Alister Browne

The ethics of elective (non-therapeutic) ventilation.

Elective ventilation (EV) is ventilation applied, not in the interest of patients, but in order to secure transplantable organs. It carries with it a small risk that patients who would otherwise have died will survive in a persistent vegetative state. Is EV ever justifiable? We argue: (1) The only thing which can justify exposing patients to risk not taken for their benefit is their consent, and we cannot rely on implied consent or third party consent in the case of EV. Thus absent explicit consent of patients, EV is not justifiable. (2) It is not clear that explicit consent should be sought, or where it is offered honoured, given the potential EV has for deterring organ donors and causing stress to staff and families.

The Institute of Medicine on Non-Heart-Beating Organ Transplantation

The current main source of transplantable organs is from heart-beating donors. These are patients who have suffered a catastrophic brain injury, been ventilated, declared dead by neurological criteria, and had their vital functions maintained mechanically until the point of transplantation. But the demand for organs far outstrips the supply, and these patients are not the only potential donors. The idea behind non-heart-beating transplantation is to expand the donor pool by including in it patients who are in hopeless conditions but who are not dying because of brain injury and hence will not suffer the neurological death necessary to become heart-beating donors. As long as we continue to hold the so-called dead donor rule, according to which dying donors cannot have their organs taken before they are dead, this requires that death be able to be declared by alternative criteria, specifically by cardiopulmonary criteria. The challenge is to find such criteria that will identify a state that the public will readily recognize as death and that will facilitate non-heart-beating transplantation. I am grateful to Don Brown for encouragement, advice, and stimulating discussion and to Michael Feld for reminding me just how resilient a theory utilitarianism is.

Should we refuse requests for complementary therapies

Health care providers sometimes receive requests from patients or families for complementary therapies. When should they accede to such requests, and when should they refuse them? This is not a problem peculiar to complementary therapies. It arises whenever patients or families request conventional therapies which health care professionals judge problematic in the circumstances. What follows is a set of rationalized recommendations about when health care professionals should and should not honour requests for therapies, whether they be conventional or complementary.

Using a harm reduction approach with clients who have alcohol/drug dependencies in a spinal cord rehabilitation program.

Abstract Background: Dissatisfied with the frequently adversarial nature of relationships with clients who use alcohol or drugs while rehabilitation inpatients, and the often less than optimal outcomes for these individuals, the Spinal Cord Program at the G.F. Strong Rehabilitation Center in Vancouver, BC, decided to pilot a new approach. Objective: The goal of the pilot project is to promote successful rehabilitation, including less conflict in rehabilitation, a completed rehabilitation program, and continued connection after discharge if needed. Method: A dedicated team was formed and trained to work with these clients using harm reduction principles. Participants: From its inception in December 2000, through May 2001, the team worked with 6 inpatients, 12% of admissions to the Spinal Cord Program during that period. Results: Outcomes based on the above goals have been positive. There have been no discharges against a clients will or instances of significant conflict with the team. Several clients have returned to the center for assistance or to visit post-discharge. Only 1 client left rehabilitation prematurely.

Mental Health Acts in Canada.

There are 12 different Mental Health Acts (MHAs) in Canada, all of which provide for the involuntary confinement of the mentally disordered to protect both them from themselves and others from them. The Acts differ in many ways, but three issues stand out above all: (1) involuntary admission criteria, (2) the right to refuse treatment, and (3) who has the authority to authorize treatment. I first describe how the MHAs differ on these issues. I then take up the methodological question of how to select or construct a MHA from the many, all of which have something to be said for them. Finally, I apply this test to the three main issues in dispute and identify which solutions would be in an ideal MHA. My aim in this last is not to settle the issues but to engage with them and so deepen our understanding of what is at stake.

Morality, Prudential Rationality, and Cheating

We have a philosopher friend who was quite ill and required surgery, but she was not ill enough to be admitted to hospital under the “life, limb, and organ preservation” guidelines that control surgical admissions. Her surgeon told her to go to emergency and gave her a list of symptoms to tell the physicians there. Those, he said, would get her a bed, and he would then come and perform the necessary surgery. And that is how our friend (who, ironically, taught ethics out of a textbook called Virtue and Vice in Everyday Life ) got her surgery. We are grateful to Don Brown for extremely helpful comments and conversation on the philosophical matters of our paper and to Dan McDonald for stimulating discussion on the culture of healthcare providers.

Blood in a time of scarcity.

In Canada, contingency planning for potential blood shortages has recently taken place. The National Plan for the Management of Shortages of Labile Blood Components (2009) divides the availability of blood into three phases: green, amber, and red. In the green phase business is carried on as usual; in the amber, elective procedures are canceled; and in the red, life-and-death decisions between patients have to be made. The plan recommends that in the green phase guidelines should be written for what to do in the red, but it does not say how those guidelines should read. My aim in what follows is to fill this gap. To this end, I first develop a theory of allocative justice that derives from John Rawls’s A Theory of Justice. I then use that theory to propose guidelines about how to allocate blood in the red phase.

The Ethics of Aggressive Discharge Planning

In any healthcare system in which demand exceeds supply—which means any typical public healthcare system—patients cannot always get the care they want or need when they want or need it. It is also unrealistic to suppose that it will ever be otherwise. There have been such advances in medicine and growth in the population that even if we forgot about all other goods such as education, roads, social services, and so forth and put the entire budget into healthcare, there would still be a gap between supply and demand. Moreover, even if we could by that expedient make them match and had eyes only for health, we still should not. For it is now understood that healthcare is the least important determinant of health, lining up well behind poverty and social status. But if suboptimal care is to be our destiny, we must plan how it is to be delivered. Such planning has already taken place at the admission and treatment stages of healthcare, where wait-lists, triage, and rationing are standard fare, and I contend in what follows that similar planning should go into the discharge phase. Specifically, I argue that hospitals will not have a comprehensive plan for the delivery of suboptimal care until aggressive discharge policies are added to the suboptimal care policies already in place, that such discharge policies include discharging patients before their ideal time, and that, unless hospitals have such a comprehensive plan, they will not provide patients with the very best care resources will allow.