Ethical Toolkit

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Ethical Toolkit
Trai n i n g Ses s i on
F or F i rs t N at i on s , M ét i s , O R
I n u i t P rograms an d Servi c es
E t hi c a l R evi ew C ommi t t ee
M embers
Training Session Outline
Day One
Opening remarks and introduction of
participants
Overview of the ethical toolkit
Implementing the ethical toolkit
Lunch
Viewing and discussion of “Do you find this
unethical, partner?”
Case study
Training Session Outline
Day Two
•Case study (cont.)
•Lunch
Application of the ethical toolkit to areas outside of
health
Viewing of “Child Welfare: The State as Parent”
Wrap-up, discussion and next steps
Overview of the
Ethical Toolkit
Purpose
 The purpose of the ethical toolkit is to provide to
First Nation, Inuit and Métis health care and social
service leaders, administrators, practitioners and
front-line workers an innovative resource to redefine
their relationship with federal and
provincial/territorial governments and other outside
funding agencies.
 Included in the framework are accountability
standards required of the outside funder by the
community, organization or group throughout the
period of the intervention.
Ethical Toolkit Goals
 Reduce and eliminate risk to vulnerable individuals
and groups resulting from the introduction, delivery
or termination of any and all front-line health care
and social services prevention and intervention
programming.
 To make equitable and reciprocal levels of
accountability between outside funding agencies and
Métis, Inuit and First Nations communities and
organizations.
Ethical Toolkit Goals
 To assist in creating an ethical relationship between
Métis, Inuit and First Nations communities and
organizations and their outside partners
(government and non-government) in health care
and social services design and delivery.
 To prevent risk to vulnerable clients and to front-line
workers delivering health programming resulting
from intentional or unintentional harmful program
design, implementation and termination practices.
Ethical Toolkit Goals
 To assist in protecting against the “watering down” of
evidence-based or “best practice” models of
programming in ways that place vulnerable
individuals/populations and/or front-line workers at risk
of experiencing harm.
 Across the spectrum of design, implementation and
termination to determine from a Métis, Inuit or First
Nations perspective “best practices” for ethical delivery
of health care and social service interventions targeting
vulnerable individuals/populations.
Background
 The idea for the toolkit comes out of community-
based participatory research data and analysis
guided by Indigenous stakeholders from across
Canada and by the First Nations, Inuit and Métis
Advisory Committee to the Mental Health
Commission of Canada.
Methodology
 Forms of data collection
 2009 national roundtable on ethics and Indigenous mental
health and addictions
 Two working papers exploring ethics from various vantage
points were completed. The documents review the research
and gray literature on ethics, with a focus on biomedical,
public health and Indigenous ethics
 Two educational documentaries were completed
How Communities Can Benefit
 Currently, government systems and processes fail to
include formal ethical standards in community
partnership engagement and in policies,
programming and funding decisions that target
vulnerable and marginalized groups.
 By modifying and using the toolkit, First Nations,
Inuit and Métis communities and organizations will
have an ethical foundation upon which they can
negotiate health and social welfare agreements with
governments.
Introducing the Ethical Toolkit
 Create a Programs and Service Ethics Committee
(PSEC).
 The committee can be new or an expansion of the
duties of the local research review committee, if one
exists.
 The role of a PSEC is to review and make
recommendations on health care and social services
related policies and initiatives proposed by federal
and provincial/territorial government departments
or other outside funders.
Introducing the Ethical Toolkit
 The PSEC serves as a protective body for community
and organizational interests, ensuring the design,
delivery and termination of health and social welfare
policy, programs and services introduced to the
community or organization from outside meet
ethical standards for work with vulnerable
populations.
 Separate committees can be set up for health care
and for social welfare or they can be combined into a
single committee.
Introducing the Ethical Toolkit
 The role of the PSEC is to review existing and
proposed health and social services policies and
programming (prevention, intervention and
promotion) using a set of ethical guidelines approved
by the community or organization.
 If a proposed policy, program or service does not
meet ethical standards, the committee will make a
series of suggested changes that the funder is
required to make in order for the initiative to
proceed.
Introducing the Ethical Toolkit
 The committee should be made up of approximately
6-10 members, including a chair and a designated
note-taker.
 The chair is responsible for reviewing each proposed
initiative and providing a summary to committee
members prior to the committee’s discussion.
 In the review the chair provides any pertinent
information that is excluded from the proposal, a
general overview of what is being proposed and areas
that may be of concern to the committee.
PSEC Mission Statement
The mission of the Programs and Services Ethics
Committee is to ensure that ethical standards of care
are met within all health and social welfare policies,
programs and services introduced to the community or
organization by federal and provincial/territorial
governments and other agencies. In this context, the
PSEC will, for both the community or organization
(including front-line workers) and clients who are
targeted by initiatives, monitor and work against
potential harms resulting from the introduction,
implementation and termination of all health and
social welfare initiatives.
Program and Service Ethics Committee
 Example One: Reserve—First Nations
 Elder
(2)
 Band council health representative (1)
 Band council social services representative
(1)
 Health director (1) (co-chair)
 Child and Family Services director (1) (cochair)
 Senior front-line worker (2)
 Front-line worker (2)
 Service recipients (2)
Program and Service Ethics Committee
• Example 2: Urban—front-line services
o
o
o
o
o
o
o
o
Elder (2)
Executive director (1)
Board member (1)
Health programs director (1) (co-chair)
Child welfare director (1) (co-chair)
Senior front-line worker (2)
Front-line worker (2)
Service recipient (2)
Modifying the PSEC Membership
 Who is targeted by the
program/service?
 Are all potential stakeholders
included on the committee?
 Are the voices of the most vulnerable
present and respected?
 Is the committee empowered to make
recommendations?
PSEC Committee Process
6. Final project proposal
and partnership
agreement is reviewed
and signed by PSEC
committee and the
funder.
5. PSEC chair and
local health care
leaders work with
funder(s) to revise
proposal to meet
ethical standards.
1. PSEC chair(s) reviews
and summarizes
information received
from funder about
proposed project(s) and
funding opportunity.
2. Committee meets to
review the project(s)
and makes
recommendations.
3. PSEC chair(s)
4. PSEC recommendation:
A. Acceptance
B. Acceptance with minor
changes
C. Acceptance with major
changes
D. Rejection of project and
funding
submits committee’s
review and
recommendations to
the funder for review.
Implementing the Toolkit
Introduction of New Interventions by
Government
 Government department introduces a new program
that targets certain communities or organizations

Some form of programming design is provided with the
funding and is based upon “best practice” evidence from the
medical research literature. Modification to programming to
meet local circumstances, training of workers and evaluation
are areas where there may or may not be resources assigned.
Introduction of New Interventions by
Government
 Government department requests communities or
organizations to submit proposals in a certain area of
interest

The government funds successful proposals either as pilot
projects or short-term contracts (1-5 years). Communities or
organizations have the opportunity to submit ideas that are
locally derived to meet the needs of clients, however generally
these proposals draw upon local, government and scientific
knowledge/evidence in their design.
Risk Assessment
Potential risk can be determined by questioning:
 Does the program/intervention target a vulnerable
group?
 Does potential risk exist for individuals or families
targeted by the intervention?
 Is there potential risk to front-line workers?
 Is there any risk to the broader community or
organization?
Ethical Guiding Questions: Programming
 Is the program/funding introduced based upon an
existing “best practice” or “evidence-based” model?
 Does the funder provide details about the application
of the “best practice” model?
 Does the funder allow for modifications of the model
based upon local circumstances and realities?
 Does the funder provide adequate resources for
optimal success of the program, including the
protection of vulnerable clients and front-line
workers?
Ethical Guiding Questions: Funding
 Does the overall funding structure support optimal
conditions for the success of the initiative?
 Is there a funding and programming accountability
policy that outlines mutual accountability
expectations for the funder and community or
organization?
 Does the funder allow for budget flexibility if
modifications to the intervention are required in
order to meet local needs and circumstances?
Ethical Guiding Questions: Client
 Does the intervention have clear policies and an
implementation plan that ensures the protection of
vulnerable clients at all phases of the project?
 Does the intervention have a client disengagement
policy that ensures the protection of vulnerable
clients?
 Does the intervention have a client-helper
relationship policy that addresses equal and healthy
relationships between the client and the front-line
worker/program?
Ethical Guiding Questions: Client
 Does the intervention have clear policies and
procedures to ensure that all information shared by
clients, recorded in client files and collected for
evaluation or research purposes is kept confidential?
 Does the intervention have clear policies and
procedures to obtain informed consent from clients
or from guardians or parents of children involved?
Ethical Guiding Questions: Workers
 Are workers empowered to provide programs and
services that meet the ethical standards of the PSEC?
 Are policies in place to protect workers’ interests and
confidentiality if they voice concerns about
anticipated or unanticipated negative impacts on
them and/or their clients resulting from some aspect
of the initiative design or implementation?
PSEC Recommendations
 Option 1: Acceptance of the proposed program or
service without change to its design or funding.
 Option 2: Acceptance of the proposed program or
service with minor changes required by the funders
and/or community/organizations.
 Option 3: Acceptance of the proposed program or
service with major changes required by the funders
and/or community/organizations.
 Option 4: Rejection of proposed program or service.
Factors for Success
 Collective support from local leadership, regional
governing bodies, provincial/territorial and national
governments.
 Political stability and leadership within the
community or organization is necessary to create the
level of continuity needed to establish positive and
healthy relationships between the community or
organization and outside funders.
Factors for Success
 Leadership and champions of ethical standards can
come from all levels of government as well as from local
elders who have knowledge of linguistic and cultural
understandings that compare, expand and explain the
meanings of local concepts that equate to Western
concepts such as “ethics,” “moral governance,” “risk” and
“ethical space.” In every local context it is important to
identify champions who are individuals who will make a
concerted effort to advance this idea within the
community or organization, and as importantly with
federal and provincial/territorial governments who
provide funding and programming support.
Factors for Success
 Government readiness and cooperation:
Success of the PSEC will rely to a certain level on
government readiness in recognizing the importance
of cultural safety and ethical responsibility.
Widespread adoption of the toolkit and advocacy
work are necessary to encourage government
(funder) support and participation.
Factors for Success
 Collaboration and reconciliation: As a grassroots
movement, the ethical toolkit is intended to transform
the current relationship that Indigenous communities
and organizations have with government funders. This
requires a commitment to nation-to-nation collaboration
in building ethically and culturally safe processes.
Recognition by both parties that the status quo is not
working for Indigenous peoples and that health and
social welfare policies and programming are greatly
enhanced by ethical standards that are derived from both
Indigenous and Western worldviews will support the
reconciliation of past wrongs created by colonial policies
and practices and experienced by Indigenous peoples.
Documentary 1:
DO YOU FIND THIS
UNETHICAL, PARTNER?
Documentary 1: Questions for Discussion
 What do you think ethics is or what does ethics mean
to you?
 What makes a healthy community?
 What are other examples of transition moments that
can lead to harm in the health care system? What
can be done about them?
 What can be done at the community level to address
these issues?
Documentary 1: Questions for Discussion
 Who is currently involved in making
funding/program delivery decisions for your
community?
 What are some examples of funding or program cuts
or gaps that have affected you or your community?
 How does accountability currently work and is it
working?
Case Study
 Application of a Best Practice Fetal Alcohol
Syndrome Prevention Project in Northern
Saskatchewan First Nation Reserve Communities
(Tait, 2008)

Outlines the implementation of a mentorship program
intended to reduce the risk of Fetal Alcohol Spectrum Disorder
(FASD) births in four northern reserve communities.
Case Study
An ethical review of this program would have flagged the
following:
 funding commitment—three-year pilot
 lack of adaptation of the program to fit the community
 watering down best-practice models
 reporting requirements (through FNIHB and NITHA)
 questioning why a proven “best-practice model” was
being piloted rather than implemented as a permanent
program may have addressed the stop-start nature of the
program
Application of the Toolkit
 Areas outside of health:
 Child welfare
 How can delivery of child welfare services in communities
benefit from a review using the tools in the ethical toolkit?
Documentary 2
CHILD WELFARE: THE
STATE AS PARENT
Documentary 2: Questions for Discussion
 What is the best way to ensure the well-being and
safety of children?
 What are individual and community responsibilities
towards children?
 What needs to change with the current system and
how can we make this happen?
 What are some of the ethical considerations around
the current child welfare system?
Wrap-up and Discussion
 Questions
 Next steps
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