More on when push comes to shove
One of the drawbacks of writing quickly is that you sometimes think of things later that you wanted to say -- so here goes.
The Canada Health Act has "accessibility" as one of its key principles. The concept of accessibility is glossed to include "without discrimination on the basis of age, health status or financial circumstances." But the Hamilton Health Sciences protocol certainly contains a criterion based on age, may contain one based on health status and also includes criteria related to ocuupation or role. Does this mean that the criteria are contrary to the Canada Health Act?
Thursday, September 24, 2009
Tuesday, September 22, 2009
When push comes to shove, ethical decision-making and the last ventilator...
We seem to be stuck in a bit of a rut discussing pandemic planning issues at the moment, but the issues are pressing and they warrant discussion and debate. Hamilton Health Sciences (in Hamilton Ontario) has just published its triage guidelines which will come into effect if the hospital gets overwhelmed by patients seeking critical care beds – or ventilators, when the supply of such resources is grossly inadequate to meet the demand. (The complete protocol is published in the September issue of “Health Care Quarterly” a short op-ed piece appeared in the Globe and Mail, Sept 21st) The initial stages of triage are relatively unproblematic; a team of experts will assess the patient’s clinical condition and his or her prospects for survival. So far so good, that the patient is likely to benefit has to be the first criterion for access to any treatment. The elements of that assessment include: “1) Does the patient need critical care? 3) Is more than one organ system affected? 4) Does the patient improve with critical care?” (Globe and Mail Sept 21st numbering added) These are the easy criteria, but let us pause for a moment to look at the elements in turn.
The first stages of triage
1) Does the patient need critical care?
This is completely uncontroversial; patients should not be in critical care if they do not need it (and this is as true outside of a pandemic as it is within one.)
2) Does the patient have underlying illnesses that predict a poor outcome?
Taken one way this is also uncontroversial. For instance, if the patient has an underlying disease process that will imminently kill the patient regardless of the success of the treatment for the flu and its aftermath, then treating the flu is futile. (For more on futility see the post June 4th below.) If the patient’s underlying condition means that the flu treatment is unlikely to be successful then again the treatment is very likely to be futile. However, what happens if the patient’s underlying condition is such that he or she will always be bed-bound or ventilator dependent? What happens if, even if the flu treatment is successful, the patient will survive only to a “poor” quality of life? Is this a “poor outcome” from the perspective of the triage decision-maker? The general point here is that it is all too easy for social (or value) type criteria to slip in under the guise of medical or clinical criteria. If question 2 above is a medical question – there is no ethical problem in having the medical experts answer it. But if it is a disguised value-criterion then it warrants clear discussion as to just what is meant by “poor outcome.”
3) Is more than one organ system affected?
It is not clear how this is not an alternative way of asking question 2.
4) Does the patient improve with critical care?
This seems to be a criterion that kicks in only after the patient has been admitted to critical care, or has been granted access to a ventilator. It really concerns when a patient should be removed from critical care (or a ventilator) in favour of someone who could benefit more (or is more likely to benefit.) Again the issue is more general than merely the pandemic situation. When, and how do we decide that continued treatment is pointless (or futile) how do we decide that enough is enough? But here is where the emergency pressures of a pandemic situation kick in. Is the decision that we have tried enough, that the treatment is not working, independent of the pressure to use that ventilator, or critical care bed for someone else? Usually we want to say that medical decisions about treatment for this patient – are made on the basis of this patient’s needs not on the basis of someone else’s needs. Another way of putting this is to say that I want my physician at my bedside to make decisions for my benefit, not for anyone else’s. For example, I do not want my physician to make a decision to deny me access to a treatment from which I might benefit because someone else might benefit more. (This issue is part of a larger discussion too. Just as we often blur medical decisions with value decisions so too we often blur medical decisions with resource reasons. We do, clearly, and not just in a pandemic, need to allocate scarce resources in the most effective means possible. But the general decisions about what treatments should be made available, and the general criteria for access to this service or that, are not simply medical decisions but rather involve social determinants and what we, as a society are willing to pay for.) It is not clear from the criteria as listed whether health care workers are being charged with taking into account, as they decide for patient X, patients Y and Z who might be able to benefit more.
So much for the easy triage decisions....
What happens when “there are many very sick patients who have a good chance of survival but not enough critical care beds or ventilators?”
Hamilton Health Sciences proposes a set of additional criteria:
1) Does the patient belong to a profession that could help save/care for others?
2) Is it likely that the patient became exposed to influenza through their professional duties?
3) Is the patient pregnant or a caregiver for dependents (children under 18, disabled adults or elders)
4) Is there any evidence that the person is significantly more likely to survive than others?
5) Is the patient significantly younger than the others, thus at risk of losing more years of life?
(Globe and Mail Sept 21st)
These criteria introduce elements that are clearly not merely, or indeed, not even, medical. As such they require a far broader discussion, understanding and agreement than expert technical criteria.
Let’s look at them in turn:
1) Does the patient belong to a profession that could help save/care for others?
I wonder what reaction comes to your mind first. On the one hand this looks like a good idea. Just as in a battlefield triage situation you would patch up the fighters first so that they could continue to fight, doesn’t it make sense to keep the carers going so that they can continue to care? But I know that the cynics amongst you will ask – who made these criteria up – surely the very health care professionals who now find themselves at the head of the queue. And what do we mean by “health care professionals?” Front-line staff, nurses, and physicians would clearly be there, but what about administrative staff? What about the managers charged with leading organizations and the community through the tough decisions required in a pandemic? And what about “professionals?” Front line “professionals” cannot do their work without the support of housekeeping, dietary services and so on would people working in these roles be given priority access too?
What do you think? Would you accept this criterion as a fair and just way of allocating a scarce resource? Who would you include in this priority professional list? (Your local MP?) Does it matter that you are (or are not) a member of the health care professions (industry)?
2) Is it likely that the patient became exposed to influenza through their professional duties?
This one is interesting because it looks not to the future (to benefits that might accrue by saving this person rather than that) but instead it looks to the past. It recognises that we, as a community, expect more things from some groups rather than others and, as such, we ought to compensate those people for the additional burdens they carry. Because it looks to the past it has a completely different grounding from moral reasons that look to the future. Most of the criteria used in triage decision-making are forward looking (“consequentialist” in the ethics jargon) they seek to maximise the good by doing those things that are most likely to have the best outcomes – that are most likely to bring about the most good.) This criterion looks back, in effect recognising an obligation to those we ask the most from. It is entirely possible that in following this principle we could, in any particular case make a decision that has worse consequences than an alternative. This type of backward looking reason is unmoved by consequences.
We could take this type of backward looking reason a step further. What happens if there is a programme of vaccination for, for example, health care workers that is encouraged but not mandatory. (See the post Sept 22nd below.) Let’s say you chose not to be vaccinated and you contracted influenza, probably as a result of your close professional contact with a high-risk group. You now need a ventilator. You meet the criterion above – but you chose not to accept a vaccination that could have been useful. Should you have access to the ventilator?
What do you think? Is this a good criterion? Who should it apply to? Should it apply to people who chose not to be vaccinated? What do you think – in general, of introducing backward looking criteria in health care decisions?
3) Is the patient pregnant or a caregiver for dependents (children under 18, disabled adults or elders)
This is another version of the social usefulness criterion that we saw in number 1. In a situation where many require care we should focus our attention on those that provide the care, so that they can return as quickly as possible to their roles as caregivers. But why is providing care to others the principal social role that needs protecting. Wouldn’t we, in a pandemic with the sorts of effects we are dreaming in our nightmares, need police to keep order in the streets, security guards to protect hospitals and stocks of Tamiflu, truck drivers to deliver supplies, funeral directors, morticians and gravediggers, administrators and managers and politicians to make the priority decisions we need to keep things functioning – and on and on and on (oh and ethicists of course to ask the difficult questions.)
Again, what do you think? Are there some occupations or roles that are more important than others in a pandemic situation? If so, what are they and should members of those professions be pushed to the head of the queue?
4) Is there any evidence that the person is significantly more likely to survive than others?
This one seems strangely out of place in this list as it seems to be just an extension of the medical criteria we saw in the first set of triage criteria. But it does take things an interesting step further. Typically we make medical decisions on the basis of need. The first criterion is that the person needs, and could benefit from access to critical care or a ventilator. This ups the ante – now it concerns people who are most likely to benefit. Who would these people be? We don’t know yet, of course, but we can make some educated guesses. In a novel flu strain there may be some benefits to having been exposed to other strains of flu. That is more likely to be the case for people who are older rather than the young. And amongst that older group there would be benefits to being generally healthy. So, as a group it could be the case that older otherwise healthy people would be more likely to survive than others.
So again, what do you think? This is a return to a consequentialist style approach – we are seeking to maximise the good and we do that by treating those most likely to survive.
5) Is the patient significantly younger than the others, thus at risk of losing more years of life?
This again, is a consequentialist form of reasoning. If you save a young person’s life rather than an older person’s you are likely to get a better return, at least in terms of years lived, from the young person who may live a long time, over the older person who has fewer years to live. But is more necessarily better? Is it better to try to save the young delinquent, drug-abusing teenager, over the older, at-the-peak-of-her-career, cancer researcher? Again, what seems straightforward and uncontroversial – a prejudice in favour of the young, seems far more difficult to defend on second reflection.
Conclusions
We are exploring new and dangerous territory. The stated objectives of proposing these triage criteria is to remove the decision from the idiosyncratic whim of an individual triage officer and share the decision amongst a group that in turn can ground the decision in a set of principles. These are important objectives. And, the criteria that are proposed have some common sense behind them – isn’t it a good idea to do the most good that we can – and don’t we, as a community, owe something to those who provide care on our behalf. But, we give up a great deal as we travel in that direction. We pride ourselves on our values of equality and diversity. We do not believe that any one is intrinsically more worthy of social benefit than anyone else, and we celebrate diversity of values and difference in ways of life. In Canadian health care that is put into practice through equality of access and care based on need. If you need the service, and it is available you will be put on a waiting list (which, in effect is a way of fairly distributing a scarce resource through random allocation.) Access to the service does not depend on who you are, ability to pay, or your job or role, or even why or how you contracted the disease in the first place. Should we abandon those principles in the emergency of a pandemic? If we do abandon them we may well achieve a greater good for the community, but at what price to the values that made that community what it is in the first place?
As always I would welcome you comments.
We seem to be stuck in a bit of a rut discussing pandemic planning issues at the moment, but the issues are pressing and they warrant discussion and debate. Hamilton Health Sciences (in Hamilton Ontario) has just published its triage guidelines which will come into effect if the hospital gets overwhelmed by patients seeking critical care beds – or ventilators, when the supply of such resources is grossly inadequate to meet the demand. (The complete protocol is published in the September issue of “Health Care Quarterly” a short op-ed piece appeared in the Globe and Mail, Sept 21st) The initial stages of triage are relatively unproblematic; a team of experts will assess the patient’s clinical condition and his or her prospects for survival. So far so good, that the patient is likely to benefit has to be the first criterion for access to any treatment. The elements of that assessment include: “1) Does the patient need critical care? 3) Is more than one organ system affected? 4) Does the patient improve with critical care?” (Globe and Mail Sept 21st numbering added) These are the easy criteria, but let us pause for a moment to look at the elements in turn.
The first stages of triage
1) Does the patient need critical care?
This is completely uncontroversial; patients should not be in critical care if they do not need it (and this is as true outside of a pandemic as it is within one.)
2) Does the patient have underlying illnesses that predict a poor outcome?
Taken one way this is also uncontroversial. For instance, if the patient has an underlying disease process that will imminently kill the patient regardless of the success of the treatment for the flu and its aftermath, then treating the flu is futile. (For more on futility see the post June 4th below.) If the patient’s underlying condition means that the flu treatment is unlikely to be successful then again the treatment is very likely to be futile. However, what happens if the patient’s underlying condition is such that he or she will always be bed-bound or ventilator dependent? What happens if, even if the flu treatment is successful, the patient will survive only to a “poor” quality of life? Is this a “poor outcome” from the perspective of the triage decision-maker? The general point here is that it is all too easy for social (or value) type criteria to slip in under the guise of medical or clinical criteria. If question 2 above is a medical question – there is no ethical problem in having the medical experts answer it. But if it is a disguised value-criterion then it warrants clear discussion as to just what is meant by “poor outcome.”
3) Is more than one organ system affected?
It is not clear how this is not an alternative way of asking question 2.
4) Does the patient improve with critical care?
This seems to be a criterion that kicks in only after the patient has been admitted to critical care, or has been granted access to a ventilator. It really concerns when a patient should be removed from critical care (or a ventilator) in favour of someone who could benefit more (or is more likely to benefit.) Again the issue is more general than merely the pandemic situation. When, and how do we decide that continued treatment is pointless (or futile) how do we decide that enough is enough? But here is where the emergency pressures of a pandemic situation kick in. Is the decision that we have tried enough, that the treatment is not working, independent of the pressure to use that ventilator, or critical care bed for someone else? Usually we want to say that medical decisions about treatment for this patient – are made on the basis of this patient’s needs not on the basis of someone else’s needs. Another way of putting this is to say that I want my physician at my bedside to make decisions for my benefit, not for anyone else’s. For example, I do not want my physician to make a decision to deny me access to a treatment from which I might benefit because someone else might benefit more. (This issue is part of a larger discussion too. Just as we often blur medical decisions with value decisions so too we often blur medical decisions with resource reasons. We do, clearly, and not just in a pandemic, need to allocate scarce resources in the most effective means possible. But the general decisions about what treatments should be made available, and the general criteria for access to this service or that, are not simply medical decisions but rather involve social determinants and what we, as a society are willing to pay for.) It is not clear from the criteria as listed whether health care workers are being charged with taking into account, as they decide for patient X, patients Y and Z who might be able to benefit more.
So much for the easy triage decisions....
What happens when “there are many very sick patients who have a good chance of survival but not enough critical care beds or ventilators?”
Hamilton Health Sciences proposes a set of additional criteria:
1) Does the patient belong to a profession that could help save/care for others?
2) Is it likely that the patient became exposed to influenza through their professional duties?
3) Is the patient pregnant or a caregiver for dependents (children under 18, disabled adults or elders)
4) Is there any evidence that the person is significantly more likely to survive than others?
5) Is the patient significantly younger than the others, thus at risk of losing more years of life?
(Globe and Mail Sept 21st)
These criteria introduce elements that are clearly not merely, or indeed, not even, medical. As such they require a far broader discussion, understanding and agreement than expert technical criteria.
Let’s look at them in turn:
1) Does the patient belong to a profession that could help save/care for others?
I wonder what reaction comes to your mind first. On the one hand this looks like a good idea. Just as in a battlefield triage situation you would patch up the fighters first so that they could continue to fight, doesn’t it make sense to keep the carers going so that they can continue to care? But I know that the cynics amongst you will ask – who made these criteria up – surely the very health care professionals who now find themselves at the head of the queue. And what do we mean by “health care professionals?” Front-line staff, nurses, and physicians would clearly be there, but what about administrative staff? What about the managers charged with leading organizations and the community through the tough decisions required in a pandemic? And what about “professionals?” Front line “professionals” cannot do their work without the support of housekeeping, dietary services and so on would people working in these roles be given priority access too?
What do you think? Would you accept this criterion as a fair and just way of allocating a scarce resource? Who would you include in this priority professional list? (Your local MP?) Does it matter that you are (or are not) a member of the health care professions (industry)?
2) Is it likely that the patient became exposed to influenza through their professional duties?
This one is interesting because it looks not to the future (to benefits that might accrue by saving this person rather than that) but instead it looks to the past. It recognises that we, as a community, expect more things from some groups rather than others and, as such, we ought to compensate those people for the additional burdens they carry. Because it looks to the past it has a completely different grounding from moral reasons that look to the future. Most of the criteria used in triage decision-making are forward looking (“consequentialist” in the ethics jargon) they seek to maximise the good by doing those things that are most likely to have the best outcomes – that are most likely to bring about the most good.) This criterion looks back, in effect recognising an obligation to those we ask the most from. It is entirely possible that in following this principle we could, in any particular case make a decision that has worse consequences than an alternative. This type of backward looking reason is unmoved by consequences.
We could take this type of backward looking reason a step further. What happens if there is a programme of vaccination for, for example, health care workers that is encouraged but not mandatory. (See the post Sept 22nd below.) Let’s say you chose not to be vaccinated and you contracted influenza, probably as a result of your close professional contact with a high-risk group. You now need a ventilator. You meet the criterion above – but you chose not to accept a vaccination that could have been useful. Should you have access to the ventilator?
What do you think? Is this a good criterion? Who should it apply to? Should it apply to people who chose not to be vaccinated? What do you think – in general, of introducing backward looking criteria in health care decisions?
3) Is the patient pregnant or a caregiver for dependents (children under 18, disabled adults or elders)
This is another version of the social usefulness criterion that we saw in number 1. In a situation where many require care we should focus our attention on those that provide the care, so that they can return as quickly as possible to their roles as caregivers. But why is providing care to others the principal social role that needs protecting. Wouldn’t we, in a pandemic with the sorts of effects we are dreaming in our nightmares, need police to keep order in the streets, security guards to protect hospitals and stocks of Tamiflu, truck drivers to deliver supplies, funeral directors, morticians and gravediggers, administrators and managers and politicians to make the priority decisions we need to keep things functioning – and on and on and on (oh and ethicists of course to ask the difficult questions.)
Again, what do you think? Are there some occupations or roles that are more important than others in a pandemic situation? If so, what are they and should members of those professions be pushed to the head of the queue?
4) Is there any evidence that the person is significantly more likely to survive than others?
This one seems strangely out of place in this list as it seems to be just an extension of the medical criteria we saw in the first set of triage criteria. But it does take things an interesting step further. Typically we make medical decisions on the basis of need. The first criterion is that the person needs, and could benefit from access to critical care or a ventilator. This ups the ante – now it concerns people who are most likely to benefit. Who would these people be? We don’t know yet, of course, but we can make some educated guesses. In a novel flu strain there may be some benefits to having been exposed to other strains of flu. That is more likely to be the case for people who are older rather than the young. And amongst that older group there would be benefits to being generally healthy. So, as a group it could be the case that older otherwise healthy people would be more likely to survive than others.
So again, what do you think? This is a return to a consequentialist style approach – we are seeking to maximise the good and we do that by treating those most likely to survive.
5) Is the patient significantly younger than the others, thus at risk of losing more years of life?
This again, is a consequentialist form of reasoning. If you save a young person’s life rather than an older person’s you are likely to get a better return, at least in terms of years lived, from the young person who may live a long time, over the older person who has fewer years to live. But is more necessarily better? Is it better to try to save the young delinquent, drug-abusing teenager, over the older, at-the-peak-of-her-career, cancer researcher? Again, what seems straightforward and uncontroversial – a prejudice in favour of the young, seems far more difficult to defend on second reflection.
Conclusions
We are exploring new and dangerous territory. The stated objectives of proposing these triage criteria is to remove the decision from the idiosyncratic whim of an individual triage officer and share the decision amongst a group that in turn can ground the decision in a set of principles. These are important objectives. And, the criteria that are proposed have some common sense behind them – isn’t it a good idea to do the most good that we can – and don’t we, as a community, owe something to those who provide care on our behalf. But, we give up a great deal as we travel in that direction. We pride ourselves on our values of equality and diversity. We do not believe that any one is intrinsically more worthy of social benefit than anyone else, and we celebrate diversity of values and difference in ways of life. In Canadian health care that is put into practice through equality of access and care based on need. If you need the service, and it is available you will be put on a waiting list (which, in effect is a way of fairly distributing a scarce resource through random allocation.) Access to the service does not depend on who you are, ability to pay, or your job or role, or even why or how you contracted the disease in the first place. Should we abandon those principles in the emergency of a pandemic? If we do abandon them we may well achieve a greater good for the community, but at what price to the values that made that community what it is in the first place?
As always I would welcome you comments.
Mandatory Vaccinations?
Flu season is imminent and fears of a possible H1N1 flu pandemic are rife. Recent reports from Vancouver Island suggest that there may be the beginnings of an outbreak there; and across Canada and around the world health authorities are gearing up. Those preparations of course include vaccination campaigns and various strategies are being entertained to encourage people, especially health care providers to get vaccinated. But what happens when encouragement is unsuccessful, what happens if too few health care workers agree to get vaccinated? It is unknown what percentage of healthcare workers will choose to get vaccinated this year, but in previous years, despite extensive campaigns, many healthcare organizations report vaccination rates that hover around 50%. New York State has decided to take more drastic action. It will require health care workers to get a vaccination by November 30th a move that has met with concerted opposition – particularly from the unions that represent health-care workers.
So, just what the issues at stake in mandatory vaccinations?
Community Benefit, Personal Risk
The whole point of vaccination is to eliminate, or minimize a particular disease or disorder from a community. The idea, of course, is that if sufficient numbers in a population are immune to a disease then even if that disease enters the community its spread will be limited. So, it is good for a community if its members are vaccinated. However, typically, vaccination is not completely without risk. Some very small proportion of the population may suffer an adverse reaction to the vaccine. In extreme cases the result could be permanent injury, or death. However, from a population perspective, immunity for the group is worth the risk that a very small number of members of the group suffer adverse consequences. It is in the interest of the community that we have vaccination programmes. But, of course, it does not look that way from the perspective of the person who ends up suffering as a result of the vaccine. Paradoxically, from a completely self-interested perspective each individual should wish that everyone else in the community be vaccinated in order to achieve so-called “herd immunity” while he or she does not – thus “free-loading” on the risks taken by others.
Personal risk-benefit analysis
For each individual there is also a personal risk-benefit analysis. On the one hand there is the risk of contracting the disease, on the other hand there is the risk associated with the vaccine. In some cases the risk-benefit analysis is simple. If the disease is catastrophic, and the chances of catching it are high while the known risks of the vaccine are very small, then it may well be prudent for me to have the vaccine. However, at the other end of the spectrum, if the effects of the disease are quite mild, then any risk associated with the vaccine may not be worth taking.
The risk benefit analysis is further complicated for the flu. Otherwise healthy health care workers may have little to fear from contracting the H1N1 virus; the effects on them may be relatively mild. But that is not the case for the vulnerable populations with whom the health care workers work. The more prevalent the H1N1 virus is in the population, and the more prevalent it is especially amongst health care workers, the more likely it is that significant numbers of vulnerable populations will catch the flu: with potentially catastrophic consequences.
Personal Freedom
The other set of arguments that gets offered on this topic tends to be grounded in personal freedom. What gives the state the right to tell me that I have to have a substance injected into my body? What happens to notions of bodily integrity and personal control if it is possible for the state to require an injection? How could the state justify that sort of intrusion into a person’s bodily integrity? (In passing I would suggest that the arguments grounded in religious belief are a sub set of the arguments grounded in personal freedom. It may be a person’s religious beliefs that cause him or her to wish to exercise control over his or her body in this way.)
An employer’s perspective
Let us complicate thing slightly. If an employee is sick, for instance with the flu, then he or she is unable to work. Most health care organizations provide some form of sickness benefits for their employees. If an employee is sick then not only is his or her valuable contribution lost to the community, the employer also has to continue to pay that employee. It is therefore in the interest of the employer to reduce days lost to sickness to a minimum. So, it is in the interest of an employer to encourage vaccination to prevent sickness.
Doing good for others
So far we have looked at this issue solely from a self-interested view, but there is a further, significant perspective. Vaccination for health care workers imposes a small – perhaps negligible personal risk, but the potential benefit for the vulnerable populations served by health care workers is huge. Should we, as health care workers do something with which we may not agree, for the sake of the good it will bring to others? (Pretty clearly I think the answer to that question ought to be a yes...)
Compulsory vaccination
So, we come back to compulsory vaccination. Much is lost if a community, or an organization uses force or power to achieve even a worthwhile or beneficial goal. Individuals are immediately pushed onto the defensive, with a reflexive retreat to “rights” and entitlement (itself a form of power.) We very rapidly get locked into an “us” versus “them” struggle where the real benefits of the programme at hand may be lost in a struggle over power and authority. So, how do we avoid that outcome? I’m sorry to sound a little clichéd here, but the way forward is through good-will and good reasoning. The good-will comes in through a reluctance to use power and a willingness to communicate openly and honestly in a reasoned and evidence-based fashion. The good reasoning will be seen in a thorough-going commitment to the use of the best available evidence. We have lost trust in our civic discourse. We are fearful that we are being deceived, or that the facts are being “spun” to achieve a predetermined outcome. In the health care community we need to rebuild that trust – not blind faith, but a trust grounded in openness and good reasons. The issue of compulsory vaccination for H1N1 for health care workers is one of the issues where we can begin to rebuild the trust in health care. If compulsory vaccination is viewed by some as necessary – just what are the evidential grounds? If some people are going to be required to give up some of their personal freedoms how do we reward them for doing that and how do we compensate them (or their families) in the tragic event that there are adverse consequences for an individual as a result of the pursuit of a community good?
Let us watch, and participate in that discussion, and let each of us be quick to reason and slow to retreat to the exercise of power.
Flu season is imminent and fears of a possible H1N1 flu pandemic are rife. Recent reports from Vancouver Island suggest that there may be the beginnings of an outbreak there; and across Canada and around the world health authorities are gearing up. Those preparations of course include vaccination campaigns and various strategies are being entertained to encourage people, especially health care providers to get vaccinated. But what happens when encouragement is unsuccessful, what happens if too few health care workers agree to get vaccinated? It is unknown what percentage of healthcare workers will choose to get vaccinated this year, but in previous years, despite extensive campaigns, many healthcare organizations report vaccination rates that hover around 50%. New York State has decided to take more drastic action. It will require health care workers to get a vaccination by November 30th a move that has met with concerted opposition – particularly from the unions that represent health-care workers.
So, just what the issues at stake in mandatory vaccinations?
Community Benefit, Personal Risk
The whole point of vaccination is to eliminate, or minimize a particular disease or disorder from a community. The idea, of course, is that if sufficient numbers in a population are immune to a disease then even if that disease enters the community its spread will be limited. So, it is good for a community if its members are vaccinated. However, typically, vaccination is not completely without risk. Some very small proportion of the population may suffer an adverse reaction to the vaccine. In extreme cases the result could be permanent injury, or death. However, from a population perspective, immunity for the group is worth the risk that a very small number of members of the group suffer adverse consequences. It is in the interest of the community that we have vaccination programmes. But, of course, it does not look that way from the perspective of the person who ends up suffering as a result of the vaccine. Paradoxically, from a completely self-interested perspective each individual should wish that everyone else in the community be vaccinated in order to achieve so-called “herd immunity” while he or she does not – thus “free-loading” on the risks taken by others.
Personal risk-benefit analysis
For each individual there is also a personal risk-benefit analysis. On the one hand there is the risk of contracting the disease, on the other hand there is the risk associated with the vaccine. In some cases the risk-benefit analysis is simple. If the disease is catastrophic, and the chances of catching it are high while the known risks of the vaccine are very small, then it may well be prudent for me to have the vaccine. However, at the other end of the spectrum, if the effects of the disease are quite mild, then any risk associated with the vaccine may not be worth taking.
The risk benefit analysis is further complicated for the flu. Otherwise healthy health care workers may have little to fear from contracting the H1N1 virus; the effects on them may be relatively mild. But that is not the case for the vulnerable populations with whom the health care workers work. The more prevalent the H1N1 virus is in the population, and the more prevalent it is especially amongst health care workers, the more likely it is that significant numbers of vulnerable populations will catch the flu: with potentially catastrophic consequences.
Personal Freedom
The other set of arguments that gets offered on this topic tends to be grounded in personal freedom. What gives the state the right to tell me that I have to have a substance injected into my body? What happens to notions of bodily integrity and personal control if it is possible for the state to require an injection? How could the state justify that sort of intrusion into a person’s bodily integrity? (In passing I would suggest that the arguments grounded in religious belief are a sub set of the arguments grounded in personal freedom. It may be a person’s religious beliefs that cause him or her to wish to exercise control over his or her body in this way.)
An employer’s perspective
Let us complicate thing slightly. If an employee is sick, for instance with the flu, then he or she is unable to work. Most health care organizations provide some form of sickness benefits for their employees. If an employee is sick then not only is his or her valuable contribution lost to the community, the employer also has to continue to pay that employee. It is therefore in the interest of the employer to reduce days lost to sickness to a minimum. So, it is in the interest of an employer to encourage vaccination to prevent sickness.
Doing good for others
So far we have looked at this issue solely from a self-interested view, but there is a further, significant perspective. Vaccination for health care workers imposes a small – perhaps negligible personal risk, but the potential benefit for the vulnerable populations served by health care workers is huge. Should we, as health care workers do something with which we may not agree, for the sake of the good it will bring to others? (Pretty clearly I think the answer to that question ought to be a yes...)
Compulsory vaccination
So, we come back to compulsory vaccination. Much is lost if a community, or an organization uses force or power to achieve even a worthwhile or beneficial goal. Individuals are immediately pushed onto the defensive, with a reflexive retreat to “rights” and entitlement (itself a form of power.) We very rapidly get locked into an “us” versus “them” struggle where the real benefits of the programme at hand may be lost in a struggle over power and authority. So, how do we avoid that outcome? I’m sorry to sound a little clichéd here, but the way forward is through good-will and good reasoning. The good-will comes in through a reluctance to use power and a willingness to communicate openly and honestly in a reasoned and evidence-based fashion. The good reasoning will be seen in a thorough-going commitment to the use of the best available evidence. We have lost trust in our civic discourse. We are fearful that we are being deceived, or that the facts are being “spun” to achieve a predetermined outcome. In the health care community we need to rebuild that trust – not blind faith, but a trust grounded in openness and good reasons. The issue of compulsory vaccination for H1N1 for health care workers is one of the issues where we can begin to rebuild the trust in health care. If compulsory vaccination is viewed by some as necessary – just what are the evidential grounds? If some people are going to be required to give up some of their personal freedoms how do we reward them for doing that and how do we compensate them (or their families) in the tragic event that there are adverse consequences for an individual as a result of the pursuit of a community good?
Let us watch, and participate in that discussion, and let each of us be quick to reason and slow to retreat to the exercise of power.
Tuesday, September 8, 2009
Flu, Pandemics and the Duty to Provide Care
It is back-to-school time – and back-to-school heralds the beginning of the flu season and triggers worries about the return of the H1N1 virus. Most of the health care organizations I work with in Ontario have been engaged for some time in a process of pandemic planning, a “what-if” planning exercise that seeks to prepare organizations for at least some of the eventualities that will unfurl in the event of a debilitating pandemic.
There are many ethical issues that require discussion as one plans for a pandemic, I want to mention one and go a little further into another. First, the mention:
Modes of health care – from patient centred care to public health
One of the great lessons from SARS in Ontario was the way in which the form of delivery and the modes of thinking changed during SARS. Before SARS the slogan in many facilities was “patient (client) centred (focussed) care. This is a development of the standard model of health care delivery. In this model, the primary relationship is between the patient, who presents with his or her symptoms and the care-giver (archetypically the physician) who diagnoses and prescribes. The model is individualistic and rights-based, with the patient or client at the heart of the enterprise and with a great deal of scope and authority for the individual physician to practise. But, of course, as SARS unfolded that model of health care and those ways of thinking were abandoned. Instead the model of health care switched to something far more like public health. Instead of the individual patient standing at the centre of the health care relationship, the dominant relationship became that between the community, and an enemy – in this case the bug. And, health care workers became the front line troops in that battle. That shift of emphasis necessitated a whole series of changes in behaviour. The rights of individual patients (to have visitors for instance) were abandoned, and physicians and others lost a great deal of their authority to practise as they saw appropriate. (You have to wear a mask...) I’m not sure that we have fully recognised the impact of that shift nor articulated its effects. That shift will occur again in the next pandemic. It will have to. In a community emergency the rights of each individual will be held to be of less account than the needs of the many. That is as it should be – however, we will need to exercise the greatest vigilance to understand what we are doing and why – to minimize the loss of rights and to reinstate those rights at the earliest opportunity.
If that is just a mention, let’s move on to look at the “duty to provide care.”
The duty to provide care.
Normally when this issue gets discussed it is in the context of a duty on health care workers to provide care to others even under conditions of personal risk. Again, one of the lessons from SARS was that even though that disease was primarily a disease of health care workers, care providers continued to work even under conditions of personal risk. Is there a “duty” to provide care and to whom does that duty apply. That tends to be where we start, but I am not sure that is the most interesting question to ask on this topic. It seems pretty clear that there is some sort of duty on health care workers to provide care. Health care is a “special” enterprise which is proudly unlike other more commercially oriented activities. Health care workers will often speak of a “calling” or an “avocation” and of being motivated by a desire to help others and serve the community. In that respect it is not unlike the police and emergency services – or indeed the armed forces. We would look quite askance at the police officer or member of the military who refused to serve because it was risky. So, if there is a duty – what are its limits?
In a number of hospitals with which I work we have had a series of conversations about pandemic planning, and the question of the ”duty to provide care” surfaces in a different form. Let me put it like this. Imagine you are a nurse, and as a nurse you recognize that you have a duty to provide care. It is your job – and you are obliged to go in to work. But let us also imagine that you are a Mum. Your duty as a Mum is to care for your children, what happens when those two duties collide?
It is worth saying at the outset that this moral dilemma is not one that can be solved by looking to professional ethics. The duty of the nurse – as a nurse, is to provide care, but the personal obligation – if you like the duty of the Mother, is to take care of her children. They are both moral (or ethical) obligations that arise from two roles the person has. Nor has the person done anything wrong to create this situation. She just has more than one role (as many, or indeed all of us do.) But let us imagine she can’t do both. What will she do? Is there a “should” here? We haven’t detailed the situation, and it is easy to imagine cases that fall along the entire spectrum. At either end of the spectrum there will be situations where it is clear that anyone should do one thing rather than another – the negative impact on the children is very minor and the benefits you bring to your community by going to work are very great – and vice versa. But what happens in the great grey mass of cases in the middle. How does that individual person decide what she (or he) will do? (I don’t think this conversation necessarily presupposes one gender or another, I’m more interested in looking at the roles people play and the obligations that arise through those roles.)
It is at this point that the discussion inevitably takes a more interesting and more practical turn. The organizations doing the pandemic planning, and the communities they serve, have an interest in getting their care providers to come to work – so how do they help them do that? How do organizations support their workers so that those workers can take care of their family and other responsibilities and still, wherever possible, be able to come to work? The turn, then, is from what looks like a question of professional ethics, its impact on the individual, and a puzzle about how to motivate people to do their duty; to a genuine moral dilemma which pits two extremely important ethical values or principles against each other. So that brings us to the practical questions. What steps are individuals taking in their personal lives to attempt to ensure that their personal obligations are taken care of in a pandemic, and secondly what steps are the organization taking to try to create the conditions that make it as likely as possible that people will be able to come to work?
It is back-to-school time – and back-to-school heralds the beginning of the flu season and triggers worries about the return of the H1N1 virus. Most of the health care organizations I work with in Ontario have been engaged for some time in a process of pandemic planning, a “what-if” planning exercise that seeks to prepare organizations for at least some of the eventualities that will unfurl in the event of a debilitating pandemic.
There are many ethical issues that require discussion as one plans for a pandemic, I want to mention one and go a little further into another. First, the mention:
Modes of health care – from patient centred care to public health
One of the great lessons from SARS in Ontario was the way in which the form of delivery and the modes of thinking changed during SARS. Before SARS the slogan in many facilities was “patient (client) centred (focussed) care. This is a development of the standard model of health care delivery. In this model, the primary relationship is between the patient, who presents with his or her symptoms and the care-giver (archetypically the physician) who diagnoses and prescribes. The model is individualistic and rights-based, with the patient or client at the heart of the enterprise and with a great deal of scope and authority for the individual physician to practise. But, of course, as SARS unfolded that model of health care and those ways of thinking were abandoned. Instead the model of health care switched to something far more like public health. Instead of the individual patient standing at the centre of the health care relationship, the dominant relationship became that between the community, and an enemy – in this case the bug. And, health care workers became the front line troops in that battle. That shift of emphasis necessitated a whole series of changes in behaviour. The rights of individual patients (to have visitors for instance) were abandoned, and physicians and others lost a great deal of their authority to practise as they saw appropriate. (You have to wear a mask...) I’m not sure that we have fully recognised the impact of that shift nor articulated its effects. That shift will occur again in the next pandemic. It will have to. In a community emergency the rights of each individual will be held to be of less account than the needs of the many. That is as it should be – however, we will need to exercise the greatest vigilance to understand what we are doing and why – to minimize the loss of rights and to reinstate those rights at the earliest opportunity.
If that is just a mention, let’s move on to look at the “duty to provide care.”
The duty to provide care.
Normally when this issue gets discussed it is in the context of a duty on health care workers to provide care to others even under conditions of personal risk. Again, one of the lessons from SARS was that even though that disease was primarily a disease of health care workers, care providers continued to work even under conditions of personal risk. Is there a “duty” to provide care and to whom does that duty apply. That tends to be where we start, but I am not sure that is the most interesting question to ask on this topic. It seems pretty clear that there is some sort of duty on health care workers to provide care. Health care is a “special” enterprise which is proudly unlike other more commercially oriented activities. Health care workers will often speak of a “calling” or an “avocation” and of being motivated by a desire to help others and serve the community. In that respect it is not unlike the police and emergency services – or indeed the armed forces. We would look quite askance at the police officer or member of the military who refused to serve because it was risky. So, if there is a duty – what are its limits?
In a number of hospitals with which I work we have had a series of conversations about pandemic planning, and the question of the ”duty to provide care” surfaces in a different form. Let me put it like this. Imagine you are a nurse, and as a nurse you recognize that you have a duty to provide care. It is your job – and you are obliged to go in to work. But let us also imagine that you are a Mum. Your duty as a Mum is to care for your children, what happens when those two duties collide?
It is worth saying at the outset that this moral dilemma is not one that can be solved by looking to professional ethics. The duty of the nurse – as a nurse, is to provide care, but the personal obligation – if you like the duty of the Mother, is to take care of her children. They are both moral (or ethical) obligations that arise from two roles the person has. Nor has the person done anything wrong to create this situation. She just has more than one role (as many, or indeed all of us do.) But let us imagine she can’t do both. What will she do? Is there a “should” here? We haven’t detailed the situation, and it is easy to imagine cases that fall along the entire spectrum. At either end of the spectrum there will be situations where it is clear that anyone should do one thing rather than another – the negative impact on the children is very minor and the benefits you bring to your community by going to work are very great – and vice versa. But what happens in the great grey mass of cases in the middle. How does that individual person decide what she (or he) will do? (I don’t think this conversation necessarily presupposes one gender or another, I’m more interested in looking at the roles people play and the obligations that arise through those roles.)
It is at this point that the discussion inevitably takes a more interesting and more practical turn. The organizations doing the pandemic planning, and the communities they serve, have an interest in getting their care providers to come to work – so how do they help them do that? How do organizations support their workers so that those workers can take care of their family and other responsibilities and still, wherever possible, be able to come to work? The turn, then, is from what looks like a question of professional ethics, its impact on the individual, and a puzzle about how to motivate people to do their duty; to a genuine moral dilemma which pits two extremely important ethical values or principles against each other. So that brings us to the practical questions. What steps are individuals taking in their personal lives to attempt to ensure that their personal obligations are taken care of in a pandemic, and secondly what steps are the organization taking to try to create the conditions that make it as likely as possible that people will be able to come to work?
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