Ethical Management of Elective Surgery Waiting Lists : A Framework of Clinicians' Values in Action.

Waiting time for elective surgery in public health systems has long been a focus for health institutions and governments. Such focus, and existing ethics literature, tends to hover at a policy or systems level. However, long waiting lists also create ethical challenges at the level of individuals' clinical practice. This project expands the focus of the elective surgery waiting list discussion from the macro systems level to the micro clinician level. We put forward a framework of values driving clinicians' ethical practice in this area, based on a literature review and iterative ethicist-led discussions with eighteen key surgical staff in one hospital network in metropolitan Melbourne, Australia. While sensitive to population-level values at play, clinicians' primary moral orientation was towards the individual patients they cared for. This orientation saw clinicians implement additional values in their practice including supporting patient autonomy through informed consent, maximizing benefits to individuals by considering patients holistically, minimizing harms to individual patients related to time spent waiting, and consistency of decision-making within teams and departments. By articulating values that can be translated into action within clinicians' sphere of agency, the framework aims to support ethical practice among surgical staff working within a constrained and imperfect system.