Exploring the ethics of health care in pandemic times

·5 min read

WALKERTON – The South Bruce Grey Health Centre’s recent meeting of the board of directors featured a special presentation on ethics, by Dr. Robert Butcher.

Butcher is an ethicist based in London. Hospital CEO Michael Barrett said every hospital has an ethicist. Butcher deals with 12-15 hospitals.

“He’s very well-informed,” said Barrett. “He knows the issues.”

SBGHC has an ethics committee that meets monthly.

At the board meeting May 5, Butcher discussed two topics: the pandemic, and MAID (medical assistance in dying).

Regarding MAID, Barrett said, “It happens. It’s important to have someone like him (hospital staff can consult).”

As for COVID-19, Barrett explained that no matter how justified the actions being taken in response to the pandemic, harm is being done. Surgeries are being cancelled; visiting is restricted.

“It will take a long time to get back on track,” he said.

Butcher began his presentation by saying the past year has been “completely unprecedented.”

With the public health emergency, everything changed. “We moved from a patient-centred care model to a public health model.” Butcher explained that with the latter, “individual patients don’t matter – what we care about is the health of the group, the community.”

“We shut the doors to hospitals,” he said.

Infection control measures meant saying, “no, you can’t come in” to people who had been “essential care partners.” Postponing and cancelling surgeries, and preventing people from being with loved ones who are dying are “harms we have caused to stem COVID.”

It hasn’t been easy for staff. Said Butcher, “That’s not the care any of them were trained to provide.”

He likened “the sheer volume of expectations, and rules changing daily,” to Odysseus steering between Scylla and Charybdis (a six-headed sea monster and a murderous whirlpool – steering far enough to avoid one meant getting destroyed by the other). To apply the analogy to the pandemic’s impact on health care, it’s meant “steering between the COVID monster and the mental health impact.”

Board member Jim Bagshaw commented that he’s not sure the transition has been complete.

“We have some of each,” he said.

Butcher said it’s been a challenge with “those patient-centred care physicians in a public health model.”

The ethicist said he hopes it helps those on the front lines to know that they care, but have been asked to change. “We require them to act differently. The burdens we’ve placed on them are tremendous.”

He went on to explain that what happens if intensive care unit (ICU) capacity is exceeded, is a conversation that’s been going on for a year.

Early in the pandemic, in Italy and New York State, decisions were made to save ICU beds “for those most likely to survive.”

The Ontario approach to the debate between “every life is equal” and “those most likely to survive,” he said, is “interestingly and refreshingly clear.”

“Most people think we will dodge that bullet again and be saved from having to make brutal decisions,” he noted.

“Most deaths have been in long-term care, where the average length of time people live is 18 months. Is it valid to use an ICU bed for someone who is not likely to live long?” It’s a choice between “lives saved vs life-years saved.”

Dr. Lisa Roth noted that “we usually have that talk with family when long-term care patients come into the ICU.”

Butcher said conflicts often arise when “families request care that would be futile.” The physician is trying to “steer away people who don’t want to go there anyway.” Should the physician be offering “ICU care to people who wouldn’t benefit?”

He explained his point by saying, “I come in with a problem and the physician offers treatment options that I accept or refuse; I don’t tell the physician what he should be offering.”

John Gilbert, board chair, briefly touched on powers of attorney for personal care. “No extraordinary measures is what most people want.”

Roth said that when people haven’t drawn up such a document and are admitted in a crisis, “the knee-jerk reaction is to do everything.”

Butcher said Ontario legislation makes the person’s decision, through the substitute decision-maker, binding – not the physician’s decision.

Another question that arose was picking and choosing vaccine – the individual’s decision vs the public health model. The public health model stresses commitment to the general good, in other words, take the first vaccine available.

Bagshaw commented that the general public does not understand “relative risk” regarding blood clots from the Astra-Zeneca vaccine.

Said Butcher, “The public health advice should be, ‘Take the bloody shot,’ and that will mean some people get clots.” He noted that’s only a very small number.

Board member Kylie Pike questioned vaccination becoming a requirement for employment.

Butcher spoke of vaccination passports being the “thin end of the wedge” and said travel will provide a “huge commercial pressure” for vaccination. He noted Israel is already requiring a vaccination if a person wants to go to a concert or gym. “That’s the way it will start, then it will go to private sector employers … I would not rule it out, it might creep in.”

Regarding MAID, Butcher said legislation has changed. The requirement for a “natural death being reasonably foreseeable” has been challenged successfully. Now the requirement for a second informed consent can be waived if a person is no longer capable of giving it. He said it means a person may not have to “go sooner than they want to” to ensure they can give that second consent. A person with dementia, for example, can make an arrangement for MAID to be done later.

Pauline Kerr, Local Journalism Initiative Reporter, The Walkerton Herald Times