Euthanasia doctor developed Ontario Covid-19 triage guidelines

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr James Downar, the former chair of the physicians advisory committee for Dying with Dignity, a Canadian euthanasia lobby group, developed the "triage protocol" for doctors who may be forced to make difficult ethical treatment decisions if hospitals become overwhelmed by the Covid-19 outbreak.

Jennifer Yang reported on March 29 that the Toronto Star obtained a copy of the document that is based on rationing critical care beds and ventilators. The document establishes policies concerning life or death choices.

When contacted by Yang for comments, Downar said he was referring all media requests to Ontario Health, which was unable to respond by deadline.

According to Yang, the document states:

The system will be triggered only if local resources have been depleted and every attempt has been made to relocate patients to other facilities that still have capacity. The document acknowledges, however, that “transportation resources will become stretched in a pandemic and this will not always be possible.”

Yang describes the Triage protocol:

Under the triage protocol, patients will be assessed according to both inclusion and exclusion criteria. Those who are excluded from treatment will be patients “who are very likely to die from their critical illness, and people who are very likely to die in the near future even if they recovered from their critical illness.”

At level 1 triage, for example, doctors are advised to exclude patients who have greater than 80 per cent predicted mortality. At level 3, patients with greater than 30 per cent predicted mortality will be excluded. Under the triage protocol, long-term-care patients who meet specific criteria will also no longer be transferred to hospitals.

Patients who no longer meet the criteria for care under the triage system will be removed from life-saving interventions like ventilation or not have them offered, according to the protocol. But this does not mean these patients will stop receiving medical treatment or care. They will also receive “the highest priority for palliative care.”

Decisions as to who will receive treatment and who will not receive treatment are difficult, but the protocol is illegal. In Ontario court decisions have determined that decisions to provide or to stop treatment require the consent of the patient or the patients healthcare advocate. Therefore to remove a patient from life-saving intervention, even with good intention, cannot be done without consent.

Yang then states that patients who are withheld or withdrawn from treatment will receive palliative care. She states:

Patients who no longer meet the criteria for care under the triage system will be removed from life-saving interventions like ventilation or not have them offered, according to the protocol. But this does not mean these patients will stop receiving medical treatment or care. They will also receive “the highest priority for palliative care.”

Yang then concludes the article by stating that the protocol outlines three guiding principles for the triage protocol:

the first being “utility,” meaning physicians should allocate resources to patients who stand to benefit the most. 

The second is “proportionality” — in other words, the number of patients who will be negatively affected by this last-resort triage system should not exceed the number of people who stand to benefit. 

The third principle is fairness, meaning only clinical information should be used to decide which patients are treated over others. “Priority should not be given to anyone on the basis of socioeconomic privilege, or political rank.”

It is sad that the rules for withdrawing treatment are being developed from a utilitarian point of view and without considering the legal ramifications of their decisions.