Ethics and SARS: Learning Lessons from the Toronto Experience

A report by a working group of The University of Toronto Joint Centre for Bioethics

Toronto, Canada

This report is dedicated to the courageous health care workers in Toronto and around the world who have been affected, became sick or died in the line of duty caring for patients with SARS.

Table of contents

Executive summary
Major ethical issues and lessons from the Toronto SARS outbreak
1. When public health trumps civil liberties: the ethics of quarantine
2. Naming names, naming communities: privacy of personal information and public need to know
3. Health care workers' duty to care, and the duty of institutions to support them
4. Collateral damage: other victims of SARS
5. SARS in a globalized world
Appendix: Decision Tool for Policy Makers in Addressing Future Epidemics
End material

Executive summary

The outbreak of Severe Acute Respiratory Syndrome (SARS) in the Toronto area forced hard choices on people in Canada's largest urban area. Medical and public health communities, federal, provincial and local governments, and ordinary citizens had to make difficult decisions, often with limited information and short deadlines. Health care providers were on the firing line, and were the most affected by the disease.¹

Decision makers had to balance individual freedoms against the common good, fear for personal safety against the duty to treat the sick and economic losses against the need to contain the spread of a deadly disease. At times like this it is necessary to rely both on science and value systems to guide decisions. The SARS outbreak raised ethical issues for which Canadian society was not fully prepared. Lessons need to be learned from this outbreak, to ensure preparedness not only against the spread of SARS, if it cannot be contained globally, but also for dealing with epidemics of other diseases.

A working group from The University of Toronto Joint Centre for Bioethics undertook to draw ethical lessons from the challenges and responses in Toronto. The group was composed of nine experts in medical ethics who came from such disciplines as medicine, surgery, health law, social work, teaching, nursing and epidemiology. A number of team members were working in directly affected hospitals, and some were involved in decision-making regarding the outbreak.

To respond to future health crises involving highly contagious diseases, an ethical framework is required. In this report, we develop such a framework (see appendix), based on five major ethical issues where SARS forced people, particularly those in the public health system, to make difficult ethical choices, and we identify 10 associated key ethical values.

The five major ethical issues are:

1. When public health trumps civil liberties: the ethics of quarantine

There are times when the interests of protecting public health override some individual rights, such as freedom of movement. At such times, society has a duty to inform people of the nature of the threat, be open in explaining the reasons for over-riding individual freedoms and do as much as possible to assist those whose rights are being infringed.

2. Naming names, naming communities: privacy of personal information and public need to know

While the individual has a right to privacy, the state may temporarily suspend this privacy right in case of serious public health risks, when revealing private medical information would help protect public health. As a general rule, the privacy and confidentiality of individuals should be protected unless a well-defined public health goal can be achieved by the release of this information.

3. Health care workers' duty to care and the duty of institutions to support them

Health care professionals have a duty to care for the sick. During infectious epidemics this must be done in a way that minimizes the possibility of their transmitting diseases to the uninfected. Institutions have a reciprocal duty to support and protect health care workers to help them cope with very stressful situations, and recognize their contributions.

4. Collateral damage: other victims of SARS

Severe restrictions on entry to SARS-affected hospitals meant that many people were denied medical care, sometimes for severe illnesses. As a result, patients in hospital, with or without SARS, and their families suffered from lack of contact due to the elimination of visits for a period of time. It is essential to maintain an equitable balance among the interests of those patients with or at risk of SARS, and those who are sick with other diseases, and need urgent treatment.

5. SARS in a globalized world

SARS is a wakeup call about global interdependence, and the increasing risk of the emergence and rapid spread of infectious diseases. There is a need to strengthen the global health system to cope with infectious diseases in the interests of all, including those in the richer and poorer nations. This will require global solidarity and cooperation in the interest of everyone's health.

Major ethical issues and lessons from the Toronto SARS outbreak

In analyzing each of the five major ethical issues the team looked at the underlying ethical values, and drew lessons from how each of the five issues was addressed. The case studies represent an amalgam of experience. In most cases, we did not use real names, in order to respect the privacy of individuals who were not identified in media coverage.

1. When public health trumps civil liberties: the ethics of quarantine

The issue

"Jean," a clerk in a medical office, is asked by Toronto's public health department to remain at home in quarantine for 10 days because of possible exposure to SARS. She wants to comply, but fears this could cost both her job and her apartment.

"Michel" is in quarantine because a family member has contracted SARS, and he may have been infected. A close family friend has died from causes not associated with the SARS epidemic, and "Michel" is torn between wanting to attend the funeral and his duty to respect the quarantine order.

Contagious diseases, like wars, test the limits of freedom in societies. SARS is a sobering reminder that the interests of the individual must on occasion be tempered by the best interests of the community. In Toronto, thousands were placed in quarantine, often at home, in order to protect millions of people not only in the city but around the world from possible exposure to a deadly disease.

Ethical values

Individual liberty. In Canada as in many other liberal democracies, the idea of virtually unfettered personal freedom has become a strongly held value. In recent years, we have faced a number of serious public health issues-including tuberculosis, AIDS and influenza-that required decisions that seek to balance the rights of the individual and the common good of society. SARS has created an even sharper test of which rights should prevail at what time. The law allows individual rights to be overridden for the common good, under defined circumstances. The goal is to do this in an ethical and even-handed manner so that people are not unfairly or disproportionately harmed by such measures.

Protection of the public from harm. When clear, serious and imminent harm to the population is demonstrable, public health authorities have a duty to restrict certain individual rights in the interest of the health and well-being of the community.² In turn, citizens have a civic duty to comply with such restrictions for the common good.

Proportionality. When protecting many from harm is ethically necessary, and when the use of public health powers to achieve those goals can be justified, authorities must also protect individuals from needless coercion. Restrictions of liberty must be relevant, legitimate and necessary. They must be exercised by people with legitimate authority, and those people should use the least restrictive methods that are reasonably available. Such restrictions should be applied without discrimination.

Transparency. In modern democratic societies, all legitimate stakeholders need to be properly informed about the issues, including the risks and benefits of various options, and have input into discussions on issues that affect them, particularly those that affect their health, well-being and personal liberty.

Reciprocity. Society has a duty to see that those quarantined receive adequate care, are not kept in quarantine for excessively long periods, and are not abandoned or psychosocially isolated. There may also be a need to eliminate economic barriers, such as loss of income, which would otherwise prevent someone from obeying a quarantine order.³

Lessons learned

There are times when the interests of protecting public health override some individual rights, such as freedom of movement. At such times, society has a duty to fully inform people of the situation, be open in explaining the reasons and do as much as possible to assist those whose rights are being infringed.

Under the ethical value of proportionality, authorities have the right to impose quarantine and isolation, but it is preferable, as was the case in Toronto, to use voluntary measures first. When people are fully informed, and see that they are being treated as fairly as possible, it is likely that voluntarism will prevail in times of emergency. In fact, most people in Toronto cooperated with restrictions. More coercive measures (such as detention orders or surveillance technology) should be reserved for those cases where non-compliance is documented, and potential harm to others is anticipated. Evidence indicates that most people can deal with a quarantine of about 10 days. In cases of incubation periods longer than 10 days, the enforcement of quarantine becomes more difficult. In the Toronto SARS outbreak, a 10-day quarantine was used.

Under the ethical value of transparency, public health authorities must regularly communicate the reasons for the imposition of quarantine or isolation, the nature of the potential harm, attendant risks to various groups of people, and publicly communicate the necessity for various restrictions on personal liberty.

Under the ethical value of reciprocity, people placed in quarantine and isolation should be assisted to overcome the hardships imposed. This will also facilitate compliance. The assistance should include ensuring that they have access to food, help with problem solving around shelter for other family members, alternative medical care, job protection and phone calls for support and comfort. In the Toronto case, volunteer agencies and organizations such as Meals on Wheels, the Red Cross and the Toronto Public Health department, have helped people in home quarantine to live as normal a life as possible. Governments indicated that people are not to suffer employment loss or discrimination, and that waiting times for benefits from employment insurance would be reduced to recognize the hardship imposed by quarantine.

2. Naming names, naming communities: privacy of personal information and public need to know

The issue

"June," a nurse at a downtown Toronto hospital that was affected by SARS, is feeling a bit unwell, but her temperature, a key sign of SARS, is normal. She weighs the risk of possibly having the disease against the costs of losing pay if she does not show up, and worries about placing a burden of extra work on her colleagues. "June" takes the GO commuter train to work. Medical officials fear she might have SARS, and have infected a group of commuters, spreading the disease into the community, where it might be impossible to control. They choose not to name her on the grounds that this would serve no purpose because she has not tested positive for SARS, but they do warn people on that train car to be checked in case they develop SARS.

In contrast, the name of the woman who was identified as accidentally bringing SARS to Canada is made public. Kwan Sui-chu, 78, and her husband visit Hong Kong in February, where she contracts the disease. Upon her return home to Toronto, she passes it to her family, starting the chain of contamination. She dies at home, but her son goes to hospital for treatment of fever and a cough, and spreads the disease to other people, beginning a series of infections in the city.

The issue of naming names applied across the spectrum from the individual to global levels. Health and government officials had to weigh the benefits and harms of exposing people, communities and whole countries to discrimination. In the case of China, the government decided not to release information about the seriousness of the SARS outbreak until the spring, several months after the initial outbreak in Guangdong Province. In Toronto, publicly linking of SARS with someone who had travelled from China stigmatized the Chinese community, and led to a precipitous fall in business for Chinese enterprises, particularly restaurants. When Toronto was put on a do-not-visit list by the World Health Organization, it had a huge economic impact in terms of lost visits and tourism.

Ethical values

Privacy and confidentiality of health information. Individuals have a right to control the amount of information about themselves to which others have access. Health authorities are bound to protect confidentiality as much as possible. However, the right to privacy is not absolute. The challenge is to balance the costs of releasing information about individuals and communities against the benefits of reducing a public health risk.

Protection of the public health. As is the case with quarantine, protection of the public health may limit the individual's right to privacy and confidentiality of health information.

Proportionality. In order to release private and confidential information, health officials must be able to argue that the protection of public health could not be achieved by less intrusive measures, and this will not often be the case. For example, in the case of "June" public health authorities were right to announce that a patient with SARS traveled on the commuter train in a particular car at a particular time, and to encourage others in that car to contact public health authorities. There would have been no added protection of the public health by releasing the person's name or photograph.

Transparency. Honest reporting about an emerging epidemic and the numbers of people affected does not violate an individual's right to privacy of medical information. Arguably, the reluctance of Chinese authorities to release information about the seriousness of SARS to the World Health Organization prolonged the epidemic.

Protection of communities from undue stigmatization. Particular caution should be taken not to unduly stigmatize communities through the release of information.

Lessons learned

There was a tendency to name names more freely at the start of the Toronto outbreak, but authorities became more protective of people's privacy, when it became evident that there was no public good served in releasing names of those affected. It appeared that the Chinese community was being stigmatized without producing any public health benefit.

As a general rule, the privacy and confidentiality of individuals should be protected unless a well-defined public health goal can be achieved by the release of this information to the general public.

3. Health care workers' duty to care, and the duty of institutions to support them

The issue

"Mary," a nurse in the Intensive Care Unit, is afraid that when she goes to work she will have to care for SARS patients and may become infected. Her husband asks her to call in sick, pleading that it is her duty as the mother of three small children not to risk giving them SARS. "Mary" feels torn. She feels her primary responsibility is to do everything in her power to protect her children. At the same time, "Mary" has a strong commitment to her profession, and the family needs her income. She has studied hard to become a staff nurse, and is aware of the importance the hospital places on good attendance. Her salary is affected by calling in sick. She also wants to support her colleagues on the front lines by going to work.

For the first time in more than a generation, Toronto health care practitioners were forced to weigh serious and imminent health risks to themselves and their families against their obligation to care for the sick. This generation of clinicians had entered their profession in an era when there was little expectation of facing deadly infectious diseases that had no ready cure. Suddenly, a large number of health care workers, particularly nurses and doctors, faced tough choices about how much risk to take. They had to put their lives at risk to help others. Dozens of medical workers, most of them nurses, caught SARS during their work. The most public example of the sacrifice by a health care worker was the untimely and tragic death of Dr. Carlo Urbani, who was infected in Vietnam.

SARS imposed great stresses on health care workers. They feared contagion for themselves and their families, and being shunned by others in case they were infectious. They suffered from disrupted routines, and loss of work for those who were quarantined or were unable to work because their hospitals had cut back on admitting non-SARS cases. Many health professionals had to wear cumbersome and very uncomfortable equipment to protect themselves, causing discomfort and hampering their ability to work. This also reduced the human contact with sick and dying patients.

Ethical values

Duty to care. Health care professionals have a duty to care based on several ethical considerations. The first is "virtue ethics" which means being of good character. The health care professional is seen as a "good person" who may be relied upon to demonstrate altruism by putting the patient's needs foremost. When they enter their profession, physicians take an oath that they will be competent, and will use their skills in caring for the sick.

As one member of this panel put it, "when we sign on as health care providers we must accept the risks. Firefighters don't get to pick whether they will attend at a particularly bad fire, and cops don't get to select which dark alleys they walk down. To me it would be unethical to deny care even if there is 'somewhere else' that could take that patient."

Reciprocity. Just as health care professionals have a duty to care, society and institutions have a reciprocal duty to assist these professionals. This includes providing information for staff so they can fully understand the risks, and having policies that support safety practices. These policies should avoid penalization from either a financial or other standpoint for events, such as loss of work that is not the fault of the employees. As part of this behaviour, institutions must practice transparency, and this will foster trust in the organizations by their staff.

Lessons learned

While health care professionals have a duty to care for the sick, this must be tempered by a duty to care for themselves in order to remain well enough to be able to carry out their duties.⁴ To extend the analogy introduced above, the fireman would not knowingly jump into a burning inferno. Where to draw the line between role-related professional responsibilities and undue risk is a question our working group struggled with, but did not fully resolve.

Health care institutions have a duty to provide the supports that enable employees to do their jobs effectively and as safely as possible. Information needs to be shared in a timely way so that health care workers are fully informed, and enjoy a climate of trust in their place of employment.

Institutions need clear guidelines in place so employees know what is expected of them, and what help they may expect. In addition, employment policies need to ensure that staff are rewarded rather than penalized for following safe practices such as staying home when they are ill. In future cases, hospitals might be able to make better use of staff in helping isolated patients make contact with their families. For example, instead of sending health care workers home with no work, they could be given the job of phoning patients and their families to provide information and support.

Finally, there is a duty for the public and persons in authority to recognize the heroism of front-line medical workers during the SARS outbreak. In Toronto, most health workers responded courageously

4. Collateral damage: other victims of SARS

The issue

"Anne" has breast cancer. Her surgery is postponed during the SARS outbreak, increasing anxiety in her and her family about the spread of her disease.

"Tom", who at 58 has valiantly fought a brain tumour for 13 years, including three major brain surgeries, is admitted to the hospital with an urgent but unrelated condition. He starts to deteriorate, and it appears that the inevitable victory by his tumour is close at hand. "Jane", his wife and soul-mate, who has been faithfully and constantly by his side through good times and bad, is not allowed into the hospital to be with her very sick husband. She waits frantically by the phone, and the surgeon spends what little time he can spare to keep her informed.

There was a great amount of "collateral damage" to a wide range of people who did not have SARS. Many people with other serious conditions had surgeries cancelled because some hospitals were considered contaminated areas, and some of these people died. Some of those patients died before receiving treatment. At the University Health Network alone, which includes Toronto General, Toronto Western and Princess Margaret hospitals, 1,050 surgical procedures were cancelled because of SARS. This included transplants, cancer and heart surgeries, hip and knee replacements and lens implants. In addition, there were cancellations of radiation, chemotherapy, dialysis, physiotherapy and other treatments. The strict "no visitors" policies during the early part of the outbreak meant that both SARS and non-SARS patients in hospitals were cut off from their families and friends. Those who were admitted, with or without SARS, suffered loss of contact and emotional support from family and friends as hospitals closed their doors to visitors.⁵

Ethical values

Equity. In the SARS emergency, authorities faced hard choices in deciding which medical services to maintain and which to place on hold. They had to weigh risks, benefits and opportunity costs. It is necessary for such hard decisions to be made in a fair manner, including appropriate access to limited resources. There needs to be equity between SARS and non-SARS patients.

Lessons learned

In the case of an epidemic, it is important to control the spread of the disease, but as much attention should be paid to the rights of the non-infected patients who need urgent medical care. There may be as many people who died from other illnesses and could not get into hospital as there were who died from SARS.
Equity is required in the amount of attention given to a wide array of people, including patients with and without SARS. Accountability for making reasonable decisions, transparency and fairness are expected. There is a need to communicate accurate information to the public, putting the risks and benefits of various strategies and decisions in focus.

5. SARS in a globalized world

The issue

In Guangdong province in rural China it is early winter and "Mr. Li," a farmer, comes down with a severe respiratory infection. His son leaves for Beijing, carrying the SARS microbe and its descendants on a journey that will span the world. One of its major destinations is Toronto, where thousands will be forced into quarantine to stop the spread of SARS.

In Geneva, the World Health Organization weighs the risks of SARS spreading from Toronto. WHO issues an unprecedented travel advisory in April, warning people not to go to Toronto unless necessary, in order to minimize the risk that Toronto could export the disease to countries not equipped to handle it. One week later, WHO lifts the travel warning, saying that the magnitude of the problem in Toronto has decreased, and there is no evidence that the city is exporting SARS cases.

In a number of institutions, scientists race to break the genetic code of the SARS virus, and then to patent it. The way the patents are exercised will have global implications for who can get access to such results, and to resulting products, such as vaccines.

Globalization is associated with increases in travel and transportation, communications and the sharing of cultures. As a result of the growing web of interconnections, microbes have an easier ride than ever. In the Middle Ages, it took three years for the plague to spread from Asia to the western reaches of Europe. The SARS virus, crossed from Hong Kong to Toronto in about 15 hours.

Ethical values

Solidarity. One of the great challenges of the 21st century is to understand the interconnections between globalization and health, and to find ways of narrowing global health disparities in different regions. A new global health ethic based on solidarity could help make the world a more stable place. Solidarity means feeling one has common cause with others who are less powerful, wealthy, or healthy. Infectious diseases can spread in either direction between poor, rural areas and rich urban areas, anywhere in the world.

There is also a need for transparency, honesty and good communications on health issues at a global level so that people and nations can take appropriate steps to protect themselves.

Lessons learned

It is clear that while health is treated as a national, regional or local responsibility, it must be seen and acted upon as a global public good. This calls for new ways of thinking and acting. Distinctions between domestic and foreign policy have become blurred, and public health, even in the most privileged nations, is closely linked to health and disease in impoverished countries. Now more than ever, local action must be linked to global action. We need a new mindset to improve health and deal with threats to health globally.

There is also a need for transparency, honesty and good communications on health issues. It is no longer acceptable for countries to hide health information that can protect others. Such sharing is part of maintaining a global public good of health protection. A new governance mechanism is needed for global surveillance of infectious diseases. The world should consider strengthening the role of the World Health Organization, giving it the right to gather information, communicate it, and to help countries deal with outbreaks.

There is also a need to strengthen the global health system to cope with infectious diseases. Countries invest large amounts in national laboratories for disease control, but relatively little in international organizations such as the WHO.

There are some pressing global needs. Countries need adequate public health laboratories, surveillance and epidemiological capacity, information systems for data gathering, storage and analysis, and health communication capabilities linked to international obligation to report. The world needs standardization and harmonization of standards and criteria. It also needs to increase and strengthen the capacity to respond to outbreaks, especially in developing countries. This requires training in public health, and the resources to put enough health workers into place.

Appendix: Decision Tool for Policy Makers in Addressing Future Epidemics

End material

About this report

As the dimensions of the SARS outbreak in Toronto and globally became clear, The University of Toronto Joint Centre for Bioethics, undertook to draw ethical lessons from the challenges and responses faced in Toronto. We hope this will assist the medical communities, governments, employers and citizens around the world to be better prepared to deal not only with this disease but with other outbreaks that threaten our health, economic well-being and quality of life.

This report is from a working group of nine experts in medical ethics who came from such disciplines as medicine, surgery, health law, social work, teaching, nursing and epidemiology. Some members of the group were involved in decision-making regarding the outbreak. The group met almost across the street from one of the affected hospitals, and one member of the team had to participate by telephone in the early stages, because of a ban on attending meetings for people who had been in high-risk medical areas.

About University of Toronto Joint Centre for Bioethics

Innovative. Interdisciplinary. International. Improving health care through bioethics.

The Joint Centre for Bioethics (JCB), a partnership between the University of Toronto and twelve hospitals, provides leadership in bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions on specific issues, although its individual members may do so.

The goals of the Centre are to:

• Foster interdisciplinary research and scholarship, link education to research, and disseminate research findings to improve policies and practices.
• Support undergraduate, graduate and postgraduate educational programs in bioethics.
• Support clinical ethics activities including continuing education for health care providers, ethics committees, ethics consultation, and projects to address specific issues arising in JCB hospitals.
• Foster collegial discussion of bioethics issues throughout JCB participating institutions, and to serve as a resource for the media, policymakers, and community groups.
  The JCB is a collaborating centre for bioethics for the World Health Organization.

For more information: http://www.utoronto.ca/jcb/

Members of the working group

Solomon R. Benatar
Solomon R. Benatar is Professor of Medicine and Founding Director of the University of Cape Town's Bioethics Centre. He was Chairman of the university's Department of Internal Medicine, and Chief Physician at Groote Schuur Hospital from 1980-1999. Dr. Benatar is Visiting Professor in Public Health Sciences and Medicine at the University of Toronto. His current research interests include International Health and the implications of Globalization for global health in the future.

Mark Bernstein
Mark Bernstein is a neurosurgeon at the Toronto Western Hospital, University Health Network, which was a "hot spot" in the recent SARS outbreak. He has written on the impacts of SARS on medical staff, patients and the community. Dr. Bernstein is Professor in the Department of Surgery at the University of Toronto and has recently completed a Masters in Health Science in Bioethics at the Joint Center for Bioethics at the University of Toronto. His areas of interest in bioethics include medical error, surgical innovation, surgical education, research ethics, and priority setting.

Abdallah S. Daar
Abdallah S. Daar is Professor of Public Health Sciences and of Surgery at the University of Toronto, where he is also Director of the Program in Applied Ethics and Biotechnology at the Joint Centre for Bioethics. Dr. Daar is a Fellow of the New York Academy of Sciences, and is on the Ethics Committee of the (International) Transplantation Society and that of the Human genome Organization. His current research interests are in the exploration of how genomics and other biotechnologies can be used effectively to ameliorate global health inequities.

Bernard Dickens
Bernard Dickens is a professor of health law and policy at the University of Toronto. Professor Dickens is a legal articles editor, serves as a member of the editorial boards of several journals legal and medical journals, and has been involved in a wide variety of organizations in the field of medical jurisprudence. He has been a director and president of the American Society of Law, Medicine and Ethics, and is a Fellow of the Royal Society of Medicine (London) and the Royal Society of Canada.

Susan MacRae
Sue MacRae is a bioethicist and Deputy Director of the University of Toronto Joint Centre for Bioethics. She has worked as a nurse in Calgary, as a clinical ethics fellow, program coordinator and ethics consultant through the MacLean Center for Clinical Medical Ethics in Chicago and as a research fellow in patient-centered care at the Picker Institute in Boston. She explores links between bioethics and quality in the current health care system. She provided leadership and support to the Joint Centre for Bioethics and affiliated hospital Bioethicists during the SARS outbreak.

Peter A. Singer
Peter A. Singer is the Sun Life Financial Chair in Bioethics, Director of the University of Toronto Joint Centre for Bioethics, and Program Leader of the Canadian Program on Genomics and Global Health. Dr. Singer directs the World Health Organization Collaborating Centre for Bioethics at the University of Toronto. He is also Professor of Medicine and practices Internal Medicine at Toronto Western Hospital. He is a member of the Scientific Advisory Board of the Bill and Melinda Gates Foundation Grand Challenges for Global Health Initiative and the Ethics Committee of the British Medical Journal, and he is a Director of The Change Foundation and the Canadian Bacterial Diseases Network. His current research focus is global health ethics.

Ross Upshur
Ross Upshur is a family physician at Sunnybrook and Women's College Health Sciences Centre, assistant professor of Family and Community Medicine and Public Health Sciences and member of the Joint Centre for Bioethics at the University of Toronto. Dr. Upshur is a community medicine specialist and researcher with graduate training in philosophy and epidemiology. During the SARS epidemic, the family practice clinic was virtually closed, so he worked in York Region with the public health department in a variety of capacities including outbreak management and epidemiological analysis.

Linda Wright
Linda Wright is Bioethicist at University Health Network, which comprises Toronto General Hospital, Toronto Western Hospital and Princess Margaret Hospital, where several SARS patients were treated. She has practiced social work in child care and medical settings, and her professional work has included establishing ethical guidelines for the care of living organ donors. She is the Past President of the International Society of Transplant Social Workers and ethics section editor of the journal Progress in Transplantation.

Randi Zlotnik Shaul
Randi Zlotnik Shaul is a bioethicist at The Hospital for Sick Children. Dr. Shaul has degrees in political theory and law, and has studied the ethical, legal and economic issues around resource allocation in the medical field. She has published in the area of health law and priority setting, and is especially interested in clinical ethics and the role of law in addressing bioethical challenges.

This paper was produced with the assistance of Michael Keating, a Toronto writer with a background in risk communications.

Grant support: Peter A Singer is a Distinguished Investigator and Ross Upshur is a New Investigator of the Canadian Institutes of Health Research. This research was supported by the Canadian Program on Genomics and Global Health (www.geneticsethics.net), which is funded in part by Genome Canada through the Ontario Genomics Institute.

Address for correspondence: Peter A. Singer, University of Toronto Joint Centre for Bioethics, 88 College St., Toronto, Canada M5G 1L4. Email: peter.singer@utoronto.ca.