Guest Writer Profile: Bashir Jiwani Bashir Jiwani is the Northern Alberta Coordinator for the Provincial Health Ethics Network and has been with PHEN for over five years. He has a Master's Degree in Applied Ethics, specializing in Bioethics, from UBC and is currently pursuing his Doctorate at the U of A in the Public Health Sciences department. In his professional capacity, Bashir's work includes developing innovative ethics education programming, offering workshops and presentations on issues in health ethics, sitting on various ethics committees, and participating in clinical ethics consultation. Bashir is also editor of the PHEN monthly bulletin, In Touch and has recently authored the text, An Introduction to Health Ethics Committees.

A Version of this article was originally published in Steps in Healthcare Ethics (March, 2002 Vol. 4, No. 2)

Decision-makers at institutional and regional (meso) levels of the healthcare system, as well as at broader government (macro) levels, regularly face and make decisions that determine the shape and structure of our health system. These decisions and policies dictate how social resources are used to advance the health of the people in our communities. Often, the decisions that are made in these settings are seen as being separate from ethics. I suggest that this assumption is mistaken - that almost every decision made that these levels involves ethics at its core in that each is a reflection of a set of values. For example, the decision to invest in a new and effective, but expensive, medication for patients in the cardiology ICU of an urban hospital, at the expense of hiring additional speech pathologists to do preventative work with children facing speech and hearing challenges in a rural community, is a reflection of the values we attach both to the lives of the patients involved, and to the modes of treatment we choose to secure well-being. Such decisions also reflect our values around what we take to be a valuable and meaningful life.

In this article, I will suggest four questions that I believe decision makers at the meso and macro levels in the health system should consider when making decisions or setting policy. For each, I will indicate what I take to be the key values at stake. I further suggest that those of us affected by the health system (in other words, all of us) should also be thinking about these questions and considering our own individual roles in determining the direction our health system takes.

Allocation Rationale

1. Who is served by the decision or policy and how is serving this segment of the population justified?

When determining resource allocation policies and strategies, we should inquire who is being targeted by the services we are providing, as well as whether and how serving this population is justified. In the above example, how is the decision to serve patients suffering from heart conditions over the children needing speech therapy justified? In addition, are those within the target group being equitably served?

It has been suggested that existing healthcare policies favour those most culturally similar to the individuals working within and shaping the health system as well as those who live in large urban centers.¹ For example, research in the history of modern medicine has focused on men's health issues, inappropriately treating women as variants of the male model.² This, of course, coincides with the predominant role of men as key decision makers within the healthcare and social establishment. To avoid any allocation based on morally irrelevant criteria (such as gender, in the above example), we should be examining of any allocation policy or decision, what reasons and values allocation patterns are based upon and whether these are justified.

The key values at stake here include fairness and equality. One interpretation of fairness holds that, because human beings are morally equal, we each deserve to have an equally rich range of choices from which to determine our life goals and then an equal opportunity to achieve our chosen dreams. Since health impacts both the range of choices we have as well as our ability to achieve our chosen life goals, we each deserve to have our health deficits addressed so that our health outcomes are reasonably equalized and we approach in our society an equality of opportunity to flourish.

Another interpretation of fairness has it that because many of the factors that determine our ability to secure good health are outside our control, individuals should not be held exclusively responsible for them. Based on both of these readings of fairness, health services should, at the very least, be available to all members of society based on need alone.

The principles of accessibility and universality found in the Canada Health Act suggest that the Canadian Health system is meant to take the notions of fairness and equality seriously. We need to be clear on how we understand and interpret these values and about whether our decisions/policies actually abide by them.

Broader Determinants of Health

2. Is the decision or policy sensitive to the broader determinants of health?

It is now generally accepted that factors such as income and social status, education, employment, and social support, the physical and natural environment, and personal health practices are the genuine determinants of health, with access to acute health care services only a relatively minor factor.³ In light of this, the values of efficiency and responsible stewardship dictate that in order to make maximum use of our common resources, efforts to improve the health of the people in a community ought not to be directed exclusively to the acute care-based health system, but rather ought to be redirected towards these broader determinants of health.

It is important to recognize that many political factors have contributed to the rise of modern health system. Within the health system today there remain forces that seek to maintain the exclusive focus on the medical care system as a means of advancing the health of the population.⁴ For example, it is very difficult for decision makers to look to broader, non-traditional approaches to advancing well-being or to focus on strategies of illness prevention and health promotion given continued pressures to fund research on technology intensive and interventionist solutions to health issues.

We need to examine whether our health policies are in fact responsive to the broader determinants of health or whether they perpetuate the almost exclusive focus on technology and resource intensive acute care efforts at advancing health and well-being.

Defining "Health"

3. What definition of health is assumed in the types of approaches under consideration?

The way a health system is organized and funded implies the acceptance of a particular definition of health, even though such a definition is not made explicit. Yet "health" is not an objective notion: all definitions of the term rely on some understanding of what constitutes a meaningful life. Thus, "health" must be located contextually within local communities where the definitions of different illnesses and diseases are interpreted according to the culture and background of the individual sufferers that, "setting health in the Buddhist conception of Kamma provides a rather different reading of health and health care than would be given in a secularized Western context".⁵

Following this, and according to the values of democracy, self-determination, and efficiency, approaches taken to resolve health issues ought to be geared towards what people themselves take to be challenges to their health - not on an understanding of health that others have imposed. In coming to understand barriers to health and developing responses to these barriers, decision makers need to ask whose notion of health are we attending to and are the means being adopted the most appropriate for meeting these ends? This richer understanding should then direct the kinds of care that are provided to different communities.

Bringing Values to Life

4. What are our values and are we living by them?

The values of integrity and honesty are critical elements of good public policy. The first three questions I have raised can be seen as tools to help achieve integrity of the decision and policy-making process. However, these values require explicit attention.

Pal suggests that four types of integrity are required for good policy: i) the integrity of the people involved in developing and carrying out the decision or policy in question; ii) the integrity of the process through which the decision making happens and policy is developed; iii) the integrity of the relevant government body in terms of its commitment to serving its citizen subjects; and iv) the integrity of purpose of the policy, or the coherence of the decision or policy tool with the overall goal of advancing the well-being of those the policy is meant to serve.⁶

Without integrity at these levels, the making of public policy can become an exercise in the deception of both the decision or policy making body itself and those whom the policy is meant to serve.

Our Role as Ordinary Citizens

Each of the questions that I have offered above rest on certain values that I take to be important. I believe that these values are accepted by and entrenched in Canadian society as well. Nevertheless, it is entirely appropriate (indeed crucial) to ask whether or not we as individuals and as a community actually espouse these values. If not, what are the values we do espouse? If the values I have identified are accepted, is this set of values complete, or are there others that we would want to include in this list?

Once this reflective work is begun, we must follow up by asking if we, as individuals and as a community, are living according to the values we cherish. And if we find that there are areas of tension between the values we treasure and the reality of our lives, as a matter of individual and collective integrity, we must seek out ways of influencing decision making to reconcile the reality of our lives with our values.

1. Blue, Arthur, Edward Keyserlingk, Patricia Rodney and Rosalie Starzomski, "A Critical View of North American Health Policy" in A Cross-Cultural Dialogue on Health Care Ethics, Coward, H and Ratankul, P. eds. Wilfrid Laurier Press, 1999.

2. Council on Ethical and Judicial Affairs, American Medical association, "Gender Disparities in Clinical Decision Making" Journal of the American Medical Association, 1991 Vol. 266, No. 4.

3. Hancock, Trevor, "Health Promotion in Canada: Did We Win the Battle but Lose the War?" in Health Promotion in Canada, Ann Pederson, Michel O'Neill, and Irving Rootman, eds. Toronto: W.B. Saunders Canada, 1994, 350-373.

4. Armstrong, Pat and Hugh Armstrong, Wasting Away: The Undermining of Canadian Health Care, Toronto: Oxford University Press, 1996, Chapter 2.

5. McDonald, Michael, "Health, Health Care and Culture: Diverse Meanings, Shared Agendas," in A Cross-Cultural Dialogue on Health Care Ethics, Coward, H and Ratankul, P. eds. Wilfrid Laurier Press, 1999.

6. Pal, Leslie A., Beyond Policy Analysis: Public Issue Management in Turbulent Times, International Thomson Publishing, 1997.

 

Announcements

PHEN is pleased to announce that the third offering of the distance education course Introduction to Bioethics will take place from January 13 to May 22, 2003. This course, featuring several of the most prominent and respected bioethicists in the world, is geared particularly towards busy and practicing health care providers and administrators in Alberta. Feedback from past participants confirms that the course provides a rare and worthwhile opportunity for individuals to develop a rich understanding of the field of bioethics, in a format that is accessible and interactive. Building upon the success of last year's final session the course will culminate with an intensive, hands-on workshop where participants will learn and practice skills in clinical ethics consultation under the guidance of Dr. Michael Burgess, Chair in Bioethics at the University of British Columbia's Centre for Applied Ethics. For more information and application forms, please visit our home page. Deadline for registration is December 2, 2002.