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The OMA and the Canada Health Act.

clinical deliberations prior to the final decision. A good proportion of the committees dealt with both research ethics and clinical ethics. Many people were simultaneously members of various ethics committees. Often neither research ethics nor clinical ethics committees met for discussions but, instead, were managed by circulation of files to the members for expedited review. The only committee we found in all the teaching hospitals was the research ethics committee. Prospective review of clinical ethics took place most frequently in consultation between staff members in the small teaching hospitals or in a variety of ad hoc committees that often functioned on a departmental level in the larger hospitals. At present several of the hospitals have a residue of difficult cases, such as those involving sterilization or medical treatment of minors, defective newborns and pregnant women. Some interviewees suggested that institutional ethics committees could provide solutions in such cases. These committees would be above all other hospital committees and would deal with questions raised by them. The larger teaching hospitals were organizing such institutional ethics committees. It was suggested that in the case of smaller or outlying hospitals a regional committee could oversee questions pertinent to clinical ethics within several hospitals in the region. Institutional ethics committees were seen variously as (a) playing an advisory role only, (b) being a forum for arbitration in cases of conflict between decisions made by the committee and decisions made by the executive of the hospital or between decisions of the committee and the wishes of the patients themselves, or (c) making mandatory and binding decisions. Further investigation of both the legal and ethical implications of hospital committees and their decisions is needed. Too much is at stake in ethical decision-making to leave it to fortuitous and unknown local initiatives. Though current practice of institutional ethics must be applauded, much is to be gained through knowledge of what other similar committees do. It is imperative that we better understand what these committees are currently doing and what they might be called on to do tomorrow.