Thursday, April 9, 2020

Decision Making Protocols during the Covid-19 Pandemic

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Canadian Medical Association (CMA) approved a Framework for Ethical Decision Making During the Coronavirus Pandemic that is based on the protocol by Ezekiel J Emanuel et al (the protocol) that was published in the NEJM on March 23, 2020 titled: Fair Allocation of Scarce Medical Resources in the Time of Covid-19

There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 

Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of resources are limited then decisions are made which are often unjust and lack equality.

I am concerned that many Covid-19 deaths in Canada are related to decisions not to provide treatment for elderly people, even when capacity for treating these people existed. The high rates of death at nursing homes is not only based on the age of those who died, but also the decision not to transfer these patients to a hospital capable of treatment. This is why a doctor at one nursing home lamented that all they could do was provide comfort care.

The triage guidelines developed by the disability rights community seem to represent the fairest and most equitable response to providing treatment during a pandemic. (Link to the guidelines).

This article will provide some insight into the NEJM protocol by Emanuel et al that has been approved by the CMA.

The protocol states that the demand for medical resources may be greater than the supply of resources. I will not comment on the projections only on the proposed allocation of scarce medical resources. The protocol is based on utilitarian principles.

The protocol based on four fundamental values that they define as: 

  1. maximizing the benefits produced by scarce resources,
  2. treating people equally, 
  3. promoting and rewarding instrumental value, and 
  4. giving priority to the worst off.
They define each of the fundamental values in this manner:
  1. Maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment.
  2. Treating people equally could be attempted by random selection, such as a lottery, or by a first-come, first-served allocation. 
  3. Instrumental value could be promoted by giving priority to those who can save others, or rewarded by giving priority to those who have saved others in the past. 
  4. Giving priority to the worst off could be understood as giving priority either to the sickest or to younger people who will have lived the shortest lives if they die untreated. 
The protocol states that none of the fundamental values should be assessed alone but in relation to the other fundamental values.

The protocol then examines who would receive health resources in a Covid-19 pandemic. They state that the four fundamental values would be examined based on six specific recommendations for allocating medical resources in the Covid-19 pandemic, which are:

  1. maximize benefits;
  2. prioritize health workers; 
  3. do not allocate on a first-come, first-served basis; 
  4. be responsive to evidence; 
  5. recognize research participation; and 
  6. apply the same principles to all Covid-19 and non–Covid-19 patients
The protocol explains how the six recommendations work.

Recommendation one focuses on priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports. ...There are many reasonable ways of balancing saving more lives against saving more years of life, whatever balance between lives and life-years is chosen must be applied consistently.

A controversial proposal is the withdrawing ventilator support from someone who is currently receiving ventilator treatment. Emanuel states:

Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission. Undoubtedly, withdrawing ventilators or ICU support from patients who arrived earlier to save those with better prognosis will be extremely psychologically traumatic for clinicians — and some clinicians might refuse to do so. However, 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.
This is simply wrong. There are many people with disabilities, including Not Dead Yet President Diane Coleman, who require oxygen assistance to live. In Withdrawing ventilator treatment is a treatment decisions and should require consent. Decisions to approve or withdraw treatment should be defined as treatment decisions and should require consent.

Recommendation two focuses on the care of front-line health care workers. Healthcare workers are needed to ensure a successful pandemic response, therefore their health is a priority. I agree with recommendation two.

Recommendation three states that when making decision for who should receive care among people with a similar prognosis that those decisions should be based on a lottery and not a first come first served basis. 

I personally don't agree with this point considering that our culture is used to a first come first served basis. Who will decide the parameters of the "lottery" and how is it to be fairly determined? I think that a lottery system will give the healthcare bureaucrat to more control of the system.

Recommendation four suggests that the approach should be based on scientific evidence, which may change over time. Therefore it is suggested that a vaccine, which are preventative, should be given to the elderly and other vulnerable patients first, to reduce the loss of life.

The protocol then states that ICU beds and ventilators, which involve curative treatments, should be allocated to those most likely to survive first. But the protocol goes further and suggests not only those who are most likely to survive but those who are most likely to survive the most number of years.

This proposal denies treatment to older persons and people with disabilities in a discriminatory manner.

As I stated in a previous article:

People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment. 
In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care. 
A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment. 
A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is medically futile. In this circumstance the person is not deemed futile but the treatment is futile.
Recommendation five states that people who are willing to participate in medical trials for Covid-19 research should receive priority.

Recommendation six states that if medical resources become scarce that all medical decision should be made based on the decision making protocol. For instance it states that if there is a scarcity of ventilators and a healthcare worker needs a ventilator for a different condition, that priority should be given.

The pandemic decision making protocols developed by the disability community represent a fair and equitable response to the possible scarcity of resources. (Link to the protocol). I am concerned that the quality of life ethic, mixed with a utilitarian and discriminatory ethic towards people with disabilities will only lead to ingraining decisions that will result in the deaths of vulnerable persons.

These utilitarian guidelines, such as the one designed by Emanuel et al, ingrains negative and discriminatory attitudes to vulnerable populations.

Medical decisions should be made based on Justice and equality (non-maleficence) and not the elimination of the weak.

More information on this topic:
  1. Pandemic Palliative care protocol. Selecting people to die (Link).
  2. As the threat of triage grows. Disability rights advocacy is needed more than ever (Link).
  3. Euthanasia doctor developed Covid-19 triage guidelines (Link).

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