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Ethics Review - Issue 3 Volume 2 - January 2004
The Ethics Team is prepared to meet to discuss specific clinical ethical issues. Hospital staff, patients and families who have concerns or need clarification about ethical aspects of patient care may consult the committee.
Dr. Jaro Kotalik
Email: jkotalik@tbaytel.net
(807) 343-8126
S Hamilton
Email: hamiltos@tbh.net
(807) 684-6012
P Lee
Email: leep@tbh.net
(807) 684-6028
The following is a summary of the Roundtable Discussions
held in October and November of 2003 regarding ethical decision
making during SARS and other infectious disease outbreaks.
The participants discussed four fictional cases involving
real ethical issues arising from SARS and similar outbreaks.
By examining these issues in the context of an ethical framework,
we hope to learn lessons about how we might manage similar
ethical decisions in our hospital and in our community in
the future.
The scenarios are reproduced with permission from P. Singer,
University of Toronto Joint Centre for Bioethics and taken
from the Report by a University of Toronto Joint Centre for
Bioethics Working Group. Ethics and SARS: Learning Lessons
from the Toronto Experience, Toronto, August 2003.
"Mary," a nurse in the Intensive Care Unit, is
afraid that when she goes to work she will have to care for
SARS patients and may become infected. Her husband asks her
to call in sick, pleading that it is her duty as the mother
of three small children not to risk giving them SARS. "Mary"
feels torn. She feels her primary responsibility is to do
everything in her power to protect her children. At the same
time, "Mary" has a strong commitment to her profession,
and the family needs her income. She has studied hard to become
a staff nurse, and is aware of the importance the hospital
places on good attendance. Her salary is affected by calling
in sick. She also wants to support her colleagues on the front
lines by going to work.
If you were Mary, how would you make your decision?
- Ethical values: Duty to Care and Reciprocity
- Virtue ethics – good character of health care worker
– is relied upon to put patient needs first
- Must be well enough to care for current and future patients
- Obligation of employers to provide supports necessary for employees to do jobs effectively and safely
- Timely sharing of information essential
- Clear guidelines for institutions from MoH so employees know expectations
- Ensure staff are rewarded for following safe practices (ie staying home when sick) instead of being penalized
- Consider using staff isolated at home in other ways, ie phoning patients and families to provide information
"Tom", who at 58 has valiantly fought a brain
tumour for 13 years, including three major brain surgeries,
is admitted to the hospital with an urgent but unrelated condition.
He starts to deteriorate, and it appears that the inevitable
victory by his tumour is close at hand. "Jane",
his wife and soul-mate, who has been faithfully and constantly
by his side through good times and bad, is not allowed into
the hospital to be with her very sick husband because of SARS
restrictions. She waits frantically by the phone, and the
surgeon spends what little time he can spare to keep her informed.
What would be involved in the Unit Manager’s decision-making?
- Ethical value – equity and solidarity
- Implications of visiting policies as well as surgical cancellations
- Hard choices – weigh risks, benefits, and balance
- Need for communication
- Accountability for making reasonable decisions, transparency and fairness are expectations
- Solidarity – would public want to subjugate own needs for the good of the whole
"June," a nurse at a downtown Toronto hospital
affected by SARS, is feeling unwell and has a fever. She weighs
the risk of possibly having the disease against the costs
of losing pay if she does not show up, and worries about placing
a burden of extra work on her colleagues. "June"
takes the GO commuter train to work. Medical officials fear
she might have SARS, and have infected a group of commuters,
spreading the disease into the community, where it might be
impossible to control. They choose not to name her, but they
do warn people on that train car to be checked in case they
develop SARS.
Does the public have the right to June’s photograph? Why or why not?
- Ethical values: Privacy & confidentiality, Protection
of Public Health, Proportionality, Transparency, and Protection
of communities from undue stigmatization
- Is the right to privacy absolute? How can it be balanced
against the public’s right to protection?
- Is there added benefit to publishing June’s name?
- Need to be cautious about exposing communities to stigmatization
(ie the Chinese community)
- Questioning of authority & making own decisions
- Respect for authority?
- How to put pressure on people to comply?
"Michel" is in quarantine because a family member
has contracted SARS, and he may have been infected. A close
family friend has died from causes not associated with the
SARS epidemic, and "Michel" is torn between wanting
to attend the funeral and his duty to respect the quarantine
order.
What would you advise Michel? What would you do if you were in his situation?
- Ethical Values: Individual Liberty, Protection of the
public from harm, Proportionality, Transparency, Reciprocity.
- Must be even-handed in quarantine so that people are
not unfairly or disproportionately harmed
- Authorities have duty to protect; citizens have duty
to comply
- Must use least restrictive measures possible and without
discrimination
- All legitimate stakeholders must be informed and have
reasonable input into discussions that affect them
- Society has a duty to see that quarantined people get
adequate care
- Not excessive quarantine or abandonment
- Address economic hardships
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