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How ethics will support Horizon’s response to COVID-19 outbreak

Tim Christie Blog

My name is Dr. Timothy Christie. I'm the Regional Director of Ethics Services and I'm the Chair of the COVID-19 Ethics Committee at Horizon Health Network. 

I'm writing this blog because I thought it might be helpful to explain the difference between normal "clinical ethics" and the tragic choices that we might have to make during a pandemic. I truly hope that we never have to resort to a "Pandemic Ethic," however, if this transition becomes necessary, it will be imperative to try and save as many lives as possible.

Normal Clinical Ethics

Under normal circumstances the health care professional and patient relationship is rooted in the best-interest principle: Everything the professional does is motivated by the desire to do what is best for the patient. This means that all other motivations are either ignored or are of lesser importance.  For example, the recommendation to put a patient on a ventilator is motivated exclusively by the needs of the patient, not the available resources. We try to provide the patient with whatever treatments are consistent with their values, beliefs and life-goals regardless of the expected outcome and regardless of the cost.

COVID-19 Pandemic

The COVID-19 Pandemic is expected to create many different ethical issues. One of the more disturbing problems is that at some point, there may be more patients requiring invasive mechanical ventilation (i.e., ventilators) than there will be ventilators available; in other words, the demand may greatly exceed the supply.

Mechanical Ventilation

Providing ventilator treatment to a patient is complex; it requires highly-trained/technical staff, the patient is typically sedated, and the patient requires careful monitoring in an intensive care unit (ICU).

Pandemic Ethics

If we follow normal clinical ethics during a pandemic situation, two things are expected: first, we might end up providing a ventilator to a patient expected to have a bad outcome, and secondly, we might not have ventilators available for those expected to have good outcomes. The patient-centered approach of normal clinical ethics could be counter productive in a pandemic. Therefore, in a pandemic situation we must adopt a "public health ethic," which emphasizes the principles of "effectiveness" and "equity." 

  • Effectiveness means to prioritize patients we expect to have the best outcomes at the lowest cost. For example, if one patient is so sick that they might require prolonged ventilator support and the second patient is expected to need only 10 to 14 days of ventilator support, then the principle of effectiveness states that we should prioritize the second patient over the first. (Even if the first has a chance of survival if we had the resources.)
  • Equity refers to the fair distribution of benefits and burdens. Put another way, we should not discriminate unfairly against groups simply to facilitate our goal of achieving "effective" results. We must be equitable, fair, non-discriminatory, non-arbitrary, unbiased, etc.

Conclusion

A pandemic ethics approach means that, because of resource limitations, we might not have enough resources to save lives that under normal conditions could have been saved. I sincerely hope that our public health interventions, like voluntary self-isolation and social distancing work, and that we never have to resort to "Pandemic Ethics."

However, if we reach the point where Pandemic Ethics are necessary, we must realize that although these will be very difficult and tragic decisions, more people will die if we continue with the approach of "Normal Clinical Ethics" rather than Pandemic Ethics.

 

 

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