Ethics ofqueuing for coronary artery bypass - NCBI

SPECIAL ARTICLE * ARTICLE SPECIAL Ethics of

queuing

for

coronary

artery

bypass

Ethics of queuing for coronary artery bypass grafting in Canada

Jafna L. Cox, BA, MD, FRCPC

Resume: Les limites du financement des soins de sante au Canada ont eu pour effet de rationner les services en mettant les patients en file d'attente lorsque les ressources medicales fixes n'ont pas reussi 'a satisfaire la demande. Il est sans doute preferable d'imposer un delai temporaire plutot qu'un acces restreint, mais seulement si la situation est securitaire et juste pour le patient. Le rationnement de ressources rares suscite chez le medecin un conflit entre sa responsabilite envers le patient et la societe. La procedure des files d'attente en vue d'un pontage aortocoronarien au Canada provient d'un.e discordance entre l'offre et la demande d'operations chirurgicales. Elle respecte des lignes directrices explicites fondees sur le besoin medical et fait appel 'a un examen par les pairs pour en assurer l'application equitable. On peut donc faire attendre les patients en toute securite et justice. En outre, cette strategie selon laquelle un groupe de pairs fait office de garde-barriere constitue une solution ethique au dilemme des responsabilites contradictoires auxquelles doivent autrement faire face les medecins au chevet de leurs patients.

policy of managed delay is preferable to one of restricted access, there are major concerns about patient safety and justice. Furthermore, rationing engenders a conflict between a physician's traditional responsibility to the individual patient and the exigencies of medical practice in the universal health care system, wherein a broader responsibility to society is required. This conflict cannot be reconciled at the bedside. The process currently used to queue patients for coronary artery bypass grafting (CABG) in Canada provides an ideal paradigm for reviewing these issues. It follows explicit, physician-established guidelines based on medical need and includes peer review to ensure their just application. This strategy allows rational selection of patients with low vital risk and, I will argue, an ethical solution to the dilemma of competing physician responsibilities to individual patients and to society. a

Limits on access to CABG in Canada

In 1988-89, a dramatic increase in referrals for CABG in Canada overtook caseload growth.2 Patients across the country waited a mean of 22.6 weeks for elective surgery,3 and some died. Although government provided funding to augment surgical capacity' a mismatch between CABG demand and supply persisted. Canadian physicians endeavoured to obtain timely T he primary objective of Canadian health care for their patients. However, approaches to queuhealth to surgery access reasonable policy is "to facilitate were inconsistent.4 In Toronto, interhospital barriers."' patients ing services without financial or other in mean wait times were as great as 8 weeks. differences health However, Canada's assets are finite. Limits on with the shortest queues, patients referred In the hospital when care funding have resulted in rationing by queue waited twice as long as similar offsite cardiologists by met demand. Although fixed medical resources have not A longer version of this paper was awarded the 1993 Knights of Malta Prize in Medical Ethics Essay. At the time of writing, Dr. Cox was with the Division of Cardiology, Victoria General Hospital, Dalhousie University, Halifax, NS. He is currently with the Institute for Clinical Evaluative Sciences in Ontario and the Clinical Epidemiology Program of Sunnybrook Health Science Centre, North York, Ont.

Reprint requests to: Dr. Jafna L. Cox, Institute for Clinical Evaluative Sciences in Ontario, GG-38, 2075 Bayview Ave., North York,

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CAN MED ASSOC J 1994; 151 (7)

953