I've been thinking a lot about the possible move of Ontario's Psychiatric Patient Advocacy Office from the Ministry of Health and Long-Term Care (MOHLTC) portfolio to the Canadian Mental Health Association (CMHA). I've read opinions from many people--a Toronto Star columnist, the executive director of CMHA's Toronto office, an Ontario MPP, the Minister of Health and Long-Term Care, as well as posts to various mental health advocacy websites. I've only been in Ontario for about five years, so to better understand historically the political, legal and social factors involved in such a move, I read sections of the PPAO's 25th-anniversary report from 2008 and "Too Much, Too Late: The Advocacy Act in Ontario," an article by Ernie Lightman and Uri Aviram published in 2000 in Law and Policy. I have also worked with PPAO staff members in some of my CAMH assignments.
Four ethics-related considerations stand out for me. The first consideration connects with one of my favourite pieces of writing about ethics. Arthur Frank, a sociology professor at the University of Calgary, has developed deeply insightful and compelling work about personal illness narratives and relationships between clients and patients, their families and health care professionals. Frank's article "Ethics as Process and Practice," published in 2004 in the Internal Medicine Journal, begins by examining the kinds of health or treatment goals or outcomes we decide to commit to.
In terms of the planned PPAO move, a more co-ordinated, patient-centred continuum of care was the initially identified goal. Patient-centredness is inarguably ethically desirable in any health care context. However "more co-ordinated" can imply different things to different people: for example, less waiting, simplified paperwork, less duplication, fewer gaps, greater efficiency or reduced direct costs. Each of these can have different implications for stakeholders. Therefore, a second ethics-related consideration centres on fairness: understanding which stakeholders gain and lose what from a possible change to the PPAO reporting relationship and whether this constitutes a fair distribution of the expected benefits, losses and burdens.
Frank's article examines the kinds of behaviours, interactions and actions we choose in order to achieve our desired goals. In recent weeks, MOHLTC has decided to suspend its plan to move the PPAO so it can obtain and consider stakeholder input. Many criticisms of the initial plan were, I think, about surprise, unilateral-ness and timing. These criticisms may have reflected more deeply felt worries, such as being unaware of dissatisfaction, being unprepared for major change, being taken for granted, inappropriate paternalism, inadequate trust, lost opportunity to propose better options, too little regard for the history of mental health rights and advocacy in Ontario and possible job loss.
Third, the public and social media have raised the issue of conflict of interest and undue influence. The question of appropriately "situating" the PPAO reminds me of the important goal of appropriately situating "ethics specialists" (i.e., a bioethicist or an ethics committee) in order to meet a health care organization's immediate and future needs and challenges. Often these specialists are initially viewed as "the ethics police" or as interlopers into the special relationship between the professional and the client. There has also been debate about whether an "ethics specialist" is more effective when employed by an external entity, such as a local philosophy or theological department, than by the health care facility itself. Identified tradeoffs included no conflict of interest but inadequate understanding of daily practice realities versus deeper practical knowledge but possible perceived/actual conflict of interest.
It is ideal to avoid conflicts of interest, whether perceived or actual. In some situations, a conflict seriously threatens the expected benefits so much that the initiative or project should not proceed because its goals will not be met or its decisions will not be trusted. But in other situations, the benefits may be so significant that disclosing the conflict of interest plus instituting safeguards and monitoring their usefulness makes good sense. A health care exemplar is organ and tissue transplantation: clinicians and teams working with potential donors and their families are proactively and administratively kept separate from those working with potential organ recipients.
The provincial government has funded the PPAO since its inception. Until a few years ago, the government not only funded psychiatric facilities; it also operated several of them (the Penetanguishene hospital was the last to be divested in 2008). Obviously, a status of "quasi-independence" meant that the PPAO has not been completely independent. So what can we learn from the safeguards and processes that have helped to avoid, minimize and manage conflicts of interest between PPAO staff and staff at government-run psychiatric hospitals? If after more input and careful reflection there are good reasons for a new reporting relationship, which safeguards can be readily replicated, which safeguards weren't working well and can be replaced, and which safeguards remain essential but cannot be effectively instituted in the new relationship?
The fourth and last ethics-related consideration I'd like to offer is about advocacy itself. Lightman and Aviram's article about the short-lived Advocacy Act affirms the relevance of past efforts by government offices, community groups, individuals, families and professionals in Ontario to help those who endure discrimination, stigmatization, abandonment or marginalization within our prosperous society or who lack basic resources, fair opportunities, abilities or supportive relationships to attain or sustain a personally meaningful, participatory life. At an ethics committee meeting a few years ago, I suggested that advocacy might not be identical to ethics. Fortunately, my wish to be provocative worked because the ensuing discussion carefully explored advocacy's role compared to that of ethics.
The discussion included the role of hospitals' ethics specialists. Some colleagues in the field believe that the complexity and routine-ness of health care warrants ever-increasing ethics consultations, often to the point of more specialists being employed. I see it differently. The role of ethics specialists is to help increase the knowledge and abilities of clinicians and teams so they engage in "preventive ethics," thereby avoiding ethics-related crises; at the same time, they themselves become more skilful at handling unforeseeable dilemmas. In other words, over time, these professionals and teams should ask for my assistance only for questions that are new, disconcertingly ambiguous or very complex. With respect to advocacy initiatives, then, are there credible and trackable indicators of successful attainment of social justice and individual empowerment (e.g., restored or regained voice, power, participation, resources and opportunities) such that an initiative's primary purpose can be considered, by and large, fulfilled? I wonder if the idea of a new PPAO reporting relationship reflects -- at least in part -- its success over almost three decades in educating and influencing professionals and their institutions, as well as helping individuals gain or resume personal control and authority over their health and well-being and gaining or resuming their own use of various societal supports and protections that are available to every citizen.
