Applying an ethical lens to the provision of care in for-profit healthcare facilities

Autonomy

The most common criticism of private cataract services has been that patients will be coerced into purchasing expensive lens implants that they don’t require, that is, “upselling.” Currently, premium lenses are offered to patients both in hospitals and in private clinics; however, private clinics, with a “for-profit” business model, may be more aggressive in offering upgrades and additional testing. Premium lenses are not fundamentally bad, as they can provide better vision and eliminate the need for glasses in some people, but when a patient is misled into purchasing a level of implant that will provide no added benefit, the actions would be unethical.

Additional criticisms aimed at for-profit clinics include that patients will be persuaded to spend money they can’t afford and that some patients may be misled by complex explanations and terms such as “monofocal lenses,” “astigmatism,” “presbyopia,” “toric lenses,” and other scientific jargon.

To preserve autonomy, patients should be provided with sufficient, and a sufficiently clear, explanation of what is covered by provincial health insurance, compared to anything else they might want to purchase based on their individual circumstances. It’s equally important to ensure that explanations are geared to the capacity of the patient to understand and/or that they are accompanied by someone who can understand and advocate for them appropriately. Ultimately, any decision to purchase additional or upgraded services, beyond what is deemed necessary by the provincial health insurance plans, is a matter of personal choice, or autonomy. After receiving all information, patients should be free to select whatever products or services suit their personal circumstances best, even if others might disagree with their choices.

Beneficence

Beneficence requires that procedures/services be provided with the intent of doing good for the patient(s) involved. Ensuring that patients do not receive products or services that they don’t require, or which don’t help in any way, is a beginning step, but other benefits can be much broader.

In the context of value-for-money, “value” is always a matter of perspective, with patients, family members, hospitals, governments, and providers often seeing the same situation quite differently, based on individual circumstances and priorities. For-profit cataract clinics are often much more conveniently located than public hospitals, offering ease of access, free/nearby parking, more flexible appointments, more comprehensive follow-up care, and other support services that are not available in hospitals and may provide material benefit/value to some patients and their companions. Many people are happy to pay more for these enhanced services.

Non-maleficence

Non-maleficence looks beyond the notion of benefit and into also avoiding “harm” to either the patient or others in society. Here, Bill 60 has been widely criticized as diverting resources (money and staff) away from public hospitals in a variety of ways. There is also considerable concern that lack of oversight will lead to private clinics providing a lower standard of care or expose patients to risk through poor infection control practices, inadequate cleaning, or insufficient process controls. Finally, previous incarnations of IHFs have abruptly exited the business,^9,10 leaving hospitals and governments scrambling to develop/step in with stopgap services.

Opponents of Bill 60 suggest that the government should instead invest additional funding into hospitals so that they can provide the services now being diverted to private clinics, and that these clinics will pull staff away from hospitals. Many hospital officials also worry about differential funding to private clinics and/or that private clinics could deliberately choose to do the less complex/more lucrative procedures, leaving hospitals to provide the more complex and problem-prone care at the same price point.

In a job market without surplus healthcare personnel, it would be expected that some clinic staff will come from hospital jobs. However, the tremendous, post pandemic backlog of required care is such that hospitals alone can’t meet these needs within their existing operating models with existing staff and facilities. Volume expansion typically requires adding evening and weekend services, something that is difficult to do in the context of the current healthcare human resources crisis. Many nurses are leaving hospital jobs because they no longer want to work evenings and weekends, and typical hospital workloads, the often-difficult working environment, and the sometimes-ageing facilities make hospital work even less attractive.^11,12 In a full-employment market, all relevant labour resources should also be used in the most efficient way possible, and therein exists an opportunity, as in some instances, working in alternate locations such as clinics may actually “keep nurses nursing” as opposed to leaving the profession for less stressful working conditions.

Similarly, hospitals in Canada have, for years, been struggling with ageing infrastructure and insufficient capacity, ¹³ requiring massive investment and repair over the next decade. ¹⁴ Since the pandemic, many hospitals’ operating rooms, especially in tertiary care, have been fully utilized in managing urgent and emergent surgery, leaving little capacity for the less urgent procedures that can be done at independent clinics. Some stakeholders have suggested that hospitals themselves could develop and run ambulatory care surgi-centres; however, implementing these will be time-consuming and challenge hospital leader resources at a time when they are fully engaged in current health human resource and service challenges.

Accreditation Canada provides oversight to hospital quality of care and facilities, with many other regulations covering pharmacy, medical device reprocessing, labs, and others. Independent health facilities are monitored differently in different provinces. In Ontario, they fall under the College of Physicians and Surgeons (CPSO), as well as some other discipline-specific bodies. In both 2012 ¹⁵ and 2024, ¹⁶ the Auditor General of Ontario Annual Report found the scope and frequency of inspections to be insufficient. In Bill 60, the Government of Ontario has committed to a robust quality and safety monitoring process; however, details are not yet available, nor is it clear how these costs will be accounted for in the funding of these facilities.

Finally, many stakeholders complain about probable differential funding of procedures at for-profit facilities versus hospitals, arguing that hospitals, already struggling to balance their budgets, will be further disadvantaged. As with other issues, the “right” answer and funding decision is complicated. Hospitals have existing infrastructure to provide required reporting, quality assurance, safety inspections, and other monitoring, but they also have significant overhead costs and ageing facilities that require constant investment. Contrastingly, without the extensive infrastructure, overhead and complex regulatory environment, independent facilities can become highly efficient—but could rapidly lose this edge when they have to pay for the many regulatory requirements suggested for ensuring adequate monitoring and consumer protection.

It is losing this “edge” that sometimes leads to a for-profit facility deciding to exit the business, and in some cases, leaving patients at risk if they have become reliant on these services (e.g. dialysis centres). Many of these private centres are established when the market is favourable, typically when there exist generous facility fees, loose regulation, or unexploited opportunities. When funding changes, costs increase, opportunities diminish, or competition drives out profitability, for-profit facilities may cut their losses and close down. The Ontario government proposes to address this by requiring evidence of strong business, clinical and professional experience, combined with a comprehensive business plan—all useful, but no guarantee of long-term success.

Justice

The ethical principle of justice focuses on treating patients fairly and equitably. In the case of providing government-funded care at for-profit healthcare facilities, this means developing strategies that ensure no one is disadvantaged in their access to care. Bill 60 immediately generated public outcry about “queue-jumping,” “two-tied healthcare,” and many other health equity concerns, including lack of access to care for those people unwilling to pay for premium services.

The Ontario government also immediately committed to ensuring that no one would be denied care if they were unwilling or unable to pay for offered premium services. They also stated they will require for-profit applicants to submit a plan for how they will address the health equity needs of diverse, vulnerable, priority, and underserviced populations, and considering linguistic needs in the region specified in the call for applications. ¹⁷

But it’s unclear what all of these “plans” will actually mean in the end and how the performance will be evaluated. As noted earlier, hospitals and independent facilities function in very different regulatory environments and with very different underlying support structure. As an example, hospitals receiving government funding must have language translation services available for patients and many hospitals already struggle with this requirement. How will this be addressed in private clinics? Will the government extend such very specific requirements to private clinics? If so, then how will cost impact be evaluated? What if a patient has a complex social situation? Will clinics also be required to provide social services?