Transcript: Medical Ethics | Nov 17, 2003

(music plays)

In animation, against a backdrop of colourful squares in hues of purple, blue and orange, words fly by as clips show people performing different activities: More to Health, More to Education, More to Science, More to Money, More to Family, More to Ontario. Finally, the title of the show reads "More to life."

Mary Ito sits in a studio made of translucent panes that mimic the animated presentation of the show.

Mary is in her late thirties, with short black hair and bangs. She's wearing a yellow tweed suit.

She says HELLO, I'M MARY ITO, AND WELCOME TO A SPECIAL WEEK ON "MORE TO LIFE." WE'RE EXAMINING THE WORLD OF ETHICS IN THE FIELDS OF LAW, BUSINESS, THE MEDIA AND RELATIONSHIPS. ETHICS ARE THE RULES OR STANDARDS GOVERNING THE CONDUCT OF A PERSON OR THE MEMBERS OF A PROVEGS. TODAY A DISCUSSION ON THE ETHICS OF HEALTHCARE. WHAT HAPPENS WHEN PATIENTS, DOCTORS AND FAMILIES DISAGREE? HERE TO POND DOR AND HOPEFULLY PRO PRIDE DOWN SOME INSIGHT INTO THESE MATTERS, Dr. CHRISTINE HARRISON, THE DIRECTOR OF BIOETHICS AT THE HOSPITAL FOR SICK CHILDREN IN TORONTO. SHE'S ALSO A MEMBER OF THE UNIVERSITY OF TORONTO'S JOINT CENTRE FOR BIOETHICS...

Christine is in her early forties, with short brown hair. She's wearing glasses and a red blazer.

Mary continues Dr. BRIAN BERGER, THE CHIEF OF CONTINUING CARE AT YORK CENTRAL HOSPITAL IN RICHMOND HILL, AND ALSO A FAMILY PHYSICIAN WITH AN INTEREST IN PALLIATIVE CARE...

Brian is in his late forties, clean-shaven, with short brown hair. He's wearing a light gray suit, a white shirt and a silver tie.

Mary continues AND Dr. LAWRENCE KLOTZ THE CHIEF OF YOU'RE IN ROLL GEE AT SUNNYBROOK AND WOMEN'S COLLEGE HEALTH OF SCIENCES CENTRE...

Lawrence is in his fifties, clean-shaven, with short, receding gray hair. He's wearing glasses, a gray suit, white shirt and spotted black tie.

Mary continues YOU CAN ALSO BE A "BIOETHICIST YOURSELF TODAY. PICK UP THE PHONE, LET US KNOW WHAT YOU WOULD DO IN OUR ETHICAL SCENARIOS. IN TORONTO, THE NUMBER TO DIAL, 416-484-2727. LONG DISTANCE, IT'S TOLL FREE...

A caption reads "416-484-2727. 1-888-411-1234."
Then, it changes to "moretolife@tvo.org"

Mary continues AND WE HAVELY COPIES OF PARKER COLLINS POCKET DICTIONARY AND THESESAURUS. THANKS TO ALL OF YOU FOR COMING IN TODAY. CHRISTINE, I'M GOING TO START WITH YOU FIRST OF ALL, BUS ETHICS IS YOUR BUSINESS AT THE HOSPITAL. HOW WOULD YOU DEFINE WHAT MAKES AN ETHICAL DILEMMA IN MEDICINE?

The caption changes to "Doctor Christine Harrison. Bioethicist."

Christine says AN ETHICAL DILEMMA IS WHERE YOU HAVE MORE THAN ONE CHOICE AVAILABLE TO YOU AND YOU'RE NOT CERTAIN WHICH IS THE RIGHT WAY TO GO. IT INVOLVE THE APPLYING YOUR OWN PERSONAL VALUES AND BELIEFS AND CULTURAL BACKGROUND TO A PARTICULARLY DIFFICULT QUESTION ABOUT MIGHT BE MEDICAL TREATMENT AND MIGHT BE WHETHER OR NOT TO ACCEPT TREATMENTOR REFUSE TREATMENT. BUT IN THE MEDICAL SETTING, IT USUALLY INVOLVES SOMETHING TO DO WITH HEALTHCARE.

Mary says Dr. KLOTZ, HOW OFTEN WOULD YOU RUN INTO AN ETHICAL DILEMMA IN YOUR PROFESSION?

The caption changes to "Doctor Laurence Klotz. Urologist."

Laurence says I WOULD SAY DILEMMAS ARISE A LOT AND THEY OFTEN HAVE AN ETHICAL COMPONENT TO THEM. FOR EXAMPLE, BREAKING BAD NEWS TO A PATIENT, TELLING A PATIENT HE HAS CANCER AND HOW THAT'S DONE, YOU MIGHT NOT THINK OF OF THAT AS STRICTLY SPEAKING AN ETHICAL DILEMMA, AND YET THERE'S A PROBLEM IN TERMS OF... OR OFTEN A PROBLEM ARISES IN TERMS OF HOW YOU RELATE THAT NEWS TO THE PATIENT AND HOW YOU DEAL WITH HIS CONCERNS. AND I THINK THEN THE OTHER BIG ISSUE IS WHERE YOU HAVE A CONFLICT BETWEEN WHAT VARIOUS FAMILY MEMBERS OR SUPPORT PEOPLE WANT AND MAYBE WHAT THE PATIENT WANTS OR WHAT YOU THINK IS RIGHT FOR THE PATIENTS. SO THAT'S ANOTHER AREA WHERE CONFLICT ARISES FROM TIME TO TIME.

Mary says Dr. BERGER, YOU HAVE A GREAT INTEREST IN PALLIATIVE CARE. THIS IS AN AREA THAT THE MEDIA HAS FOCUSED A LOT ON AS FAR AS ETHICAL CONCERNS. WHAT WOULD BE SOME THE ISSUES YOU'D BE DEALING WITH?

The caption changes to "Doctor Brian Berger. Palliative Care Specialist."

Brian says NO A DAY GOES BY WITHIN THE PALLIATIVE CARE FRAMEWORK WHERE YOU DON'T DEAL WITH ONE OR ANOTHER TYPE OF ETHICAL ISSUE. UNDERSTANDABLY, WE'RE DEALING WITH PEOPLE FROM A LOT OF DIFFERENT CULTURAL BACKGROUNDS. A LOT OF DIFFERENT RELIGIONS. AND A LOT OF SOMETIMES DIFFICULT, SOMETIMES EASILY FAMILY DYNAMICS. DIFFERENT PEOPLE ARE AT DIFFERENT LEVELS OF WHAT THEY THINK MAY OR MAY NOT BE THE CORRECT APPROACH OF THE MANAGEMENT TO DIFFERENT PROBLEMS SO AT THE ROOT OF IT ALL, HOPEFULLY WITHIN PALLIATIVE CARE, IS EVERYBODY HAS THE PEOPLE ARE INTERESTS OF THE INDIVIDUAL AT THEIR HEART. BUT THEY SOMETIMES APPROACH IT FROM DIFFERENT ANGLES. SO NOT A DAY GOES BY WHERE WE AS A TEAM IN PALLIATIVE CARE DON'T DEAL WITH DIFFERENT ISSUES AND SOME OF THE ISSUES MAY BE VARIOUS MEDICAL PERSONNEL MAY HAVE DIFFERENT OPINIONS AS TO WHAT MAY BE THE RIGHT APPROACH FOR THAT INDIVIDUAL'S COMFORT.

Mary says YOU SEE, NOW WHAT HAPPENS, YOU HAVE VARIOUS MEDICAL PERSONNEL, THESE PEOPLE COULD BE COMING FROM MANY DIFFERENT CULTURES THEMSELVES, RIGHT? DOES IT EVER... HOW OFTEN DOES IT BECOME AN ISSUE WHEN YOUR OWN PERSONAL ETHICS COME UP IN CONFLICT AGAINST PERHAPS THE ETHICS OF MEDICINE THAT YOU'RE DEALING WITH? AND IN FACT THE ETHICS OF THE... I MEAN, IT CAN BE VERY COMPLICATED.

Brian says SURE. I THINK, YOU KNOW, ONE ALWAYS HAS TO TAKE A STEP BACK, YOU KNOW, FROM ONE'S OWN PERSONAL BELIEFS AND JUST MOVE BACK A LITTLE BIT AND JUST VIEW IT... BECAUSE SOMETIMES WHAT HAPPENS IS OTHERWISE YOU GET CAUGHT INTO A TUSSLE SOMETIME, WHICH IS NO VALUE. WHAT I OFTEN DO WITHIN THE PALLIATIVE FRAMEWORK IS TAKE A STEP BACK, REMIND EVERYBODY THAT, YOU KNOW, OBVIOUSLY THEY'RE HERE... WE'RE ALL HERE FOR THE INDIVIDUAL'S GOOD IN TERMS OF SEEING WHAT... HOW THAT INDIVIDUAL CAN BE MORE COMFORTABLE. AND WHAT CAN BE IN THE BEST INTERESTS, AND EVEN THOUGH MY CULTURAL BACKGROUND MAY BE DIFFERENT FROM SOMEBODY ELSE'S, OFTEN I ASK FAMILIES OR FAMILY MEMBERS OR DIFFERENT PERSONNEL TO GIVE ME THEIR PERSPECTIVE BECAUSE MAYBE I CAN LEARN AND MAYBE THEY CAN HELP ME AS WELL UNDERSTAND WHERE THEY'RE COMING FROM AND THAT'S OFTEN A VERY USEFUL APPROACH TO THAT SITUATION.

Mary says BUT NOT ALWAYS EASY, I'M SURE. I DON'T KNOW, Dr. KLOTZ HAVE YOU EVER COME INTO A SITUATION WITH WHERE YOU PERHAPS HAVE STRONG PERSONAL CONVICTIONS ABOUT SOMETHING AND YOU FEEL YOU HAVE TO CROSS A LINE IN A CERTAIN GIVEN SCENARIO?

The caption changes to "Today's topic: Medical ethics."

Laurence says WELL, ONE EXAMPLE THAT COMES TO MIND, AND I BASICALLY AGREE WITH BRIAN, THAT YOU TRY AND... YOU LEAVE YOUR OWN PREFERENCES AT THE DOOR. BUT, FOR EXAMPLE, I... I HAVE A PERSONAL COMMITMENT TO OPENNESS WITH PATIENTS. AND NOT ALL PATIENTS MAY WANT OPENNESS. AND, FOR EXAMPLE, THERE'S SOME CULTURES WHERE A DIAGNOSIS OF CANCER, WHICH IS MY FIELD, IS SHAMEFUL. AND PATIENTS MAY NOT WANT TO EITHER KNOW THE DIAGNOSIS OR THE FAMILY MAY BE ADAMANT THAT THE PATIENT, ESPECIALLY IF THEY'RE ELDERLY, NOT BE TOLD. AND SO THAT'S POTENTIALLY AN AREA WHERE MY STRONG COMMITMENT TO BE OPEN AND DIRECT RUNS INTO CULTURAL PERCEPTIONS A ACTUALLY I DON'T REALLY UNDERSTAND TOO WELL. SO YES, I WOULD SAY THE ANSWER TO YOUR QUESTION IS YES.

The phone numbers and email reappear briefly.

Mary says SO WHAT DO YOU DO? WHAT HAVE YOU DONE?

Laurence says WELL, IT'S HARD TO GENERALIZE, BUT FIRST OF ALL, I USUALLY... IN THE SITUATION WHERE THE FAMILY COMES AND SAYS PLEASE DON'T TELL HIM, HE CAN'T TAKE IT, I MAKE A FEW POINTS. ONE IS USUALLY PATIENTS SUSPECT.

Mary says YOU HAVE TO GO FOR CHEMO.

Laurence says IF YOU'RE COMING TO THE CANCER CENTRE FOR CHEMOTHERAPY AND RADIATION, USUALLY THEY HAVE AN IDEA THERE'S SOMETHING WRONG. SO ONE IS TO MAKE IT CLEAR THAT EVEN IF WE DON'T TELL THEM, HE OR HER, THE PATIENT'S PROBABLY GOING TO FIGURE IT OUT AND THE SECOND, I THINK WHAT REALLY CONVINCES PEOPLE IS THE OUTCOME OF NOT SHARING IT WITH THE PATIENT, THE DIAGNOSIS, IS THE PATIENT GETS ISOLATED FROM THE FAMILY BECAUSE HE SENSES THE FAMILY KNOWS SOMETHING, HE CEASE THEY'RE UPSET, HE HASN'T HEARD, THEY CAN'T TALK ABOUT IT OPENLY, AND JUST AT THE TIME WHERE HE NEEDS THE SUPPORT, HE GETS ISOLATED. SO IN MOST CASES, PEOPLE COME AROUND, AND THE FINAL POINT IS I SAY TO THEM LOOK, TO THE FAMILY, I'LL GIVE HIM THE CHOICE. I'LL ASK HIM IF HE WANTS ME TO TELL HIM. IF HE SAYS NO, FINE. THAT HARDLY EVER HAPPENS.

Mary says OH, OKAY.

Brian says I PERSONALLY FIND THAT TRUTH TELLING, WHICH IS OBVIOUSLY WHAT IT IS, GIVES ONE AT LEAST SOMETIME TO... EVEN IF IT'S A VERY TERMINAL DIAGNOSE CIRCUMSTANCE GIVES YOU TIME TO SORT AFFAIRS OUT TO SHARE SOME THINGS WITH YOUR FAMILY. I THINK IT'S UNFAIR TO NOT REALLY ALLOW THE INDIVIDUAL TO HAVE THAT INFORMATION. HOWEVER, THE ROOT BEHIND THIS ONCE AGAIN IS THEY'RE MEANING WELL FOR THAT INDIVIDUAL, THEY'RE THINKING THAT'S GOING PROTECT THEM. THEY'RE TRYING TO BE IN A PROTECTIVE MODE.

Laurence says YES, YEAH.

Mary says YEAH, BECAUSE EVERYONE IN THE BEST OF LIGHT, EVERYONE HAS HAD THE PATIENT'S INTERESTS AT HEART, RIGHT? ALTHOUGH THE WAY THEY GO ABOUT THAT COULD BE TOTALLY FROM OPPOSITE SIDES.

Brian says AND YOU KNOW, IN MY EXPERIENCE, ALSO, YOU KNOW, APPROACHING DIFFERENT CONSULT CULTURES AND UNDERSTANDING THAT MY PHILOSOPHY WOULD BE TO TRY AND KEEP SOMEBODY AS TOTALLY AS COMFORTABLE AS POSSIBLE TOWARDS THE END OF LIFE WITHOUT ANY SYMPTOMS OF PAIN OR NAUSEA OR WHATEVER SYMPTOMS MAY OR MAY NOT OCCUR AT THE END OF LIFE. FOR EXAMPLE IN THE BUDTIST CULTURE, IT'S IMPORTANT TO BE A LITTLE BIT MORE ALERT SO YOU CAN HEAR SOME PRAYERS AND BE ABLE TO MOUTH SOME WORDS BEFORE YOU GO ONTO THE NEXT LIFE. SO IN FACT A BUDDHIST FAMILY WHO I MAY SEE MAY NOT BE COMFORTABLE THAT THAT PERSON'S COMPLETELY SEDATED BECAUSE THAT MAY BE COUNTERACTIVE TO THEIR RELIGION. THAT'S WHY I'M SAYING ONE HAS TO TAKE A STEP BACK SOMETIMES AND REALISE WHERE THEIR FAMILY ARE... IN PALLIATIVE CARE, FOR EXAMPLE, MEN TIMES INITIALLY WHEN WE'RE TAUGHT THE SORT OF FIELD WE SAY CONSIDER THE INDIVIDUAL. THE INDIVIDUAL THAT'S THE CENTRE OF ATTENTION. WELL IN SOME CULTURE, THE ELDEST SON IS IMPORTANT, OR THE OTHER FAMILY MEMBER'S IMPORTANT TO MAKE A DECISION AND I MAY HEAR THEM SAYING NO, WELL DON'T GIVE AN ANALGESIC AND I'M THINKING WELL THE INDIVIDUAL NEEDS ONE BUT OBVIOUSLY IT'S VERY PORN FOR THAT PERSON WHO'S TERMINAL TO HAVE THAT INDIVIDUAL WHO'S CARING FOR HIM TO MAKE THE DECISIONS AND I HAVE TO RESPECT THAT SOMETIMES.

Mary says YES, YES. OH, SORRY, CHRISTINE.

Christine says I WAS JUST GOING TO SAY I THINK WHAT YOU'VE DRAWN OUT HERE ARE A PERFECT COUPLE OF EXAMPLES WHERE YOU MAY HAVE PROFESSIONAL ETHICS AND THE PERSONAL ETHICS OF THE HEALTHCARE PROFESSIONALS A LITTLE OFF FROM WHAT THE PERSONALETH THIBS OF THE FAMILY ARE AND DEPENDING HOW STRONGLY THE INDIVIDUALS FEEL ABOUT IT YOU CAN HAVE SERIOUS CONFLICT OR JUST A NICE OPPORTUNITY FOR NEGOTIATION AND MEDIATION.

Mary says LET'S TAKE A CALL HERE. MURIEL ON THE LINE FROM OTTAWA. HI MURIEL.

The Caller says I WAS GOING ASK, IN RELATION TO GYNECOLOGOCAL PROBLEMS, WHERE BOTH THE MOTHER AND THE CHILD'S LIFE IS AT STAKE, WHAT WOULD THE OBSTETRICIAN DO? SAVE WHO?

Mary says CHRISTINE.

Christine says WELL IT DEPENDS ON THE OBSTETRICIAN, AND IT CERTAINLY TO A LARGE EXTENT DEPENDS ON THE WISHES OF THE PREGNANT WOMAN. IT IS FORTUNATELY MORE RARE, I BELIEVE, THAT THESE SORTS OF CIRCUMSTANCES COME UP, BUT...

Mary says BUT WITH THAT, IF THE PREGNANT WOMAN WAS, YOU KNOW, AWAKE, LUCID, WHATEVER SHE DECIDES WOULD BE WHAT THE DOCTOR...

Christine says I THINK THAT OFTEN, AGAIN, DEPENDING ON THE PHYSICIAN, THAT IS LIKELY TO HAVE A VERY STRONG INFLUENCE ON HOW THE DECISION IS GOING TO PLAY OUT.

Mary says AND WHAT IF SHE WAS NOT CONSCIOUS? WHO EVER MAKES THE DECISION...

Christine says THEN THE PRIMARY DECISION MAKER WOULD BE LIKELY HER SPOUSE OR PARTNER. WILL IS A LEGAL HIERARCHY OF WHO GETS TO MAKE DECISIONS FOR UNCONSCIOUS PEOPLE. AND MOST OFTEN FOR A MARRIED WOMAN IT WOULD BE HER SPOUSE OR PARTNER. BUT AGAIN, THAT'S A VERY TOUGH DECISION AND IF YOU THINK ABOUT ALL THE FACTORS THAT HAVE TO... WOULD HAVE TO BE CONSIDER, YOU MIGHT HAVE A WOMAN WHO'S NOT JUST PERHAPS WILLING TO SACRIFICE HER LIFE FOR HER CHILD'S LIFE, BUT SHE MAY HAVE OTHER CHILDREN THAT SHE MAY HAVE TO CONSIDER. SHE SMAI HAVE OTHER FAMILY MEMBERS THAT SHE HAS OBLIGATIONS TO TAKE INTO CONSIDERATION AS WELL. IN TERMS OF WHAT, IN AN EMERGENCY SITUATION A PHYSICIAN OR TEAM IS LIKELY TO DO IF THEY HAVE TO DECIDE WITHOUT CONSULTATION WITH THE FAMILY, I'M NOT SURE. WHAT DO YOU FELLOWS THINK?

Brian says I WOULD THINK MOST TIMES THE, IF YOU HAVE TO MAKE AN URGENT DECISION, YOU MAKE A DECISION IN FAVOUR OF THE MOTHER BECAUSE THIS IS AN UNBORN FOETUS. BUT I'M NOT AN ETHICIST...

Mary says OH THAT'S INTERESTING. MAYBE I'VE WATCHED MANY MADE FOR TV MOVIES BUT I ALWAYS THOUGHT YOU WENT FOR THE CHILD.

Laurence says NOT MY AREA, BUT...

Mary says NO, I KNOW IT'S NOT YOUR AREA.

Laurence says BUT THE THEORY IS THAT IN THAT SITUATION, UNDERSTANDING EVERY CASE IS DIFFERENT, YOU GO FOR THE MOTHER'S LIFE. BECAUSE SHE IS A... WELL THE REASONS ARE ANOTHER STORIES, BUT I THINK THAT'S THE PRACTICE.

Mary says AH. OKAY. BUT THAT... AS YOU SAY SO, YOU COULD OVERRIDE THAT IF THE MOTHER SAID NO...

Christine says IF THERE'S TIME FOR CALM REFLECTION AHEAD OF TIME. ONE OF THE EXAMPLES THAT I'M FAMILIAR WITH IS WHERE YOU HAVE, MAYBE HAVE A HE HOVE HAVE'S WITNESS FAMILY AND THE WOMAN'S GIVING BIRTH AND MAY HAVE NEED FOR BLOOD TRANSFUSION AND HAS REFUSEDDED THAT. NOW THAT'S NOT A SITUATION WHERE IT'S... IT'S ONE LIFE OR THE OTHER. BUT IT'S AN ENORMOUSLY CHALLENGING DECISION FOR THE PERSON WHO'S PROVIDING HEALTHCARE.

Mary says AND IF SHE DOESN'T WANT THE BLOOD TRANSFUSION BASED ON RELIGIOUS REASON, RIGHT, THE HOSPITAL WOULD HONOUR THAT?

Christine says WELL IF IT WOULD BE UP TO THE PHYSICIAN AND THE TEAM NOT SO MUCH THE HOSPITAL AND IT VARIES FROM PHYSICIAN TO PHYSICIAN AS TO WHETHER OR NOT THEY'RE WILLING TO TAKE PATIENTS WITH THEIR HANDS TIED IN THAT WAY.

Mary says OH, INTERESTING. SO IT'S NOT AS IF THERE ARE GUIDE LINE, IF THIS HAPPEN, THEN THESE ARE THE GUIDELINES...

Laurence says NO BUT IF A PATIENT REFUSES A BLOOD TRANSFUSION, THEY DON'T GET A BLOOD TRANSFUSION. ASSUMING THAT THEY ARE AN ADULT AND CONSCIOUS AND ABLE TO GIVE INFORMED CONSENT. THAT'S, THAT IS, IN MY OPINION, PRETTY MUCH UNEQUIVOCAL.

Mary says IS THAT RIGHT, CHRISTINE? ARE YOU TALKING ABOUT REALITY AND ARE YOU TALKING ABOUT GUIDE... SORT OF GUIDE LINES HERE? I MEAN WHAT'S THE REALITY...

Christine says I THINK THERE ARE CIRCUMSTANCES WHERE... AND WE'RE NOT JUST TALKING JUST BLOOD TRANSFUSION, I THINK IT'S WHERE PEOPLE ARE REFUSING LIFE SUSTAINING TREATMENT. I THINK THAT YES, SOCIETY HAS COME TO THE POINT WHERE THEY'VE SAID PEOPLE, CAPABLE PEOPLE IS IS THE RIGHT TO REFUSE LIFE SUSTAINING TREATMENT, EVEN IF IT MEANS THAT THEY'RE GOING TO DIE. I THINK THAT PROBABLY MOST OF THOSE DECISIONS ARE HONOURED, BUT I THINK FROM TIME TO TIME DEPENDING ON THE CIRCUMSTANCES THEY MIGHT NOT BE.

Mary says OKAY. LET'S LOOK AT ONE OF OUR CASE STUDIES NOW AND WE'LL GET EVERYONE'S OPINION. AND ALSO WE HAVE A CALLER ON THE LINE. ARE YOU THERE, MARY? HELLO, MARY?

The Caller says HELLO.

Mary says HI, WE'RE GOING TO SHOW A CASE SCENARIO AND WOULD YOU LIKE TO GIVE YOUR OPINION AT THE END OF IT?

The caller says OKAY.

Mary says OKAY, ALL RIGHT, HERE'S OUR CASE SCENARIO.

Text on screen reads "Case 1: Betty is elderly and has had emphysema for years. She is near the end and has lost consciousness. Betty's doctor has informed her two adult daughters that it is unlikely she will regain consciousness and it would be best to remove treatment at this point. The younger daughter has been caring for Betty during her illness. She knows her mother would not want to go on in this state. She wants treatment to be removed. The elder daughter lives away. She hasn't had much contact with Betty and feels tremendous guilt. She insists everything be tried to save her mother."

Mary says SO WE HAVE A SITUATION WHERE THE TWO DAUGHTERS DISAGREE ON WHAT IS TO HAPPEN TO THE MOTHER.

Brian says THAT'S A VERY COMMON SCENARIO FOR ME TO BE INVOLVED IN FOR SURE. AND IT'S INTERESTING BECAUSE MOST TIMES IT'S THE CHILD THAT HAS BEEN AWAY THAT HASN'T BEEN PARS AND PARCEL OF THE PROCESS WHO WANTS TO BE SEEN AS SORT OF THE SAVIOUR SO TO SPEAK IN TERMS OF EVERYTHING SURELY THIS OR THAT COULD BE DONE, ET CETERA, AND A LOT OF IT IS AS YOU SAY HER FEELINGS OF GUILT AND THAT REALLY IS WHERE ONE'S AT. SHE DOES MEAN WELL FOR HER MOTHER ONCE AGAIN BUT SHE DOESN'T UNDERSTAND ALL THE NUANCES OF WHAT CONTINUING TREATMENT WOULD BE. I THINK IN MY DEAL DELINGS WITH THOSE SORT OF SITUATIONS, THERE'S A FEW THINGS IT THAT I ALWAYS CALL UPON. THE ONE IS THAT I WOULD TELL THAT OTHER SISTER, EXPLAIN WHAT HER MOTHER'S LIKE, EXPLAIN WHAT I UNDERSTAND HER MOTHER'S WISHES TO BE, UNDERSTAND HOW DIFFICULT IT IS FOR HER BUT ALSO EXPLAIN TO HER THAT IT TAKES A LOT TO CARE FOR ONE'S MOTHER, BUT IT TAKES A HIGHER DEGREE OF CARING TO KNOW WHEN TO LET GO. AND THESE ARE THE CIRCUMSTANCES AT THE PRESENT TIME, AND JUST BECAUSE WE WOULD REMOVE A LIFE SUSTAINING TREATMENTS, DOESN'T MEAN TO SAY THAT WE WOULD PUSH HER MOTHER ASIDE AND NOT CARE FOR HER. THROUGH THAT TERMINAL TIME WE WOULD PROVIDE PAIN RELIEF, ENSURE SHE DOESN'T SUFFER, ENSURE EVERYTHING'S DONE WHAT WE COULD DO AND IT'S THE SAME SCENARIO I WOULD DESCRIBE FOR DO NOT RESUSCITATE. DO NOT RESUSCITATE DOESN'T MEAN DO NOT CARE. CARING REMAINS AN INTEGRAL PART OF THE THE CARE OR SERVICE TO BE DONE FOR THAT PERSON AND WHAT YOU'RE DOING IS ALTERNATING A FAMILY'S FEELING OF HOPE. YOU GO FROM HOPE FOR A CURE AND CONTINUAL CARE TO HOPEFUL COMFORT, CALM, AND EVENTUALLY A PEACEFUL DEATH. IT'S JUST A DIFFERENT PERSPECTIVE.

Mary says SO LET ME ASK YOU, IF SHE DIDN'T CHANGE HER MIND, THE SISTER WHO WAS AWAY, WHOSE DECISION WOULD YOU ULTIMATELY GO WITH?

Brian says SOMETIMES IT DOES COME TO AN ETHICAL SORT OF COMMITTEE MEETING AT A HOSPITAL OR SOMETHING OF THAT NATURE BUT I FIND MOST TIMES IF YOU HAVE A FRANK DISCUSSION, AS I'VE SPOKEN ABOUT, AND APPRECIATING WHERE THAT INDIVIDUAL'S COMING FROM, GIVE THEM THE RIGHT TO HEAR, TO LISTEN, YOU KNOW, TO HAVE BEEN HEARD, TO BE LISTENED TO, ET CETERA, AND I FIND IN MOST CIRCUMSTANCES THEY'RE ABLE TO TURN AROUND. AND EVEN YOU MAY WANT TO TALK ABOUT WHAT THEIR MOTHERS MEANT TO THEM THROUGH THEIR LIFE AND HOW OFTEN THEY'VE SEEN THEM. I'M SURE THAT WOULD OFFER A LOT OF MEANING. REASSURE THEM THE TIMES THEY DID SPEND WAS OF SOME MEANING, YOU HAVE THE ABILITY TO TURN THAT AROUND.

Mary says CHRISTINE, LET ME ASK YOU, WHAT IF YOU CAN'T TURN THE OTHER DAUGHTER AROUND WHO'S AWAY AND YOU'RE BASICALLY IN A DEADLOCK SITUATION?

Christine says AS Dr. BERG SAYS, THERE ARE SOME RESOURCES YOU CAN TRY USUALLY WITHIN THE HOSPITAL, IF YOU'RE IN A TEACHING HOSPITAL OR A COMMUNITY THAT HAS AN ETHICS COMMUNITY, THEY'RE IN MAYBE ETHICISTS OR ETHICS COMMITTEES IT OR CONFLICT RESOLUTION EXPERT, PATIENT REPRESENTATIVES THAT CAN TRY TO HELP FAMILY MEMBERS COME TO SOME KIND OF AN AGREEMENT.

Mary says BUT LET'S SAY YOU'VE TRIED EVERYTHING. YOU'RE TALKING YOURSELF BLUE IN THE FACE AND YOU JUST CAN'T GET THEM TO AGREE.

Christine says SO I MENTIONED EARLIER HOW THERE'S A HIERARCHY OF DECISION MAKERS. DAUGHTERS WOULD BE ON THE SAME LEVEL OF THIS HIERARCHY. SO...

Mary says WHETHER YOU'RE OLDER OR YOUNGER?

Christine says MAKES NO DIFFERENCE. AND IN FACT IF THERE WERE BROTHERS AS WELL, ALL THIS WOMAN'S CHILDREN WOULD BE AT THE SAME LEVEL OF THE DECISION MAKING AND AS AN ABSOLUTE LAST RESORT, I GUESS WHAT WE'RE REQUIRED TO DO IF WE CAN'T GET AGREEMENT IS CONSULT WITH THE OFFICE OF THE PUBLIC GUARDIAN AND TRUSTEE. THIS IS PART OF THE ATTORNEY GENERAL'S OFFICE, PART OF THE ONTARIO GOVERNMENT, WHICH HAS TREATMENT DECISION CONSULTANTS AVAILABLE TO BASICALLY GIVE THE FINAL ANSWER. ALSO IT'S ACTUALLY... IT BECOMES OUT OF YOUR HANDS. YOU DON'T END UP MAKING THE DECISION. ALTHOUGH WHAT THEY DO IS THEY REALLY TRY TO GO BACK TO GET YOU TO WORK MORE WITH THE FAMILY AND TO TRY TO GET FAMILY TO AGREE.

Brian says I THINK THAT'S UNUSUAL. I THINK THAT'S UNUSUAL. I MEAN, OUR SITUATION AT OUR HOSPITAL FOR EXAMPLE, I THINK I WOULD HAVE HAD SOME INPUT, THE SOCIAL WORKER IN OUR UNIT WOULD HAVE HAD SOME INPUT, THE PATIENT CARE COORDINATORS, NURSE WOOING HAVE HAD INPUT, THE CHAPLAINCY WOULD HAVE HAD SOME INPUT. SO I THINK ALL IN ALL, I KNOW YOU'RE COMING AT IT FROM DIFFERENT ANGLE, BUT THE END PHILOSOPHY WOULD BE THE SAME. ONE WHAT'S IN THE BEST INTERESTS OF THIS PERSON. I KNOW IT'S HARD TO LET GO.

Mary says BUT IT'S INTERESTING. EARLIER YOU BROUGHT UP THE ULT RAL DIFFERENTS AND YOU WERE SAYING IN SOME CULTURES THE Des SON WOULD MAKE THE DECISION. HE WOULD BE THE TOP DOG IN THAT FAMILY.

Brian says IN THAT FAMILY BUT IF IT WAS THIS SITUATION AND THE ELDEST SON WAS FAR AWAY AND REMOVED FROM THE TOTAL CARE OF THAT INDIVIDUAL, I THINK IT DOES MAKE IT MORE DIFFICULT, BECAUSE THE INDIVIDUAL BEING THERE ALL THE TIME DOES MAKE A DIFFERENCE.

Mary says MARY, ARE YOU STILL THERE?

The Caller says YES I AM.

Mary says CAN I ASK WHETHER YOU AGREE WITH OUR PANEL OR HOW YOU FEEL ABOUT IT?

The caller says WELL I THINK I WOULD SIDE WITH THE YOUNGER DAUGHTER. I WOULDN'T WANT TO BE LIVING IN A HOSPITAL IN A CONDITION WHERE I COULDN'T DO ANYTHING FOR MYSELF AND I WAS IN CONSTANT PAIN AND I WOULDN'T WANT TO BE REVIVED OR HELPED TO LIVE LONGER THAN I NEED TO. SO I WOULD GO WITH THAT. BUT I WAS JUST WONDERING, WOULDN'T WHAT THE PATIENT HAD ASKED FOR BE CONSIDERED?

Mary says YES.

Christine says SO THAT IS SUCH AN IMPORTANT OBSERVATION TO MAKE AND IN FACT WHEN WE'RE MAKING DECISIONS OR OTHER PEOPLE WHO CAN'T MAKE DECISIONS FOR THEMSELVES AND THEY'RE ADULT, THAT'S THE FIRST THING WE'RE SUPPOSED TO THINK ABOUT. NOT WHAT WE WOULD WANT FOR THEM OR WE THINK IS BEST FOR THEM, WE'RE SUPPOSED TO TRY AND PUT OURSELVES INTO THEIR MIND AND BE SAY OKAY, HOW WOULD THEY MAKE THIS DECISIONTOR THEMSELVES? AND IN A WAY THAT'S WHY THE DAUGHTER WHO'S BEEN CARING FOR THE MOTHER IS MORE LIKELY TO KNOW WHAT THE RIGHT ANSWER IS BECAUSE SHE KNOWS THE MOTHER BETTER THAN THE DAUGHTER.

Brian says AND I THINK YOU DID MENTION THAT THE MOTHER SAID SHE WOULDN'T WANT TO LIVE LIKE THAT IN THE INITIAL... AND THAT'S... I MEAN, WHETHER THAT WAS WRITTEN...

Mary says NO ACTUALLY THE MOTHER HAD NEVER COME OUTSTATED, IT WAS THE DAUGHTER WHO TOOK CARE OF HER WHO SAID MY MOTHER WOULD PROBABLY NOT. YEAH.

Christine says AND THAT'S THE RIGHT WAY TO MAKE DECISIONS BUT TO TRY TO PUT YOURSELF IN THE MIND OF THE OTHER PERSON AND NOT VERY MANY PEOPLE WOULD WANT TO LIVE ON IN A CONDITION LIKE IT BUT IT IS A VERY STRESSFUL TIME AND DIFFICULT FOR FAMILY MEMBERS, AND I'VE BEEN THERE MYSELF. WE DON'T ALWAYS MAKE THE MOST RATIONAL DECISIONS.

Mary says LET'S TAKE ANOTHER LOOK AT ANOTHER SCENARIO YOU HAVE HERE. THIS IS CASE NUMBER TWO, THAT WILL LOOK AT SOMETHING WE TOUCHED ON EARLIER.

Text on screen reads "Case 2: Giovanni is 83 years old and in deteriorating health. Tests have shown he has advanced pancreatic cancer. His adult children insist he not be told. They say knowing he has cancer will frighten Giovanni and worsen his condition."

Mary says Dr. KRAO STMD Z, YOU RAN INTO THIS SITUATION.

Laurence says WE DID, AND THIS PATIENT HAS THE WORST KIND OF CANCER AND NOT KNOWING THE DETAILS IN MOST CASES SURVIVAL IS A COUPLE OF MONTHS. HE HAS SOME IMPORTANT THINGS TO DO BEFORE HE DIES IN TERMS OF SAYING GOOD-BYE TO HIS FAMILY MEMBERS, AND IT'S TEARIBLE TO NOT GIVE SOMEONE THE OPPORTUNITY TO DO THAT THIS IS A CASE WHICH COMES UP A LOT IN MY EXPERIENCE, AND USUALLY THE FAMILY MEMBERS WHO OF ARE NEW TO THIS AS WELL MAY NOT HAVE PREVIOUSLY HAD A FAMILY MEMBER WHO'S DIED, THEY USUALLY COME AROUND TO MORE REASONABLE POSITION AND AS LONG AS THE MESSAGE IS GIVE TO THE PATIENT IN A TWHAI IS CARING AND COMPASSIONATE AND NOT BRUTAL, THEN IN MOST CASES, IN MY EXPERIENCE, THE FAMILY MEMBER COMES AROUND TO THAT. THE FINAL POINT TO MENTION THOUGH IS YOUR DUTIES TO THE PATIENT. SO IF THE PATIENT... THE PATIENT'S PREFERENCES AS CHRISTINE SAID ARE WHAT COUNTS. YOU SO YOU GO TO THE PATIENT AND YOU SAY WELL, WE HAVE A DIAGNOSIS. AND IF PE HAS NO INTEREST IN THAT DIAGNOSIS OR ACTIVELY SAYS HE'S NOT INTERESTED, THAT'S A DIFFERENT STORY. BUT THE FAMILY'S PREFERENCES HERE ARE CLEARLY SECONDARY TO THE INTERESTS OF THE PATIENT'S AND I THINK THAT'S A KEY POINT.

Christine says AND I SUPPOSE ANOTHER STRATEGY AS WELL MIGHT BE WHEN YOU'RE FIRST ESTABLISHING YOUR RELATIONSHIP WITH YOUR PATIENTS THAURX SAY, YOU KNOW, WELL HOW DO YOU WORK WITHIN YOUR FAMILY? YOU KNOW, WHO DO YOU WANT TO HAVE SPEAK FOR YOU?

Brian says AND THAT'S EASY AS A FAMILY PHYSICIAN SOMETIMES LONG BEFORE BUT NOT ALWAYS. YOU KNOW, BECAUSE DEATH AND DYING AND TERMINAL ILLNESS AND ALL THAT IS SOMETHING THAT PEOPLE LIKE TO BE SAY VOID AND IT'S SORT OF THE WHITE ELEPHANT. WE'RE ALL GOING TO DIE BUT I'D RATHER NOT TALK ABOUT IT. THESE ISSUES ARE SO COMMON MANY TIMES I'VE VISITED PATIENT'S HOME TO BE GREETED AT THE FRONT DOOR, JUST OPENING A LITTLE BIT. ARE YOU THE DOCTOR? YES. HOLD ON, AND THEY COME OUTSIDE AND THEY SAY TO ME, DON'T TELL MY FATHER HE'S GOT CANCER BEFORE YOU COME IN BECAUSE THAT'LL MAKE HIM DIE STRAIGHTAWAY.

Mary says WELL LET ME ASK YOU, Dr. KLOTZ, YOU SAID THAT USUALLY IN YOUR EXPERIENCE THE OUTCOME HAS BEEN GOOD, THAT THE FAMILY HAS COME ON SIDE ONCE YOU'VE SPOKEN TO THEM. DOES IT EVER HAPPEN THOUGH THAT IT WAS BERT NOT TO HAVE TOLD THE PATIENT? THAT THE PATIENT REALLY DID SUFFER FROM HEARING THE NEWS AND THE OUTCOME WAS NOT VERY GOOD?

Christine says YOU KNOW, IT'S A BAD SITUATION. YOU CAN'T AVOID SUFFERING. SO COULD THERE EVER BE A SITUATION WHERE THE PATIENT MIGHT BE BET PER OFF... POSSIBLY ONE COULD CONSTRUCT ONE. BUT I THINK THEY'RE BETTER OFF KNOWING. AT SOME LEVEL. AND IT MAY BE IN SOME SITUATIONS TOO MUCH INFORMATION HAS BEEN GIVEN. THE PATIENT GETS CONFUSED, BUT I WOULD SAY THAT IN ALMOST EVERY SITUATION THEY'RE BETTER OFF KNOWING.

Brian says BUT AS YOU SAY, I THINK THE REAL ISSUE IS HOW YOU SAY IT. AND WHAT YOU LEAVE THE PERSON WITH. TOO OFTEN IN MEDICINE WE MAY BE TEMPTED, OR PEOPLE MAY BE TEMPTED TO SAY THERE'S NOTHING MORE I CAN DO. WHICH IS PROBABLY THE WORST THING AN INDIVIDUAL CAN HEAR.

Mary says DO THEY SAY THAT IN MEDICAL SCHOOL? NEVER SAY THERE'S NOTHING MORE I CAN DO? ARE THEY TAUGHT THAT?

Christine says THEY'RE STARTING TO NOW. THEY REALLY ARE.

Brian says THERE'S NOTHING MORE I CAN DO. YOU KNOW, YOU'VE GOT VERY SEVERE CANCER, IT'S SPREAD. THIS KIND OF SCENARIO IS THE WORST NEWS TO SORT OF TELL SOMEBODY. I MEAN, AS BAD AS NEWS, IS YOU CAN ALWAYS GIVE PEOPLE HOPE THAT THERE ARE THINGS OUT THERE TO KEEP THEM COMFORTABLE, TO ENSURE THIS PASSAGE IS AS EASY AS POSSIBLE AND LINK THEM UP WITH APPROPRIATE RESOURCES. IT'S NOT GOOD, IT'S NOT PLEASANT, IT'S NOT NICE NEWS, IT'S NOT WHAT YOU MAY TO WANT HEAR BUT EVEN AN INDIVIDUAL KNOWS YOU'RE GOING TO BE THERE FOR THEM OR GET THE RESOURCES THAT ARE IN PLACE FOR THEM. THAT MAKES A WHOLE LOT OF DIFFERENCE.

Laurence says BUT IF I CAN JUST CLARIFY, I DO THINK THERE'S A POINT IF THERE IS NO CURATIVE TREATMENT AVAILABLE THAT IT'S IMPORTANT TO TELL THAT TO THE PATIENT TO SAY WE CANNOT CURE THE CANCER, YOU ARE GOING TO DIE OF THIS CANCER. THAT MESSAGE... YOU MAY NOT PUT IT IN SO MANY WORDS BUT THAT'S IMPORTANT TO GET ACROSS TO PEOPLE. THAT'S DIFFERENT FROM SAYING THERE'S NOTHING MORE WE CAN DO, BECAUSE YOU CAN ALWAYS PALLIATE. BUT I ALWAYS THINK GIVING FALSE HOPE WHICH IS DONE TO SAY WE'RE GOING TO TRY THIS THING AND THAT THING, WE'RE GOING TO GIVE YOU THEME THERAPY, KNOWING THERE'S ESSENTIALLY NO LIKELIHOOD, CURE'S NOT EVEN IN THE PICTURE, IT'S IMPORTANT TO GIVE THEM, I THINK A REALISTIC ASSESSMENT OF WHAT YOU CAN EXPECT.

Mary says YES. LET ME JUST ASK... WE HAVE A CALLER ON THE LINE, ANNE FROM NEWBERRY SON THE PHONE ARE. YOU THERE ANNE?

The Caller says YES.

Mary says HI. WHAT IS YOUR FEELING ABOUT THIS SCENARIO?

The caller says OH, I THINK PRETTY MUCH EVERYTHING THEY'VE SAID I AGREE WITH. I ALSO TEND TO SEE... I'M A NURSE SO I TEND TO SEE I THINK SOMETIMES IN A CASE WHEN THE FAMILY DON'T WANT TO TELL THE PATIENT BUT I THINK OFTEN THE PATIENT KNOWS THEMSELVES, EVEN THOUGH THEY HAVEN'T BEEN TOLD BY ANYBODY, THEY HAVE THAT GUT FEELING AND SEEM TO KNOW THAT THEY'VE GOT SOMETHING BAD GOING ON, AND, AND YOU KNOW, JUST KIND OF... ABLE TO FIGURE IT OUT FOR THEMSELVES WITHOUT EVER BEING TOLD, I THINK SOMETIMES.

Mary says RIGHT. THANKS VERY MUCH, ANNE. THANKS. CHRISTINE, DO YOU HAVE ANYTHING TO ADD? ACTUALLY I JUST SORT OF CUT YOU OFF THERE WHEN YOU WERE ABOUT TO SAY SOMETHING.

Christine says WELL IF YOU THINK ABOUT THESE CIRCUMSTANCES WHEN THE PATIENT'S AN ADULT YOU CAN IMAGINE IT WOULD GET MORE TROUBLING AND DISTRESSING WHEN THE PATIENT'S A CHILD AND I THINK THAT ANNE'S CORRECT IN THAT OFTEN PATIENTS WILL KNOW BUT THEY WANT TO PROTECT THEIR FAMILY, AND SO SOMETIMES THEY WILL BE ALMOST COMPLICIT IN THE SECRET. THEY'LL AGREE IN THEMSELVES NOT TO TALK ABOUT IT OR TO NOT DISCUSS THE POSSIBILITY OR THE FACT THAT THEY'RE DYING JUST TO PROTECT THE FAMILY FROM BEING STRESSED.

Mary says AND HERE'S ANOTHER THING, TOO, Dr. KLOTZ YOU WERE TALKING ABOUT IT'S BETTER TO BE HONEST, RIGHT? LET'S DEAL WITH WHAT IS THE REALITY OF THEUATION AND NOT MAYBE SUGAR COAT IT. DOES THAT MEAN DEALING WITH QUESTIONS SUCH AS "HOW LONG DO I HAVE TO LIVE?"

Christine says DO YOU KNOW WHAT I LEARNED WHEN MY MOTHER WAS DYING, AND IT'S FROM SOMEONE WHO LOOKS AFTER DYING PATIENTS AND IT WAS THE MOST HELPFUL PIECE OF ADVICE I EVER HEARD. DON'T ASK A DOCTOR WHEN A PERSON'S GOING TO DIE OR HOW MUCH TIME THEY HAVE LEFT BECAUSE THEY CAN'T ANSWER THAT QUESTION. IT'S REALLY NOT A FAIR QUESTION.

Mary says WHY CAN'T THEY ANSWER IT BASED ON EVIDENCE?

Christine says BECAUSE THE EVIDENCE ISN'T GOING TO SAY EXACTLY HOW MANY MONTHS OR WHATEVER. THE...

Laurence says THE EVIDENCE APPLIES TO A POPULATION. AND YOU SAY THE AVERAGE PATIENT.

Mary says BUT AM I NOT ENTITLED TO KNOW THAT.

Laurence says IT'S DIFFERENT.

Christine says YES, YOU CAN SAY 80 percent OF PEOPLE WITH YOUR CONDITION WOULD PROBABLY BE DEAD WITHIN A YEAR. THAT'S NOT GOING TO BE TOO HELPFUL TO YOU, THE QUESTION TO ASK THE DOCTOR IS WOULD YOU BE SURPRISED IF MY MOTHER WAS STILL ALIVE THREE MONTHS FROM NOW? AND THEY'RE MUCH MORE LIKELY...

Mary says I WOULDN'T THINK OF ASKING EXACTLY THAT PARTICULAR QUESTION. I'M SURE THE QUESTION MOST PATIENTS ASK IS HOW LONG DO I HAVE TO LIVE. LET'S JUST GET RIGHT DOWN TO IT HERE. YOU SAY IT'S NOT HELPFUL. WELL, MAYBE THAT'S THE WAY YOU FEEL, CHRISTINE? BUT MAYBE IT IS HELPFUL TO ME. MAYBE I NEED TO KNOW THAT GEE, THE ODDS ARE I'M ONLY GOING TO HAVE A YEAR TO LIVE AND MAYBE I NEED TO GET THINGS IN ORDER AND DO CERTAIN THINGS I WOULDN'T HAVE CONSIDERED WITHOUT THAT INFORMATION.

Brian says BUT YOU KNOW, OBVIOUSLY I GET THAT QUESTION A LOT, AND I THINK WHAT YOU HAVE TO DO IS ONCE AGAIN REFOCUS. YOU HAVE TO REFOCUS, TO SAY NONE OF US CAN SAY HOW LONG YOU'VE GOT TO LIVE WITHOUT ANY GREAT PRECISION, WITHOUT KNOWING EVERYTHING. OF COURSE YOU'VE GOT A CONDITION THAT'S GOING TO POTENTIALLY TAKE YOUR LIFE. MANY PEOPLE WITH YOUR CONDITION, IT MAY BE THREE MONTHS, SIX MONTHS, NINE MONTHS, 12 MONTHS, BUT WHO KNOWS, LET'S RATHER REFOCUS. EACH DAY IS PRECIOUS, EACH DAY THE SUN COMES CAN UP. LET'S SEE WHAT WE CAN DO WITH THE REMAINING TIME TO MAKE THIS AS VALUABLE FOR YOU AND YOUR FAMILY AS POSSIBLE.

Mary says RIGHT BUT I NEED TO KNOW ROUGHLY...

Brian says I'M JUST SAYING THE WAY TO DO IT IS IN THAT FASHION OF AN OPEN ENDEDNESS BECAUSE THAT'S THE HONEST TRUTH. I MEAN, I HAVE BEEN... SEEN SO MANY AUTO PEOPLE WHERE IT'S CAUGHT UP... MANY PEOPLE FOR EXAMPLE "BUT THE DOCTOR SAID THREE MONTHS AND LOOK THEY'RE DEAD IN A WE CAN OR TWO." OR THE DOCTOR HAD SAID SIX MONTHS, YOU SEE I'M OVER MY SIX MONTH TIME.

Mary says THAT'S GREAT.

Brian says AND IT GOES ALL DOWNHILL FROM THERE BECAUSE THEY GAVE THAT AS A SCENARIO AND I JUST THINK IF YOU FOCUS TOO MUCH ON STATISTICAL TIMES, YOU DON'T TAKE AN INDIVIDUAL INTO CONSIDERATION SO MUCH.

Laurence says WELL I TAKE A SLIGHTLY DIFFERENT APPROACH WHICH IS I TELL THEM WHAT YOU SAID, WHICH IS WE DON'T KNOW, BUT I CAN GIVE YOU STAT TIT STICKS THAT APPLY TO GROUP OF PEOPLE LIKE YOU. WOULD YOU LIKE THAT INFORMATION? YES. WELL, THE AVERAGE PATIENT WHO HAS WHAT YOU HAVE LIVES FOR ONE YEAR. AND THEN I ALWAYS SAY, NOW, DO NOT INTERPRET THIS AS MY TELLING YOU YOU HAVE ONE YEAR TO LIVE. THEY ALL DO INTERPRET IT THAT WAY. SO IT'S A PROBLEM. THEY HEAR A YEAR, I'M TELLING THEM IT'S AN AVERAGE, THEY MAKE THE... THEY DRAW THEIR OWN INTERPRETATION. I HAVEN'T GOT INTO TROUBLE WITH THAT APPROACH, AND IT DOES GIVE THEM SOME INFORMATION, EVEN THOUGH I KNOW THEY'RE VERY LIKELY TO KIND OF MISINTERPRET IT ALONG THE LINES THAT HAVE BEEN SUGGESTEDDED.

Christine says BUT IT IS THE MOST NATURAL QUESTION TO WANT TO KNOW.

Laurence says OF COURSE.

Mary says YES, YES.

Brian says BUT AS IF ONE HAS THE ANSWER AND I THINK A LOT OF PEOPLE THINK THAT'S WHAT'S BEING HIDDEN BY THE MEDICAL PROFESSIONALS BUT NOT REALLY BECAUSE NONE OF US REALLY DO KNOW.

Mary says OKAY LET'S LOOK AT A THIRD SCENARIO WE HAVE HERE.

Text on screen reads "Case 3: A couple gave birth to twins conjoined at the abdomen and with a fused spine. Doctors determined that unless the twins were separated, both would die. Olivia, the weaker twin, has an underdeveloped brain and will not survive the separation. Hannah is stronger but has a 75 percent chance of dying if surgery is not performed. If she lives, she will likely be severely disabled. The parents refuse to give consent on religious and moral grounds."

Mary says NOW THIS WAS AN ACTUAL CASES THAT DID OCCUR AND I'M SURE SOME OF THE VIEWERS MIGHT BE FAMILIAR WITH IT AND READ ABOUT IT IN THE NEWS. Dr. KLOTZ I'LL GO WITH YOU FIRST. WHAT IS YOUR OPINION OF THIS SCENARIO.

Laurence says I WAS AFRAID YOU WERE GOING TO ASK ME. THIS IS A DIFFICULT SITUATION, AND THIS IS UNEQUIVOCALLY A SITUATION FOR THE MEDICAL ETHICISTS TO GET INVOLVED BECAUSE THERE ARE MANY NUANCES HERE AND IT'S THE ISSUE OF THE STATE'S INTEREST IN THE WELFARE OF A CHILD VERSUS THE PARENTS AND EACH ONE OF THESE CASES, WHICH FORTUNATELY ARE RELATIVE LIE FEW AND FAR BETWEEN RAISE A LOT OF DIFFICULT QUESTIONS SO I WILL DEFER ON THIS ONE.

Mary says DOES THAT MEAN YOU DON'T WANT TO GIVE YOUR OPINION AT ALL OR YOU'LL WAIT TO HEAR WHAT CHRISTINE SAYS AND THEN YOU'LL DECIDE?

Laurence says AH, YOU KNOW, YES.

Mary says YES, OKAY.

Christine says HE DOESN'T KNOW ETHICISTS VERY WELL. THEY NEVER HAVE BEEN OPINION FOR ANYTHING. I GUESS THE IMPORTANT THING IN THIS CASE IS TO THINK ABOUT PROCESS RATHER THAN WHAT THE RIGHT ANSWER IS, BECAUSE IT IS ONE OF THOSE CASES WHERE IT'S SO DIFFICULT TO BE ABLE TO SAY FOR SURE WHAT THE RIGHT THING TO DO IS THAT YOU FOCUS ON THE RIGHT WAY TO COME FOLLOW A DECISION. AND SO PART OFETH THIBS IS SUBSTANCE, WHICH WHAT'S THE RIGHT THING TO DO. BUT PART IS WHO GETS TO MAKE THE DECISION.

Mary says YEAH, THAT'S REALLY... IN THE END, THAT'S THE REALITY OF THE SITUATION.

Christine says AND WHEN YOU HAVE PATIENTS WHO COME FROM A PARTICULAR RELIGIOUS BACKGROUND, THIS CASE, I THINK, IS BASED ON A REAL CASE THAT HAPPENED WITHIN THE LAST COUPLE OF YEARS, FAMILY HAD A VERY SPECIFIC RELIGIOUS POSITION, THEY HAD CONTACTS, OTHER FAMILY MEMBERS, THEY HAD A COMMUNITY IN WHICH THEY LIVED... WHO SUPPORTED THEM MERCHANDISE WHO SUPPORTED THEM. THEY WERE CLEARLY MOTIVATED BY LOVE FOR BOTH THEIR CHILDREN IN MAKE THE DECISION, AND IT WAS DECIDED FOR BETTER OR FOR WORSE THAN THAW THE DECISION THAT THEY MADE, WHICH WAS TO ALLOW BOTH CHILDREN TO DIE RATHER THAN ACTIVELY INTERVENE AND BE CAUSE THE DEATH OF ONE OF THEIR DAUGHTERS, IT WAS BELIEVED BY THE COURTS THAT THAT WAS NOT A DECISION THAT THEY COULD MAKE WHEN ONE OF THE CHILDREN COULD SURVIVE.

Mary says RIGHT SO THE DECISION WAS TAKEN OUT OF THEIR HANDS AND IT BECAME A LEGAL MATTER.

Christine says YEAH. THAT WAS IN THE BIOETHICS ROLL. THAT WAS THE COULDN'T VERSE SEE. THE CONTROVERSY WAS WHETHER OR NOT THE PARENTS SHOULD HAVE BEEN ALLOWED TO MAKE THE DECISION, GIVEN HOW MUCH MORAL AUTHORITY WE GIVE PARENTS TO MAKE DECISIONS FOR THEIR CHILDREN.

Mary says AND HOW DO YOU FEEL ABOUT THAT? OR HOW DID THE ETHICS COMMITTEE FEEL AT THE HOSPITAL FOR SICK CHILDREN?

Christine says I GUESS THERE WAS, THERE WERE DIFFERENT OPINIONS EXPRESSED IN THE HOSPITAL. WE HAD DISCUSSIONS WITH SOME OF OUR SURGEON, FOR EXAMPLE, AND SAID SO WHAT WOULD HAPPEN IF THIS HAPPENED IN OUR HOSPITAL? AND THE SURGEONS I THINK FELT PRETTY STRONGLY THAT IF YOU HAVE A GOOD CHANCE OF SAVING ONE CHILD THAT YOU HAVE TO DO THAT. SO THEY WOULD HAVE BEEN READY, WILLING AND ABLE TO SEPARATE THE TWINS, EVEN THOUGH THEY KNEW IT WOULD BE CAUSING THE DEATH OF ONE.

Mary says SO IF THAT'S THE REASON, ARE YOU GOING... IS THAT BASED ON THE ETHICS... YEAH, WHERE ARE THOSE ETHICS COMING FROM? IS THAT YOUR PROFESSION'S ETHICS? DO NO HARM? WHERE IS THAT COMING FROM?

Christine says IT CERTAINLY IS WEIGHING DIFFERENT OPTIONS IN A DIFFERENT WAY, AND THAT'S PART OF ETHIC, AND WE HAVE MANY DIFFERENT CONTRIBUTING FACTORS TO WHAT OUR HEALTHETH THIBS ARE. SOME OF IT IS PROFESSIONAL, SOME OF IT IS OUR OWN PERSONAL UP BRINGING AND VALUES. SURGEONS ARE THERE TO SAVE LIVE, IT'S A POWERFUL VALUE FOR THEM AND WE APPRECIATE THAT WHEN WE NEED THEM.

Mary says IT'S MORE OF AN ISSUE WITH CHILDREN, ISN'T IT? BECAUSE IF IT'S AN OLDER PERSON, WE CAN LET THEM GO, I THINK IN SITUATIONS... BUT WITH A CHILD, IT'S DIFFERENT, ISN'T IT?

Christine says IT'S PROBABLY EASIER TO ACCEPT, PLUS WE HAVE WITH AN OLDER PERSON, WE HAVE I THINK THE ABILITY TO TRY TO FIGURE OUT WHAT THEY WOULD HAVE WANTED FOR THEMSELVES. WE DON'T HAVE THAT CHILDREN.

Mary says RIGHT. Dr. BERGER, HOW DO YOU FEEL ABOUT THIS?

Brian says WELL IT'S VERY DIFFICULT. I MEAN FOR A LOT OF THE ISSUES THAT YOU'VE RAISED BEFORE. I MEAN, I THINK WITH CHILDREN IT'S ALWAYS HARDER. IN MY LINE OF WORK SPEEG CHILDREN WITH TERMINAL CANCER IS HEARTBREAKING. WHEN CHILDREN HAVE TO BE KEPT COMFORTABLE AND PRESSING MORPHINE PUMPS INSTEAD OF PRESSING A GAME BOY, IT'S NEVER EASY.

Mary says AND ALSO, I MEAN, THAT'S A SEN ROMARIO, TOO, WHERE PARENTS PERHAPS SHUN TRADITIONAL MEDICAL TREATMENT AND WANT TO TRY PERHAPS UNPROVEN ALTERNATIVE THERAPIES. THAT SITUATION ARISES AS WELL.

Laurence says TO ME IT'S EASIER WHEN OFF LIFE SAVE THERAPY. LET'S SAY A BLOOD TRANSFUSION IN A JEHOVA'S WITNESS CHILD THAT WILL SAVE THAT PERSON'S LIFE. THEY WILL GO ON TO HAVE A NORMAL LIFE. THEY DIE IF THEY DON'T GET IT. TO ME, THERE AND THERE HAVE BEEN A NUMBER OF CASES OF THIS, IN, WHERE THE STATE HAS STEPPED IN AND INSISTED THAT THAT CHILD BE TREATED. IT'S MORE DIFFICULT, I THINK IF YOU'RE FACING A SITUATION WHERE THE PROSPECT OF TREATMENT IS A SEVERELY DISABLED BUT ALIVE CHILD. AND TO PLACE THE BURDEN OF CARING FOR THAT SEVERELY DISABLED CHILD ON THE FAMILY, IT'S VERY VERY MESSY IN MY OPINION AND I'M NOT SURE WHERE I WOULD COME DOWN OR WHAT I WOULD DO AS THE PARENT.

Mary says HOW DO YOU FEEL AS FAR AS... BECAUSE IN THIS SITUATION, AS YOU SAY, THE CHILDREN CANNOT SPEAK FOR THEMSELVES, HOW DO YOU FEEL ABOUT THE AUTHORITY GIVEN TO FAMILIES? IS THAT PARAMOUNT?

Laurence says MOSTLY, PARENTS HAVE THEIR CHILDREN'S BEST INTERESTS AT HEART. BETTER THAN ANYBODY ELSE, IN MY OPINION.

Brian says AND MANY TIMES IT PARENTS ARE THE ONES THAT HAVE TO LIVE WITH THE CONSEQUENCES... ALL TIME, REALLY... I MEAN IN TERMS OF MAKING THOSE DECISIONS AND IF A CHILD DOES DIE, FOR EXAMPLE, THEY'VE GOT TO BE IT THE ONES TO LIVE WITH THE BEREAVEMENT, ET CETERA THAT GOES THROUGH THEM AND I'M SURE THAT WAS GOING THROUGH THAT FAMILY MIND. TO HAVE ONE CHILD ALIVE AND CONSTANT WATCHING WHERE THE OTHER CHILD HAD DIED AS A CONSEQUENCE MAY NOT BE EASY FOR CERTAIN FAMILIES.

Mary says YOU KNOW WE'RE ALMOST OUT OF TIME BUT I WANT TO SORT OF QUICKLY GET THROUGH THE LAST SCENARIO BECAUSE WE JUST HAVE A FEW MINUTES LEFT.

Text on screen reads "Case 4: Rosa is a 35 year-old woman whose family physician, Doctor Smith, is her mother's friend. Rosa has just been diagnosed with breast cancer."

Mary says NOW HOW COMMON WOULD THAT SCENARIO BE. CHRISTINE? WE RUN INTO DOCTORS TREATING THEIR FRIENDS AND...

Christine says NOT VERY OFTEN BECAUSE I DON'T THINK IT'S ADVISED FOR THIS EXACT SAME REASON, IS THAT PHYSICIANS WOULD FEEL CONFLICTING OBLIGATIONS.

Mary says WHAT ABOUT IN A SMALL TOWN THOUGH? THERE'S ONLY ONE DOCTOR THERE.

Christine says THAT CAN BE A PROBLEM, ONE PSYCHIATRIST, ONE UROLOGIST AND YOU MAY HAVE TO TREAT YOUR FRIENDS. THERE ARE PROFESSIONAL OBLIGATIONS THOUGH AND ONE THE MOST IMPORTANT ONES IS CONFIDENTIALITY, AND I THINK THAT IF YOU'RE TREATING FRIENDS OR RELATIVES OF YOUR FRIENDS ONE THING YOU MAKE CLEAR IS YOU DON'T TALK ABOUT YOUR PATIENTS, WHO EVER THEY ARE.

Mary says BUT SHE'S YOUR BEST FRIEND!

Laurence says THIS ONE IS ACTUALLY A NO-BRAIRN.

Mary says IS IT?

Laurence says IT IS. THIS COMES UP LOT. THIS COMES UP LOT, BUT THIS IS A VERY FUNDAMENTAL PART OF PROFESSIONAL BEHAVIOUR THAT YOU DO NOT TALK ABOUT ANYTHING TO DO WITH YOUR PATIENTS TO OTHER PEOPLE IN A WAY THAT THEY CAN BE IDENTIFIED AND NO PHYSICIAN REALLY SHOULD HAVE A PROBLEM WITH THAT AT ALL SO IN THIS CASE THERE'S ABSOLUTELY NO QUESTION WHAT THIS DOCTOR'S RESPONSIBILITY IS, TO SAY TO HER FRIEND, YOUR DAUGHTER'S MY PATIENT, I CAN'T SAY ANYTHING TO HER ABOUT YOU, YOU HAVE TO TALK TO HER.

Mary says BUT YOU KNOW WHAT? I THINK YOU HAVE TO PUT YOURSELF IN THE POSITION OF ACTUALLY BEING THERE. THIS IS YOUR BEST FRIEND THERE. COULD BE EVEN... LET'S SAY AN ESTRANGED RELATIONSHIP...

Laurence says IF SHE PUSHES YOU, SHE'S NOT YOUR BEST FRIEND BECAUSE SHE IS TRYING TO UNDERMINE YOUR PROFESSIONALISM, AND YOU THINK TO EXPLAIN THAT TO HER. I'VE HAD ABSOLUTELY NO PROBLEM WITH THIS. I'VE BEEN IN THIS SITUATION MANY TIMES.

Brian says ABSOLUTELY. AND I AGREE WITH YOU COMPLETELY. I THINK WHAT YOU NEED TO DO REALLY IS SAY I UNDERSTAND HOW YOU'RE FEELING. I'M NOT PREPAREDDED TO DISCUSS THE INTRICACIES OF THE CASE. IF YOU'RE VERY CONCERNED I'M GOING TO GO WITH WHAT YOUR MOTHER NEEDS OR WANTS TO SAY OR WHAT THE PERSON WHO'S ILL NEEDS OR WANTS TO SAY BUT IF YOU ARE CONCERNED WHY DON'T YOU ASK HER IF YOU CAN COME IN WITH HER WITH AN INTERVIEW AND SEE WHAT YOU CAN DO TO HELP THE SCENARIO.

Mary says WE'RE GOING TO HAVE TO END ON THAT KNOW. THANK YOU TO ALL OF YOU FOR COMING IN Dr. CHRISTINE HARRISON, THE DIRECTOR OF BIOETHICS AT THE HOSPITAL FOR SICK CHILDREN IN TORONTO. Dr. BRIAN BERGER A PALLIATIVE CARE SPECIALIST AT YORK CENTRAL HOSPITAL IN RICHMOND HILL AND Dr. LAWRENCE KLOTZ, THE CHIEF OF UROLOGY AT SUNNY BROOK AND WOMEN'S COLLEGE HEALTH SCIENCES CENTRE AND THE WINNERS OF THE HARPER COLLINS POCKET DICTIONARY...

A picture shows three copies of the Collins Pocket Dictionary and Thesaurus.

Mary continues MURIEL IN OTTAWA, MARY IN MISSISSAUGA AND ANNE IN NEWBERRY. CONGRATULATIONS AND THANKS TO EVERYONE FOR PHONING IN TODAY. EARLIER THIS SEASON WE FEATURED AN INTERVIEW WITH A TRULY AMAZING WOMAN. RUTH EWART IS A NURSE WHO STREETS STREET KIDS OUT OF THE EVERGREEN DROP IN CENTRE IN TORONTO. HER WORK HAS TAKEN HER BEYOND THE SUFFERING ON TORONTO'S MEAN STREETS. RUTH TALKED TO ME ABOUT LIFE, HEALTH AND HOPE ON THIS EX-FACTOR PROFILE.

A clip plays on screen in which Mary and Ruth talk in the studio.

Ruth is in her forties, with curly brown hair. She's wearing a printed green and black sweater, and pendant earrings.

Mary says DID YOU EVER THINK... YOU'VE HAD SUCH AN INTERESTING PAST, GROWING UP AS I SAID IN MANITOBA AND WHERE DID YOU I UNDERSTAND UP GOING TO NURSING SCHOOL AND.

A caption appears on screen. It reads "Ruth Ewert. Street Youth Nurse."

Ruth says IN WINNIPEG, AND THEN I ENDED UP GOING TO AFRICA AS A MISSIONARY AND DURING THAT TIME, THOSE NEXT 15 YEAR, I ACTUALLY DID MY MID-WIFERY TRAINING AND MASTERS IN COMMUNITY TROPICAL MEDICINE.

Mary says HOW DID YOU ACTUALLY END UP IN AFRICA?

Ruth says WELL I HAVE ALWAYS HAD AN INTEREST IN AFRICA. I HAD SOME RELATIVE, COUSINS, AN AUNT AND UNCLE THAT WERE MISSIONARIES IN WEST AFRICA, AND I ALWAYS WAS FASCINATED BY THEIR DISPREERS I HAD A REAL HEART FOR HELPING PEOPLE THAT WEREN'T AS PRIVILEGED AS I HAD BEEN, EVEN THOUGH I GREW UP FAIRLY POOR, IT WAS STILL A LIFE OF PRIVILEGE IN COMPARISON TO WHAT I KNEW THAT SOME PEOPLE GREW UP. AND SO I WANTED TO IN SOME WAY DO SOMETHING WITH MY LIFE THAT MADE A DIFFERENCE.

Mary says AND WHAT WAS THAT EXPERIENCE LIKE, WORKING THERE?

Ruth says IT CHANGED ME COMPLETELY. I HAD NEVER BEEN IN THE PRESENCE OF SUCH POVERTY AND YET SUCH FAMILY WARMTH IN AFRICA. WHEN SOMEBODY COMES TO VISIT, THEY ALWAYS BRING SOMETHING, SUCH GENEROSITY.

Mary says EVEN IF THEY HAVE...

Ruth says EVEN IF THEY HAVE NOTHING. I LIVED IN MUD HUTS WHILE I WAS THERE AND WORKED IN VERY REMOTE AREAS AMONGST SOME VERY, VERY POOR AND REMOTE PEOPLE, AND SOME NOMADIC TRIBES AS WELL AND IT WAS A VERY BROADENING EXPERIENCE, A VERY HUMBLING EXPERIENCE AND A VERY GROWTH-PRODUCING EXPERIENCE.

Mary says HOW LONG WERE YOU THERE?

Ruth says 15 YEARS.

Mary says 15 YEARS BUT IT DID ACTUALLY TAKE A TOLL ON YOUR HEALTH.

Ruth says IT DID. I HAD TO LEAVE AFRICA AS A RESULT OF A VIRUS THAT I PICKED UP THERE, AND FOR ALMOST A YEAR I WAS FAIRLY ILL AND EVEN NOW HAVE SOME PERMANENT DISABILITY AS A RESULT OF THAT VIRUS. HOWEVER I'M GRATEFUL FOR THE OPPORTUNITY THAT I HAD TO DO SOMETHING IN THIS... THAT I HAVE TO DO SOMETHING IN THIS COUNTRY THAT ALLOWS ME TO CONTINUE MY MEDICAL WORK.

Mary says ABSOLUTELY AND THAT CERTAINLY DIDN'T STOP YOU FROM LAUNCHING THE HEALTH CENTRE AT EVERGREEN. THAT WAS YOUR BRAIN CHILD BACK IN 1993.

Ruth says IT WAS.

Mary says TELL US ABOUT IT.

Ruth says WELL AS I WAS CONVALESCING, I WANTED TO DO SOMETHING BESIDES JUST LIE AROUND IN BED OR SIT AROUND IN AN APARTMENT. SO I ASKED AROUND. I SAID WHAT CAN I DO TO GET INVOLVED WITH THE LIVES OF PEOPLE RIGHT HERE IN TORONTO? AND SOMEBODY SAID HAVE YOU THOUGHT OF EVERGREEN CENTRE FOR STREET YOUTH? AND SO I WENT DOWN WILL AND AFTER TWO OR THREE MONTHS OF VOLUNTEERING ALMOST EVERYDAY, THEY ASKED ME "WOULD YOU CONSIDER SETTING UP A HEALTH CENTRE FOR STREET KIDS BECAUSE THEY SAID SOMEBODY HAS TO DO SOMETHING. THESE KIDS ARE NOT GETTING HEALTHCARE." SO THEY SAID WELL WHY, DON'T YOU DO SOMETHINGING? AND SO I JUST KIND OF TALKED TO STREET KIDS AND ASKED THEM IF THERE WAS THE PERFECT HEALTH CENTRE FOR YOUTH, WHAT WOULD IT LOOK LIKE? SO IT WOULD HAVE A DOCTOR TOO, DENTIST, AN EYE DOCTOR, AND A GREAT NUMBER OF THINGS THAT WOULD I DRESS THE NIDZ OF STREET KIDS WHILE THEERNT STREET.

Mary says AND WHAT ARE THOSE NEEDS? I MEAN WHAT KIND OF CONDITIONS ARE YOU TREATING AT THE CENTRE?

Ruth says YOU WOULD BE AMAZED TO KNOW THAT THE CONDITIONS ARE VERY SIMILAR TO THOSE THAT I SAW IN AFRICA, APART FROM THE TROPICAL DISEASES THAT WE SEE IN AFRICA, THE DISEASES WE SEE HERE AMONGST STREET KIDS AND DOWNTOWN TORONTO ARE ALL PREVENTABLE, INFECTIOUS DISEASES, INJURIES.

Mary says FOR INSTANCE WHAT THEN THAT WOULD BE SIMILAR BETWEEN THIS AREA AND AFRICA?

Ruth says CHEST INFECTIONS. CHEST INFECTIONS ARE A NUMBER ONE REASON KIDS COME IN UPPER RESPIRATORY TRACT INFECTIONS. TERRIBLE DENTAL PROBLEMS, BECAUSE IN OUR... ACCORDING TO OUR GOVERNMENT HEALTHCARE STANDARDS, THE MOUTH ISN'T REALLY A PART OF THE BODY AND SO IT DOESN'T GET CARED FOR THROUGH OHIP, NOT THAT THESE KIDS HAVE OHIP ANYWAY. SO INFECTIOUS DISEASES...

Mary says MOZ NOT THAT THESE KIDS HAVE OHIP?

Ruth says 90 percent OF THE KIDS WE SEE DON'T HAVE AN OHIP CARD AND CAN'T ACCESS HEALTH CARE IN THE WAY YOU AND I DO. EVEN IF THEY COULD SEE A DOCTOR SAY IN AN EMERGENCY IN A HOSPITAL. THEY CAN'T GET THE DRUGS THAT THEY NEED THEN TO...

Mary says HOW IS IT THAT THEY DON'T HAVE AN OHIP CARD?

Ruth says WELL IF YOU'RE LIVING IN AN ABUSIVE HOME, SAY, WHICH 99 percent THE KIDS THAT WE SEE ARE, THE LAST THING YOU'RE GOING TO THINK ABOUT WHEN YOU'RE THINKING ABOUT LEAVING THAT SITUATION IS WHERE'S MY BIRTH CERTIFICATE, WHERE'S MY HEALTH CARD? YOU'RE JUST GOING TO PACK A KNAPSACK AND SAY WHERE A FEW CLOTHES AND LEAVE AND THAT'S WHAT HAPPENS WITH THESE KIDS AND FOR THE MOST PART THEY ARE UNABLE TO GET HEALTHCARE IN ANY KIND OF A WAY THAT IS MEPFUL TO THEM. AND SO THEREFORE THE REASON FOR THE HEALTH CENTRE AT EVERGREEN WHERE NO OHIP CARD IS REQUIRED THE DOCTORS ARE VOLUNTEERS, THE DENTISTS, THE NURSES ARE VOLUNTEERS. NOBODY GETS PAID THERE.

Mary says WHAT HAVE YOU NOTICED? BECAUSE THE CENTRES HAVE BEEN OPEN WELL OVER 10 YEARS NOW.

Ruth says THE HEALTH CENTRE'S BEEN OPEN TEN YEARS.

Mary says EXACTLY TEN YEARS?

Ruth says YEAH, TEN YEARS IN JANUARY.

Mary says WHAT HAVE YOU YOU NOTICED SINCE YOU FIRST OPENED THE CENTRE TO NOW? WHAT'S CHANGED? THE KIDS THAT YOU'RE SEEING WHAT YOU'RE SEEING.

Ruth says I WOULD SAY THERE'S PROBABLY FOUR THINGS THAT I CAN IDENTIFY. ONE IS THAT THE KIDS ARE YOUNGER THAN THEY EVER WERE BEFORE. SECONDLY THERE'S MORE GIRLS ON THE STREETS THAN THERE WERE 10 YEARS AGO. MORE BABIES ON THE STREETS AND THERE'S MORE VIOLENCE ON THE STREETS. THOSE WOULD PROBABLY BE THE FOUR MAIN AREAS THAT I COULD IDENTIFY.

Mary says AND THIS IS IN SPITE OF THE GREAT ATTEMPTS WE MAKE AT PUBLIC EDUCATION, RIGHT? PUBLIC HEALTH EDUCATION. SEX EDUCATION, ET CETERA, YOU KNOW, WE'VE BEEN TRYING TO MAKE ATTEMPTS IN THOSE AREAS BUT...

Ruth says AND THAT'S A COMMON MISCONCEPTION IS THAT GIRLS ARE GETTING PREGNANT BY ACCIDENT BUT GIRLS THAT ARE LIVE ON THE STREETS ARE GETTING PREGNANT ON PURPOSE BECAUSE A BABY FOR THEM REPRESENTS SOMEBODY THAT WILL LOVE THEM. FINALLY SOMEBODY WHO LOVES THEM. SOMEBODY THAT WILL BELONG TO THEM IT SOMEBODY THAT WILL CALL THEM MAMA. SOMEBODY SOMEONE THAT WILL MAKE THEM FEEL IMPORTANT AND GIVE MEANING TO THEIR LIVES, AND MAYBE SOMEONE EVEN THAT WILL GIVE THEM ACCESS TO SOME HEALTH PHYSICAL AND GOVERNMENT SERVICES THAT THEY DIDN'T HAVE BEFORE. SO FOR THEM A BABY IS A VERY IMPORTANT STEP FORWARD IN THEIR LIVES, UNFORTUNATELY. BECAUSE THEY ARE UNABLE TO PARENT THEIR BACK BEES VERY OFTEN BECAUSE OF THEIR LIVES ON THEIR STREETS, THEY LOSE THEIR CHILDREN AND THEN THE CYCLE STARTS AGAIN. THEY'VE LOST A CHILD, SO THIS NEED IS STILL THERE, AND SO THEY'LL GO OUT AND GET PREGNANT AGAIN.

Mary says AND WHAT HAPPENS TO THESE CHILDREN?

Ruth says A LOT OF THEM EVENTUALLY GET TAKEN AWAY BY THE CHILDREN'S AID SOCIETY SIMPLY BECAUSE THE CHILD IS BEING NEGLECTED OR IN SOME WAY ABUSED BECAUSE OF THEIR LIVES THAT ARE CONNECTED WITH THE STREET, AND SO A LOT OF THEM GET INVOLVED IN THE GOVERNMENT CHILDREN'S AID SYSTEM.

Mary says TELL US THE STORY. I REMEMBER YOU TELLING ME ABOUT ONE YOUNG GIRL, AND HER STORY WHEN SHE SHOWED UP AT THE CENTRE AND THE BABIES ACTUALLY THAT SHE ENDED UP LOSING.

Ruth says THAT'S RIGHT. SHE WAS A 13-YEAR-OLD GIRL WHEN I FIRST MET HER AND SHE'D BEEN ON THE STREETS SINCE SHE WAS 11 YEARS OLD AND SHE'D HAD A TERRIBLE FAMILY LIFE UP TO THAT POINT, AND SO FOR HER THERE WAS NOTHING TO LOSE BY GOING TO THE STREETS AND SO SHE BECAME A PROSTITUTE AT 11 AND AT 13 I MET HER AND SHE WAS STILL PROSTITUTEING AND DOING DRUGS AS WELL. AND SO SHE BECAME PREGNANT AT 14, AND BETWEEN 14 AND 20 NOW SHE'S HAD ABOUT FIVE DIFFERENT CHILDREN. THE FIRST TWO SHE MANAGED TO KIND OF GET CLEAN FOR A WHILE, AND LOOK AFTER HER CHILDREN AND THEN SOMETHING HAPPENED TO KIND OF TAKE HER DOWNHILL AGAIN AND SHE STARTED DOING DRUGS AGAIN. SHE LOST THOSE TWO CHILDREN AND SINCE THEN HAS HAD THREE MORE, ALL OF WHICH HAVE BEEN TAKEN AWAY AND THE LAST TWO OF WHICH HAVE BEEN TAKEN AWAY BEFORE SHE WAS EVEN ABLE TO REALLY HOLD THEM IN HER ARMS.

Mary says WHAT'S SHE DOING NOW?

Ruth says I DON'T KNOW. SHE CALL IMMEDIATE ABOUT TWO MONTHS AGO AND SAID RUTH, I WANT YOU TO KNOW I'M OKAY. SHE WAS IN ANOTHER TOWN IN ONTARIO, I WON'T NAME THE TOWN, BUT SHE WAS, SHE WAS DOING OKAY. SHE WAS IN A DRUG REHAB PROGRAMME AND SAID TO ME I JUST WANT YOU TO KNOW THAT ALL THE TIMES THAT YOU HELPED ME WHEN I WAS YOUNG, THEY'VE MADE A DIFFERENCE AND I'M STILL LOOKING FORWARD TO A BETTER LIFE.

Mary says WELL HOW FAR DO YOU LET YOURSELF GET INVOLVED WITH THESE KIDS?

Ruth says WELL, I THINK IT'S IMPORTANT FOR ME TO ALLOW MY HEART TO BE BROKEN TO A DEGREE, BECAUSE UNLESS I CAN FEEL SOME OF THEIR PAIN AND PUND SOME OF WHAT THEY'VE BEEN THROUGH, NOT IN THE ACTUAL CIRCUMSTANCES, BUT SOME OF WHAT IT DOES TO THEM, I LOSE MY EFFECTIVENESS. AND SO SOMETIMES THE BEST GIFT I CAN GIVE TO A YOUNG PERSON IS WHILE THEY'RE WEEPING OVER THEIR SITUATION TO CRY WITH THEM. I CAN'T FIX THEIR SITUATION.

Mary says I READ IN AN ARTICLE ONCE WHEN THEY WERE PROFILING YOU, YOU SAID THAT YOU ACTUALLY CRY EVERYDAY.

Ruth says YEAH, PROBABLY. AND BY FEEL THAT IT KEEPS MY HEART IN TUNE WITH WHAT'S IMPORTANT.

Mary says AND I GUESS, TOO, WHAT'S IMPORTANT IS NOT EVEN JUST WHAT'S HAPPENING HERE, BUT YOU KNOW, YOU HAVE YOUR EYE ALSO ON THE BIG PICTURE, A WORLD PICTURE, I KNOW YOU WENT BACK TO AFRICA AS WELL.

Ruth says I DID.

Mary says YOU WENT BACK TO UGANDA.

Ruth says I DID. I WAS LEADING A TEAM OF MEDICAL AND NURSING STUDENTS WITH A MISSION ORGANISATION IN UGANDA, WITH THE VIEW TO INTERESTING THESE YOUNG PEOPLE IN A CAREER, POSSIBLY, IN MEDICAL, IN MEDICINE OVERCEASE.

Mary says DID YOU ACCOMPLISH THAT?

Ruth says POSSIBLY, I DON'T KNOW, THEY'RE STILL IN TRAINING MANY OF THEM. I DON'T KNOW WHAT'S GOING TO HAPPEN OVER THERE BUT I KNOW THEIR LIVES WERE CERTAINLY IMPACTED. IT WAS A VERY MEANINGFUL EXPERIENCE.

Mary says WERE THERE A COUPLE OF THEM SO SHAKEN BY THEIR EXPERIENCE.

Ruth says THEY DID MAKE IT THROUGH.

Mary says WHAT CHANGED THROUGH... WHAT HAPPENED WHEN YOU WENT BACK AND WHAT DID YOU SEE?

Ruth says IT WAS A VERY SHOCKING SITUATION FOR ME. WHEN I LEFT OF A CAM 15 YEARS AGO, AIDS WAS JUST BEGINNING SORT OF BECOME DISMON BACK PROBLEM IN THE POPULATION. NOW 15 YEARS LATER WHOLE GENERATION OF PEOPLE HAVE BEEN AFFECTED BY AIDS AND MANY HAVE DIED AND IN ONE AREA IN PARTICULAR, 60 percent OF THE ADULT POPULATION IN CHILD BEARING YEARS WERE HIV POSITIVE, LEAVING WHOLE FAMILIES OF YOUNG CHILDREN TRYING TO KEEP KEEP AND LOOK AFTER THEMSELVES WITHOUT PARENTS. YOUNG BABY, CRAWLING AROUND IN OPEN SEWERS WITH NOBODY TO LOOK AFTER THEM, JUST EATING WHAT THEY COULD. IT WAS, IT WAS HEARTBREAKING. I FELT AT TIMES I WOULD NOT BE ABLE FOLLOW STOP CRYING. IT WAS SO HARD.

Mary says AND THEN WHAT HAPPENS YOU? LEAVE THAT SITUATION, YOU COME BACK TO TORONTO, HOW DO YOU THEN TAKE THAT EXPERIENCE AND GO ON WITH YOUR WORK? WHAT DOES THAT DO TO THE WORK YOU'RE DOING NOW?

Ruth says WELL, I THINK FOR ME IT TELLS ME EVERY SINGLE LIFE IS IMPORTANT AND IS WORTH IMPACTING. THE YOUTH THAT I MEET TODAY, IF I MEET THAT YOUNG PERSON FOR JUST FIVE MINUTES, PERHAPS THERE'S SOMETHING SMALL THAT I CAN SAY OR DO TO THAT YOUNG PERSON TO GIVE THEM A LITTLE BIT HOPE TO KEEP GOING. I MAY NOT MAKE A HORRIBLY I BIG IMPACT IN THE WORLD VIEW OF THINGS BUT FOR THAT YOUNG LIFE I CAN HOPEFULLY MAKE A DIFFERENCE. HOWEVER SMALL.

Mary says I JUST WANTED TO END OFF THERE ARE A LOT OF PARENTS OUT THERE WHO ARE LISTENING AND THEY ARE HAVING PROBLEMS. SOME, VERY SERIOUS PROBLEMS WITH THEIR THEIR KIDS AND THEY'RE AT THEIR WITT'S END. THEY SAY I'VE TRIED EVERYTHING, I DON'T KNOW WHAT TO DO, I'M NOT CONNECTING WITH THIS CHILD. WHAT WOULD YOU STY THOSE PARENTS?

Ruth says I WOULD SAY KEEP LOVING THAT CHILD IN A WAY THAT THAT CHILD KNOWS YOU LOVE THEM. TELL THAT CHILD YOU LOVE THEM. SHOW THAT CHILD THAT YOU LOVE THEM. BECAUSE WHAT STREET KIDS SAY IT TO ME EVERY DAY IS I HAD NOBODY IN MY LIFE THAT LOVES ME. ONE OF THE QUESTIONS WE ASK ON OUR MEDICAL QUESTIONNAIRE IS WHO SHOULD WE CONTACT IN CASE OF AN EMERGENCY AND THREE QUARTERS OF THE TIME THEY SAY I HAVE NOBODY WHO WOULD CARE. AND I SAY JUST PUT SOMEBODY WHO YOU WOULD WANT TO KNOW IF YOU DIE SAID AND THEY SAID NOBODY WOULD KNOW IF YOU CARE. SO TO THOSE PARENTS OUT THERE I'D WANT THEM TO JUST KNOW THAT YOUR LOVE MAKES A DIFFERENCE TO THAT CHILD, SO PERSIST IN LOVING THAT CHILD.

Mary says THANK YOU, RUTH. BEST OF LUCK WITH YOUR WORK AND CONGRATULATIONS ON YOUR TENTH ANNIVERSARY.

Ruth says THANK YOU VERY MUCH, Mary.

Mary says RUTH EWART, THE HEALTH CENTRE PROGRAMME COORDINATOR AND ASSISTANT DIRECTOR OF THE EVERGREEN CENTRE FOR STREET YOUTH IN TORONTO TO FIND OUT MORE ABOUT VFR GREEN GO, TO THE YONGE STREET MISSION AT...

A slate reads "Evergreen Yonge Street Mission, ysm.on.ca."

Mary says but that's it for our show today. Thank you for watching, and please join us each weekday, Monday to Friday, for More to Life at 1 o'clock.

A slate reads "The advice given in the preceding program is of a general nature only. Viewers should consult their own medical professional for medical advice specific to their circumstances."

Watch: Medical Ethics