The ethics of clinical forms

A good example that what matters is complex is this query I received from a staff member: "Our program uses a clinical form that needs updating. Right now, to indicate one's sex, the person checks the box marked either "male" or "female." We're wondering whether this needs to be revised. Are there enough boxes? Are they even the right boxes? Or are they okay?"

I knew enough about gender identity and sexual orientation to say "I don't think so." And recalling my years of working in the oil industry, I also knew that forms, whether paper or electronic, have limits in terms of space and usability. Thinking about a form's ethical aspects is an everyday example of organizational ethics. Organizational ethics, now recognized widely as an inescapable part of a hospital or community-based ethics specialist's work, focuses on how the operation of a hospital, unit, clinic or office enhances, maintains or unintentionally undermines the ethical work of those interacting with or working on behalf of clients, patients and their families. Policies and procedures describe staff responsibilities and accountabilities, standards of care and working relationships. Responsibility, accountability, care and relationships are all ethical concepts. Forms, too, reflect what's important and who needs to know what.

Conversations with a few people knowledgeable about gender and sexuality directed me to what I continue to find to be a valuable resource: Asking the Right Questions 2, a tool that is publicly accessible on CAMH's website. Reading it, I learned that there are not just four or five gender identities and sexual orientations, but several more. Also - and I think this is important - there is ongoing recognition that people can understand themselves uniquely. The act of acknowledging or recognizing self-descriptions is indicative of the ethical notion of recognition rights.

My advice to the staff member asking about the clinical form was that it was gender identity that they likely wanted to know, not sexual orientation, given the form's purpose. Furthermore, it was a good idea ethically to more clearly affirm recognition of identity and orientation's diversity, which, in turn, meant having more options on the form. If, however, space was limited on the paper form, then, as guided by the advice of those I contacted, list four or five gender identity groups, as well as one marked "other," and provide space for the person to describe their identity.

I was invited several months later to give a workshop about ethical complexities in mental health and addictions care and settings. participants were front-line staff and supervisors of another health care system. The workshop organizers developed a few scenarios or cases to discuss with participants. One scenario involved a person seeking emergency attention at a hospital in a small community. The emergency department's recovery beds were divided into two pods: one for women and one for men. During the first 30 or so minutes of being treated by ER staff, the person indicated that the process of changing their gender was "going on." This person had a few more months of hormone therapy and psycho-emotional and relational support to complete before undergoing the scheduled surgery to alter certain body parts. Once the ER team stabilized the person that day, they wondered whether the patient should be moved to the women's or men's recovery pod. I asked participants at the workshop what they would have done. Some chose the men's section, some the women's. Others said they couldn't say.

As part of developing the scenarios for the workshop, I contacted the same people who helped with the clinical forms question to get their insights into this "two-pod" case. Incorporating their input, I recommended at the workshop that if the individual identified as a woman, then she should be looked after in the women's pod. If the person identified as a man, then recovery would be in men's pod. Trying to figure out "which were you before you began the gender change process - male or female?" or "which are you going to become - male or female?" was the incorrect question. Instead, asking "which of our pods do you think will be the best fit for you?" was the appropriate question because its focus was on the patient "here and now" and it invited the person's self-description or identification.

Ensuing questions from workshop participants included: What, if anything, should be said to people already in the recovery pod who might now see this new person as "male" or "female"? How does the provincial privacy legislation apply? Should there even be a men's pod and a women's pod? What should health care workers do when they encounter patients' biases? Understanding sexual orientation and gender identity well and having accompanying skills to engage people on these aspects of who they are is more complicated than "it used to be," but only because how "it used to be" was erroneous, too narrow or discriminatory.

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Barbara Russell, bioethicist at the Centre for Addiction and Mental Health in Toronto, answers ethics questions that arise in the mental health and addiction fields. She is connected with the University of Toronto's Joint Centre for Bioethics and heads the neuroethics interest group of the Canadian Bioethics Society. She is also a contributing editor to the Journal of Ethics in Mental Health.

Do you have an ethics question for Barbara? Submit questions to be considered for this column to CrossCurrents editor Hema Zbogar at hema_zbogar@camh.net. Please omit personally identifiable health-related information in order to respect people's privacy and follow privacy legislation.