Volume 1, Issue 12 - February 1999

An Ethical Cry for Injury Control!

The annual health care burden of injury on our society exceeds that of cancer, yet the resources allocated to injury control research -- both financial and in terms of public attention -- pale in comparison to cancer research. Why is that? In spite of all the recent talk of creating a more preventive, well-being based health care system we are not moving in that direction; as a matter of fact we may actually be losing ground.

What has happened quite inadvertently instead, is that the treatment arm of health care has been pitted against the preventive arm for the limited resources available. Given our current addiction to the treatment perspective, I for one am not holding our much hope for any real signs of improvement.

It's NO 'accident'!

You may better know injuries as "accidents" or "freak accidents". However, these terms are misnomers as they imply events about which nothing can be done. But injuries are preventable events! Injuries should be categorized as either intentional or unintentional. Intentional injuries can be either self-directed (such as suicide or suicide attempts) or directed at others (family violence, assaults, rapes, murders, for example). Unintentional injuries include things like motor vehicle collisions, falls, fires, scalds, and drowning.

Injuries differ from other diseases in that they usually do not have a pre-clinical stage. An individual goes from being perfectly health one minute and a millisecond later is either dead or seriously disabled. There is no time to form the close relationships and support groups that other slower evolving diseases provide. A care crash, a gunshot wound, a knife stabbing, a fall, a burn, a drowning, a choking, a suffocation, a broken neck -- all of these are injuries and, again, all of these involve events that are predictable and preventable. That is the only good news about this field.

Controlling Injury

There is a science to injury prevention, there is an art to the treatment of seriously injured individuals, and great strides can be made in the rehabilitation of those injured. Injury control starts with prevention; focuses on improving pre-hospital and trauma care and aggressively rehabilitates those injured. Effective injury control is based on injury surveillance, data analysis, and program evaluation. The injury problem needs the same commitment to funding for research that has been made to AIDS research, breast cancer, and heart and stroke disorders.

Injuries can be prevented by a combination of different approaches. The most successful strategy is through engineering changes such as better vehicle and road design, and the design of safer products and environments. This approach does not require the individual to make a conscious safety choice. An enforcement approach through legislation, though not popular at times, is another effective means. For example, seat-belt legislation with significant fines and demerit points has been effective in reducing injuries. Economic incentives, such as discounted insurance premiums for having smoke detectors and fire extinguishers in the home, or for having a collision-free driving record are a novel way of taking steps in injury reduction. Finally, education campaigns aimed at injury prevention, though not very successful in the past, for a variety of reasons, remain a method for trying to reduce and control incidence of injury. Most successful strategies involve a combination so engineering, enforcement, economic incentives, and education.

In spite of knowing how, it is clear that we have not taken enough strides in this direction. Injuries are the leading cause of death for Canadians under the age of 44. Motor vehicle related injuries are the leading cause of death in those under the age of 34. Injuries account for more potential years of productive life lost that any other disease. Injuries kill more children over the age of one that all other childhood diseases combined.

Ethical Justification

Although it should be obvious, it appears to remain necessary to ask, why should we pay attention to injury prevention and control? What ethical imperative would required us to do so at the expense of attention to other diseases? Presumably, the reason that we devote the resources that we do as a society to health and health care initiatives is that we wish to advance the well-being of the members of our community. That we offer these services on the basis of need implies that we believe all members of our community have an equal opportunity to be free of the burdens of disease and disability. The value of this expresses is that the health and well-being of all members of our society is equally important.

If this is the case, that is, if we agree that the goal of the health system is to advance the well-being of all the members of our community starting with those most in need, then it make sense from an efficiency perspective to attend to those factors that are known to compromise health the most. And again, it is clear that injuries, intentional and unintentional, are a major factor, if not the most important cause, of compromise to individual health and well-being. Therefore, we should as society be doing as much as we can (which is significantly more than we are doing at present) to research and control the incidence of injury in our community.

Given the startling statistics mentioned above one would think that the login of this ethical argument would prevail and we, as a society, would be outraged and demand that something be done about injuries. Yet, relatively little is done. Every other disease known to man has an organization that raises concern about that disease. The best examples are the Cancer Society and the Heart and Stroke Foundation. We know who they are and what they do. And they do it very well. When was the last time someone knocked on your door or phoned you for a donation so that more

research could be done for injury control? When was the last time you read an obituary for someone who have died from an injury a request to contribute to the Injury Research Foundation of your choice? Why is this? The answer remains elusive but theories abound. Potential responses include...

• that decision-makers, health policy developers, and those that set the research agenda are not threatened by injuries as much as they are by heart disease and cancer; after all, cancer and heart disease is well described in this population.

• that many of those affected by injuries are socially stigmatized members of society

• that a (mis)perception exists that injuries are random events and unavoidable; we have become desensitized by media reports of how common place these events are

• that past attempts have been made by well meaning individuals with no training in the field with limited results

Whatever the reasons, Alberta has unfortunately failed to meet the challenge with adequate resources to truly make a difference. The Provincial Health Council in its June 1998 report identified injuries as an area that needed immediate attention. The Province has responded with a positive first step in the creation of the Alberta Centre for Injury Control and Research. The Centre is properly funded and mandated can possibly make a difference, but one does not tackle a multibillion-dollar problem with limited resources and expect measurable outcomes.

The ethical cry for injury control makes sense. We can and should spend our health care dollars more efficiently by addressing predictable and preventable injuries.

PHEN Annual Conference and General Meeting

This year, the PHEN's annual general conference will tackle issues that arise when the values of health care providers collide with those of the recipients of their services. The conference will take place on Friday, May 21, 1999 in Red Deer, Alberta (Canada) and will feature prominent local and national health ethicists including Edward Keyserlink of McGill University, Alister Browne of the University of British Columbia, Patricia Rodney of the University of Victoria, and Stephen Lewis of the Government of Saskatchewan. Be sure to mark this date on your calendar and stay tuned for more information on this exciting event.

Announcements

• PHEN will be hosting a meeting of RHA representatives to discuss the state of regional and institutional ethics committees across the province. The meeting will be held on March 29, 1999 in Edmonton. For further information, contact Bashir at the PHEN Northern Office.

• Representatives from Alberta Health have requested PHEN's participation in:
  1. providing feedback on Health Information Protection legislation and on
  2. the Steering Committee for Alberta Project to Enhance Organ and Tissue Donation and Transplantation in Alberta.
  For more information or to provide input, contact Al-Noor at PHEN's Southern Alberta Office.

• The Alberta Heritage Foundation for Medical Research has established a Community Health Ethics Research Review Committee with a mandate to assist in the ethics review of community-based protocols that would not normally fall under the purview of any of the existing Research Ethics Boards in the province. The PHEN Board will be exploring the question of the Network's potential involvement with this project at its next scheduled meeting, March 9, 1999, in Edmonton. For more information or to provide suggestions, please contact one of the Regional Coordinators or a PHEN Board member.

• PHEN has received a grant of $16,000 from the Calgary Foundation to begin exploration into developing a values-based decision-making framework for public consultation around priorities in health and health care. The Foundation's financial and "moral" support is gratefully acknowledged and appreciated.

• Revenue Canada has informed PHEN that its application for tax-exempt status as a registered charity under the Income Tax Act has been approved. Tax receipts will now be issued to any person or institution wishing to make a contribution in support of the Network's activities.

• Health Summit '99, a provincial forum for addressing important questions about the future of Alberta's Health system, will be held on February 25-27, 1999. 

• PHEN Board and Staff Notes:
  • Joe MacGillivray, CEO of St. Mary's Health Care Centre, Trochu, has agreed to assist the Network in its development and fundraising efforts as its seeks to partner with other agencies, foundations, and organizations interested in supporting health ethics work in Alberta. We Look forward to Joe's continued support of and enthusiasm for PHEN's activities.
  • PHEN welcomes Sheela Kumar -- a new volunteer who will be working in the Network's Edmonton Office.

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