59. CASE: HPV Vaccine for Boys

PEI is expanding its human papilloma virus (HPV) vaccination program to include grade six boys. Girls have been receiving the HPV vaccine since 2007. HPV is the most common sexually-transmitted infection among young adults. It can lead to genital warts and, in girls, cervical cancer. For boys it can also lead to cancers of the mouth, throat and genital area.

Deputy chief public health officer, Dr. Lamont Sweet, said vaccinating the boys will not only protect them, it will also lead to fewer women dying from cervical cancer. “Boys can be the source of the virus for their female partners,” said Sweet. “By preventing boys from carrying the virus, you in turn will help prevent girls from getting the virus which causes cervical cancer.” The new program won’t cost more than the original vaccination program, he said, because the price of the vaccine is half what it used to be. The cost of vaccinations for girls in PEI has been $280,000 a year, with about 85 per cent of girls vaccinated. Health Minister Doug Currie said PEI is the first province to offer the vaccine to boys. Nancy Bickford, public affairs for the Society of Obstetricians and Gynecologists of Canada, was pleased by the news. “The SOGC welcomes this move and in fact will be contacting other provincial and territorial ministers of health to follow PEI’s lead,” Bickford said.

You are asked to respond to media questions about this issue – should Nova Scotia follow PEI’s lead and vaccinate grade six boys?

  • Identify the values that are relevant to this discussion and select the ones that will guide your response.
  • How would you justify this response?

Some Values and Ethics Issues to Consider

  • Duty to provide care
  • Fairness
  • Community/ public health ethics
  • Priority setting
  • Resource allocation
  • Risk
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41. CASE: Ethical Budgeting

This is the day you’ve been dreading as manager of the geriatric day program at your local hospital. Word has come down that your budget is going to be cut by 15% in the next fiscal year (indeed everyone’s budget at your facility faces the same cut). You have three months to determine how this money will be eliminated from your budget and must meet with your director to explain both the ways in which the money will be “saved” and what implications will follow from the “cuts.” The geriatric day program has been one of the most successful programs at this facility, based on client and family feedback. Among other activities, the geriatric day program includes rehabilitation support, general health monitoring and facilitated access to health professionals, psychosocial support and counseling, organized recreation therapy sessions, transportation to and from the health facility for those who can’t otherwise get there, and hosts a variety of speakers on topics of interest. You know that whatever change you make, the effects will be felt in the community. And, you know that some of the very vulnerable people – the clients without many social supports and multiple health issues – could potentially be affected the most.

  • Where do you start?
  • What questions should you ask?
  • What information do you need?
  • Who should you talk to?
  • What might be a good process to use for this type of decision-making?
  • Who should be involved in the process?
  • How will you know when you’ve got it right (or as right as it can be)?

 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting

40. CASE: All Things Being Equal…

As a member of your health region Foundation Board, you know that there is going to be a rather intense, lengthy, and difficult discussion tonight. A high profile community member recently passed away and left $500,000 in her will to the Foundation. This was an unexpected donation and means that the Foundation is in a position to put the money towards an important project for the health region in addition to what was already planned. Many suggestions for the use of this money have been made, and in conversation with senior leadership, the Foundation Board has narrowed these options down to three for consideration:

  • The accreditation report from a few years ago strongly recommended equipment upgrades for both the Emergency Department and the Intensive Care Unit. While some upgrades have been made, there are still a number of important ones left to do. Knowing that accreditation is coming up again soon, there is increasing pressure to find the resources to complete these upgrades.
  • The health care teams on several inpatient units recently highlighted the need for equipment to accommodate persons who are obese. This equipment includes specialized beds, lifts, chairs, etc. and will require some renovation of doorways for the new equipment. Issues of patient and staff safety, as well as good patient care, have been identified as motivating this request. Given some local press on the difficulties experienced and the associated shame expressed by patients who are morbidly obese in the health region, a number of people have indicated that this is an issue that requires immediate attention.
  • A pledge to expand community palliative care services was made last year by the health region. With the aging population and difficulty for many in accessing hospital-based palliative care, this pledge was received with much anticipation. To date, however, it has been difficult to attract the needed staff. Additional funds could go towards incentive packages as well as to greatly improve the infrastructure for this type of service.
  • How would you advise your board to make such a decision?
  • What further information do you need to move ahead with the discussion?
  • What underlying values should be considered?
  • How will you justify and communicate the decision that you made?

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting

39. CASE: Setting Priorities

In the wake of a mass casualty event, a hurricane that devastated much of Nova Scotia, blood resources within the province are extremely scarce. There is not enough blood to meet all the legitimate blood-related health needs of Nova Scotians, and the blood supply is not expected to increase significantly in the next two months. Tough choices have to be made. The following three patients have been admitted to a rural general hospital and are in need of blood transfusion:

Jim is a relatively healthy, 87-year old man who requires a colectomy for a benign hemorrhagic bowel disorder. He is scheduled for surgery along with many urgent others, and it is anticipated that he will not rise to the top of the waiting list for at least two months. To bridge the gap between now and then, he requires regular (e.g., q 3 weeks) transfusions. Jim lives independently in the community and is very engaged with two of his children and six grandchildren who live in the local area.

Sue is a 42-year old woman admitted to the palliative care service whose progressive leukemia is causing her to be significantly fatigued and short of breath. The attending hematologist estimates that regular blood transfusions would allow her to remain functional at home for about another eight months. She has three children ages 4, 7 and 11. The family is dependent on the single income of her husband who is a plumber.

Kevin is a six-year old boy with a poor prognosis cancer diagnosis. His present quality of life is poor – he is confined to bed and spends most of his time asleep. He is not experiencing any pain. Kevin is able to communicate with his parents for an hour or two a day. His medical oncologist estimates that regular blood transfusions would extend his life for about another five months. It is anticipated that Kevin’s quality of life will remain essentially unchanged during this period of time. Kevin’s parents are demanding that their son receive these blood transfusions.

Dr. Fairchance, as the hematologist on-call, is asked to make a decision about which of these three patients should be started on blood transfusions. She recognizes that there is currently enough available blood to meet the needs of only one of these patients. Dr. Fairchance is also asked to prioritize the other two patients in the unlikely event that more blood becomes available in the next week or two. As the medical resident on-call, you have been requested to assess Jim, Sue and Kevin and to report back to Dr. Fairchance regarding their present health status. She would also like you to assist her with the rationing decision.

  • What factors should be considered in micro-allocation decisions? How do you prioritize them?
  • What principles and values would inform your decision-making?
  • What decision-making process would you use to work through this decision?
  • Is there a better way than ‘bedside rationing’ to allocate scarce health resources?
  • What are the implications – organizational or otherwise – of your decision?

 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Priority setting

37. CASE: A Question of Resources

Joyce Skinner is a 38-year old woman with non-curative leukemia. She is the single mother of two children, ages 11 and 8, and her ex-husband is ‘out of the (parental) picture’. Since her leukemia diagnosis, Joyce has approached her progressive hematological cancer in an assertive manner, seeing it as her responsibility to fight to stay alive and look after her children for as long as possible.

Over the past few years, her attending hemato-oncologist, Dr. Jones, has arranged for her to be a research participant in a variety of experimental chemotherapy trials, which have extended her life beyond what was initially anticipated. However, about 6 months ago, Joyce’s leukemia moved into a treatment-resistant phase and her medical regime is currently palliative in nature and intent.

Joyce is now residing in a hematology clinical unit of a tertiary care hospital where she is followed regularly by a palliative care consultant, Dr. Miller. In the last 3 weeks, the frequency of blood transfusions required to keep Joyce’s hemoglobin at a low functional level has progressively increased such that she is now receiving transfusions every second day. Joyce is not eligible for transfer to the hospital’s Palliative Care Unit while blood transfusions are a component of her care plan.

She is very weak and is confined to her hospital bed. Her children visit her regularly with their aunt Cathy, who has assumed parental responsibility for them. They have missed a considerable amount of school time in the last few months.

Despite the honest information provided by Dr. Jones, Joyce is in some denial about her grim prognosis and strongly believes that she can continue to ‘beat the odds’. She remains reasonably clear-headed and is capable of making health care and treatment decisions on her own. She insists that Dr. Jones continue the blood transfusions indefinitely. Her sister and Dr. Jones and Dr. Miller are of the shared opinion that the transfusions should be discontinued and that Joyce should be transferred to the Palliative Care Unit.

Dr. Jones, who sits on the provincial blood management committee, is aware that there has been an exceptional demand on existing provincial blood resources in the last few weeks due to a number of major highway accidents. The hospital is chronically under-resourced. There are typically one or more patients waiting in the emergency department for admission to the hematology clinical unit.

  • What do you think is important to Joyce (in terms of her personal values)?
  • On what basis could Joyce claim a right to continue receiving blood transfusions?
  • What ethics principles and values are at play in these circumstances?
  • What weight in the decision-making should be given to the clinical judgments of Dr. Jones and Dr. Miller?
  • Should Cathy (as an engaged family member) participate and have some authority in the decision-making? Would this change if Joyce loses capacity and Cathy becomes her sister’s substitute decision-maker?
  • Is ‘bedside rationing’ of limited health resources an appropriate form of health resource allocation?
  • With their mandates to manage limited health resources prudently, should the District Health Authority and/or the provincial Department of Health & Wellness have a role in such end-of-life decision-making?
  • Under what circumstances would it be ethical to deny Joyce’s request for further blood transfusions?

 

Some Values and Ethics Issues to Consider

  • Resource allocation
  • Distributive justice
  • Substitute decision-making
  • Patient-centered care
  • Respect for patient autonomy
  • Respect for professional integrity
  • Compliance with organizational policy
  • Quality of life
  • End of life decision-making

4. CASE: Expectations for Care

Ned is an elderly patient with relatively advanced dementia who is recovering from surgery to repair a hip fracture. He spends most of every 24-hour period screaming unless someone familiar sits with him. Staff members on the unit are becoming increasingly frustrated and stressed. The unit manager has received numerous complaints, verbal and written, from other patients on the unit and from some of their family members. She decides to call the ethics line.

  • What are the ethics issues?
  • What are the non-ethics issues?
  • What underlying values are at stake?
  • How would you respond to this call?

 Some Values and Ethics Issues to Consider

  • Moral distress among health care providers
  • Distributive justice
  • Resource allocation
  • Patient-centered care
  • Capacity
  • Empathy
  • Respect for human dignity
  • Quality of life

3. CASE: Superbugs

Jeannette Cutler is an 83-year old woman admitted to hospital after falling and breaking her arm.  She reports that she fell because she passed out, and so further investigations are being conducted.  She has mild dementia but is otherwise seemingly healthy.  Upon admission, she screens positive for MRSA and is subject to strict isolation procedures as per hospital policy.

Jeannette was a long-time volunteer at the hospital where she is now a patient. Jeannette is having trouble adhering to the isolation protocol, and several times a day she gets up and starts going into other patients’ rooms to “visit”.  The team has had discussions with her regarding the need for her to remain in her room, but they have failed to achieve the desired effect.

Staff is concerned that she is spreading MRSA and are considering various means of confining her to her room.  They aren’t sure how best to express respect for Jeannette while also ensuring that other patients are not unnecessarily exposed to harm.  They have contacted the ethics committee and the legal department asking for help in working through this case.

  • What ethics concerns are you thinking about as you respond?
  • Who should be involved in making this decision?
  • What are some competing values that arise in this case?
  • Should the well-being of others take precedence over Jeannette’s freedom of     mobility?
  • What potential creative solutions can you think of to resolve this issue?

 Some Values and Ethics Issues to Consider

  • Respect for individual liberty
  • Patient-centered care
  • Distributive justice
  • Policy compliance
  • Respect for autonomy
  • Responsibility for health
  • Quality of life
  • Respect for dignity
  • Capacity
  • Beneficence and non-maleficence