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

John Watts: The Voice of Reason!!!

Philosophy & Health Care Ethics at McMaster and HHS

Bioethics in Canada

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

Presenter

Presentation Notes

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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

Presenter

Presentation Notes

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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– frolic@hhsc.ca; 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

Intranet site – employees only

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?