Debate rages over whether Canadian provincial and territorial governments should allow healthcare institutions to conscientiously object to providing medical assistance in dying (MAiD). This issue is likely to end up in court soon through challenges from patients, clinicians, or advocacy groups such as Dying With Dignity Canada. When it does, one key question for the courts will be whether allowing institutional conscientious objection (ICO) to MAiD respects (i.e., shows due regard for) the consciences of the objecting healthcare institutions, understood as (...) unitary entities. This question has been thoroughly explored elsewhere in the academic literature. However, another key question has been underexplored. Specifically, precedent set by the Supreme Court of Canada’s decision in Loyola High School v. Quebec (Attorney General) suggests that the courts will consider whether allowing ICO to MAiD respects the consciences of the personnel within objecting healthcare institutions. My answer to this question is no, by which I mean that allowing ICO to MAiD shows undue disregard for some consciences and undue regard for others. To justify this answer, I analyze the arguments that hold that allowing ICO in healthcare respects the consciences of the personnel within objecting healthcare institutions. My conclusion is that none of these personnel-based arguments succeed in the case of ICO to MAiD. Some fail because they are wrong about the nature of conscience and complicity. Others fail because they contradict the arguments’ proponents’ positions on conscientious objection by individual healthcare providers. Still others fail because they are internally inconsistent. (shrink)

The humanitarian sector continually faces organizational and operational challenges to respond to the needs of populations affected by war, disaster, displacement, and health emergencies. With the goal of improving the effectiveness and efficiency of response efforts, humanitarian innovation initiatives seek to develop, test, and scale a variety of novel and adapted practices, products, and systems. The innovation process raises important ethical considerations, such as appropriately engaging crisis-affected populations in defining problems and identifying potential solutions, mitigating risks, ensuring accountability, sharing benefits (...) fairly, and managing expectations. This paper aims to contribute to knowledge and practice regarding humanitarian innovation ethics and presents two components related to a value-sensitive approach to humanitarian innovation. First is a mapping of how ethical concepts are mobilized in values statements that have been produced by a diverse set of organizations involved in humanitarian innovation. Analyzing these documents, we identified six primary values (do-no-harm, autonomy, justice, accountability, sustainability, and inclusivity) around which we grouped 12 secondary values and 10 associated concepts. Second are two proposed activities that teams engaged in humanitarian innovation can employ to foreground values as they develop and refine their project’s design, and to anticipate and plan for challenges in enacting these values across the phases of their project. A deliberate and tangible approach to engaging with values within humanitarian innovation design can help to ground humanitarian innovation in ethical commitments by increasing shared understanding amongst team members, promoting attentiveness to values across the stages of innovation, and fostering capacities to anticipate and respond to ethically challenging situations. (shrink)

The COVID-19 pandemic disrupted academic life worldwide for students as well as educators. The purpose of this study is to shed light on the collective adversity experienced by international medical students and bioethics educators caused by the COVID-19 pandemic in relation to both personal and academic life. The authors wrote their subjective memoirs and then analyzed them using a collective autoethnography method in order to find the similarities and differences between their experiences. The results reveal some consistent patterns in experience (...) that are captured in two metaphors: Falling apart and Bouncing back. “Falling apart” involves the breakdown of daily lives during the initial stages of the pandemic, shown through subjective quotes contextualized through the authors’ commentary. The consensus is that returning home and the transition to remote education were the two main reasons for the breakdown. “Bouncing back” encompasses the authors’ recovery after the initial breakdown, achieved by acquiring new information about the virus, discovering how to continue their hobbies at home, such as working out or dancing, and learning to adjust exam expectations. At the educational level, the bioethics course, which guided students through the ethical dilemmas of the pandemic, played an important role in the recovery/bouncing back process. For that reason, we report on how it was to learn about and teach this subject during the pandemic, and how bioethics knowledge was applied for better understanding and coping with some of the moral dilemmas related to the pandemic. The study testifies to the importance of bioethics education during a pandemic and explains how this can contribute to shaping the moral resilience of future medical practitioners. (shrink)

This history of the modern introduction of assisted suicide in North America follow a tortuous course, with complete rejection of the idea, to implementation in many of its jurisdictions. North America was not a leader in this approach to end-of-life care, with the Netherlands and Belgium playing that role. Tracing the path from a felonious and ethically anathematic place in North American society it was resurrected into a legally and ethically acceptable practice over a period of two decades. The historical (...) course of PAS (Physician Assisted Suicide) and MAID (Medical Assistance in Dying) in many ways mimicked the evolution of other major changes in our view of the world, and like assisted suicide, experienced almost universal rejection and ultimately the embrace of those people and institutions that initially rejected the ideas first expressed by thoughtful and heroic persons. Galileo Galilei was one of the icons of science and discovery: he was almost burned at the stake during the Inquisition only to be “resurrected” to his place in the pantheon of great thinkers – but it took almost four hundred years to reach that pinnacle. We must be very careful how we interpret new ideas and thoughts about the process we apply and the consequences if we reject them. (shrink)

Sending patients “home to fail” while anticipating their speedy readmittance is, prima facie, ethically troubling as are all unsafe discharges. However, “home to fail” cases may also be covertly ethically troubling insofar as they raise questions of medical paternalism due to a motivational component which drives these types of cases: by discharging a patient “home to fail” she will come to appreciate that living at home is unsafe and thus unwise, prompting her to choose differently in the future.

Online resources offer a uniquely efficient way of sharing health research with scientists and the public. Using web portals to make results and study information available to diverse audiences could work to accelerate research translation and empower patients to play a more active role in their care. But using online tools to broadly share health information raises several challenging ethical and regulatory questions. Issues such as equity, privacy, and patient empowerment may create challenges for regulators, portal developers, as well as (...) researchers. It is additionally unclear whether web portals designed to facilitate access to research results and general health information will be regulated as medical devices under emerging regimes that control software with medical purposes. This paper aims to comparatively address whether online therapeutic portals for sharing health research are likely to be regulated in Canada, the United States, the United Kingdom, and France. We find that though these jurisdictions have each taken recent steps to regulate software as medical devices, the applicable regimes will generally not capture online portals for sharing health research. Though online portals for sharing health research are probably unregulated in many (if not most) jurisdictions, agencies have nevertheless signalled their concerns regarding several important ethical considerations (such as equity, transparency, and safety), to which portal developers and researchers should be attentive and respond. We describe here one set of issues highlighted by regulators – that is, efficiency, equity, transparency, confidentiality, communication, empowerment, training, and safety & efficacy – and consider how to best guide the design of online portals in a context of regulatory uncertainty. (shrink)

This article summarizes several Canadian court decisions from 2015 onward stemming from wrongful birth and wrongful life litigation. Plaintiff success often turns on whether causation is established, on a balance of probabilities, between a physician’s breach of standard of care and the harm to the parents and/or the child later born. Physicians’ failure to offer or order screening or diagnostic tests has been a source of wrongful birth liability, as too can be failure to ensure patient understanding of results. Physicians (...) should ensure that they recommend diagnostic testing when presented with concerning clinical indications in accordance with professional practice guidance. Given non-invasive prenatal screening’s (NIPS) advantages and the threat of wrongful birth liability for failure to discuss this procedure, it is likely to be propelled into an ever more prominent position as a first-choice offering for aneuploidy screening. Appropriately cautious physician behaviour involves discussing and offering NIPS, and also involves ensuring that results are understood. This can reduce physician liability, improve patient reproductive autonomy, and sometimes benefit patient health by preventing or lessening trauma that informed women may opt to mitigate when granted the opportunity. (shrink)

Precision medicine can put clinicians in a position where they must act more as resource allocators than their traditional role as patient advocates. In the allocation of transplantable organs and tissues, the use of eplet matching will enhance precision medicine but, in doing so, generate a tension with the present reliance on rule of rescue and justice-based factors for allocations. Matching donor and recipient human leukocyte antigens (HLA) is shown to benefit virtually all types of solid organ transplants yet, until (...) recently, HLA-matching has not been practical and was shown to contribute to ethnic/racial disparities in organ allocation. Recent advances using eplets from the HLA molecule has renewed the promise of such matching for predicting patient outcomes. The rule of rescue in organ allocation reflects a combination of ethical, policy, and legal imperatives. However, the rule of rescue can impede the allocation strategies adopted by professional medical associations and the optimal use of scarce transplant resources. While eplet-matching seeks to improve outcomes, it may potentially frustrate current ethics-motivated initiatives, established patient-practitioner relationships, and functional conventions in the allocation of medical resources such as organ and tissue transplants. Eplet-matching allocation schemes need to be carefully and collaboratively designed with clear, fair and equitable guidelines that complement functional conventions and maintain public trust. (shrink)

Behavioural variant frontotemporal dementia (bvFTD) is a subtype of frontotemporal dementia characterized by changes in personality, social behaviour, and cognition. Although neural abnormalities cause bvFTD patients to struggle with inhibiting problematic behaviour, they are generally considered fully autonomous individuals. Subsequently, bvFTD patients demonstrate understanding of right and wrong but are unable to act in accordance with moral norms. To investigate the ethical, legal, and social issues associated with bvFTD, we conducted a scoping review of academic literature with inclusion & exclusion (...) criteria and codes derived from our prior work. Among our final sample of fifty-six articles, four mentioned bvFTD patient-offenders as unfit to stand trial by insanity, and sixteen mentioned the use of dementia evidence in a court of law to better understand the autonomy of bvFTD patients. Additional emergent issues that were discovered include: training police officers to handle situations involving bvFTD patients and educating healthcare providers on how to help caregivers navigate bvFTD. The current literature highlights the inadequacy of traditional applications of medico-legal categories such as autonomy, capacity and competence, in informing cognitive capacity assessments in clinical and legal settings and deserves consideration by neuroethicists. (shrink)

Uterine transplantation is an experimental procedure currently available only to cisgender women recipients suffering from absolute uterine factor infertility. Clinicians, researchers, and advocates have advanced the possibility of providing these quality-of-life transplantations to transgender women. This article examines the ethical and practical implications of removing sex- and gender-based requirements entirely for uterine transplantation recipients. Given the significant costs and risks, and the modest quality-of-life benefits, ethical arguments against offering uterine transplantations to people who do not identify as women but are (...) otherwise suitable recipients are dubious and prejudicial. Successful uterine transplantations with non-women recipients could potentially diminish the socio-cultural connection between uterine functionality and womanhood, which is a key motivation for women now seeking this high-risk procedure. (shrink)

The allocation of critical care resources and triaging patients garnered a great deal of attention during the COVID-19 pandemic, but there is a paucity of guidance regarding the ethical aspects of resource allocation and patient prioritization in ‘normal’ circumstances for Canadian healthcare systems. One context where allocation and prioritization decisions are required are surgical waitlists, which have been globally exacerbated due to the COVID-19 pandemic. In this paper, we detail the process used to develop an ethics framework to support prioritization (...) for elective surgery at The Hospital for Sick Children, Toronto, a tertiary pediatric hospital. Our goal was to provide guidance for the more value-laden aspects of prioritization, particularly when clinical urgency alone is insufficient to dictate priority. With this goal in mind, we worked to capture familial, relational, and equity considerations. As part of our institution’s concerted efforts to ethically and effectively address our surgical backlog, an ethics working group was formed comprising clinicians from surgery, anesthesiology, intensive care, a hospital bioethicist, a parent advisor, and an academic bioethics researcher. A reflective equilibrium process was used to develop an ethics framework. To this end, the same methodology was used to create a support for patient prioritization that identifies clinically and morally relevant factors for prioritization among medically similar surgical cases, with a substantive goal being to identify and redress health inequities in surgical prioritization, inasmuch as this is possible. While further steps are needed to validate several aspects of the framework, our research suggests that an ethics framework grounded in the practical realities of hospital operations provides consistency, transparency, and needed support for decisions that are often left to individual clinicians, as well as an opportunity to reflect upon the presence of health inequities in all domains of healthcare delivery. (shrink)

In Ontario, adolescents can be confidentially prescribed contraceptives. However, some adolescents must pay pharmacies to have their confidentiality respected when it comes to contraceptives; if their parents’ private insurance plan covers them, the adolescent has to pay out of pocket to be given contraceptive in a confidential manner. It is unethical to make anyone pay to have their confidentiality respected, particularly for a vulnerable population like adolescents who tend to be economically disadvantaged.

In debates surrounding the biomedical enhancement of human morality, it is widely believed that morality was evolutionarily shaped to be rigidly tribal. Allen Buchanan challenges this assumption by making the case that a plastic morality that responds to our environment would be evolutionarily favored, and thus the best way to shape human morality going forward would not be through biomedical interventions, but by designing better institutions.

Canada’s Medical Assistance in Dying (MAID) legislation changed in 2021; persons without a reasonably foreseeable natural death (RFND) could now be eligible for MAID and would have to wait at least 90 days before their intervention. This legislative change caused a new ethically complex question to arise, which we explore in this commentary, namely: Where should individuals without a RFND wait (for 90 days) in a publicly funded health system?

Most of us would agree with the almost trite saying that “life is a journey”. Of course it is, unless it ends tragically at birth, and even then it is a very short journey. All of us can describe how we got from one stage in life to another, whether personal, family, education or career. Many journeys seem to be in an almost straight line while others meander from one place to another, changing direction and alternating goals, sometimes zigging back (...) and forth. I have had many wonderful journeys in my life; the choice to change career aspirations from engineering to medicine, the choice the study in medicine in Scotland, the choice to focus on geriatrics and then the choice to branch out into medical ethics to add more depth to clinical medicine. The early undergraduate study of philosophy planted the seed that eventually grew into my completing a Master’s in Medical Ethics; and then expanding my teaching and practice to include palliative care and end of life-decision-making, to most recently participating in the assessment of those requesting medical assistance in dying (MAID in Canada). (shrink)

The attack on the written word is not new. It has happened many times through history, especially in modern times as the availability of books has grown so rapidly. It is most often in authoritarian regimes that books are deemed a potential threat, and the elimination of this threat a means to maintain control of a potentially rebellious population. Probably the most heinous of book banning and burnings occurred during Nazi rule, prior to and during the Second World War. To (...) witness, recently, in the United States the ugly head book banning and their removal from libraries is a sad commentary on the state of some senior politicians, including Governors and Judicial leaders. Fortunately, there is vigorous opposition to these efforts and notable successes in the quest for universal access to the world of books. (shrink)

This Perspective sheds light on the major barriers behind Asian American invisibility in bioethics, such as the inconsistencies in defining a coherent identity in North American society, the systemic mechanisms of invisibility from history to healthcare based on immigration status, and scarcity of bioethics literature about their perspectives. The consequences of Asian American invisibility in bioethics and healthcare practises are also discussed, including a reflection of the interconnected mechanisms between academic bioethical theory and healthcare practises that perpetuate Asian American invisibility. (...) Finally, recommendations are provided to begin a critical reflection of bioethical theory with Asian Americans in mind. This serves as the stepping-stone for future discussions on Asian American bioethics, to highlight a missing perspective in North American race-based activism regarding the equity, diversity, and inclusion of an underrepresented demographic. (shrink)

The complex health and social circumstances of living-at-risk, frequent users of emergency departments (aREDFUs) in the health jurisdictions of high-income countries, and the related, significant challenges posed for emergency departments and the health care providers working within them, are identified and explored in the paper. Ethical analyses of a set of relevant domains are performed, i.e., individual and relational autonomy considerations, relevant social construction and personal responsibility conceptions, patient welfare principles (beneficence, nonmaleficence, continuity of care), harm reduction methodologies and their (...) applications, health equity, and justice considerations of the distributive, formal and social types. The outcomes of these analyses demonstrate that there are ethically compelling reasons for emergency departments to adopt an ethics-informed, policy-based approach to the longitudinal care and management of living-at-risk, frequent users of emergency departments. From a formal justice perspective, the development and uses of such an approach are justified by a demonstrable relevant difference between living-at-risk, frequent users of emergency departments and other persons and groups of patients who visit emergency departments. We propose an example of such a policy-based approach. Examples of possible, pragmatic applications of this approach, which help ensure that aREDFUs who present to the ED are managed in a fair and optimally consistent manner, are provided for the consideration of an urban emergency department’s policymaking working group. (shrink)

Clinical ethics is widely recognised as an essential contribution to the quality of health and psychosocial service delivery. However, the lack of a common understanding of ethics within teams and insufficient organisational support often limits its optimal integration into the workplace. To address this problem, the clinical ethics committee of a rehabilitation centre developed a new clinical ethics framework based on a theoretical model and conducted a pre-implementation evaluation by interviewing future users. The study estimated the acceptability and initial adoption (...) of the new clinical ethics framework. The quantitative results of the study indicated a high level of acceptability for the definitions, tools and supporting strategies, with the exception of the definition of the concept of ethical issues. The qualitative results showed that the future users perceived positively the attributes of the new framework, such as its benefits and its compatibility with their professional concerns. In addition, they appreciated the fact that the framework was easy to understand and could potentially be applied in daily practice. The suggestions provided by future users also helped to improve the content of the clinical ethics framework. Finally, all the results will be useful for the planification of its eventual implementation. (shrink)

In some families, there is an inseparable connection between showing love, caring, and providing food. These conceptual connections can create tension between families and care teams over end-of-life care for critically ill late-stage cachexic patients with cancer when families demand that their loved one receive feeds. This case study describes how to dissolve these tensions without compromising the family’s values or the medical team’s ethical duty of nonmaleficence.

The COVID-19 pandemic has had a global effect. The disproportionate impact on Indigenous peoples and racialized groups has brought ethical challenges to the forefront in research and clinical practice. In Canada, the Tri-Council Policy Statement (TCPS2), and specifically the principle of justice, emphasizes additional care for individuals “whose circumstances make them vulnerable”, including Indigenous and racialized communities. In the absence of race-based data to measure and inform health research and clinical practice, we run the risk of causing more harm and (...) contributing to ongoing injustices. However, without an accepted framework for collecting, maintaining, and reporting race-based data in Canada, more guidance is needed on how to do this well. Importantly, a framework for collecting race-based data should build on existing guidance from Indigenous and other structurally marginalized communities, the TCPS2, recommendations from the World Health Organization, and involve relevant stakeholders. In this paper, we describe historical examples of unethical studies on Indigenous and racialized groups, discuss the challenges and potential benefits of collecting race-based data, and conclude with objectives for a pan-Canadian framework to inform how race-based data is collected, stored, and accessed in health research. (shrink)

In the aftermath of the ongoing COVID-19 pandemic, there is a predicted (and emerging) increase in experiences of mental illness. This phenomenon has been described as “the next pandemic”, suggesting that the concepts used to understand and respond to the COVID-19 pandemic are being transferred to conceptualize mental illness. The COVID-19 pandemic was, and continues to be, framed in public media using military metaphors, which can potentially migrate to conceptualizations of mental illness along with pandemic rhetoric. Given that metaphors shape (...) what is considered justifiable action, and how we understand justice, I argue we have a moral responsibility to interrogate who benefits and who is harmed by the language and underlying conceptualizations this rhetoric legitimates. By exploring how military metaphors have been used in the context of COVID-19, I argue that this rhetoric has been used to justify ongoing harm to marginalized groups while further entrenching established systems of power. Given this history, I present what it may look like were military metaphors used to conceptualize a “mental illness pandemic”, what actions this might legitimate and render inconceivable, and who is likely to benefit and be harmed by such rhetorically justified actions. (shrink)