Health care ethics pdf download

Our Impact Our social responsibility consists of corporate giving, local community relations, volunteerism, diversity and inclusion, ethics and compliance, wellness and sustainability initiatives.

Our Impact. Who We Serve We work hard to provide our members with the most innovative, cost efficient and helpful tools to manage their health. Who We Serve. Our Ethics We strive to do the right thing every day, acting ethically and honestly in everything we do. Our Ethics. Our Purpose To do everything in our power to stand with our members in sickness and in health. Another challenge that falls into this category surrounds the timing of palliative care, i.

Seventh on the list according to the panel was the challenge of obtaining informed consent in the health care setting. Research [ 5 ] and experience of the panel have shown that there is a huge gap between informed consent in theory and informed consent in practice: many patients do not or cannot read the consent forms they're asked to sign; consent discussions and capacity assessments are often superficial and rushed due to time constraints; and those same time constraints often contribute to staff not using interpreters with patients whose first language is other than English.

The implication of this is that many patients may be subjected to medical interventions without providing properly informed consent. Since the ethical principle of respect for patient autonomy, on which the doctrine of informed consent is based, has become a central and foundational principle in modern Western health care, the implication of this challenge is troubling.

The eighth top challenge was a family of issues associated with participant involvement in research. There are a wide range of ethical issues related to research in the health care setting, including obtaining informed consent, the balance between providing participants with fair compensation and the risk that the compensation will be a coercive influence, the challenge of balancing benefits and risks of the research, issues around patient privacy and confidentiality, and the ethical appropriateness of involving in research participants who are not capable of giving an informed consent.

The ninth ranked challenge, finishing closely behind the challenges associated with research, was the challenge of substitute decision making. When a patient is incapable of making a particular health care decision, the health care team will turn to the substitute decision maker to make the decision. Depending on the particular jurisdiction there may be a legal hierarchy of decision makers, which typically places the patient's most intimate relationship at the top spouse or partner and other relatives toward the bottom of the hierarchy many Canadian provinces and US states have such a hierarchy written into health care consent legislation.

In the experience of the panel members, substitute decision makers often find this task to be a heavy burden, and struggle with the responsibility attached to making a potentially life-altering and often life-ending decision on behalf of their loved ones. This burden is experienced to the greatest degree when no guidance has been provided by the patient as to what his or her wishes would be in the current circumstances. Finally, the tenth ranked challenge was that of surgical innovation.

This is a challenge that patients and families will only face indirectly, as the general public is likely unaware of what the issues are related to surgical innovation. Surgical innovation raises such questions as, should innovative surgical techniques be considered research and be required to go through research ethics approval? Since variation is often part of the routine process of perfecting surgical techniques, it becomes difficult to ascertain when a surgical innovation becomes an experiment that requires research ethics approval.

Also, what protections should be in place to ensure that innovative techniques or procedures can be developed while the risks to patients are minimized?

There are a number of benefits that can be realized with an exercise focused on ranking the top ten ethical issues the public may face. These include providing new contributions to knowledge, raising public awareness, and re-focusing attention on the top challenge.

These benefits will be discussed in the discussion section below. The issues described as top ethical challenges by the panel have all been discussed individually in the literature, some extensively. And there have been a few attempts in the past to elicit the views of particular groups on major ethical issues in specific areas.

For example, Ersek at al. Along slightly different lines, Walker et al. However, these previous studies have typically focused on the views of a specific group of health care professionals on ethical issues in particular health care contexts.

No attempt has ever been made to seek the opinion of clinical bioethicsts who are in a unique position to offer comment on the overall ethical issues in the health care system. Furthermore, despite extensive coverage of ethical issues in the healthcare literature, no systematic effort has been made to collate and rank these kinds of issues from the perspective of the impact on the public. A second benefit of such an exercise is that it can be part of an effective strategy to bring these challenges to the public's attention.

Another component of the public awareness strategy might include a press release or other form of media attention coordinated with the publication of the research paper. Even the paper itself can spark discussion and bring the issues to the public's attention. Not only would this help to inform the public about ethical challenges they may confront in the health care system to they can be better prepared for those challenges, but it can help garner the public's support in advocating for steps to be taken to address the top challenges.

The challenges described by the panel will impact patients and their families in different ways and to varying degrees. For example, waiting lists ranked 2 nd and the shortage of family physicians ranked 4 th are challenges that will likely have an impact that is felt directly by a large percentage of the public. The same can be said of the third ranked challenge, access to needed health care resources for the aged, chronically ill, and mentally ill, and that challenge will impact an increasing number of patients and families in the future as our populations age and the number of elderly and chronically ill patients rise.

This direct impact on the public, combined with the attention that issues like waiting lists do receive in the media, means that some of the challenges described by the panel are already at the forefront of the public's attention. On the other hand, the public is likely to be largely unaware of some of the other challenges mentioned by the panel. These are the challenges that tend to impact a smaller number of patients and families, such as issues related to participation in research ranked 8 th , or may impact patients and families more indirectly, such as the issues related to surgical innovation ranked 10 th.

The most interesting result of this study is that the ethical challenge ranked highest by the panel is a challenge that actually receives very little attention in the popular media and at the level of government, and a challenge of which most members of the public are likely completely unaware. It is not surprising because it is probably the most common reason for requests for ethics consultations, and an area in which many bioethicists focus their research activities.

A study by DuVal et al. These conflicts can be as serious as an emotionally charged fight over a decision to withdraw aggressive treatment from a terminally ill patient in the intensive care unit, or as mundane as a family physician refusing to acquiesce to a patient's request for antibiotics for a viral infection.

According to the panel, it's the end-of-life critical care cases that tend to be the most emotionally charged, and the most intractable, because these are the cases in which the most is at stake — they typically amount, literally, to conflicts over life and death.

A paradigm example of what has become the most common scenario would involve a patient in the late stages of a terminal illness, such as cancer with multiple metastases, or an elderly patient with multiple co-morbidities, who is ventilated in the intensive care unit. The family would be demanding that "everything" be done to maintain the patient's life, while the team feel strongly that subjecting the patient to aggressive interventions would amount to torture.

Emotions run high, conflict ensues, and communication inevitably breaks down. The above is a paradigm example of what is often referred to in the literature and by health care professionals in the clinical setting as a "futility" case.

Although there are volumes of literature on the problems associated with the definition and use of the concept of futility, health care professionals know exactly what is meant when a colleague uses the concept: the likely harms of the aggressive intervention s outweigh the potential benefits to such a degree that subjecting the patient to the intervention s violates their professional and sometimes personal values.

From the perspective of the health care professionals, the "right" decision is obvious and they cannot understand why the family doesn't see it the way they do. This often leads to these families being labelled as "irrational" or "unreasonable" by members of the health care team. The family, on the other hand, views the situation very differently. They will tend to focus on the positive, holding out hope that their loved one will beat the odds. They may also be guided by deeply held religious beliefs, which they claim are also held by the patient.

From the family's perspective, the health care professionals are being insensitive and disrespectful, unwilling to listen to or accept what is important to them. Sometimes families will go so far as to accuse the health care team of wanting to withdraw treatment to save money or to give the resources to another patient. Many of the panel members reported having been involved in ethics consultations where family members have expressed these sentiments.

What lies at the root of these conflicts is a clash of value systems. It is our value systems that influence the decisions we make, especially when we are faced with significant life-altering decisions in the health care setting.

But it is not just patients and their families that are guided in their decisions by their values; health care professionals also come to their encounters with patients and families with their own value systems, both personal and professional.

Compared to the attention given to many of the challenges listed in the top ten, it is remarkable how little attention has been given to the top challenge. It is especially remarkable given that these conflicts occur in health care institutions across the country on a daily basis. Below, we propose several steps to help address this top challenge. Educating health care professionals : Although most health care professionals are now taught communication skills, they are not taught the negotiation and mediation skills needed to address serious disagreements.

The key is to make an attempt to understand the patient's perspective. We recommend that all health professional programs — undergraduate, postgraduate and continuing — takes steps to address this deficiency;.

Creating policies for health care institutions : Some institutions have developed policies on cases of disagreement, especially at the end of life, but there is no consistency in this area across institutions. We recommend this requirement be sharpened to include mechanisms to resolve disagreements between the health care team and patents or their substitute decision makers.

In addition, it may be worthwhile to explore the plausibility of approaching policy development in this area through a process of public consultation. Having stakeholders with diverse value systems come together to discuss the challenge may prove to be a more fruitful approach than applying the standard top-down approach;. Examining the patient's perspective : Disagreements between patients or their substitute decision makers and health care teams present a difficult problem with no perfect solution.

What is needed is a better understanding of the patient's perspective on this challenge. Some excellent work has been done in the attempt to shift the focus of end-of-life issues from the perspective of health care professionals and bioethicists to patients themselves [ 9 , 10 ].

However, what is still needed is quality research that focuses specifically on the perspectives of patients toward disagreements over treatment decisions;. Reporting to the public : Research studies like ours are only one part of a strategy to address the top challenge.

A key part of the strategy would be a systematic effort to keep the public informed of such research and the attempts being made to address the challenge. National health councils or other similar bodies would be an excellent mechanism to pull together the diverse initiatives described above and to keep the public informed.

Not only should the public be kept informed of steps to address the challenge but they should ideally be involved in the process itself. As mentioned above, one example of involving the public in the process would be to engage the public in the development of policies or guidelines to help address the top challenge. The main limitations of this study relate to the generalizability of the results. First, the ranking of challenges may not be generalizable to contexts outside of Canada.

Some of the challenges listed may be challenges that are particular to the Canadian context because of our Medicare system, such as the challenge of waiting lists or the shortage of family physicians. If this same study were conducted in other countries, it is possible that these challenges would be ranked much lower than in our study, or may not be ranked as a major challenge at all.

However, we believe that on the whole our results are likely generalizable at least to other industrialized nations. The challenge of medical error, for example, is a universal challenge because medicine is, by its nature, a human endeavour.

As long as humans remain imperfect, medical errors will occur. Thus, although the panel was asked to report on the top ethical challenges facing Canadians in health care, we believe the results of this study would be of interest to other countries. Second, because the panel was made up of clinical bioethicists in Toronto, the ranking of challenges may not be representative of the challenges facing the entire Canadian public.

Some of the challenges might be considered more or less significant or prevalent in other parts of Canada, especially since there are some very apparent differences between the health care systems of the different provinces. Nevertheless, for the same reasons as mentioned above in the context of generalizability to other nations, we believe the results are in general representative of the challenges facing the Canadian public. Third, since our panel was made up entirely of clinical bioethicists, we recognize that the results may not be generalizable to other groups.

For example, if the panel was comprised of, or included, members of the public, hospital administrators, or clinicians, the results might have looked very different. Moreover, although the panel members do represent a wide range of health care instutitions, there were health care settings not represented amongst the group e. However, we believe that this is not a significant limitation of the study because the purpose was not to make a factual claim about what, objectively speaking, are the top ten ethical challenges facing the public.

Rather, the purpose was to identify what those top ten challenges are from the perspective of a group of highly qualified and experienced clinical bioethicists who work in a variety of health care institutions.

Finally, we recognize that the modified Delphi process that we have presented in this paper is not typical because of the face-to-face meeting of panel members that took place prior to the final round of ranking. One of the potential limitations of including a face-to-face meeting during a consensus process is that a member or members of the group could exert influence over others, thus skewing the process away from genuine consensus.

Nevertheless, we believe this potential problem was mitigated by the fact that the face-to-face meeting was not actually part of the ranking process but was an intermediate step between ranking rounds for the purpose of clarifying and differentiating the items.

Thus, the consensus process itself was not directly affected by the face-to-face meeting. Patients and their families face a number of ethical challenges in health care. Many of these challenges are no different from the kinds of challenges faced by patients and families in other industrialized nations. Other challenges on the list are more particular to our social context, with their roots in the very nature of the Canadian Medicare system.

Waiting lists, access to needed care for the aged, chronically ill, and mentally ill, and the shortage of family physicians, are challenges that may impact Canadians to a greater or lesser degree than citizens of other nations. Interestingly, these three context-specific challenges were all ranked in the top four of the top ten ethical challenges facing Canadians. Moreover, some of the challenges have received far more public attention than others. Google Scholar.

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