Fair Innings: Equality and Children’s Healthcare

Commentaire / CommentaryCe commentaire évalue les implications éthiques en soins de santé d’une approche axée sur le “fair innings” à travers la loupe de la garantie d’égalité inscrite dans la Charte canadienne des droits et libertés.This commentary assesses the ethical implications of a fair innings inspired approach to healthcare through the lens of the equality guarantee contained in the Canadian Charter of Rights and Freedoms

Legal liabilities in research: early lessons from North America

The legal risks associated with health research involving human subjects have been highlighted recently by a number of lawsuits launched against those involved in conducting and evaluating the research. Some of these cases have been fully addressed by the legal system, resulting in judgments that provide some guidance. The vast majority of cases have either settled before going to trial, or have not yet been addressed by the courts, leaving us to wonder what might have been and what guidance future cases may bring. What is striking about the lawsuits that have been commenced is the broad range of individuals/institutions that are named as defendants and the broad range of allegations that are made. The research community should take this early experience as a warning and should reflect carefully on practices where research involving human subjects is concerned

On pandemics and the duty to care: whose duty? who cares?

BACKGROUND: As a number of commentators have noted, SARS exposed the vulnerabilities of our health care systems and governance structures. Health care professionals (HCPs) and hospital systems that bore the brunt of the SARS outbreak continue to struggle with the aftermath of the crisis. Indeed, HCPs – both in clinical care and in public health – were severely tested by SARS. Unprecedented demands were placed on their skills and expertise, and their personal commitment to their profession was severely tried. Many were exposed to serious risk of morbidity and mortality, as evidenced by the World Health Organization figures showing that approximately 30% of reported cases were among HCPs, some of whom died from the infection. Despite this challenge, professional codes of ethics are silent on the issue of duty to care during communicable disease outbreaks, thus providing no guidance on what is expected of HCPs or how they ought to approach their duty to care in the face of risk. DISCUSSION: In the aftermath of SARS and with the spectre of a pandemic avian influenza, it is imperative that we (re)consider the obligations of HCPs for patients with severe infectious diseases, particularly diseases that pose risks to those providing care. It is of pressing importance that organizations representing HCPs give clear indication of what standard of care is expected of their members in the event of a pandemic. In this paper, we address the issue of special obligations of HCPs during an infectious disease outbreak. We argue that there is a pressing need to clarify the rights and responsibilities of HCPs in the current context of pandemic flu preparedness, and that these rights and responsibilities ought to be codified in professional codes of ethics. Finally, we present a brief historical accounting of the treatment of the duty to care in professional health care codes of ethics. SUMMARY: An honest and critical examination of the role of HCPs during communicable disease outbreaks is needed in order to provide guidelines regarding professional rights and responsibilities, as well as ethical duties and obligations. With this paper, we hope to open the social dialogue and advance the public debate on this increasingly urgent issue

Accountability and pediatric physician-researchers: are theoretical models compatible with Canadian lived experience?

Physician-researchers are bound by professional obligations stemming from both the role of the physician and the role of the researcher. Currently, the dominant models for understanding the relationship between physician-researchers' clinical duties and research duties fit into three categories: the similarity position, the difference position and the middle ground. The law may be said to offer a fourth "model" that is independent from these three categories

Operationalizing Equity in Surgical Prioritization

The allocation of critical care resources and triaging patients garnered a great deal of attention during the COVID-19 pandemic, but there is a paucity of guidance regarding the ethical aspects of resource allocation and patient prioritization in ‘normal’ circumstances for Canadian healthcare systems. One context where allocation and prioritization decisions are required are surgical waitlists, which have been globally exacerbated due to the COVID-19 pandemic. In this paper, we detail the process used to develop an ethics framework to support prioritization for elective surgery at The Hospital for Sick Children, Toronto, a tertiary pediatric hospital. Our goal was to provide guidance for the more value-laden aspects of prioritization, particularly when clinical urgency alone is insufficient to dictate priority. With this goal in mind, we worked to capture familial, relational, and equity considerations. As part of our institution’s concerted efforts to ethically and effectively address our surgical backlog, an ethics working group was formed comprising clinicians from surgery, anesthesiology, intensive care, a hospital bioethicist, a parent advisor, and an academic bioethics researcher. A reflective equilibrium process was used to develop an ethics framework. To this end, the same methodology was used to create a support for patient prioritization that identifies clinically and morally relevant factors for prioritization among medically similar surgical cases, with a substantive goal being to identify and redress health inequities in surgical prioritization, inasmuch as this is possible. While further steps are needed to validate several aspects of the framework, our research suggests that an ethics framework grounded in the practical realities of hospital operations provides consistency, transparency, and needed support for decisions that are often left to individual clinicians, as well as an opportunity to reflect upon the presence of health inequities in all domains of healthcare delivery

Adoption of an innovation to repair aortic aneurysms at a Canadian hospital: a qualitative case study and evaluation

<p>Abstract</p> <p>Background</p> <p>Priority setting in health care is a challenge because demand for services exceeds available resources. The increasing demand for less invasive surgical procedures by patients, health care institutions and industry, places added pressure on surgeons to acquire the appropriate skills to adopt innovative procedures. Such innovations are often initiated and introduced by surgeons in the hospital setting. Decision-making processes for the adoption of surgical innovations in hospitals have not been well studied and a standard process for their introduction does not exist. The purpose of this study is to describe and evaluate the decision-making process for the adoption of a new technology for repair of abdominal aortic aneurysms (endovascular aneurysm repair [EVAR]) in an academic health sciences centre to better understand how decisions are made for the introduction of surgical innovations at the hospital level.</p> <p>Methods</p> <p>A qualitative case study of the decision to adopt EVAR was conducted using a modified thematic analysis of documents and semi-structured interviews. Accountability for Reasonableness was used as a conceptual framework for fairness in priority setting processes in health care organizations.</p> <p>Results</p> <p>There were two key decisions regarding EVAR: the decision to adopt the new technology in the hospital and the decision to stop hospital funding. The decision to adopt EVAR was based on perceived improved patient outcomes, safety, and the surgeons' desire to innovate. This decision involved very few stakeholders. The decision to stop funding of EVAR involved all key players and was based on criteria apparent to all those involved, including cost, evidence and hospital priorities. Limited internal communications were made prior to adopting the technology. There was no formal means to appeal the decisions made.</p> <p>Conclusion</p> <p>The analysis yielded recommendations for improving future decisions about the adoption of surgical innovations. ese empirical findings will be used with other case studies to help develop guidelines to help decision-makers adopt surgical innovations in Canadian hospitals.</p

The implications of sections 1, 15 and 24 of the Canadian Charter of Rights and Freedoms on health care allocation decisions

grantor: University of TorontoThis thesis explores how sections 1, 15, and 24 of the ' Canadian Charter of Rights and Freedoms' can and ought to serve as a framework for addressing complex public policy issues associated with allocating health care resources. Chapter one describes the factual milieu of health policy in Canada. It explores the nature of health care policy in a pluralistic society. It also discusses the legal/political dimensions of the Canadian health care system. Chapter two examines the 'Charter' as a source of guidance for health policy makers. It examines the implications of section 15 for allocation decisions. Chapter three is a case study, that applies section 15 analysis to women. Chapter four describes the implications of sections 1 and 24 of the 'Charter', general government obligations and judicial remedies. The thesis concludes with some general thoughts on the ' Charter' and its implications for the delivery of health care in Canada.LL.M

The implications of Canadian law for economic approaches to allocating health care resources: The round hole and the square peg

grantor: University of TorontoChapter one explains that the purpose of this thesis is to analyze legal principles at issue when attempts are made to ground allocation policies in economics. Chapter Two examines the ethical values reflected by economics and law. It explores the tensions between the philosophical perspectives of consequentialism and deontology and describes options for bringing normative theories to practice. The purpose of this chapter is to provide the reader with the ethical context of law and economics. Chapter Three describes and analyzes the contribution economics can bring to resource allocation. The chapter addresses four utilitarian based methods of priority setting: cost-minimization analysis, cost-benefit analysis, cost-effectiveness analysis and cost-utility analysis. These are formal methods of comparing costs and consequences of medical interventions to determine whether they are worth funding. Chapter Four examines the legal implications of making allocation decisions according to economic principles. It focuses on the areas where economics and law conflict in relation to resource allocation, the legal theory behind the values at issue in resource allocation and the potential for reconciliation of economic and legal principles. The areas of law focused on are the principles of comprehensiveness, accessibility, public administration, universality and portability under the 'Canada Health Act', the doctrines of legitimate expectations, public interest standing and rules around discretion in administrative law, the right to equality (s.15), available remedies (s.24) and the principles of pressing and substantial, and proportionality (s.1) under the 'Canadian Charter of Rights and Freedoms' (Charter). Chapter Five of the thesis concludes that the legislative objective of making allocation decisions that respect economic principles can be accomplished to the extent that allocation decisions do not violate Canadian law. In recent cases, courts have shown a new willingness to expand the range of issues they are willing to address and consider the legality of government allocation decisions, an area that has traditionally been left to the discretion of government. Evolving case law suggests that allocation policies focusing on consequentialism expressed by economics will have to be compromised if Canadian allocation policy is to accommodate legally binding deonotological values entrenched in law.Ph.D