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From Rebels with a Cause to Corporate Committees:
a 40 year retrospective on the evolution of healthcare ethics
Dr. John Watts, MD, Neonatologist and long-time member of the Hamilton Health Sciences Clinical Ethics Committee
Dr. Lisa Schwartz, PhD, Arnold L. Johnson Chair in Healthcare Ethics, McMaster Faculty of Health Sciences
Donna Peace, BSW, MHSc, Social Worker and Ethics Consultant, Hamilton Health Sciences
Dr. Andrea Frolic, PhD, Clinical & Organizational Ethicist, Hamilton Health Sciences
April 27, 2011
Objectives
• Trace the ~40 year history of healthcare ethics at Hamilton Health Sciences
• Discuss the evolution of bioethics theory• Describe the evolution of ethics
consultation as a distinctive professional practice
• Describe state-of-the-art in hospital ethics programs
Dedication and visionArnold L. Johnson
• Royal Canadian Navy• Cardiologist(1946-1972):
– McGill University,– Royal Victoria– Montreal Children's
Hospital• Performed the first
heart catheterization in Canada in 1946
• Royal College of Physicians & Surgeons of Canada: Committee on Cardiology
• Governor of the American College of Cardiology
• Chair, Committee on Education in Medical Ethics for the Faculty of Health Sciences, McMaster University
• Introduction to Ethical Decision Making in the Health Care Settingbooklet for the MD Program
• Arnold L. Johnson Chair in Health Care Ethics
Philosophy Department
John Thomas• Pioneer of biomedical
ethics
• Course staffed by himself & FHS health professionals
• Associate Member of the Faculty of Medicine from 1985-1991
• Medical ethics consultant to the Faculty of Health Sciences until 1992
Philosophy Department
• David Hitchcock• Elisabeth Gedge• Will Waluchow
• Student interns: – Jason Robert – Ann Iverson
(Heesters) – Sylvia Stolberg – Claudia Emerson– Jonathan Breslin
Bioethics at McMaster
Courses• Undergraduate:
Humanities; Social Sciences; BHSc
• Graduate: Humanities; Health Research Methodologies...
• Faculty Development Ethics Series
• Research ethics workshops
• MD Programme• Professional
Competencies• Ethics and Moral
Reasoning
• Bioethics Interest Group (BIG)
• Michael Coughlin, Wendy Hollinshead, Michael Wilson, Karen Szala-Meneok, Suzette Salama
The evolving field of health care ethics: beyond the Georgetown Mantra
Empirical bioethics
Global Health Ethics– Focus on justice and
equity– Cultural contexts– Disaster bioethics – Pandemic– Public health ethics
• Health Policy
Feminist ethics– Relational
autonomy– Focus on power
imbalances
• Social Sciences• Philosophy of science• Legal theory
The evolving field of health care ethics
Research ethics• Tri-council Policy
Statement (TCPSv2)• CIHR Guidelines for
health research involving aboriginal people
• Privacy• Conflict of Interest• Genetics• Health Technology
assessment
At McMaster• 3 core REBs• Student REBs• Education
• Recognized as leaders by WHO and CIHR
Canadian Cases
• Morgentaler• Malette v Shulman• Sue Rodriguez• Nancy B• Latimer• Surrogacy• Eve and involuntary
sterilization• Tainted Blood• Winnipeg paediatric
heart surgery
Canadian Leadership in Bioethics
Abbyann Lynch
Bernard Dickens
Susan Sherwin
Michael McDonald
Michael Burgess
Bartha KnoppersBenjamin Freedman
George Webster
Edward Keyserlingk
Margaret Sommerville
What do you do when…
• A patient’s family requests treatment that staff feel is inappropriate
• A patient refuses care that staff feel is in their best interest
• Budget decisions need to be made that may impact staff or compromise patient care
• A situation arises that isn’t anticipated in any HHS policies or procedures
Making the best decisions in complex situations
• Complexity of Clinical decision making– Emerging technologies– Large health care teams/diverse professions– Competing interest
• Moral diversity– Cultural/religious diversity of patients and staff – Constant cultural change– Diverse professional commitments – Individual autonomy
Evolution of Role of Ethics Consultation at HHS over the past 15 years
• Core Ethics Committee – Members would respond to request for consultations.
• Various training and expertise in the field, primarily physician representation.
• Practice would vary from site to site.• No formal evaluation and quality
improvement mechanisms.
Standardization of Consultation Practices over the past 5 years
• Recruitment process – multi site, multi disciplinary.
• Team trained in clinical ethics theory, communication and mediation skills.
• First hospital to pilot the ASBH curriculum for ethics consultants.
• Guiding principles – Integration, sustainability and accountability.
• ECS provides range of services:– Coaching– Mediation– Debriefing– Education
Our experience mirrors the evolving standards of the profession
• Role clarity and accountability• Practice Standards (Canadian and
American)• Competence of consultants• Integration and responsiveness of service• Commitment to continuous improvement• Expanded scope to include organizational
ethics consultations
Current Ethics Consultation Team
• Sandy Andreychuk (NP)• Donna Peace (SW)• Angela Djuric-Paulin (Clinical Leader)• Christina Grant (MD)
EC Learners:• Elaine Principi (chief of PT)• Laurie Fox (SW)• Sylvia Fung (Pharm)• Marie Reynolds (RN)• Elaine Walters (coordinator)• Laura-Lee Walter (NP)
Ethics Consultation Service Utilization (Sept 07-Mar 11)
• 197 consults – 128 coaching conversations (intake only)– 69 were formal/facilitated consults
• Themes:– Substitute decision-making *– Moral distress (team members/family members)*– End of life (feeding, treatment options)*– Consent, capacity and best interests*– Team conflict re: standard of care– Withdraw/withhold treatment – Living wills/advance directives– Donation after Cardiac Death– Discharge planning
Common Ethical Concerns in Health Care Environments
• Shared decision making with patients• Ethical practices in end-of-life care• Patient privacy and confidentiality• Professionalism in patient care• Ethical practices in resource allocation• Ethical practices in business and management• Ethical practices in human resource
management• Ethical conduct and conflict resolution• Ethical practices in research and innovation• Ethical practices in the everyday workplace
Drivers of Ethics Program Development
• Increased public expectations of transparency and accountability in public institutions
• Client-centred care movement• Accreditation Canada standards
– Ethics framework intergration and implementation– Access to resources to support ethical decision-making
• Integrated Ethics from VA in the US• Growing evidence of the effectiveness of hospital
ethics services to: – enhance staff morale– support team function in difficult cases, – avoid nonbeneficial treatments
Ethics Resources @ HHSHub & Spoke Model
Macrae, Sue, Chidwick P, et.al. (2005). Clinical bioethics integration, sustainability, and accountability: the Hub and Spoke Strategy. Journal of Medical Ethics, May 2005, 256-261.
New “Hub” of Clinical & Organizational Ethics @ HHS
Integrated Ethics Council (IEC)• Based on best practice developed at VHA (US)
and peer hospitals• Purpose: to integrate, align and champion all
elements of ethics (decisions, systems & processes, culture & environment) to promote ethics quality throughout the organization.
• Reports to: Executive Committee of the Board• Annual report sent to: Board of Directors, MAC,
PAC and Senior Executive Team
IEC Activities/Objectives:
• Coordinate ethics-related activities across the hospital by providing key leaders with opportunity to discuss and identify areas of mutual concern regarding ethical issues.
• Promote ethics quality in hospital systems and processes
• Oversee, support and promote the work of the Clinical Ethics Committee (CEC)
• Support Ethics Consultation Service when conducting organizational ethics-focused consultations
• Enable strategic planning for the ethics program
Clinical Ethics Committee
• Subcommittee of the Integrated Ethics Council• Mandate: “The Clinical Ethics Committee
provides resources and leadership to enhance the role of clinical ethics in patient care.”
• Membership: interdisciplinary & community representatives; multi-site; 3-year terms
• Builds ethics capacity of members and HHS community through three working groups:– Education: creates educational
strategies/resources– Policy: reviews ethics-related policies– Ethics Consultation Service
CEC Working Groups
Policy• Collaboration with
Office of Document Management
• Reviews and provides recommendations on policies with ethical dimensions
Education• Builds ethics capacity• Develops resources• Hosts Bioethics
Interest Group (monthly ethics grand rounds)
Current CEC Members
• Deb Hutchinson (co-chair)• Cynthia Cupido (co-chair)• Anna-Marie Pietrantonio
(co-chair Education)• Christine Todoroff (co-chair
Education) • Kim Bryanton (co-chair
Policy)
• Andrew Spurgeon • Carole Caron• Deb Harding• April Kam• Judy Keczan• Lori MacCall• Lisa Schwartz• John Vlainic
The CEC is Recruiting!!
• 7 new members: interprofessional & multi-site• 3 year term, starts September 2011• Time commitment: ~ 4 hrs/month (meetings +
projects)• Professional development: CEC members gain:
– Knowledge of principles, values and theories in clinical ethics
– Knowledge of the HHS ethics program and resources
– Skills in ethical reasoning and case analysis
• Deadline for application: May 16, 2011• Visit HHS Ethics intranet site under Departments
and Committees for application information
For More Information:
• Clinical & Organizational Ethicist: Andrea Frolic– [email protected]; ext. 73446– Organizational ethics issues and questions– Educational events for staff
• Clinical Ethics Intranet site– Resources (including Ethics Framework)– Info on Clinical Ethics Committee, Ethics
Consultation, Ethicist and more– Bioethics Interest Group Archives
• Clinical Ethics Internet site– Info for Public on Ethics Consultation Service
Summary
• Growing breadth of Bioethics: disciplines, issues, domains
• Ethics at HHS started on the frontlines and remains active there
• Continuing innovation (consultation service, commitment to quality)
• Enhanced connection/integration between organizational and clinical ethics
• Question: What is lost and what is gained through the evolution of hospital ethics programs?