DEATH PANELS OR LIFE SAVERS?
Triage teams may have to make tough calls
Did you get a good chance at life?
That’s the kind of question ethicists begin asking if masses of struggling humans begin pleading for medical help when life-saving resources are scarce.
The broad life-evaluation question connects to triage, which prioritizes battlefield casualties in war and patients in emergency wards. It points to the moral concerns that flooded the minds and hearts of doctors and nurses in Italy when people suffering dire breathing problems from the COVID-19 virus were overwhelming the supply of ventilators.
It’s a question at the centre of the dilemma with which Dr. Michael Kenyon, head of the intensive care unit at Nanaimo Regional General Hospital, recently confronted B.C.’s provincial health officer, Dr. Bonnie Henry. Kenyon publicly complained that, should his hospital’s 14 ventilators all be in use, he would follow the lead of some Italian health officials and start taking 70-year-olds off the ventilators, followed by 60-year-olds, and so on. Kenyon warned he would be ready to give precious ventilators mainly to 30-year-olds with three children. Families that had not had a full chance at life.
Henry, in her news briefings, responded that Kenyon had raised agonizing issues that reflect “what we’re seeing around the world, which puts us in moral distress.” She later clarified that a team of medical ethicists, specializing in nursing, is fine-tuning a provincewide ethical protocol for ventilator rationing, which will be posted online.
Should the COVID-19 crisis spin out of control in Canada — and it is important to remember it has not — many heartbreaking questions will have to be answered, the overall one being: Which patients should get precedence for the country’s limited supply of ventilators?
A recent national study estimated the total number of ventilators in Canada at about 5,000. On Tuesday, Ottawa ordered 1,700 more, and said it’s considering seeking 4,000 extra. B.C. Health Minister Adrian Dix says there are 1,372 in this province.
The urgency is understandable. Patients who need their breathing assisted after being intubated by a tube linked to a ventilator can die within minutes of being detached from the air pumps. At the peak of Italy’s crisis, doctors made headlines when some were said to be weeping in the hallways about the prospect of being forced to make life-anddeath decisions about which struggling patients the computerized technology would benefit the most.
It’s not hard to make projections that can scare the public. Canada so far has more than 12,000 confirmed and probable cases of COVID19, with more than 1,100 in B.C. There have been 183 deaths nationally, with 35 deaths in B.C. as of Friday, median age 85.
Dr. Theresa Tam, Canada’s top public health official, says seven per cent of cases have required hospitalization, with three per cent of those patients needing to be hooked up to ventilators. If the number of infected people skyrockets, demand for ventilators could exceed supply.
A B.C. Health Ministry spokeswoman, Laura Stovel, would not provide anyone to interview on the subject of the government’s ethical protocol for access to ventilators, saying only she will send “the link once they have been posted online.”
However, the ministry released a general document on March 28 called COVID-19 Ethical Decision-Making Framework, which attempts to lay out broad guidelines for allocating scarce medical resources. It doesn’t mention ventilators.
“The needs of the community may outweigh the needs of individuals in such crises; personal rights and freedoms must sometimes be constrained,” says the framework. Some of the key principles to be balanced in rationing resources include respect, reasonableness, equity, efficiency and fairness.
“Those who most need and can derive the greatest benefit from resources ought to be offered resources preferentially. Resources ought be to distributed such that the maximum benefits to the greatest number will be achieved,” the B.C. framework says.
At the peak of the Italian surge, health providers did not want to discuss the criteria for so-called pulling the plug, telling investigators such as Dr. Lisa Rosenbaum that “you will just scare a lot of people.” Some, however, told Rosenbaum, for her article in the New England Journal of Medicine, “The citizens won’t accept the restrictions unless you tell them the truth.”
Along with most medical ethicists, Henry has said the judgment calls about who gets ventilators would be made by a triage committee, separate from front-line physicians and nurses, who advocate for each patient. Henry made that point, which is crucial to ethicists, after the head of Nanaimo’s ICU unit suggested he personally would determine who should continue to be intubated to assist their breathing.
It’s only through a clear, transparent process, suggest ethicists and the health ministry, that the public will buy in to the ethical values that go into the excruciating decisions over which order patients should be offered mechanical breathing.
TRIAGE ACCORDING TO AN AT-RISK ETHICIST
For Michael McDonald, former head of the University of B.C.’s Centre for Applied Ethics, the question of whether one had a decent chance at life is more than hypothetical.
At age 77, with a heart condition, McDonald says he feels he has “a target on my back” in regards to the possibly low priority he and his wife, who is in a wheelchair, would be given should they require a ventilator during a mass-care surge.
Nevertheless, McDonald said the supply of ventilators will never be infinite. “Have you had fair innings?” That’s how the late Daniel Callaghan, founder of the influential Hastings Center for bioethics research, talked about who should get medical treatment in a time of rationing, McDonald said.
“Have you had a good chance at life? He was talking about this in terms of the larger context, like people in my age group, seniors. He asks how much resources should we spend on seniors, how much in general in our health-care system?”
McDonald, who has served on hospital ethics boards and taught many students who now specialize in bioethics, fully recognizes that determining whether someone has had “fair innings” is not precise. And never will be.
And he is not suggesting, like Texas Lt.-Gov. Dan Patrick did on March 24, that 69-yearold grandparents like Patrick himself should be willing to risk contracting COVID-19 so the U.S. could end the lockdown that is crippling the economy.
Yet McDonald supports people learning more about the specific factors and values to consider should a pandemic lead to a shortage of ventilators.
When Ontario was battered by a SARS epidemic in 2004, the University of Toronto’s bioethics committee put out a publication called Stand On Guard for Thee. It maintained that medical triage should balance principles such as duty to provide care, equality, trust, solidarity, individual liberty and openness.
Easier to say than do. But at least the Stand on Guard statement makes clear which value should not be paramount when rationing ventilators.
Triage is not based on the marketplace value of firstcome, first-served, like being the first to plonk down your blanket in front of the stage at a folk festival. In a pandemic, as B.C.’s Health Ministry ethics framework suggests, it is the needs of the broader community that matter.
The most specific fact-based question medical staff will ask during a surge of demand, according to a protocol called The New York Guidelines, is: “How can we save the most lives, as defined by the
Those who most need and can derive the greatest benefit from resources ought to be offered resources preferentially.”
B.C. Health Ministry framework
patient’s short-term likelihood of surviving the acute medical episode?”
Patient ranking should proceed in three steps, according to The Toughest Triage — Allocating Ventilators in a Pandemic, a March 25 essay in The New England Journal of Medicine written by Dr. Robert Truog and two other physicians.
The first is to check whether the patient has had “irreversible shock” that renders ventilator treatment futile.
The second step is to assess each patient’s risk of mortality via a scoring system called the Sequential Organ Failure Assessment. Common to ICU departments, it uses a score to rank a patient’s likelihood of survival based on the condition of their blood, heart, lung, liver and nervous systems.
The third step, say Truog and his co-authors, involves continually assessing a patient’s progress, such that those “whose condition is not improving are removed from the ventilator to make it available for another patient.”
‘SOFT UTILITARIANISM’ CAN GUIDE US
Triage ethics have been shaped by a philosophical school some describe as “soft utilitarianism.”
And in a crisis situation, it’s not bad to seek what one early Stoic thinker called “the consolation of philosophy.” There was a time, less than 50 years ago, when “physicians argued that withdrawing a ventilator was an act of killing, prohibited by both law and ethics,” say Truog and his co-authors.
In recent years, the main cause of fatalities in ICU units has been voluntary ventilator withdrawal at the request of a patient or patient representative. Some jurisdictions have been leaning toward utilitarianism by also allowing physicians to unilaterally remove life support when treatment is deemed futile.
Utilitarianism is often associated with British political philosopher John Stuart Mill, who taught the ultimate aim of ethics should be “the greatest good for the greatest number.” B.C.’s Health Ministry borrows an explicit utilitarian view when it says it will distribute medical resources so “the maximum benefits to the greatest number will be achieved.”
Utilitarianism is not a perfect guideline to life and death, however. As University of Minnesota emergency physician Dr. Daniel O’Laughlin says, it is hard for society to define “the greatest good.”
Does it refer, for instance, to total lives saved, total potential years of life saved or something else? Utilitarianism can also threaten what many believe is every individual’s right to care.
Yet O’Laughlin acknowledges that in a time of medical scarcity physicians’ Hippocratic Oath — “do no harm” to any individual — does not stand up. Those forced to ration ventilators will need to cause harm to one patient whose prognosis is bad for “the greater good” of a second or third patient who has a better chance.
Another key value to balance with the “greatest good” is equality, often associated with philosopher John Rawls. Some obvious ways to be unequal, or unfair, would be to deny people access to a ventilator based on their ethnicity, their poverty or because they are addicted to drugs, McDonald says.
Equality is a value the B.C. Health Ministry shares, since its framework says, “resource allocation decisions must be made with consistency” regardless of “human condition,” including disability, ability to pay or “social worth.”
Still, no matter how many ethical principles one brings into weighing who should get access to a ventilator, some situations present true dilemmas, with no clear right or wrong. As Rosenbaum asks rhetorically: “Would you preferentially intubate a healthy 55-year-old over a young mother with breast cancer whose prognosis is unknown?”
Ethics is often an imperfect process. Yet McDonald, who feels he’s had a full life even though he’s part of a vulnerable seniors population with existing health conditions, says sometimes humans must weigh their own self-interest against larger principles.
“The great English utilitarian Henry Sidgwick talked about ‘the point of view of the universe’ as the right perspective. That is to take seriously the welfare of all those whom we affect in our actions and not be partial to ourselves. John Rawls asks us to think of constructing a moral order that we could endorse from the point of view of the least well off,” McDonald says.
“I try to see the world from a more universal perspective, but I can’t help but think about what my judgments mean for me. So in a way I am happy to say that, yes, I am 77 with pre-existing health conditions. People can then ask do I exhibit the requisite impartiality.”
Some people refer to the committees that would make ethical decisions about who receives ventilator treatment as “death panels.” But defenders say they’re the opposite: They save lives.
A potential ventilator shortage during the COVID-19 pandemic is not the first time health officers will have faced triage. It first came to the fore in the 1800s, in a formal way, under Napoleon, when battle surgeon Dominique Jean Larrey sorted wounded soldiers into numbered categories for the purpose of giving immediate care to those most likely to benefit.
Hospital emergency wards also do triage. Faced with floods of people with different degrees of wounds, panic attacks and fevers, emergency-room doctors and nurses are constantly following risk protocols that help them decide who gets treatment first and who has to wait for hours, if not longer.
Extraordinary medical treatments are also not always provided to patients, even when resources are available. When he was on the ethics board of a major B.C. hospital, McDonald and his team found physicians just out of medical school incorrectly thought they were legally compelled to resuscitate patients who had suffered catastrophic cardiac arrest.
The desperate resuscitations were almost entirely unsuccessful. Worse yet, they caused extreme distress for families and patients who had to witness them. The hospital had to put out notices reminding doctors and nurses that they weren’t actors in an imaginary TV medical show, where dramatic resuscitations almost always magically saved the patient.
Ventilator triage is as much about the complex facts of each patient’s case as it is about ethical values, says McDonald. It’s also about being honest, with patients and their loved ones. Health professionals who determine they must pull a patient off a ventilator must not tell white lies to try to make people feel better.
“Clinicians may be motivated to try to comfort the family by telling them that mechanical ventilation is not being provided because it would be futile and by reassuring them that everything has been done,” says the New England Journal of Medicine.
In a triage situation, with a shortage of ventilators, sometimes the plug could be pulled simply because someone else could probably benefit from it more.
“Though well-intentioned,” says the journal, “inaccurate representations could ultimately undermine public trust and confidence.”
It’s crucial to avoid giving the impression triage decisions will ever be flawless.
Despite the wonders of modern medicine, it’s still a sphere that contains uncertainty and even mystery. Just as it is hard to answer the question of whether someone has had a good chance at life.
Humans are called upon to muddle with integrity through even life-and-death choices. At the best of times being alive requires some stoicism and a larger perspective, a willingness to patiently face the worst with forbearance.
Doctors treat a coronavirus patient in an intensive care unit at the Covid 3 Hospital (Istituto clinico CasalPalocco) last week in Rome.
UBC ethics professor emeritus Michael McDonald is 77 and knows he’s compromised medically should there ever be a triage situation. But he thinks age is partially relevant should there be ventilator rationing.
An employee works at Ventec Life Systems in March. The ventilator manufacturer in Bothell, Wash., has seen an increase in demand for its product since the COVID-19 outbreak began.
Doctors stand at the entrance of the Nomentana hospital outside of Rome on Thursday.
A nurse checks a patient in a COVID-19 ward at Cremona Hospital on Thursday in Cremona, Italy.