77. Case: Accommodating Requests: Which Differences Make a Difference?

 

Michelle Yoder is 8 months pregnant and a member of the Amish community.  She requests that only female health care providers and staff be involved in providing her care during labour and delivery.

Michelle Federov is 8 months pregnant.  She requests that only white health care providers and staff be involved in providing her care during labour and delivery.

 

Discussion:

  • What are the ethical concerns raised by these cases?
  • How are your responses different to these two scenarios?
  • How do you think health care organizations should respond to requests like these?

Resources:

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75. Case: Cultural Competence: Truth and Reconciliation in Action

 

Case 75: Cultural Competence: Truth and Reconciliation in Action

Alex Sylliboy has been referred to the diabetes clinic and this is his first appointment.  He identifies as Indigenous on the intake form.  Andrew Sullivan, the nurse, has read recently that the experience of residential schools has long-lasting, intergenerational effects on health, but isn’t sure if he should ask about it in the context of addressing Alex’s diabetes and is also uncertain about how to bring it up.

Discussion:

  • What are the ethics concerns raised here?
  • How might Andrew proceed with this encounter?
  • What are some words or phrasing that Andrew might find helpful?

Resources:

 

66. Case: Blood Transfusions

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 Drs. Jones and 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.

 

 

  1. What do you think is important to Joyce (in terms of her personal values)? What do you suspect about her personality structure?

 

  1. On what basis, if any, could Joyce claim a right to continue receiving blood transfusions? What other ethics principles and values are at play in these circumstances?

 

  1. What weight in the decision making should be given to the clinical judgments of Drs. Jones and Miller?

 

  1. Should Cathy (as an engaged family member) participate and have some authority in the decision making? Would the nature of this authority change if Joyce loses capacity?

 

  1. Is ‘bedside rationing’ of limited health resources an appropriate form of health resource allocation?

 

  1. With their mandates to manage limited health resources prudently, should the Nova Scotia Health Authority and/or the provincial Department of Health & Wellness have a role(s) in such end-of-life decision making?

 

  1. Under what circumstances, if any, would it be ethical to deny Joyce’s request for further blood transfusions?

 

 

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

35. CASE: Competing Interests?

A medical device had been developed by a physician who provides care at your local hospital. The department he works in wants to begin to use that device on a regular basis. A process to guide this action has been developed by the physician in question and his team. They would like the ethics committee to review the process to ensure fairness and discuss any ethics aspects of the possible adoption of a medical device developed by a practitioner.

  • What ethics issues would you consider?
  • Who else should be involved in this review?
  • What other organizational policies could align with this issue and/or be consulted to inform the review process?


Some Values and Ethics Issues to Consider

  • Conflict of interest
  • Fairness
  • Patient safety
  • Transparency
  • Resource allocation

30. CASE: Awards – Who Gets Them and Why?

This case involves an organizational concern about inconsistency in the approach to applying for, being nominated for, and receiving awards.  Specifically, the requestor identified that there wasn’t a process or policy in place to objectively review each application and there were inconsistencies in the process for selecting those to receive individual awards.

Overall, the motivation for identifying these issues for consideration from an organizational ethics perspective was a genuine concern about maintaining the integrity of the awards and recognitions that are bestowed by the hospital. There is a strong desire to help ensure that suitable persons and teams are given appropriate awards and recognition now and in the future. Further, a clear commitment to the stewardship of these awards (especially for the ones that have a financial component) is connected with the need for exploring these issues.

  • How would your committee work respond to this request?
  • Upon which values could such a policy be based?
  • What process would you use to assist the policy-makers with this request?


Some Values and Ethics Issues to Consider

  • Compliance with policy
  • Fairness
  • Accountability
  • Resource allocation
  • Transparency
  • Organizational ethics