We believe that quality standards for ethics consultations may improve the consultation process. Dr. La Puma's work contributes to the literature in establishing standards of quality for individual consultants. We encourage further debate on these standards, as well as on similar guidelines for consultations done by ethics committees.

We share Dr. Finucane's concerns about the development of a consultation process that is too burdensome to benefit the patients it is designed to protect. We also agree that an adversarial model serves no one, least of all the patient. It is only when physicians, patients, and families are unable to resolve complex treatment questions that ethics committees have a role.

We maintain that attention to procedural due process is an important component of ethics committee discussions. A rigorous case consultation process enables ethics committees to facilitate compassionate resolution of difficult decision without resorting to the cumbersome judicial process and offers a valuable framework for safeguarding patients' interests. Procedural guidelines increase the likelihood that a committee will consider all relevant information and viewpoints, including the patient's, and that it will arrive at a reasonable recommendation.