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The purpose of this text is to tell the story of the implementation of the Act Respecting End-of-Life Care, referred to hereafter as Law 2 (Gouvernement du Québec, 2014) with an emphasis on the ambiguous role of ethics in the Interdisciplinary Support Groups (ISGs), created by Quebec's Ministère de la santé et des services sociaux (MSSS). As established, ISGs provide "clinical, administrative and ethical support to health care professionals responding to a request for Medical aid in dying (MAiD)" (Gouvernement du Québec, 2015). It is suggested that their composition includes the participation of a person with an expertise in ethics. These ISGs represent an important innovation for stakeholders involved in MAiD. To date, no scientific research has specifically addressed ISGs and little research has been conducted in other jurisdictions on the roles, operations and practices of MAiD support structures, especially the implication of ethics. Several ISGs have certainly developed promising practices that could benefit all stakeholders in the wider field of ethics and end of life. We will explore the development of ISGs in Quebec as a support structure for MAiD by highlighting the role that ethics has played (and should play) in these morally and humanly challenging situations.

Background To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers. Objectives To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic. Methods The steps described by Arksey and O’Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public’s perspectives on tiebreakers and their underlying values, according to these studies. Results Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19. Conclusions There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public’s perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers.

Canada has legalized medical assistance in dying (MAID) for mentally competent persons who satisfy the legal requirements. Debate is ongoing as to whether MAID should be accessible to no-longer-competent persons through an advance request. We conducted an anonymous vignette-based survey among 367 social workers from Quebec to (1) elicit their attitudes toward MAID in the context of dementia; (2) assess their underlying values and beliefs; and (3) compare their attitudes to those of nurses (

Summary In many countries, health care institutions have ramped down nonemergent activities in order to free up hospital and critical care beds in anticipation of a wave of patients with coronavirus disease 2019 (COVID-19). Medical activities were reduced to a minimum, leaving operating rooms to run semiurgent and urgent surgeries only. The status quo of systematically prioritizing resources away from surgical care to patients with COVID-19 may lead to unintended long-term outcomes. We propose a 4-step prioritization system based on resource availability and clinical criteria, as well as supplemental triage criteria for instances where multiple patients have equal claims to priority. The algorithm aims to guide clinicians and decision-makers toward allocating resources to surgical patients while still optimizing pandemic-specific benefits to the population.

Background: Under Quebec’s Act respecting end-of-life care, physicians may refuse to provide medical aid in dying because of personal convictions, also called conscientious objections. Before legalisation, the results of our survey showed that the majority of physicians were in favour of medical aid in dying (76%), but one-third (28%) were not prepared to perform it. After 18 months of legalisation, physicians were refusing far more frequently than the pre-Act survey had anticipated. Aim: To explore the conscientious objections stated by physicians so as to understand why some of them refuse to get involved in their patients’ medical aid in dying requests. Design/participants: An exploratory qualitative study based on semi-structured interviews with 22 physicians who expressed a refusal after they received a request for medical aid in dying. Thematic descriptive analysis was used to analyse physicians’ motives for their conscientious objections and the reasons behind it. Results: The majority of physicians who refused to participate did not oppose medical aid in dying. The reason most often cited is not based on moral and religious grounds. Rather, the emotional burden related to this act and the fear of psychological repercussions were the most expressed motivations for not participating in medical aid in dying. Conclusion: The originality of this research is based on what the actual perception is of doing medical aid in dying as opposed to merely a conceptual assent. Further explorations are required in order to support policy decisions such as access to better emotional supports for providers and interdisciplinary support.

Canada deployed a digital exposure notification app (COVID Alert) as a strategy to support manual contact tracing. Our aims are to (1) assess the use, knowledge, and concerns of the COVID Alert app, (2) identify predictors of app downloads, and (3) develop strategies to promote social acceptability. A 36-item questionnaire was co-designed by 12 citizens and patients partnered with 16 academic researchers and was distributed in the province of Québec, Canada, from May 27 to 28 June 2021. Of 959 respondents, 43% had downloaded the app. Messaging from government sources constituted the largest influence on app download. Infrequent social contacts and perceived app inefficacy were the main reasons not to download the app. Cybersecurity, data confidentiality, loss of privacy, and geolocation were the most frequent concerns. Nearly half of the respondents inaccurately believed that the app used geolocation. Most respondents supported citizen involvement in app development. The identified predictors for app uptake included nine characteristics. In conclusion, this project highlights four key themes on how to promote the social acceptability of such tools: (1) improved communication and explanation of key app characteristics, (2) design features that incentivize adoption, (3) inclusive socio-technical features, and (4) upstream public partnership in development and deployment.

La bioéthique s’intéresse depuis quarante ans aux enjeux de la recherche et des pratiques en biomédecine. L’intérêt de la santé publique pour l’éthique est cependant récent. Dans les deux cas, l’autonomie des personnes est au cœur des débats. Dans l’un, l’autonomie affirme le droit de la personne de prendre ses décisions et s’oppose au paternalisme des experts. Dans l’autre, le débat oppose la protection de la collectivité au respect de la liberté individuelle. L’article représente une contribution originale au débat et découle d’une étude traitant de l’adhésion des personnes immigrantes aux valeurs de l’autonomie véhiculées dans les programmes de santé publique. Trois dimensions sont abordées : les modèles éthiques qui cherchent à s’imposer en santé publique, les principes de l’autonomie et les tensions qu’ils génèrent entre l’individu et la collectivité et les nouveaux courants de pensée qui visent à renouveler les visions éthiques de l’autonomie en santé publique.

Cet article traite, à l’aide de la petite éthique de Paul Ricoeur, des problèmes éthiques rencontrés dans la pratique de 26 intervenants montréalais oeuvrant auprès de personnes toxicomanes dans des programmes d’échange de seringues et de distribution de méthadone. Ces intervenants rencontrent des difficultés au quotidien, certaines de nature éthique. Les problèmes éthiques ont été classés en deux catégories, dégagées selon les niveaux de relation de la petite éthique de Ricoeur. Premièrement, les problèmes liés aux contextes politique, légal et organisationnel, notamment, la judiciarisation des personnes toxicomanes, le décalage entre la gestion technocratique et les réalités du terrain et les incohérences dans les pratiques et les services. Deuxièmement, les problèmes liés à la pratique sur le plan relationnel dont l’accès aux services pour certaines personnes (mineurs, femmes enceintes, personnes violentes), les relations de proximité avec les aidés, la confidentialité, les relations de pouvoir et la moralisation. Cette étude montre la complexité inhérente des problèmes et la nécessité de les aborder dans un système éthique intégrant toutes les dimensions de l’intervention en réduction des méfaits., Workers who work with drug addicts in needle-exchange and methadone-provision programs encounter ethical challenges every day. This article presents the results of a qualitative analysis of the ethical problems encountered by 26 Montreal workers in their daily practice. The data was analysed using an ethical framework inspired by Paul Ricoeur’s ethical approach. Problems were classified in two categories. First, those linked to the political, legal, or organizational context, notably, the prosecution of drug addicts, the discrepancy between technocratic management and ground-level realities, and inconsistencies in practices and services. Second, the problems mentioned involve the relationships that develop during these programs related to access for certain people (e.g. minors, pregnant women, violent individuals) to services, outreach workers’ relationships with the people being helped, confidentiality, power relationships, and moralizing. This study shows the complexities inherent in these problems and the necessity of analysing them in an ethical system that integrates all dimensions of harm reduction intervention., Este artículo, con la ayuda de la pequeña ética de Paul Ricoeur, se refiere a los problemas éticos encontrados en la práctica de 26 personas de apoyo de Montreal, que trabajan con los toxicómanos en los programas de intercambio de jeringas y de distribución de metadona. Estas personas encuentran dificultades en la actividad cotidiana, en algunos casos de naturaleza ética. Los problemas éticos se clasifican en dos categorías, definidas según los niveles de relación de la pequeña ética de Ricoeur. En primer lugar, los problemas relacionados con el contexto político, legal y organizativo, en particular la judicialización de los toxicómanos, la separación entre la gestión tecnocrática y las realidades del terreno y las incoherencias en las prácticas y los servicios. En segundo lugar, los problemas relacionados con la práctica en el plano de relación, entre ellos el acceso a los servicios para ciertas personas (menores, mujeres embarazadas, personas violentas), las relaciones de proximidad con las personas a las que se ayuda, la confidencialidad, las relaciones de poder y la moralización. Este estudio demuestra la complejidad inherente de los problemas y la necesidad de abordarlos en un sistema ético que integre todas las dimensiones de la intervención para la reducción de los delitos.

Autonomy, a basic ethical value in public health, is regularly put under pressure by the demands of empowerment, rights of individuals and healthy communities. This article describes the results of a study about the support of non-immigrants and immigrants subjects (n = 137) from the Montreal area on the value of autonomy conveyed in six public health programs. The results indicate that non-immigrants Quebecers and longstanding immigrants differ from recent immigrants concerning activities about commitment of fathers, poverty families, screening for sexually transmitted diseases and treatment of tuberculosis.