Ethics in the Time of COVID-19: Navigating Uncharted Waters
The Nova Scotia Health Ethics Network acknowledges we are in Mi’kma’ki – the unceded territory and ancestral homeland of the Mi’kmaq Nation. We are All Treaty people. We also acknowledge the work done for this conference by presenters living in the traditional territories of diverse peoples including the Huron-Wendat, the Seneca, the Mississaugas of the Credit River, the Beothuk, the Inuit, the Innu, the Blackfoot Confederacy (Siksika, Kainai, Piikani), the Tsuut’ina, the Îyâxe Nakoda Nations, the Métis Nation (Region 3), all people who make their homes in the Treaty 7 region of Southern Alberta, and the Traditional Owners of the land upon which Queensland University of Technology now stands.
COVID-19 has starkly demonstrated the necessity of explicitly addressing ethical questions in healthcare decision making and implementation, especially when there is significant clinical and moral uncertainty. The urgency of pandemic response and the complexity of decisions that need to be made increase the difficulty of addressing ethical questions faced by everyone in the health system.
The intention with the presentations, scenarios, and conversations that follow is to (a) provide some sense of validation for those within the healthcare system who have been grappling with ethical challenges and (b) to spur further discussions about addressing ethics questions as we continue to chart our course through the COVID-19 pandemic.
Some of the central values that arise in these discussions include:
- Evidence-based practice
- The common good
These values continue to be relevant with the advent of the second wave of the pandemic. Notwithstanding the promise of relief in the form of vaccines, many challenging ethical questions remain. How will we manage high rates of burnout and moral distress among healthcare providers and policy makers? Who among the identified priority groups will be first to receive vaccines in Nova Scotia? How will we respond to an individual’s vaccination status? If a targeted therapy is identified or developed, how do we manage access? Will we be able to integrate key learning into health system structures and function? We recognize that many of the conversations we hope to start with this conference will need to continue over the coming months and years.
As always, NSHEN is happy to facilitate further discussion around ethical questions related to the Nova Scotia COVID-19 response (or other ethical concerns); please contact Krista Mleczko-Skerry to make arrangements for your group.
Ethics in Previous Pandemics: Insights from SARS and H1N1
Jennifer Gibson, PhD, Sun Life Financial Chair in Bioethics and Director, Joint Centre for Bioethics, Associate Professor, Dala Lana School of Public Health, University of Toronto
Making Public Health Policy Decisions in Conditions of Uncertainty
Fiona McDonald, Co-Director, Australian Centre for Health Law Research, Queensland University of Technology, Australia, Adjunct Associate Professor, Department of Bioethics, Dalhousie University
Simulated Conversation – Delay of Treatment
These interactions are structured to promote discussion about the realities of addressing ethical challenges in practice settings; they are not intended as demonstrations of what to do or what not to do.
These interactions are semi-scripted scenarios designed to illustrate some of the ways that ethical challenges arise and are addressed in healthcare practice. The opinions expressed are not necessarily those of the individuals involved, even if they have chosen to use their real names in the simulation.
Patient: Ginny Adams (Played by Carolyn E. Fowler)
Physican: Dr. Liam Mulroy, Radiation Oncologist, Nova Scotia Cancer Centre, Associate Professor, Faculty of Medicine, Dalhousie University
Simulated Conversation – Fear and Reporting to Work
Health Care Provider: Ashley Francis (Played by Max Dysart)
Manager (Played by Lynn Boudreau, Physiotherapist, Nova Scotia Health)
Panel Discussion – Fault Lines, Equity and Covid-19
OmiSoore Dryden, James R Johnson Chair in Black Canadian Studies, Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University
Gerry Post, Accessibility Directorate, Nova Scotia Department of Justice
Athanasius ‘Tanas’ Sylliboy, Nurse Practitioner, Eskasoni Health Centre
Panel Discussion – Views from Within Long-Term Care, Public Health and Policy
Alyson Lamb, Registered Nurse, Interim Chief Nursing Informatics Officer, IWK Health Centre and Nova Scotia Health
Lisa Snodgrass, Director of Clinical Practice and Infection Control Specialist, Shannex Inc.
Gary O’Toole, Senior Director for Population and Public Health, Nova Scotia Health
Panel Discussion – Views from Away – Ethics Perspective from Other Provinces
Duncan Steele, Alberta Health Services’ Organizational Ethics, Ethics Member for BC’s Health Technology Assessment Committee
Dianne Godkin, Senior Ethicist, Trillium Health Partners, Mississauga, Adjunct Professor with the Faculty of Nursing, University of Toronto, Ontario
Chris Kaposy, Health Care Ethicist, Provincial Health Ethics Network of Newfoundland and Labrador, Associate Professor of Bioethics, Faculty of Medicine, Memorial University
Ethics Issues and Lessons Learned (so far)
Amanda Porter, PhD, Department of Bioethics, Dalhousie University
Duncan heads Alberta Health Services’ Organizational Ethics office. He mainly supports and leads work covering two areas: value-laden policy contexts (e.g. pandemic planning and response), and resource allocation and priority setting (decision frameworks, assessing initiatives and health technologies to fund). He is the Ethics Member for BC’s Health Technology Assessment Committee. Duncan received his MA in Applied Ethics from Utrecht University with a focus on Public Health Ethics and his Master of Health Administration from the University of British Columbia with a capstone on physician governance structures and decision sciences.
Chris Kaposy is a health care ethicist who works with the Provincial Health Ethics Network of Newfoundland and Labrador, and an Associate Professor of Bioethics in the Faculty of Medicine at Memorial University. He is program director of the Master of Health Ethics degree program, and editor of the Canadian bioethics blog Impact Ethics (www.impactethics.ca).
Associate Professor Fiona McDonald is Co-Director of the Australian Centre for Health Law Research at Queensland University of Technology in Australia, an Adjunct Associate Professor at the Department of Bioethics at Dalhousie University, and Senior Research Fellow at the New Zealand Centre for Public Law at Victoria University of Wellington in New Zealand. Her research interests are at the nexus of law and bioethics and focus on the governance of health systems, the health workforce, and innovative health technologies.
Amanda Porter is an Assistant Professor in the Department of Bioethics at Dalhousie University and member of the Ethics Collaborations Team which participates in ethics-based collaborations between the Department, Nova Scotia Health, the IWK Health Centre and the Nova Scotia Health Ethics Network (NSHEN). Amanda completed her doctorate in philosophy at Western University, and a fellowship in Clinical Ethics at London Health Sciences Centre and St. Joseph’s Health Care London. Prior to joining the Bioethics Department, she worked as a Clinical Ethicist for Alberta Health Services and then as a Policy Analyst for the Nova Scotia College of Pharmacists. Amanda’s work focuses on clinical and organizational ethics issues that arise in health care. Her collaborative work is intended to build capacity and opportunity for thoughtful handling of ethically challenging situations that arise in everyday practice.
Dianne Godkin is Senior Ethicist at Trillium Health Partners, Mississauga, Ontario. After completing a PhD in Nursing at the University of Alberta, she completed a clinical ethics post-graduate fellowship at the University of Toronto. Her research interests include the use of qualitative methods to explore end-of-life decision-making and advance care planning. She is an Adjunct Professor with the Faculty of Nursing, University of Toronto and Past President of the Canadian Bioethics Society.
Professor Gibson is the Director of the University of Toronto Joint Centre for Bioethics (JCB), and the Sun Life Financial Chair in Bioethics. She is also Associate Professor in the Institute of Health Policy, Management, and Evaluation. She holds a PhD in philosophy, with a specialization in Bioethics, from the University of Toronto. Her current funded research focuses on ethics and health system integration, organizational ethics, and resource allocation ethics. Professor Gibson leads the WHO Collaborating Centre for Bioethics at the University of Toronto, is a program team leader at the Canadian Centre for Applied Research in Cancer Control (a partnership of the Canadian Cancer Society, Cancer Care Ontario, BC Cancer Agency, the University of British Columbia, and the University of Toronto), and has served as an expert member on government advisory committees on policy issues related to critical care triage, drug funding and supply, organ transplantation, pandemic planning, citizen engagement, and health system integration.
Dr. OmiSoore Dryden
Dr. OmiSoore H. Dryden, a Black queer femme, is the James R Johnston Chair in Black Canadian Studies, Faculty of Medicine, and Associate Professor, Community Health & Epidemiology at Dalhousie University. Dr. Dryden engages in interdisciplinary scholarship and research that focuses on Black LGBTQI people and HIV vulnerability within Black diasporic communities in Canada, systemic/structural issues that affect health and well-being, including experiences with blood donation; medical education, and Black health curricular content development. Dr. Dryden is a content expert and Associate Scientist with the Maritime Strategy for Patient-Oriented Research (SPOR) SUPPORT Unit (MSSU). In that capacity, Dr. Dryden provides guidance on Canadian Black Health metrics needed to inform the development of health policies and improve the health care system, this specifically focuses on survey data and demographic information, determinants of trust, sexual health and qualitative data collection and analysis. Dryden has published in peer-reviewed journals and book collections and has an edited collection (with Dr. Suzanne Lenon): Disrupting Queer Inclusion: Canadian Homonationalisms and the Politics of Belonging (UBC Press, 2015) and she is currently working on a new edited collection (with Dr. Nicole Charles) titled, Black Technoscience “Here.” Dr. Dryden is a board member of the Health Association of African Canadians and provides supports to the newly founded Black Physicians of the Health Associations of African Canadians (BP@HAAC) and she is the co-president of the Black Canadian Studies Academic Association.
Athanasius Sylliboy ‘Tanas’
Athanasius Sylliboy ‘Tanas’ is a Mi’kmaq Family Nurse Practitioner at Eskasoni Health Centre. Tanas received his nursing education at Cape Breton University becoming one of the first two Mi’kmaq male graduates to complete their program. Tanas’ primary nursing background is both adult and pediatric emergency / critical care in various departments across Nova Scotia. His area of interest includes bridging gaps in healthcare for marginalized populations through health advocacy and collaboration. He provides the team with knowledge of working with pediatric patients and First Nation populations in both acute care and primary care settings.
Gerry Post is with the Accessibility Directorate at the Nova Scotia Department of Justice. Gerry is an urban planner who has worked and lived around the globe. He’s been honoured with various awards, including the World Leadership Award in Town Planning and Urban Governance for his international work and the Nova Scotia Human Rights Award for his accessibility advocacy. In retirement his advocacy helped the Province of Nova Scotia to adopt an Accessibility Act. He was subsequently appointed the first Executive Director for Accessibility in Nova Scotia and recently retired. He currently serves as an advisor to the Accessibility Directorate. Gerry uses a wheelchair.
Alyson Lamb is Registered Nurse and the Interim Chief Nursing Informatics Officer for the IWK and Nova Scotia Health and One Person One Record Program. Alyson has experience in med/surg and critical care nursing, youth sexual health, quality and patient safety and professional practice. Alyson has a Master of Nursing and Master of Health Administration, with a research interest in healthcare leadership. During the initial wave of the COVID-19 pandemic, Alyson had the opportunity to co-chair the COVID Clinical Medical Advisory Committee with Infectious Disease and Interprofessional Leaders from across Nova Scotia Health.
Lisa Snodgrass is a Registered Nurse in the role of Director of Clinical Practice and Infection Control Specialist for Shannex Inc. She has a Certification in Infection Control (CIC) from the Canadian Board of Infection Control and Epidemiology and a Specialty Certification in Gerontological Nursing (GNC©) from the Canadian Nurses Association. She believes in continuous education and research to ensure a best-practice approach to support seniors to live their best lives.
In addition to geriatrics, Lisa’s professional experiences included emergency nursing, intensive care, family practice, and telehealth. She feels these experiences has helped shape her approach to and understanding of geriatric care by providing insight into geriatric experiences in a variety of settings.
Lisa’s approach to improving quality of care for seniors is one of commitment and collaboration. She believes that together we achieve more and that approaches must evolve to ensure continuous improvement for the seniors in our communities.
Gary O’Toole holds a Master of Arts degree in leadership from Royal Roads University as well as a Bachelor’s degree in public health sciences from Cape Breton University, and has worked in public health his entire career. He has developed legislation, programs and teams to protect and promote health, with an emphasis on understanding the conditions and factors that contribute to improved health outcomes and mitigating or controlling risk factors. Gary is the senior director for population and public health with Nova Scotia Health, and is based in Dartmouth.
Liam Mulroy is a Radiation Oncologist at the Nova Scotia Cancer Centre and an Associate Professor in the Faculty of Medicine at Dalhousie University. He graduated from Western University in 1986 and completed a Residency in Family Medicine at Dalhousie University in 1988. After holding a variety of locum tenens positions in Nova Scotia, PEI, and Ontario, he entered Radiation Oncology Residency at the University of Toronto in 1992 and completed specialty training in 1995. Clinical activities include patient care and participation in clinical trials for patients with lung, CNS and hematologic malignancies.
Lynn Boudreau is a physiotherapist with Nova Scotia Health. Currently her role is professional practice leader for the Western Zone of NSHA. She has been a member of various ethics teams since 2015.
Conferences are always labour-intensive, and with the additional challenges and demands stemming from the COVID-19 pandemic we are especially grateful to all of the following individuals for their invaluable contributions.
Thanks to presenters and panelists for their time, patience, and for the keen insights that they shared as well as for contributing resources to help guide discussion. We are very grateful for the contributions of Jennifer Gibson, Fiona McDonald, Chris Kaposy, Duncan Steele, Dianne Godkin, OmiSoore Dryden, Gerry Post, Tanas Sylliboy, Alyson Lamb, Lisa Snodgrass, Gary O’Toole, and Amanda Porter.
Thank you to both the simulated patients, Max Dysart and Carolyn Fowler, and the actual health care providers, Lynn Boudreau and Liam Molroy, who made our simulated healthcare encounters come alive. Our gratitude also goes to Jacquie Thillaye with the Dalhousie Centre for Collaborative Clinical Learning and Research for support with developing the scenarios.
Thank you to Matthew Stones and Jordan Urquhart from Dalhousie MedIT, who provided expert support to us and to the panelists and who went above and beyond to ensure that everything looks and sounds as good as possible given the circumstances.
Thank you to NSHEN’s Lisbeth Witthoefft Nielsen and Krista Mleczko-Skerry for all of their efforts in making the behind-the-scenes work go smoothly!
Thank you to members of the NSHEN Advisory Council, the IWK Ethics Committee, and Ethics Nova Scotia Health Ethics Leads Group for providing guidance around conference content.
Finally, thank you, the viewer, for engaging with the hard questions that are raised in these sessions; as always the promise of ethics support is not that we will give you the “right” answer but that we will help you to ask the right questions to assist you in identifying the values at play as you find your way to a defensible, “more-right” (or “less-bad”) decision.
Marika Warren, Ph.D.
Network Ethicist, Nova Scotia Health Ethics Network