted Judgment, and Best
Interest, August 2009
Diagnosing The Permanent Vegetative State, August 2004
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect
the views and policies of the AMA.
Copyright 2016 American Medical Association. All rights reserved.