Issues in Health Care: Legal Issues

Part A

Introduction: Health law and interprofessional collaboration
Welcome to Healthcare Issues - Interprofessional Course Series - Legal Issues in Interprofessional Healthcare, an online course offered by the Faculty of Health Sciences at Queen’s University. This six-hour module is intended as an introduction to a course-length exploration of the importance of health law to interprofessional collaboration. The module is intended to provide a foundation for the key concepts as well as other materials that will be covered in the remaining five modules that comprise this course. The module begins with a general explanation of the importance and relevance of both interprofessional collaboration and health law and then offers an overview of the general topics and areas that will be developed in more detail later.

Why law matters to collaborative healthcare
Healthcare and the law frequently intersect in their distinct but common service of the interests of patients. Consequently, as healthcare grows more complex and accomplished so do the legal and rights-based issues facing patients and their families. New legal questions proliferate to challenge health professionals and the communities in which they work. These days, for example, the continued expansion of health law includes increasingly complicated legislation concerning biotechnology, end-of-life decisions, sexual and reproductive options and many other issues brought to life by accelerating advances in medicine and technology.

Meanwhile, these same advances—and the complexity they add—have made interprofessional care a high priority for federal and provincial initiatives aimed at improving patient care and patient safety while reducing costs and increasing efficiency.

This online course
This online course explores the relevance of health law to interprofessional collaboration through six modules. The modules cover aspects of health law that intersect with interprofessional collaboration practices in Canadian healthcare (with an emphasis on Ontario).

The course modules are designed to encourage:

An understanding of relevant health law through the lens of the National Interprofessional Competency Framework, 2010;
An understanding of the importance of roles of regulated health professionals to interprofessional collaboration in the provincial context (with particular attention to the Ontario example);
Recognition of the rights of patients and involvement of families in the context of collaborative practice;
An understanding of the legal protection of health information and the legal reporting duties of health professionals working in collaboration;
An awareness of the legal implications for health professionals of collaborative healthcare practice;
An understanding of the legislative and other law-related barriers to interprofessional collaboration;
An awareness of the legal risks and consequences of interprofessional collaborative practices in the context of Canadian healthcare; and
An understanding of law reform initiatives needed to facilitate interprofessional collaboration.

Learning objectives
The primary goal of this module is to introduce definitions and concepts as well as to provide learning activities to enhance your understanding of the objectives outlined below. Learners will have the opportunity to test their comprehension of the ideas introduced in this course through a variety of reflective exercises and will be encouraged to consider the application of this material in clinical and other learning environments.

By the end of this module, participants should
i.         Understand the meaning, breadth, and importance of interprofessional collaboration in healthcare;
ii.         Be familiar with the National Interprofessional Competency Framework, 2010;
iii.         Understand the concept of health law and its relevance for 1. patients and their families and 2. health professionals;
iv.         Understand the role of health law in interprofessional collaboration; and
v.         Understand the relevance of the Constitution and provincial and federal legislation to health law and health professionals.

Reflection

WATCH:
Benefits of Teamwork 1:
A film about the benefits of teamwork in healthcare

http://www.youtube.com/watch?v=JQyPqAOPA-o&list=UUm-tze53Qzz2nZzLLVK0mVA&index=57&feature=plcp

As the film makes clear views concerning the benefits of interprofessional healthcare are divergent. Compare and contrast arguments for and against interprofessional collaboration in healthcare.

Part B

What is interprofessional collaboration?
Interprofessional care “is a collaborative, team-based approach to providing optimal patient care, given the systemic demands and unprecedented challenges in healthcare” (HealthForceOntario, 2010). Interprofessional collaboration, meanwhile, involves “developing and maintaining effective interprofessional working relationships with learners, practitioners, patients/clients/ families and communities to enable optimal health outcomes” (CIHC, 2010 p. 8).

In particular, interprofessional collaboration encourages a continuous relationship of cooperation, respect, and communication between and among health disciplines—and patients—to maximize the effectiveness of care. This idea is perhaps best articulated in the description of collaborative healthcare offered by Lahey and Currie (2005) at p. 217:

Collaborative patient-centered practice is a practice orientation, a way of health care professionals working together and with their patients. It involves the continuous interaction of two or more professions or disciplines, organized into a common effort, to solve or explore common issues with the best possible participation of the patient. Collaborative patient-centered practice is designed to promote the active participation of each discipline in patient care. It enhances patient – and family – centered goals and values, provides mechanisms for continuous communication among care givers, optimizes staff participation in clinical decision-making (within and across disciplines), and fosters respect for the contributions of all disciplines.

The idea has been gaining momentum in recent years, not least because it is seen by some as a more efficient and economical approach to quality care in the Canadian health context. See the development of this idea in Ontario in the timeline below.

A growing emphasis on interprofessional collaboration: Timeline

2000 Federal, provincial and territorial health ministers agree to the need for a plan for national healthcare system renewal. The agreement outlines a federal vision, principles, and an action plan.

2003 The federal, provincial and territorial governments meet again to hammer out the First Ministers’ Accord on Health Care Renewal(2003).The agreement between the Government of Canada, the provincial premiers, and territorial leaders commits to strengthening Canada’s healthcare system and making it more accountable to the public. The Accord sets out an action plan for reform that reflects a commitment to healthcare services that are high quality, effective, patient-centered and safe (http://www.hc-sc.gc.ca/hcs-sss/delivery-prestation/fptcollab/2003accord/index-eng.php).

2007 In Ontario, HealthForceOntario, an arm’s length advisory body to the Ministry of Health, publishes Interprofessional Care: A Blueprint for Action in Ontario (2007). The report identifies the benefits of Interprofessional Care and creates a guiding framework for government, educators, health caregivers, organizational leaders, regulators, and patients in how to implement this collaborative team-based approach to care (http://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdf).

2010 The Implementing Interprofessional Care in Ontario: Final Report of the Interprofessional Care Strategic Implementation Committee is released. Building on the 2007 report, the new document lays the groundwork for a culture of collaboration and patient-focused care by promoting best practices to guide and implement interprofessional care. Integral to this initiative is the development of a framework for interprofessional education; the identification of core competencies for interprofessional care; and a model for implementing interprofessional care. The report reflects Ontario’s commitment to making a collaborative team-based approach to care the gold standard for healthcare (http://www.healthforceontario.ca/upload/en/whatishfo/ipcproject/hfo%20ipcsic%20final%20reportengfinal.pdf).

Benefits of interprofessional collaboration
The theoretical benefits of interprofessional care have been widely recognized in Canada. In 2007, HealthForceOntario, an advisory body to the Ontario Ministry of Health and Long-term Health, published a report on interprofessional collaboration called Interprofessional Care: A Blueprint for Action in Ontario. The report outlined six central benefits to healthcare arising from interprofessional care:

increased access to healthcare;
improved outcomes for people with chronic diseases;
reduced tension and conflict among caregivers;
improved the efficient use of clinical resources;
improved the recruitment of caregivers; and
reduced rates of staff turnover.

READ THE REPORT: http://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdf

National Interprofessional Competency Framework
The Canadian Interprofessional Health Collaborative, an organization of health educators, researchers, health professionals, and students from across Canada, developed the National Interprofessional Competency Framework in 2010 (“The Framework”). The Framework is a “living document” intended as a starting place to engage professionals in the development of interprofessional competencies that can be “tested and either verified, adjusted or discarded.”

These core competency domains are intended to set a standard for not only for the skills and knowledge necessary for successfully cooperating healthcare professionals but also for the most effective “attitudes and behaviours required to be a successful practitioner in any profession” (CIHC, 2010 p. 7). The Framework identifies competencies that are both relevant to particular professions but also apply across all health professions (CIHC, 2010).

Six competency domains of interprofessional collaboration
The National Interprofessional Competency Framework has six competency domains that include the two overarching domains of patient-centered care (including family and community) and interprofessional communication. These domains are intended to highlight the knowledge, skills, attitudes, values and judgments involved in practicing collaboratively. These six competencies are:

interprofessional communication
patient/client/family /community-centered care
role clarification
team functioning
collaborative leadership
interprofessional conflict resolution

The two overarching competency domains are patient-centered care (including family and community) and interprofessional communication, which are considered to support and influence the other four domains and are relevant to all aspects of interprofessional, collaborative practice (CIHC, 2010).

Reflection
WATCH:
Canadian Health Services Research Foundation (5 short videos)

Cooperate, Coordinate, Collaborate
An Interprofessional Model of Patient Care
Interprofessional Education
Building Interprofessional Teams
Patient-Centred Collaborative Care

http://www.youtube.com/user/CHSRF/videos?query=interprofessional

What are the objectives of interprofessional healthcare and how are they best facilitated?

Part C

Why does law matter to interprofessional collaboration?
Common to the competency domains recommended in the National Interprofessional Competency Framework are the characteristics important to effective relationships in healthcare—those between and among health professionals working together and those involving professionals and the patients they care for (as well as patients’ families). Importantly, laws regulating professions, healthcare delivery and quality, and patient rights all affect—and potentially limit—how healthcare relationships are managed.

What is health law?
Health law is difficult to define. These days, it covers a very broad field, but this was not always the case. Historically, health law fell within the parameters of tort law (a legal wrong or injury), and as such, focused primarily on issues of medical malpractice. These included the physician-patient relationship, the standards of care of healthcare professionals, and informed consent (Caulfield, Flood, & Downie, 2011).

But health law has evolved so that it now rears its head in almost every area of law, including contract, property, constitutional, criminal and tort law. It involves such disparate topics as human rights, patenting and research ethics. It is informed by other fields of study including philosophy, economics, sociology, genetics, neuroscience, cell biology and information technology (Caulfield et al., 2011).

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Direct: http://openclipart.org/people/SteveLambert/SteveLambert_Library.svg

Why is health law important?
Health law is more than the study of laws relevant to areas of medicine; it is a field of law that draws together all the legal and policy issues that are relevant to human health. — Caulfield et al., 2011

Health law is about the legal protection of patients, families, communities, and health professionals.

Laws protect people by making sure patients and their families in the healthcare system are safe and get quality care. Protection involves showing respect for patients, families and health professionals and by ensuring healthcare environments are sensitive to privacy and that healthcare practices are non-discriminatory (Caulfield et al., 2011).

Who is affected by health law?
The sweep of health law is surprisingly wide in Canadian healthcare and affects care delivery at almost all points of contact between patients and families and the health system. For that reason, aspects of health law are relevant to:

patients and
families

and also to the range of professionals including:

Essential areas of health law?
This course discusses the impact of many essential areas of health law that have a significant bearing on the feasibility and effectiveness of interprofessional collaboration in healthcare. Other legal areas not discussed in this course may also have an impact on how and how well interdisciplinary care can be delivered, but the elements of law described in the following pages may be considered among the most relevant. These legal areas are discussed in this and later modules and include the following:

health law and interprofessional collaboration (Module I);
how regulation can be a barrier to interprofessional collaboration (Module II);
how malpractice law is a barrier to interprofessional collaboration (Module III);
interprofessional collaboration and the rights of patients and involvement of their families (Module IV);
interprofessonal collaboration and personal health information law (Module V); and
health law reform and interprofessional collaboration (Module VI).

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PUBLIC DOMAIN: Under this: http://creativecommons.org/publicdomain/zero/1.0/

Why is health law important to interprofessional collaboration?
Health law and interprofessional collaboration are closely interrelated. Law affects the ability of health professionals to collaborate through legislation that directly governs professional relationships. Health law also helps professionals understand and establish clear roles, responsibilities, and liabilities, in order to better facilitate collaboration.

For example, the 2007 Interprofessional Care: A Blueprint for Action in Ontario recognized the relationship between law and collaboration by healthcare teams when it called for the incorporation of interprofessional care into existing healthcare legislation (HealthForceOntario, 2007). The report recommended a legislative review of healthcare laws to identify legal barriers to interprofessional care and to recommend amendments to better facilitate collaboration.

In general, knowing about existing health law is an important early step in developing effective interdisciplinary teams for interprofessional collaboration because it can provide insight into three key areas of understanding:

legal clarity on the rights of patients and involvement of families;
legal clarity on roles and responsibilities of healthcare team members; and
clarity on the legal liability borne by collaborating health team members.

http://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdf

Reflection
READ: Chapter 1: Interprofessional Care – the Context at pp. 11 to 17 in Blue Print for Action.

HealthForce Ontario. (2007). Interprofessional Care: A Blueprint for Action in Ontario. Retrieved fromhttp://www.healthforceontario.ca/upload/en/whatishfo/ipc%20blueprint%20final.pdf

What role could streamlining legislation and regulation play in achieving interprofessional care?

Part D

Legal frameworks, health law and interprofessional collaboration
Legal frameworks define jurisdictions and authority for making laws and regulations that impact healthcare. Understanding how legal frameworks and authority shape healthcare is important to health professionals seeking to know what laws apply where and to whom. The legal framework for health law in Canada is created by the Constitution, federal and provincial legislation, and regulatory powers provided to the governing bodies of health professions themselves

The legal frameworks affecting health professionals represent a complicated mix of federal and provincial health law along with self-regulation by individual healthcare professions. This layering of authority substantially complicates an understanding of the legal responsibilities and liabilities of health professionals functioning in the context of interprofessional healthcare teams.

Constitutional division of powers and health law
The federal and provincial division of powers set out in the Constitution Act, 1867 is the basis for the legal framework of healthcare in Canada. How the authority over healthcare issues is constitutionally divided is mainly a consequence of history and culture (Wakulowsky, 2010).

While the provinces are considered to have “primary” jurisdiction over issues of healthcare (MacIntosh, 2011), much of this country’s healthcare authority is shared by the federal and provincial governments. Any disputes between these levels of government over jurisdiction to legislate in an area of healthcare is typically clarified by the courts (Wakulowsky, 2010).

READ IT HERE: Constitution Act, 1867, can be viewed online at http://laws.justice.gc.ca/eng/Const/Const_index.html

http://commons.wikimedia.org/wiki/File:Map_of_Canada.jpg
PUBLIC DOMAIN

Federal jurisdiction
Powers affecting healthcare law in the federal context are distributed in many ministerial portfolios, and have their source in enumerated federal powers including Spending, Criminal Law, Peace, Order & Good Government, Indians & Land Reserved for Indians, and other powers found in Section 91 of the Constitution Act, 1867 (Wakulowsky, 2010).

Significantly, the federal government’s spending power translates into a significant “regulatory presence” in healthcare through the Canada Health Act (Wakulowsky, 2010 p.3). “This legislation establishes provincial eligibility for federal cash contributions towards health insurance costs” (Wakulowsky, 2010, p. 3).

The Canada Health Act forms the “legal foundation” for federal authority over Canadian healthcare, and is animated by a variety of laws, policies, and administrative systems (Lahey, 2011 p. 1). “The Canada Health Act promises uniform and universal access to a comprehensive range of physician and hospital services” (Lahey, 2011, p. 1). This program of public health insurance is best known to Canadians as medicare (Lahey, 2011).

The Canada Health Act sets out five criteria the health care insurance plan of a province must meet in order to qualify for transfer payments. These criteria are public administration, comprehensiveness, universality, portability and accessibility.

READ IT HERE: The Canada Health Act can be viewed online at http://laws-lois.justice.gc.ca/eng/acts/C-6/index.html

http://commons.wikimedia.org/wiki/File:Parliament_Hill_Front_Entrance.jpg
PUBLIC DOMAIN

Provincial jurisdiction
Section 92 of the Constitution Act, 1867 has a number of enumerated powers from which provincial authority for healthcare flows. These include powers relating to Hospitals, Property & Civil Rights, and Local/Private Matters (Wakulowsky, 2010).

The fundamental nature of these powers with respect to caring for the sick means the provinces have primary constitutional responsibility for healthcare in Canada. The federal government’s jurisdiction over healthcare, meanwhile, is limited to issues of healthcare relevant to particular portfolios of federal concern (e.g.,Spending, Criminal Law, Peace, Order & Good Government, Indians & Land Reserved for Indians) outlined under Section 91 (MacIntosh, 2011).

http://commons.wikimedia.org/wiki/File:George_Brown_Monument,_Queens_Park,_Toronto,_Ontario.jpg
PUBLIC DOMAIN

Law, healthcare and indigenous peoples
The question of who has responsibility and authority over healthcare affecting Aboriginal peoples in Canada is contentious. The central legal issue relates to whether the federal government’s authority over Indians, and Lands reserved for Indians 91(24)-- creates the basis for the federal government having jurisdiction over the healthcare of “Indians” (either directly, or as an ancillary matter). In this connection, a further related legal issue is about who falls within the meaning of “Indian” for the purposes of section 91(24) (MacIntosh, 2011).

The federal government takes the position that there is no constitutional obligation that requires it to offer health programs or services to indigenous peoples. It takes the position that any medical assistance it provides to indigenous peoples is a discretionary (and not legally required) exercise of its jurisdiction under section 91(24) (MacIntosh, 2011).

In practice, however, the federal government assumes responsibility for the health of indigenous peoples who are Inuit or are registered Indians, and expects the provinces to be responsible for the health of the remainder of the indigenous population. This is in addition to the federal government’s legal obligation to provide health services and products to certain indigenous peoples pursuant to treaties (MacIntosh, 2011).

Why Aboriginal healthcare matters
Who has legal jurisdiction and authority over Aboriginal healthcare remains the subject of debate, yet the health problems facing indigenous peoples in Canada are unique and uniquely in need of urgent action.

WATCH AND LISTEN:

Jurisdiction of professional colleges

The practice of a profession is a privilege granted by the province to the professional. There is no right to practice a profession. Since the province grants the privilege it can take it away if the privilege holder fails to abide by the conditions attached to it. It’s like a driver’s licence which can be taken away by the province if you break the “rules of the road.” This has been affirmed in many cases including Mussani v. College of Physicians and Surgeons of Ontario [2003] O.J. No 1956, 64 O.R. (3d) 641, para. 142 “A licence is not a right but a privilege…”http://canlii.ca/t/6xxz

While provinces and territories have primary constitutional responsibility for healthcare in Canada, these governments have generally adopted legislative models that authorize the healthcare professions themselves to regulate the healthcare delivery of their own members. In particular, provincial laws provide powers to the governing bodies of many health professions—or professional colleges—so that they may enact binding regulations regarding who may practice in a profession and how they must conduct themselves.

This is referred to as self-regulation and it is the most common form of health profession regulation in this country (Epps, 2011). Governments retain control over self-regulating health professions through law delegating the self-regulating authority (although this often varies for different jurisdictions). Provincial or territorial governments maintain power to approve regulations established by the professional body. Regulations must be approved by the Governor General in Council or the Lieutenant Governor in Council before they become law. This isn’t true of by-laws and other types of self-regulatory instruments used by the professions.

What is regulation in healthcare?
The term regulation refers to “any process or set of processes by which norms are established, the behavior of those subject to the norms monitored or fed back into the regime, and for which there are mechanisms for holding the behavior of regulated actors within the acceptable limits of the regime (whether by enforcement action or by some other mechanism)” (Scott, 2001 p. 331). That is, regulations are what establishes, monitors, and enforces acceptable standards of behavior.

In healthcare, regulation allows policy makers to establish norms that health professionals must follow (Epps, 2011). These regulations are crucial for maintaining public safety and public confidence in the Canadian healthcare system. One role of health regulation is to help define the scopes of practice, outlining what each regulated profession may do, as well as what activities health professionals are restricted from doing known ascontrolled acts.

In this way, regulatory frameworks may influence collaboration by constraining efforts to cross between professional silos in the spirit of cooperation and consensus-focused patient care. The impact of professional regulation on interprofessional collaboration is discussed in more detail in Module II.

The legal status of public hospitals: The application of the Charter
Virtually all health care in Canada is delivered by private actors, i.e. health professionals, hospitals, clinics, diagnostic facilities which are subject to regulation in the public interest.

The legal context for the existence and operation of hospitals in Ontario affects interprofessional healthcare teams working within these institutions.

Ontario public hospitals, for example, are not owned by government. They are private not-for-profit corporations, governed and managed by private citizens. Hospitals are incorporated under provincial legislation and the ‘Articles of Incorporation’ determine the hospital’s objectives. At the same time, hospitals are regulated by provincial legislation and dependent on public funding (Wakulowsky, 2010).

The legal status of public hospitals has implications for the application of The Canadian Charter of Rights and Freedoms (“Charter”). The Charter was enacted as part of Canada’s Constitution Act, 1982, and protects specified rights and freedoms of individuals from unjustified governmental infringements. Since the Charter only applies to government, publicly funded hospitals are only subject to the Charter to the extent that the hospital applies government laws or policies (Reis, 2011). Notably, the Charter applies to doctors exercising authority under mental health legislation.

READ IT HERE: The Canadian Charter of Rights and Freedoms can be viewed online at http://laws.justice.gc.ca/eng/Charter/

http://openclipart.org/detail/129253/hospital--hospital-by-lmproulx
Under this: http://creativecommons.org/publicdomain/zero/1.0/

The application of the Charter for private facilities including hospitals
In what circumstances the Canadian Charter of Rights and Freedoms applies to private healthcare facilities including hospitals is a question of law that has been developed by the courts within the last several years. Two central cases—Eldridge v. BC (AG), 1997 and Canadian Blood Services vs. Freeman 2010—establish that the Charter applies to hospitals only in the institutional application of laws or policies that are imposed by governments and that it does not apply in cases involving private health services at all.

I. Eldridge v. BC (AG), 1997

In Eldridge v. BC (AG), 1997 the Supreme Court of Canada held that the Charter applies to private entities only to the extent that they act in furtherance of a specific government program or policy (Wakulowsky, 2010). In their day to day operations (with respect to employment issues, for example), hospitals are not subject to the Charter (Epps, 2011).

READ IT HERE: Eldridge v. BC (AG), 1997 http://www.canlii.org/en/ca/scc/doc/1997/1997canlii327/1997canlii327.html

II. Canadian Blood Services vs. Freeman 2010

In Canadian Blood Services v. Freeman, 2010 an Ontario court ruled that Canadian Blood Services is not subject to the Charter, “since it is a private corporation and its policy development and operational activities are not controlled by government” (Epps, 2011, p. 618).

READ IT HERE (Westlaw database – available to Queen’s students): Canadian Blood Services v. Freeman, 2010http://canada.westlaw.com/Welcome/LawPro/default.wl?RS=WLCA12.01&VR=2.0&FN=_top&MT=LawPro&SV=Split

Reflection
Consider health facilities where members of your profession commonly work. Do the patients in those facilities have their rights protected by theCharter of Rights and Freedoms based on what you know from the previous cases?

References

Course Information

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.

Part A: Decision Making Frameworks

Learning Objectives

Define the key decision making frameworks in bioethics.
Understand the main differences between frameworks.
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 Ethics, 35(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 Ethics, 17, 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 Ethics, 35(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.

Part B: Decision Making Applications in Healthcare

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.

Alberta Provincial Ethics Health Network (PHEN): Guide to Making Difficult Healthcare Decisions
- http://phen.ab.ca/hopesandwishes/docs/CHWFinalDraftJan282010.pdf
Ryerson University Ethics Network: Sample Ethical Decision Making Models
- http://www.ryerson.ca/ethicsnetwork/resources/ethicaldecision/index.html
A Counseling Model: Transcultural Integrative Ethical Decision-Making Model
- 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.
Ontario Shores: Clinical Ethical Decision-Making Framework
- http://www.ontarioshores.ca/about_us/our_approach/ethical_decision_making/

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.

References

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 Ethics, 17, 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 Humanities, 14, 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 Bioethics, 20(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 Ethics, 35(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 Ethics, 35(4), 229-231. Retrieved from: http://jme.bmj.com/content/35/4/229.full.pdf

Course Information

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

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

Part A: Introduction – Ethics, Autonomy & Paternalism

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.

Part B: Conflict Between Autonomy & Paternalism

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 Oath: http://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 Bioethics, 5(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 Nursing, 28(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 Humanities, 34, 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

Part C: Competency & Substitute Decision Making

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 Journal, 156(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 Ethics, 29, 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 Journal, 155(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 Ethics, 37, 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?

Part D: Informed Consent

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 Ethics, 34, 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 Report, 19, 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.

Part E: Advance Directives & Advanced Care Planning

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 Ethics, 24, 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 Ethics, 22, 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 Bioethics, 25, 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.

Summary Learning Activity

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.

References

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 Ethics, 24, 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 Report, 19, 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 Bioethics, 5(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 Ethics, 37, 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 Journal, 156(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 Ethics, 34, 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 Journal, 155(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 Ethics, 22, 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 Ethics, 29, 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 Bioethics, 25, 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 Humanities, 34, 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 Nursing, 28(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.

Course Information

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

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

Part A: Introduction – Communication & Conflict Resolution

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.

Part B: Communication - Veracity

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 Medicine, 97, 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 Care, 13, 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?

Part C: Communication - Privacy

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 Affairs, 4(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 Ethics, 12(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 Ethics, 10(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 Research, 13(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 Ethics, 33, 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 Quarterly, 12(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 Health, 11, 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 Bioethics, 10(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. Bioethics, 3(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?

Part D: Informed Consent

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 Ethics, 34, 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 Report, 19, 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.

Part E: Communication and Conflict Resolution

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 Care, 23(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 Care, 20(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 Care, 22(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 Care, 25(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 Care, 18(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?

Summary Learning Activities

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?

References

Allison, A. & Ewens, A. (1998). Tensions in sharing client confidences while respecting autonomy: implications for interprofessional practice. Nursing Ethics, 5(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 Care, 20(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 Medicine, 97, 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 Care, 25(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 Ethics, 32(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 Care, 21(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 Care, 22(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 Health, 11, 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 Ethics, 20, 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 Care, 23(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 Nursing, 109(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 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

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
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Kottow, M. (1986). Confidentiality: an intransigent and absolute obligation. Journal of medical ethics. 12, 117-122. Retrieved from
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Lamb, R. (2004). Open disclosure: the only approach to medical error. Quality and Safety in Health Care, 13, 3-5. Retrieved from
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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 Journal, 321, 1464-1466. Retrieved from
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Malcolm, H. (2005). Does privacy matter? Former patients discuss their perceptions of privacy in shared hospital rooms. Journal of Nursing Ethics, 12(2), 156-166. Retrieved from
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Malonda, J. et al. (2009). Lessons learned from a privacy breach at an academic health science centre. Health Care Quarterly, 12(1), 61-65. Retrieved from
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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 Ethics, 33, 695-698. Retrieved from
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O'Brien, M. (1989). Mandatory HIV antibody testing policies: an ethical analysis. Bioethics, 3(4), 274-400. Retrieved from
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Rachels, J. (1975). Why privacy is important. Philosophy & Public Affairs, 4(4) (Summer), 323-333. Retrieved from:
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Rogers, T. (2004). Managing the interprofessional environment: a theory of action perspective. Journal of Interprofessional Care, 18(3), 239-249. Retrieved from
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Thompson, L. (2011). Protected health information on social networking sites: ethical and legal considerations. Journal of Medical Internet Research, 13(1). Retrieved from
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Warwick, S. J. (1989). A vote for no confidence. Journal of Medical Ethics, 15, 183-185. Retrieved from
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Course Information

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.

Part A: Key Considerations for Ethical Resource Allocation

Learning Objectives

Define key considerations in resource allocation in healthcare.
Understand the application to interprofessional practice.
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?

Part B: Resource Allocation in Practice

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:

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:

The declaration of death for the donor be made by a physician who is not part of the transplant team,
consent be given by the family prior to donation, with attention to the deceased’s wishes,
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.

Summary Learning Activity

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:

Who are the stakeholders in the case?
Of the health professionals involved, how might perspectives differ?
What is your preferred course of action? How might it conflict with other views?
How can resources (both material and human resources) be allocated?
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.

References

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.

Course Information

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.

Part A: Key Considerations for Providing Ethical Care in the Community

Learning Objectives

Define key considerations in community care ethics.
Understand the application to interprofessional practice.
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 care. Generations, 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 environment. The 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 teams. Journal 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.

Part B: Care in the Community

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 risk. Perspectives, 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 health. Community 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 adults. BC Medical Journal, 53, 421-425.

2. Strang, D.G., Molloy, D.W., & Harrison, C. (1998). Capacity to choose place of residence: Autonomy vs Beneficence. Journal 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.

Summary Learning Activity

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:

Who are the stakeholders in the case?
Of the health professionals involved, how might perspectives differ?
What is your preferred course of action? How might it conflict with other views?
How can autonomy and beneficence be balanced?
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.

References

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.

Interprofessional Collaboration and Health Law

Ethical Decision-Making

Issues in Client Autonomy

Communication & Conflict Resolution

Resource Allocation in Healthcare

Community Care Ethics