There is one ventilator, two people.
The first person is a 12-year-old with COVID-19, the disease caused by the new coronavirus. The second person is 74 years old and has COVID-19, too, but he’s an infectious diseases doctor and an expert in vaccine development.
Neither is breathing very well, and the window to choose who gets the machine, which mechanically helps patients struggling to breathe, is closing quickly. Unlike other forms of treatment, experts note, “the decision about initiating or terminating mechanical ventilation is often truly a life-or-death choice.”
So, says Timothy Christie, a medical ethicist, you have the 12-year-old, the 74-year-old and a choice:
“One is going to live and one is going to die.”
Who do you save?
***
Save the child or save the doctor is the first scenario that Christie, regional director of ethics services for Horizon Health Network in New Brunswick, will put to the network’s ethics board this week.
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He’s writing a discussion paper outlining different scenarios, which the board will discuss at length. What they decide will become policy should New Brunswick reach the point where COVID-19 patients overwhelm its health-care system and force its doctors into the same position as their Italian counterparts, who’ve had to make heartbreaking life-or-death decisions with alarming frequency.
That hasn’t happened in Canada. Yet.
But across the country, hospitals and medical ethicists are readying for similar shortages.
A recent study from the University of Toronto, University Health Network and Sunnybrook Hospital says Ontario could run short of machines and space to ventilate very sick patients in a little over a month. Companies like Dyson are trying to produce as many new ventilators as fast as they can.
“Public health is going to do whatever it can to reduce the impact of this epidemic so that you don’t go beyond your capacity,” chief public health officer of Canada, Dr. Theresa Tam, told reporters on March 28.
“Having said that, of course, you have to prepare for much more worst-case scenarios.”
A worst-case scenario is an inadequate number of ventilators.
It’s what’s happening right now in Italy, where doctors consider age, pre-existing medical conditions and whether a person has a family to help them recover before deciding who gets a coveted intensive care unit (ICU) bed — where they can access intubation, ventilators and other life-saving treatment — and who doesn’t.
It’s also happening in the United States. The country’s top infectious disease expert, Dr. Anthony Fauci, said on March 29 that he expects upwards of 100,000 deaths linked to COVID-19.
In Michigan, one hospital says patients who have severe health issues like heart, lung, kidney or liver failure, as well as terminal cancer or severe burns, may be ineligible for critical care in a worst-case scenario.
In states like Alabama and Washington, similar worst-case plans indicate that people with intellectual disabilities may not be prioritized for life-saving treatment.
In New York, Dr. Eric Cioe-Pena said it already feels as though “we’ve ventured into a battle.”
In the likely event Canada runs short, Kerry Bowman, a bioethicist at the University of Toronto, says Canadians need to talk about how we choose who gets life-saving treatment and who doesn’t.
The hope is that if Canadians continue to self-isolate and physically distance themselves, we will flatten the curve, reduce the surge of people needing critical care resources at the same time and, in doing so, avoid more deaths.
But if it isn’t enough, Bowman says, “people have a fundamental right to know” how we’ll pick who gets what care.
“It’s not just what decisions were made but how people made those decisions that’s going to be very very important,” he says.
“Trust is the cornerstone of every element of health care.”
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In 2003, the SARS outbreak killed 44 Canadians and infected more than 400 others in Toronto. In the aftermath, a provincial working group, made up of doctors and ethicists, put together a report for providing critical care during future pandemics.
“Every human life is valued and every human being deserves respect, caring and compassion,” the group noted — even if not every person gets critical care. Like Bowman, the working group said transparency and accountability in developing triage protocols are key.
To do that, the group stressed that health-care systems would need an effective strategy for when their services were stretched thin by a sudden influx of patients. In the short term, doctors and nurses can double up on shifts, but a pandemic is about long-term sustainability.
Part of ensuring sustainability will mean knowing when to implement pandemic triage protocols, the group wrote. Do it too soon and you risk unnecessarily hurting patients, do it too late and you’ll use many resources on only a few patients and risk filling all critical care beds, limiting care options for anyone who comes after.
For all the great strides Canada has made post-SARS — including creating the Public Health Agency of Canada — there are still limits to what can be done. Many hospitals were struggling with overcrowding before the COVID-19 outbreak hit in earnest in March.
“One of the strongest recommendations after SARS was our hospitals had to have surge capacity. They don’t,” Bowman says. He isn’t blaming hospitals; he’s blaming a lack of public funding.
“We’ve put off ethical decisions and we’ve put off major (health-care) changes… which has gotten us into big trouble with this outbreak.”
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Right now, Judy Illes, professor of neurology at the University of British Columbia and Canada Research Chair in neuroethics, says Canada is “in triage… not rationing.”
In other words, we’re deciding who goes first and who goes second. We haven’t yet started deciding who gets and who doesn’t.
But any plan requires “good ethics principles,” she says.
“There’s no black and white, no right and wrong — it’s all balance.”
In balancing risk and benefit, Illes says a utilitarian framework used by Canadian hospitals and health-care systems will focus on making choices that maximize the best outcomes for the highest number of people.
These are hard choices but “a necessary response to the overwhelming effects of a pandemic,” wrote 10 doctors in the New England Journal of Medicine on March 23.
“The question is not whether to set priorities, but how to do so ethically and consistently.”
Those 10 doctors recommend prioritizing COVID-19 tests, personal protective equipment, ICU beds, ventilators and vaccines for front-line health-care workers and those who provide the critical infrastructure that keeps hospitals operating.
“These workers should be given priority not because they are somehow more worthy but because of their instrumental value,” the doctors wrote. “They are essential to pandemic response.”
The doctors also suggest that in some cases, it will be necessary to remove somebody who is already on a ventilator to give it to someone else who may have a better prognosis.
“(That) will be extremely psychologically traumatic for clinicians,” the doctors cautioned, and yet:
“Many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.”
In cases where two patients have a similar prognosis, the doctors recommend deciding based on a lottery method because sticking with the usual “first come, first served” health-care approach would be unfair to those who become critically ill later during the outbreak.
“These are essential conversations,” says Bowman, even though he expects to be called a fearmonger for trying to discuss it now with the public.
“We cannot simply wait until people are being taken off ventilators or denied ventilators to start having this conversation,” he says.
“Let’s hope this never happens, but we have to be prepared.”
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If Toronto health organizations learned anything after SARS, it is that not speaking openly about difficult life-or-death decisions can be damaging, several ethicists wrote in the BMC Medical Ethics journal a few years after the outbreak.
“The costs of not addressing the ethical concerns are severe,” they wrote in 2006. “Loss of public trust, low hospital staff morale, confusion about roles and responsibilities, stigmatization of vulnerable communities and misinformation.”
Christie, the bioethicist in New Brunswick, says that after the ethics committee decides on a policy, it will be communicated to the broader public.
The work, Christie says, is very much in progress — a point echoed by many of the hospitals, provincial health authorities and physician licensing bodies to which Global News reached out.
In Nova Scotia, a health ministry spokesperson said an ethical framework is in progress but “it’s a little too soon” to share publicly. While a ministry spokesperson in Quebec did not respond to requests for comment, a spokesperson for the Jewish General Hospital in Montreal said there is a provincial working group putting together triage guidelines.
Ontario recently announced an ethics table, which the University of Toronto Joint Centre for Bioethics would lead, to help devise a plan for prioritizing who gets treatment.
While a spokesperson for B.C. did not provide responses on the province’s approach, Bowman says his understanding is a provincial ethics group has also been convened there.
It would be beneficial to have those policies sync up nationwide, says Illes, the neuroethicist.
“We have disproportionate people with disabilities, socio-economic challenged people, Indigenous people across different provinces, but their rights and their views and their needs need to be taken into consideration,” she says.
“A strong policy that’s harmonized, that takes all those factors into consideration, is the best way forward.”
While Canadians cannot gather in person right now to share their opinions, Illes says she is pleased to see “vital” public engagement happening through medical opinion pieces and webinars, like the two-hour virtual discussion the University of Alberta recently hosted on pandemic ethics.
“We want to stay socially engaged, even more than we are normally, and support each other,” Illes says. “If there’s a silver lining to this story, it’s how well we can band together as Canadians in terrible times.”
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Christie has had to make life-or-death decisions before. But this might be the first time he has to make end-of-life decisions “because of blatant rationing.”
“We were trying to be conservative, realistic and practical, but this is exponentially worse than any of us had planned for,” he says. “It’s hard to believe how big it’s getting and how quickly.”
It’s why he says this needs to be a community endeavour. It’s not only about an ethics committee deciding who gets a ventilator and who doesn’t — if that’s what it comes to.
It’s about asking people to self-isolate when they’re sick or have been exposed to the virus or are newly home from travelling abroad. It’s about asking everyone to take physical distancing seriously so there is no surge in patients needing critical care.
“This situation is no one’s fault, but we have to deal with it,” Christie says.
“I would rather us be heartbroken but really agonize over making good decisions.”
— With files from the Associated Press and Reuters
Email us: Jane.Gerster@globalnews.ca
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