Toronto hospitals implement new ethics strategy

Health care ethics gained the limelight during the recent battle over Terry Schiavo's fate, but ethical decision-making is already a growing part of the corporate culture at a number of Toronto hospitals, thanks to a "hub and spokes" strategy pioneered by the University of Toronto's Joint Centre for Bioethics.

"It's important for the public to know that in our technologically-based, resource-strapped system, it is possible to effectively integrate and value ethical decision-making," says nurse and bioethicist Susan MacRae, the Joint Centre for Bioethics (JCB) deputy director. MacRae, who also teaches at U of T's Faculty of Nursing, is lead author of a paper describing this ethics model, published today in the Journal of Medical Ethics.

In a hub and spokes model, there is a central ethics resource – usually the hospital's clinical bioethicist – who shares ethics knowledge and offers guidance to designated frontline employees. These employees, in turn, assist others in their departments in dealing with ethical dilemmas that arise during daily interactions with patients and their families – anything from whether to prolong life with various treatments to whether it is worth allocating hospital resources to a particular, expensive course of medication to whether to give a patient the truth about a dire diagnosis.

"This model allows and encourages ethical responsibility across the whole organization," says MacRae. "Without local buy-in, the clinical ethicist can be seen as the ethics police, rather than as a resource and a support."

By committing to a hub and spokes model, an organization gains three key benefits: integration, sustainability and accountability. It is being adopted at several of JCB's Toronto-area partner hospitals because, as MacRae notes, "people saw it as something that made sense and filled a need."

"The moral distress brought about by ethical dilemmas is quite a concern in hospitals," says clinical ethicist Karen Faith, director of the Clinical Ethics Centre at Sunnybrook and Women's College Health Sciences Centre and a study co-author. "Whatever we can do to give people the language and the skills to talk about these issues, the easier it will become to deal with them."

MacRae says the hub and spokes model also makes good business sense and believes it can be used in the corporate world. "It has been adopted because it's good practice," she says. "People saw it as something that made sense and filled a need."