Hospital ethics committees: responsibilities, competencies and challenges

Abstract

Background

Hospital Ethics Committees (HECs) aim to address complex ethical dilemmas and provide ethical counselling and guidance in hospital and clinical setting. Despite their formal and legalistic authority in Israel, little is known about their actual practices, structure and perceived role by their members.

Methods

This qualitative study employed Interpretative Phenomenological Analysis (IPA) to explore the lived experiences of HEC members in Israeli hospitals and the meaning they attach to their roles. Thirteen semi-structured interviews were conducted with committee chairs and members with diverse professional and institutional backgrounds in nine hospitals throughout the country. Data were analyzed using thematic coding to identify key patterns and insights.

Results

Five major themes emerged: (1 Offering support through decisive means; (2) Committee composition, member characteristics and ethics training; (3) Common ethical issues discussed in the Ethics Committee; (4) Committee’s decisional functioning; and (5) Committee’s relationships with various entities, and the limitations of its operation.

Conclusions

HECs in Israel serve a unique dual role as legal and ethical decision-making bodies. While they support clinicians and, to some extent, patients, their potential is hindered by systemic gaps in training, collaboration and engagement. Further research is recommended to explore patient experiences and evaluate committee effectiveness in advancing ethical clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-025-01365-4.

Background

Institutional ethics committees, mostly referred to as hospital ethics committees (HECs), are formal entities within medical institutions which aim to address ethical dilemmas and provide ethical counselling and guidance in hospital and clinical settings [1–3]. Developed at the same time as the flourishing of bioethics and ethics consultation [4], HECs have been established since the 1970s (although their full-scale creation did not occur until the late-1980s and through-out the 1990s), and increasingly so following the Supreme Court of New Jersey decision in the matter of Karen Ann Quinlan, confirming HECs’ authority to advise the medical team on decisions regarding cessation of life-saving treatment. T’wo additional cases that contributed to the flourishing of HECs are the landmark decision in Roe v. Wade, reflecting the polarized pro-life and pro-choice debate and the legal recognition in a constitutional right of a competent patient to refuse unwanted medical interventions in the case of Nancy Cruzan [5] .

This mandate has been further verified in a subsequent Presidential Commission report in 1983 [6, 7], and as of 1992, the establishment of a mechanism to address ethical issues arising in the care of patients and to educate caregivers and patients on ethical issues in healthcare has become a requirement of hospital accreditation following the Joint Commission on Accreditation of Healthcare Organizations within the US and in countries applying this regulatory framework [4], although the requirement to have such a process has been removed by 2023 HECs’ role is increasingly becoming more significant, particularly as more support, advice and education are required by clinicians as they encounter ethically/legally challenging cases, and with the increasing role of external factors in medical decision making [8].

HECs evolved from advisory groups providing ethical counselling and addressing clinical controversies and technological advances to encompass policy, education, and organizational ethics. In recent years and especially in developed countries, they confront heterogeneity, resource constraints, and demands for standardized quality measures, including advocating for the implementation of ethical principles in care providers’ interactions with patients and their families [9–12]. Although HECs vary significantly in their purposes, scope and authorities, members of HECs generally exercise an approach of ethics facilitation whereby they elucidate issues, identify ethical needs in the clinical settings, offer effective communication, and integrate the perspectives of the relevant stakeholders [13]. Their overarching goals are to protect patients’ rights, safety and wellbeing, and to support the healthcare staff, patients and their families [14].

While the level of HECs’ effectiveness has not yet been fully explored, studies indicate some positive impact on stakeholders’ satisfaction, change in medical treatment and decrease in the reported healthcare professionals’ moral distress [15]. Other contributions of HECs’ activities involve policy development and scrutiny of the medical decision making process [16], as well as increasing the overall use of ethical guidelines in medical institutions [17]. When combined with adequate composition, transparent procedures and targeted training [18], and supported by sufficient resources [19, 20], HECs’ ethical deliberations could be extremely useful.

A comprehensive review of world literature between 2014 and 2016 revealed that although HECs are well-established and operationally active in most developed nations, developing countries demonstrate significant gaps in implementation strategies, even where such committees formally exist [1]. A more recent review further elaborated the varied challenges of HECs, including personal views and believes in healthcare professionals, sense of fear in the healthcare professionals, medical culture, environmental factors, managerial and structural factors, characteristics of the HECs’ members, factors related to the HECs, problematic process for HECs’ consultations, and weakness of knowledge about HECs [2]. Indeed, HECs vary in different countries. While in the US, HECs developed from the need to support professionals with missing knowledge needed to deal with complex ethical issues and defend medical authority that has gradually become suspect with the rise of the patients’ rights movement, in Italy they were regarded as democratic forums within medical institutions, offering a space to think of new challenges in medical practice [21]. In Israel, HECs are legally required by the 1996 Patient Rights Act (Hereinafter: “the Act”]. As such, in contrast to the typical consultive function of HECs [22], they serve as quasi-judicial committees authorized to approve, change or cancel healthcare professionals’ decisions. When acting as consulting committees, they typically comprise of one or two members with no medical background, and there is usually no obligation to refer to them at all [11].

As quasi-judicial committees, HECs in Israel are legally comprised of professionals from different backgrounds including law (1 member serving as the chair); medicine (2 members with different medical expertise); social work or psychology (1 member), nursing (1 member), in addition to a public or religious representative (1 member). An extended approach demands of these members to be skilled not only in ethics, but also in communication, interpersonal relationships and conflict management, in line with the development of the field of mediation in clinical ethics consultation more generally [22]. As reported in similar contexts focusing on the more narrow context of clinical ethics consultation [23], typical issues that may also be included in HECs’ responsibilities are informed consent for competent patients and refusals for treatment, decision-making for incompetent patients, end-of-life care, reproduction and beginning-of-life care, confidentiality, and resource allocation.

An additional and extremely controversial role of HECs in Israel authorized under Sect. 15 [2] of the Act, is enforcing medical treatment contrary to specific objections of a competent patient [24]. Under this exceptional role, HECs can approve enforced treatment in circumstances of serious risk to the patient, under three conditions: (1) the patient was fully provided with all necessary information; (2) it is expected that the proposed treatment will significantly improve their medical condition ; and (3) there is reasonable ground to believe that the patient will have retrospectively given their consent to the proposed treatment. In a more controversial case, one HEC used this section to force-feed a competent political prisoner [25].

As a relatively recent phenomenon, the constitution and spread of HECs in Israel has increased, particularly in the 1990s. A study conducted six years after their establishment showed that only a third of hospitals had ethics committees, and that in those who did, HECs rarely convened so that access to them was significantly curtailed [26]. Anecdotal evidence published nine years later suggested that nothing has changed [26]. An examination of the State Comptroller in 19 hospitals in 2014 further revealed that 18 of them had established HECs. However, most of them rarely convened and no actual use has been made of these bodies. Heads of Internal Medicine Departments and senior medical doctors expressed the view that they did not refer to HECs as a result of overload and the inability of HECs to provide a satisfying response to their needs due to their unavailability. They also stated that in many cases they did not realize that cases raised ethical questions, rather regarding them as being under their sole professional responsibility [27].

The data on Israeli HECs relate to findings on HECs in other countries, suggesting that their role is not well perceived in a hospital environment [28], especially by medical doctors who feel these committees are of limited use [29], or do not like to be interfered with in what they regard as their primary domain [30], usually under poor inter- and intra-professional communication settings [31]. These join other worries referring to HECs’ lack of independence and impartiality, sufficient size and diversity, adequate resources and training, and adequate methods and procedures [32], as well as questioning the competencies of committee members [33, 34]. Other concerns also apply to fairness issues, particularly due process considerations applying to dispute resolution mechanisms used by HECs as their power and authority grow [35], and to HECs’ involvement in issues of legal liability [36]. Overall, these findings suggest that HECs ’fail to thrive’, struggling with their purpose and meaning [37].

Despite their significance and legal status, the structure, scope of activities and mandate of HECs in Israel remain unclear [26]. Their work and function, as well as their composition and exercise of authority, continue to be unsettled and far from supervision or the public eye [38]. Empirical research of what takes place during deliberations and consultations is scarce. Specifically disturbing is that, as of this date, there is no research of the exercise of Sect. 15 [2] by HECs, authorizing a regulated violation of patient autonomy [39]. While some improvement has been made as a result of a Ministry of Health special committee which followed the State Comptroller’s report [40], and the publication of new guidelines published in 2018 [41], it remains to be seen whether the practice of HECs has been significantly changed. Moreover, while HECs are based on an American model of institutional healthcare counselling and decision-making, it is far from clear that such a model has been successfully applied in Israel, given the cultural and political contexts as well as their unique legal status, all of which could have influenced their functioning.

This study attempts to fill this gap, investigating the views and attitudes of hospital ethics committee members in Israel regarding their roles and responsibilities, and exploring and understanding the ways in which these committees work, their composition, and the normative approaches they pursue.

Methods

Design

This is a descriptive qualitative study following the Interpretive Phenomenological Approach (IPA). IPA constitutes a qualitative research framework enabling comprehensive investigation into how individuals construct meaning from their personal experiences, particularly within complicated and emotionally demanding circumstances, such as with activities undertaken by HECs. The study integrates phenomenological analysis with interpretive insights from both study participants and researchers regarding the examined phenomenon [42]. We used IPA to answer the following research questions: (1) What are the attitudes, views and perceptions of HEC members with regards to the committee’s status, roles, authority, actions and suitability to perform their roles (2)? Which main challenges and difficulties do HEC members face while fulfilling their roles?

Study population

Our research population includes HEC chairs and/or members with at least two years’ experience as HEC members. In order to explore the views and attitudes of HEC members, we conducted 13 in-depth semi-structured interviews with HEC members from nine hospitals varying in size, homogeneity and religiosity level. Participants were sampled using the snowball and purposive sampling methods, elected purposefully to yield cases that are ’information rich’ [43].

The interview guide

The interview guide was developed specifically for this study, based on the relevant literature on HECs that was reviewed in the Background Section, focusing on the main issues explored with regard to it: Members’ general perceptions regarding the committees; Committee structure and working methods; Decision-making; Members’ specific approaches and perceptions regarding the ommittees; and Training. These issues helped organize the interview guide under eight sections. The full interview guide in attached in Appendix A.

Data collection

Participants were recruited following direct calls-for-participation. They were then provided with thorough explanations regarding the study, and gave their informed written consent. Initially, only HEC chairpersons from the potential hospitals were interviewed. Following this stage, HEC members who agreed to participate in the study were also interviewed, until data saturation was reached with no new and significant information or theme noted [44].

The interviews were conducted by the first and last authors, who have extensive experience in and understanding of qualitative research and bioethics. They were held in Hebrew and lasted in average 75 min. As per participants’ choice, 12 interviews took place via Zoom and one in person. Interviews were recorded and transcribed.

Data analysis

Employing IPA methodology [45], we followed an inductive approach whereby we conducted repeated comprehensive readings of interview transcripts while highlighting and engaging with meaningful participant responses. The preliminary notes from the initial reading were converted into brief descriptive phrases and provisional coding categories. Through an iterative and contrastive analytical approach, we systematically examined the data to develop themes, sub-themes and codes. Subsequently, we structured these components analytically to explore relationships and deeper significance embedded within the gathered information. To increase trustworthiness [46], the major subjects and concepts obtained from the preliminary data analysis have been discussed by all researchers in several meetings. In addition, all interviews were thoroughly and independently analyzed by the first and last authors, as well as a research assistant with experience in qualitative research. We used ATLASti.8 for sorting and organizing themes and subthemes. This has helped with the data analysis.

Ethical considerations

Participants’ privacy rights have been protected throughout the study, and informed consent was obtained. The study was approved by the Ethics Committee at the authors’ affiliated academic institution (Approval no. 494/21, dated 2 December 2021). Throughout the article pseudonyms are used to present the participants’ citations, in order to protect their privacy.

Results

Thirteen HEC members from nine hospitals were interviewed. Table 1 below provides the participants’ characteristics.

Table 1.

Participants’ characteristics

Pseudonym	Gender Male/Female	Profession (Physician/Other)	Role (Chair/Member)	Hospital (A/B/C) & location (North/Center/South)
Haya	Female	Lawyer	Chair	A-North
Linda	Female	Social worker	Member	D-Center
Ofra	Female	Lawyer	Chair	E-Center
Yosef	Male	Lawyer	Chair	B-North
Michal	Female	Lawyer	Chair	C-North
Aharon	Male	Lawyer	Chair	F-South
Boaz	Male	Lawyer	Chair	D-Center
Haim	Male	Lawyer	Chair	G- Center
Avraham	Male	Physician	Member	D-Center
Meirav	Female	Physician	Member	H-Center
Omer	Male	Physician	Member	F-South
Rotem	Female	Nurse	Member	D-Center
Meir	Male	Physician	Member	I-North

The findings reveal substantial diversity in attitudes and ethical approaches held by HEC members, as well as HEC managerial type, operation, size and composition. The analysis yielded five major themes and 11 sub-themes, described below. These are organized in Table 2 and described in much detail below.

Table 2.

Map of themes and Sub-themes

Theme	Sub-theme
1. Offering support through decisive means	1.1 Decisive body in complex ethical dilemmas
	1.2 Support mechanism for healthcare professionals
2. Committee composition, member characteristics and ethics training	2.1 Committee meetings and composition
	2.2 Members’ characteristics 2.3 Training in the field of ethics
3. Common ethical issues discussed in the Ethics Committee	3.1 Patients who refuse medical treatment
	3.2 Medical decisions regarding incompetent patients
	3.3 Medical treatment of prisoners and special populations
4. Committee’s decisional functioning	4.1 Committee decision-making process
	4.2 Guiding principles in decision making
5. Committee’s relationships with various entities, and the limitations of its operation	5.1 Committee’s relationships with various entities
	5.2 Limitations of committee work

Theme 1: offering support through decisive means

Decisive body in complex ethical dilemmas

All Participants described the Ethics Committee as an authoritative entity palying advisory roles. As Linda, a social worker, noted:

There is no doubt that there is very strong justification for the Ethics Committee in both of its roles, both when it functions as a statutory committee where decisions truly have statutory status and when it operates as an advisory committee. (Linda, social worker)

In its statutory capacity, the committee’s decisions are binding, while in its advisory capacity, the committee offers ethical and educational guidance to the medical teams.

Several participants emphasized that the committee is not limited to making final decisions in ethical dilemmas artising from the clinical practice, but also provides a forum for ethical reflection and multidisciplinary collaboration. Omer, a physician, explained:

The committee’s role is not only to make decisive rulings, but also to provide a space for deep ethical thinking and the involvement of many professionals. (Omer, physician)

Similar insight was echoed by Boaz, a Committee Chair, who stressed that the committee offers a framework for collective ethical discussions rather than relying solely on the judgment of an individual case.

The committee was also described as fulfilling a supervisory function, ensuring that decisions are transparent, measurable, and protect patient rights. As Haim, Committee Chair, observed:

The committee provides the medical team with a framework for professional ethical discussion, instead of relying only on the personal judgment of an individual caregiver.

Additionally, the committee oversees medical decision-making, ascertaining that they are made in an ethical manner, while protecting patient rights and balancing the patient’s personal welfare and medical and system-wide considerations. Thus, Haim describes:

In sensitive cases, the committee serves as a monitoring body that ensures decisions are made in a measured and transparent manner, while protecting patient rights. (Haim, Committee Chair)

Finally, the committee serves not only in its capacity to make decisions but also as a mediator among conflicting stakeholders relevant to the patient. Meir, a physician and committee member, says:

Often, the committee serves not only as a decision-maker but also as a mediator among conflicting positions – among the patient, their family, and the medical team.

Overall, the findings suggest that RECs operate as both decision-making entities and a space for ethical dialogue, while also safeguarding patient rights and mediating between competing perspectives.

Support mechanism for healthcare professionals

Beyond its formal role in decision-making, the Ethics Committee perceived as a source of support for healthcare professionals who frequently encounter complex cases requiring difficult decisions with significant implications. In these situations, the committee provides them with professional and ethical support. Often, the very existence of the committee eases the personal burden experienced by doctors and nurses, thereby reducing their exclusive decision-making responsibility and allowing them to share their responsibility for making tough medical decisions.

It really helps doctors to live with themselves, to know that the decision was made in the best possible way, there is a sharing of responsibility here. (Linda, social worker)

Many times, it provides some kind of backing and support for the team. This is very important. (Meirav, physician)

Theme 2: committee composition, member characteristics and ethics training

Committee meetings and composition

The interviews reveal that committee meeting frequency varies, with some committees meeting monthly while others meet 4–5 times annually. The committee typically convenes to discuss a single case. Occasionally, the committee meets to discuss matters of principle or policy.

In most places, the Ethics Committee includes senior physicians from various fields, legal experts, social workers, nurses and public representatives. In addition, religious figures are also included as members, especially in medical institutions with culturally and religiously diverse populations. In many cases, when committee members leave their job or retire, their positions are filled by relevant experts with appropriate experience. All positions are voluntary and unpaid. The study shows that maintaining diversity within the committee helps in making informed, balanced decisions.

Ethics Committee members are typically experienced professionals who bring rich medical, legal and ethical knowledge to the table. Senior physicians with decades of clinical experience play a key role in the ethical discussions. The interviews highlight that the physicians’ practical experience helps committee members understand the medical implications of the decisions they make. Alongside physicians, the committee also includes legal experts who provide their perspective on ethical issues and ensure that decisions comply with the law.

The findings reveal that the Ethics Committees draw their strength from the professional diversity of their members. Physicians who participated in the study emphasized the significance of their seniority and accumulated experience to the committee As Avraham, a physician, noted:

"Let’s say that the doctors who belong to the committee are all very senior and very experienced doctors. I think that their life experience over decades is appropriate training."

Such experience was viewed as a form of ethical preparation, enabling physicians to address and manage complex dilemmas with practical wisdom.

Legal professionals in the committeedescribed themselves as ensuring that deliberations remain consistent with statutory requirements and defensible in legal terms. Aharon, a committee chair and a former judge, explained: “As a former judge, I bring a broader legal perspective to the committee regarding the legal implications of the decisions being made.” Similarly, Haim, a committee chair, stated: “The fact that I am a lawyer allows me to bring a different perspective to the discussion, to ensure that decisions also stand up to legal scrutiny.”

Nurses were portrayed by participants as bringing a unique and indispensable perspective, rooted in proximity to patients and clinical reality. As described by one of the participants:

Even if they don’t know a single word in legal language, they know this better than anyone in the world. So even when nurses sit on a committee, their contribution is always clearly seen — from… as I call it, from the hallway, right? From the field, from the floor. From the hospital floor. (Michal, Committee Chair)

Together, these accounts show how the committee benefits from multiple forms of expertise: the experiential authority of physicians, the normative oversight of legal professionals, and the grounded, human-centered knowledge of nurses.

Members’ characteristics

A dominant view explored by many participants in the study held that committee members should be endowed with a variety of personal and professional qualities to enable them to handle the moral, emotional and practical complexities of the decision-making process well. One of the central qualities evident from participants’ narratives is empathy. Empathy emphasizes the need to be able to put oneself in the patients’ shoes, listen to them and understand their feelings without being judgmental. From the participants’ point of view, empathy serves as a cornerstone in the ethical decision-making process, allowing for a deep understanding of the subjective experience of the patient and their family.

We usually go to the same department ourselves and examine the patient with our own eyes, interview them, and listen to their opinion as much as they are able to express it, in order to gain a clear, face-to-face impression of the patient, their desires, and their thoughts. … it adds depth and insight into the patient’s state of mind. )Avraham, physician)

Another aspect found to be important in the study is listening to the patient and their family. Committee members emphasize their commitment to give patients and their families a voice in the discussions, with the understanding that despite the healthcare professionals’ extensive medical knowledge, patients and their families may hold significant insights regarding their personal and medical needs. Asexplained, for example by Meirav, a physician:A good committee member should be a person with the ability to listen attentively, with sensitivity, emotional intelligence, and the capacity to understand all the complexityץ.

Sensitivity is indeed another central component integrating with empathy and attentiveness. This is expressed not only in understanding patients’ distress reflected in the case to be discussed by the committee, but also in considering aspects that are not solely medical, i.e., emotions, thoughts and personal circumstances. Committee members are fully aware that their decisions affect the lives of patients and their families, and therefore they must exercise sensitive and balanced judgment.

Mental flexibility constitutes another essential aspect in the committee’s work, given that, as participants explain, ethical issues are not reduced to a ’black and white’ dichotomy. The need to deal with complex situations in a ’gray area’ requires committee members to exercise flexible judgment and be open to diverse modes of thinking. As one participant notes, an inability to accept complexity can be an obstacle in the committee’s work.

Additionally, professional seniority is perceived as a critical factor in the committee’s functioning. Participants hold the view that dealing with complex ethical dilemmas requires years of experience and life wisdom, helping to understand the nuances of cases and establish professional authority with patients and their families. Along this line, it is mentioned that senior doctors are able to bring a broader perspective to ethical deliberations.

Finally, knowledge in bioethics is an important component in members’ required qualities, although there seems to be no formal requirement to demonstrate such knowledge or to be trained in ethics (see below).

Training in the field of ethics

Ethics Committee members come from diverse professional backgrounds, but most of them do not have formal background in ethics. Some participants believe that such training is essential and should even become mandatory, to ensure a higher professional level in ethical decision-making. For example, Ofra, a Committee Chair, says:

I could have been much better as an Ethics Committee member if I took a course in ethics, but there’s no requirement to take an ethics course from any side, and I think that’s a bit of a shame. Maybe once there weren’t ethics courses, but today there are courses, so it’s worthwhile.

Formal and standardized training would contribute to the committee’s ability to operate professionally and provide optimal support to both medical teams and patients. A few participants also commented that members’ training should also include mediation skills, which could help resolve disputes between different parties. Other members recommend a mentorship model, whereby a new committee member could join the discussions as an observer before making decisions independently. However, according to most committee members who participated in this study, valid and well-founded decisions can be made by the committee even without formally trained members. In particular, experienced medical doctors report that their practical knowledge can be a substitute for such training. Avraham, a physician and committee member reflects on this topic:

Well, since I am a very experienced doctor, I think this qualifies me for this role. And I haven’t taken a course in ethics, that is, there’s no training that I know of. But that’s why we have social workers and psychologists who are more alert to the psychological aspects of the patient. The total of this complex provides us with the right tools. (Avraham, physician)

Few participants were also those who expressed a desire to study ethics and law in a broader way:

" I would be happy for a refresher in the field of general ethical concepts, not necessarily at my nursing level, but broader. As you say, the place of the Ethics Committee, also from a legal perspective. Things that are broader and more like that, I say. (Rotem, nurse)

Theme 3: common ethical issues discussed in the ethics committee

All Participants raised three major ethical issues that are common in committee discussions and are within the committees’ legal authority. These are discussed below.

Patients who refuse medical treatment

Refusal to receive medical treatment, usually life-saving treatment, is one of the central and most common ethical issues discussed in medical Ethics Committees. This issue creates tension between the principle of patient autonomy and the duty to benefit the patient and prevent harm to them. The interviews reveal that one of the most common cases involves patients who refuse limb amputation, despite the significant risk to their lives. This refusal, usually perceived by the medical team as irrational, creates controversy among committee members. The following question then arises: to what extent should the patient’s wishes be respected, especially when they involve life-saving treatment. According to participants, this dilemma intensifies when the refusal to comply with medical treatment stems from religious belief, e.g., in the case of a Jehovah’s Witness patient refusing blood transfusions. Such situations require committees to consider whether and how to intervene without violating the patient’s rights and beliefs.

Medical decisions regarding incompetent patients

A second issue that frequently comes up for discussion in the ethics committee concerns patients who lack the capacity to make medical decisions. This issue raises complex questions regarding who is authorized to decide on behalf of the patient. One participant, for example, described the ethical dilemma that takes place when a family member insists on a medical procedure being performed for a patient who is not competent to decide for themselves. In such cases, the medical team must determine whether to comply with the family member’s demands or act following medical considerations only. Another participant adds that when there is doubt regarding the extent to which the patient understands the implications of their decisions, one common approach is to appoint a guardian to make decisions for them. This process is designed to ensure that whoever makes decisions for the patient does so in the patient’s best interest, although it might also provoke opposition from other family members who feel their wishes are not being respected.

Medical treatment of prisoners and special populations

A third issue that emerged less frequently than the two previous issues through the participants’ descriptions (and is unique to Israel), relates to medical treatment of prisoners, particularly security prisoners. This issue raises the tension between respecting values of medical ethics and enforcing political and legal considerations. Our study describes cases brought to Ethics Committees in which force-feeding or forced medical examinations of prisoners have been discussed. As some of the participants share, these cases involve the conflict between the protection of the prisoner’s human rights and shielding the public interests, or the interests of other patients. These dilemmas become particularly complex when dealing with medical examinations intended to serve a third party, as illustrated by the case presented in one of the interviews, which discussed whether a prisoner could be forced to undergo an HIV test to assist in treating a woman who was harmed by him. In such a case, questions of privacy, medical rights, and the doctor’s social responsibility conflict with each other, requiring a context sensitive ethical decision.

Taken together, these issues, which appear repeatedly in Ethics Committee discussions, reflect the complexity of medical decisions when principles such as autonomy, medical justice and the duty of beneficence may contradict each other.

Theme 4: committee’s decisional functioning

Committee decision-making process

All The participants described how the decision-making process in the committee is characterized by in-depth multi-professional discussions, and the committee members’ aspiration to reach a decision agreed upon by all members.

In-depth multi-professional discussion

The decision-making process in the Ethics Committee is based on an in-depth discussion involving members from a variety of professional fields. The committee chairperson usually guides the discussion and gives each committee member an opportunity to present their perspectives. The treating physician presents the case, followed by a comprehensive review of the relevant medical, legal, social and ethical aspects. The committee does not function only as a ruling institution but also serves as an arena for multi-disciplinary discussion, where all relevant considerations are taken into account. In some cases, discussions focus on the patient’s worldview, for example in cases where ideological or religious considerations influence the patient’s decision.

We hear the case, consider the medical, legal, social and ethical aspects, and then formulate a decision. (Rotem, nurse)

Sometimes we encounter situations where the patient refuses treatment for ideological reasons, and then we need to consider not just their medical condition but also their personal worldview. (Aharon, Committee Chair)

The committee is not only required to rule, but to create a space for genuine dialogue that allows all considerations to be taken into account. (Meir, physician)

Desire for consensus

The study shows that the decision-making process aims to achieve consensus among committee members. In most discussions, committee members succeed in reaching a mutual agreement on the required decision. Yet, even when disagreements exist, participants report that there is much listening to different opinions to find a solution that reflects an agreed-upon balance between the competing principles. It is evident that the decision-making process focuses on broad consensus rather than majority opinion, while maintaining the principles of respectful discussion and giving weight to all positions presented.

I don’t remember that there was ever a vote by majority, there was always a decision. (Ofra, Committee Chair)

There are always different opinions, if only to develop the discussion… but people listen, hear each other, hear more opinions. (Meirav, physician)

When disagreements exist, we try to find a solution that allows not only a decision but also mutual understanding. (Haim, Committee Chair)

Guiding principles in decision making

The interviews revealed that HECs operate according to several guiding principles in their decision-making process. These include respecting patient autonomy, evaluating the urgency and severity of the condition, and ’residual’ principles required for balancing the competing principles. The combination of all these principles, that were raised by all participants, enables balanced and fair decisions that are ethically and legally justified.

Respecting patient autonomy

The central principle is respecting patient autonomy, particularly a person’s right to make decisions regarding their own body, even if their decision jeopardizes their medical condition. The approach to patient autonomy is complex and difficult, giving maximum consideration to the patient’s insights and wishes. One participant conveyed the impression that medical professionals “feel obligated both legally and ethically” to respect the patient’s wishes, but the challenge lies in the fact that implementing this principle is not always straightforward. Another participant sharpens this point when she explains that “the starting point is always the patient’s autonomy,” but in the same breath she notes that the committee’s authority may override or limit this autonomy.

At the beginning of each discussion, we need to remind ourselves of this again. That is, to remember again that our discussion framework is always, always, always the patient’s wishes, unless we decide that everything, everything, everything, yes? That all criteria and all considerations and so on, and only then do we deviate from the patient’s decision, from the patient’s wishes. (Michal, committee Chair).

Research participants describe the constant emotional need of caregivers “to give up treatment and prioritise patient autonomy.” They describe this as an internal struggle, as their professional identity as physicians directs them to treat patients and save lives, while the principle of autonomy sometimes requires them to stop and respect the patient’s refusal of treatment. Often, disagreements arise among committee members regarding the extent to which autonomy should be respected when a patient refuses treatment, especially life-saving treatment, testifying to the complexity of the discussion and the diversity in professional and personal approaches of committee members.

We are committed, we feel committed both legally and ethically, to take all measures to respect the patient’s wishes. (Avraham, physician)

We need to remember, we are sitting in a committee that consists mostly of medical professionals, caregivers. The very fact that healthcare and medical professionals need to give up treatment and prioritise to patient autonomy is difficult. (Michal, Committee Chair)

In the committee, there are disagreements about how much to respect the patient’s autonomy when they refuse life-saving treatment. (Meir, physician)

Evaluating urgency and severity of the condition

At the same time, the participants described how there are situations where the medical team and the committee evaluate the urgency and severity of the specific case, especially when a patient refuses life-saving treatment or lacks decision-making capacity. In this context, the committee members assess the degree of severity that will occur if the required treatment will not be performed and the urgency of its required implementation, where the impact of non-intervention is a significant factor in decision-making.

The need for quick decisions is expressed in the fact that committee members may be called upon to decide during emergencies, thereby presenting additional challenges to the medical teams in evaluating ethical considerations within time constraints. An example that emerged in our study relates to hunger strikes. This case illustrates the difficulty in making decisions in situations where the reason for refusing treatment is not medical but ideological. This case also raises the following question: is there room to take into account political or ideological considerations in medical decisions?

On occasion committee members need to assess whether the patient’s explicit wish truly represents their real wish, in other words whether it is based on full understanding of their condition and its implications. This is a particularly complex ethical consideration, as it concerns the distinction between respecting the patient’s autonomy and protecting the patient from decisions that are not necessarily in their best interest.

When it comes to a hunger striker, then we are in a different problem, he doesn’t want treatment not because he doesn’t want the treatment itself, but to convey an ideological statement. Should we as doctors consider this? (Michal, Committee Chair)

We need to remember that even when talking about forced treatment, we also need to talk about what treatment we’re referring to, what is forced treatment? (Michal, Committee Chair)

Sometimes the consideration is whether the patient’s free will is truly their real wish, and this is a very delicate judgment. (Michal, Committee Chair)

Additional ethical principles in the decision-making process

One of the central challenges arising from the ethical dilemmas described concerns the need to balance different ethical principles. In addition to the principles discussed above, the committee needs to balance various ethical principles, including the patient’s welfare, principles of non-maleficence (Do No Harm), justice and legal considerations. According to one participant, “the teams strive to check what is actually in the patient’s best interest, how we reduce the harm that can be caused to them, and what the patient would want to happen.” These words demonstrate the search for balance between the objective welfare of the patient (as understood by the treating physician) and their subjective welfare (as understood by the committee members’ perception).

The ethical discussion takes place within a complex framework of principles that usually do not align with each other. The need to reach an agreed upon position leads committee members, according to another participant, “to reach a position that is as agreed upon as possible, not to make drastic decisions but to try to integrate much information and many considerations.”

However, some participants feel that in practice, the committee often operates according to legal considerations more than according to ethical principles. This indicates an additional tension between the legal framework, which provides clear boundaries for decisions, and medical ethics, which may require a softer approach tailored to each individual case. This internal struggle, most probably shaped by the legal regulation of the committee, reflects a great challenge of making medical-ethical decisions in the healthcare system through a committee that is regulated and subject to the Patient’s Rights Law.

We always check what is actually in the patient’s best interest, how we reduce the harm that can be caused to them, and what the patient would want to happen…In our committees, we don’t always define it explicitly, but ultimately it’s a balance between the patient’s welfare, autonomy, do no harm, and principles of justice. (Haya, Committee Chair)

We try to reach a position that is as agreed upon as possible, and not to make drastic decisions, but to try to integrate much information and many considerations. (Michal, Committee Chair)

Theme 5: committee’s relationships with various entities, and the limitations of its operation

Committee’s relationships with various entities

HECs operate within a complex network of relationships with various entities, both within and outside the hospital, including hospital leadership, healthcare professionals, patients and their families, additional ethics committees, and the Ministry of Health. Each of these relationships shapes the committee’s functioning and effectiveness in making ethical decisions.

Relationship with the hospital leadership

Our study shows that the committee’s relationship with hospital leadership is characterized by relative independence granted to the committee, where the hospital leadership typically does not actively intervene in its discussions, but sometimes keeps ‘a finger on the pulse’ regarding its activities through appointing its representatives in the committee, such as legal advisors or management members who sometimes serve as committee members or are involved in its background operations. The participants emphasize that although, in general, there is no direct intervention or attempt to shape committee decisions by the hospital leadership, its presence in some of the committees creates a dynamic of consultation that can shape committee decisions. In any case, it is emphasized in the interviews that the relationships with the hospital leadership appear minimal, and sometimes even merely formal.Our study endence granted to the committee, where the hospital leadership typically does not actively intervene in its discussions, but sometimes keeps ‘a finger on the pulse’ regarding its activities through appointing its representatives in the committee, such as legal advisor ommittee members or are involved in its background operations. The participants emphasize that although, in general, there is no direct intervention or attempt to shape committee decisions by the hospital leadership, its presence in some of the committees creates a dynamic of consultation that can shape committee decisions. In any case, it is emphasized in the interviews that the relationships with the hospital leadership appear minimal, and sometimes even merely formal.

Although the hospital’s legal advisor is a committee member, and that way there’s, you know, a finger on the pulse from the management’s perspective on, generally, the committee’s operations. But again, never at the level of… you know, active involvement or setting boundaries or restricting the committee’s discussions, never. (Haya, Committee Chair)

They don’t talk to me about the committee, and I don’t talk to them about the committee. Beyond that, I ask them to schedule the committee meetings once every four months, that I do ask them. (Aharon, Committee Chair)

Relationship with healthcare professionals

The committee’s relationship with healthcare professionals is described as a positive one, whereby the committee is not perceived by the healthcare teams as obstructing or coercive, but rather as a helpful body supporting the medical teams in dealing with complex ethical dilemmas. The healthcare professionals also recognize that the Ethics Committee sometimes even serves as a formal framework documenting tough decisions and, as such eases the professionals’ burden and responsibility. In this sense, the committee serves as an additional working tool for the healthcare teams, helping them make difficult decisions while providing legitimacy for complex ethical processes.

The team looks at the committee as a tool and that’s perfectly fine. No one sees us as an interfering factor or as a foreign factor in the hospital or, at least in my perception, …they look at the committee as another tool that must cope with the work. (Haya, Committee Chair)

The teams want this coverage of the case, this recording of the ethics committee that says such and such. ….an ethics committee can only contribute to the process of treating issues that bother teams and also truly gives backing, …for teams that work, help and assist in decision-making, that rely on. (Rotem, nurse)

Relationship with patients

According to participants, the relationship with patients is characterized by the fact that the committee, being external to the treatment process, manages to create understandings with patients regarding the required treatment, and even become a persuasive factor for providing treatment. However, the interviews reveal some difficulty with patients suffering from psychiatric illnesses, who sometimes do not distinguish between the different roles of committee members. This makes it difficult for the committee to reach an understanding with them, although they admit that it may indirectly and inadvertently positively affect their decision-making.

We come from outside, we are not biased, we want to hear from you what weighs on you, what your insights are, what your wishes are. Some accept it and some don’t. There are patients, especially psychiatric patients, who don’t quite understand people on the committee, whether it’s the doctors or other doctors or a social worker or a psychologist or a rabbi. It’s all one unit, and we don’t always have, we manage to create a relationship of understanding with the patients. (Avraham, physician)

The very fact that the committee meets and the very fact that the committee comes to the patient, the fact that he (the patient) sees a group of high-ranking people around him changes his decisions. It’s also strange to think about it, but it’s also a therapeutic event for the patient. He understands that he is important to someone… the very fact that the committee convenes and comes to him already many times completely changes his view of the situation. (Omer, physician)

Relationship with other ethics committees

The study revealed additional connections between the committee and entities outside the hospital. One focus that emerged in the interviews concerns the relationship between different ethics committees in different hospitals. The study clearly shows that the connection with other ethics committees is not sufficiently developed, even though it is perceived as very important for knowledge sharing and mutual consultation. Thus, several participants emphasize the need for meetings among different ethical committees (possibly coordinated by the Ministry of Health, which is legally responsible for the committees), where committee chairs could share experiences, present cases, and learn from each other. Although such a collaboration has not yet been realized in practice, the participants emphasize that such a proposal reflects a recognition that ethical dilemmas are not unique to a specific hospital, and that connections between committees can contribute to enhancing the professional level of ethical decisions.

I think an interface with other ethics committees in other hospitals must be something with significant value. (Ofra, Committee Chair)

They need to establish a national meeting of the committees that, maybe not the whole committee but part of the committee, but clearly the chairs. That is, each of the chairs should tell how it works for them, give examples of cases brought before the committee so we can learn from each other and enrich our knowledge from each other. Unfortunately, this has not happened yet. (Aharon, Committee Chair)

If meetings were held where, like today, you are interviewing me, at each meeting there would be an exchange of opinions and telling about cases and coping and consulting together, I think all ethics committees would benefit from this. (Haim, Committee Chair)

In addition, regardless of such formal collaboration, some of the chairs interviewed shared that they consult with other committee chairs informally, usually regarding legal aspects relating to the committee’s work:

We consult between legal advisors frequently, but not as ethics committees. There is no official forum where ethics committees in hospitals can meet and exchange information. (Boaz, Committee Chair)

Limitations of committee work

Against the committee’s complex system of relationships and professional networks, several limitations of its functioning emerge from this study. One limitation that was discussed in the interviews is related to the fact that the committee operates within the boundaries of the law, so that the discretion exercised by its members is limited to the narrow confines of the law. In practice, there is a noticeable gap between the situations that come before the committees and the areas of expertise and authorities through which they may act.

We feel committed both legally and ethically to take all measures to respect the patient’s wishes. His right, according to the Patient’s Rights Law, over his body, over his fate. This is basically the framework imposed on us and within this law we try to do what’s best in this matter. (Yosef, Committee Chair)

Experience from other hospitals has shown that also from a practical perspective there are issues that don’t fall under the statutory provisions of the law, but the hospital can benefit from having a body that thinks about it. (Michal, Committee Chair)

The law is very limited. It requires us to make a decision in very, very specific situations, but in practice there are many more ethical dilemmas in the daily routine of doctors, nurses and medical teams. (Michal, Committee Chair)

Another limitation is related to the process by which decisions are made in the committee. According to some of the interviews, sometimes the committee is approached after the issue has been discussed within the relevant medical department, and referral to the committee is made only as a formal requirement without the ability to contribute in practice or shape clinical decision making.

Sometimes the committee is just a formal framework for a process that already takes place in the departments themselves, and most decisions are made there in advance. (Haya, Committee Chair)

Discussion

The study explored the varied ways through which HECs in Israel operate and make decisions through the lens of the living experiences of HECs’ Chairs and members. As described in the Findings section, the study demonstrates how dedicated Ethics Committee members serve to protect and enhance patients’ rights, while also balancing healthcare professionals’ interests and responsibilities, and other organizational and legal aspects shaping the committee’s decisions.

The existing literature describes HECs as having many functions [9–11, 47]. However, in our study, their decision-making tasks were more evident than their other consultation and educational responsibilities. This finding was also echoed in the members’ perceptions of the committee as a quasi-judicial entity with decisive authority. These data may be explained by the exceptional legal regulation of HECs in Israel, confirming their legalistic status [24]. As this study shows, the law-ethics mix in the case of HECs in Israel also shapes members’ decision-making processes and considerations, at times also leading to confusion or a defensive mode of acting, limiting the committees’ work in general. Thus, this study illustrates how HECs uphold the patients’ rights by considering whether and how to intervene in refusal decisions or actions to save the lives of special populations, such as prisoners, thereby serving as institutional means through which bioethical issues promote the legal conception of patients’ rights [47].

Our findings highlight the unique role of HECs as enhancing multi-professional ethical decision-making in the healthcare institution. The interviews further reveal that the physicians’ practical experience contributes to the medical implications of the decisions to be made, nurses add a practical perspective to the discussion, and the members with legal background, usually the chairs, ensure that decisions comply with the law. The complex and unspoken ways through which various professions negotiate their expertise and authority can be supported by Abbott’s Systems of Professions Theory (1988) [48], as well as other empirical findings [49] emphasizing “workplace assimilation” by which professional boundaries are fuzzy and blur thereby increasing members’ agency and competence with HECs. Yet, in line with more recent studies [50, 51], our findings also show how members with different professional backgrounds compete, construct and expand their own boundaries to achieve more control in the decision-making process, thereby a broader and more comprehensive view of inter-professional work exercising ethical decision making in healthcare settings.

The findings of this study also reveal and emphasize the complex relationships between committee members and hospital leadership. As described in the Findings, the interviews reveal that committee members try and succeed in detaching themselves from the hospital management, seeking much discretional autonomy and independence. This description is puzzling because HECs depend heavily on management’s goodwill for their operations, composition, and resources. However, such independence is ethically desirable as it ensures committees make decisions based primarily on professional and ethical considerations rather than administrative pressures. Given the lack of data on how well committee may function and the little effort that has been made to evaluate such committees, one would have expected more interest and involvement on behalf of the hospital leadership. This is because hospital administrators typically monitor and assess other institutional committees through regular performance reviews, outcome metrics etc. The absence of such managerial influence in this case suggests either a lack of recognition of ethics committees’ potential value or uncertainty about how to effectively oversee bodies designed to maintain independence from administrative influence.

Recently, a proposal to replace HECs with professional clinical ethicists when the first fall below the threshold of effectiveness has been made. This proposal stems from accumulating criticism against HECs, focusing on two major challenges to maintaining a high-functioning Ethics Committee: first, committee members are insufficiently trained to engage in clinical ethics consultation and other related ethics work; and second, volunteer committee members lack time and availability to perform their work, prioritizing their main institutional or professional roles [51]. While such a proposal is still controversial [52–54], it should be examined in light of empirical data, as those presented in our study, suggesting that hospital leadership may hesitate to make this move.

Furthermore, our interviews show positive although somehow instrumental relationships between the committees and the healthcare teams, with the latter using the committees to safeguard themselves or otherwise ease their burden and sense of responsibility when providing care in tough situations. This finding is in line with other findings, although rare, acknowledging the therapeutic role of HECs in providing emotional support and reassurance to healthcare professionals carrying out psychologically difficult actions [55].

Our study reports on more promising relationships between committees and patients: although only through short descriptions, our interviews explore committee members’ perceptions according to which the committee’s work provides patients with the feeling that they are heard, that their interests are protected, and that the deliberation and re-consideration of their decisions are legitimate. Although not supported by more direct means such as patients’ surveys or interviews, these findings are encouraging, as one of the major criticisms against HECs is that they mainly serve as consultants for healthcare professionals and not for patients or their families, and that patients are rarely informed of them [38, 39, 56]. Recent studies also show that patient participation in clinical ethics consultations are required for its contribution to cultivating the quality of decision making, improving the understanding of patients and their perspectives, and enhancing the collaboration among all parties involved in medical treatment [57]. Considering our findings, further studies are required to examine the perspectives and experiences of patients in their interactions with HECs in Israel.

A unique aspect highlighted in this study refers to committee members’ interest in forming collaborative work with other Ethics Committees coordinated by the Ministry of Health. Such an approach reflects not only the collective sharing of ethical knowledge, but may also pave the way for fairer and more accountable actions taken by the committees. Indeed, one of the challenges HECs face stems from their focus on individual cases as understood in the context of a specific medical institution [2, 58]. Such a challenge is especially acute, as these committees lack unified formation, criteria for decision making, transparency or monitoring. Applying the proposal set in this study may not only strengthen committees’ legitimacy in making decisions, but can also help them better construct policy in related areas, supported by broader experience.

According to our study, three major issues are being discussed in HECs: patients’ refusal of medical treatment, making medical decisions for incompetent patients, and providing enforced care of prisoners or other special populations. The central among these concerns cases where the patient’s autonomy may be violated or overruled by the required medical procedure. The most severe cases include hunger strikes involving delicate questions of whether, and to what extent, medical doctors and HEC members should consider political or ideological considerations at the base of the patient’s decision to refuse treatment. While such a question creates much ethical controversy and requires further development which is outside the scope of this article, one can argue that if one accepts that HECs are authorized and qualified to develop policy on various issues with ethical aspects or to advocate for a specific policy – a contested issue in itself [58, 59], there is no prima facie reason to exclude the consideration of these matters from HECs’ decision-making processes. Common to all these issues is a principlist approach to decision-making. Indeed, and except of the indirect description of the ways that nurses’ mange ethical dilemmas in the committees, our study did not explore other approaches that could comeplement or replace the principlist approach for example, casuistry, narrative, feminist, phenomenological, etc [47, 60, 61]. The fact that Israeli RECs are legally mandated and chaired by lawyers may explain why their decision-making approach emphasizes principlism, supported by procedural compliance and systematic protocols rather than adopting more flexible methodologies that prioritize contextual and experiential considerations.

Our study acknowledges the importance of the training and gaining of new knowledge in medical ethics required for the committee’s work on the one hand, but without making it mandatory on the other. In this sense, participants’ views preserve and perpetuate the status quo of not requiring such training, leaving members to seek training on an individual basis. Furthermore, as shown in our study, some of the committee members, especially the medical doctors, do not think training is necessary at all, as issues are resolved through the joint discussion of all committee members. Indeed, lack of training is supported by recent data, suggesting that HEC members lack sufficient knowledge, skills and experience to meet their required competencies [62]. Such a phenomenon raises much criticism especially given the wide range in the work performed today by HECs [11]. Thus, it seems that the issue of training requires a deeper look and a more systematic approach than has been given to it thus far.

Conclusions

This study reveals that HECs in Israel primarily function as quasi-judicial decision-making bodies, shaped significantly by a unique legal framework. While this regulatory structure grants them formal authority and legitimacy, it also imposes limitations on their ethical flexibility. The committees operate within a strong sense of institutional independence, yet often in the absence of meaningful involvement from hospital leadership. Moreover, their relationships with healthcare professionals tend to be instrumental, while patient involvement, though limited, shows encouraging potential for enhancing ethical deliberation.

A major challenge identified is the lack of mandatory ethics training for committee members, which hinders their ability to effectively address complex ethical dilemmas. Future research should further explore patients’ and families’ experiences with HECs, evaluate the committees’ clinical and ethical effectiveness, and examine alternative models, such as professional clinical ethicists. In addition, there is a need to investigate mechanisms for standardized training and cross-institutional collaboration, which may enhance consistency, transparency and ethical quality in committee practices.

Authors’ contributions

**DS** and **GY** have made substantial contributions to the research conception; **DS** and **ID** have designed the study; **DS** and **GY** have collected, analysed and interpreted the data; **DS** and **GY** have drafted the paper, and **all authors** have substantively revised it.

Funding

The study was funded by the Faculty of Social Welfare and Health Sciences at the University of Haifa.

Data availability

The datasets generated and/or analysed during the current study are not publicly available, as they are private and have been obtained through in-depth interviews, but they are available from the corresponding author anonymously upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the Research Ethics Committee of the Faculty of Social Welfare and Health Sciences (Approval no. 494/21, dated 2 December 2021), and was performed in accordance with the Helsinki Declaration.

Consent for publication

N/A.

Competing interests

The authors declare no competing interests.