“Hospitals have always been in a position of deciding how to allocate resources,” she said. “It’s not a new problem, although certainly with the state of the world’s economy it is at the forefront of discussions.”

 The Centre for Clinical Ethics has been helping its hospitals navigate ethical questions, including the ethical rationing of services, since 1982 as a joint effort of St. Michael’s Hospital , St. Joseph’s Health Centre and Providence Healthcare in Toronto. From its home-base, the centre provides educational opportunities, case consultations, policy development and research to help health care professionals identify and resolve ethical issues in the workplace. Its ethicists have also been called on by staff at other hospitals to provide quick assistance on ethical dilemmas where there are no full-time staff to do so.

Markwell said the top ongoing ethical issues in hospitals today are the same as they were outlined in a report released by the University of Toronto Joint Centre for Bioethics in 2005. The top four challenges then included disagreement between patients/families and health care professionals about treatment decisions, waiting lists, access to needed health care resources for the aged, chronically ill and mentally ill and the shortage of family physicians or primary care teams in both rural and urban settings.

Markwell said that Catholic hospitals, in being the first to incorporate ethical standards, have set a good precedent for other hospitals seeking ethical guidance on these and other issues.

“Catholic health care has done an extraordinary job and should lead the way in discussions on ethical dilemmas like resource allocation,” Markwell said.

The demand for ethical consultations has risen in the past few years, she said, as many non-Catholic institutions aim to meet certain hospital accreditation standards which speak to the need for an ethics framework, which is part of the reason why non-Catholic hospitals are coming to the centre for help. This need may increase with the expected release of an ethical framework being drafted by Local Health Integration Networks meant to complement the LHINs’ base principles of accountability and equity.

If she and the centre’s other clinical ethicists weren’t there to facilitate the ethical discussions, the questions would still get raised, Markwell said, but having experts to consult with helps add depth to the conversation.

“I think the economical situation is forcing us to ask deeper questions,” she said. “We have a strong commitment to both justice and compassion because they are at the root of health care. If we say that we are committed to the human being because they are made in the likeness and image of God.”

Ontario Hospital Association president and CEO Tom Closson said all of the 157 hospitals in Ontario are facing a greater challenge this year because of the economy, and he estimates about 20 to 30 of them, which are already running deficits, will no doubt have to make service cuts in order to balance their budgets.

“Based on surveys we’ve done, most hospitals are facing challenges and making cuts,” he said. “The government has not (yet) confirmed their funding increase for 2009-2010, which they announced would be about 2.1 per cent, although we estimate inflation to be 3.5 per cent.”

Though ethicists from the Centre for Clinical Ethics can make recommendations on resource allocation to hospital management, the final decision on cuts rests on the shoulders of the LHINs.

Closson said that one item costing hospitals significant cash right now is that about 20 per cent of beds are filled by elderly persons who could otherwise be cared for in the community. Although not an easy solution to fix, if many elderly people didn’t have to stay in the hospital while waiting for a room to become available at a long-term care centre, significant financial stress would be taken away.

To help hospitals keep their footing, Closson said he submitted recommendations to the ministry of health that the government put in place a productivity improvement fund of $150 million for work force adjustment costs and investments that would help cut costs down the road. He also proposed the government provide extra assistance to hospitals in remote communities (about half of the hospitals in Ontario) and additional funding to the 20 to 30 Ontario hospitals that are in deficit.

The 14 LHINs across the province are currently exploring ways to partner health care institutions with other agencies in the community to transfer services for improved patient care, according to a Toronto spokesperson.