Volume 3, Issue 09 - November 2000

The RHA Board: Challenges From an Ethics Perspective

I have been asked to provide some reflections on ethical aspects of Regional Health Authority (RHA) Boards' decisions. Obviously, RHA Boards face numerous difficult issues. As former Chair of the Capital Health Authority during its first two rather turbulent years, it is easy to remember the times and decisions, many with important ethical dimensions, as ones of conflict. In what follows, I will describe three ethical issues RHAs face, along the way describing how our own Board dealt with these issues.

The Challenges of Diverse Values

Every issue facing our RHA Board was complex, made more so by the flood of opinions we received from every imaginable source. One key in examining an issue from an ethics perspective is discovering the values of those analyzing the issue and making the decision. So who were the decision-makers sifting through the mountain of advice? In our case, for the most part they were community-minded, dedicated citizens free of political agendas, but with high ideals and indeed a vision as to how they believed a health care system would lead to a healthy community. They brought with them their own value systems, biases, personal experiences, and faiths, which were as varied and diverse as one can imagine - and that was a good thing.

The first issue, therefore, facing us as an RHA Board was whether to challenge each other on our value systems. Should we try as a Board to reach some consensus, harmonizing our own individual values? Or ought we to simply leave each individual's own value system intact to contribute to the decision-making process?

This issue presented itself early on as the Board was forced to grapple with establishing a priority of values. As many will recall, in the early life of RHAs "efficiency" was touted as a primary value (and in some media reports, erroneously as the sole value) guiding Board decisions. Yet, most Board members insisted also on an individual basis that the value of a healthy community made up of healthy individuals should certainly be given priority. This is a clear example in which the Board was required to reconcile two competing values. The best illustration of how the Board struggled with this dilemma regarded the issue of staff layoffs. At the time our Board was asked to implement a 15% to 20% cut in its budget. Given that 80% of the RHA's costs were labour-related, the harsh reality was that staff reductions were inevitable - people were going to lose their jobs.

All those on the Board appreciated that job loss was one of the major negative factors impacting on an individual's health. And here we were in the name of efficiency about to make life less healthy for 1,000 to 1,500 staff in our region. So to balance the values of efficiency and community health, the Board decided to ensure reasonable severance payments were made to the individuals who would be losing their jobs - notwithstanding the fact that no contract required us to do so.

Allocating Resources

This example leads us to the greater issue of resource allocation. As the first Board of an RHA, we did not have the benefit of inheriting the customs, traditions, values, and priorities of any pre-existing organization. Neither did we have the kind of support and training in ethics now offered by agencies such as PHEN. As previously indicated, we had a myriad of cultures, backgrounds, and personal principles that we brought to the table - along with a cornucopia of information placed before us by administrators, physicians, nurses, bureaucrats, economists, businesspeople, media, public, and experts of absolutely every description. From this complex of perspectives, we had to determine how to allocate the various resources at our disposal to meet the health needs of the regional population.

What was remarkable about the information we received was that the individuals and groups bearing the information all had something different, and in many respects contradictory, to submit to us. Indeed, even within what one might have expected to be a homogeneous group, entirely opposing viewpoints seemed to present. For example, we were surprised to find that an emergency physician, family physician, gerontologist, and public health physician had markedly different priorities pertaining to resource allocation; though they all agreed on the need for more rather than less - an option, regrettably, we did not have in 1994.

While allocation of limited resources was never an easy issue, it became manageable for us by the Board's establishment of a deeply held vision of health reform. We knew that attempting to allocate resources based on the entrenched values of a pre-RHA existing healthcare system would quickly drive us to distraction. Instead we committed to a reform system based on the value of a healthy community with a focus on health versus sickness and wholeness versus bits and pieces.

In this way, we justified our first major budget in which we reduced funding to all aspects of the healthcare system except for public health. We did this to the dismay naturally of most everyone in the system other than the public/community health proponents. Indeed, we did this despite a plethora of squeaky wheels, all of which represented undoubtedly legitimate needs. However, our vision of a healthy community, supported by principles of compassion, fairness, integrity, and yes, efficiency, convinced us that we were doing the right thing.

Accountable to Whom?

Many accused us at the time of basing our decisions solely upon dispassionate number crunching. This was not unexpected given the rather superficial media coverage which naturally led the general public to similar conclusions. This was indeed problematic and leads to the next major issue I wish to raise as a fundamental ethical dilemma facing a Board member: To whom is he or she accountable? Let me explore the possible candidates to whom a Board might be accountable:

1. The government. But if this is true, then another question arises: To whom within the government is the Board member responsible? The Health Minister? The Provincial Treasurer? The health bureaucracy? The Premier? The Cabinet? With us, there were times when it was abundantly clear the Provincial Treasurer expected a greater accountability than the rest. This was neither a good nor bad thing, but was certainly something that had to be recognized by the Board and weighed against the Board's own accountability priorities before assigning to it an appropriate level of influence.
2. The region's administrators. These individuals provided a considerable amount of information directly to the Board (having vetted huge quantities of information from third parties) upon which the Board based decisions. Thus, it was natural to feel some sense of accountability to them - because the decisions that we reached would very heavily impact their plans.
3. The regional staff generally. Beyond the administrators, the lives of thousands of staff were altered tremendously by Board decisions, some in ways which resulted in irrevocable career decisions of their own. How could one not feel accountable to these dedicated employees? And how could that not at times be irreconcilable with an accountability to the Provincial Treasurer?
4. The individual patient. While we struggled vigorously at times to shift from a health care emphasis to a health emphasis, we obviously could not overlook the fact that most of what we governed was the provision of health care, which, for the most part, meant caring for the sick.

Decisions to reduce acute care bed numbers and shut down emergency departments were interpreted by some to suggest that we felt no accountability to the patient. But, in fact, we did feel an accountability to the patient and demonstrated this by putting the individual once again in the context of our vision of a healthy community; a community in which caring and compassion was not confined to an emergency ward, where individuals with appropriate assistance could lead lives to the full in their homes, not in institutions, and where healthcare workers worked as teams to the benefit of all of the individuals' needs.

5. The medical profession. Certainly we stood accused of disempowering the medical profession and thereby displaying no accountability to this most significant, and unquestionably, most powerful element of the healthcare system. The physician community needs what RHAs provide and RHAs desperately need what physicians provide. Ideally, these two groups should develop a relationship of mutual accountability that leads to a mutual respect and understanding of the respective roles of each.

What became apparent for us was that the Board's broad view of health was as mysterious to many of the physicians as was the physicians' absolute focus on his or her particular specialty to the Board. So, while the Board did not knowingly reject an accountability to the medical profession, it became exceedingly difficult to know how to channel such an accountability. Perhaps current Boards have figured this out.

Our Board did not reflect an underprivileged background, though undoubtedly we recognized the impact of the less advantaged as part of the health system. Should one feel more or less accountable to the more advantaged? It became clear that to exercise any accountability to this all-encompassing entity called "community" required meaningful performance measurements of a healthy community in its broader sense. The ethical dilemma then became a matter of what it was that we ought to have been measuring.

And so one very large ethical issue facing RHA boards is that of sorting through and then balancing its accountability to all of these various parties -- clearly no small feat!

Final Thoughts

While as Board members, untrained in the academics of ethics, we may not have been able to identify, in an ethicist's terms, that we were dealing with social justice issues and the ethics of meso-level allocations, that is exactly what were doing in grappling with the issues above. Had we been better equipped to identify the issues explicitly as ethical, been educated to address them from an ethical perspective and had the luxury of time to put such valuable tools to use, the road would have been less bumpy.

I would suggest that Boards should recognize the value in learning to think from an explicitly ethics-based perspective. Such an understanding of this process won't make the issues they face any less complex, but they will make them more readily solvable.

Bioethics Distance Education

A reminder that the deadline for applications to participate in the first offering of PHEN's distance education course in Introductory Bioethics is January 8, 2001. Those interested in participating in the course are encouraged to apply early as space is limited and some consideration will be given in participant selection to when applications are received.

Prospective participants may be interested to know that those who successfully complete the course will be eligible to receive 3 academic credits from Grant MacEwan College. Tax receipts for the course will accordingly be made available to participants. Continuing education credits for various health professional groups will also be available.

Announcements

• Members of the Network are asked to take note that the next application deadline for PHEN's User Fund is April 10, 2001. The User Fund provides grants to PHEN members who require financial assistance to attend a conference or sponsor an educational event on bioethics.
• Representatives of the Network have been asked to present to the Premier's Advisory Council on Health in February 2001. If you have any comments or suggestions in this regard, please contact PHEN Board Chair, Campbell Miller or Executive Director, Al-Noor Nathoo.
• PHEN Board members engaged in a one-day retreat in Canmore in October to revisit the goals and activities of the organization. Participants affirmed the role of PHEN as an 'umpire' to inform, catalyze and guide discussion on ethical issues in health. It was felt that where resources allowed, the Network should make greater efforts to expand its visibility and availability to a wider audience and focus its goals on its coordination, connection and education functions.

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