A Catholic Perspective: Triage Principles and Moral Distress in Pandemic Scarcity.

Striving to be faithful to the moral core of medicine and to spiritual, moral, and social teaching of the church, Catholic physicians see their role as an extension of the healing ministry of Jesus. When faced with a situation in which a large number of gravely ill people are seeking care, but optimal treatment such as ventilation in intensive care unit cannot be offered to all because of scarcity of resources, Catholic physicians recognize the need to consider the common good and to assign a priority to patients for whom such treatments would be most probably lifesaving. Making these evaluations, physicians will use only objective medical criteria regarding the benefits and risks to patients and will be mindful that all persons deserve equal respect for their dignity. Discrimination or prejudicial treatment against patients based on factors such as age, disability, race, gender, quality of life, and possible long-term survival cannot be morally justified. Triage process should incorporate respect for autonomy of both the patient and the professional and opportunity for an appeal of a triage decision. Other principles and values that will affect how a triage protocol is developed and applied are proportionality, equity, reciprocity, solidarity, subsidiarity, and transparency. The current coronavirus pandemic can provide valuable lessons and stimulus for reforms and renewal. SUMMARY: Catholic physicians strive to continue the healing ministry of Jesus Christ and be faithful to the moral core of medicine. In situations such as pandemic, the scarcity of personnel and technological resources create serious challenges and even moral distress. Church teachings on dignity, the common good and protection of the vulnerable help guide decisions based on public medical criteria and shared decision-making.

Aboriginal Health Care and Bioethics: A Reflection on the Teaching of the Seven Grandfathers.

Contemporary bioethics recognizes the importance of the culture in shaping ethical issues, yet in practice, a process for ethical analysis and decision making is rarely adjusted to the culture and ethnicity of involved parties. This is of a particular concern in a health care system that is caring for a growing Aboriginal population. We raise the possibility of constructing a bioethics grounded in traditional Aboriginal knowledge. As an example of an element of traditional knowledge that contains strong ethical guidance, we present the story of the Gifts of the Seven Grandfathers. We note a resemblance of this Ojibway teaching to virtue ethics in European traditions, but we suggest that there are also important differences in how these two traditions are currently presented. We hope that further engagement with a variety of indigenous moral teachings and traditions could improve health care involving Aboriginal patients and communities, and enrich the discipline of bioethics.

Framework for ethical decision-making based on mission, vision and values of the institution.

The authors led the development of a framework for ethical decision-making for an Academic Health Sciences Centre. They understood the existing mission, vision, and values statement (MVVs) of the centre as a foundational assertion that embodies an ethical commitment of the institution. Reflecting the Patient and Family Centred Model of Care the institution is living, the MVVs is a suitable base on which to construct an ethics framework. The resultant framework consists of a set of questions for each of the MVVs. Users of the framework are expected to identify two or more possible decisions to address the issue at hand and then, by applying the provided sequence of questions to each, examine these options and determine the overall ethically preferable decision. The construction of such a framework requires the creative involvement of the institution's staff. Thus the development of the framework can represent a training process in ethical decision-making as well as advance the ethical atmosphere of the institution. This novel approach has the advantage of placing the MVVs on active duty, at the centre of ethical decision-making, and lifts it from its otherwise relative obscurity in most institutions.

Controlling pain and reducing misuse of opioids: ethical considerations.

OBJECTIVE: To help family physicians achieve an ethical balance in their opioid prescribing practices. QUALITY OF EVIDENCE: MEDLINE was searched for English-language articles published between 1985 and 2011. Most available evidence was level III. MAIN MESSAGE: It is essential to follow practice guidelines when prescribing opioids, except when another course of action is demonstrably justified. In addition, when considering the appropriateness of an opioid prescription, with its many ethical implications, the decision can be usefully guided by the application of the ethical principles of beneficence, nonmaleficence, respect for autonomy, and justice. As well, it is essential to keep current about legal and regulatory changes and provincial electronic registries of opioid prescriptions. CONCLUSION: Physicians need to ensure that their patients' pain is properly assessed and managed. Reaching optimal pain control might necessitate prescribing opioids. But the obligation to provide pain relief needs to be balanced with an equally important responsibility not to expose patients to risk of addiction and not to create opportunities for drug diversion, trafficking, and the addiction of others. Basic ethical principles can provide a framework to help physicians make ethically appropriate decisions about opioid prescribing.

Examining the suitability of the principle of subsidiarity for bioethics.

The political and social principle of subsidiarity can be useful as a general principle of bioethics. The principle states that only those decisions and tasks that cannot be effectively decided upon or performed by a supported or subsidized lower level authority ought to be relegated to a more central or higher authority. The concept of subsidiarity has been embedded tacitly in Western political thought for two millennia, but it has been articulated expressly only in the twentieth century. The principle has unique strengths: it is the only principle that addresses the issue of locus of decision making; it is strongly linked to human dignity, democracy, and solidarity; and it can assist in reaching agreements on the common good. There are also potential drawbacks that need to be taken into account when developing rules and guidelines for the principle's application in bioethics. The principle is particularly helpful in public health ethics, but it is also of use in the ethics of personal care and human research ethics.

Preparing for an influenza pandemic: ethical issues.

In the near future, experts predict, an influenza pandemic will likely spread throughout the world. Many countries have been creating a contingency plan in order to mitigate the severe health and social consequences of such an event. Examination of the pandemic plans of Canada, the United Kingdom and the United States, from an ethical perspective, raises several concerns. One: scarcity of human and material resources is assumed to be severe. Plans focus on prioritization but do not identify resources that would be optimally required to reduce deaths and other serious consequences. Hence, these plans do not facilitate a truly informed choice at the political level where decisions have to be made on how much to invest now in order to reduce scarcity when a pandemic occurs. Two: mass vaccination is considered to be the most important instrument for reducing the impact of infection, yet pandemic plans do not provide concrete estimates of the benefits and burdens of vaccination to assure everyone that the balance is highly favorable. Three: pandemic plans make extraordinary demands on health care workers, yet professional organizations and unions may not have been involved in the plans' formulation and they have not been assured that authorities will aim to protect and support health care workers in a way that corresponds to the demands made on them. Four: all sectors of society and all individuals will be affected by a pandemic and everyone's collaboration will be required. Yet, it appears that the various populations have been inadequately informed by occasional media reports. Hence, it is essential that plans are developed and communication programs implemented that will not only inform but also create an atmosphere of mutual trust and solidarity; qualities that at the time of a pandemic will be much needed.

Physician's ethical responsibilities when there is a discrepancy between demand and supply of medical services.

BACKGROUND: The discrepancy between the demand for and the supply of physician's services is the result of actions of multiple parties, including physicians. This situation raises ethical challenges for physicians, because it involves the profession's core values. OBJECTIVE: To discuss physicians' ethical obligations regarding the quantity of services that they might provide. METHOD: The obligations to accept new patients and to provide services to existing patients are deduced from the Code of Ethics of the Canadian Medical Association and The Royal College of Physicians and Surgeons of Canada. A model of physicians' ethics proposed by Pellegrino and Thomasma is examined as an example of a possible higher ethical standard. RESULTS: According to the Code of Ethics, physicians may refuse or accept new patients provided they do not discriminate improperly, and do not deny aid when there is "urgent need." It also states that the termination of medical services is permissible after "adequate notice" is given to the patient. The code states that physicians are to be guided by principles such as justice and compassion. Motivated by these principles, overworked physicians may accept new patients or delay the justifiable termination of services. Such action is praiseworthy as long as the physician can provide to all his or her patients the quantity and quality of care that meets professional standards. More altruistic ethical standards of practice than those in the Code of Ethics have been advocated. Physicians who, in making decisions about the quantity of services they provide, are guided by altruism rather than self-interest deserve recognition and encouragement.