COVID-19 has highlighted the ethical challenges in our health-care system, and nowhere is this more apparent than in an overcrowded intensive care unit. ICUs are where the sickest of the sick receive life-saving treatments and where their crashing bodily functions are taken over by high-tech machines.
Even when there isn’t a pandemic, not everyone can get access to intensive care, and not everyone will benefit from it. It is costly, invasive and requires a highly skilled workforce to make it run.
In the early days of the COVID-19 pandemic, people around the world were shocked by the images of ICU doctors working around the clock in Wuhan, Turin and New York. Their faces were etched with bruises from their tight-fitting face masks. Their eyes were haunted by the sheer number of patients they were treating – and by the sheer number they couldn’t treat.
These early warnings from other countries signaled that Canadian provinces needed to avoid a major surge of patients that would strain intensive care resources. But, preparing for the worst, work on guidance for intensive care triage began very early on in the pandemic, with Saskatchewan and Quebec starting in late winter 2020 and Ontario in the spring of 2020 across several of its COVID-19 advisory tables.
As bioethicists involved in developing an ethical framework for ICU triage at the Ontario COVID-19 Bioethics Table, we have serious concerns about the lack of transparency and public engagement around the constraints the Table works under. To be clear, we do not speak on behalf of the COVID-19 Bioethics Table, but we do speak as scholars in clinical and public health ethics and in human rights law who are also members of that Table.
We are beholden to the public as bioethicists helping to develop guidance for the ethical use of public resources – especially to the people most likely to be impacted by intensive care triage decisions – as well as to the physicians who will be forced to make these fraught decisions. This requires that the process be informed, transparent, inclusive, reasonable and subject to revision in light of new information or legitimate concerns or claims.
To date, these requirements have not been met in several provinces, including Ontario, and we entreat governments to make available their triage frameworks and protocols for public deliberation.
Rationing intensive care beds is fundamentally an ethical endeavour
Science alone cannot tell us how to allocate ICU beds. Should they go to the sickest patients? Should they go to those who are most likely to benefit from treatment? Should we use a lottery system? Should we withdraw treatment from patients if they are not going to have a meaningful recovery to give the bed to someone who will? And what constitutes a meaningful recovery? These are ethical questions requiring value judgements.
Many pandemic response plans focus on maximizing the benefit of scarce resources to save the most lives. Allocating ICU beds to people who are unlikely to benefit from them is often considered unethical and inefficient. Clinicians who work in the ICU often talk about the moral difficulty of providing treatments that sometimes do more harm than good. The moral burden of care in these circumstances weighs heavily on ICU clinicians when left to make these decisions alone and without ethical guidance.
How should health equity be balanced with utility in intensive care triage?
Society’s failure to address upstream causes of ill health and inequities means that the futility or efficacy of ICU care is often determined well before people are brought to the doors of an ICU. To fail to attend to this in triage frameworks and clinical protocols undermines trust. Whose lives we save is not just a matter of how we apply clinical criteria. It is a matter of redressing unfair inequalities in health and a matter of protecting fundamental human rights.
And while utility is one worthwhile objective of health policy, it must be balanced with due consideration of the human rights of people who might be disproportionately, unjustifiably or morally harmed by clinically based triage decisions. Relying on clinical criteria like judgments about mortality risk in the short or long term, functional status or clinical frailty scores compounds health inequities by failing to help distribute health benefits fairly across society through explicit consideration of social disadvantage.
Human rights advocates, disability rights advocates, Indigenous health partners and members of the Black community have voiced concerns about the potential for discrimination when triage does not take stock of societal factors and when they are not involved in the process of developing triage criteria. Meaningful inclusion of these communities and their perspectives is essential for the ethical legitimacy of ICU triage frameworks to balance utility with equity.
The public needs to join the conversation on an ethical approach to triage
Consensus on a proposed ethical framework for pandemic triage, even just among bioethicists, is unrealistic. Nor is it necessarily desirable. In fact, the role of dissensus in bioethics is crucial to avoiding the narrowing of possible policy avenues and avoiding presumptive constructions of various stakeholders.
As bioethicists, our expertise is in sketching the moral landscape, providing options and framing ethical debate. Our job is to propose a possible approach to intensive care triage that the public and stakeholders can then weigh and deliberate. It is also to propose and promote accessible and ethically defensible processes for doing so.
Bioethicists are not moral authorities, and governments ought not decide on an approach to intensive care triage without engaging in broader moral deliberation with the public and with those who will be most affected.
To be sure, public deliberation will not make the decisions about how to prioritize patients for intensive care any easier, nor will it necessarily make it easier to live with the consequences. But it would ensure that all voices have been heard, innovative approaches have been considered, and that new ethical considerations can come to light. It is a distinctly political obligation to ensure that the triage protocol is grounded in an ethical, democratic process and that it is based on values that have been justified through stated public reasons.
We join the COVID-19 Bioethics Table, the Ontario Human Rights Commission and disability rights advocates in calling for transparency and public deliberation on the unfinished work of developing Ontario’s approach to critical care triage in a major surge during the COVID-19 pandemic. Other provinces must also follow suit. Specific attention needs to be paid to partnering with people who have been marginalized by both the process and the products of ICU triage development.
The protection of fundamental legal and human rights during an emergency is a litmus test for society, and we need to do everything in our power to avoid overriding rights unjustifiably. Without public discussion, the vulnerability of already marginalized groups is intensified and trust eroded.
No province in Canada can claim to have a morally legitimate and human rights compliant approach to triage until an accessible and public discussion takes place about how to balance equity with the aim of saving lives in a pandemic.
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Anyone who has been the decision-maker for an elderly person has probably seen informal triage in action long before Covid-19 bought the issue to wider public attention. A lack of beds in a pandemic is a valid reason to try to triage but elderly people are often left to die untreated because care dollars spent on them are seen as a waste. My father-in-law was waiting for most of a day for a CT scan but was sent home in the middle of the night with no diagnosis, no notice to the private home or to us and his IV lead left in, which he ripped out en route. When I spoke to the then Head of Emergency Services in Halifax he said “It got busy and his bed became prime real estate”, beds were needed for younger people with no dementia, in other words. He died shortly thereafter. My mother broke her hip but the emergency doctor said jauntily that it was a hairline crack and that she wouldn’t need a pin but she suffered and died slowly over the next few weeks. LTC homes pressure decision-makers to sign DNR orders and to agree to ‘Comfort Care’, a practice which has meant many people died in their LTC beds rather than getting care in hospital and it gave cover for some very bad practices such as withdrawing food and water from patients who were sometimes able to indicate to family kept outside how bad their situation was. When you are elderly, have dementia, have cancer or another chronic disease your life hangs on a thread if you are taken to Emergency or are in LTC, Let’s have a public discussion of this, it is long past due.
Stop trying to fix something which is not broken!
For many many years this problem has existed and medical intensive care specialists have been dealing with these problems using risk benefit analysis.
For example: someone with severe COPD or fibrotic lung disease with very limited FEV1 /FVC ( pulmonary function measurements ) would NEVER be placed on a ventilator as it would be IMPOSSIBLE to get them off of it and would tie up an ICU bed for potentially months!
Same way some one with advanced dementia would never be placed on a ventilator
Physicians are NOT obligated to provide any treatment if it is deemed futile including ICU care.
Alternatives to intubation and ventilation on a ventilator is to use CPAP
on a ward setting for those thought not to be candidates for ICU therapy.
Leave this problem to those who deal with it and have felt with it for years.
Hard hard decisions and I agree they have to be transparent and more voices at the table although I have NO idea what that would look like. The burden and responsibility belongs to society as a whole though
your comments are interesting but we are no where near a disaster when we have over 2300 icu beds with only 600 covid patients in them. Late March we had 1800 of theses 2300 beds occupied.. Still a surplus of 500. Plus we have surge capacity and field hospitals. How can you ethically discuss euthanization and please admit that that is what it is.. Transfer people to hospitals that have capacity before you start killing people.. Toronto is overburdened but other cities are not. This is unbelievable that they want you to have a license to kill!
Thanks for bringing this forward. Its a difficult issue for sure. The term “transparency” is often used these days which, in my mind, I equate with being “invisible” while I prefer to think of transparency as being “inclusive”. In looking this up I quote trusty Google as follows:
“Information transparency is not an ethical principle per se, seeing that it can be ethically neutral, but it can easily become an ethically ”enabling” or ”impairing” factor”.
Table experts pertaining to COVID were given their gag orders. Nothing new here as this is standard government business practice. Example first to my mind was the new “The Canada Food Guide”. Transparency can only be arrived at with mutual trust. Where there is no trust ie. where our political masters are involved, what is to be done? We just witnessed what can happen south of this border when powerful people in powerful roles are too scared to speak out. And only when the political tide turns, they find the courage to speak out. Experts should not have to “manage” government and play politics although I understand the reasons they do as its better to be close to the enemy. Then the other argument is “are you doing harm” to patients? Definitely doctors should not have to make these very difficult decisions about who will live and who will die. But that is what the elected officials want, to not be held accountable. Unless we stand together, we will continue to be divided, gagged and conquered. Please continue to speak out any way you can.
Thank you to the authors for this submission and to Healthy Debate for publishing this article. In the context of our third wave and when ICUs in Ontario are filling to beyond capacity, MDs will be faced with the horrible task of having to enact Ontario’s Triage Criteria. I agree and support that those marginalized by race, socio-economics and/or disability should be ‘partnered with.’ If our words matter about respecting the dignity and worth of each person we must be transparent and partner with affected peoples. My concern is that even with best intentions, in difficult situations, implicit bias could lead denial or access to CPR, ventilatory support and ICU admission for marginalized communities. Remember the words of the disabled community in a post SARs review: “If you are not at the table, you are on the menu.”
There should be a lottery system, whether this pertains to COVID-19 or any other health care crisis (flood, fire, massive motor vehicle or mass transit casualties, etc.) Period. Doctors and nurses have no right to decide who is more “worfhy” of treatment based on age, ability to survive, socioeconomic status, ethnicity, future earning capacity,, or other variables. Like the rest of us, they are human and their biases will be a part of their decisions, consciously or unconsciously. If a patient *chooses* to give up her/his place in line and has done so without coercion, so be it. All lives are equally valuable.