As COVID-19 Infections Hit Record Highs and Hospital ICUs Reach the Brink, Six Bioethicists on The Ford Government’s Bioethics Table Release a Public Statement Revealing Major Concerns with Ontario’s Plans for Triage of Critical Care, that Echo Disability Community Objections


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As COVID-19 Infections Hit Record Highs and Hospital ICUs Reach the Brink, Six Bioethicists on The Ford Government’s Bioethics Table Release a Public Statement Revealing Major Concerns with Ontario’s Plans for Triage of Critical Care, that Echo Disability Community Objections

April 15, 2021 Toronto: A body blow has just been delivered to the Ford Government’s controversial plans for deciding which patients would be refused life-saving critical care, if the crisis overload in Ontario hospital intensive care units requires that life-saving critical care must be rationed or “triaged”. Six members of the Ford Government’s own advisory “Bioethics Table” have today published an online statement, set out below, that strongly criticizes Ontario’s critical care triage plans. Their concerns reflect serious objections to Ontario’s triage plans from the disability community, including from the AODA Alliance.

The six bioethicists (who don’t claim to speak for the entire Bioethics Table) urge that the Government should now reveal its secret critical care triage plans to the public, should consult the public, and should hold and open discussion of how critical care should be triaged, if rationing becomes necessary, without treating this as a purely clinical issue or one for bioethicists to monopolize. (Key excerpts also set out below)

These six authors make it clear that Ontario needs a better approach to critical care triage. This is a direct blast at the Ford Government’s persistent secrecy on this issue and its refusal to speak directly to key stakeholders like those from the disability community. We offer the example that the Government has refused to even answer eight detailed letters from the AODA Alliance since last September which identify well-researched objections.

The six bioethicists explain that decisions over who should get life-saving critical care and who should be refused it during critical care triage is not simply a clinical question (i.e. one of medical science alone). Ontario’s secret critical care triage protocol treats this triage as purely a clinical question. The six authors humbly emphasize that bioethicists themselves have no monopoly on wisdom in the area of how critical care triage should be conducted.

These authors urge that it is important to respect the human rights of disadvantaged groups in society. We add that the AODA Alliance and others have been showing for months that Ontario’s plans are replete with disability discrimination, contrary to the Ontario Human Rights Code.

We expect that the Ford Government will answer that the Bioethics Table, of whom these six authors are a part, held consultations with a number of disability advocates, including the AODA Alliance. That would be no answer. Those discussions ended months ago. The external Bioethics Table only gives advice to The Government. The Bioethics Table makes no decisions on how critical care triage should be conducted, and rejected some of our major concerns without giving reasons for doing so. Those in the Government who do make the decisions have steadfastly refused to talk to us. The Government has hidden behind them for months, like human shields.

The secret January 13, 2021 Critical Care Triage Protocol is not available on any Government website, but is available on the AODA Alliance website.

In light of this important statement by several of The Government’s own external advisors, the AODA Alliance calls on the Ford Government to take these four urgent steps:

  1. Now make public the current version of the critical care triage protocol, all reports and recommendations by its external Bioethics Table since September 11, 2021, The Government’s plan of action for rolling out critical care triage if needed, and the results of drills or simulations of critical care triage held at any Ontario hospitals.
  2. Remove disability discrimination from the January 13, 2021 Critical Care Triage Protocol, and
  3. Immediately hold a public consultation on how critical care triage should be conducted.
  4. Introduce legislation on critical care triage for debate in the Legislature, rather than dealing with it by an internal memo to hospitals.

Key statements to this effect by the six bioethicists on the Ford Government’s external Bioethics Table in this article include:

“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.”

“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.”

“Science alone cannot tell us how to allocate ICU beds.”

“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”

“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.”

“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.”

“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.”

Contact: AODA Alliance Chair David Lepofsky, [email protected]

For More Background

  1. The AODA Alliance’s new February 25, 2021 independent report on Ontario’s plans for critical care triage if hospitals are overwhelmed by patients needing critical care.
  2. Ontario’s January 13, 2021 triage protocol.
  3. The eight unanswered letters from the AODA Alliance to the Ford Government on its critical care triage plan, including the AODA Alliance‘s September 25, 2020 letter, its November 2, 2020 letter, its November 9, 2020 letter, its December 7, 2020 letter, its December 15, 2020 letter, its December 17, 2020 letter, its January 18, 2021 letter and its February 25, 2021 letter to Health Minister Christine Elliott.
  4. The Government’s earlier external advisory Bioethics Table’s September 11, 2020 draft critical care triage protocol, finally revealed in December 2020.
  5. The AODA Alliance website’s health care page, detailing its efforts to tear down barriers in the health care system facing patients with disabilities, and our COVID-19 page, detailing our efforts to address the needs of people with disabilities during the COVID-19 crisis.

Healthy Debate April 15, 2021

Originally posted at https://healthydebate.ca/opinions/icu-triage/?utm_source=mailpoet&utm_medium=email&utm_campaign=we-need-to-talk-about-triaging-critical-care_12

Opinion

Public conversation on the ethics of intensive care triage during pandemic is overdue

by Alison Thompson, Paula Chidwick, Lisa Jennifer Schwartz, Stephanie Nixon, Lisa Forman, Robert Sibbald

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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