Volume 1, Issue 01 - March 1998

Editor's Comments

Welcome to the first edition of In Touch, PHEN's new monthly publication to complement Health Ethics Today (put out in conjunction with the JDHEC). As the title implies, the aim of this publication is to create a forum where members of the Network can communicate and share ideas.

To this end, the main body of In Touch will be taken up by a monthly editorial on an issue in health ethics. This piece will be written by a different guest writer each month. Our hope is that the membership will use this space to share their thoughts on relevant topics in health ethics. A profile of the guest writer will also be included with each article.

If you have a suggestion for a topic or wish to submit an article, please contact me at PHEN's Edmonton office (contact information is at bottom of page).

As well, each issue will contain a short section for announcements where we will report on some of the activities with which PHEN has been engaged. We also hope you will use this section as a forum to announce any activities or other information that you or your organization wish to share with the PHEN community.

Once again, welcome to the first edition of PHEN's In Touch. We hope you will work with us to make this publication a success.

Bashir Jiwani <jiwani@phen.ab.ca>
Research Associate, PHEN
Editor

Health Ethics is mainly concerned with how we treat each other, what our standards or norms of right and wrong behaviour are, and how we nurture our relationships both with those whom we serve and those with whom we work.

The answers to these age-old questions at what is called the micro-level change over time, slowly. For example, no longer can one justify not telling dying patients the truth of their condition on the grounds that it is not in their best interests to know. Increasing numbers of providers no longer believe that getting close to and sharing another's vulnerability is unprofessional and should be avoided. The concept of seeing health delivery as "team work" is growing, with increased respect for the value of each team member's professionalism.

Contemporary health ethics was established on the four main principles of beneficence, non-maleficence, patient autonomy, and distributive justice. These are grandiloquent phrases for "Do good", "Avoid doing harm", "Promote the interests of others, especially those we serve", and "Be fair in distributing resources in proportion to need". They became established through the work of Beauchamp and Childress¹. They are sometimes called "middle level principles" as they do not claim to stem from any fundamental ethical basis other than the "common morality".

The principles represent a tension in health ethics between the desire to balance deontologic or duty-based ethics (where each person is the moral equal of the other, and each individual's life is beyond value or price) with utilitarian or outcome-based ethics. For example: One may want to respect a person's autonomous wish to have dialysis when, say, ureteric obstruction from untreatable cancer is causing urinary obstruction -- a duty-based obligation to relieve the obstruction and treat renal failure. Yet longer term outcome realities may suggest that lack of real benefit - or lack of utility - should preclude expensive resource utilization which serve only to prolong suffering.

But the dominance of principles in ethics principleism is now being questioned, not because they are no longer relevant, but because they may fail to take important contextual features or perspectives adequately into account. For example: a principles-based analysis might conclude that an intervention on a dying person might be inappropriate because it is essentially non-beneficial, with a low benefit/burden ratio. However, other considerations anticipated arrival of loved family members from afar, or desire to meet other values or short term wishes of the dying person might provide a context in which the intervention could seem to be the appropriate thing to do.

Thus, in addition to the principles, there is need to recognise the importance of virtues (compassion, patience, making time for listening) and the ethical importance of relationships (their shared experience, their context, epitomised by the injunction "Don't just do something, stand there!"). Indeed, relational ethics may be often seen to be in balance, and sometimes in tension, with principleism.

As the focal point of health delivery moves to the community, away from acute care institutions towards health promotion and illness prevention, so interest in healthcare ethics is moving towards the ethical problems which occur in long-term care, in palliative care, in mental illness and in the delivery of health care in the community. Institutional ethics committees, designed to serve the needs of institutions, are less suitable for issues in the home or community, and new ways of addressing these new complex ethics perspectives are being developed. How does one cope with the ethical stresses in a home where different providers are acting independently, some for profit, some in the public sector? Where is the concept of the "health team", in such situations? Who is best able to promote the best interests of the person needing care in such circumstances?

And recently, new ways of handling health information are generating new ethical dilemmas. There is clearly much to be gained by new systems for monitoring health outcomes using large amounts of aggregated data which are not linked to individuals by personal identifiers. There is also much to be gained, at the personal level, by having one's identifiable previous health information available in emergency for use by healthcare providers whom one has not encountered previously.

But how does one cope with issues of privacy and confidentiality as this stream of information - presently no more than a dribble - swells to a torrent? Individuals handling such data have what is termed a "fiduciary duty" to those persons whose data they are handling - but do they fully realise the obligations of that relationship? How does one build up trust and integrity in a system where the relationships are so indirect and remote?

The world of health ethics is evolving, and this article has not even touched on the broader issues of resource allocation at the meso- or macro-level.

Personally, I hope that Canada remains committed to the ethically defensible principles of the Canada Health Act with a single-insurer system, with no monetary obstacles at the point of entry for health care and full coverage for all essential services. This would seem to be a bastion to defend. Isn't that what being a Canadian is all about?

John Dossetor, Network Director, PHEN

References

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. Oxford Univ. Press. 4th Ed.

(This article is modified from a similar article published in the Canadian Medical Association Journal in December, 1997.)

• On January 21, 1998 an official ceremony was held to announce the renaming of the John Dossetor Health Ethics Centre, formerly known as the Bioethics Centre, of the University of Alberta in Edmonton. The renaming recognizes the immense contribution Dr. Dossetor has made to the field of health ethics and signals a change in focus for the field of bioethics towards a greater multidisciplinary approach and to a wider scope of issues and activities.
• The PHEN Annual General Meeting and Provincial Workshop will be held at the Sheraton Cavalier in Calgary on the 8th and 9th of May, 1998. The focus of the meeting will be on the work and function of ethics committees. Members and non-members are invited to participate in this conference. Further information regarding cost, lodging and other details can be obtained by calling either PHEN office.
• A reminder that PHEN has created a user fund to provide grants of up to $500 to Network members wishing to undertakeeducational projects to enhance their awareness of health ethics issues. For information on how to apply for this award, please contact the Edmonton office at (800) 472 - 4066. Application Deadlines for the fund are May 1, September 1 and November15, 1998.
• Recent PHEN Activities: PHEN has been busy in the first two months of the year having done ten module presentations. Interest has concentrated on Modules 4 (Personal Directives), 1 (Introduction to Health Ethics) and 2 (Making Ethical Decisions). Another six presentations are scheduled for March including a presentation at the Canadian Society for Hospital Pharmacists' conference in Banff on the 21st and 22nd of this month. To book your PHEN workshop or for information on available workshops, please contact either PHEN office.
• A reminder that this space can be made available to advertize your upcoming event. For more information about this offer, please contact PHEN's Edmonton office.

Edited by John B. Dossetor

1997 Revision of the 1994 Handbook of Healthcare Ethics and Institutional Ethics for Staff in Healthcare Institutions.

The Handbook was written by a group of Alberta authors and was facilitated with funding from the Capital Health Authority. The aim of the book is to discuss ethical issues of relevance to all healthcare providers in clear and simple language. The Handbook is intended as a practical guide and is recommended for all those who work in the complex field of health care.

PHEN is pleased to be able to offer this valuable resource at a discounted price to its members. The members' price for the Handbook is $15 per book. The price for non-members is $20.

To order the handbook, or for more information, please contact our Edmonton office at (403) 492-8239 in Edmonton or at (800) 472-4066 from anywhere else within Alberta.

Questions or comments about this publication are welcome and can be directed to either PHEN office. Please feel free to copy and distribute this document.

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.