Correspondence and reprint requests: David C. Mendelssohn, 200 Elizabeth Street, 13 Eaton 239, Toronto, Ontario M5G 2C4, Canada.
Physicians face conflicting priorities working in the complex Canadian health-care system of the 1990s. Their traditional role as patient advocate has been part of the art of medicine at least since the time of Hippocrates, whose oath states explicitly "that into whatsoever house I shall enter, it shall be for the good of the sick to the utmost of my power, holding myself far aloof from wrong... I will exercise my art solely for the cure of my patients..." This time-honored focus on patient advocacy is threatened when physicians assume responsibility for controlling health care expenditures, or when resource constraints limit their ability to provide reasonable access to necessary services.
Exactly such a dilemma was faced by nephrologists at The Toronto Hospital in 1994. This paper will use Toronto's limited access to dialysis as a model to illustrate these conflicts, and to offer ethical and legal analysis that may interest physicians in other sectors who face similar challenges.
There is a well documented chronic shortage of hemodialysis resources in the Toronto region. (1) By the spring of 1994 (and even as this is written in mid 1996) all adult hospitals in the region were operating at over 100% of capacity. At the same time, the referral of additional patients requiring dialysis continued to fuel the predictable rate of growth of 10% per year.
Nephrologists at The Toronto Hospital (TTH), the site of the largest program in the region, perceived that the Ministry of Health would not condone capping of the dialysis program even when it became clear that further growth might compromise patient care. (2) When all outpatient hemodialysis positions at TTH were filled, patients requiring this treatment were increasingly admitted to inpatient beds, to positions normally reserved for hospitalized patients. During the spring of 1994, this option also became saturated so that physicians had to make daily triage decisions about which inpatients might be stable enough to miss a regularly scheduled treatment because of lack of equipment or nurses. (3) All inpatients requiring hemodialysis were receiving sub-optimal care; in fact, one patient died of a hyperkalemic cardiac arrest as a direct result of a decision to postpone her hemodialysis so that another patient, deemed to be more in need on that particular day, could receive it.
What Are the Conflicts?
The problems described above high-light many of the dilemmas faced by physicians, in many different settings, who are trying to live up to the ideals enshrined in the Canada Health Act, (4) such as the provision of "universal" and "reasonable access" to "comprehensive" quality care.
Provincial governments in Canada have reacted to the combined pressures of economic recession, massive public debt, and falling revenues from both taxation and federal transfer payments, with measures to reduce public spending in many sectors, including health care. Often these macroeconomic decisions have unforeseen consequences, because hospitals then must reassess priorities as they attempt to cope with reduced funding levels. High technology, high cost programs like dialysis must compete within the hospital for resources that are funded from a common global budget. Administrative decisions to allocate insufficient resources to a program like dialysis eventually trickle down to the physician-patient interface, where individual treatment decisions must be made.
The primary conflicts for the physician working with insufficient resources are between advocating for the best possible care for a particular patient, the duty to other current patients, and the responsibility to provide for new referrals and future patients. Allocation decisions that have potentially negative consequences pose crucial questions at the interface of medicine, politics, ethics and law. …