When safety and confidentiality collide.
How do we decide what to do?
Many organizations, in Ontario in particular, are reviewing their policies to enhance patient and staff safety. Recent legislation has required health care organizations to rethink their attitudes to risk and to take positive steps to protect workers and patients from violence and other risks to health. At a recent ethics committee meeting at a small hospital in rural Ontario the patient safety co-ordinator brought forward two proposals for discussion.
The first concerned the spread of infection, in particular antibiotic resistant organisms. The proposal was to identify patients who had tested positive for MRSA, VRE or C. Difficile by highlighting their names on their identification wristband. (Alternatives had been suggested such as coloured wristbands, but the method of highlighting had been proposed as the least intrusive option.) Easy visual identification of a patient who had tested positive for these infections would allow the staff who came into contact with that patient to take additional precautions as required.
The second concerned patients who had a history of violence. The proposal here was to have such patients wear a white wristband. The reasoning here was the same: staff (and patients, volunteers and visitors?) would readily be able to identify a patient who was believed to have the potential for future violence and they would be able to take steps to protect themselves.
In each of these proposals there is a clear clash between the desire to promote safety and the rights of a patient to privacy and confidentiality. Under what circumstances should safety and the minimisation of risk trump a patient’s expectations of, or rights to, privacy?
What do you think?
Thursday, September 16, 2010
Friday, April 16, 2010
Evidence, Ethics and Responsible Care
A radically innovative “treatment” approach to MS has sparked worldwide interest and huge demand for a surgery that has not been “proven” to bring a benefit for MS sufferers. I will not go into the details of the proposed “treatment” here but rather look at the issues of ethics, evidence and responsibility that are raised by this situation and situations like it.
Evidence
In most (all) areas of human endeavour we do things for reasons. So, if I perform some action or another you could ask “Why?” and could reasonably expect a reply that would give my reasons. Typically those reasons would consist of something like an outcome I wished to achieve and some method for reaching that outcome. “Why did you go to the store?” “To buy curry powder.” “Why did you want curry powder?” “To make curry for dinner.” And so on. Indeed in health care one of the ways that a professional would evaluate a person’s capacity to make health care decisions would be on the basis of the person’s ability to undertake this sort of means-ends reasoning; identifying intelligible goals and appropriate methods of achieving those goals. In everyday life we accept quite a wide range of goals as intelligible and quite a wide range of types as reasons as possible methods of achieving those goals. In health care in general, however, and more specifically in medicine, the goals are more restricted – health or physical outcomes or states, and the reasons given have come to be called “evidence.” “Why did you prescribe that drug?” “Because it increases blood flow.” “Why did you want to increase blood flow?” “Because it will increase oxygen uptake which will ease the patient’s symptoms of shortness of breath, which will allow him to perform more of his everyday activities.” The key question here, however, is what would count as evidence for the claim that this drug, or other form of treatment, will have this outcome. What counts as evidence (or good evidence) that this “X” causes that “Y?”
It is worth reiterating that the standards of evidence in medicine (and indeed the standards of evidence in professional life generally) are quite different from the standards, or indeed what might even be counted as evidence, that might be acceptable in ordinary life. That is because the professional – in this case the physician or other health care professional stands in a special “fiduciary” relationship to the patient (or client.) Professionals – and let’s use the example of physicians, have undergone a specialised training and licensing process which confers on them an expert status. They have been trained in the methods of their profession and they are committed to practising within the professional guidelines and standards of that profession. In medicine the standards of professional practice require that medical decision-making be “evidence based.” A physician – as physician cannot prescribe a drug because he or she thinks the stars are in appropriate alignment, or because he or she had a dream which suggested this drug, or because the drug manufacturer has paid him or her to do so. The physician is bound by standards of good professional practice only to prescribe the drug or other treatment, which, on the evidence, is likely to cause the outcome which is desired.
So far so good. But what counts as evidence of the causal efficacy of a drug or other treatment? This is an area for some debate. The so called “gold standard” for evidence in medicine is a randomised clinical trial performed on a suitably large group of suitably diverse subjects for an appropriate length of time. The reason for randomised clinical trials is that this is the best method we have devised of isolating the causal effects of the drug or other intervention on the outcome we are measuring. The assumption is that randomisation, over sufficiently large numbers will even out the background noise of naturally occurring variation to allow the true causal effect to shine through. The idea is that with a well-designed clinical trial we will be able to say with a certain degree of confidence (typically 95%) that the effect “Y” is caused by the intervention “X.” (More precisely that the effect “Y” is not attributable to chance.) Perhaps we should add a word on confidence. Certainty, the absolute, cannot- be- wrong, kind that can be found in mathematics, is not to be found anywhere in medicine. The best we get are probabilities. Clinical trials are designed so that we can make causal statements with a high degree of probability. A clinical trial is designed so that we can make causal statements with a high degree of confidence that the effects we have observed are very unlikely to have been caused by chance. (Typically only a 1 in 20, 1 in 100 or 1 in a 1000 possibility that the observed effect was caused by chance and not the effect of the drug or intervention under study. )
The other significant component of a clinical trial in medicine is the search for possible side effects. Not only does the drug or intervention have to be effective, but its side effects must be sufficiently slight or unlikely that the anticipated benefit outweighs the possible negative side effects. Again, trials are designed to be able to maximise the chances of identifying possible negative side effects.
So, the good clinician will only prescribe treatments or interventions for which there is good evidence.
Radical Innovations
But what happens when something new comes along? What happens when someone proposes or discovers a radically new way of thinking about – and approaching a disease or condition? In the first instance the demand will be for evidence. What are the reasons to believe that this proposed approach will bring about the effects that are intended? Why should we think this will work? In some cases the initial answer to this question is that the new approach builds on ways that the disease is understood, and works by extending or developing existing approaches. In cases like this the development is incremental, we would still need evidence in order to proceed, but the search for that evidence would typically fit into the research programmes that already exist. What happens when the approach is radically different and requires a new way of thinking about the disease and is treatment. This situation is far more difficult, because on top of the standard demands for evidence there is the added layer of what could be thought of as the sociology and psychology of medical and scientific practice. If you have spent your life and research efforts exploring a disease using one approach you may not be the best person to evaluate a radically new approach which basically undercuts your life’s work. That is not to impute bad faith to anyone – just to recognise that we approach problems from a particular perspective and within a particular framework or paradigm. Those working within that framework or paradigm may well find it extremely difficult to appreciate, understand, accept or evaluate an approach to the problem that employs a different framework or paradigm. On the flip side, those advocating the revolutionary approach may well – at this stage, be doing so without sufficient evidence to make the new paradigm or framework compelling. What plays out is a scientific (and sometimes small “p” political) debate and the search for more and better evidence. But that is the scientific debate. What about the physician – the practitioner who faces demands from her patients for an unproven therapy?
Responsible Practice
Responsible practice requires evidence. In the cases we are discussing, by hypothesis, the evidence is insufficient to warrant a change in the way in which care is standardly provided. That is, there is not a consensus on the standards of good practice that has changed the current approaches. In practical terms this means that the expert bodies in the relevant areas are not recommending a change in practice. The “evidence” for the new approach may be anecdotal or theoretical but is not yet validated or accepted. The good practitioner should monitor the evidence and the debate as it emerges and may well wish to participate in research and clinical trials to seek evidence one way or the other. The responsible practitioner recognises that standards of good care are community decisions – the community being the expert practitioners engaged in the collaborative enterprises that are science and medicine. Does this mean that sometimes individuals will be harmed because of the relatively slow adoption of new treatment approaches (that in fact turn out to be successful) as we wait for the evidence of effectiveness and safety to accumulate? Undoubtedly yes. But the flip side is that if we introduce new approaches too soon we will harm people either by performing treatments and interventions that are simply ineffective, or by causing side effects both known and unknown.
The patient’s perspective
So far we have looked at this issue from the perspective of the medical practitioner and the scientist behind that practice. The perspective of the patient may well be completely different. That is, if the disease I face is sufficiently debilitating it may well make sense to me to try anything that holds any prospect of success. It may well be rational for the drowning man to clutch at straws. If I am going to die I may (quite rationally) wish to try anything I think may save my life. And, if we go back to the point at which we started I am under no compulsion to have “evidence” for my belief or desired. I may wish to try shark’s cartilage, or grapes or I may wish to pray or bathe in a particular pool. I am entitled to have my own beliefs and my own reasons for those beliefs, and those beliefs or reasons do not need to fit within the canons of contemporary science. I may also be quite willing to undergo any risk of known or unknown side effects. And, if the treatment or intervention I seek is under the control of my medical practitioner – which it may well be (for instance if it is a drug or controlled substance or a surgical intervention) I may seek to pressure him or her to provide me with that treatment. What should the patient-focussed , caring practitioner do under those circumstances?
I think this question takes us right back to questions of responsible practice. I believe the physician or other medical practitioner practices within a community of good care and professional standards. I believe that community determines what constitutes good care, professional practice and appropriate types of evidence. Which leaves the practitioner in a really tough spot, having to say no to a desperate patient as he or she clutches at straws.
I realise that this leaves many things unsaid – we have not discussed the ways in which responsible researchers may choose, in effect on ethical grounds, to stop a clinical trial early (either because the results are especially good, or because the side effects appear unacceptably bad). Nor have we discussed the added pressures which arise within a publicly funded health care system. In such a system the medical practitioner has an additional commitment not to waste scarce resources (for instance by pursuing unproven or highly unlikely treatments.) But we will leave those topics for another time.
What do you think?
Evidence
In most (all) areas of human endeavour we do things for reasons. So, if I perform some action or another you could ask “Why?” and could reasonably expect a reply that would give my reasons. Typically those reasons would consist of something like an outcome I wished to achieve and some method for reaching that outcome. “Why did you go to the store?” “To buy curry powder.” “Why did you want curry powder?” “To make curry for dinner.” And so on. Indeed in health care one of the ways that a professional would evaluate a person’s capacity to make health care decisions would be on the basis of the person’s ability to undertake this sort of means-ends reasoning; identifying intelligible goals and appropriate methods of achieving those goals. In everyday life we accept quite a wide range of goals as intelligible and quite a wide range of types as reasons as possible methods of achieving those goals. In health care in general, however, and more specifically in medicine, the goals are more restricted – health or physical outcomes or states, and the reasons given have come to be called “evidence.” “Why did you prescribe that drug?” “Because it increases blood flow.” “Why did you want to increase blood flow?” “Because it will increase oxygen uptake which will ease the patient’s symptoms of shortness of breath, which will allow him to perform more of his everyday activities.” The key question here, however, is what would count as evidence for the claim that this drug, or other form of treatment, will have this outcome. What counts as evidence (or good evidence) that this “X” causes that “Y?”
It is worth reiterating that the standards of evidence in medicine (and indeed the standards of evidence in professional life generally) are quite different from the standards, or indeed what might even be counted as evidence, that might be acceptable in ordinary life. That is because the professional – in this case the physician or other health care professional stands in a special “fiduciary” relationship to the patient (or client.) Professionals – and let’s use the example of physicians, have undergone a specialised training and licensing process which confers on them an expert status. They have been trained in the methods of their profession and they are committed to practising within the professional guidelines and standards of that profession. In medicine the standards of professional practice require that medical decision-making be “evidence based.” A physician – as physician cannot prescribe a drug because he or she thinks the stars are in appropriate alignment, or because he or she had a dream which suggested this drug, or because the drug manufacturer has paid him or her to do so. The physician is bound by standards of good professional practice only to prescribe the drug or other treatment, which, on the evidence, is likely to cause the outcome which is desired.
So far so good. But what counts as evidence of the causal efficacy of a drug or other treatment? This is an area for some debate. The so called “gold standard” for evidence in medicine is a randomised clinical trial performed on a suitably large group of suitably diverse subjects for an appropriate length of time. The reason for randomised clinical trials is that this is the best method we have devised of isolating the causal effects of the drug or other intervention on the outcome we are measuring. The assumption is that randomisation, over sufficiently large numbers will even out the background noise of naturally occurring variation to allow the true causal effect to shine through. The idea is that with a well-designed clinical trial we will be able to say with a certain degree of confidence (typically 95%) that the effect “Y” is caused by the intervention “X.” (More precisely that the effect “Y” is not attributable to chance.) Perhaps we should add a word on confidence. Certainty, the absolute, cannot- be- wrong, kind that can be found in mathematics, is not to be found anywhere in medicine. The best we get are probabilities. Clinical trials are designed so that we can make causal statements with a high degree of probability. A clinical trial is designed so that we can make causal statements with a high degree of confidence that the effects we have observed are very unlikely to have been caused by chance. (Typically only a 1 in 20, 1 in 100 or 1 in a 1000 possibility that the observed effect was caused by chance and not the effect of the drug or intervention under study. )
The other significant component of a clinical trial in medicine is the search for possible side effects. Not only does the drug or intervention have to be effective, but its side effects must be sufficiently slight or unlikely that the anticipated benefit outweighs the possible negative side effects. Again, trials are designed to be able to maximise the chances of identifying possible negative side effects.
So, the good clinician will only prescribe treatments or interventions for which there is good evidence.
Radical Innovations
But what happens when something new comes along? What happens when someone proposes or discovers a radically new way of thinking about – and approaching a disease or condition? In the first instance the demand will be for evidence. What are the reasons to believe that this proposed approach will bring about the effects that are intended? Why should we think this will work? In some cases the initial answer to this question is that the new approach builds on ways that the disease is understood, and works by extending or developing existing approaches. In cases like this the development is incremental, we would still need evidence in order to proceed, but the search for that evidence would typically fit into the research programmes that already exist. What happens when the approach is radically different and requires a new way of thinking about the disease and is treatment. This situation is far more difficult, because on top of the standard demands for evidence there is the added layer of what could be thought of as the sociology and psychology of medical and scientific practice. If you have spent your life and research efforts exploring a disease using one approach you may not be the best person to evaluate a radically new approach which basically undercuts your life’s work. That is not to impute bad faith to anyone – just to recognise that we approach problems from a particular perspective and within a particular framework or paradigm. Those working within that framework or paradigm may well find it extremely difficult to appreciate, understand, accept or evaluate an approach to the problem that employs a different framework or paradigm. On the flip side, those advocating the revolutionary approach may well – at this stage, be doing so without sufficient evidence to make the new paradigm or framework compelling. What plays out is a scientific (and sometimes small “p” political) debate and the search for more and better evidence. But that is the scientific debate. What about the physician – the practitioner who faces demands from her patients for an unproven therapy?
Responsible Practice
Responsible practice requires evidence. In the cases we are discussing, by hypothesis, the evidence is insufficient to warrant a change in the way in which care is standardly provided. That is, there is not a consensus on the standards of good practice that has changed the current approaches. In practical terms this means that the expert bodies in the relevant areas are not recommending a change in practice. The “evidence” for the new approach may be anecdotal or theoretical but is not yet validated or accepted. The good practitioner should monitor the evidence and the debate as it emerges and may well wish to participate in research and clinical trials to seek evidence one way or the other. The responsible practitioner recognises that standards of good care are community decisions – the community being the expert practitioners engaged in the collaborative enterprises that are science and medicine. Does this mean that sometimes individuals will be harmed because of the relatively slow adoption of new treatment approaches (that in fact turn out to be successful) as we wait for the evidence of effectiveness and safety to accumulate? Undoubtedly yes. But the flip side is that if we introduce new approaches too soon we will harm people either by performing treatments and interventions that are simply ineffective, or by causing side effects both known and unknown.
The patient’s perspective
So far we have looked at this issue from the perspective of the medical practitioner and the scientist behind that practice. The perspective of the patient may well be completely different. That is, if the disease I face is sufficiently debilitating it may well make sense to me to try anything that holds any prospect of success. It may well be rational for the drowning man to clutch at straws. If I am going to die I may (quite rationally) wish to try anything I think may save my life. And, if we go back to the point at which we started I am under no compulsion to have “evidence” for my belief or desired. I may wish to try shark’s cartilage, or grapes or I may wish to pray or bathe in a particular pool. I am entitled to have my own beliefs and my own reasons for those beliefs, and those beliefs or reasons do not need to fit within the canons of contemporary science. I may also be quite willing to undergo any risk of known or unknown side effects. And, if the treatment or intervention I seek is under the control of my medical practitioner – which it may well be (for instance if it is a drug or controlled substance or a surgical intervention) I may seek to pressure him or her to provide me with that treatment. What should the patient-focussed , caring practitioner do under those circumstances?
I think this question takes us right back to questions of responsible practice. I believe the physician or other medical practitioner practices within a community of good care and professional standards. I believe that community determines what constitutes good care, professional practice and appropriate types of evidence. Which leaves the practitioner in a really tough spot, having to say no to a desperate patient as he or she clutches at straws.
I realise that this leaves many things unsaid – we have not discussed the ways in which responsible researchers may choose, in effect on ethical grounds, to stop a clinical trial early (either because the results are especially good, or because the side effects appear unacceptably bad). Nor have we discussed the added pressures which arise within a publicly funded health care system. In such a system the medical practitioner has an additional commitment not to waste scarce resources (for instance by pursuing unproven or highly unlikely treatments.) But we will leave those topics for another time.
What do you think?
Thursday, February 25, 2010
Public and Private Health Care, Freedom and Responsibility
When the Premier of Newfoundland, Danny Williams, opted to go to the US (Miami) for his heart surgery earlier this month he ignited a flurry of discussion about public and private health care and what should, and should not be available in Canada. All of the details are not available, but the main gist of the story is that Premier Danny Williams needed heart valve surgery that was not available in Newfoundland. He then opted to pay to have the surgery performed at a medical centre in Miami. He has subsequently claimed that the minimally invasive surgery was not available in Canada, a claim that has been strenuously denied by cardiologists across the country. “It’s my health, it’s my choice,” he is quoted as saying.
In many ways the exact details of the case are not the critical issue. What this situation serves to do – in a very high profile fashion, is highlight some of the debate about what should – and should not be available and what limitations on personal freedom should be permitted in a free and democratic society. Danny Williams was free to take his cheque book and buy his care in the US. After all it is indeed his health and his choice; however Danny Williams could not take his cheque book and buy his care in his own country. Canada is one of the very few countries in the world where there is no private health care. It is easy to see how this is a limitation on individual freedom. A Canadian is not permitted to take his or her own money and purchase a wide range of medical services in his or her own country. Conversely a Canadian medical practitioner is not allowed to set up shop and provide that same wide range of medical services. What is the public good that could justify these restrictions on individual freedom?
There are a variety of arguments in favour of the prohibition on private care, some of those arguments are practical – others are ideological. Let’s have a look at them. The principal practical argument against permitting private care is that somehow the existence of private care (a two-tiered system) would undermine or diminish the publicly funded system. This argument gets vigorously pursued in both directions. Thos who think that private care would undermine the public system argue that private care would siphon resources, facilities, talent, staff etc away from the public system. They also argue that those with the resources to afford private care (or private insurance for that private care) would then become demotivated to protect the public system. And, as those with the resources to afford private care or insurance, are those with the preponderance of political power, the public system would decline through lack of funding and political neglect. On the other side, however, proponents of private care argue that the influx of additional funds into health care as a whole cannot help but be a benefit. They argue that increased resources would increase facilities and personnel, and that the for-profit facilities would take people out of public health care waiting lists and so would result in better care for the entire community. It is difficult to know what evidence would settle this one way or the other. European countries mostly have a mix of public and private care and many observers agree that the French health system is amongst the world’s best, most comprehensive and affordable.
But there are ideological arguments too. Some would argue that permitting people to pay for health care embodies a fundamental inequality. They argue that each human life is inherently of the same value. However, if we allow people preferential, paid access to health care services, if we allow them to buy their way past queues, or to buy better treatment, even if those waiting in the queues are no worse off (in fact, on ideological grounds, even if they were better off) then we have created an inequality, we have manufactured an injustice, we have valued some people more than others – and we Canadians, don’t do that. But, of course, there is ideology on the other side too. As we noted earlier, preventing people from buying products or services from willing sellers is a restriction of personal freedom, which, those on this side of the argument would claim, is unwarranted by any public good that might accrue from the restriction. What do you think?
Finally, the debate about public and private and public health care leaves untouched the very wealthy, like Danny Williams, who can just take their cheque books and buy the services they want where they want. But Danny Williams isn’t just another rich guy; he’s the Premier of a Province in a country where the provinces have jurisdi ction over health care. I’ll leave it up to the reader to decide if special considerations should apply to political leaders... What do you think?
In many ways the exact details of the case are not the critical issue. What this situation serves to do – in a very high profile fashion, is highlight some of the debate about what should – and should not be available and what limitations on personal freedom should be permitted in a free and democratic society. Danny Williams was free to take his cheque book and buy his care in the US. After all it is indeed his health and his choice; however Danny Williams could not take his cheque book and buy his care in his own country. Canada is one of the very few countries in the world where there is no private health care. It is easy to see how this is a limitation on individual freedom. A Canadian is not permitted to take his or her own money and purchase a wide range of medical services in his or her own country. Conversely a Canadian medical practitioner is not allowed to set up shop and provide that same wide range of medical services. What is the public good that could justify these restrictions on individual freedom?
There are a variety of arguments in favour of the prohibition on private care, some of those arguments are practical – others are ideological. Let’s have a look at them. The principal practical argument against permitting private care is that somehow the existence of private care (a two-tiered system) would undermine or diminish the publicly funded system. This argument gets vigorously pursued in both directions. Thos who think that private care would undermine the public system argue that private care would siphon resources, facilities, talent, staff etc away from the public system. They also argue that those with the resources to afford private care (or private insurance for that private care) would then become demotivated to protect the public system. And, as those with the resources to afford private care or insurance, are those with the preponderance of political power, the public system would decline through lack of funding and political neglect. On the other side, however, proponents of private care argue that the influx of additional funds into health care as a whole cannot help but be a benefit. They argue that increased resources would increase facilities and personnel, and that the for-profit facilities would take people out of public health care waiting lists and so would result in better care for the entire community. It is difficult to know what evidence would settle this one way or the other. European countries mostly have a mix of public and private care and many observers agree that the French health system is amongst the world’s best, most comprehensive and affordable.
But there are ideological arguments too. Some would argue that permitting people to pay for health care embodies a fundamental inequality. They argue that each human life is inherently of the same value. However, if we allow people preferential, paid access to health care services, if we allow them to buy their way past queues, or to buy better treatment, even if those waiting in the queues are no worse off (in fact, on ideological grounds, even if they were better off) then we have created an inequality, we have manufactured an injustice, we have valued some people more than others – and we Canadians, don’t do that. But, of course, there is ideology on the other side too. As we noted earlier, preventing people from buying products or services from willing sellers is a restriction of personal freedom, which, those on this side of the argument would claim, is unwarranted by any public good that might accrue from the restriction. What do you think?
Finally, the debate about public and private and public health care leaves untouched the very wealthy, like Danny Williams, who can just take their cheque books and buy the services they want where they want. But Danny Williams isn’t just another rich guy; he’s the Premier of a Province in a country where the provinces have jurisdi ction over health care. I’ll leave it up to the reader to decide if special considerations should apply to political leaders... What do you think?
Thursday, February 18, 2010
A final word on pushing and shoving
The topic of secondary triage criteria and their applicability in a pandemic has aroused a great deal of debate in many different venues. At the Queensway-Carleton Hospital (QCH)in Ottawa we decided to try to take a formal look at the issue. We arranged a debate -- in standard debate format, on the resolution: "Be it resolved that the QCH adopt societal criteria for the allocation of scarce medical resources in the event of a catastrophic pandemic”. The resolution was deliberately vague on what those "societal" criteria might be in order to generate as open a discussion as possible. The debate was impassioned, and the questions from the audience interested and interesting -- but it is the result of the voting that is most noteworthy. The votes split 21 to 19 against the resolution, which I would say, is about as close to a tie as you can get. Our approach was unscientific, and of course the results were swayed by the approaches of the debaters,but that close a result, I think, means two things. First, we are split on this topic. There is not agreement that we unequivocably should -- or should not introduce non-medical, or "societal" criteria into triage decision-making. And second -- if we don't have a clear agreement to change what we currently do -- we should be cautious about taking a path that leads away from our currently espoused and practiced values.
Thursday, September 24, 2009
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?
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?
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.
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