Why Cases Sometimes Go Wrong Consultation? Case review? Counseling? Case discussion? The lack of a single term to characterize ethics committee reviews of difficult questions that arise in the care of patients suggests that there is no single understanding of this distinctive committee function. Those who request a meeting of a committee may arrive with one understanding of this function only to meet a group with a wholly different approach. As a consequence, they are likely to talk past each other and to part dissatisfied. This is why case discussions sometimes go wrong. There are at least three different understandings of the case review function of ethics committees. One is that it involves a consultation. This conception comes from the medical model of consultation in which a primary physician who faces a difficult or unusual patient care question seeks the advice of another physician with special expertise in that area. Ethics committees that follow this model believe they are being asked to use their expertise in ethics to advise about perplexing ethical issues that arise in the care of a patient. They may ask such questions as whether they must personally see the patient, read the chart, and interview family members. They wonder whether the committee must write its recommendation in the chart and what they are to do if the physician does not follow the committee's recommendation. Committees functioning on this model are not likely to talk about whether the committee should make a recommendation but to whom it should make the recommendation. As the medical model of consultation depends on perceptions of medical norms, so the ethics committee consultation model depends on perceptions of moral norms. For example, when considering a case that involves a comatose patient with AIDS and pneumonia who is on a respirator and whose mother and lover disagree about appropriate care, an ethics committee working with the consultation model might focus on what is in the patient's best interests and what most people would want in this situation. Other committees may follow a case review model; this is indebted to the legal system. The emphasis in this model is on the procedural precision of the committee and its ability to weigh evidence, rather than its substantive expertise. The committee is expected to make a decision on this model; the critical question is how it (as judge and jury) comes to that decision. When the case review model is dominant, the committee asks such questions as who can bring a case to the committee, who attends the review, who provides information, who votes, and who acts as the patient's advocate. Ethics committees with this understanding of their function regularly speak of the decision they reach about a case, even as they say that they are not the decisionmakers. When substantive issues are addressed on this model, committees are more likely to focus on identifying the proper decisionmaker than the appropriate decision. Thus, in the previously described case of the man with AIDS, the committee might be particularly attentive to whether the mother or the lover is the best surrogate decisionmaker for the patient. A third approach that some ethics committees use to discuss patient care questions is educational. …