Hospital Ethics Committees: Responsibilities, Competencies and Challenges

Hospital Ethics Committees: Responsibilities, Competencies and Challenges | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Hospital Ethics Committees: Responsibilities, Competencies and Challenges Daniel Sperling, Israel (Issi) Doron, Gila Yakov This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7225178/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Jan, 2026 Read the published version in BMC Medical Ethics → Version 1 posted 10 You are reading this latest preprint version 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 Perception of committee role; ( 2 ) Committee composition, member characteristics and ethics training; ( 3 ) Common ethical issues discussed in the Ethics Committee; ( 4 ) Committee’s manner of operation; 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. 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 ). Developed at the same time as the flourishing of bioethics and ethics consultation ( 2 ), HECs have been established since the 1970s, 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. This mandate has been further verified in a subsequent Presidential Commission report in 1983 ( 3 , 4 ), and as of 1992, the establishment of HECs 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 ( 2 ). 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 ( 5 ). Other than providing ethical counselling, HECs’ additional functions include establishing institutional ethical policy and educating all members of the medical institution on issues related to medical ethics, including advocating for the implementation of ethical principles in care providers’ interactions with patients and their families ( 6 – 8 ). Members of HECs 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. Their overarching goals are to protect patients’ rights, safety and wellbeing, and to support the healthcare staff, patients and their families ( 9 ). 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 ( 10 ). Other contributions of HECs’ activities involve policy development and scrutiny of the medical decision making process ( 11 ), as well as increasing the overall use of ethical guidelines in medical institutions ( 12 ). When combined with adequate composition, transparent procedures and targeted training ( 13 ), and supported by sufficient resources ( 14 , 15 ), HECs’ ethical deliberations could be extremely useful. 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 Europe they were regarded as democratic forums within medical institutions, offering a space to think of new challenges in medical practice ( 16 ). 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 ( 17 ), 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 ( 6 ). As quasi-judicial committees, HECs in Israel are comprised of professionals from different backgrounds including law, medicine social work or psychology, in addition to a public or religious representative. An extended approach demands of these members to be skilled not only in ethics, but also in communication, interpersonal relationships and conflict management ( 18 ). Typical issues included in HECs' responsibilities include 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 ( 19 ). An additional and extremely controversial role of HECs in Israel authorized under Section 15( 2 ) of the Act, is enforcing medical treatment contrary to specific objections of a competent patient ( 20 ). 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 ( 21 ). 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 ( 22 ). Anecdotal evidence published nine years later suggested that nothing has changed ( 23 ). 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 ( 24 ). 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 ( 25 ), especially by medical doctors who feel these committees are of limited use ( 26 ), or do not like to be interfered with in what they regard as their primary domain ( 27 ), usually under poor inter- and intra-professional communication settings ( 28 ). 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 ( 29 ), as well as questioning the competencies of committee members ( 30 , 31 ). 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 ( 32 ), and to HECs' involvement in issues of legal liability ( 33 ). Overall, these findings suggest that HECs ’fail to thrive’, struggling with their purpose and meaning ( 34 ). Despite their significance and legal status, the structure, scope of activities and mandate of HECs in Israel remain unclear ( 23 ). 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 ( 35 ). 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 Section 15( 2 ) by HECs, authorizing a regulated violation of patient autonomy ( 36 ). While some improvement has been made as a result of a Ministry of Health special committee which followed the State Comptroller’s report ( 37 ), and the publication of new guidelines published in 2018 ( 38 ), 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 ( 39 ). 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? Research Population, Sampling and Sample 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’ ( 40 ). The Interview Guide The interview guide was developed specifically for this study, based on the relevant literature, and contains eight sections. The first section includes biographical questions. The second section refers to the way participants view the HEC and their contribution to it. Sample questions include “How do you regard the HEC?”, and “Tell me about your role in the committee”. The third section relates to the way participants describe and understand the HEC’s structure and functions. Sample questions include “Which typical ethical issues are discussed in the committee?”, and “How often does the committee meet?”. The fourth section includes questions concerning the decision-making processes pursued by HEC members, Sample questions include “Tell me about a complex decision you had to make in the committee”, and “How are disagreements among HEC members managed?”. The fifth section of the guide relates to participants’ attitudes and perceptions, referring to more concrete issues related to the HEC, such as the questions “What are the disadvantages related to the existence or work of HECs?”, and “What is the unique contribution of HECs?”. The sixth section concerns the relationships between HEC members and external bodies/entities, such as clinicians, patients and their families, hospital management and the Ministry of Health. Sample questions include “How is the HEC regarded in the hospital?”, and “How would you characterize the relationship between the committee and clinicians in the hospital?”. The seventh section relates to training of HEC members and their required competencies. Sample questions include “What in your biography makes you qualify to serve as a committee member?”, and “How should committee members be trained, in your opinion?”. The last part of the interview guide explores issues that have been raised by the researchers and that participants have thought about during the interview, or to questions that participants would like to ask the researcher following the interview. 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 ( 41 ). 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 minutes. As per participants’ choice, 12 interviews took place via Zoom and one in person. Interviews were recorded and transcribed. Data Analysis Employing IPA methodology ( 42 ), we conducted repeated comprehensive readings of interview transcripts while highlighting and engaging with meaningful participant responses. These preliminary observations 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 ( 43 ), 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 to help us 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. Perception of committee role 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 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 manner of operation 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: Perception of committee role 1.1. Decisive body in complex ethical dilemmas The interviews reveal that Ethics Committees fulfill a central role in resolving complex ethical dilemmas, as described by Linda: 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) The participant stressed that the committee serves not only as an institution with decisive authority but also as an advisory body, assisting medical teams in making decisions in cases sensitive from different perspectives. For example, Omer describes: 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) Beyond this, the committee constitutes a space for multi-professional and multi-disciplinary ethical thinking, where medical professionals, legal experts, nurses and social workers jointly discuss the complexities of each case, as described by Boaz, Committee Chair: 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 . 1.2 Support mechanism for healthcare professionals Beyond its formal role in decision-making, the Ethics Committee also serves 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 2.1 Committee composition 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. They are top-tier doctors, that is, with a lot of seniority, a lot of experience, a lot of knowledge. (Yosef, Committee Chair) 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. (Avraham, physician) As a former judge, I bring a broader legal perspective to the committee regarding the legal implications of the decisions being made. (Aharon, Committee Chair). 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. (Haim, Committee Chair) The study shows that nurses’ contribution to the Ethics Committee stems from a deep understanding of the clinical and human reality “from the hospital floors”, adding a practical perspective to the discussion, grounded in direct experience with patients and staff, even without formal knowledge of legal language. 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) 2.2 Members' characteristics Participants explore the view 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. This usually does not contradict what we hear from the treating physicians, but 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. Sensitivity is 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). 2.3 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. It’s worthwhile for all Ethics Committee members in their free time in one way or another to take this course. 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) If I wanted, I learned some of these things, but 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 Participants raised three major ethical issues that are common in committee discussions. These are discussed below. 3.1. 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. 3.2. 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. 3.3. Medical treatment of prisoners and special populations A third issue that emerged 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 manner of operation 4.1 Committee decision-making process 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. A. 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) B. 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. At some point in the discussion we reach an agreement. (Linda, social worker) 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) 4.2 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 enables balanced and fair decisions that are ethically and legally justified. A. 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) I think we try to keep saying this to ourselves all the time, so that the discussion framework reaches this place. (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) B. 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) C. 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) Sometimes there is a feeling that the committee operates more according to the law and less according to ethical principles, and this is an internal struggle that we need to deal with. (Avraham, physician) Theme 5: Committee’s relationships with various entities, and the limitations of its operation 5.1 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. A. 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, 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) B. 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. In our days, I think that even if sometimes it wasn't necessarily the most desired thing in the world, an ethics committee can only contribute to the process of treating issues that bother teams and also truly gives backing, not backing but as some kind of... yes, maybe yes backing, backing for teams that work, help and assist in decision-making, that rely on. (Rotem, nurse) C. 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 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) Here we meet them, we talk to them, we try to encourage them to talk, to remind them that they have families, they have children, true they are here and they don't know when they will be released, on the other hand they should think about the people who love them and that they love. Trying to bring them to eventually agree to receive some kind of treatment. This usually works. (Haim, Committee Chair) D. 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 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) 5.2 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 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. 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 ( 6 – 8 ). 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 ( 21 ). 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 serve as institutional means through which bioethical issues promote the legal conception of patients’ rights ( 44 ). 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. Such a description is perplexing, although ethically welcome. Given the lack of data on the committees’ effectiveness 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. 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 ( 45 ). While such a proposal is still controversial ( 46 – 48 ), it should be examined in light of empirical data, as those presented in our study, suggesting that hospital leadership may not be ready 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 ( 49 ). Our study reveals more promising relationships between committees and patients: although only through short descriptions, our interviews do demonstrate that 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. These findings are reassuring, 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 ( 35 , 36 , 50 ). 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 ( 51 ). 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 ( 52 , 53 ). 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 to develop policy on various issues with ethical aspects ( 53 , 54 ), there is no prima facie reason to exclude the consideration of these matters from HECs’ decision-making processes. 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 ( 55 ). 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. 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 Availability of data and materials 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. Competing interests The authors declare that they have no competing interests. Funding The study was funded by the Faculty of Social Welfare and Health Sciences at the University of Haifa. 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. Acknowledgements We would like to acknowledge Dr. Galia Golan Sprinzak’s assistance with the data analysis. Clinical Trial Number Not applicable. References Fuscaldo G, Cadwell M, Wallis K, Fry L, Rogers M. Developing clinical ethics support for an Australian Health Service: A survey of clinician’s experiences and views. AJOB Empir Bioeth. 2019;10(1). Avci E, ten Have H. Ethics Education and Institutional Ethics Committees. In 2023. p. 329–41. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forgo life-sustaining treatment: Ethical, medical and legal issues in treatment decisions. Washington, DC; 1983. Fleetwood JE, Arnold RM, Baron RJ. Giving answers or raising questions?: The problematic role of institutional ethics committees. J Med Ethics. 1989;15(3). Bloom JR, Sindhu KK. Time to evolve? Modernizing the hospital ethics committee. J Hosp Med. 2025 May 14; Grunfeld G. Ethics committees in medical institutions. In: Cohen-Almagor R, editor. Moral dilemmas in medicine. Tel Aviv: Hakibbutz Hameuchad Publishing House; 2002. p. 88–104. Post L, Blustein J. Handbook for Health Care Ethics Committees. 3rd ed. Johns Hopkins University Press; 2021. Moon M, Macauley RC, Geis GM, Laventhal NT, Opel DJ, Sexson WR, et al. Institutional Ethics Committees. Pediatrics. 2019 May 1;143(5). Rasoal D, Skovdahl K, Gifford M, Kihlgren A. Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review. HEC Forum. 2017 Dec 9;29(4):313–46. Crico C, Sanchini V, Casali PG, Pravettoni G. Evaluating the effectiveness of clinical ethics committees: a systematic review. Med Heal Care Philos. 2021 Mar 21;24(1):135–51. Civaner MM. The Effectiveness of a Hospital Ethics Committee in a Non-Western Country: Lessons from a Ten-Year Experience. Asian Bioeth Rev. 2024 Oct 12;16(4):615–34. Akabayashi A, Slingsby BT, Nagao N, Kai I, Sato H. An eight-year follow-up national study of medical school and general hospital ethics committees in Japan. BMC Med Ethics. 2007;8. Pedersen R, Akre V, Førde R. What is happening during case deliberations in clinical ethics committees? A pilot study. J Med Ethics. 2009;35(3). Førde R, Pedersen R. Clinical ethics committees in Norway: What do they do, and does it make a difference? Cambridge Q Healthc Ethics. 2011;20(3). Danis M, Fox E, Tarzian A, Duke CC. Health care ethics programs in U.S. Hospitals: results from a National Survey. BMC Med Ethics. 2021 Dec 29;22(1):107. Refolo P, Raimondi C, Sacchini D, Spagnolo AG. The New Organization of Ethics Committees in Italy: What is the Future of Clinical Ethics? J Bioeth Inq. 2025 Feb 13; Brierley J, Archard D, Cave E. Challenging misconceptions about clinical ethics support during COVID-19 and beyond: a legal update and future considerations. J Med Ethics. 2021 Aug;47(8):549–52. Akah H. Expanding the Scope of Bioethics Mediation: New Opportunities to Protect the Autonomy of Terminally Ill Patients. Ohio State J Disput Resolut. 2016;31:73–100. Scott C. Ethics consultations and conflict engagement in health care. Cardozo J Confl Resolut. 2013;15:363–423. Levinger U. Coercion of treatment and depriving the patient of information. Harefuah. 2020;159(5):360–3. Lederman Z, Essex R. Using Ethics Committees to Justify Force-Feeding Political Prisoners in Israel. Health Hum Rights. 2023;25(2). Wenger NS, Golan O, Shalev C, Glick S. Hospital ethics committees in Israel: Structure, function and heterogeneity in the setting of statutory ethics committees. J Med Ethics. 2002;28(3). Simonstein F. Hospital Ethics Commitees : Patient‘s Rights Ethics Committees in Israel and Organisational Ethics. Eubios J Asian Int Bioeth. 2011;21(3):88–90. State Comptroller. Ministry of Health: Protection of the rights of the hospitalized patient and his dignity. Annual report 65C. 2015. Borovečki A, ten Have H, Orešković S. Education of ethics committee members: experiences from Croatia. J Med Ethics. 2006 Mar;32(3):138–42. Weiss Goitiandia S, Axelrod JK, Batten JN, Dzeng E. Hospital Ethics Committees and Consultants: How Do Clinicians Perceive Their Utility in Resolving Disagreements About Life-Sustaining Treatments? Am J Bioeth. 2025 Mar 4;25(3):81–5. McLean SAM. What and who are clinical ethics committees for? J Med Ethics. 2007 Sep;33(9):497–500. Volpe RL, Benrud J, Gordon EJ, Green MJ. Perceived low-quality communication is not associated with greater frequency of requests for ethics consultation: Null findings from an empirical study. AJOB Empir Bioeth. 2016;7(4). Pope T. Multi-institutional healthcare ethics committees: The procedurally fair internal dispute resolution mechanism. Mitchell Hamline Sch Law Mitchell Hamline Open Access. 2009;31(Campbell Law Review 257). Prince A, Davis A. Navigating Professional Norms in an Interprofessional Environment: The “Practice” of Healthcare Ethics Committees. Connect Public Interes Law J . 2016;15(1):115–56. Yoon NYS, Ong YT, Yap HW, Tay KT, Lim EG, Cheong CWS, et al. Evaluating assessment tools of the quality of clinical ethics consultations: a systematic scoping review from 1992 to 2019. BMC Med Ethics. 2020 Dec 1;21(1):51. Pope TM. The Growing Power of Healthcare Ethics Committees Heightens Due Process Concerns. Cardozo J Confl Resolut . 2013;15(1):425–47. Annas G, Grodin M. Hospital ethics committees, consultants, and courts. AMA J Ethics. 2016;18(5). McCruden P, Kuczewski M. Is Organizational Ethics the Remedy for Failure to Thrive? Toward an Understanding of Mission Leadership. HEC Forum. 2006 Dec 5;18(4):342–8. Ben-Yaakov S. The Patient Rights Act: To dream big . In: Shemer J (Shuki), Ben-Yaakov S, Weiss Y, editors. The Patient’s Rights Law: The Incomplete revolution. Assuta Medical Cetners LTD; 2021. p. 31–9. Edelstein Y. Can legislated ethics committees in Israeli hospitals fulfill their goals? Med Law Bioeth. 2010;3:77–124. Fleishman T, Ezra V, Librant-Taub S, Agmon T. Activity of the Division of Medicine to promote ethics committees in the health system. Bioethics. 2020;20:28–38. Ministry of Health. Guideline 9/2018: Activity of ethics committees in health institutions. 2018. Smith JA, Osborn M. Interpretative Phenomenological Analysis. In: Doing Social Psychology Research. Wiley; 2004. p. 229–54. Patton MQ. Qualitative research and evaluation methods. Thousand Oaks. Cal Sage Publ. 2002; Lowe A, Norris AC, Farris AJ, Babbage DR. Quantifying Thematic Saturation in Qualitative Data Analysis. Field methods. 2018;30(3). Larkin M, Flowers P, Smith JA. Interpretative phenomenological analysis: theory, method and research. Sage; 2009. Stahl NA, King JR. Understanding and Using Trustworthiness in Qualitative Research. J Dev Educ. 2020;44(1). Sperling D. Law and Bioethics: A Rights-Based Relationship and Its Troubling Implications. In: Law and Bioethics: Current Legal Issues. 2008. Mabel H, Crites JS, Cunningham T V., Potter J. Reimagining Thriving Ethics Programs without Ethics Committees. Am J Bioeth. 2025 Mar 4;25(3):55–70. Danis M. The Value of Preserving Ethics Committees. Am J Bioeth. 2025 Mar 4;25(3):71–3. Cunningham T V., Potter J, Crites JS, Mabel H. An Earnest (and Unanswered) Call to Reimagine What Thriving Ethics Programs Can Look Like. Am J Bioeth. 2025 May 16;1–3. Manson D. What Can Committees Demonstrate That Professional Ethicists Can’t? Impartial Review with Adequate Due Process. Am J Bioeth. 2025 Mar 4;25(3):87–9. Chooljian DM, Hallenbeck J, Ezeji-Okoye SC, Sebesta R, Iqbal H, Kuschner WG. Emotional Support for Health Care Professionals: A Therapeutic Role for the Hospital Ethics Committee. J Soc Work End Life Palliat Care. 2016 Jul 2;12(3):277–88. Dekeuwer C, Bogaert B, Eggert N, Harpet C, Romero M. Falling on deaf ears: a qualitative study on clinical ethical committees in France. Med Heal Care Philos. 2019 Dec 30;22(4):515–29. Eijkholt M, de Snoo-Trimp J, Ligtenberg W, Molewijk B. Patient participation in Dutch ethics support: practice, ideals, challenges and recommendations—a national survey. BMC Med Ethics. 2022 Dec 22;23(1):62. Raoofi S, Arefi S, Zarnaq RK, Nayebi BA, Mousavi MSS. Challenges of hospital ethics committees: a phenomenological study. J Med Ethics Hist Med. 2021;14. Magelssen M, Bærøe K. Can clinical ethics committees be legitimate actors in bedside rationing? BMC Med Ethics. 2019 Dec 19;20(1):97. Physicians and Political Advocacy. AMA J Ethics. 2011 Oct 1;13(10):690–6. Ong YT, Yoon NYS, Yap HW, Lim EG, Tay KT, Toh YP, et al. Training clinical ethics committee members between 1992 and 2017: systematic scoping review. J Med Ethics. 2020 Jan;46(1):36–42. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Jan, 2026 Read the published version in BMC Medical Ethics → Version 1 posted Editorial decision: Revision requested 08 Sep, 2025 Reviews received at journal 02 Sep, 2025 Reviews received at journal 01 Sep, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers invited by journal 19 Aug, 2025 Editor invited by journal 13 Aug, 2025 Editor assigned by journal 12 Aug, 2025 Submission checks completed at journal 12 Aug, 2025 First submitted to journal 27 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7225178","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":503997684,"identity":"28025468-9320-4897-93b7-9d724a67715a","order_by":0,"name":"Daniel Sperling","email":"data:image/png;base64,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","orcid":"","institution":"University of Haifa","correspondingAuthor":true,"prefix":"","firstName":"Daniel","middleName":"","lastName":"Sperling","suffix":""},{"id":503997685,"identity":"faceae4b-7c72-461c-a525-9e15b69c9d3a","order_by":1,"name":"Israel (Issi) Doron","email":"","orcid":"","institution":"University of Haifa","correspondingAuthor":false,"prefix":"","firstName":"Israel","middleName":"(Issi)","lastName":"Doron","suffix":""},{"id":503997686,"identity":"d11310b5-4853-4573-a971-0268f204f90d","order_by":2,"name":"Gila Yakov","email":"","orcid":"","institution":"Max Stern Academic College of Emek Yezreel","correspondingAuthor":false,"prefix":"","firstName":"Gila","middleName":"","lastName":"Yakov","suffix":""}],"badges":[],"createdAt":"2025-07-27 08:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7225178/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7225178/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-025-01365-4","type":"published","date":"2026-01-21T15:59:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101152417,"identity":"a445811e-e736-4eb6-b8bb-38b1e4f49c50","added_by":"auto","created_at":"2026-01-26 16:11:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":782229,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7225178/v1/b29ba6ae-0f33-4282-a99c-2dda2a36cd6c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Hospital Ethics Committees: Responsibilities, Competencies and Challenges","fulltext":[{"header":"Background","content":"\u003cp\u003eInstitutional 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 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Developed at the same time as the flourishing of bioethics and ethics consultation (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), HECs have been established since the 1970s, and increasingly so following the Supreme Court of New Jersey decision in the matter of Karen Ann Quinlan, confirming HECs\u0026rsquo; authority to advise the medical team on decisions regarding cessation of life-saving treatment.\u003c/p\u003e\u003cp\u003eThis mandate has been further verified in a subsequent Presidential Commission report in 1983 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and as of 1992, the establishment of HECs 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 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). HECs\u0026rsquo; 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 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther than providing ethical counselling, HECs\u0026rsquo; additional functions include establishing institutional ethical policy and educating all members of the medical institution on issues related to medical ethics, including advocating for the implementation of ethical principles in care providers\u0026rsquo; interactions with patients and their families (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Members of HECs 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. Their overarching goals are to protect patients\u0026rsquo; rights, safety and wellbeing, and to support the healthcare staff, patients and their families (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile the level of HECs\u0026rsquo; effectiveness has not yet been fully explored, studies indicate some positive impact on stakeholders\u0026rsquo; satisfaction, change in medical treatment and decrease in the reported healthcare professionals\u0026rsquo; moral distress (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Other contributions of HECs\u0026rsquo; activities involve policy development and scrutiny of the medical decision making process (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), as well as increasing the overall use of ethical guidelines in medical institutions (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). When combined with adequate composition, transparent procedures and targeted training (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and supported by sufficient resources (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), HECs\u0026rsquo; ethical deliberations could be extremely useful.\u003c/p\u003e\u003cp\u003eHECs 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\u0026rsquo; rights movement, in Europe they were regarded as democratic forums within medical institutions, offering a space to think of new challenges in medical practice (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). 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 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), they serve as quasi-judicial committees authorized to approve, change or cancel healthcare professionals\u0026rsquo; 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 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs quasi-judicial committees, HECs in Israel are comprised of professionals from different backgrounds including law, medicine social work or psychology, in addition to a public or religious representative. An extended approach demands of these members to be skilled not only in ethics, but also in communication, interpersonal relationships and conflict management (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Typical issues included in HECs' responsibilities include 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 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAn additional and extremely controversial role of HECs in Israel authorized under Section 15(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) of the Act, is enforcing medical treatment contrary to specific objections of a competent patient (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Under this exceptional role, HECs can approve enforced treatment in circumstances of serious risk to the patient, under three conditions: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) the patient was fully provided with all necessary information; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) it is expected that the proposed treatment will significantly improve their medical condition ; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) 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 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAs 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 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Anecdotal evidence published nine years later suggested that nothing has changed (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). 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 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe data on Israeli HECs relate to findings on HECs in other countries, suggesting that their role is not well perceived in a hospital environment (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e), especially by medical doctors who feel these committees are of limited use (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), or do not like to be interfered with in what they regard as their primary domain (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), usually under poor inter- and intra-professional communication settings (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). 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 (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), as well as questioning the competencies of committee members (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). 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 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and to HECs' involvement in issues of legal liability (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Overall, these findings suggest that HECs \u0026rsquo;fail to thrive\u0026rsquo;, struggling with their purpose and meaning (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite their significance and legal status, the structure, scope of activities and mandate of HECs in Israel remain unclear (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). 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 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). 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 Section 15(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) by HECs, authorizing a regulated violation of patient autonomy (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). While some improvement has been made as a result of a Ministry of Health special committee which followed the State Comptroller\u0026rsquo;s report (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), and the publication of new guidelines published in 2018 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), 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.\u003c/p\u003e\u003cp\u003e 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.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eDesign\u003c/h2\u003e\u003cp\u003eThis 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 (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). We used IPA to answer the following research questions: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) What are the attitudes, views and perceptions of HEC members with regards to the committee\u0026rsquo;s status, roles, authority, actions and suitability to perform their roles? (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Which main challenges and difficulties do HEC members face while fulfilling their roles?\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResearch Population, Sampling and Sample\u003c/h3\u003e\n\u003cp\u003eOur research population includes HEC chairs and/or members with at least two years\u0026rsquo; 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 \u0026rsquo;information rich\u0026rsquo; (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eThe Interview Guide\u003c/h3\u003e\n\u003cp\u003eThe interview guide was developed specifically for this study, based on the relevant literature, and contains eight sections. The first section includes biographical questions. The second section refers to the way participants view the HEC and their contribution to it. Sample questions include \u0026ldquo;How do you regard the HEC?\u0026rdquo;, and \u0026ldquo;Tell me about your role in the committee\u0026rdquo;. The third section relates to the way participants describe and understand the HEC\u0026rsquo;s structure and functions. Sample questions include \u0026ldquo;Which typical ethical issues are discussed in the committee?\u0026rdquo;, and \u0026ldquo;How often does the committee meet?\u0026rdquo;. The fourth section includes questions concerning the decision-making processes pursued by HEC members, Sample questions include \u0026ldquo;Tell me about a complex decision you had to make in the committee\u0026rdquo;, and \u0026ldquo;How are disagreements among HEC members managed?\u0026rdquo;. The fifth section of the guide relates to participants\u0026rsquo; attitudes and perceptions, referring to more concrete issues related to the HEC, such as the questions \u0026ldquo;What are the disadvantages related to the existence or work of HECs?\u0026rdquo;, and \u0026ldquo;What is the unique contribution of HECs?\u0026rdquo;. The sixth section concerns the relationships between HEC members and external bodies/entities, such as clinicians, patients and their families, hospital management and the Ministry of Health. Sample questions include \u0026ldquo;How is the HEC regarded in the hospital?\u0026rdquo;, and \u0026ldquo;How would you characterize the relationship between the committee and clinicians in the hospital?\u0026rdquo;. The seventh section relates to training of HEC members and their required competencies. Sample questions include \u0026ldquo;What in your biography makes you qualify to serve as a committee member?\u0026rdquo;, and \u0026ldquo;How should committee members be trained, in your opinion?\u0026rdquo;. The last part of the interview guide explores issues that have been raised by the researchers and that participants have thought about during the interview, or to questions that participants would like to ask the researcher following the interview.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eParticipants 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 (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe 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 minutes. As per participants\u0026rsquo; choice, 12 interviews took place via Zoom and one in person. Interviews were recorded and transcribed.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eEmploying IPA methodology (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), we conducted repeated comprehensive readings of interview transcripts while highlighting and engaging with meaningful participant responses. These preliminary observations 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 (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), 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 to help us with the data analysis.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eEthical Considerations\u003c/h2\u003e\u003cp\u003eParticipants\u0026rsquo; privacy rights have been protected throughout the study, and informed consent was obtained. The study was approved by the Ethics Committee at the authors\u0026rsquo; affiliated academic institution (Approval no. 494/21, dated 2 December 2021). Throughout the article pseudonyms are used to present the participants\u0026rsquo; citations, in order to protect their privacy.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThirteen HEC members from nine hospitals were interviewed. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below provides the participants\u0026rsquo; characteristics.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants\u0026rsquo; Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePseudonym\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003cp\u003eMale/Female\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProfession (Physician/Other)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRole (Chair/Member)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eHospital (A/B/C) \u0026amp; location (North/Center/South)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaya\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLawyer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eA-North\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLinda\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSocial worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMember\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD-Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOfra\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLawyer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eE-Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYosef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLawyer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eB-North\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMichal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLawyer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eC-North\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAharon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLawyer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF-South\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoaz\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLawyer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD-Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLawyer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChair\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eG- Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAvraham\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMember\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD-Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeirav\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMember\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eH-Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMember\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eF-South\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRotem\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMember\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eD-Center\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeir\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMember\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eI-North\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe 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\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and described in much detail below.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMap of Themes and Sub-themes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-theme\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1. Perception of committee role\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.1 Decisive body in complex ethical dilemmas\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.2 Support mechanism for healthcare professionals\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e2. Committee composition, member characteristics and ethics training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.1 Committee composition\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.2 Members\u0026rsquo; characteristics\u003c/p\u003e\u003cp\u003e2.3 Training in the field of ethics\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e3. Common ethical issues discussed in the Ethics Committee\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.1 Patients who refuse medical treatment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.2 Medical decisions regarding incompetent patients\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.3 Medical treatment of prisoners and special populations\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e4. Committee\u0026rsquo;s manner of operation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.1 Committee decision-making process\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.2 Guiding principles in decision making\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e5. Committee\u0026rsquo;s relationships with various entities, and the limitations of its operation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.1 Committee\u0026rsquo;s relationships with various entities\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.2 Limitations of committee work\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 1: Perception of committee role\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003e1.1. Decisive body in complex ethical dilemmas\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe interviews reveal that Ethics Committees fulfill a central role in resolving complex ethical dilemmas, as described by Linda:\u003c/p\u003e\u003cp\u003e\u003cem\u003eThere 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.\u003c/em\u003e (Linda, social worker)\u003c/p\u003e\u003cp\u003eThe participant stressed that the committee serves not only as an institution with decisive authority but also as an advisory body, assisting medical teams in making decisions in cases sensitive from different perspectives. For example, Omer describes:\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe committee\u0026rsquo;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.\u003c/em\u003e (Omer, physician)\u003c/p\u003e\u003cp\u003eBeyond this, the committee constitutes a space for multi-professional and multi-disciplinary ethical thinking, where medical professionals, legal experts, nurses and social workers jointly discuss the complexities of each case, as described by Boaz, Committee Chair:\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe committee provides the medical team with a framework for professional ethical discussion, instead of relying only on the personal judgment of an individual caregiver\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eAdditionally, the committee oversees medical decision-making, ascertaining that they are made in an ethical manner, while protecting patient rights and balancing the patient\u0026rsquo;s personal welfare and medical and system-wide considerations. Thus, Haim describes:\u003c/p\u003e\u003cp\u003e\u003cem\u003eIn sensitive cases, the committee serves as a monitoring body that ensures decisions are made in a measured and transparent manner, while protecting patient rights.\u003c/em\u003e (Haim, Committee Chair)\u003c/p\u003e\u003cp\u003eFinally, 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:\u003c/p\u003e\u003cp\u003e\u003cem\u003eOften, the committee serves not only as a decision-maker but also as a mediator among conflicting positions \u0026ndash; among the patient, their family, and the medical team\u003c/em\u003e.\u003c/p\u003e\u003cp\u003e\u003cem\u003e1.2 Support mechanism for healthcare professionals\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Beyond its formal role in decision-making, the Ethics Committee also serves 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eIt 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.\u003c/em\u003e (Linda, social worker)\u003c/p\u003e\u003cp\u003e\u003cem\u003eMany times, it provides some kind of backing and support for the team. This is very important.\u003c/em\u003e (Meirav, physician)\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 2: Committee composition, member characteristics and ethics training\u003c/h2\u003e\u003cp\u003e\u003cem\u003e2.1 Committee composition\u003c/em\u003e\u003c/p\u003e\u003cp\u003eIn 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.\u003c/p\u003e\u003cp\u003eEthics 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\u0026rsquo; 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey are top-tier doctors, that is, with a lot of seniority, a lot of experience, a lot of knowledge.\u003c/em\u003e (Yosef, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eLet\u0026rsquo;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.\u003c/em\u003e (Avraham, physician)\u003c/p\u003e\u003cp\u003e\u003cem\u003eAs a former judge, I bring a broader legal perspective to the committee regarding the legal implications of the decisions being made.\u003c/em\u003e (Aharon, Committee Chair).\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe 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.\u003c/em\u003e (Haim, Committee Chair)\u003c/p\u003e\u003cp\u003eThe study shows that nurses\u0026rsquo; contribution to the Ethics Committee stems from a deep understanding of the clinical and human reality \u0026ldquo;from the hospital floors\u0026rdquo;, adding a practical perspective to the discussion, grounded in direct experience with patients and staff, even without formal knowledge of legal language.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEven if they don\u0026rsquo;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 \u0026mdash; from... as I call it, from the hallway, right? From the field, from the floor. From the hospital floor.\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003e2.2 Members' characteristics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eParticipants explore the view 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\u0026rsquo; narratives is empathy. Empathy emphasizes the need to be able to put oneself in the patients\u0026rsquo; shoes, listen to them and understand their feelings without being judgmental. From the participants\u0026rsquo; 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe 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. This usually does not contradict what we hear from the treating physicians, but it adds depth and insight into the patient's state of mind.\u003c/em\u003e )Avraham, physician)\u003c/p\u003e\u003cp\u003eAnother 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\u0026rsquo; extensive medical knowledge, patients and their families may hold significant insights regarding their personal and medical needs.\u003c/p\u003e\u003cp\u003eSensitivity is another central component integrating with empathy and attentiveness. This is expressed not only in understanding patients\u0026rsquo; 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.\u003c/p\u003e\u003cp\u003eMental flexibility constitutes another essential aspect in the committee\u0026rsquo;s work, given that, as participants explain, ethical issues are not reduced to a \u0026rsquo;black and white\u0026rsquo; dichotomy. The need to deal with complex situations in a \u0026rsquo;gray area\u0026rsquo; 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\u0026rsquo;s work.\u003c/p\u003e\u003cp\u003eAdditionally, professional seniority is perceived as a critical factor in the committee\u0026rsquo;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.\u003c/p\u003e\u003cp\u003eFinally, knowledge in bioethics is an important component in members\u0026rsquo; required qualities, although there seems to be no formal requirement to demonstrate such knowledge or to be trained in ethics (see below).\u003c/p\u003e\u003cp\u003e\u003cem\u003e2.3 Training in the field of ethics\u003c/em\u003e\u003c/p\u003e\u003cp\u003eEthics 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:\u003c/p\u003e\u003cp\u003e\u003cem\u003eI could have been much better as an Ethics Committee member if I took a course in ethics, but there\u0026rsquo;s no requirement to take an ethics course from any side, and I think that\u0026rsquo;s a bit of a shame. Maybe once there weren\u0026rsquo;t ethics courses, but today there are courses, so it\u0026rsquo;s worthwhile. It\u0026rsquo;s worthwhile for all Ethics Committee members in their free time in one way or another to take this course.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFormal and standardized training would contribute to the committee\u0026rsquo;s ability to operate professionally and provide optimal support to both medical teams and patients. A few participants also commented that members\u0026rsquo; 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:\u003c/p\u003e\u003cp\u003e\u003cem\u003eWell, since I am a very experienced doctor, I think this qualifies me for this role. And I haven\u0026rsquo;t taken a course in ethics, that is, there\u0026rsquo;s no training that I know of. But that\u0026rsquo;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\u003c/em\u003e. (Avraham, physician)\u003c/p\u003e\u003cp\u003e\u003cem\u003eIf I wanted, I learned some of these things, but 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.\u003c/em\u003e (Rotem, nurse)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Common ethical issues discussed in the Ethics Committee\u003c/h2\u003e\u003cp\u003eParticipants raised three major ethical issues that are common in committee discussions. These are discussed below.\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.1. Patients who refuse medical treatment\u003c/em\u003e\u003c/p\u003e\u003cp\u003eRefusal 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.2. Medical decisions regarding incompetent patients\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.3. Medical treatment of prisoners and special populations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA third issue that emerged through the participants\u0026rsquo; 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.\u003c/p\u003e\u003cp\u003e 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.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eTheme 4: Committee\u0026rsquo;s manner of operation\u003c/h2\u003e\u003cp\u003e\u003cem\u003e4.1 Committee decision-making process\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe 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.\u003c/p\u003e\u003cp\u003eA. In-depth multi-professional discussion\u003c/p\u003e\u003cp\u003eThe 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe hear the case, consider the medical, legal, social and ethical aspects, and then formulate a decision.\u003c/em\u003e (Rotem, nurse)\u003c/p\u003e\u003cp\u003e\u003cem\u003eSometimes 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.\u003c/em\u003e (Aharon, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe committee is not only required to rule, but to create a space for genuine dialogue that allows all considerations to be taken into account.\u003c/em\u003e (Meir, physician)\u003c/p\u003e\u003cp\u003eB. Desire for consensus\u003c/p\u003e\u003cp\u003eThe 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAt some point in the discussion we reach an agreement.\u003c/em\u003e (Linda, social worker)\u003c/p\u003e\u003cp\u003e\u003cem\u003eI don't remember that there was ever a vote by majority, there was always a decision.\u003c/em\u003e (Ofra, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThere are always different opinions, if only to develop the discussion... but people listen, hear each other, hear more opinions.\u003c/em\u003e (Meirav, physician)\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen disagreements exist, we try to find a solution that allows not only a decision but also mutual understanding.\u003c/em\u003e (Haim, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003e4.2 Guiding principles in decision making\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe 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 \u0026rsquo;residual\u0026rsquo; principles required for balancing the competing principles. The combination of all these enables balanced and fair decisions that are ethically and legally justified.\u003c/p\u003e\u003cp\u003eA. Respecting patient autonomy\u003c/p\u003e\u003cp\u003eThe 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 \u003cem\u003e\"feel obligated both legally and ethically\"\u003c/em\u003e 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 \u003cem\u003e\"the starting point is always the patient's autonomy,\"\u003c/em\u003e but in the same breath she notes that the committee's authority may override or limit this autonomy.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAt 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\u0026rsquo;s wishes.\u003c/em\u003e (Michal, committee Chair).\u003c/p\u003e\u003cp\u003eResearch participants describe the constant emotional need of caregivers \u003cem\u003e\"to give up treatment and prioritise patient autonomy.\"\u003c/em\u003e 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe are committed, we feel committed both legally and ethically, to take all measures to respect the patient's wishes.\u003c/em\u003e (Avraham, physician)\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe 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.\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eI think we try to keep saying this to ourselves all the time, so that the discussion framework reaches this place.\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eIn the committee, there are disagreements about how much to respect the patient's autonomy when they refuse life-saving treatment.\u003c/em\u003e (Meir, physician)\u003c/p\u003e\u003cp\u003eB. Evaluating urgency and severity of the condition\u003c/p\u003e\u003cp\u003eAt 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.\u003c/p\u003e\u003cp\u003eThe 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?\u003c/p\u003e\u003cp\u003eOn 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\u0026rsquo;s autonomy and protecting the patient from decisions that are not necessarily in their best interest.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWhen 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?\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe 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?\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eSometimes the consideration is whether the patient's free will is truly their real wish, and this is a very delicate judgment.\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e C. Additional ethical principles in the decision-making process\u003c/p\u003e\u003cp\u003e 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, \"\u003cem\u003ethe 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\u003c/em\u003e.\" 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\u0026rsquo; perception).\u003c/p\u003e\u003cp\u003e 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, \u003cem\u003e\"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.\"\u003c/em\u003e\u003c/p\u003e\u003cp\u003e 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003e 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\u0026hellip;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.\u003c/em\u003e (Haya, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe 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.\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003e Sometimes there is a feeling that the committee operates more according to the law and less according to ethical principles, and this is an internal struggle that we need to deal with.\u003c/em\u003e (Avraham, physician)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eTheme 5: Committee\u0026rsquo;s relationships with various entities, and the limitations of its operation\u003c/h2\u003e\u003cp\u003e\u003cem\u003e5.1 Committee\u0026rsquo;s relationships with various entities\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHECs 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.\u003c/p\u003e\u003cp\u003eA. Relationship with the hospital leadership\u003c/p\u003e\u003cp\u003eOur study shows that the committee\u0026rsquo;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 \u0026lsquo;a finger on the pulse\u0026rsquo; 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, the relationships with the hospital leadership appear minimal, and sometimes even merely formal.\u003c/p\u003e\u003cp\u003e\u003cem\u003eAlthough 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.\u003c/em\u003e (Haya, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey 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.\u003c/em\u003e (Aharon, Committee Chair)\u003c/p\u003e\u003cp\u003eB. Relationship with healthcare professionals\u003c/p\u003e\u003cp\u003eThe 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\u0026rsquo; 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe 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.\u003c/em\u003e (Haya, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe teams want this coverage of the case, this recording of the ethics committee that says such and such. In our days, I think that even if sometimes it wasn't necessarily the most desired thing in the world, an ethics committee can only contribute to the process of treating issues that bother teams and also truly gives backing, not backing but as some kind of... yes, maybe yes backing, backing for teams that work, help and assist in decision-making, that rely on.\u003c/em\u003e (Rotem, nurse)\u003c/p\u003e\u003cp\u003eC. Relationship with patients\u003c/p\u003e\u003cp\u003e 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 it may indirectly and inadvertently positively affect their decision-making.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe 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.\u003c/em\u003e (Avraham, physician)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe 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\u003c/em\u003e. (Omer, physician)\u003c/p\u003e\u003cp\u003e\u003cem\u003eHere we meet them, we talk to them, we try to encourage them to talk, to remind them that they have families, they have children, true they are here and they don't know when they will be released, on the other hand they should think about the people who love them and that they love. Trying to bring them to eventually agree to receive some kind of treatment. This usually works.\u003c/em\u003e (Haim, Committee Chair)\u003c/p\u003e\u003cp\u003eD. Relationship with other ethics committees\u003c/p\u003e\u003cp\u003eThe 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 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI think an interface with other ethics committees in other hospitals must be something with significant value.\u003c/em\u003e (Ofra, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey 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\u003c/em\u003e. (Aharon, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003e 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.\u003c/em\u003e (Haim, Committee Chair)\u003c/p\u003e\u003cp\u003eIn 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:\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe 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.\u003c/em\u003e (Boaz, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003e5.2 Limitations of committee work\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAgainst the committee\u0026rsquo;s complex system of relationships and professional networks, several limitations of its functioning emerge from this study. One limitation 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe 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.\u003c/em\u003e (Yosef, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eExperience 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.\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe 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.\u003c/em\u003e (Michal, Committee Chair)\u003c/p\u003e\u003cp\u003eAnother limitation is related to the process by which decisions are made in the committee. 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.\u003c/p\u003e\u003cp\u003e\u003cem\u003eSometimes 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.\u003c/em\u003e (Haya, Committee Chair)\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe study explored the varied ways through which HECs in Israel operate and make decisions through the lens of the living experiences of HECs\u0026rsquo; Chairs and members. As described in the Findings section, the study demonstrates how dedicated Ethics Committee members serve to protect and enhance patients\u0026rsquo; rights, while also balancing healthcare professionals\u0026rsquo; interests and responsibilities, and other organizational and legal aspects shaping the committee\u0026rsquo;s decisions.\u003c/p\u003e\u003cp\u003eThe existing literature describes HECs as having many functions (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). 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\u0026rsquo; 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 (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). As this study shows, the law-ethics mix in the case of HECs in Israel also shapes members\u0026rsquo; decision-making processes and considerations, at times also leading to confusion or a defensive mode of acting, limiting the committees\u0026rsquo; work in general. Thus, this study illustrates how HECs serve as institutional means through which bioethical issues promote the legal conception of patients\u0026rsquo; rights (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e 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. Such a description is perplexing, although ethically welcome. Given the lack of data on the committees\u0026rsquo; effectiveness 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.\u003c/p\u003e\u003cp\u003eRecently, 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 (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). While such a proposal is still controversial (\u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), it should be examined in light of empirical data, as those presented in our study, suggesting that hospital leadership may not be ready to make this move.\u003c/p\u003e\u003cp\u003eFurthermore, 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 (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur study reveals more promising relationships between committees and patients: although only through short descriptions, our interviews do demonstrate that the committee\u0026rsquo;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. These findings are reassuring, 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 (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). 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 (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Considering our findings, further studies are required to examine the perspectives and experiences of patients in their interactions with HECs in Israel.\u003c/p\u003e\u003cp\u003eA unique aspect highlighted in this study refers to committee members\u0026rsquo; 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 (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). 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\u0026rsquo; legitimacy in making decisions, but can also help them better construct policy in related areas, supported by broader experience.\u003c/p\u003e\u003cp\u003eAccording to our study, three major issues are being discussed in HECs: patients\u0026rsquo; 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\u0026rsquo;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\u0026rsquo;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 to develop policy on various issues with ethical aspects (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), there is no prima facie reason to exclude the consideration of these matters from HECs\u0026rsquo; decision-making processes.\u003c/p\u003e\u003cp\u003eOur study acknowledges the importance of the training and gaining of new knowledge in medical ethics required for the committee\u0026rsquo;s work on the one hand, but without making it mandatory on the other. In this sense, participants\u0026rsquo; 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 (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). 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.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis 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.\u003c/p\u003e\u003cp\u003eA 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\u0026rsquo; 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.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe 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.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was funded by the Faculty of Social Welfare and Health Sciences at the University of Haifa.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDS \u003c/strong\u003eand\u003cstrong\u003e GY\u003c/strong\u003e have made substantial contributions to the research conception; \u003cstrong\u003eDS \u003c/strong\u003eand\u003cstrong\u003e ID \u003c/strong\u003ehave designed the study; \u003cstrong\u003eDS\u003c/strong\u003e and\u003cstrong\u003e GY \u003c/strong\u003ehave collected, analysed and interpreted the data; \u003cstrong\u003eDS \u003c/strong\u003eand\u003cstrong\u003e GY \u003c/strong\u003ehave drafted the paper, and \u003cstrong\u003eall authors\u003c/strong\u003e have substantively revised it.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge Dr. Galia Golan Sprinzak\u0026rsquo;s assistance with the data analysis. \u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical Trial Number\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFuscaldo G, Cadwell M, Wallis K, Fry L, Rogers M. Developing clinical ethics support for an Australian Health Service: A survey of clinician\u0026rsquo;s experiences and views. AJOB Empir Bioeth. 2019;10(1). \u003c/li\u003e\n\u003cli\u003eAvci E, ten Have H. Ethics Education and Institutional Ethics Committees. In 2023. p. 329\u0026ndash;41. \u003c/li\u003e\n\u003cli\u003ePresident\u0026rsquo;s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forgo life-sustaining treatment: Ethical, medical and legal issues in treatment decisions. Washington, DC; 1983. \u003c/li\u003e\n\u003cli\u003eFleetwood JE, Arnold RM, Baron RJ. Giving answers or raising questions?: The problematic role of institutional ethics committees. J Med Ethics. 1989;15(3). \u003c/li\u003e\n\u003cli\u003eBloom JR, Sindhu KK. Time to evolve? Modernizing the hospital ethics committee. J Hosp Med. 2025 May 14; \u003c/li\u003e\n\u003cli\u003eGrunfeld G. Ethics committees in medical institutions. In: Cohen-Almagor R, editor. Moral dilemmas in medicine. Tel Aviv: Hakibbutz Hameuchad Publishing House; 2002. p. 88\u0026ndash;104. \u003c/li\u003e\n\u003cli\u003ePost L, Blustein J. Handbook for Health Care Ethics Committees. 3rd ed. Johns Hopkins University Press; 2021. \u003c/li\u003e\n\u003cli\u003eMoon M, Macauley RC, Geis GM, Laventhal NT, Opel DJ, Sexson WR, et al. Institutional Ethics Committees. Pediatrics. 2019 May 1;143(5). \u003c/li\u003e\n\u003cli\u003eRasoal D, Skovdahl K, Gifford M, Kihlgren A. Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review. HEC Forum. 2017 Dec 9;29(4):313\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eCrico C, Sanchini V, Casali PG, Pravettoni G. Evaluating the effectiveness of clinical ethics committees: a systematic review. Med Heal Care Philos. 2021 Mar 21;24(1):135\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eCivaner MM. The Effectiveness of a Hospital Ethics Committee in a Non-Western Country: Lessons from a Ten-Year Experience. Asian Bioeth Rev. 2024 Oct 12;16(4):615\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eAkabayashi A, Slingsby BT, Nagao N, Kai I, Sato H. An eight-year follow-up national study of medical school and general hospital ethics committees in Japan. BMC Med Ethics. 2007;8. \u003c/li\u003e\n\u003cli\u003ePedersen R, Akre V, F\u0026oslash;rde R. What is happening during case deliberations in clinical ethics committees? A pilot study. J Med Ethics. 2009;35(3). \u003c/li\u003e\n\u003cli\u003eF\u0026oslash;rde R, Pedersen R. Clinical ethics committees in Norway: What do they do, and does it make a difference? Cambridge Q Healthc Ethics. 2011;20(3). \u003c/li\u003e\n\u003cli\u003eDanis M, Fox E, Tarzian A, Duke CC. Health care ethics programs in U.S. Hospitals: results from a National Survey. BMC Med Ethics. 2021 Dec 29;22(1):107. \u003c/li\u003e\n\u003cli\u003eRefolo P, Raimondi C, Sacchini D, Spagnolo AG. The New Organization of Ethics Committees in Italy: What is the Future of Clinical Ethics? J Bioeth Inq. 2025 Feb 13; \u003c/li\u003e\n\u003cli\u003eBrierley J, Archard D, Cave E. Challenging misconceptions about clinical ethics support during COVID-19 and beyond: a legal update and future considerations. J Med Ethics. 2021 Aug;47(8):549\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eAkah H. Expanding the Scope of Bioethics Mediation: New Opportunities to Protect the Autonomy of Terminally Ill Patients. Ohio State J Disput Resolut. 2016;31:73\u0026ndash;100. \u003c/li\u003e\n\u003cli\u003eScott C. Ethics consultations and conflict engagement in health care. Cardozo J Confl Resolut. 2013;15:363\u0026ndash;423. \u003c/li\u003e\n\u003cli\u003eLevinger U. Coercion of treatment and depriving the patient of information. Harefuah. 2020;159(5):360\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eLederman Z, Essex R. Using Ethics Committees to Justify Force-Feeding Political Prisoners in Israel. Health Hum Rights. 2023;25(2). \u003c/li\u003e\n\u003cli\u003eWenger NS, Golan O, Shalev C, Glick S. Hospital ethics committees in Israel: Structure, function and heterogeneity in the setting of statutory ethics committees. J Med Ethics. 2002;28(3). \u003c/li\u003e\n\u003cli\u003eSimonstein F. Hospital Ethics Commitees : Patient\u0026lsquo;s Rights Ethics Committees in Israel and Organisational Ethics. Eubios J Asian Int Bioeth. 2011;21(3):88\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eState Comptroller. Ministry of Health: Protection of the rights of the hospitalized patient and his dignity. Annual report 65C. 2015. \u003c/li\u003e\n\u003cli\u003eBorovečki A, ten Have H, Ore\u0026scaron;ković S. Education of ethics committee members: experiences from Croatia. J Med Ethics. 2006 Mar;32(3):138\u0026ndash;42. \u003c/li\u003e\n\u003cli\u003eWeiss Goitiandia S, Axelrod JK, Batten JN, Dzeng E. Hospital Ethics Committees and Consultants: How Do Clinicians Perceive Their Utility in Resolving Disagreements About Life-Sustaining Treatments? Am J Bioeth. 2025 Mar 4;25(3):81\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eMcLean SAM. What and who are clinical ethics committees for? J Med Ethics. 2007 Sep;33(9):497\u0026ndash;500. \u003c/li\u003e\n\u003cli\u003eVolpe RL, Benrud J, Gordon EJ, Green MJ. Perceived low-quality communication is not associated with greater frequency of requests for ethics consultation: Null findings from an empirical study. AJOB Empir Bioeth. 2016;7(4). \u003c/li\u003e\n\u003cli\u003ePope T. Multi-institutional healthcare ethics committees: The procedurally fair internal dispute resolution mechanism. Mitchell Hamline Sch Law Mitchell Hamline Open Access. 2009;31(Campbell Law Review 257). \u003c/li\u003e\n\u003cli\u003ePrince A, Davis A. Navigating Professional Norms in an Interprofessional Environment: The \u0026ldquo;Practice\u0026rdquo; of Healthcare Ethics Committees. Connect Public Interes Law J . 2016;15(1):115\u0026ndash;56. \u003c/li\u003e\n\u003cli\u003eYoon NYS, Ong YT, Yap HW, Tay KT, Lim EG, Cheong CWS, et al. Evaluating assessment tools of the quality of clinical ethics consultations: a systematic scoping review from 1992 to 2019. BMC Med Ethics. 2020 Dec 1;21(1):51. \u003c/li\u003e\n\u003cli\u003ePope TM. The Growing Power of Healthcare Ethics Committees Heightens Due Process Concerns. Cardozo J Confl Resolut . 2013;15(1):425\u0026ndash;47. \u003c/li\u003e\n\u003cli\u003eAnnas G, Grodin M. Hospital ethics committees, consultants, and courts. AMA J Ethics. 2016;18(5). \u003c/li\u003e\n\u003cli\u003eMcCruden P, Kuczewski M. Is Organizational Ethics the Remedy for Failure to Thrive? Toward an Understanding of Mission Leadership. HEC Forum. 2006 Dec 5;18(4):342\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eBen-Yaakov S. The Patient Rights Act: To dream big . In: Shemer J (Shuki), Ben-Yaakov S, Weiss Y, editors. The Patient\u0026rsquo;s Rights Law: The Incomplete revolution. Assuta Medical Cetners LTD; 2021. p. 31\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eEdelstein Y. Can legislated ethics committees in Israeli hospitals fulfill their goals? Med Law Bioeth. 2010;3:77\u0026ndash;124. \u003c/li\u003e\n\u003cli\u003eFleishman T, Ezra V, Librant-Taub S, Agmon T. Activity of the Division of Medicine to promote ethics committees in the health system. Bioethics. 2020;20:28\u0026ndash;38. \u003c/li\u003e\n\u003cli\u003eMinistry of Health. Guideline 9/2018: Activity of ethics committees in health institutions. 2018. \u003c/li\u003e\n\u003cli\u003eSmith JA, Osborn M. Interpretative Phenomenological Analysis. In: Doing Social Psychology Research. Wiley; 2004. p. 229\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003ePatton MQ. Qualitative research and evaluation methods. Thousand Oaks. Cal Sage Publ. 2002; \u003c/li\u003e\n\u003cli\u003eLowe A, Norris AC, Farris AJ, Babbage DR. Quantifying Thematic Saturation in Qualitative Data Analysis. Field methods. 2018;30(3). \u003c/li\u003e\n\u003cli\u003eLarkin M, Flowers P, Smith JA. Interpretative phenomenological analysis: theory, method and research. Sage; 2009. \u003c/li\u003e\n\u003cli\u003eStahl NA, King JR. Understanding and Using Trustworthiness in Qualitative Research. J Dev Educ. 2020;44(1). \u003c/li\u003e\n\u003cli\u003eSperling D. Law and Bioethics: A Rights-Based Relationship and Its Troubling Implications. In: Law and Bioethics: Current Legal Issues. 2008. \u003c/li\u003e\n\u003cli\u003eMabel H, Crites JS, Cunningham T V., Potter J. Reimagining Thriving Ethics Programs without Ethics Committees. Am J Bioeth. 2025 Mar 4;25(3):55\u0026ndash;70. \u003c/li\u003e\n\u003cli\u003eDanis M. The Value of Preserving Ethics Committees. Am J Bioeth. 2025 Mar 4;25(3):71\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eCunningham T V., Potter J, Crites JS, Mabel H. An Earnest (and Unanswered) Call to Reimagine What Thriving Ethics Programs Can Look Like. Am J Bioeth. 2025 May 16;1\u0026ndash;3. \u003c/li\u003e\n\u003cli\u003eManson D. What Can Committees Demonstrate That Professional Ethicists Can\u0026rsquo;t? Impartial Review with Adequate Due Process. Am J Bioeth. 2025 Mar 4;25(3):87\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eChooljian DM, Hallenbeck J, Ezeji-Okoye SC, Sebesta R, Iqbal H, Kuschner WG. Emotional Support for Health Care Professionals: A Therapeutic Role for the Hospital Ethics Committee. J Soc Work End Life Palliat Care. 2016 Jul 2;12(3):277\u0026ndash;88. \u003c/li\u003e\n\u003cli\u003eDekeuwer C, Bogaert B, Eggert N, Harpet C, Romero M. Falling on deaf ears: a qualitative study on clinical ethical committees in France. Med Heal Care Philos. 2019 Dec 30;22(4):515\u0026ndash;29. \u003c/li\u003e\n\u003cli\u003eEijkholt M, de Snoo-Trimp J, Ligtenberg W, Molewijk B. Patient participation in Dutch ethics support: practice, ideals, challenges and recommendations\u0026mdash;a national survey. BMC Med Ethics. 2022 Dec 22;23(1):62. \u003c/li\u003e\n\u003cli\u003eRaoofi S, Arefi S, Zarnaq RK, Nayebi BA, Mousavi MSS. Challenges of hospital ethics committees: a phenomenological study. J Med Ethics Hist Med. 2021;14. \u003c/li\u003e\n\u003cli\u003eMagelssen M, B\u0026aelig;r\u0026oslash;e K. Can clinical ethics committees be legitimate actors in bedside rationing? BMC Med Ethics. 2019 Dec 19;20(1):97. \u003c/li\u003e\n\u003cli\u003ePhysicians and Political Advocacy. AMA J Ethics. 2011 Oct 1;13(10):690\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eOng YT, Yoon NYS, Yap HW, Lim EG, Tay KT, Toh YP, et al. Training clinical ethics committee members between 1992 and 2017: systematic scoping review. J Med Ethics. 2020 Jan;46(1):36\u0026ndash;42. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7225178/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7225178/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHospital 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.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis 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.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFive major themes emerged: (1 Perception of committee role; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Committee composition, member characteristics and ethics training; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Common ethical issues discussed in the Ethics Committee; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Committee\u0026rsquo;s manner of operation; and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Committee\u0026rsquo;s relationships with various entities, and the limitations of its operation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eHECs 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.\u003c/p\u003e","manuscriptTitle":"Hospital Ethics Committees: Responsibilities, Competencies and Challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 07:16:10","doi":"10.21203/rs.3.rs-7225178/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T04:32:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T16:03:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-01T08:11:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120778573456141735091211158907080917159","date":"2025-08-21T12:22:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"292843524549483381707931140433093985894","date":"2025-08-19T14:14:55+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-19T06:10:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-13T10:45:52+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-12T16:13:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-12T16:12:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2025-07-27T08:44:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"039dedbd-ab0e-4115-bfeb-b99861c12212","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-26T16:08:22+00:00","versionOfRecord":{"articleIdentity":"rs-7225178","link":"https://doi.org/10.1186/s12910-025-01365-4","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2026-01-21 15:59:10","publishedOnDateReadable":"January 21st, 2026"},"versionCreatedAt":"2025-08-27 07:16:10","video":"","vorDoi":"10.1186/s12910-025-01365-4","vorDoiUrl":"https://doi.org/10.1186/s12910-025-01365-4","workflowStages":[]},"version":"v1","identity":"rs-7225178","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7225178","identity":"rs-7225178","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}