Skip to main content

Issues in Health Care: Bioethics in Health Care

Module 1

Foundations in Bioethics

Defining Bioethics

The study of bioethics considers the ethical issues that arise in healthcare situations. In other words, it confronts the complex and often competing moral decisions that healthcare practitioners are required to make in every day practice. Some issues may be more frequently encountered by specific professions, but most issues are interprofessional. For example, while ethical issues surrounding euthanasia are likely specific to certain professions, issues surrounding privacy and confidentiality are relevant to all healthcare professions. The objective of these modules is therefore to explore the way interprofessional ethical issues are addressed in healthcare practice, and how collaboration may be improved.

Module Description

This 6-hour module begins with an introduction to the theoretical foundation of bioethics. Prominent theories will be described and explained; students will have the opportunity to apply the various theories to real world situations. The theoretical foundations are followed with an application of bioethics in various healthcare settings: clinical practice, organizations and research.

As future healthcare practitioners, it is important to understand the role bioethics plays in everyday healthcare practice. Clinicians encounter ethical issues on a regular basis, and often must work together to make decisions. Throughout this course you will be introduced to the concepts and knowledge necessary to practice as ethical healthcare professionals.

Learning Goals

Depending on the number of registered learners, it is anticipated that learners will have an opportunity to combine both online and face-to-face types of learning activities in an interprofessional format.

The primary goal of this module is to provide experiential learning activities related to the introductory topic of bioethics. The learners will have the opportunity to define terms, understand the theoretical background of bioethics and engage in the process of examining the application of bioethics in organizations, clinical practice and research. Learners will be guided to consider the application of their learning to various environments, such as in the classroom, online and in the clinical setting.

Module Format

Each of the 6 modules in this course will begin with an activity that introduces key content for that module. The module will progress with written material that will explain and elaborate on bioethical principles, frameworks, ideas and their application. Throughout the module, learning activities (hi-lighted by red text boxes) will engage learners with their peers to better understand key concepts and their interprofessional application. Finally, summary learning activities will be completed to apply the content from the module.

Grading Scheme

This course is designed to incorporate a high level of interprofessional collaboration, where learners can learn with, from and about their interprofessional peers. As such, participation is a large portion of the grade.

It is recommended that the grading scheme recognize individual participation in discussion groups as well as evaluate learning through both individual and group methods.

Interprofessional Care

Interprofessional care is a collaborative, team-based approach to providing optimal healthcare, given the systemic demands and unprecedented challenges in healthcare (Interprofessional Care Steering Committee, 2007). Interprofessional collaboration, meanwhile, involves “developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes” (Canadian Interprofessional Health Collaborative [CIHC], 2010, p. 8).

National Interprofessional Competency Framework

Education to support competency in interprofessional healthcare delivery is widely recognized as vital to the success of interprofessional collaboration in Canadian healthcare. The Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework identifies six principle competency domains: 1) interprofessional communication, 2) patient/client/family/community-centred care, 3) role clarification, 4) team functioning, 5) collaborative leadership, and 6) interprofessional conflict resolution. In particular, the first two—interprofessional communication and patient/client/family /community-centred care—are considered the keystone domains which support the competencies in the other four domains (CIHC, 2010).

All of the six competency domains considered critical to interprofessional collaboration are relevant to bioethics in healthcare.

 

Course Overview

There are 6 modules in the Bioethics in Healthcare package, which have been designed to be completed as a 3 credit (36 hour) interprofessional online course. The modules are:

MODULE 1: Foundations in Bioethics

MODULE 2: Ethical Decision Making

MODULE 3: Issues in Client Autonomy

MODULE 4: Communication & Conflict Resolution

MODULE 5: Resource Allocation in Healthcare

MODULE 6: Community Care Ethics

1. This course will involve discussion and collaboration with your peers. We will begin by introducing ourselves. Please write a short paragraph that describes your personal background, interests, and what you hope to get out of this course.

2. Once you have written a short paragraph introducing yourself, visit http://www.wordle.net/create

3. Paste your paragraph into Wordle, and it will create a word cloud.

 

4. Share your paragraph and your word cloud in your discussion group. Make sure to comment on at least 2 of your peers’ postings.

Learning Objectives

1. Define key theoretical material for bioethics.

2. Understand the main differences between key ethical theories.

3. Apply the theories to healthcare scenarios.


Introductory Cases

Consider the following situations:

1. You are waiting with a few other people to board a bus. The bus pulls up and before you can board the driver gets out and goes into the convenience store across the street. You are the last to get on the bus. Do you pay your fare?

2. It is 3 am and you are late driving home. As you approach an intersection you notice that no one is around, and this light usually takes a really long time to change. Do you drive through the red light?

3. Visit the description of the Queen v. Dudley & Stephens. What would you have done in their situation?http://www.wadsworth.com/criminaljustice_d/templates/student_resources/0534616232_gaines/landmark/ch03.html

 

Ethical Theories

1. Deontology

Immanuel Kant was a German philosopher who lived from 1724-1804.  He wrote extensively in the areas of epistemology, metaphysics, ethics, aesthetics, and political philosophy.  Kant held that there is one fundamental principle of morality, which stems from human reason.  He called this principle the ‘categorical imperative’. The categorical imperative commands us to obey certain objective moral rules.  One formulation of this imperative (among others) is that we should only act in accordance with maxims that we could will to become a universal law.  Take, for instance, “I will make a lying promise, to get what I want”.  According to Kant, it would be impossible to will this maxim to become a universal law, because to conceive of a world in which everyone makes lying promises would nullify the very concept of a promise.  Lying is therefore not morally permissible (Kant, 1785).  The following readings will help you to understand Kant’s ethics in more detail.  The first reading will provide you with a brief introduction to deontology.  The second is a selection from Kant’s seminal work, The Groundwork of the Metaphysic of Morals. The third will provide you with a contemporary perspective on deontological ethics.

Required Readings

1. Degrazia, D. & Mappes, T, (Eds.) (2006). Biomedical ethics. (6th ed.) (pp. 17-23). New York , NY: McGraw-Hill Higher Education.

Note: It is highly recommended that students read the selection from this text, as it provides an overview and critical assessment of deontology, and situates deontological ethics in the context of biomedical ethics.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library. 

2. Kant, I. (1999). Groundwork of the metaphysic of morals. In M. Gregor (Ed. & Trans), Practical philosophy (pp. 37-108). Cambridge: Cambridge University Press. (Original work published 1785)

Note:  A publicly available version of a different translation of this text can be found at: http://www.gutenberg.org/ebooks/5682 (Project Gutenberg).  The corresponding selection can be found by going to ‘Generated HTML’.  Please read from Section 2, paragraph 33 through until the heading “The Autonomy of the Will as the Supreme Principle of Morality”.

3. Boyle, J. (2009). Exceptionless rule approaches. In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 77-84). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue. 

 

2. Consequentialism

Jeremy Bentham and John Stuart Mill were British philosophers.  Bentham lived from 1748-1832, and Mill from 1806-1873.  Both were proponents of utilitarianism (Mappes & Degrazia, 2006).  In contrast to deontologists, who believe in objective moral rules, utilitarians generally hold that we should act in such a way that maximizes the greatest amount of good for the greatest number of people (Mappes & Degrazia, 2006).  In other words, deontologists are rule-oriented and utilitarian are results-oriented.  Bentham proposed that, to determine which acts are morally permissible, we should add up the pain and pleasure that each act produces and perform those that produce the most pleasure.  For Bentham, all pleasures were equal (Bentham, 1823).  Mill held, however, that some pleasures were more worthwhile than others, and that some acts would undermine pleasure so much that they should never be permissible. He thus revised Bentham’s principle and held that morally permissible acts were those that produced the greatest amount of good for the greatest number of people (Mill, 1863).  The required readings will help you to understand Bentham and Mill’s ethics in more detail.  The first reading will provide you with a brief introduction to utilitarianism.  The second and third are selections from original texts.  The fourth will provide you with a contemporary perspective on utilitarianism.

Watch the following video for an overview of Utilitarianism:
http://www.youtube.com/watch?v=knCIPpkdyVE

Required Readings

1. Degrazia, D. & Mappes, T. (Eds.) (2006). Biomedical ethics. (6th ed.) (pp. 7-17). New York, NY: McGraw-Hill Higher Education.

Note: It is highly recommended that students read the selection from this text, as it provides an overview and critical assessment of utilitarianism, and situates utilitarian ethics in the context of biomedical ethics.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

2. Bentham, J. (2005). The collected works of Jeremy Bentham: An introduction to the principles of morals and legislation. J.H. Burns & L.A. Hart (Eds.) (pp. 11-16). New York: Oxford University Press. (Original work published 1823)

Note: A publicly available version of a different edition of this text can be found at: http://www.econlib.org/library/Bentham/bnthPML.html (Library of Economics and Liberty).  The corresponding selection is Chapter 1, ‘Of the Principles of Utility.’

3. Mill, J.S. (2001). Utilitarianism and the 1868 speech on capital punishment. (2nd ed.) G. Sher (Ed.) (pp. 6-27). Indianapolis: Hackett Publishing Company Inc. (Original work published 1863)

Note:  A publicly available version of a different edition of this text can be found at: http://books.google.ca/books?id=lyUCAAAAQAAJ&dq=Mill%2C%20John%20Stuart%20Utilitarianism&pg=PP6#v=onepage&q=Mill%2C%20John%20Stuart%20Utilitarianism&f=true(Google Books).  The corresponding selection is Chapter 2, ‘What Utilitarianism Is.’

4. Hare, R.M. (2009). A utilitarian approach. In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 85-90). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.


3. Ethics of Care

Nel Noddings and Virginia Held are two proponents of the ethics of care.  Care ethics developed in the late 20th century in the gender studies of Carol Gilligan (Mappes & Degrazia, 2006). It was originally identified with feminism, but is now held to be an ethical theory with a distinct set of concerns.  It is, arguably, a form of ‘virtue ethics’ (Mappes & Degrazia, 2006).  While deontological and utilitarian ethics propose an impartial method of evaluating what acts are morally permissible (according to objective moral rules and the greatest good for the greatest number, respectively), care ethics stresses the importance of human relationships and that all human beings are dependent on other human beings.  Our moral choices must therefore not be made abstractly, but be guided by our relational responsibilities (Noddings, 2003).  The required readings will help you to understand the ethics of care in more detail.  The first reading will provide you with a brief introduction to the ethics of care.  The next two readings are selections from original texts.  The third reading will provide you with a contemporary perspective on care ethics, and situate it in the context of bioethics.

Required Readings

1. Degrazia, D. & Mappes, T. (Eds.) (2005). Biomedical ethics. (6th ed.) (pp. 30-33). New York, NY: McGraw-Hill Higher Education.

Note: It is highly recommended that students read the selection from this text, as it provides a concise overview of the ethics of care.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

2. Noddings, N. (2003). Caring: A feminine approach to ethics & moral education (2nd ed.) (pp. 1-7, 79-98). Berkeley: University of California Press.

Note:  A publicly available version of a different edition of this text can be found at: http://books.google.ca/books?id=G6HMcn1kwfwC&printsec=frontcover&source=gbs_ViewAPI&redir_esc=y#v=onepage&q&f=false (Google Books).  The corresponding selections are the ‘Introduction’ and Chapter 4, ‘An Ethic of Caring.’

3. Held, V. (2005). The ethics of care: personal, political, and global (pp. 9-29). New York, NY: Oxford University Press.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.  The corresponding selection is Part I, ‘Care and Moral Theory’.

4. Manning, R.C. (2009). A care approach. In H. Kuhse & P. Singer (Eds.), Companion to Bioethics (2nd ed.) (pp. 105-117). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

 

Learning Activities

1. Now that you are familiar with several bioethical theories, choose one and revise your answers to the introductory cases using that theory. Discuss how your own views are similar to or different from your chosen theory. Post your response in your discussion group, and comment on at least 2 responses from peers whose chosen theory differs from yours.

2. Which ethical theory do you find to be the most persuasive, and why? Briefly summarize the theory, and provide a critical analysis (i.e. explain and assess criticisms of the theory) (500-750 words). Submit your summary to the Course Instructor when complete.

Learning Objectives

1. Develop an understanding of the application of ethics in healthcare settings.

2. Increase attention to the need to apply ethics to everyday healthcare practice.

3. Explore the potential for interprofessional conflict in clinical ethics practice.

4. Define and understand the differences between clinical, organizational and research ethics, and where they overlap in healthcare delivery.


Introductory Cases

View these 2 short videos (or read the written summaries) that detail historic experiments using human subjects.

After viewing them, post a short comment to your discussion group regarding the application of ethical principles to research, and to daily life. Make sure to comment on at least one of your peer’s posts.

1. Stanford Prison Experiment

Video: http://www.bbc.co.uk/news/world-us-canada-14561818

Written summary: http://www.prisonexp.org/

2. Milgram Experiments

Video: http://www.youtube.com/watch?v=W147ybOdgpE&feature=related

Written summary: http://cnr.berkeley.edu/ucce50/ag-labor/7article/article35.htm

 

 

Types of Ethics

1. Clinical Ethics

All clinicians have both moral and professional principles they practice by, often related to providing competent care. The formalization of clinical ethics pairs clinical skills with the ethical choices that pertain to all interactions with patients/clients. The field of clinical ethics seeks to improve the quality of patient/client care by dealing with the ethical issues that arise in clinical practice. Clinical ethics is often focused at the individual level, with decisions revolving around specific situations that are short in duration and episodic (Bean, 2011).

Visit the website of the Toronto area Centre for Clinical Ethics for an example of a clinical ethics program: http://www.ccethics.com/index.html

Be sure to read their mission statement, as well as the explanation of the services they provide to clinicians.

Robert Veatch, an ethicist and author, makes the case that we make ethical decisions constantly in the provision of healthcare, but may not name them as such until we encounter a challenging decision.

Listen to his thoughts on clinical ethics in this video: http://www.youtube.com/watch?v=VRm37TyIJII&feature=related

In the context of interprofessional healthcare service delivery, conflict may arise regarding clinical ethics. Many healthcare professionals may not fully understand the values of other professions, and may have received different clinical training. Ethical dilemmas can be difficult to navigate individually, and a team environment may present further challenges.

Required Reading

Gaudine, A., LeFort, S.M., Lamb, M., & Thorne, L. (2011). Clinical ethical conflicts of nurses and physicians. Nursing Ethics18(1), 9-19.

Comment in your discussion group regarding the challenges raised by nurses and physicians. Would the challenges be the same for physiotherapists and occupational therapists? Why or why not?


2. Organizational Ethics

Lozano (2003) defines organizational ethics as the set of values that distinguish an organization, for those who work in the organization, as well as those who have dealings with it.

In the mainstream media, organizational ethics may be discussed in reference to business decisions. At times, values asserted by a business or organization may not be a match with its actions. Ethical business practices may be scrutinized, with criticism regarding the use of child labour or sweatshops for manufacturing, or damage to the environment by industry. Public pressure may be exerted to change the behaviour of the business or organization.

 

Here are a few examples of how companies publicly address organizational ethics:

Walmart Corporate: http://ethics.walmartstores.com/

Encana Natural Gas: http://www.encana.com/aboutus/

Kraft Foods: http://www.kraftfoodscompany.com/DeliciousWorld/sustainability/index.aspx

Note the language used, such as sustainability, corporate commitment, ethics and mission.        

Organizational ethics in healthcare pertains more to the organizational behaviour of our healthcare institutions, and often receives less media attention than the business world. Organizational ethics in healthcare applies to any institution that provides care, such as hospitals, clinics, community agencies, and the colleges and universities that educate health professionals.

Organizational ethics are distinct from clinical ethics, in that organizational ethics pertain to ethical issues for administrators and board members, and decisions that affect multiple stakeholders (such as health professionals, patients/clients, families and community members) (Silva, Gibson, Sibbald, Connolly & Singer, 2008). Issues may be political, social or economic in nature, and are typically dealt with proactively through mission or values statements and organizational policies (Bean, 2011).

While clinical ethics may apply more to individual cases or families, organizational ethics apply at a system level, but may still impact the care that individuals receive. In fact, clinical ethics and organizational ethics may come into conflict when hospital policies impact decision making at the individual level (Bean, 2011).

Required Reading

Silva, D.S., Gibson, J.L., Sibbald, R., Connolly, E., & Singer, P.A. (2008). Clinical ethicists' perspectives on organizational ethics in healthcare organisations. Journal of Medical Ethics34(5), 320-3.

Consider the growing prominence of organizational ethics in healthcare. Search the internet to find one example of organizational ethics in practice at a Canadian healthcare institution. Sources might include mission statements, accreditation reports, or other published information. Post the example to your discussion board and be sure to comment on one other peer’s example.


3. Research Ethics

Modern day research ethics are a relatively young phenomenon; before World War II, formal agreements regarding research ethics did not exist. The ethical principles that researchers around the world use on a daily basis find their origins in the Nuremburg Code. This code was articulated in 1947 as a result of the Nuremburg Military Tribunals and details 10 basic principles for research with human subjects.

 

Visit the following link to view the Nuremburg Code (1947):

http://ohsr.od.nih.gov/guidelines/nuremberg.html

Visit the following link for a detailed history of the development of research ethics in Canada:

http://www.pre.ethics.gc.ca/english/tutorial/00_intro_overview_context.cfm

The principles of the Nuremburg Code (such as informed consent, avoidance of unnecessary suffering and protection from risk) provide a foundation for ethical research. However, both examples of unethical research from the introduction (the Milgram experiments and the Stanford Prison study) took place after this code was in place.

Since issues with research ethics continue to arise, governments and institutions set their own policies and procedures to regulate and monitor research. In Canada, these are generally called research ethics boards, in the United States they are known as institutional review boards, and in the United Kingdom they are referred to as research ethics boards or committees.

The function a research ethics board (REB) is to ensure that research proceeds in an ethical manner. In the health sciences, the area of concern is typically research involving humans. All research that takes place at an educational or healthcare institution must be approved by the appropriate REB before proceeding. Most universities and hospitals will have an independent REB, made up of an interprofessional team of clinicians, researchers, administrators and community members.

Follow this link to the Queen’s University Health Sciences Research Ethics Board:

http://www.queensu.ca/ors/researchethics/REB.html

Be sure to make note of their Human Ethics Procedural Guidelines:

http://www.queensu.ca/ors/researchethics/REB/humanethicsguidelines.html

 

Learning Activities

Clinical & Organizational Ethics

1. Read the following article:

Bean, S. (2011). Navigating the murky intersection between clinical and organizational ethics: A hybrid case taxonomy. Bioethics25, 320-5.

In your discussion group, collaborate using Bean’s (2011) Ethics Continuum (Table 3). Create one short example of a potential ethical dilemma for each of the 4 hybrid categories (4 examples total). Discuss who would be involved in decision making in each of the dilemmas.

Research Ethics

1. Read the Canadian Tri-Council Policy Statement:

Ethical Conduct for Research Involving Humans (2nd Ed.)

Chapter 1-Ethics Framework

http://www.pre.ethics.gc.ca/eng/policy-politique/initiatives/tcps2-eptc2/chapter1-chapitre1/

2. Complete module 1 of the TCPS 2 course on research ethics.

Tutorial Course on Research Ethics: Module 1

http://tcps2core.ca/welcome

Note: The entire tutorial may be completed if the student wishes. Completion of the entire tutorial is a requirement from the Queen’s Health Sciences Research Ethics Board in order to submit a research proposal. Students who will complete research projects in the future may want to complete this tutorial now.

 

3. Consider if your role on a research team would differ depending on your profession. Meet with your discussion group via web-interface or in person to discuss your perception of your own role and that of others.

Module 2

Ethical Decision-Making

Defining Bioethics

The study of bioethics considers the ethical issues that arise in healthcare situations. In other words, it confronts the complex and often competing moral decisions that healthcare practitioners are required to make in every day practice. Some issues may be more frequently encountered by specific professions, but most issues are interprofessional. For example, while ethical issues surrounding euthanasia are likely specific to certain professions, issues surrounding privacy and confidentiality are relevant to all healthcare professions. The objective of these modules is therefore to explore the way interprofessional ethical issues are addressed in healthcare practice, and how collaboration may be improved.

Module Description

This 6-hour module explores foundational decision-making frameworks in bioethics, and the application of decision-making in healthcare. Central theoretical frameworks will be described and explained and learners will have an opportunity to see how organizations use frameworks to make decisions.  Learners will have the opportunity to apply these frameworks to case scenarios.

As future health professionals, it is important to understand the role bioethics plays in everyday healthcare practice. Clinicians encounter ethical issues on a regular basis, and often must work together to make decisions. Throughout this course you will be introduced to the concepts and knowledge necessary to practice as ethical health professionals.

Learning Goals

Depending on the number of registered learners, it is anticipated that learners will have an opportunity to combine both online and face-to-face types of learning activities in an interprofessional format.

The primary goal of this module is to provide experiential learning activities related to decision making in bioethics. Learners will have the opportunity to apply frameworks to healthcare cases, and consider the usefulness of each. Learners will be guided to consider the application of their learning to various environments, such as in the classroom, online and in the clinical setting.

Module Format

Each of the 6 modules in this course will begin with an activity that introduces key content for that module. The module will progress with written material that will explain and elaborate on bioethical principles, frameworks, ideas and their application. Throughout the module, learning activities (hi-lighted by red text boxes) will engage learners with their peers to better understand key concepts and their interprofessional application. Finally, summary learning activities will be completed to apply the content from the module.

Grading Scheme

This course is designed to incorporate a high level of interprofessional collaboration, where learners can learn with, from and about their interprofessional peers. As such, participation is a large portion of the grade.

It is recommended that the grading scheme recognize individual participation in discussion groups as well as evaluate learning through both individual and group methods.

Interprofessional Care

Interprofessional care is a collaborative, team-based approach to providing optimal healthcare, given the systemic demands and unprecedented challenges in healthcare (Interprofessional Care Steering Committee, 2007). Interprofessional collaboration, meanwhile, involves “developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes” (Canadian Interprofessional Health Collaborative [CIHC], 2010, p. 8).

National Interprofessional Competency Framework

Education to support competency in interprofessional healthcare delivery is widely recognized as vital to the success of interprofessional collaboration in Canadian healthcare. The Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework identifies six principle competency domains: 1) interprofessional communication, 2) patient/client/family/community-centred care, 3) role clarification, 4) team functioning, 5) collaborative leadership, and 6) interprofessional conflict resolution. In particular, the first two—interprofessional communication and patient/client/family /community-centred care—are considered the keystone domains which support the competencies in the other four domains (CIHC, 2010).

All of the six competency domains considered critical to interprofessional collaboration are relevant to bioethics in healthcare.

Learning Objectives

  1. Define the key decision making frameworks in bioethics.
  2. Understand the main differences between frameworks.
  3. Apply the various frameworks to healthcare scenarios.

Introductory Case

Consider the following situation:

Mrs. Sharma is an 83 year old woman who had a left sided cerebrovascular accident (CVA) 1 month ago. She has some right sided weakness in her leg and arm, as well as some minor speech deficits. She has been on an in-patient rehabilitation unit for 2 weeks, and has made some progress. She is able to walk the length of the hallway with the use of a 4 wheeled walker and minimal supervision from the physiotherapist. She and the occupational therapist have been working on transferring, and she now requires minimal assistance to get in and out of bed, and to use the bathroom. At this point, nursing is assisting her with showering, and providing minimal assistance with her transfers, as well as monitoring her medication. She is medically stable, and her physician is monitoring her general health while her discharge location is decided. The family tends to approach the physician to inquire about her progress.

The Sharma’s home is a small 2 story duplex, with the bedrooms and bathroom on the second floor. It has carpeting, small doorways, and is quite cluttered with furniture.

Mrs. Sharma is very keen to return home with her 85 year old husband, who is in good health and is able to drive. They have 2 children who live in the area, who have children of their own and are very busy. Mrs. Sharma feels that with family support, she can return safely home. The healthcare team agrees that with a few more weeks of rehabilitation, some home modifications and support in the home, Mrs. Sharma could return home safely, but have not yet communicated this to Mrs. Sharma or her family.

One evening, Mrs. Sharma’s husband and 2 children quietly approach the physician to express concerns regarding the discharge planning. The children feel that they cannot offer the kind of support Mrs. Sharma will expect when she returns home, and that they are concerned for the burden on their father. They are also concerned that the home environment is not ideal for her limitations. All 3 of them would prefer that she consider moving to a retirement home that offers assisted living, where they all could visit her regularly.

The family is aware of how upsetting this plan will be for Mrs. Sharma. They would like the healthcare team to recommend discharge to the retirement home, so that the decision comes from the healthcare team, and not them. They feel this will allow them to maintain a positive family relationship.

The healthcare team meets to consider the family’s request. They have difficulty deciding if it is acceptable to steer Mrs. Sharma in a particular discharge direction, in order to preserve a positive family relationship.

Consider what course of action you would take and post your gut reaction in your discussion group. Make sure to comment on at least one peer’s response as well.

 

Introductory Reading

In the previous module, you were introduced to various ethical theories. This raises the question of what the relationship is between ethical theory and bioethics. The following article by Rachels (2009) suggests that we cannot just apply ethical theories to particular cases in order to determine an appropriate course of action.  Neither, however, can we engage in cases studies independent of ethical theory.  There is therefore an interplay between ethical theory and particular cases. The Rachels’ article emphasizes the importance and place of ethical theory in bioethics.  As you progress through the rest of the module, you will learn about the different ways in which ethical theories can be integrated into decision making frameworks and models.

Rachels, J. (2009). Ethical theory and bioethics. In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 15-23). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

Decision Making Frameworks

1. Top-Down Frameworks (Principlism)

Tom Beauchamp and James Childress are perhaps the original and most prominent advocates of a principle-based framework for decision-making in bioethics (although their framework has evolved over the years).  Principle-based frameworks are premised on the assumption that our moral reasoning should be guided by objective moral principles or rules (Beauchamp & Childress, 2009).  This does not mean that such frameworks are necessarily rooted in a deontological system of ethics.  Principle-based frameworks can use either deontological or utilitarian principles, and in fact can even use both.  For example, one such framework might require that ethical decisions be based on the principle of never harming others (deontological ethics) and probable benefit to the client (utilitarian ethics) (Childress, 2009). Using a principle-based framework, we must then apply these principles to particular moral dilemmas, in order to determine an appropriate course of action (Beauchamp & Childress, 2009).  The following readings will help you to understand principle-based frameworks for decision making in more detail.  The first reading provides an overview of principle-based approaches.  The second introduces the work of Beauchamp and Childress, who identify four primary principles of bioethics (these principles are respect for autonomy, beneficence, non-maleficence and justice) and several derivative rules (Beauchamp and Childress, 2009).  The third explains the certain criticisms of this approach.

Required Readings

1. Childress, J.F. (2009). A principle-based approach. In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.)(pp. 67-76). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

2. Beauchamp, T.L. & Childress, J.F (2009). Principles of biomedical ethics (6th ed).New York, NY: Oxford University Press, 12-29.

Note: It is highly recommended that learners read the selection from this text, in which Beauchamp and Childress discuss their four principles of biomedical ethics.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library. As a supplement to this material, instructors may also wish to direct learners to:

Lawrence, Dana J. (2007).  The four principles of biomedical ethics: A foundation for current bioethical debate. Journal of Chiropractic Humanities,14, 34-40.  Retrieved from: http://archive.journalchirohumanities.com/Vol%2014/JChiroprHumanit2007v14_34-40.pdf

3. Walker, T. (2009). What principlism misses. Journal of Medical Ethics35(4), 229-231.

 Retrieved from: http://jme.bmj.com/content/35/4/229.full.pdf

2. Bottom-Up Frameworks (Casuistry)

Principle-based frameworks for decision-making in bioethics emphasize the application of objective moral principles and rules to particular cases.  Casuistry, conversely, rejects objective principles and their application.  It emphasizes that how we understand any given principle must be determined in the context of the case.  That is, casuistry proposes that we start with our intuitive response to particular cases and from there develop context-specific principles and rules (Arras, 2009).  There are two kinds of casuists.  Radical casuists hold that moral principles are abstractions of our intuitions.  As such, these principles cannot be used to criticize our initial intuitive responses.  In other words, they have no normative force (Arras, 2009).  More moderate casuists, however, believe that casuistry is not an alternative to principle-based approaches, but is complementary (this view is further discussed in section 3, below, on ‘reflective equilibrium’) (Arras, 2009).  The following readings will help you to understand casuist frameworks for decision-making in more detail.  The first reading provides an overview of casuist approaches.  The second introduces the origins of casuistry.  The third explains the main criticisms of this approach.

Required Readings

1. Arras, J.D. (2009). A case approach.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 117-125) New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

2. Hoose, B. (1991). The abuse of casuistry: A history of moral reasoning. Journal of Medical Ethics17, 221. Retrieved from:http://jme.bmj.com/content/17/4/221.1.full.pdf

3. Beauchamp, T.L. & Childress, J.F (2009). Principles of biomedical ethics (6th ed).New York, NY: Oxford University Press, 375-81.

Note: It is highly recommended that learners read the selection from this text, in which Beauchamp and Childress discuss some of the main criticisms of casuistry.  This text is not publicly available and copyright permission to reproduce it is required. It is suggested that instructors place this material on reserve the library. As a supplement to this material, instructors may also wish to direct learners to:

Strong, C. (1999).  Critiques of casuistry and why they are mistaken. Theoretical Medicine and Bioethics, 20(5), 395-411.  This article can be access through the Queen’s University catalogue at: http://www.springerlink.com.proxy.queensu.ca/content/u0865h588u647t1g/fulltext.pdf.

3. Reflective Equilibrium

Reflective equilibrium originated in the writings of American philosopher John Rawls and was then later adopted by applied ethicists in response to concerns associated with principle-based and casuist approaches to decision-making. The theory proposes taking neither a principle-based nor a casuist approach to decision-making, but an integrative one. This is to say that its proponents suggest that we can use specific cases to inform our ethical principles, and that these principles can then guide our decision-making in specific cases. Significantly, then, the framework allows for the possibility that ethical principles exist, but can be modified. Our principles are neither so rigid that they cannot be revised, nor so particular that they cannot guide our decision-making. Fundamentally, reflective equilibrium represents the idea that principle-based and casuist approaches are not distinct, but are complementary (Mappes & Degrazia, 2006).  Beauchamp and Childress, above, currently endorse this view (Beauchamp & Childress, 2009).  The following readings will help you to understand reflective equilibrium in more detail.  The first reading provides a basic overview of the framework.  The second is an excerpt of the theory in the original context. The third discusses various criticisms of the position and potential ways to overcome these problems.

Required Readings

1. Mappes, T.A. & Degrazia, D. (2006). Biomedical ethics (6th ed.) (pp. 36-37). New York, NY: McGraw-Hill.

Note: It is highly recommended that learners read the selection from this text, as it provides an overview of reflective equilibrium in the context of principle-based and casuist frameworks for decision-making.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

2. Rawls, J. (1999). A theory of justice. New York, New York: Oxford University Press. (Original work published 1971) (pp. 17-22, 46-53)

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

3. van Thiel, G. & van Delden, J. (2009). The justificatory power or moral experience. Journal of Medical Ethics35(4), 234-7. Retrieved from:http://jme.bmj.com.proxy.queensu.ca/content/35/4/234.full.pdf

 

Learning Activities

1.  Describe which framework for decision making in bioethics you feel most drawn to.  What are the main objections to this framework?  How do you think they can be overcome?

Write a short paper that addresses these questions and submit to the Course Instructor (750 words).  You may find it helpful to do additional independent research.  Please list any sources supplementary to the required readings.

2. Using the case of Mrs. Sharma from the introduction, apply your chosen framework. Post to your discussion group and within your group, discuss alternative decisions that could be reached with a different framework.

Learning Objectives

1. Develop an understanding of the application of ethical decision making in healthcare settings.

2. Increase attention to the need to apply ethics to everyday healthcare practice.

3. Explore the potential for interprofessional conflict in ethical decision making.

Introductory Case

 

Consider the case of Mrs. Sharma again.

The healthcare team could not come to an agreement on a course of action. Some team members feel that it is never acceptable to deceive a patient (a principle based approach) while others feel that rules are difficult to apply to everyone (a case based approach).

They engage the hospital ethicist, who suggests they use a decision making tool to examine the decision in detail, as well as possible courses of action. A discharge plan needs to be created within 1 week. 

Applied Decision Making

 

Models and frameworks used in everyday healthcare decisions tend to have similar elements, such as:

1. Assess or understand the ethical issue.

2. Consult key stakeholders involved in the decision.

3. Agree upon a course of action.

4. Act on the decision.

5. Evaluate the results of the decision.

Depending on the healthcare setting, the organizational structure, the health professionals involved, and the type of patient/client involved in the decision, a variety of frameworks may be used. Some institutions and groups have their own frameworks that they have developed to suit their specific needs, while others are more generic.

The following section will detail a few popular decision making models or frameworks that are publicly available, as well as the codes of ethics and proposed decision making frameworks of several professional Colleges in Ontario.

1. IDEA: Ethical Decision-Making Framework

The IDEA Framework was originally articulated by the Community Ethics Network, a Toronto-based collaboration of community health partners. To learn more about the Network, visit: www.communityethicsnetwork.ca.

In their Community Ethics Toolkit, they provide a simple ethical decision making framework that can be used interprofessionally in a variety of settings. It is called the IDEA Framework, and the steps fit the acronym “IDEA”:

1. Identify the facts

2. Determine the ethical principles in conflict

3. Explore the options

4. Act on the decision and evaluate

In step 1, “identify the facts,” health professionals are encouraged to consider information that may not already be known. This may include the values held by the individual involved, their family and other stakeholders, as well as the emotions attached to the potential decision. At this point, health professionals should identify their own biases, and if they cannot remain objective, find a colleague who can step into the situation.

In step 2, “determine the ethical principles in conflict,” is not meant to provide a simple solution, but to further explore and clarify the issue. Conflict may occur due to different values held by health professionals, a difference in viewpoints or experience, or potentially between cultural values or views.

Step 3, “explore options,” requires that strengths and weakness of potential options be explored, and that alternative courses of action be sought. The magnitude of advantages and disadvantages of each option requires particular attention.

Step 4, “act on your decision and evaluate,” is the stage where an action plan is developed and carried out, and the actions and results are documented. Evaluation of the decision may involve the stakeholders from step 1 as well as self-evaluation. Both objective data and subjective feelings should be considered.

The following document provides more information on the clinical use of the IDEA Framework, and also contains worksheets that may be useful in decision making.

Required Reading

The Community Ethics Network: http://www.jointcentreforbioethics.ca/partners/documents/cen_toolkit2008.pdf

 

2. CARE: An Approach for Teaching Ethics

This framework was originally designed for medical education, but has been adopted by other health professions in the past decade. This four step decision making framework leads an individual or team to examine both the individual and collective levels of healthcare decision making.

1. What are my Core beliefs and how do they relate to this situation?

2. How have I Acted in the past when faced with similar situations? (What do I like about what I have done, what do I not like?)

3. What are the Reasons others have for their opinions about similar situations? (What does our culture seem to say about this situation?)

4. What has been the Experience of others in the past when faced with similar situations? (What do I like about what they have done, what do I not like?)

The Schneider and Snell (2000) article describes each step in detail, and uses a case study of a man with amyotrophic lateral sclerosis (ALS) to illustrate considerations at each step.

Required Reading

Schneider, G.W., & Snell, L. (2000). CARE: An approach for teaching ethics in medicine. Social Science and Medicine, 51, 1563-7.

3. Interprofessional Shared Decision Making (IP-SDM) Model

The IPSDM Model was designed by an interprofessional team to acknowledge that healthcare decisions are shared beyond the patient-practitioner dyad. While it was not specifically developed for use with ethical decisions, it is the only model currently in use that specifically acknowledges the complexity of interprofessional decision making. Its generality, and acknowledgement of the healthcare environment, make it a useful model in a bioethics context.

The model addresses 3 levels within the healthcare system:

  • Micro: This level is individual focused, and will involve the individual who has the healthcare issue, or is currently the recipient of healthcare, as well as their family and support system, and their healthcare providers.
  • Meso: At this level, a healthcare team is involved in the healthcare decision, and may be the initiators of the decision, as well as the decision making coaches for the individual and their family/support system.
  • Macro: This level acknowledges the broader healthcare environment, such as the institutional factors, policies, funding and social context.

Decisions that involve an interprofessional healthcare team, and require the use of a decision making model, will most likely occur at the meso and macro levels.

Required Reading

1. Ontario hospital research institute: Patient decision aids. Retrieved from:   http://decisionaid.ohri.ca/ip-sdm.html

2. Légaré, F., et al. (2011). Validating a conceptual model for an interprofessional approach to shared decision making: a mixed methods study.Journal of Evaluation in Clinical Practice, 17, 554-64. Retrieved from : http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3170704/?tool=pubmed

4. Profession Specific Resources

 

Professional Colleges and Associations provide resources regarding professional ethics, and potential decision making tools. Browse through the following resources to become familiar with what is available in Ontario:

  • The College of Nurses of Ontario
    • Ethics Practice Standard

http://www.cno.org/Global/docs/prac/41034_Ethics.pdf

  • Working Through Ethical Situations Online Module

http://www.cno.org/en/learn-about-standards-guidelines/educational-tools/learning-modules/ethics/

  • The College of Occupational Therapists of Ontario
    • Code of Ethics

http://www.coto.org/pdf/Code_of_Ethics.pdf

  • Conscious Decision-Making In Occupational Therapy Practice

http://www.coto.org/pdf/Concsious_Decision-Making.pdf

  • The College of Physicians & Surgeons of Ontario
    • Values of the Profession

http://www.cpso.on.ca/policies/guide/default.aspx?id=1700

  • Canadian Medical Association Code of Ethics

http://www.cma.ca/index.php/ci_id/53556/la_id/1.htm

  • The College of Physiotherapists of Ontario
    • Code of Ethics

http://www.collegept.org/Physiotherapists/Practice%20Advice/Online%20Learning%20Modues/Ethics

  • Decision Making Online Module

http://www.collegept.org/Physiotherapists/e-learning/M4C3/index.htm

 

 

5. Learning Resources

The following websites and article provide other useful decision making tools, both for individuals and their families, and interprofessional healthcare teams. They are provided for future reference, and are not required reading.

 

Learning Activities

 

1. Consider the 3 main decision making tools that have been provided (IDEA, CARE and the IP-SDM). Which do you find the easiest to use and why? Post a brief summary of your preferred tools strengths and drawbacks in your discussion group, and comment on at least one peer’s posting.

2. Meet in your discussion group, either in person or via web interface. Choose one of the 3 main decision making tools (IDEA, CARE and the IP-SDM) and use it to come to decision regarding the case of Mrs. Sharma. Walk through the steps of the model, and submit a short group summary (750 words) of the steps you took and your resulting course of action to the Course Instructor.

Arras, J.D. (2009). A case approach.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 117-126). New Jersey: Wiley-Blackwell Publishing.

Beauchamp, T.L. & Childress, J.F (2009). Principles of biomedical ethics (6th ed). New York, NY: Oxford University Press.

Childress, J.F. (2009). A principle-based approach.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 67-76). New Jersey: Wiley-Blackwell Publishing.

Garcia, J. G., Cartwright, B., Winston, S. M., & Borzuchowska, B. (2003). A transcultural integrative model for ethical decision making in counseling. Journal of Counseling and Development, 81, 268–277.

Hoose, B. (1991). The Abuse of casuistry: A history of moral reasoning. Journal of Medical Ethics17, 221. Retrieved from:http://jme.bmj.com/content/17/4/221.1.full.pdf

Lawrence, D.J. (2007). The four principles of biomedical ethics: A foundation for current bioethical debate. Journal of Chiropractic Humanities14, 34-40. Retrieved from: http://archive.journalchirohumanities.com/Vol%2014/JChiroprHumanit2007v14_34-40.pdf

Légaré, F., et al. (2011). Validating a conceptual model for an interprofessional approach to shared decision making: a mixed methods study.Journal of Evaluation in Clinical Practice, 17, 554-64. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3170704/?tool=pubmed

Mappes, T.A. & Degrazia, D. (2006). Biomedical ethics (6th ed.). New York, NY: McGraw-Hill.

Rachels, J. (2009). Ethical theory and bioethics. In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 15-23). New Jersey: Wiley-Blackwell Publishing.

Rawls, J. (1999). A theory of justice. New York, New York: Oxford University Press. (Original work published 1971)

Schneider, G.W., & Snell, L. (2000). CARE: An approach for teaching ethics in medicine. Social Science and Medicine, 51, 1563-7.

Strong, C. (1999). Critiques of casuistry and why they are mistaken. Theoretical Medicine and Bioethics20(5), 395-411. Retrieved at:http://www.springerlink.com.proxy.queensu.ca/content/u0865h588u647t1g/fulltext.pdf

Toronto Central Community Care Access Centre. (2008). Community ethics toolkit. Retrieved fromhttp://www.jointcentreforbioethics.ca/partners/documents/cen_toolkit2008.pdf

van Thiel, G. & van Delden, J. (2009). The justificatory power or moral experience. Journal of Medical Ethics35(4), 234-7. Retrieved from:http://jme.bmj.com.proxy.queensu.ca/content/35/4/234.full.pdf

Walker, T. (2009). What principlism misses. Journal of Medical Ethics35(4), 229-231. Retrieved from: http://jme.bmj.com/content/35/4/229.full.pdf

Module 3

Issues in Client Autonomy

Defining Bioethics

The study of bioethics considers the ethical issues that arise in healthcare situations. In other words, it confronts the complex and often competing moral decisions that healthcare practitioners are required to make in every day practice. Some issues may be more frequently encountered by specific professions, but most issues are interprofessional. For example, while ethical issues surrounding euthanasia are likely specific to certain professions, issues surrounding privacy and confidentiality are relevant to all healthcare professions. The objective of these modules is therefore to explore the way interprofessional ethical issues are addressed in healthcare practice, and how collaboration may be improved.

Module Description

This 6-hour module explores the issues surrounding client autonomy in bioethics.  The concepts of paternalism and autonomy will be described and explained.  Learners will then have an opportunity to see how these concepts relate to those of informed consent, competency and substitute decision-making, and advanced care planning.  Learners will then be required to apply what they have learned to cases.

 

As future healthcare practitioners, it is important to understand the role bioethics plays in everyday healthcare practice. Clinicians encounter ethical issues on a regular basis, and often must work together to make decisions. Throughout this course you will be introduced to the concepts and knowledge necessary to practice as ethical healthcare professionals.

Learning Goals

Depending on the number of registered learners, it is anticipated that learners will have an opportunity to combine both online and face-to-face types of learning activities in an interprofessional format.

The primary goal of this module is to provide experiential learning activities that help learners to appreciate the issues surrounding client autonomy.  Learners will have the opportunity to engage with these issues through the required readings and the application of concepts to real cases. Learners will be guided to consider the application of their learning to various environments, such as the classroom, online and in the clinical setting.

Module Format

Each of the 6 modules in this course will begin with a case study, reading or activity that introduces key content for that module. The module will progress with written material that will explain and elaborate on bioethical principles, frameworks, ideas and their application. Throughout the module, learning activities (hi-lighted by red text boxes) will engage learners with their peers to better understand key concepts and their interprofessional application. Finally, summary learning activities will be completed to apply the content from the module.

Grading Scheme

This course is designed to incorporate a high level of interprofessional collaboration, where learners can learn with, from and about their interprofessional peers. As such, participation is a large portion of the grade.

It is recommended that the grading scheme recognize individual participation in discussion groups as well as evaluate learning through both individual and group methods.

Interprofessional Care

Interprofessional care is a collaborative, team-based approach to providing optimal healthcare, given the systemic demands and unprecedented challenges in healthcare (Interprofessional Care Steering Committee, 2007). Interprofessional collaboration, meanwhile, involves “developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes” (Canadian Interprofessional Health Collaborative [CIHC], 2010, p. 8).

National Interprofessional Competency Framework

Education to support competency in interprofessional healthcare delivery is widely recognized as vital to the success of interprofessional collaboration in Canadian healthcare. The Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework identifies six principle competency domains: 1) interprofessional communication, 2) patient/client/family/community-centred care, 3) role clarification, 4) team functioning, 5) collaborative leadership, and 6) interprofessional conflict resolution. In particular, the first two—interprofessional communication and patient/client/family /community-centred care—are considered the keystone domains which support the competencies in the other four domains (CIHC, 2010).

All of the six competency domains considered critical to interprofessional collaboration are relevant to bioethics in healthcare.

Learning Objectives

 

  1. Describe and explain the concepts central to an understanding of client autonomy.
  2. Apply these concepts to various different healthcare scenarios.

 

In module one, you became familiar with various ethical theories.  In module two, you learned how these theories underlie decision-making frameworks and models in bioethics.  In this module, you will begin to see how ethical theories, and decision-making frameworks and models, are integrated into specific themes in bioethics.  This module considers the ethical issues surrounding client autonomy. Should clients, for example, be allowed to make their own healthcare decisions and, if so, to what extent? You should bear in mind that this is not (in this context) a legal question, but an ethical one.  In other words, a bioethicist would not answer this question according to what the law is, but according how he or she thinks the law ought to be.  To begin, you should become familiar with the concepts of client autonomy and paternalism in bioethics.  Understanding these concepts will set the stage for the rest of the content in the module.  Client autonomy is broadly understood as a client’s right to self-determination or to decide what will or will not be done to his or her body (Mappes & Degrazia, 2006). Paternalism, conversely, is a limit on this right.  It is defined as the “interference with a person's liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests, or values of the person being coerced" (Dworkin, as cited in Mappes & Degrazia, 2006, p. 48). The following reading will further assist you in understanding the various different ways in which it is possible to conceptualize both autonomy and paternalism.

Required Readings

1. Mappes, T.A. & Degrazia, D. (2006). Biomedical ethics (6th ed.) (pp. 40-53) New York, NY: McGraw-Hill Higher Education.

Note: It is highly recommended that learners read the selection from this text, as it succinctly defines autonomy and paternalism in the context of bioethics.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

Paternalism or ‘beneficence’ (as it is sometimes referred to) has historically been the primary goal of healthcare (there is no mention of respect for autonomy in the Hippocratic Oathhttp://classics.mit.edu/Hippocrates/hippooath.html).  Over the years, however, there has been an increasing focus on clients’ rights to make independent decisions about their healthcare (Beauchamp & Childress, 2009).  Healthcare providers therefore often feel a tension between respecting their clients’ wishes and sometimes overriding these wishes in what they feel is their clients’ best interest.  This is the inherent conflict between respect for autonomy and paternalism.  This section addresses the ethical questions that arise in this situation.  For example, which of these principles, respect for client autonomy or paternalism ought to have primacy?  If respect for client autonomy should have primacy, are there instances where paternalism is nevertheless justified? The following readings will assist you in forming an opinion on these issues.  The first two readings consider the healthcare provider-client relationship and the relationship between respect for client autonomy and paternalism. The third reading considers the question of why the public might find fictional depictions of paternalism attractive.  The fourth and fifth readings consider the issues of respect for client autonomy specifically in the context of nursing and rehabilitation care.  Finally, the sixth reading leads into the next section in this module on the relationship between respect for client autonomy and paternalism, and decision-making capacity. 

Required Readings

1. Childress, J.F. & Siegler, M. (1984). Metaphors and models of doctor-patient relationships:  Their implications for autonomy.  Theoretical Medicine and Bioethics5(1), 17-30.  Retrieved from:

http://www.springerlink.com.proxy.queensu.ca/content/p7328m380376p394/fulltext.pdf

 

2. Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed) (pp. 206-221). New York, NY: Oxford University Press.

 

Note: It is highly recommended that learners read the selections from this text, in which Beauchamp and Childress discuss their position on respect for autonomy and beneficence, and the conflict between the two principles.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

 

3. Woodward, V.M. (1998). Caring, patient autonomy and the stigma of paternalism. Journal of Advanced Nursing28(5), 1046-1052.  Retrieved from:

http://onlinelibrary.wiley.com.proxy.queensu.ca/doi/10.1046/j.1365-2648.1998.00741.x/pdf

 

4. Hunt, M. & Ells, C. (2011). Partners towards autonomy: Risky choices and relational autonomy in rehabilitation care. Disability and Rehabilitation, 33(11), 961-967.  Retrieved from:

http://informahealthcare.com.proxy.queensu.ca/doi/pdf/10.3109/09638288.2010.515703

 

5. Wicclair, M. (2008). Medical paternalism in House M.D. Medical Humanities34, 93–99. Retrieved from:

http://mh.bmj.com.proxy.queensu.ca/content/34/2/93.full.pdf+html?sid=b53ea375-40ef-4437-8b76-37c0c2a16832

 

6. Strang, D.G., Molloy, D.W. & Harrison, C. (1998).  Capacity to choose place of residence: Autonomy vs beneficence. Journal of Palliative Care,14(1), 25-29. Retrieved from:

http://search.proquest.com.proxy.queensu.ca/docview/214199521/fulltextPDF/134E6B7A9C23F7C93FB/7?accountid=6180

Learning Activities

Choose one of the following 3 articles to read and make a posting in your discussion group.

1.  Read the following article:

Patient Seeks Right Not to Eat

http://news.google.com/newspapers?id=twEtAAAAIBAJ&sjid=xs4FAAAAIBAJ&pg=2241,5862191&dq=patient+seeks+right+not+to+eat&hl=en

Paternalism is arguably justified when a client no longer has decision-making capacity.  These clients are deemed to be incompetent or marginally competent (Elliott, 2009).  The issue arises, however, of when we should deem clients as being incompetent to make their own healthcare decisions.  Where do we draw the line between competence and incompetence?  How do we differentiate between unreasonableness and incompetence?  A further complexity arises in that questions of competency arise in cases involving the elderly, children, and people with mental disorders and/or disability.  Should the same considerations apply to all of these individuals?  The following readings address all of these issues. The first two readings will give you an overview of the ethical issues surrounding competency and the problems involved in assessing competency.  The subsequent three readings offer a discussion of competency as related to the elderly, children, and individuals with mental disorders.  Finally, the last three readings deal with substitute decision-making.  Substitute decision-makers are individuals who are authorized to make decisions for clients who are incompetent (Beauchamp & Childress, 2009).  The first of these readings will give you an overview of who a substitute decision-maker should be, and how decisions should be made.  The second will you provide you with more detail on standards of substitute decision-making.  The final reading is a study on how some individuals tend to choose their decision-makers in light of these standards.

 

Required Readings

1. Elliott, C.. (2009).  Patients doubtfully capable or incapable of consent.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 541-550). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

2. Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed) (pp. 111-117). New York, NY: Oxford University Press.

Note: It is highly recommended that learners read the selections from this text, in which Beauchamp and Childress discuss their position on competence.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

 

3. Rao, G. & Blake, L. (2002). Decision-making capacity in the elderly. Primary Care Update for OB/GYNS,  9(2), 71-75.  Retrieved from:

http://www.sciencedirect.com.proxy.queensu.ca/science/article/pii/S1068607X0100110X

 

4. Harrison C., Kenny, N.P., Sidarous, M. & Rowell, M. (1997). Bioethics for clinicians: 9. Involving children in medical decisions. Canadian Medical Association Journal156(6), 825–828. Retrieved from:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1227047/pdf/cmaj_156_6_825.pdf

 

5. Van Staden, C W. & Krüger, C. (2003). Incapacity to give informed consent owing to mental disorder. Journal of Medical Ethics29, 41-43. Retrieved from:

http://jme.bmj.com/content/29/1/41.full.pdf+html?sid=058c8ede-7e35-4b0a-b70c-dde8c2ae51eb

 

6. Lazar, N. M. (1996). Bioethics for clinicians: 5. Substitute decision-making. Canadian Medical Association Journal155(10), 1435–1437.  Retrieved from:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1335116/?page=1

 

7. Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed) (pp. 135-140). New York, NY: Oxford University Press.

 

Note: It is highly recommended that learners read the selections from this text, in which Beauchamp and Childress discuss their position on substitute decision making.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

 

8. Edwards, S.J.L. (2011). A qualitative investigation of selecting surrogate decision-makers.  Journal of Medical Ethics37, 601-605.  Retrieved from:

http://jme.bmj.com.proxy.queensu.ca/content/37/10/601.full.pdf+html?sid=7791b0d0-7018-4df3-9c42-1e38606b7d78

 

 

Learning Activities

 

Read the following case:

Starson v. Swayze 2003 SCC 32

2          Professor Starson is an exceptionally intelligent man who in earlier years did remarkable work in physics and still counts leading physicists among his friends. He suffers from long-standing mental illness. He has been in and out of mental hospitals in the United States and Canada, since at least 1985. His illness has led to erratic behaviour; his tendency to utter death threats against acquaintances and strangers has repeatedly brought him into conflict with the criminal law and is the reason for his current detention. Professor Starson entertains delusions of varying severity. He talks about plans to run the "Starson Corporation" from inside his current inpatient unit, insists that he is "leading on the edge of efforts to build a starship," claims to be a world-class skier and arm-wrestler, and has asserted that he is the greatest scientist in the world and communicates with extraterrestrials. While Professor Starson would not agree, his illness appears to have progressed and his condition has deteriorated.

3          Professor Starson has received medication for his mental illness in the past. It successfully reduced his delusions. But it had side effects that Professor Starson did not like. The most serious of these was Professor Starson's complaint that the medication dulled his mind and diminished his creativity. As a consequence of his past experiences with medication, Professor Starson has set his mind against all further treatment by medication. He categorically asserts that "no benefits exist for medication" and refuses all treatment except psychoanalysis.

4          Professor Starson's doctors have told him that new medications are available which promise much better results, with reduced negative side effects. They have also explained to him that, without medication, his condition is likely to continue to deteriorate. Professor Starson, however, continues to refuse treatment by medication. Professor Starson's doctors have concluded that in his present condition, he does not understand the benefits of treatment with the new medications, nor does he appreciate that without treatment his condition will probably continue to deteriorate. Faced with this conclusion, which would open the door to imposed medication, Professor Starson applied to the Consent and Capacity Board for a determination that he is capable under the HCCA and can therefore refuse treatment.

In light of the required readings, consider the ethical issues in this case.  What do you think the outcome should be?  Why?  Meet in your discussion group in person or via web interface and discuss your perspectives. How might different professions view this issue?

If a client is competent, then healthcare providers should arguably respect his or her right to make autonomous healthcare decisions.  Generally speaking, this so-called respect for autonomy seems to require two things: (1) that the healthcare provider give to the client, and the client must understand and appreciate, all of the information necessary for the client to make an informed decision with respect to the treatment – including not to have it; and (2) that the healthcare provider obtain the client’s voluntary consent to the treatment.  Bioethicists refer to this as obtaining a client’s “informed consent” (Young, 2009).  There are several ethical issues that arise in obtaining informed consent.  For example, how much must a client understand?  Where do we draw the line between influencing a client’s decision regarding a particular treatment and coercion, manipulation, and undue influence?  The following readings will highlight the complexities surrounding issues of informed consent. The first reading will give you an overview of the underlying requirements of and exceptions to informed consent (our focus is on the ethical).  The second will flesh out these requirements further.  The subsequent two readings challenge various underlying assumptions of the doctrine of informed consent.  The final reading covers the issue of coercion, and when it is that coercion might be said to invalidate a client’s consent. 

Required Readings

1. Young, R. (2009). Informed consent and patient autonomy.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 530-540). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

2. Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed.) (pp. 117-135). New York, NY: Oxford University Press.

Note: It is highly recommended that learners read the selections from this text, in which Beauchamp and Childress discuss their position on informed consent.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

3. Kihlbom, U. (2007).  Autonomy and negatively informed consent.  Journal of Medical Ethics34, 146-149.  Retrieved from:

http://jme.bmj.com.proxy.queensu.ca/content/34/3/146.full.pdf+html?sid=bd383dd2-85d7-433c-84f5-950745427800

4. Brody, H. (1989).  Transparency: Informed consent in primary care.  Hastings Center Report19, 5-9.  Retrieved from:

http://www.jstor.org.proxy.queensu.ca/stable/3562634

5. Mallary, S.D. (1986). Family coercion and valid consent. Theoretical Medicine and Bioethics, 7, 123-126. Retrieved from:

http://www.springerlink.com.proxy.queensu.ca/content/m0667271t5953703/fulltext.pdf


Learning Activities

1. Write a 500-750 word commentary on one of the require readings and submit it to the Course Instructor.

2.  Read the following article:

When Informed Consent Is Impossible

http://abcnews.go.com/Health/ActiveAging/story?id=2831392&page=1#.TyIKEhwhsmU

In light of the readings you have completed on both competency and substitute decision-making, and informed consent, write a response to this article and post it in your discussion group. Be sure to comment on at least one peer’s posting.

There are two types of advance directives (Mappes & Degrazia, 2006).  We addressed proxy directives in Part C of this module.  In making a proxy directive, a competent individual appoints a substitute decision-maker to make healthcare decisions for him or her, in the event that competency is lost (Mappes & Degrazia, 2006).  This section discusses instructional directives and the planning that goes into such instruments.  In making an instructional directive, a competent individual not only appoints a substitute decision-maker, but also gives this person specific instructions with respect to his or her care, in the event that competency is lost (Mappes & Degrazia, 2006).  The following readings will help you understand this kind of advance directive in more detail.  The first reading will give you an overview of the types of advance directives, and some associated benefits of making one.  The second reading is a study performed comparing clients’ and healthcare providers’ attitudes towards advanced directives.  The subsequent two readings discuss the ethical complexities associated with certain advance directives.  The final two readings address advanced care planning.  The first is the Canadian website of an Ottawa organization dedicated to advanced care planning, which discusses the steps that clients should take in making a plan.  The second is a guide that was prepared to assist healthcare authorities in Canada in developing advanced care planning initiatives.

Required Readings

1. The Dalhousie End of Life Project:  Advance Directives. Health Law Institute, Dalhousie University. Retrieved from:
http://as01.ucis.dal.ca/dhli/cmp_documents/documents/AD_Brochure.pdf


2. Blondeau, D., Valois, P., Keyserlingk, E.W., Hébert, M. & Lavoie, M. (1998). Comparison of patients’ and healthcare professionals’ attitudes towards advance directives. Journal of Medical Ethics24, 328-335.  Retrieved from:
http://jme.bmj.com.proxy.queensu.ca/content/24/5/328.full.pdf+html?sid=dae718ab-a66e-4c33-b4f6-b1893737a934

3. Ryan, C. (1996). Betting your life:  an argument against certain advance directives.  Journal of Medical Ethics22, 95-99. Retrieved from: 
http://jme.bmj.com.proxy.queensu.ca/content/22/2/95.full.pdf+html?sid=61576270-36d1-4321-ab9f-3c54882d82c5

4. Varelius, J. (2011).  Respect for autonomy, advance directives, and minimally conscious state. Journal of Bioethics25, 505-515.  Retrieved from:
http://onlinelibrary.wiley.com.proxy.queensu.ca/doi/10.1111/j.1467-8519.2009.01799.x/pdf

5. Canadian Hospice Palliative Care Association:  Advanced Care Planning:
http://www.advancecareplanning.ca/

Learners should do a general review of the contents of the website.

6. Implementation Guide to Advance Care Planning in Canada: A Case Study of Two Health Authorities (March, 2008). 
http://www.hc-sc.gc.ca/hcs-sss/pubs/palliat/2008-acp-guide-pps/index-eng.php

Learning Activities

1.  You have now had a chance to read about some of the benefits and drawbacks of advance directives.  Are there additional benefits or drawbacks?  Post your answer in your discussion group.

2.  Read the following article:

Janesville Man Develops Program that Tackles End of Life Decisions

http://gazettextra.com/news/2012/jan/08/janesville-man-develops-program-tackle-end--life-d/

This is an article from the United States, and thus the same concerns motivating the development of such a ‘program’ may or may not be applicable to Canada.  Do you think that this be an appropriate way to go about advance care planning in Canada?  Why or why not?  Meet in your discussion group in person or via web interface to consider the application in Canada. 

1.  Read the following case:

 

Malette v. Shulman  63 O.R. (2d) 243

5          About 13:15 hours on June 30, 1979 the plaintiff, a 57 year-old housewife, was a passenger in, and her husband was the operator of, a motor vehicle involved in a head-on collision with a truck resulting in injury to the plaintiff and the immediate death of her husband. Gerald Blanchard, an employee of a car dealership near the accident site and an elder of the local Jehovah's Witnesses congregation, attended the plaintiff while she was still seated in the vehicle at the accident scene. He described a "trickle of blood" from her facial injuries to the upper part of her white suit. He observed no other blood on her person, in the car or on the ground. Police Officer Brian Clarke arrived at 13:20 hours and observed that the plaintiff had facial injuries with some bleeding. Gary Hodgins, an ambulance attendant, also arrived at 13:20 hours. His only recollection of the incident was seeing the plaintiff seated in her vehicle. By reconstruction from his ambulance report, he gave evidence of sustained external bleeding with no serious blood loss in the 5-minute ambulance trip to hospital.

6          On arrival at Kirkland and District Hospital emergency department about 13:30 hours, the plaintiff was received by the defendants Registered Nurses Johnson and Matijek (Matijah). Dr. Shulman, who was on duty as hospital casualty officer, was called from a cardiac case in the emergency department and within a few minutes examined Mrs. Malette. Thereafter, he attended her almost constantly in hospital as well as during her air ambulance flight to Toronto.

7          The plaintiff was "shockey" in appearance, semi-conscious, not responding to verbal stimuli (her native language was French), moaning, groaning and uttering no coherent sounds. Nurses Johnson and Matijek noted a steady, constant stream of severe bleeding from her nose and mouth which they described as "too quick and too bright red" to be normal. Nurse Hannah, who was called from the intensive care unit to assist, observed that the plaintiff was semi-conscious and bleeding profusely. The blood was "too bright" and she concluded that this was arterial blood.

8          The plaintiff presented to Dr. Shulman in a very dramatic manner with large quantities of blood visible including a trail on the floor from ambulance to emergency room as well as on walls, stretcher and nurses' uniforms. This abundance of blood was recorded in Dr. Shulman's admission record dictated almost contemporaneously at 14:30 hours and in his discharge summary dictated about 6 weeks later.

9          At the emergency department the plaintiff was found to have:

(1) Severe facial lacerations. Her nose appeared to be completed severed. Her face, which was flattened and balloon shaped with eyes swollen closed and mouth distorted open, was detached from the skull. There were obvious multiple fractures of facial bones with a constant stream of blood from the area of nose and mouth. The plaintiff was vomiting blood.

(2) Indications of abdominal injuries, with the plaintiff holding her left flank. Her abdomen was tender with fullness of the upper left central chest. Bruising was observed in the area of the iliac crest.

(3) Pale, cold and clammy skin.

10          Immediately and regularly the plaintiff's vital signs were taken. They were initially recorded in the nursing notes at blood pressure 150/90 and pulse rate 90. I accept the nurses' evidence that these vital signs were carefully monitored at regular intervals of 5, 15 or 30 minutes and that Dr. Shulman was kept current with the results although, because of concern for and attention to the patient, those results were not always recorded in the nursing notes as usual practice would indicate.

11          Dr. Shulman concluded that the patient suffered from incipient shock resulting from the blood loss and he was concerned about the risk of falling blood pressure. The immediate treatment was by the standard therapy of replenishing blood loss with intravenous glucose followed immediately at 13:45 hours by Ringer's Lactate, a clear volume expander, administered in both arms by large bore intravenous.

12          About 14:00 hours Dr. Shulman anterior packed the plaintiff's nose with plain gauze followed by a second anterior packing, both of which did little to stop the blood flow. The laceration about her eye was sutured. Her respiration was relatively normal and oxygen was administered by face mask.

13          Since the patient was unable to speak, Nurse Johnson checked the purse which accompanied the plaintiff to hospital and about 13:45 hours to 14:00 hours found a Jehovah's Witness card signed but bearing neither date nor witness signature. Although in French, it was promptly translated. The card read as follows:

Pas De Transfusion Sanguine!

En tant que témoin de Jéhovah à mes convictions religieuses, je demande que l'on ne m'administre ni sang ni dérivés du sang en aucune circonstance. Je suis pleinement conscient de la portée de ma décision, mais je suis absolument résolu à obéir au commandement de la Bible qui dit de 's'abstenir ... du sang'. (Actes 15:28, 29.) Toutefois, mes croyances me permettent d'accepter des le Plasmagel, le Plasmion et le Rhéomacrodex ou une solution saline.

The parties have agreed upon the following translation:

No Blood Transfusion

As one of Jehovah's witnesses with firm religious convictions, I request that no blood or blood products be administered to me under any circumstances. I fully realize the implications of this position, but I have resolutely decided to obey the Bible command: 'Keep abstaining ... from blood.' (Acts 15:28, 29.) However, I have no religious objection to use of the nonblood alternatives, such as Dextran, Haemaccel, PVP, Ringer's Lactate or saline solution.

14          This information was communicated by the nursing staff to the hospital executive director, the defendant McAnulty, who discussed the issue with the hospital chief of staff, Dr. Middlemiss. Mr. McAnulty concluded that the administration of blood, as a medical decision was Dr. Shulman's responsibility. He directed that if Dr. Shulman decided to administer blood, it should be "hung" by the doctor, not by the hospital staff and that the staff should co-operate with the doctor. He further specifically directed that Dr. Shulman be advised of the contents of the card.

15          Nurse Johnson, as directed by her nursing supervisor, on three separate occasions in the presence of Nurses Hannah and Matijek, while Dr. Shulman was attending the plaintiff in the emergency room, advised Dr. Shulman of the presence and contents of the card. This advice was recorded on the emergency department chart. Although he did not specifically look at the card as he was attending the plaintiff, Dr. Shulman did acknowledge that he was advised of and understood the purport of the card prior to blood being administered at 15:20 hours. He acknowledged that he assumed it to be Mrs. Malette's card and signature.

16          Between 13:50 hours and 15:00 hours the patient received 3 litres of Ringer's Lactate.

17          At 14:15 hours Dr. Shulman consulted Dr. Dakin, a general and orthopedic surgeon on duty in the hospital. Dr. Dakin was informed of the available partial history relating to a high-energy, head-on car crash with a fatality and of the plaintiff's substantial facial and other injuries and blood loss.

18          At 15:00 hours Dr. Dakin examined the patient noting the level of consciousness. Although she was unable to respond verbally and her eyes were swollen closed, he had the impression that she was aware of his presence. The obvious facial injuries were associated with substantial swelling. The face was quite unstable. The abdomen was distended with bruising at the iliac crest. There were indications of chest pain. The bright bleeding continued in spite of the nasal pack. The systolic blood pressure was barely 100. The pulse rate was slow from blood loss suggestive of some stimulation slowing the heart rate, mainly through the vagus system.

19          Dr. Dakin concluded that there had been a major significant force to the face and abdomen with considerable potential for crush, blood loss, and damage to the vagus system. He found the patient's airway and ventilation to be sufficient. He was very much concerned about potential damage to the heart and great blood vessels, abdominal injury and relieving possible pressure on the brain. The swelling was indicative of risk of other potential damage [such] as bleeding sources contributing to the stomach blood. He was of the opinion that it was vital to maintain blood volume to avoid irreversible shock. The extent and nature of the fractures being as yet undetermined, immediate intubating or posterior nasal packing involving passing a catheter through the airway was contra-indicated because of the risk of any such insertion in the vital areas of the brain and spinal cord. The patient's general condition was too unstable to permit any further attempt at posterior nasal packing in an effort to staunch the blood flow.

20          On Dr. Dakin's order, the patient was transferred to the x-ray department for x-rays of skull, pelvis and chest. These x-rays revealed a normal cervical spine and minor rib fractures.

21          Before the x-rays were satisfactorily completed, the plaintiff's condition deteriorated, with systolic blood pressure dropping to the 50 - 40 range. Respiration was becoming increasingly distressed and the level of consciousness was dropping. This was a demonstration of increasing signs of hypovolemic shock. She continued to bleed profusely and was becoming critically ill.

22          The laboratory report on the crossing and matching of blood was now available. Dr. Shulman made the decision to administer blood and he did so personally "hanging" two units of blood simultaneously at 15:20 hours while the plaintiff was still in the x-ray room.

23          At 15:50 hours, because of her deteriorating condition, the plaintiff was transferred to the intensive care unit with its monitored life support systems. She continued "shockey" with further significant drop in heart rate and blood pressure. She was semi-conscious to stuporous — although Nurse Winters (now Blea) described her as "lucid and rational" in the limited sense that she was able to respond to commands such as "turn over".

24          At 16:15 hours, having determined by x-ray results that there was no gross abnormality of the cervical spine, an endo-tracheal tube (from mouth to trachea attached to a respirator) was inserted to protect her breathing.

25          At 16:30 hours Dr. Shulman made an unsuccessful attempt at posterior nasal packing by passage of a Foley catheter with an attached balloon to be inflated to produce a block by direct pressure on bleeding areas.

26          At 17:30 hours, under a local anaesthetic only, Dr. Dakin performed a mini-laparotomy involving insertion of a tube into the abdomen to check for significant abdominal bleeding. The patient was in a depressed level of consciousness and was unresponsive to pain.

27          At 18:00 hours a bronchostomy was performed to check by direct visualization for bleeding in order to rule out concern with respect to the abdominal cavity. Again the patient was unresponsive to marked pain stimuli.

28          Celine Bisson, daughter of the plaintiff, was advised of the accident about 15:00 hours by police and immediately phoned her sister Paulette Doucet. They discussed the question of administration of blood. Mrs. Bisson drove from Timmins, arriving at the hospital about 18:00 — 18:30 hours. She immediately spoke to Nurse Winter, objecting to the administration of blood. Mrs. Bisson refused to sign an authorization to give blood. About 19:00 hours, with her husband Hubert Bisson and Mr. Blanchard the local church elder, she saw Dr. Shulman and informed him that the plaintiff was her mother and that they were both Jehovah's Witnesses. She expressed her conviction that her mother wanted no blood and also that she did not want blood. A biblical justification was attempted by her. She mentioned a second medical opinion, alternative bloodless treatment and a transfer to hospital in Toronto. Dr. Shulman was quoted by her as saying "Don't you care if your mother dies? You will be responsible. I am in charge. I am responsible and I will give blood." According to her, Dr. Shulman "could not stand them" and walked out.

29          At 19:00 hours Mrs. Bisson signed "A Consent to Treatment and a Release of Liability Form" specifically prohibiting blood transfusions. Nurse Winters told her that because it was the July 1st holiday week-end the hospital administrator was unavailable to discuss the problem. According to Mrs. Bisson, 15 or 20 minutes later, Dr. Shulman returned and threw the release on the desk indicating that it was of no value and that the blood would continue. She did not see Dr. Shulman again. About midnight the nursing staff informed her that her mother was being transferred to hospital in Toronto.

30          Dr. Shulman had a limited recollection of the interview with Mrs. Bisson. He thought that had a second opinion been requested, he would have advised that the patient had already been seen by Dr. Dakin and another doctor at the hospital. He had no recollection of the second meeting with Mrs. Bisson and asserts that he had no intention to be unavailable or to walk out of any meeting. He knew that Mrs. Bisson did not want blood for her mother and that she had signed the qualified release. Dr. Shulman indicated that he would have been happy to turn the patient over to some other doctor as it was a difficult case. He continued because that was his ethical responsibility.

31          Mrs. Bisson did not further pursue her unhappiness with the medical treatment nor did she retain another doctor although Mr. Blanchard, who accompanied her, was a local businessman and knew area doctors sympathetic to Jehovah's Witnesses.

32          Hubert Bisson visited the plaintiff in the intensive care unit and asked in French if she wanted blood, directing her to indicate her response by squeezing his hand. Mrs. Malette testified that she recalls the incident. By hand signal Mrs. Malette indicate "no blood". Nurse Winters, although present, did not understand what was said. Hubert Bisson told her what had happened. Dr. Shulman was not informed about this incident.

33          At 18:10 hours the results of the mini-laparotomy and bronchostomy being negative, attention was turned to the most obvious bleeding site in the area of the nose. About 19:00 hours Dr. Dakin consulted an ear, nose and throat resident at Toronto General Hospital who suggested that the external cartoid artery be tied off below the jaw, a procedure which Dr. Dakin considered to be beyond his competence involving risk of compromising brain circulation. This procedure was not carried out and instead between 18:15 hours and 18:30 hours there was another unsuccessful attempt at posterior nasal packing after which the anterior packing was replaced. Bleeding and the blood transfusions continued.

34          About 19:30 to 20:00 hours the plaintiff's condition stabilized somewhat with improving blood pressure, level of consciousness and skin condition.

 

35          About 23:20 hours Dr. Shulman again consulted Dr. Dakin, and together they inserted the Foley catheter so that the balloon was in place as posterior nasal packing. Dr. Dakin described feeling crepitation in the process. He regarded the procedure as only partially successful with no significant change in bleeding.

36          About 00:20 hours on July 1, Dr. Dakin examined the plaintiff for the last time. He was then, and remains now, strongly of the belief that the patient suffered from hypovolemic shock.

37          About 02:20 hours the patient, accompanied by Dr. Shulman and two nurses, was taken by air ambulance to Toronto General Hospital, arriving at about 04:30 hours. The blood transfusions were discontinued there. On August 11 she was discharged from Toronto General Hospital.

 

Succinctly state the ethical issues in this case (note that previous issues explored in this module are integrated).  How would you go about making a decision in this case?  What do you think the outcome of this case should be?  Why?  Post your commentary in your discussion group.  Be sure to comment on at least one other peer’s posting.

 

Note to course instructors:  An article that discusses the outcome of this case can be found here: http://www.humanehealthcare.com/Article.asp?art_id=300.  The citation for the Court of Appeal decision itself is: 37 O.A.C. 281.  Ask learners if they agree with the outcome of the case and why or why not.

 

2.  Watch the following video and read the following article:

 

http://www.ctv.ca/CTVNews/TopStories/20120203/w5-life-or-death-investigation-120204/

 

Succinctly state the ethical issues in this case (note that previous issues explored in this module are integrated).  Provide a 500-750 word response to these issues with reference to the required readings, and submit it to your Course Instructor.

Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed). New York, NY: Oxford University Press.

Blondeau, D., Valois, P., Keyserlingk, E.W., Hébert, M. & Lavoie, M. (1998). Comparison of patients’ and health care professionals’ attitudes towards advance directives. Journal of Medical Ethics24, 328-335.  Retrieved from:http://jme.bmj.com.proxy.queensu.ca/content/24/5/328.full.pdf+html?sid=dae718ab-a66e-4c33-b4f6-b1893737a934

Brody, H. (1989).  Transparency: Informed consent in primary care.  Hastings Center Report19, 5-9.  Retrieved from:http://www.jstor.org.proxy.queensu.ca/stable/3562634

Brown, P., Enns, B., Wasylenko, E., Barwich, D., Grant, S., Hoffman, C.,...Dunbrack, J. (2008) Implementation guide to advance care planning in Canada: A case study of two health authorities (prepared for Health Canada). Retrieved from: http://www.hc-sc.gc.ca/hcs-sss/pubs/palliat/2008-acp-guide-pps/index-eng.php

Canadian Hospice Palliative Care Association. (2012). Advanced care planning. Ottawa, Canada. http://www.advancecareplanning.ca/

Childress, J.F. & Siegler, M. (1984). Metaphors and models of doctor-patient relationships:  Their implications for autonomy.  Theoretical Medicine and Bioethics5(1), 17-30.  Retrieved from: http://www.springerlink.com.proxy.queensu.ca/content/p7328m380376p394/fulltext.pdf

Conflicts pitting doctors vs. patients/kin over treatment decisions is #1 issue in medical ethics today, Canadian experts say. (2005, June 20). Retrieved from: http://www.jointcentreforbioethics.ca/rss/news/news_ethicschallenges.shtml

Edwards, S.J.L. (2011). A qualitative investigation of selecting surrogate decision-makers.  Journal of Medical Ethics37, 601-605.  Retrieved from: http://jme.bmj.com.proxy.queensu.ca/content/37/10/601.full.pdf+html?sid=7791b0d0-7018-4df3-9c42-1e38606b7d78

Elliott, C. (2009).  Patients doubtfully capable or incapable of consent.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.). New Jersey: Wiley-Blackwell Publishing.

Harrison C., Kenny, N.P., Sidarous, M. & Rowell, M. (1997). Bioethics for clinicians: 9. Involving children in medical decisions. Canadian Medical Association Journal156(6), 825–828. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1227047/

Hippocrates (400 BCE). The Hippocratic Oath (F. Adams, Trans.). Retrieved from http://classics.mit.edu/Hippocrates/hippooath.html

Hunt, M. & Ells, C. (2011). Partners towards autonomy: Risky choices and relational autonomy in rehabilitation care. Disability and Rehabilitation, 33(11), 961-967.  Retrieved from: http://informahealthcare.com.proxy.queensu.ca/doi/pdf/10.3109/09638288.2010.515703

Karlawish, J. (2007, Jan 29). When informed consent is impossible. ABC News. Retrieved from: http://abcnews.go.com/Health/ActiveAging/story?id=2831392&page=1#.TyIKEhwhsmU

Kihlbom, U. (2007).  Autonomy and negatively informed consent.  Journal of Medical Ethics34, 146-149.  Retrieved from:http://jme.bmj.com.proxy.queensu.ca/content/34/3/146.full.pdf+html?sid=bd383dd2-85d7-433c-84f5-950745427800

Laidlaw, S. (2009, Feb 6). Patient’s right to guide treatment does have limits. The Toronto Star. Retrieved from :http://www.healthzone.ca/health/article/583102

Lazar, N. M. (1996). Bioethics for clinicians: 5. Substitute decision-making. Canadian Medical Association Journal155(10), 1435–1437.  Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1335116/?page=1

Leute, J. (2012, Jan 8). Janesville man develops program that tackles end of life decisions. The Janesville Gazette. Retrieved from:http://gazettextra.com/news/2012/jan/08/janesville-man-develops-program-tackle-end--life-d/

Malette v Shulman (1987), 63 OR (2d) 243, 47 DLR (4th) 18

Mallary, S.D. (1986). Family coercion and valid consent. Theoretical Medicine and Bioethics, 7, 123-126. Retrieved from:http://www.springerlink.com.proxy.queensu.ca/content/m0667271t5953703/fulltext.pdf

Mappes, T.A. & Degrazia, D. (2006). Biomedical ethics (6th ed.). New York, NY: McGraw-Hill Higher Education.

Patient Seeks Right Not to Eat http://news.google.com/newspapers?id=twEtAAAAIBAJ&sjid=xs4FAAAAIBAJ&pg=2241,5862191&dq=patient+seeks+right+not+to+eat&hl=en

Rao, G. & Blake, L. (2002). Decision-making capacity in the elderly. Primary Care Update for OB/GYNS, 9(2), 71-75.  Retrieved from:http://www.sciencedirect.com.proxy.queensu.ca/science/article/pii/S1068607X0100110X

Ryan, C. (1996). Betting your life:  an argument against certain advance directives.  Journal of Medical Ethics22, 95-99. Retrieved from:http://jme.bmj.com.proxy.queensu.ca/content/22/2/95.full.pdf+html?sid=61576270-36d1-4321-ab9f-3c54882d82c5

Starson v Swayze, 2003 SCC 32, [2003] 1 SCR 722.

Strang, D.G., Molloy, D.W. & Harrison, C. (1998).  Capacity to choose place of residence: Autonomy vs beneficence. Journal of Palliative Care,14(1), 25-29. Retrieved from: http://search.proquest.com.proxy.queensu.ca/docview/214199521/fulltextPDF/134E6B7A9C23F7C93FB/7?accountid=6180

The Dalhousie End of Life Project:  Advance Directives. Health Law Institute, Dalhousie University, Halifax, Canada. Retrieved from:http://as01.ucis.dal.ca/dhli/cmp_documents/documents/AD_Brochure.pdf

Van Staden, C W. & Krüger, C. (2003). Incapacity to give informed consent owing to mental disorder. Journal of Medical Ethics29, 41-43. Retrieved from: http://jme.bmj.com/content/29/1/41.full.pdf+html?sid=058c8ede-7e35-4b0a-b70c-dde8c2ae51eb

Varelius, J. (2011).  Respect for autonomy, advance directives, and minimally conscious state. Journal of Bioethics25, 505-515.  Retrieved from:http://onlinelibrary.wiley.com.proxy.queensu.ca/doi/10.1111/j.1467-8519.2009.01799.x/pdf

W5 Staff (Feb 4, 2012). Life or death – who gets to decide? [Television series episode]. In W5. Toronto, Ontario: CTV News. Retrieved at:http://www.ctv.ca/CTVNews/TopStories/20120203/w5-life-or-death-investigation-120204/

Wicclair, M. (2008). Medical paternalism in House M.D. Medical Humanities34, 93–99. Retrieved from:http://mh.bmj.com.proxy.queensu.ca/content/34/2/93.full.pdf+html?sid=b53ea375-40ef-4437-8b76-37c0c2a16832

Woodward, V.M. (1998). Caring, patient autonomy and the stigma of paternalism. Journal of Advanced Nursing28(5), 1046-1052.  Retrieved from:http://onlinelibrary.wiley.com.proxy.queensu.ca/doi/10.1046/j.1365-2648.1998.00741.x/pdf

Young, R. (2009). Informed consent and patient autonomy.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 530-540). New Jersey: Wiley-Blackwell Publishing.

Module 4

Communication & Conflict Resolution

Defining Bioethics

The study of bioethics considers the ethical issues that arise in healthcare situations. In other words, it confronts the complex and often competing moral decisions that healthcare practitioners are required to make in every day practice. Some issues may be more frequently encountered by specific professions, but most issues are interprofessional. For example, while ethical issues surrounding euthanasia are likely specific to certain professions, issues surrounding privacy and confidentiality are relevant to all healthcare professions. The objective of these modules is therefore to explore the way interprofessional ethical issues are addressed in healthcare practice, and how collaboration may be improved.

Module Description

This 7.5-hour module explores the issues surrounding communication and conflict resolution in bioethics.  The concepts of veracity, privacy, and confidentiality will be described and explained. Learners will have the opportunity to apply their learning to case scenarios.

 

As future healthcare practitioners, it is important to understand the role bioethics plays in everyday healthcare practice. Clinicians encounter ethical issues on a regular basis, and often must work together to make decisions. Throughout this course you will be introduced to the concepts and knowledge necessary to practice as ethical healthcare professionals.

Learning Goals

Depending on the number of registered learners, it is anticipated that learners will have an opportunity to combine both online and face-to-face types of learning activities in an interprofessional format.

 

The primary goal of this module is to provide experiential learning activities that help learners to appreciate the issues surrounding communication and conflict resolution.  Learners will have the opportunity to engage with these issues through the required readings and the application of concepts to real cases. Learners will be guided to consider the application of their learning to various environments, such as the classroom, online and in the clinical setting.

Module Format

Each of the 6 modules in this course will begin with a case study, reading or activity that introduces key content for that module. The module will progress with written material that will explain and elaborate on bioethical principles, frameworks, ideas and their application. Throughout the module, learning activities (hi-lighted by red text boxes) will engage learners with their peers to better understand key concepts and their interprofessional application. Finally, summary learning activities will be completed to apply the content from the module.

Grading Scheme

This course is designed to incorporate a high level of interprofessional collaboration, where learners can learn with, from and about their interprofessional peers. As such, participation is a large portion of the grade.

 

It is recommended that the grading scheme recognize individual participation in discussion groups as well as evaluate learning through both individual and group methods.

Interprofessional Care

Interprofessional care is a collaborative, team-based approach to providing optimal healthcare, given the systemic demands and unprecedented challenges in healthcare (Interprofessional Care Steering Committee, 2007). Interprofessional collaboration, meanwhile, involves “developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes” (Canadian Interprofessional Health Collaborative [CIHC], 2010, p. 8).

National Interprofessional Competency Framework

Education to support competency in interprofessional healthcare delivery is widely recognized as vital to the success of interprofessional collaboration in Canadian healthcare. The Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework identifies six principle competency domains: 1) interprofessional communication, 2) patient/client/family/community-centred care, 3) role clarification, 4) team functioning, 5) collaborative leadership, and 6) interprofessional conflict resolution. In particular, the first two—interprofessional communication and patient/client/family /community-centred care—are considered the keystone domains which support the competencies in the other four domains (CIHC, 2010).

All of the six competency domains considered critical to interprofessional collaboration are relevant to bioethics in healthcare.

 

Learning Objectives

  1. Describe and explain the concepts central to an understanding of communication and conflict resolution.
  2. Apply these concepts to various healthcare scenarios.

In module one, you became familiar with various ethical theories.  In module two, you learned how these theories underlie decision-making frameworks and models in bioethics.  In module three, you began to see how ethical theories, and decision-making frameworks and models, are integrated into specific themes in bioethics.  Module three dealt with the ethical issues surrounding client autonomy.  This module covers the ethical issues surrounding veracity, privacy, confidentiality, and interprofessional communication and conflict resolution.  For example, is it ever okay to withhold information from a client and, if so, to what extent?  Is it ever okay to invade client privacy, or breach client confidentiality and, if so, under what circumstances? How can interprofessional teams prevent and resolve conflicts in decision-making? You should bear in mind that these are not (in this context) legal questions, but ethical ones.  In other words, a bioethicist would not answer these question according to what the law is, but according how he or she thinks the law ought to be.  To begin the module, read and intuitively respond to the case studies in theintroductory activities below and share your answer with your peers. 

Introductory Activity

 

Read Case Studies Nos. 1, 12, and 19 in Mappes, T.A. & Degrazia, D. (2006). Biomedical ethics (6th ed.) (pp. 697-718) New York, NY: McGraw-Hill Higher Education.

 

How would you respond in these situations?  Post your response in your discussion group.

 

Note: It is highly recommended that learners engage in this introductory activity.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

Watch the following video for a humorous look at veracity in healthcare:

http://www.yourdailymedia.com/video/watch/2108/

 

Veracity in a healthcare setting refers to obligation that healthcare practitioners have to provide “comprehensive, accurate and objective” information to clients (Beauchamp & Childress, 2009, p. 289).  This section will cover the ethical issues that arise in exercising this obligation. Is it ever okay to not tell a client the truth?  Is it ever okay to withhold information from a client?  Must all medical errors be disclosed?  The following readings deal with the above issues.  The first reading will provide you with an introduction to the obligation of veracity and issues surrounding disclosure. The second elaborates on certain theoretical aspects of truth telling, including the various arguments against deception, kinds of deception, and the importance of effective communication between healthcare providers and clients.  The third reading provides various applied models for ‘breaking bad news’. The fourth specifically considers the ethical issues that arise in the context of truth telling and third parties (e.g. when a father tells a clinician not to tell his child the truth).  The fifth discussed the ethical issues surrounding deception and giving placebos.  Finally, the sixth reading addresses the issue of disclosure in relation to medical error.

Required Readings

1.  Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed.) (pp. 289-295). New York, NY: Oxford University Press.

 

Note: It is highly recommended that learners read the selections from this text, in which Beauchamp and Childress discuss the obligation of veracity.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

 

2.  Higgs, R. (2009).  Truth-telling.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.). New Jersey: Wiley-Blackwell Publishing.  Retrieved from

http://site.ebrary.com.proxy.queensu.ca/lib/queen/docDetail.action?docID=10355255

 

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

 

3.  Girgis, A. & Sanson-Fisher, R. W. (1995). Breaking bad news: consensus guidelines for medical practitioners.  Journal of Clinical Oncology,13(9), 2449-2456.  Retrieved from

http://jco.ascopubs.org.proxy.queensu.ca/content/13/9/2449.full.pdf+html?sid=fd404add-ff52-44d1-810d-deb5b80617c5

 

4. Higgs, R. (1985).  Case conference.  A father says "Don't tell my son the truth".  Journal of Medical Ethics. 11(3), 153-158.  Retrieved from

http://jme.bmj.com.proxy.queensu.ca/content/11/3/153.full.pdf+html?sid=ed52c4f6-bc0b-471e-8b40-d6637884bcd6

 

5. Brody, H. (1982). The lie that heals: the ethics of giving placebos.  Annals of Internal Medicine97, 112-118.  Retrieved from

http://www.annals.org.proxy.queensu.ca/content/97/1/112.full.pdf+html

 

6.  Lamb, R. (2004). Open disclosure: the only approach to medical error.  Quality and Safety in Health Care13, 3-5.  Retrieved from

http://qualitysafety.bmj.com.proxy.queensu.ca/content/13/1/3.full.pdf+html?sid=da47a876-c4e2-4900-a121-e8541c79c224

 

Note:  This article can be found on the second page of the web document that it is linked to.

Learning Activities

 

1.  Lamb, R (2004) writes that “open, honest, and timely disclosure should be the only approach to medical error.” Do you agree with this statement?  Explain your answer in light of the required readings.  Post your answer in your discussion group.

2.  Read the following article:

Do doctors have to be honest?

http://articles.philly.com/2012-02-28/news/31107742_1_doctors-and-patients-ethics-and-health-policy-financial-conflicts

Do you agree with the author’s position on mistakes that affect the client’s care?  What about his position on delivering bad news to clients?  What does the author mean when he writes that telling the truth should be a ‘process’ and not an ‘event’?  Is it ever acceptable to ‘exaggerate the risks’ in the way the author suggests?  Explain your answers in light of the required readings.  Post your answer in your discussion group.

3.  Watch the following video:

How the powerful placebo effect works

http://www.cbsnews.com/8301-504803_162-57380908-10391709/how-the-powerful-placebo-effect-works/

“The American Medical Association does consider it unethical.  The Germans don’t, by the way, so this varies from country to country.”

Do you think that Canada should adopt the American, or the German approach? 

Meet in your discussion group in person or via web interface. Debate the approach that you find most ethical. Is truth always the best approach? 

Consider the respect for privacy depicted in this cartoon:

http://www.cartoonstock.com/newscartoons/cartoonists/mba/lowres/mban1481l.jpg

 

A person can be said to have privacy “when other individuals do not without permission invade what may be called his or her ‘sphere of privacy’: a realm of intimate or sensitive information about the person that he or she generally does not wish to share with others or wishes to share with only a small circle of persons” (Mappes & Degrazia, 2006, p. 168).  The issues surrounding privacy in bioethics are multiple.   The following readings will help you become familiar with many of them.  The first reading will introduce you to the forms of privacy as identified by Beauchamp and Childress (2009).  The second will provide you with some philosophical considerations as to why privacy is important.  The third and fourth reading considers the issue of privacy from the client’s perspective.  The fifth addresses privacy issues specific to the field of occupational therapy.  The sixth and seventh readings address public concerns about information privacy, in a comparative North American context and in a global social-networking context.  The eight and ninth readings discuss the question of how to secure information privacy and lessons to be learned from information privacy breaches.  The final three readings consider the question of whether it is okay to invade an individual’s privacy for the benefit of other people, public safety, or the public good.

 

Required Readings

1.  Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed) (pp. 296-302). New York, NY: Oxford University Press.

 

Note: It is highly recommended that learners read the selections from this text, in which Beauchamp and Childress discuss the forms of privacy, justification of the right to privacy and privacy issues as they relate to public policy.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library

 

2.  Rachels, James. (1975).  Why privacy is important.  Philosophy & Public Affairs4(4) (Summer), 323-333. Retrieved from

http://www.jstor.org.proxy.queensu.ca/stable/pdfplus/2265077.pdf?acceptTC=true

 

3.  Malcolm, H. (2005).  Does privacy matter?  Former patients discuss their perceptions of privacy in shared hospital rooms.  Journal of Nursing Ethics12(2), 156-166.  Retrieved from

http://search.proquest.com.proxy.queensu.ca/docview/201439309/fulltextPDF/134FCEB37BF9B575D6/14?accountid=6180

 

4.  Schopp, A. (2003).  Perceptions of privacy in the care of elderly people in five European countries.  Journal of Nursing Ethics10(1), 40-47.  Retrieved from

http://search.proquest.com.proxy.queensu.ca/docview/201445345/fulltextPDF/134FCF3B70A2810BEF0/24?accountid=6180

 

5.  Heikkinen, A., Launis V., Wainwright, P, & Leino-Kilpi H. (2006).  Privacy and occupational health services.  Journal of Medical Ethics, 32, 522-525.  Retrieved from

http://jme.bmj.com.proxy.queensu.ca/content/32/9/522.full.pdf+html?sid=dead188b-2bf3-4547-82dc-24ca7f8210d6

 

6.  Laric, M. V., Pitta, D.A., & Katsanis, L.P. (2009).  Consumer concerns for healthcare information privacy:  a comparison of US and Canadian perspectives.  Retrieved from

http://www.freepatentsonline.com/article/Research-in-Healthcare-Financial-Management/208588735.html

 

7.  Thompson, L. (2011).  Protected health information on social networking sites:  ethical and legal considerations.  Journal of Medical Internet Research13(1). Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130674/pdf/1471-2458-11-454.pdf?tool=pmcentrez

 

8.  Mizani, M. A. & Baykal, N. (2007).  A software platform to analyse the ethical issues of electronic patient privacy policy: the S3P example. Journal of Medical Ethics33, 695-698.  Retrieved from

http://jme.bmj.com.proxy.queensu.ca/content/33/12/695.full.pdf+html?sid=16325678-2fb0-4e9a-af8e-f975ed7b775b

 

9.  Malonda, J. et al.  2009).  Lessons learned from a privacy breach at an academic health science centre.  Health Care Quarterly12(1), 61-65.  Retrieved from

http://www.longwoods.com/content/20416

 

10.  Emam, K. (2011).  Physician privacy concerns when disclosing patient data for public health purposes during a pandemic influenza outbreak. BMC Public Health11, 1-16.  Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130674/pdf/1471-2458-11-454.pdf?tool=pmcentrez

 

11.  Rothstein, M. A. (2010).  Is deidentification sufficient to protect health privacy in research? American Journal of Bioethics10(9), 3-11.  Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032399/?tool=pmcentrez

 

12.  O'Brien, M. (1989). Mandatory HIV antibody testing policies: an ethical analysis.  Bioethics3(4), 274-400.  Retrieved from

http://onlinelibrary.wiley.com.proxy.queensu.ca/doi/10.1111/j.1467-8519.1989.tb00347.x/pdf

 

 

Learning Activities

1.  What are the forms of privacy as identified by Beauchamp and Childress?  Can you identify these forms of privacy in the required readings?  Can you think of other examples of each form of privacy?

2.  Schopp (2003) writes that “Privacy is a culturally defined concept that is situationally dependent”.  Do you agree with this statement?  Explain you answer and post it in your discussion group.

3.  Read the following article:

Former Capital Health worker sorry for privacy breach

http://www.cbc.ca/news/canada/nova-scotia/story/2012/02/14/ns-capital-health.html

How can organizations prevent privacy breaches?  In an organization where various different of types professionals are entitled to access different levels of information, how might one effectively structure a privacy policy?  Meet in your discussion group in person or via web interface and discuss what should be included in an organizational privacy policy.

4.  Read the following article:

http://www.montrealgazette.com/health/Health+records+privacy/6217785/story.html

Do you think that individuals’ health records should be available online, as Nonen suggests? 

 

If a client is competent, then healthcare providers should arguably respect his or her right to make autonomous healthcare decisions.  Generally speaking, this so-called respect for autonomy seems to require two things: (1) that the healthcare provider give to the client, and the client must understand and appreciate, all of the information necessary for the client to make an informed decision with respect to the treatment – including not to have it; and (2) that the healthcare provider obtain the client’s voluntary consent to the treatment.  Bioethicists refer to this as obtaining a client’s “informed consent” (Young, 2009).  There are several ethical issues that arise in obtaining informed consent.  For example, how much must a client understand?  Where do we draw the line between influencing a client’s decision regarding a particular treatment and coercion, manipulation, and undue influence?  The following readings will highlight the complexities surrounding issues of informed consent. The first reading will give you an overview of the underlying requirements of and exceptions to informed consent (our focus is on the ethical).  The second will flesh out these requirements further.  The subsequent two readings challenge various underlying assumptions of the doctrine of informed consent.  The final reading covers the issue of coercion, and when it is that coercion might be said to invalidate a client’s consent. 

Required Readings

1. Young, R. (2009). Informed consent and patient autonomy.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.) (pp. 530-540). New Jersey: Wiley-Blackwell Publishing.

Note:  The online edition of this text can be found through the Queen’s University library catalogue.

2. Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed.) (pp. 117-135). New York, NY: Oxford University Press.

Note: It is highly recommended that learners read the selections from this text, in which Beauchamp and Childress discuss their position on informed consent.  This text is not publicly available and copyright permission to reproduce it is required.  It is suggested that instructors place this material on reserve the library.

3. Kihlbom, U. (2007).  Autonomy and negatively informed consent.  Journal of Medical Ethics34, 146-149.  Retrieved from:

http://jme.bmj.com.proxy.queensu.ca/content/34/3/146.full.pdf+html?sid=bd383dd2-85d7-433c-84f5-950745427800

4. Brody, H. (1989).  Transparency: Informed consent in primary care.  Hastings Center Report19, 5-9.  Retrieved from:

http://www.jstor.org.proxy.queensu.ca/stable/3562634

5. Mallary, S.D. (1986). Family coercion and valid consent. Theoretical Medicine and Bioethics, 7, 123-126. Retrieved from:

http://www.springerlink.com.proxy.queensu.ca/content/m0667271t5953703/fulltext.pdf


Learning Activities

1. Write a 500-750 word commentary on one of the require readings and submit it to the Course Instructor.

2.  Read the following article:

When Informed Consent Is Impossible

http://abcnews.go.com/Health/ActiveAging/story?id=2831392&page=1#.TyIKEhwhsmU

In light of the readings you have completed on both competency and substitute decision-making, and informed consent, write a response to this article and post it in your discussion group. Be sure to comment on at least one peer’s posting.

Not only must healthcare providers communicate effectively with clients (for example, by means of disclosing information, and respecting privacy and confidentiality), but they must also communicate with each other.  This is particularly true of an interprofessional healthcare team.  When different types of healthcare professionals are required to communicate on a daily basis, the occasional conflict is bound to arise.  The following readings will help you become aware of how to prevent conflict, types of conflict that might arise and how to resolve conflict. The first reading addresses how members of an interprofessional team can effectively communicate with clients’ family members.  The second emphasizes the value of interprofessional training courses in the developing of interprofessional collaborative skills.  The third reading stresses the important role that collaborative discussion in team meetings plays in team decision-making and problem-solving.  The fourth suggests that “interprofessional cultural competence” is an educational goal that serves work to increase collaboration and reduce conflict in teams. The fifth reading addresses conflict and whether and how it can be resolved.  The sixth reading explores how to manage interprofessional teams from a ‘theory of action’ perspective.

 

Required Readings

1.  Fronek, P. (2009).  Towards healthy professional-client relationships: the value of an interprofessional training course.  Journal of Interprofessional Care23(1), 16-29. Retrieved from

http://journals1.scholarsportal.info.proxy.queensu.ca/tmp/15357800342176406315.pdf

 

2.  Dwight, T. (2007). Interprofessionalism in healthcare: communication with the patient's identified family.  Journal of Interprofessional Care,21(5), 561-563. Retrieved from

http://journals1.scholarsportal.info.proxy.queensu.ca/tmp/5600239713905251987.pdf

 

3.  Bokhour, B. G. (2006).  Communication in interdisciplinary team meetings: what are we talking about?  Journal of Interprofessional Care20(4), 349-363.  Retrieved from

http://journals1.scholarsportal.info.proxy.queensu.ca/tmp/6935765021864043038.pdf

 

4.  Edwards, P., Doyle, O., & Bliss, D.L. (2008). Reducing barriers to interprofessional training: promoting interprofessional cultural competence.Journal of Interprofessional Care22(4), 417-428.  Retrieved from

http://informahealthcare.com.proxy.queensu.ca/doi/pdf/10.1080/13561820802190442

 

5.  Brown, J. et al (2011). Conflict on interprofessional primary healthcare teams - can it be resolved? Journal of Interprofessional Care25(1), 4-10.  Retrieved from

http://journals2.scholarsportal.info.proxy.queensu.ca/tmp/3191831532647827850.pdf

 

6.  Rogers, T. (2004). Managing the interprofessional environment: a theory of action perspective. Journal of Interprofessional Care18(3), 239-249. Retrieved from

http://journals1.scholarsportal.info.proxy.queensu.ca/tmp/11358440067286697053.pdf

 

 

Learning Activities

1.  Write a 500 word commentary on any of the assigned readings and submit it to the Course Instructor.

2.  Read the following article:

N.S. midwifery facing 'collapse,' report finds

http://www.cbc.ca/news/canada/nova-scotia/story/2011/08/10/ns-midwifery-report-raises-questions.html

"Interprofessional and interpersonal conflicts were both cause and effect for a widespread loss of trust and confidence among all parties," the report continued. "We discerned sadness, disappointment and regret across all sectors at the present circumstance coupled with a desire to re-establish midwifery at IWK."

In your opinion, how could this result have been avoided? Meet in your discussion group in person or via web interface and discuss preventative solutions, and what could be done moving forward.

3. Visit the following website:

Programs & Focus Areas:  Inner City Health Program

http://www.stmichaelshospital.com/programs/ich/index.php

What kinds of healthcare providers do you think might work on a team that facilitates this program?  What types of conflicts might arise?  How might these conflicts be resolved?

1.  Revisit the case studies that you responded to in the introductory activity.  Now that you have been introduced to new ideas through the assigned readings, learning activities, and your peers, how would you respond to these case scenarios?  Would you respond the same way, or differently?  Explain your answer and post it in your discussion group.

 

2.  Write your own case study on one of the ethical issues addressed in this section.  Trade scenarios with your team members.  Each team member should respond to the case scenario they are given and post his or her response in the discussion group.

 

3.  What is the difference between privacy and confidentiality?  Revisit the Emam (2011) article that you read in the section on privacy.  This article contains privacy concerns and confidentiality concerns.  Identity them both and how they are distinct.

 

4. Watch the following video:

http://winstream.creighton.edu/jja01162/Bad.wmv

Within your team, identify the obstacles to effective collaboration that exist among this team.  What kind of problems might arise from this type of communication?  How might this team improve their team meeting?  Contemplate what potential decision-making conflicts might arise in this case.  How might they be resolved?

Allison, A. & Ewens, A. (1998).  Tensions in sharing client confidences while respecting autonomy: implications for interprofessional practice. Nursing Ethics5(5), 441-450.  Retrieved from
http://search.proquest.com.proxy.queensu.ca/docview/201432610/fulltextPDF/135489745ED2BFB06C4/7?accountid=6180

Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed) (pp. 289-295). New York, NY: Oxford University Press.

Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed) (pp. 296-302). New York, NY: Oxford University Press.

Beauchamp, T.L. & Childress, J.F. (2009). Principles of biomedical ethics (6th ed.) (pp. 302 311). New York, NY: Oxford University Press.

Bokhour, B. G. (2006).  Communication in interdisciplinary team meetings: what are we talking about?  Journal of Interprofessional Care20(4), 349-363.  Retrieved from
http://journals1.scholarsportal.info.proxy.queensu.ca/tmp/11358440067286697053.pdf

Brody, H. (1982). The lie that heals: the ethics of giving placebos.  Annals of Internal Medicine97, 112-118.  Retrieved from
http://www.annals.org.proxy.queensu.ca/content/97/1/112.full.pdf+html

Brown, J. et al (2011). Conflict on interprofessional primary healthcare teams - can it be resolved? Journal of Interprofessional Care25(1), 4-10.  Retrieved from
http://journals2.scholarsportal.info.proxy.queensu.ca/tmp/9336209614323579078.pdf

Carlisle, J., Shickle, D., Cork, M., & McDonagh, A. (2006). Concerns over confidentiality may deter adolescents from consulting their doctors.  A qualitative exploration.  Journal of Medical Ethics32(2), 133-137.  Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564464/?tool=pmcentrez

Dwight, T. (2007). Interprofessionalism in healthcare: communication with the patient's identified family.  Journal of Interprofessional Care21(5), 561-563. Retrieved from
http://journals1.scholarsportal.info.proxy.queensu.ca/tmp/5600239713905251987.pdf

Edwards, P., Doyle, O., & Bliss, D.L. (2008). Reducing barriers to interprofessional training: promoting interprofessional cultural competence.Journal of Interprofessional Care22(4), 417-428.  Retrieved from
http://informahealthcare.com.proxy.queensu.ca/doi/pdf/10.1080/13561820802190442

Emam, K. (2011).  Physician privacy concerns when disclosing patient data for public health purposes during a pandemic influenza outbreak. BMC Public Health11, 1-16.  Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130674/pdf/1471-2458-11-454.pdf?tool=pmcentrez

Emson, H. E. (1994). Minimal breaches of confidentiality in healthcare research: a Canadian perspective.  Journal of Medical Ethics20, 165-168. Retrieved from
http://jme.bmj.com.proxy.queensu.ca/content/20/3/165.full.pdf+html?sid=b3bdb509-41db-46ff-9a95-727aa9a99153

Fleck, L. (1991). Please don't tell. Hastings Center Report, 21(6), 39-40.  Retrieved from
http://search.proquest.com.proxy.queensu.ca/docview/222365703/fulltextPDF/134FD4CF7AFAB15773/1?accountid=6180

Fronek, P. (2009).  Towards healthy professional-client relationships: the value of an interprofessional training course.  Journal of Interprofessional Care23(1), 16-29. Retrieved from
http://journals2.scholarsportal.info.proxy.queensu.ca/tmp/9336209614323579078.pdf

Gallo, A., Angst, D.B., & Knafl, K.A. (2009).  Disclosure of genetic information within families. How nurses can facilitate family communication. American Journal of Nursing109(4), 65-69.  Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2677756/pdf/nihms-107268.pdf?tool=pmcentrez

Gillon R. & Sokol, D.K. (2009).  Confidentiality.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.). New Jersey: Wiley-Blackwell Publishing.  Retrieved from
http://site.ebrary.com.proxy.queensu.ca/lib/queen/docDetail.action?docID=10355255

Girgis, A. & Sanson-Fisher, R. W. (1995). Breaking bad news: consensus guidelines for medical practitioners.  Journal of Clinical Oncology13(9), 2449-2456.  Retrieved from
http://jco.ascopubs.org.proxy.queensu.ca/content/13/9/2449.full.pdf+html?sid=fd404add-ff52-44d1-810d-deb5b80617c5

Heikkinen, A., Launis V., Wainwright, P, & Leino-Kilpi H. (2006).  Privacy and occupational health services.  Journal of Medical Ethics, 32, 522-525.  Retrieved from http://jme.bmj.com.proxy.queensu.ca/content/32/9/522.full.pdf+html?sid=dead188b-2bf3-4547-82dc-24ca7f8210d6

Higgs, R. (2009).  Truth-telling.  In H. Kuhse & P. Singer (Eds.), Companion to bioethics (2nd ed.). New Jersey: Wiley-Blackwell Publishing.  Retrieved from
http://site.ebrary.com.proxy.queensu.ca/lib/queen/docDetail.action?docID=10355255

Higgs, R. (1985).  Case conference.  A father says "Don't tell my son the truth".  Journal of Medical Ethics, 11(3), 153-158.  Retrieved from
http://jme.bmj.com.proxy.queensu.ca/content/11/3/153.full.pdf+html?sid=ed52c4f6-bc0b-471e-8b40-d6637884bcd6

Kottow, M. (1986). Confidentiality: an intransigent and absolute obligation.  Journal of medical ethics. 12, 117-122. Retrieved from
http://jme.bmj.com.proxy.queensu.ca/content/12/3/117.full.pdf+html?sid=bbde356b-5a0a-454c-b082-f599bb26160b

Lamb, R. (2004). Open disclosure: the only approach to medical error.  Quality and Safety in Health Care13, 3-5.  Retrieved from
http://qualitysafety.bmj.com.proxy.queensu.ca/content/13/1/3.full.pdf+html?sid=da47a876-c4e2-4900-a121-e8541c79c224

Laric, M. V., Pitta, D.A., & Katsanis, L.P. (2009).  Consumer concerns for healthcare information privacy:  a comparison of US and Canadian perspectives.  Retrieved from
http://www.freepatentsonline.com/article/Research-in-Healthcare-Financial-Management/208588735.html

Leung, W.C. (2000).  Results of genetic testing:  when confidentiality conflicts with a duty to warn relatives.  British Medical Journal321, 1464-1466.  Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1119174/pdf/1464.pdf?tool=pmcentrez

Malcolm, H. (2005).  Does privacy matter?  Former patients discuss their perceptions of privacy in shared hospital rooms.  Journal of Nursing Ethics12(2), 156-166.  Retrieved from
http://search.proquest.com.proxy.queensu.ca/docview/201439309/fulltextPDF/134FCEB37BF9B575D6/14?accountid=6180

Malonda, J. et al.  (2009).  Lessons learned from a privacy breach at an academic health science centre.  Health Care Quarterly12(1), 61-65.  Retrieved from
http://www.longwoods.com/content/20416

Mappes, T.A. & Degrazia, D. (2006). Biomedical ethics (6th ed.). New York, NY: McGraw-Hill Higher Education.

Mizani, M. A. & Baykal, N. (2007).  A software platform to analyse the ethical issues of electronic patient privacy policy: the S3P example.  Journal of Medical Ethics33, 695-698.  Retrieved from
http://jme.bmj.com.proxy.queensu.ca/content/33/12/695.full.pdf+html?sid=16325678-2fb0-4e9a-af8e-f975ed7b775b

O'Brien, M. (1989). Mandatory HIV antibody testing policies: an ethical analysis.  Bioethics3(4), 274-400.  Retrieved from
http://onlinelibrary.wiley.com.proxy.queensu.ca/doi/10.1111/j.1467-8519.1989.tb00347.x/pdf

Rachels, J. (1975).  Why privacy is important.  Philosophy & Public Affairs4(4) (Summer), 323-333. Retrieved from:
http://www.jstor.org.proxy.queensu.ca/stable/pdfplus/2265077.pdf?acceptTC=true

Rogers, T. (2004). Managing the interprofessional environment: a theory of action perspective. Journal of Interprofessional Care18(3), 239-249. Retrieved from
http://journals2.scholarsportal.info.proxy.queensu.ca/tmp/9336209614323579078.pdf

Rothstein, M. A. (2010).  Is deidentification sufficient to protect health privacy in research? American Journal of Bioethics10(9), 3-11.  Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3032399/?tool=pmcentrez

Schopp, A. (2003).  Perceptions of privacy in the care of elderly people in five European countries.  Journal of Nursing Ethics10(1), 40-47.  Retrieved from
http://search.proquest.com.proxy.queensu.ca/docview/201445345/fulltextPDF/134FCF3B70A2810BEF0/24?accountid=6180

Tarasoff v. Regents of the University of California.  Retrieved from
http://www.publichealthlaw.net/Reader/docs/Tarasoff.pdf

Thompson, L. (2011).  Protected health information on social networking sites:  ethical and legal considerations.  Journal of Medical Internet Research13(1). Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3130674/pdf/1471-2458-11-454.pdf?tool=pmcentrez

 

Warwick, S. J. (1989).  A vote for no confidence.  Journal of Medical Ethics, 15, 183-185.  Retrieved from
http://jme.bmj.com/content/15/4/183.full.pdf+html?sid=07ab9135-762c-4e5c-a4d2-d49ad036d015

Module 5

Resource Allocation in Healthcare

Defining Bioethics

The study of bioethics considers the ethical issues that arise in healthcare situations. In other words, it confronts the complex and often competing moral decisions that healthcare professionals are required to make in every day practice. Some issues may be more frequently encountered by specific professions, but most issues are interprofessional. For example, while ethical issues surrounding euthanasia are likely specific to certain professions, issues surrounding privacy and confidentiality are relevant to all healthcare professions. The objective of these modules is therefore to explore the way interprofessional ethical issues are addressed in healthcare practice, and how collaboration may be improved.

Module Description

This 4.5-hour module explores ethical issues that present when allocating resources in healthcare. Central considerations for ethically allocating resources will be explored, and the interprofessional implications.  Learners will have the opportunity to apply these ideas to case scenarios.

As future healthcare professionals, it is important to understand the role bioethics plays in everyday healthcare practice. Clinicians encounter ethical issues on a regular basis, and often must work together to make decisions. Throughout this course you will be introduced to the concepts and knowledge necessary to practice as ethical healthcare professionals.

Learning Goals

Depending on the number of registered learners, it is anticipated that learners will have an opportunity to combine both online and face-to-face types of learning activities in an interprofessional format.

The primary goal of this module is to provide experiential learning activities related to resource allocation in healthcare. Learners will have the opportunity to consider this content in relation to healthcare cases. Learners will be guided to consider the application of their learning to various environments, such as in the classroom, online and in the clinical setting.

Module Format

Each of the 6 modules in this course will begin with a case study, reading or activity that introduces key content for that module. The module will progress with written material that will explain and elaborate on bioethical principles, frameworks, ideas and their application. Throughout the module, learning activities (hi-lighted by red text boxes) will engage learners with their peers to better understand key concepts and their interprofessional application. Finally, summary learning activities will be completed to apply the content from the module.

Grading Scheme

This course is designed to incorporate a high level of interprofessional collaboration, where learners can learn with, from and about their interprofessional peers. As such, participation is a large portion of the grade.

It is recommended that the grading scheme recognize individual participation in discussion groups as well as evaluate learning through both individual and group methods.

Interprofessional Care

Interprofessional care is a collaborative, team-based approach to providing optimal healthcare, given the systemic demands and unprecedented challenges in healthcare (Interprofessional Care Steering Committee, 2007). Interprofessional collaboration, meanwhile, involves “developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes” (Canadian Interprofessional Health Collaborative [CIHC], 2010, p. 8).

National Interprofessional Competency Framework

Education to support competency in interprofessional healthcare delivery is widely recognized as vital to the success of interprofessional collaboration in Canadian healthcare. The Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework identifies six principle competency domains: 1) interprofessional communication, 2) patient/client/family/community-centred care, 3) role clarification, 4) team functioning, 5) collaborative leadership, and 6) interprofessional conflict resolution. In particular, the first two—interprofessional communication and patient/client/family /community-centred care—are considered the keystone domains which support the competencies in the other four domains (CIHC, 2010).

 

All of the six competency domains considered critical to interprofessional collaboration are relevant to bioethics in healthcare.

Learning Objectives

  1. Define key considerations in resource allocation in healthcare.
  2. Understand the application to interprofessional practice.
  3. Apply information to healthcare scenarios.

Introductory Activity

Browse Canadian newspapers in print or online and find a story that applies to Canadian healthcare and resource allocation.

Post or summarize your news article to your discussion group, including information regarding the source.

Consider what course of action you could take to resolve the issue, from the perspective of your health profession, and post your thoughts in your discussion group. You might include questions you have or information you feel would assist with decision making. Who else would you like to be part of the decision making process?

Make sure to comment on at least one peer’s response as well.

 

Introduction

In module one, you became familiar with various ethical theories.  In module two, you learned how these theories underlie decision-making frameworks and models in bioethics.  In module three, you began to see how ethical theories, and decision-making frameworks and models, are integrated into specific themes in bioethics; module three dealt with the ethical issues surrounding client autonomy.  Module four covered the ethical issues surrounding veracity, privacy, confidentiality, and interprofessional communication and conflict resolution. Module five explores ethical resource allocation in healthcare.

In order to consider resource allocation in healthcare, we must first define health resources. Orb (2007, p.301) states that the term health resources “refers to any goods or services that have a positive effect on health.” The resource allocation challenges for health systems vary greatly between countries and regions. For example, in developing nations, the availability of prescription medications and access to medical professionals may be a major issue. In Canada, issues may centre around emergency room wait times, long waiting lists for specialty treatment or the availability of donor organs. Stories regarding the scarcity of healthcare resources, or the expense of providing healthcare in Canada and beyond, are commonplace in the media.

The average healthcare professional in Canada may never manage a waitlist for services or organ transplantation, however, every healthcare professional manages health resources on a daily basis, often without noticing. When someone sets their schedule for the week, or decides which individual to serve first or prioritize, they are making decisions about resource allocation.

In order to discuss resource allocation in the Canadian context, we must first understand how decisions are made within our healthcare system. The Canadian system uses a single-payer, publicly funded approach that affords universal access to healthcare. The healthcare system is funded at both the federal and provincial level, and healthcare recipients do not pay out of pocket for most medical care (Health Canada, 2009).

This system allows the country to keep the administrative costs of care low, spending 1/8 of every healthcare dollar on administration, where the United States, with its multi-payer system, spends 1/4 of every healthcare dollar on administration (Mappes, Degrazia & Brand Ballard, 2011). While healthcare expenditures are much lower per capita than the United States, and on par with countries such as the Netherlands and Australia (Orb, 2007), health resources are still scarce, with lengthy waits for specialists and elective services (Mappes et al., 2011).

The demand for health resources may be limitless, while the available resources are limited (Orb, 2007). This module will explore the issues that arise in resource allocation, as well as potential solutions and considerations in clinical practice.

 

Read the following news story:

Royal Columbian ER patients moved into Tim Hortons:

http://www.globalnews.ca/royal+columbian+er+patients+moved+into+tim+hortons/96926/story.html

Consider the issue of scarce health resources that hospitals face on a daily basis.

What are the health resources at issue in this story? Post your thoughts to your discussion group.

 

Accountability for Reasonableness

When managing health resources, decisions must be made about healthcare priorities. This can happen at the level of individual healthcare professionals or healthcare teams, as well as at program and administrative levels. Often, budgets are set by administrators who are removed from the day-to-day delivery of health services. However, spending within a program, or the time use of healthcare professionals, may be negotiated within a team.

Regardless of who makes healthcare decisions, ethical priority setting should be guided by a desire for fairness (Daniels, 2000). An ethical framework designed to assist with priority setting is known as “accountability for reasonableness” (Daniels & Sabin, 1997; 2002, as cited in Martin, Gibson & Singer, 2008). This framework specifies conditions that are characteristic of fairness.

The four conditions of “accountability for reasonableness”

Condition

Characteristic

Relevance

Priority setting decisions must rest on reasons that “fair-minded” people can agree are relevant in the context; “fair-minded people seek to cooperate according to the terms they can justify to each other.

Publicity

Priority setting rationales must be publicly accessible.

Revision

There must be a mechanism for challenge, including the opportunity for revising decisions in light of considerations that stakeholders may raise.

Enforcement

Leaders within the organization are responsible for ensuring that the other conditions of fairness are met.

(Table 33.1, Martin et al. (2008), p. 253)

This generic framework is most useful for higher level decision making, where leadership and accountability is involved. The following articles discuss the usefulness of the framework. Martin et al. (2002) consider its use in the Canadian context of cancer and cardiac care, and Russell & deVlaming (2011) apply the framework to a Canadian home care setting.

Required Readings

1. Martin, D.K., Giacomini, M., & Singer, P.A. ( 2002). Fairness, accountability for reasonableness, and the views of priority setting decision-makers. Health Policy, 61, 279-290.

2. Russell, B., & deVlaming, D. (2011). Priority setting up close. The Journal of Clinical Ethics, 22, 61-70.

Interprofessional Priority Setting

While “accountability for reasonableness” (Daniels, 2000) may be applicable to healthcare organizations and institutions, it does not necessarily assist health professionals in day to day decision making around resource allocation. As well, it does not specifically target the interprofessional nature of decision making.

Nelson (2009, p. 181) suggests the following mechanisms for interprofessional teams to resolve resource allocation conflicts:

  • Consider the long-term implications of decisions
  • Maintain ongoing communication and dialogue
  • Be deliberate when establishing service-area boundaries
  • Identify the extent to which community service is owed or expected for service area(s)
  • Promptly address imbalances in benefits and harms
  • Consider the addition of an ethicist to the strategy/leadership team

 

Dialogue and teamwork are key in resolving resource allocation conflicts.

 

Learning Activity

Imagine that you work in a fast-paced acute care setting in a large urban hospital. It is a surgical unit, and there is pressure to discharge people as quickly as possible post-surgery. The team is made up of several surgeons and nurses, a physiotherapist, an occupational therapist, a social worker, and several other professionals.

You have a caseload of many patients, as do your interprofessional co-workers. Your healthcare team meets several mornings a week to discuss the patients on the unit. On Friday morning, the case of Mr. McCarthy comes up.

He is a 75 year old man who has recovered well from a recent surgery, but will require attention from all team members to ready him for discharge before the weekend. Several team members voice concerns that they have a very full case load for the day, with many other patients requiring attention. There are several surgeries scheduled that day, as well as many other patients who would like to be discharged before the weekend. To compound issues, many of the team members do not work over the weekend.

One team member voices that it is Mr. McCarthy’s birthday on the weekend, and that he and his family are very keen to have him home to celebrate. Many relatives are coming that weekend for the party.

Meet in your discussion group in person or via web-interface. In your discussion, represent the views of your profession and imagine your role on this healthcare team. How can the team come to a decision about their resource allocation for the day?

Should they consider Nelson’s (2009) mechanisms for resolving interprofessional resource allocation conflict? Should the unit as a whole adopt an “accountability for reasonableness” (Daniels, 2000) approach and create policies that guide future decision making around resource allocation?

Learning Objectives

1. Develop an understanding of the application of resource allocation in healthcare.

2. Increase attention to the need to apply ethics to everyday healthcare practice.

3. Explore the potential for conflict in allocating scarce healthcare resources.

4. Explore the potential for interprofessional conflict in resource allocation.

An exploration of resource allocation in practice will include the following topics: pandemic preparedness, rural settings and organ transplantation. The breadth of these topics will cover a variety of potential ethical issues that surround resource allocation in healthcare practice.

Pandemic Preparedness

Managing a pandemic, defined as a widespread and contagious outbreak of illness (Merriam-Webster, n.d.), is fraught with ethical issues, such as who to vaccinate first, or allocate medications to, dilemmas regarding the level of risk faced by healthcare professionals, and the potential restriction of personal liberties due to quarantine and travel restrictions (U of T Joint Centre for Bioethics Pandemic Influenza Working Group, 2005).

Many people remember the SARS outbreak of 2003, (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004460/)

and the H1N1 outbreak of 2009. (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0005157/)

For some general information on pandemic preparedness for governments and citizens, watch these videos from the Ontario Public Service:

Part 1- http://www.youtube.com/watch?v=ToXKYsDENTc

Part 2- http://www.youtube.com/watch?v=B2uyL6P3EI4&feature=related

 

Past pandemicas have tested healthcare systems worldwide. In response to the SARS outbreak, the Emergency Management Branch of the Ontario Ministry of Health and Long Term Care (MOHLTC) created a number of programs and resources that can be used during a healthcare emergency.

Visit the Emergency Planning & Preparedness website of the MOHLTC:

http://www.health.gov.on.ca/english/providers/program/emu/emu_mn.html

 

The Canadian government acknowledges that:

“A pandemic will require a regional prioritization of needs and resources, across the health

care system, not just a review of resources at a single institution. For example, in terms of

human resources, healthcare professionals may need to be moved from vaccination clinics to hospitals or from one hospital to another. Beds, ventilators and other equipment may need to be moved to non-traditional sites. This will require a review of logistical, ethical and practical issues throughout the region” (Government of Canada, 2006, Annex H, p. 4).

 

Visit the Canadian Pandemic Influenza Plan for the Health Sector:

http://www.phac-aspc.gc.ca/cpip-pclcpi/pdf-eng.php

 

 

The 2011 film Contagion depicts the intense resources needed to manage a pandemic, and how quickly a disaster can spread.

 

Watch the trailer for the movie at:

http://contagionmovie.warnerbros.com/dvd/#/videos/trailer-1

 

If you are able, watch the movie and consider its depiction of resource allocation in the creation of triage and treatment centres, as well as the prioritization of treatment for infected healthcare professionals versus the general population.

 

To take a less serious look at pandemic preparedness, here are a few clips from the Rick Mercer Report from the 2009 H1N1 outbreak:

1. Swine Flu Rant: http://www.youtube.com/watch?v=CDs8v_3WgFA

2. Priority Flu Shot!: http://www.youtube.com/watch?v=Jg_D9jYoXKE

 

 

Because of the multiple ethical issues faced in the management of a pandemic, The University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group (2005, p. 6-7) advocate for the use of ten substantive values to guide ethical decision-making for a pandemic influenza outbreak:

  1. Individual liberty
  2. Protection of the public from harm
  3. Proportionality
  4. Privacy
  5. Duty to provide care
  6. Reciprocity
  7. Equity
  8. Trust
  9. Solidarity

10.Stewardship

 

Read their report and consider the ethical issues presented in part C, where cases from the SARS pandemic are used as examples. What do you think of the recommendations that are made? How far have we come as a health system in preparing for a future pandemic?

Required Reading

University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group (2005). Stand on guard for thee: Ethical considerations in preparedness planning for pandemic influenza. Retrieved from: http://www.jointcentreforbioethics.ca/people/documents/upshur_stand_guard.pdf

Resource Allocation in Rural Settings

Rural healthcare is a highly relevant area of practice, since up to 30% of Canadians live in rural settings. As well, rural areas may have higher rates of poverty and fewer healthcare professionals per capita than urban areas (Nelson & Schmidek, 2008).

“Allocation of scarce resources is a reality for healthcare professionals and organizations. Resource allocation issues can be particularly challenging for rural communities, where resources are not enough to meet all needs and fewer alternatives exist to resolve conflicts between competing needs. In addition, the ramifications of decisions may be more visible in the rural setting. Decisions regarding allocation of resources can be troubling for clinicians and administrators to make, at both the personal and professional levels. Such decisions can be at odds with providers’ deeply held beliefs about benefiting others without harm. Resource allocation decisions can create conflicts for personal, professional, organizational, and community priorities and commitments” (Nelson, 2009, p. 166).

Rural settings are often short on resources. This could mean a shortage of health human resources, such as health professionals, as well as a shortage of funding or institutional resources such as hospitals and clinics (Nelson & Schmidek, 2008). As well, ethical issues such as privacy and confidentiality can be problematic in smaller communities, where people may know their care providers personally.

Approaches to rural healthcare ethics (Nelson & Schmidek, 2008):

  • Develop professional networks that can provide advice in the face of ethical dilemmas
  • Proactively create and disseminate ethical guidelines for rural institutions and agencies when they are absent
  • Develop and implement community based ethical programs that address issues such as end of life care, consent, privacy and confidentiality to foster community  understanding and proactively address ethical issues
  • Participate on national and international professional committees to raise the profile of rural healthcare ethics 

 

The following 2 readings provide perspectives on rural healthcare.

Nelson, Pomerantz, Howard & Bushy (2007) articulate an ethical agenda for rural healthcare practice. Consider what your role might be in this if you were a rural healthcare provider.

Consider the experience of people who must relocate to receive healthcare, when the resources are not available locally. Kolewaski, Paterson, Yeates & King-Van Vlack (2011) write about the experiences of Cree dialysis recipients from the Mushkegowuk Territory in northern Ontario. What ethical dilemmas are encountered by healthcare providers in the rural area that lacks resources, and the urban area that provides them? Post your thoughts to your discussion group.

 

Required Readings

1. Nelson, W., Pomerantz, A., Howard, K., & Bushy, A. (2007). A proposed rural healthcare ethics agenda. Journal of Medical Ethics,33,136-139. doi:10.1136/jme.2006.015966

2. Kolewaski,C., Paterson, M., Yeates, K. & King-Van Vlack, C. (2010). Relocating from the Mushkegowuk Territory for hemodialysis: The Cree illness experience and perceived quality of life. Pimitasiwin, 8, 103-148. Retrieved from:http://www.pimatisiwin.com/uploads/jan_2011/05KolewaskiPaterson.pdf

Organ/Tissue Donation & Transplantation

Organ and tissue transplantation is a medical procedure that can improve quality of life for recipients, often extending or saving life. Since the first successful kidney transplantation in 1954, live tissue and organs have had a demand that far exceeds supply around the world (Wright, Ross & Daar, 2008).

Canada’s organ donation rate varies around 13-15 per million population (PMP), a number that has been criticized as being lower than other countries such as the United States (US) or Spain, which have rates that are 60-100% higher (Norris, 2009). However, Canada has a younger population than Spain, and a much lower rate of motor vehicle accidents and gunshot victims than the US, as well as superior preventative healthcare when compared to both nations, leading to fewer deaths, and thus fewer donors. As well, the methods of calculations for donor rates vary somewhat between the countries, and Canada’s large geographic area and small population base also limits transplants, further explaining the disparity (Norris, 2009).

Regardless of how Canada’s rates compare internationally, the demand for organs continues to exceed donations. In Ontario in 2010, 916 people received organ transplants, with a total 1498 on the provincial waitlist; figures for previous years are similar (Trillium Gift of Life Network, 2012). In Canada in 2010, 4529 people remained on the waitlist and 247 died while waiting for a transplant (LHSC, 2011).

A recent media campaign has sought to raise the profile of organ donation in Canada:

http://www.ctv.ca/CTVNews/Entertainment/20120131/justin-bieber-organ-donation-effect-120131/

Live donation is possible for tissues such as blood, collected and distributed by blood banks, and organs such as kidneys, often with donation between relatives. While issues of scarcity and distribution of resources apply in these cases, the ethical issues are not usually as difficult to navigate since live donors are typically able to give consent for donation (Orb, 2007).

However, when tissues and organs come from deceased donors, the issues increase in complexity. The central issue of debate is around the property of organs once a person is deceased; are organs a societal resource for the good of all, or personal property, requiring consent from the individual or their next of kin (Wright, et al., 2008). This question of autonomy is a difficult one to answer, and while a few European countries have used a model of presumed consent to operationalize the former, internationally, the latter is usually respected (Wright et al., 2008).

In Ontario, the Trillium Gift of Life Network manages organ donations. Their video, Tissue Donation and Saving Lives in Ontario can be found at:http://www.giftoflife.on.ca/en/healthcareproviders/videos.htm

The video examines the process of donation, as well as the nurse, physician, recipient and family perspectives.

Their Donor Resource Manual details the consent process in Chapter 4: http://www.giftoflife.on.ca/assets/pdfs/5792_TGLN_Manual_Eng11.pdf

Practice guidelines for ethical organ donation from deceased donors (Wright et al., 2008) dictate that:

  1. The declaration of death for the donor be made by a physician who is not part of the transplant team,
  2. consent be given by the family prior to donation, with attention to the deceased’s wishes,
  3.  and that the use of donated organs be coordinated by regional organ procurement agencies who manage a waitlist (such as the Trillium Gift of Life Network).

While many healthcare professionals will never be directly involved in the donation or transplant surgery or the management of a transplant waitlist, they may be involved in the care of donors, the consent process, and the aftercare of transplant recipients. Organ donation and transplantation is a unique case of health resource allocation, and an important area for teamwork, as time is often a critical aspect for successful transplantation.

 

Griffin & Prieto (2008) detail several case studies related to the ethics of organ donation, as discussed by an interprofessional audience at a Mayo Clinic transplant ethics course in 2007. Read the article and consider your personal response to each of the scenarios. What do you consider the best course of action in each of the cases?

Post a response to one of the cases in your discussion group, and be sure to respond to at least one of your peers’ responses.

Required Reading

Griffin, M.D., & Prieto, M. (2008). Case studies in transplant ethics. Transplantation Reviews, 22(3), 178-83.

Revisit a case presented in this module or in any of the required readings. Using the resources contained in this module, and any research you complete on your own to better understand the case, write a critical reflection on the case. Consider the following elements:

  1. Who are the stakeholders in the case?
  2. Of the health professionals involved, how might perspectives differ?
  3. What is your preferred course of action? How might it conflict with other views?
  4. How can resources (both material and human resources) be allocated?
  5. How does interprofessional teamwork add complexity to the issue?

Write a 750 word critical reflection on your chosen case. Please include academic references and submit it to the Course Instructor.

Daniels, N. (2000). Accountability for reasonableness. British Medical Journal, 321, 1301-2.

Degrazia, D., Mappes, T.A., & Brand-Ballard, J. (2011). Biomedical Ethics (7th Ed.). McGraw-Hill: New York, NY.

Government of Canada. (2006). The Canadian pandemic influenza plan for the health sector. Cat.: N° HP40-10/2006E-PDF

Griffin, M.D., & Prieto, M. (2008). Case studies in transplant ethics. Transplantation Reviews, 22(3), 178-83.

Health Canada. (2009). The Health Care System. Retrieved from: http://www.hc-sc.gc.ca/hcs-sss/index-eng.php

Kolewaski,C., Paterson, M., Yeates, K. & King-Van Vlack, C. (2010). Relocating from the Mushkegowuk Territory for hemodialysis: The Cree illness experience and perceived quality of life. Pimitasiwin, 8, 103-148. Retrieved from:http://www.pimatisiwin.com/uploads/jan_2011/05KolewaskiPaterson.pdf

London Health Sciences Centre. (2011). Multi-organ Transplantation Program- Statistics. Retrieved from:http://www.lhsc.on.ca/About_Us/MOTP/Statistics/index.htm

Martin, D.K., Giacomini, M., & Singer, P.A. ( 2002). Fairness, accountability for reasonableness, and the views of priority setting decision-makers.Health Policy, 61, 279-290.

Martin, D.K., Gibson, J.L., & Singer, P.A. (2008). Priority setting. In P.A. Singer & A.M. Viens (Eds.) The Cambridge Textbook of Bioethics (pp.251-256). Cambridge University Press: Cambridge, UK.

Merriam-Webster. (n.d.). Pandemic. Retrieved from: http://www.merriam-webster.com/dictionary/pandemic

Nelson, W. (2009). Handbook for Rural Health Care Ethics: A Practical Guide for Professionals. Dartmouth College Press: Lebanon, NH. Retrieved from: http://dms.dartmouth.edu/cfm/resources/ethics/chapter-09.pdf

Nelson, W., Pomerantz, A., Howard, K., & Bushy, A. (2007). A proposed rural healthcare ethics agenda. Journal of Medical Ethics,33,136-139. doi:10.1136/jme.2006.015966

Nelson, W., & Schmidek, J. (2008). Rural healthcare ethics. In P.A. Singer & A.M. Viens (Eds.) The Cambridge Textbook of Bioethics (pp. 289-295). Cambridge University Press: Cambridge, UK.

Norris, S. (2009). Organ Donation and Transplantation in Canada. Library of Parliament, PRB 08-24E. Retrieved from:http://www.parl.gc.ca/Content/LOP/ResearchPublications/prb0824-e.htm#Trends

Orb, A. (2007). Who gets what? In other words, the allocation of resources. In G. Hawley (Ed.) Ethics in clinical practice: A interprofessional approach (pp. 300-318). Pearson Ed: Essex, England.

Russell, B., & deVlaming, D. (2011). Priority setting up close. The Journal of Clinical Ethics, 22, 61-70.

Trillium Gift of Life Network. (2012). Statistics. Retrieved from http://www.giftoflife.on.ca/en/statistics/

University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group (2005). Stand on guard for thee: Ethical considerations in preparedness planning for pandemic influenza. Retrieved from: http://www.jointcentreforbioethics.ca/people/documents/upshur_stand_guard.pdf

Wright, L., Ross, K., & Daar, A. (2008). Organ transplantation. In P.A. Singer & A.M. Viens (Eds.) The Cambridge Textbook of Bioethics (pp. 145-152). Cambridge University Press: Cambridge, UK.

 

Module 6

Community Care Ethics

Defining Bioethics

The study of bioethics considers the ethical issues that arise in healthcare situations. In other words, it confronts the complex and often competing moral decisions that healthcare practitioners are required to make in every day practice. Some issues may be more frequently encountered by specific professions, but most issues are interprofessional. For example, while ethical issues surrounding euthanasia are likely specific to certain professions, issues surrounding privacy and confidentiality are relevant to all healthcare professions. The objective of these modules is therefore to explore the way interprofessional ethical issues are addressed in healthcare practice, and how collaboration may be improved.

Module Description

This 6-hour module explores ethical issues that present when healthcare is provided in the community. Central considerations for providing ethical care in the community will be explored, and the interprofessional implications.  Learners will have the opportunity to apply these ideas to case scenarios.

As future healthcare professionals, it is important to understand the role bioethics plays in everyday healthcare practice. Clinicians encounter ethical issues on a regular basis, and often must work together to make decisions. Throughout this course you will be introduced to the concepts and knowledge necessary to practice as ethical healthcare professionals.

Learning Goals

Depending on the number of registered learners, it is anticipated that learners will have an opportunity to combine both online and face-to-face types of learning activities in an interprofessional format.

The primary goal of this module is to provide experiential learning activities related to community care ethics. Learners will have the opportunity to consider this content in relation to healthcare cases. Learners will be guided to consider the application of their learning to various environments, such as in the classroom, online and in the clinical setting.

Module Format

Each of the 6 modules in this course will begin with a case study, reading or activity that introduces key content for that module. The module will progress with written material that will explain and elaborate on bioethical principles, frameworks, ideas and their application. Throughout the module, learning activities (hi-lighted by red text boxes) will engage learners with their peers to better understand key concepts and their interprofessional application. Finally, summary learning activities will be completed to apply the content from the module.

Grading Scheme

This course is designed to incorporate a high level of interprofessional collaboration, where learners can learn with, from and about their interprofessional peers. As such, participation is a large portion of the grade.

It is recommended that the grading scheme recognize individual participation in discussion groups as well as evaluate learning through both individual and group methods.

Interprofessional Care

Interprofessional care is a collaborative, team-based approach to providing optimal healthcare, given the systemic demands and unprecedented challenges in healthcare (Interprofessional Care Steering Committee, 2007). Interprofessional collaboration, meanwhile, involves “developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/families and communities to enable optimal health outcomes” (Canadian Interprofessional Health Collaborative [CIHC], 2010, p. 8).

National Interprofessional Competency Framework

Education to support competency in interprofessional healthcare delivery is widely recognized as vital to the success of interprofessional collaboration in Canadian healthcare. The Canadian Interprofessional Health Collaborative (CIHC) National Interprofessional Competency Framework identifies six principle competency domains: 1) interprofessional communication, 2) patient/client/family/community-centred care, 3) role clarification, 4) team functioning, 5) collaborative leadership, and 6) interprofessional conflict resolution. In particular, the first two—interprofessional communication and patient/client/family /community-centred care—are considered the keystone domains which support the competencies in the other four domains (CIHC, 2010).

All of the six competency domains considered critical to interprofessional collaboration are relevant to bioethics in healthcare.

Learning Objectives

  1. Define key considerations in community care ethics.
  2. Understand the application to interprofessional practice.
  3. Apply information to healthcare scenarios.

Introductory Case

Read the case of Joy from the Community Ethics Network Blog:

http://communityethicsnetwork.wordpress.com/2011/12/05/cen-case-joy-not-her-real-name-is-in-her-late-teens-living-with-her-family-and-totally-dependent-upon-others-for-all-of-her-care-needs/

Consider what course of action you would take, from the perspective of your health profession, and post your thoughts in your discussion group. You might include questions you have or information you feel would assist with decision making. Who else would you like to be part of the decision making process?

Make sure to comment on at least one peer’s response as well.

 

Introduction

In module one, you became familiar with various ethical theories.  In module two, you learned how these theories underlie decision-making frameworks and models in bioethics.  In module three, you began to see how ethical theories, and decision-making frameworks and models, are integrated into specific themes in bioethics; module three dealt with the ethical issues surrounding client autonomy.  Module four covered the ethical issues surrounding veracity, privacy, confidentiality, and interprofessional communication and conflict resolution. Module five explored ethical resource allocation in healthcare, and module six introduces the topic of community care ethics.

Community care ethics is an emerging area in the bioethics literature. Unlike clinical ethics, which is traditionally based in institutional healthcare settings and has an extensive evidence base, community care ethics have been neglected by organizations, researchers and policy makers (Anstey & Wagner, 2008). Most educational material is focused on clinical ethics, and many people who work in community settings, such as personal support workers and other unregulated health professionals, receive little training in the area.

However, it is these front line workers who encounter daily ethical issues in the community, and often have very little support to address them. For many professionals working in community settings, care is delivered individually; even if a healthcare team is involved in an individual’s care, they might rarely encounter one another.

Community care ethics seeks to support clients’ independence and integration (or reintegration) into the community, and ideally delivers care in the recipient’s home (Anstey & Wagner, 2008). A client’s self-determination is highly valued, but may also come into conflict with the care that is being delivered by various professionals and organizations.

In an effort to address the unique ethical situations encountered when care is delivered in the community, the Toronto area Community Ethics Network was founded in 2005.

Visit the Community Ethics Network website at: http://www.communityethicsnetwork.ca/home_menu.html

Under the “About Us” tab, take note of their history, mission and explanation of community care ethics.

The Community Ethics Network points out an essential issue in community care, the intersection between the autonomy of the individual, and the care provided by health professionals. In order to better understand the potential conflict, we will first explore the ethics of care.

 

 

The Ethics of Care

In Module 1, ethics of care were first introduced, with reference to the work of Nel Noddings and Virginia Held. The ethics of care is rooted in feminism, but there has been a more recent move to consider the broader meaning of “care” (Tronto, 1998).

This ethical theory assumes that care has a dual meaning- that it is both a value held, and a caring action. The ethics of care also seeks to change health structures so that the care provided is not experienced as oppressive by its recipients (Held, 2006). This philosophy links well to community care, as the autonomy of individuals is highly valued and often emphasized in the practice of community care ethics.

Tronto (1998) points out that caring is a process that transcends healthcare delivery and permeates many contexts and life circumstances. People may experience four separate phases of care: caring about, caring for, caregiving and care receiving, both as healthcare professionals and in their personal lives.

Read Joan Tronto’s article, “An ethic of care,” and consider the many facets of caring that might occur in a health professional’s personal and professional life. Make note of the guiding questions she provides for future caring decisions. How might your approach to care differ from other health professions?

Required Readings

Tronto, J.C. (1998). An ethic of careGenerations, 22, 15-21.

Community Environments

While clinical ethics is a well established field, the ethical dilemmas faced in institutions vary greatly from those encountered in the community. Thus, a unique approach to ethics is necessary to acknowledge the blurred boundaries that exist in community care. With an increasingly aged population, decreasing lengths of stay in hospitals, and increased government attention to reducing healthcare costs, care is increasingly provided in the community. With this comes an increase in moral dilemmas for those providing the community care, often with very few policies or structures built in to address the issues (Anstey & Wagner, 2008).

Many services that are delivered in the community are unique, and may include assistance with personal care, home maintenance, transportation, and assistance with shopping and finances. An individual’s home environment can include family members, pets, friends, and neighbours; as well the community environment may present safety risks that are difficult to plan for and control (Aulisio, 1998).

Home and community environments often receive attention when they are unclean, uncared for, or present risks due to crime in the neighbourhood. In these situations, the ethics of care conflict with the safety of healthcare providers.

Different health professions may hold conflicting views on providing care in community environments that are unsanitary or unsafe. As well, health professionals may struggle with balancing their desire to provide care and their own personal judgements and safety concerns. Baumrucker et al.’s (2009) article explores multiple viewpoints on providing care in an unacceptable environment.

Required Readings

Baumrucker, S.J., et al. (2009). Providing care in an unacceptable environmentThe American Journal of Hospice and Palliative Medicine, 26, 493-499.

Available online through the Queen’s Library catalogue.

Interprofessional Teamwork in the Community

When considering ethical care in the community, we may neglect the functioning of the healthcare teams that provide services. Community organizations are varied in their structure, management and level of policy development. Often when teams in the community face interprofessional conflict, there are no structures in place to assist with resolution.

While community care ethics highly values autonomy and beneficence, healthcare services are influenced by interpersonal factors, organizational policies and issues, legal constraints and professional obligations (Clark et al., 2007). Often, teams may not be equipped to proactively address ethical issues in a team setting.

In the exploration and practice of ethics, most attention is paid to interactions with healthcare recipients, while ethical teamwork may be ignored. When interacting on a team, it is important to consider ethical behaviour toward teammates, based on mutual respect and understanding of the strengths and roles of others on an interprofessional team.

Clark et al.’s (2007) article explores ethical conduct on an interprofessional team, separated out from the care that is provided. The ethical treatment of teammates is the foundation of team functioning. A framework for interprofessional ethics is presented.

Required Readings

Clark, P.G., Cott, C., & Drinka, T. (2007). Theory and practice in interprofessional ethics: A framework for understanding ethical issues in healthcare teamsJournal of Interprofessional Care, 21, 591-603.

Learning Activities

1. Consider the case of healthcare team conflict on page 597 of Clark et al.’s (2007) article. Using the interprofessional ethics framework (Tables 1 & 2), work in your discussion group to create a concrete strategy the team in the case study could use at the individual, team and organization levels to diffuse this situation. Post your strategies in the discussion forum.

2. Using the article by Baumrucker et al. (2009), consider the multiple viewpoints on the provision of palliative home care for an individual who is deemed to live in unsafe conditions. Of the professionals who responded to the case, whose response resonates most with you? What course of action would be reasonable to take? How does this align with your personal ethics of care? Write a 400-500 word response to the article and submit to the Course Instructor.

Learning Objectives

1. Develop an understanding of the application of ethical care in the community.

2. Increase attention to the need to apply ethics to everyday healthcare practice.

3. Explore the potential for conflict between individual autonomy and healthcare provision.

4. Explore the potential for interprofessional conflict in community care.

Living with Risk

While client autonomy and independence is often highly valued in community care, the choices that individuals make may conflict with the values of health professionals, or may leave them at risk for poor health or harm.

However, we all live with a degree of risk in our lives; different people will find different amounts of risk acceptable. There are many competent, independent people in the world who make decisions to smoke, eat fast food, drink alcohol more than is recommended, or exercise less than recommended. People also make decisions to skydive, rock climb, and ride their bikes on busy roads. No matter how health conscious, or risk averse, we may be in our daily lives, risk is unavoidable.

Why, then, do health professionals expect the individuals they serve to live risk-free lives? It is common for health professionals to recommend that older adults stop living independently because they are at risk for falls or unsafe when cooking (Baker et al., 2007), but it is not as common for them to examine what degree of risk is simply a normal part of life in the community.

This dilemma points out the conflict between individual autonomy, and the right to live at risk, and health professional beneficence, or the desire to care for those we view as requiring assistance.

Read Baker et al.’s (2007) article, and consider the case of Mary & George, who place more value on their autonomy than on their personal safety. If these were your family members, how would you feel? And, if you were a health professional involved in their care, would you feel differently? Post your 2 answers to your discussion group, and be sure to comment on at least one peer’s posting.

Required Reading

Baker, K., Campton, T., Gillis, M., Kristjansson, J., & Scott, C. (2007). Whose life is it anyway? Supporting clients to live at riskPerspectives, 31,19-24.

 

Community Care Ethics Application

Three areas of community care will be explored in order to showcase potential ethical issues faced by health professionals. Community mental health practice, palliative care in the community and community care for older adults will all be presented as these are common areas where ethical issues present in the daily context of community care.

1. Community Mental Health Practice

In the past 4 decades in Canada, mental health practice has evolved from largely institution based to increased focus on service provision in the community. The process of “deinstitutionalization” moved many people into the community who now receive mental healthcare in their home environments (Whitehead & Sealy, 2004). Although this move to the community has supported client autonomy, healthcare practice in this area has a legacy of paternalism.

Paternalism can be defined as: “the policy or practice on the part of people in positions of authority of restricting the freedom and responsibilities of those subordinate to or otherwise dependent on them” (Pearsall, 1998, as cited in Roberts, 2004, p. 583). Paternalistic approaches to healthcare often directly conflict with individual autonomy, and may further stigmatize people with mental illness and deny their personal choice and freedom (Roberts, 2004). The potential for community mental health practice to restrict individual choice can lead to numerous ethical dilemmas for health professionals.

Paternalistic practices often arise from the desire to help individuals (beneficence) and to keep them from harm (non-maleficence). Unfortunately, this approach may lead to the restriction of the freedom of the individual, the right to choose one’s own destiny, and the right to live at risk. Healthcare practitioners may sometimes coerce individuals into preferred courses action, such as having them take medication, live in prescribed situations, or follow rules set out by the healthcare services (Davis, 2002). These issues highlight the intersection of individual autonomy and paternalism.

Recently, the Recovery Model has gained popularity in community mental health practice. The central concept is that people can lead fulfilling lives despite a diagnosis of mental illness, and that healthcare services need to reflect this belief. The Recovery Model fosters independence, empowerment and dignity for individuals (CMHA, 2011).

Read the Canadian Mental Health Association’s summary of “recovery”

http://www.ontario.cmha.ca/about_mental_health.asp?cID=7667

Visit the Mental Health America of LA- MHA Village, housing with a recovery vision

http://www.mhala.org/mha-village.htm

Consider the concept of “recovery.” How does it fit with your own personal ethic of care? Which professions might embrace this model, and which may have philosophical differences? What are the potential ethical conflicts?

In any area of healthcare provision, the larger system and structures often conflict with the values of health professionals, those who receive care, and their support networks. The same is true in community mental health practice. Davis (2002) explores the tensions between self-determination and coercion, considering multiple perspectives. Trinh et al. (2008) consider the tensions in the daily work of a community mental healthcare team, providing three examples of ethical dilemmas frequently encountered by the team.

Read these two articles and reflect on the ethical dilemmas encountered in community mental health practice. Consider the varied perspectives of healthcare team members, and where ethical conflict may occur between team members’ values and approaches.

Required Reading

1. Davis S. (2002). Autonomy versus coercion: reconciling competing perspectives in community mental healthCommunity Mental Health Journal, 38, 239–50.

2. Trinh, Nhi-Ha, Moore, Derek & Brendel, David H. (2008). Ethics consultation to PACT teams: Balancing client autonomy and clinical necessity.Harvard Review of Psychiatry, 16, 365-372. doi:10.1080/10673220802564160

2. Palliative Care in the Community

“Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (World Health Organization, 2002).

In Canada, palliative care is moving out of institutional environments, with more people now choosing to die at home. This move to the community poses unique challenges, and moves some ethical dilemmas from the clinical setting into the homes of those receiving palliative care, where resources may be limited. Health professionals providing palliative care in the community may offer practical assistance, such as coordinating services, assisting with symptom management, and offering emotional support (Brazil et al., 2010).

Enabling people to experience their final phase of life in the place of their choosing, which is often their own home, respects their autonomy and dignity. However, this process is often impossible without the support of family, friends, and health professionals (Karlsson & Berggren, 2011). The goal of palliative care is to provide the highest quality care possible, in the individual’s preferred environment. Fulfilling this goal often requires an interprofessional team that may involve physicians, pharmacists, nurses, occupational and physical therapists, personal support workers and others (Hutton, 2005). Medications must be managed, activities of daily living completed, personal care supported.

Community organizations may also assist with this goal. Hospice Kingston’s mission is “to provide comfort and support for individuals and families living with a life-limiting illness or coping with grief and loss.” Visit their website at: http://hospicekingston.ca/

Consider how health professionals, support networks and community organizations can work together to provide optimal care in the community.

The autonomy and dignity of the individual receiving palliative care is often paramount in caregiver and health professional’s minds, however, limited resources may conflict with this ideal. Brazil et al. (2010) completed a qualitative study of community health professionals (nurses, social workers, personal support workers, physiotherapists, occupational therapists and speech language pathologists) working in palliative care in Ontario. They identified numerous ethical issues they regularly encounter, including caregiver burden, competency, communication and decision making. Karlsson & Berggren (2011) completed a qualitative study of nurses in Sweden providing palliative home care and found that autonomy, integrity and safety were significant factors in providing high quality palliative care.

Read these two articles and reflect on the ethical dilemmas encountered in palliative care in the community. Consider the varied perspectives of healthcare team members, and where ethical conflict may occur between team members’ values and approaches.

Required Reading

1. Brazil, K., Kassalainen, S., Ploeg, J., & Marshall, D. (2010). Moral distress experienced by healthcare professionals who provide home-based palliative care.  Social Science & Medicine, 71, 1687-91.

2. Karlsson, C., & Berggren, I. (2011). Dignified end-of-life care in the patients' own homes.  Nursing Ethics, 18, 374-85.

3. Older Adults Living in the Community

The Canadian population is experiencing a shift in age demographics, with a continued increase in the proportion of Canadians over the age of 65 (Health Canada, 2002).

Visit the Human Resources and Skills Development Canada (HRSDC) website to view graphs that depict our changing population:http://www4.hrsdc.gc.ca/.3ndic.1t.4r@-eng.jsp?iid=33

Currently, 16% of the population is over the age of 65, but by 2051, it is projected that 1 in 4 people in Canada will be.

With the impending change in demographics comes attention to aging in the community. Many older adults value living independently in their own homes, even with physical health challenges and cognitive issues such as dementia (Baker et al., 2007; Culo, 2011; Strang et al., 1998).

The Ontario Government recognizes the need to support healthy aging in the community, both from a financial and quality of life perspective. They recently introduced an Aging at Home Strategy, which can be viewed here:http://www.health.gov.on.ca/english/public/program/ltc/33_ontario_strategy.html

HealthForceOntario has championed interprofessional care, funding a recent research project that raised the profile of interprofessional community care for older adults. See the Interprofessional Leadership Project on the Research Institute for Aging’s website:

 http://www.the-ria.ca/research/detail_other-01.cfm

Take note of the group poster presentations that showcase many interprofessional approaches to care for older adults in the community.

 

While the Ontario government and many organizations and healthcare providers are committed to high quality community healthcare services for older adults, providing these services can be challenging. Ethical dilemmas are frequently encountered in community care for older adults, especially when an individual experiences health challenges that limit their autonomy. Strang et al.(1998) explore these issues in the context of capacity to choose where one lives. This article was included in module 3 in the context of autonomy and capacity, and will be re-examined here from the perspective of aging in the community.

Culo (2011) raises the need to assess risk for vulnerable community dwelling individuals, and the potential ethical dilemmas in balancing safety and self-determination. She also points out on page 423 that health professionals may be overly reliant on cognitive tests to decide competency, when normal scores do not necessarily indicate competence, just as abnormal scores do not equal incompetence. The importance of approaching each case as unique, considering the environment, and the use of community supports to enable independence are discussed.

Read these two articles and reflect on the ethical dilemmas encountered in community care for older adults. Consider the varied perspectives of healthcare team members, and where ethical conflict may occur between team members’ values and approaches.

Required Reading

1. Culo, S. (2011). Risk assessment and intervention for vulnerable older adultsBC Medical Journal, 53, 421-425.

2. Strang, D.G., Molloy, D.W., & Harrison, C. (1998). Capacity to choose place of residence: Autonomy vs BeneficenceJournal of Palliative Care, 14, 25-9.

Learning Activities

1. Choose one of the three community care areas (mental health, palliative care, older adults) and create a summary of how autonomy and beneficence conflict. You may wish to create a table that summarizes pros and cons to prioritizing autonomy over beneficence, and vice versa. Post your summary to your discussion group and be sure to comment on at least one peer’s posting.

2. In your interprofessional discussion group, meet in person or via web interface. Discuss your profession-specific views on each of the three community care areas. Agree to be respectful, but try to discuss both sides of an issue, and how conflict might be experienced between health professionals working in the community. Discuss strategies that might be used to address ethical conflicts.

Revisit a case presented in this module or in any of the required readings. Using the resources contained in this module, and any research you complete on your own to better understand the case, write a critical reflection on the case. Consider the following elements:

  1. Who are the stakeholders in the case?
  2. Of the health professionals involved, how might perspectives differ?
  3. What is your preferred course of action? How might it conflict with other views?
  4. How can autonomy and beneficence be balanced?
  5. How does care in the community add complexity to the issue?

 

Write a 750 word critical reflection on your chosen case. Please include academic references and submit it to the Course Instructor.

Anstey, K.W., & Wagner, F. (2008). Community healthcare ethics. In P.A. Singer & A.M. Viens (Eds.) The Cambridge Textbook of Bioethics (pp.299-305). Cambridge, UK: Cambridge University Press.

Aulisio, P. (1998). Vulnerabilities of clients and caregivers in the homecare setting. Generations, 22, 58-64.

Baker, K., Campton, T., Gillis, M., Kristjansson, J., & Scott, C. (2007). Whose life is it anyway? Supporting clients to live at risk. Perspectives, 31,19-24.

Baumrucker, S.J., et al. (2009). Providing care in an unacceptable environment. The American Journal of Hospice and Palliative Medicine, 26, 493-499.

Brazil, K., Kassalainen, S., Ploeg, J., & Marshall, D. (2010). Moral distress experienced by health care professionals who provide home-based palliative care.  Social Science & Medicine, 71, 1687-91.

Clark, P.G., Cott, C., & Drinka, T. (2007). Theory and practice in interprofessional ethics: A framework for understanding ethical issues in health care teams. Journal of Interprofessional Care, 21, 591-603.

CMHA. (2011). Recovery. Retrieved from http://www.ontario.cmha.ca/about_mental_health.asp?cID=7667

Culo, S. (2011). Risk assessment and intervention for vulnerable older adults. BC Medical Journal, 53, 421-425.

Davis S. (2002). Autonomy versus coercion: reconciling competing perspectives in community mental health. Community Mental Health Journal, 38, 239–50.

Health Canada. (2002). Canada’s Aging Population. Minister of Public Works and Government Services Canada, Cat. H39-608/2002E.

Held, V. (2006). Ethics of care: personal, political and global. Oxford Scholarship Online.

Hutton, N. (2005). Palliative care, time, and core values. Patient Education & Counseling, 56, 255-6.

Karlsson, C., & Berggren, I. (2011). Dignified end-of-life care in the patients' own homes.  Nursing Ethics, 18, 374-85.

Roberts, M. (2004). Psychiatric ethics: a critical introduction for mental health nurses. Journal of Psychiatric and Mental Health Nursing, 11 (5), 583-588.

Strang, D.G., Molloy, D.W., & Harrison, C. (1998). Capacity to choose place of residence: Autonomy vs Beneficence. Journal of Palliative Care, 14,25-19.

Trinh, Nhi-Ha, Moore, Derek & Brendel, David H. (2008). Ethics consultation to PACT teams: Balancing client autonomy and clinical necessity.Harvard Review of Psychiatry, 16, 365-372. doi:10.1080/10673220802564160

Tronto, J.C. (1998). An ethic of care. Generations, 22, 15-21.

Whitehead, P. C., & Sealy, P. (2004). Forty years of deinstitutionalization of psychiatric services in canada: An empirical assessment. Canadian Journal of Psychiatry, 49(4), 249-57.

World Health Organization. (2002). National cancer control programmes: policies and managerial guidelines (2nd ed.). Geneva:WHO.

ACKNOWLEDGEMENTS

Theresa Bernard, BA
- Curriculum Design Assistant

Hannah Kaufman, MHSc (Bioethics)
- Bioethicist

Dr. Margo Paterson
- Professor, School of Rehabilitation Therapy, Director of OIPEP, Queen’s University

Dr. Jennifer Medves
- Vice Dean, Faculty of Health Sciences, Professor and Director, School of Nursing, Queen’s University


Curriculum Developers

Megan Edgelow, MSc(RHBS), BSc(OT), OT Reg.(Ont.)
Erin Holder, BA (Hons.)


Recommended Citation:

Edgelow, M. & Holder, E. (2012). Healthcare Issues – Interprofessional Course Series:  Bioethics in Healthcare. Curriculum developed for the Faculty of Health Sciences. Kingston: Queen’s University.

 

This interprofessional curriculum development project has been funded by a Queen’s University Reinvestment Funds. The views expressed here do not necessarily reflect those of the University.