Francoise Baylis argues that access to life-saving treatment should not be determined by geography.
In the early days of the COVID-19 pandemic, many worried that our health care system — already near (or at) capacity in terms of space, supplies, and staff would be overwhelmed with a surge in infected patients. In anticipation of increased demand for hospital beds, ICU beds, mechanical ventilators, critical care staff, and respiratory therapists, clinical care triage protocols were developed. These protocols provide clinicians with direction on priority setting among patients in times of scarcity. When healthcare resources are limited and patients might die as a consequence of not getting access to life-saving treatment, triage protocols determine who lives and who dies.
To my knowledge, no Canadian health care institution has been called upon to use its triage protocol. This is a very good thing. But should that day come, one thing that worries me is the multiplicity and variably of the triage protocols across Canada. To put in bluntly – in my opinion we have too many localized triage protocols for our own good. I say this without even knowing the total number of triage protocols that exist in Canada at departmental, institutional, regional, or provincial levels.
Canada needs one triage protocol for the COVID-19 pandemic. This is advisable for a number of pragmatic reasons: to promote efficiency, to ensure access to the best available policy-making expertise, and to avoid chaos, confusion and righteous anger. More importantly, this is ethically imperative to ensure fairness and non-discrimination.
Many Canadian families are spread across this country. I live in Halifax, Nova Scotia. I have immediate family in New Brunswick, Quebec, Ontario, Alberta, and British Columbia. Should I or anyone of my family members contract COVID-19, I would not want to learn that in this time of shared crisis, access to life-saving treatment was determined by geography. Imagine, for example, learning that a parent or sibling was denied access to a ventilator on the basis of age or disability, when they would have had access if they lived in a different province, or were at a different healthcare institution in the same province. Neither the distribution nor the withdrawal of life-saving treatment should depend on one’s postal code.
Canadians have provincial allegiances, of this there is no doubt. But many of us are first and foremost Canadians. This is especially so as concerns our commitment to government-funded health care. Though we have long tolerated provincial differences in the delivery of healthcare, now is the time to address this fundamental injustice. With death potentially staring all of us in the face, there is now a dramatic incentive to promote fairness and equity in our health care systems.
In a recent article in the New England Journal of Medicine on “Fair Allocation of Scarce Medical Resources in the Time of Covid-19” colleagues outline four values and guiding principles: maximize benefits; treat people equally; promote and reward instrumental value; and give priority to the worse off. From these values and principles they derive six discrete recommendations for the allocation of scarce resources: ensure the responsible stewardship of resources in efforts to save the most lives and the most life years; give priority to front-line health care workers and others caring for ill patients; allocate available resources among patients with a similar prognosis using a random selection, such as a lottery as this best serves the commitment to equality; rely on scientific evidence for the distribution of different resources; give priority to those who put themselves in harms way by volunteering to participate in research; and do not discriminate between COVID-19 patients and non-COVID-19 patients with other health conditions who require access to the same resources.
This is a reasonable starting point for discussion about the elements of a fair, socially just, non-discriminatory, national policy for both the distribution and the withdrawal of scarce critical-care resources. But this is only a starting point. There is obvious tension between maximizing benefit (utility) and treating people equally (fairness). There is, for example, a significant difference between saving the most lives and saving the most life years. As well, the commitment to promote and reward instrumental value is both complicated and contested.
This call for a national triage policy is a significant political challenge given the constitutional division of powers in Canada where health is largely a provincial/territorial responsibility. But it is a call our governments must answer. Triage protocols are harbingers of death and we simply can’t risk a decentralized response where who lives and who dies is based on geography.