Preferential Access to Care:
Ethical Considerations and Policy Development for SickKids
Jonathan Hellmann, MBBCh, FRCPC, MHSc, Senior Medical Bioethics Associate, Randi Zlotnik Shaul, JD LLM, PhD, Director, Bioethics Department
Background
The Canadian health care system is premised on the ideal of
equitable access to medically-necessary hospital services
Aims to ensure patients with same medical conditions have
reasonable access to equivalent services
Equity implies access based on medical need alone
and absence of avoidable health disparities between groups.
Equity may be in relation to access, utilization or quality of
health care
Risks of Preferential Access (PA)
Conflict of interest for health care professionals (HCPs)
Moral uncertainty and/or moral distress for HCP
Contravention of commitment to Future of Medicare Act which
states that
•no person shall pay or confer a benefit upon any person or
entity in exchange for conferring upon an insured person a
preference in obtaining access to an insured service;
•or accept payment or a benefit for conferring upon an insured
person a preference in obtaining access to an insured service
Erosion of societal trust that care premised on equitable access
Alberta Inquiry Report
Concern in Alberta following number of incidents that faster
access for reasons other than medical need had occurred led to
Alberta Health Services Preferential Access Inquiry 2013
•uncovered instances of improper PA
•did not find evidence anyone medically harmed as a result
•concerns largely proved unfounded
BUT raised larger issue:
Does improper PA cause harm to the principles underlying
publically funded health care?
The SickKids Statement
Alberta Inquiry Recommendations
Strengthen queue jumping provisions of Health Care Protection Act
Expand whistle blower protection
Clarify scope and application of professional
courtesy
Develop and implement wait list
management strategies
Develop standardized referral procedures
Consider creating position/office of Health Advocate
Develop policy on courtesy calls
Develop policy on special accommodation during pandemic
Develop policy on preferential access
Professional Courtesy
Produces a form of preferential access
Seeing a colleague or family member more quickly
Only acceptable for essential HCP to carry out duties
Is There Tolerance for Certain Types of PA?
Sports stars, Olympians, leaders of government, celebrities?
Those in research protocols?
Individual’s social utility e.g. police, fire fighters, HCP in front
line of pandemic?
BUT public needs to be involved in determining what is tolerable
At SickKids
Bioethics Department asked to lead development of hospital
preferential access statement
11 person stakeholder working group
Numerous revisions with feedback from MAC
The Hospital is a public hospital, operating in accordance with
Ontario’s Public Hospitals Act and the Commitment to the Future
of Medicare Act.
The organization is committed to the provision of equitable
access to paediatric care.
As is the case with all public hospitals working within finite
resources, SickKids staff must prioritize the order in which
patients receive access to care.
Maintenance of trust in how access is prioritized at SickKids
requires transparency and accountability, through adherence
to relevant Ontario legislation and hospital polices
Factors to be Considered:
Severity of illness or condition
Urgency of illness or condition
Potential impact on the patient: physical and psychosocial
Potential impact on other patients
Potential impact on the healthcare team
Potential impact on families
Conflict of interest: actual or perceived
Fairness: must be applied even when conditions not urgent
Availability of alternative: ie likely to achieve a comparable
standard of care as temporary or alternative measure in situations
of limited supply
Current Application:
1. Consequences of violation same as for violation of any
hospital policy
2. Guideline a reminder to staff of Hospital and Canadian values
3. Provides grounds for discussion amongst staff
Next Steps
Imbed in Hospital’s Conflict of Interest policy?
Post on Bioethics Department website?
Include in donation agreements?
Post on external website?
Include in Family guide book?