The SARS epidemic showed how easy it is for infectious diseases to spread round the world. Ethical as well as clinical issues need to be resolved to improve the response to the next epidemicThe outbreak of severe acute respiratory syndrome (SARS) in the Toronto area earlier this year forced medical and government workers to make hard choices, often with limited information and short deadlines. Healthcare providers were on the firing line, and were the people most affected by the disease. Decision makers had to balance individual freedoms against the common good, fear for personal safety against the duty to treat sick people, and economic losses against the need to contain the spread of a deadly disease. Such decisions have to be guided by both scientific knowledge and ethical considerations. The SARS outbreak showed that Canadian society was not fully prepared to deal with the ethical issues. Evaluating ethical issuesWe formed a working group to identify the key ethical issues and values most important for an analysis of ethical dimensions of the SARS epidemic. The final list of issues and values was agreed by a consensus process and found to have face validity and credibility. We then developed a framework for looking at the ethical implications of the SARS outbreak, identifying 10 key ethical values relevant to SARS (box), and five major ethical issues faced by decision makers.We examined the underlying ethical values for the five major issues and drew lessons from how each was tackled. The following case studies illustrate the issues and are an amalgam of our experiences.

BackgroundThere are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds.DiscussionThe top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill.SummaryAlthough many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge.

Kidney transplantation from living donors is generally a safe, effective form of renal replacement therapy. When evaluating potential living donors and their intended recipients, a careful assessment process is followed in order to ensure that ethical standards are upheld. During this assessment, important medical information with serious consequences, which was not being sought as part of the donor/recipient evaluation, may be discovered. The information may or may not be relevant to the decision to donate. However, such a discovery raises the difficult questions of whether or not there is an obligation to disclose the information, to whom does the information belong, and what process should be used to resolve the issue? We present a case that forced us to confront these questions and raised issues of truth telling, autonomy, paternalism, confidentiality, and the nature of the relationship between patients and health care professionals.

The “lone” clinical bioethicist working in a large, multisite hospital faces considerable challenges. While attempting to build ethics capacity and sustain a demanding range of responsibilities, he or she must also achieve an acceptable level of integration, sustainability, and accountability within a complex organisational structure. In an effort to address such inherent demands and to create a platform towards better evaluation and effectiveness, the Clinical Ethics Group at the Joint Centre for Bioethics at the University of Toronto is implementing the Hub and Spokes Strategy at seven hospitals. The goal of the Hub and Spokes Strategy is to foster an ethical climate and strengthen ethics capacity broadly throughout healthcare settings as well as create models in clinical bioethics that are excellent and effective.