Ruby Rajendra Shanker Reflects on Her First Year as a Fellow in Clincial and Organizational Bioethics

Lauren Notini

In October 2015, when I began the Fellowship in Clinical and Organizational Bioethics with the University of Toronto Joint Centre for Bioethics, I wrestled with mixed emotions. While I was jubilant to embark on a new journey, I was also uncertain of the experiences that might transpire. The clinical environment does not necessarily daunt me, for I trained as a physician before transitioning into bioethics. Yet this past year has brought me numerous experiences that have reinforced for me the importance of beginning with patience and humility in order to pursue and apply knowledge.


The JCB Fellowship is a two-year program, consisting of three rotations per year, each rotation lasting for four months. My three rotations so far have provided me with a spectrum of experiences within clinical, organizational/policy development, and research ethics. The diverse care settings of each of rotation have also illuminated for me unique ethical considerations, that have made my journey so far through the Fellowship fascinating.


My first rotation was at The Hospital for Sick Children (SickKids) with the SickKids Bioethics Team of Randi Zlotnik-Shaul, Becky Greenberg, Jonathan Hellmann, and towards the end of my rotation, Alison Williams. I was primarily supervised by Randi and Rebecca, although the feedback I received and lessons learnt from Jonathan and Alison continue to influence my approach to PHE practice. The highly specialized pediatrics care setting at SickKids can seem quite intimidating, yet I found SickKids quite supportive of learners. I was fortuitous to have been at SickKids during the annual SickKids Bioethics Week. The topics by invited speakers and poster displays were an excellent snapshot of the spectrum of themes that arise within pediatric bioethics. I participated regularly in ethics consults where some of the ethical themes revolved around assessing the newborn's best interests based on grave yet unpredictable prognoses, staff concerns regarding child safety and parenting approaches, interpretations of child and family-centred care, and most importantly, the limits to cultural accommodation. Often, ethical concerns around parental or teen use of social media also emerged where crowdfunding was involved. I had the opportunity to co-facilitate teaching sessions and bioethics rounds in the NICU around intriguing cases. Becky also included me regularly in the SickKids Transplant and Regenerative Medicine Centre's working group for developing guidelines for social media use by transplant families.


Randi and I had the opportunity to deliver a bioethics session together for the SickKids International Resource Team (IRT). The lessons I learnt from the formidable global experiences of the accomplished IRT nurses will always be etched in my mind. In addition to these activities, I was also exposed to fascinating discussions around trauma-informed care, and youth access to mental health services without a guardian. My interactions with Jonathan encouraged me to review the literature and seek deeper understanding of clinical uncertainty and various responses by clinicians in practice.


One of the more protracted activities I undertook was meeting with key individuals across the organization who liaised with Bioethics regularly. These meetings were facilitated by Randi, who encouraged me to explore the scope of practice for different professions in the pediatric healthcare setting, especially where there may be overlap with bioethics. Each meeting provided me with new perspectives to understanding the organizational culture and sub-cultures for context. The finale of my rotation at SickKids was my presentation at the SickKids Grand Rounds on navigating the ethical implications of clinical uncertainty. The ensuing discussions from the audience provided much food for thought, proving for me that the role of the Practicing Healthcare Ethicist (PHE) in ensuring safe moral spaces is critical for encouraging reflective practice in the face of clinical uncertainty.


After four months at SickKids, I moved on to commence my second rotation at the Centre for Addictions and Mental Health (CAMH), where Kevin Reel was my supervisor. Having been his student in the MHSc in Bioethics program at the JCB, I had the pleasure of continuing to learn under Kevin's mentorship. Background themes appeared to revolve around the interpretation of hope, the recovery approach, and the notion of empathy fatigue amongst mental health professionals. Due to lack of comparable experiences, it may be more difficult for one to empathize with mental health clients as opposed to those with a physical ailment. Kevin and I enjoyed numerous discussions around the concept of gravity and grace from the work of Simone Weil, as well as the approach of enabling and empowering for PHE practice.


Kevin encouraged me to participate in ethics consults where some of the themes revolved around staff concerns with challenging client behaviors, concerns around staff safety, and advocating for the mental health client's right to be involved in care decisions. I found deep respect for the inspiring task the empowerment council at CAMH undertakes in representing client rights. A looming concern identified repetitively was the lack of provincial infrastructure to accommodate the high needs of clients with mental health and addictions.


Through one of the student events organized by Workman Arts at CAMH, I was inspired to contribute to the CAMH website on understanding patient narratives through art. I was also fortunate to be able to attend a one-day course to explore Aboriginal health and healing in the context of mental health and addictions. Further, I gained much for the classroom discussions when I attended University teaching sessions for which Kevin serves as a course director.


A major involvement for me during this rotation was around Medical Assistance in Dying (MAID). Through his active work on the JCB Task Force on MAID, and as a member of the task force's mental health and addictions subgroup, Kevin encouraged me to explore the ethical considerations around MAID. I was eventually offered the opportunity to lead a literature review of the capacity assessment tools available within mental health practice on behalf of the JCB Task Force. This venture continues to be one of my longitudinal project experiences as part of the Fellowship. A briefing document summarizing the key findings of my review was recently released by the JCB. I am currently in the process of drafting a report of the ethical analysis and review for future publication.


By accompanying Kevin to several working groups and committees, I gained familiarity with the organizational culture at CAMH. Being a part of the working group on MAID provided me with invaluable insight into the evolving perspectives and responses of psychiatrists and staff to provision of MAID to mental health populations. I am grateful for the myriad conversations I have had with Kevin and others, in terms of broadening my understanding of the ethical implications for implementing MAID in Canada.


My third and current rotation is at the brand new location of the Humber River Hospital (HRH). Bob Parke has been my supervisor, and together we have been exploring quite a busy summer in terms of bioethics work. During my first week at HRH, I was privileged to present at the Medicine Grand Rounds, my work around the ethical implications of clinical uncertainty in practice. This proved to be a valuable introduction for me to the majority of staff and physicians. The environment of HRH is distinct for its unassuming community care setting. However, the automated guided vehicles that roam the corridors of HRH performing a variety of porter tasks serve as a constant reminder of the hospital's commitment to digital technology within healthcare.


The ethical issues I have seen at HRH represent those that routinely arise in the delivery of healthcare, commonly referred to as "quotidian ethics". Under Bob's mentorship, I have been exploring the particular approach to PHE practice involving the notion of "presence" or being routinely available to patient, families, and staff on the clinical floors. Integration and sustainability of ethics services across the hospital is a familiar challenge for PHEs. Presence helps mitigate this challenge. Regular strolls through the clinical floors may evolve into happenstance liaisons with staff and physicians, as well as serve as a reminder of an accessible resource to patients, families, and staff. Prioritization of the PHE’s time for organizational and research ethics activities may be a question. However, this is easily balanced through experience. Ultimately, patient care must precede all other activities.


In a short span of time, I have had the fascinating opportunity to be involved in a number of cases with several ethical themes including questions around the patient's capacity to make treatment decisions, disagreements around end-of-life and resuscitation status, challenging family dynamics (including, as Bob terms, the "Seagull Syndrome"; where a largely absent family member flies in from afar, makes a ruckus around care decisions out of guilt, and leaves abruptly after complicating family or therapeutic relationships), difficult transitions in care involving concerns around patient safety, and responding to inquiries for MAID.


Following the gradual release of responsibility model, Bob has encouraged me to grow in my degree of participation within consults to eventually conduct ethics consultations independently. An exciting venture during this rotation has been with bioethics documentation, particularly for transparency and potential legal review. My involvement within organizational ethics work has largely been around the implementation of MAID. I continue to support the development of the HRH MAID policy and procedures, including the creating of learning modules for staff. There have also been several opportunities to teach bioethics through the new staff orientation sessions, as well as through in-services to nursing students on the floors. My experiences at HRH have certainly influenced my approach to and philosophy of bioethics practice.


In addition to the fervent activities at the rotation sites, this year has been remarkably fruitful for academic activities. I have had the opportunity to present at the JCB Seminar series, as well as to present on a variety of bioethics topics at the annual conference of the Canadian Bioethics Society held in Toronto this year. My academic research topic for the Fellowship revolves around uncovering the hidden curriculum within the practice and training of PHEs. I continue to reflect upon the attributes for PHE practice, and draw inspiration from my conversations with supervisors, colleagues, and particularly my co-Fellow, Lauren Notini.


The first year of the JCB Fellowship has been a rewarding journey for me. Among the lessons I have learnt from diverse styles and approaches of my mentors to PHE practice, the importance of employing narrative ethics stands out. The stories of the patient's life, especially those from the family, must never be underestimated with regards to their significance in improving the outcome of the consult. Narratives humanize us all, and provides deeper context for underlying values. They also highlight that the responses of those involved ultimately stem from a shared sense to do right by the patient. Also, ethics consults often begin with emotions running high, which is why I will never discount the value of making sure every family meeting venue is stocked with a box of tissues.


As I draw close to the end of my first year of the Fellowship, I am reminded of what a colleague once opined to me, and I paraphrase; As a student, one is like a monk. One may roam through several institutions, collecting and sharing pearls of wisdom, but ultimately belongs to none. This has been the most difficult realization for me as I have had to move through rotation sites. Each supervisor and rotation have gifted me with lessons galore. With that, I remain optimistic and eagerly look forward to the wonderment of continued learning through practice in the second year of the JCB Fellowship.