Few weeks ago, the Minister of Health, Grenada, Mr. Nickolas Steele angered many when he said that government was about to put an Ethics Committee in place “who will decide when the hospital gets inundated who gets let in and who does not.”
With the spread of COVID-19, all over the globe, countries have been faced with the question of what to do when hospitals become overwhelmed. This is a deeply emotional issue and public outcry after such an announcement is not unexpected.
However, retreating after a sound bite, as Steele did, undoubtedly encouraged more mystery, confusion and disinformation and left me looking for facts.
I began with a story in the January/February 2021 issue of The Atlantic magazine, What The Chaos In Hospitals Is Doing To Doctors.
The opening paragraphs describe an occurrence in Seattle, Washington State in 1961 that was centered around the invention of the dialysis machine. At the time, as Jason Kirsten tells it in the article, over 100,000 persons in the US were dying each year from end stage kidney failure so there was much euphoria – for a machine that could give sufferers with months to live a chance – if they sat at it for 12 hours a day, a couple days per week.
With only 10 slots available, a committee was formed to decide who would get access. The committee was made up of a surgeon, a religious minister, a banker, a labour leader, a housewife, a government worker, and a lawyer. People over 45 and children were already excluded. The committee chose the 10 out of a field of 17. The chosen 10 lived and the seven who were not, died. This is what today would be called an Ethics Committee.
Kisner said that her source for this vignette was Life magazine, November 1962, so I went to the source. And there it was – how the committee made their decision. The reporting of which enraged Americans so much that they nicknamed the group the “God Committee”.
Life also reported that the committee was given “no moral or ethical guidelines save their own individual consciences”. The criteria used – were based largely on their middle class values – marital status, church attendance, education, and net worth.
The consideration that candidates should live close to a hospital so they could keep up their regular 12 hour dialysis sessions seemed a solid enough decision. The fact that the man with six children was chosen over the one with three because it was felt that the widow with 3 children had better chances of finding a husband – was like going from the sublime to the ridiculous. Talk about sexism – it was 1961!
Still, the ‘God Committee’ was a cautionary tale from which I got three takeaways:
- When resources are scarce, rationing is inevitable.
- Such rationing is not to be left to doctors and nurses.
- Ethics committees are useless without guidelines.
Prioritising vs rationing
Doctors are used to prioritising care. It is the basis on which the Emergency Room (ER) operates. The most at-risk gets the most immediate attention – never on a first come first serve basis. Called triage from a French word ‘trier’ meaning to sort, it developed from a practice introduced at the end of the 1700s, by the Surgeon in Chief of Napoleon’s Imperial Guard.
It is said that he set up field hospitals right on the battlefield and treated the wounded by sorting the casualties. Rather than by rank, first officers, then soldiers and last the enemy, he categorised the severity of their wounds and tended them in that order.
Modern day triage is based largely on this model. The most at risk gets attended first and, ultimately, all patients would end up receiving care. It is just not in the order that they came. The problem arises, however, when there is a disaster or a public health crisis and demand for care outpaces capacity.
This is when prioritising gives way to rationing – to saving the most lives by withholding critical care from those deemed least likely to benefit from it. In the circumstances, “[m]ass casualty triage”, to quote a NATO document on Emergency war surgery, “treats the patients according to the salvage value when the injured overwhelm available medical facilities and not all can be treated.”
In fact, “triage may require making decisions that some patients will not receive treatment at all”, adds the American Medical Association in a manual on Management of public health emergencies.
Such battlefield talk! However, with the dramatic upsurge in COVID-19 cases and fatalities in Grenada, rationing seems unavoidable. But Mr. Steele, in delivering the troubling news, appeared to be either hiding what he knew or did not have the details.
When he said that the committee will decide who to let in when the hospital gets overwhelmed, the question has to be asked, was he speaking figuratively? Using the hospital to stand for the resources that the hospital supplies such as ventilators, ICU beds, medicine, or was he actually talking about closing the door to COVID patients? Surely, he wouldn’t need a committee to do that!
One week after Mr. Steele’s announcement, Dr Merle Clarke, the President of the Saint Lucia Medical and Dental Association (SLMDA) would call for an Ethics Committee on that island. She was careful to point out that “to a certain extent this is done every day in hospitals particularly in hospitals with limited resources, one has to determine, is this patient an ICU candidate?“
She further pointed out that with the entry of COVID 19, and so “many patients requiring intensive care ….dialysis …and other invasive services and procedures”, hospital personnel who make such decisions was burnout.
One of the arguments against rationing care is that it is the responsibility of government to provide the resources to take care of its people, as the NDC pointed out in its publication, Sep.11, 2021.
“Our focus and that of our leaders should be putting proper hospital facilities in place to save lives, not putting systems in place to decide who dies. Has the administration taken any steps to get help from the United States to set up field hospitals as they did for the people of Trinidad?”
Field hospitals are an excellent idea if they come with personnel. Where staffing is a scarce resource, increasing bed capacity does not, unfortunately, eliminate or decrease the need for rationing.
As much as some members of the public are against rationing, some say that if it has to be done, the decisions should be made by doctors and nurses. Maybe forgetting that in overwhelmed hospitals, doctors and nurses too are overwhelmed.
Having to prioritise who gets an ICU bed, even in normal circumstances, is anathema to a doctor – committed to saving all lives. Yes, the pandemic changed the rules of engagement but this doesn’t make it easy for them, as Robert H Jerry noted, “Because the medical profession’s core values align in absolute support of patients, undertaking or being cast in a role in which one must decide not to care for a patient is the assumption of a profoundly unwelcome task.”
Rationing care in the middle of a COVID surge is, indeed, a tough call for doctors and nurses and a recipe for mayhem. Take for example, what happened at Cornwall Regional Hospital in western Jamaica.
According to the Jamaica Observer, Novelette Cooper, a retired teacher, was admitted to the hospital July 27, 2021, with asthma problems. The hospital could not find a bed for her. Forced to sit on a chair for two days, she toppled over, hit her head and died few days later.
“We have a lot of beds at the warehouse, but where to put them? That is our problem. If we put them under tents outside, that is another bad story. The tent is hot and will kill patients faster, and the bathrooms are portable so that is not feasible. So we are stuck …. between a rock and a hard place,”’ a doctor struggled to explain to the family.
In the Caribbean, establishing guidelines for Ethics Committees is not new. The difference is that these are Review Ethics Committees (RECs) that deal essentially with reviewing the ethical and legal standards for human, and in some cases, animal research.
The University of the West Indies (UWI), Caribbean Public Health Agency (CARPHA) and Pan-American Health Organisation (PAHO) are just some of the institutions involved in this work.
Hospital Ethics Committee or Clinical Ethics Committees that Steele is calling for, handle ethical problems arising in clinical practice. They are found mostly in Europe, Canada and the United States, with the US, having by far the highest concentration – in hospitals with 400 or more beds.
Wherever they exist, care is usually taken to ensure that they are not made up entirely of health care practitioners but also include social workers, chaplains, community representatives, lawyers and increasingly, individuals with training in bioethics.
Steele did not say who was going to be on his committee, but, composition aside, the importance of protocols to a committee can hardly be overstated. Americans were upset with the ‘God Committee’, not for the composition of its members but the arbitrary way in which the opportunity to get life-saving kidney care was distributed.
Today, there is widespread agreement that fairness should be employed when allocating scarce resources – everyone should be treated the same, regardless of age, sex, disability and other such factors. If you think that treating patients in the order that they come and a lottery system will not achieve the goal of saving the most lives, how then can fairness be achieved?
Dr Douglas White, Bioethicist, University of Pittsburgh thinks that he has come up with a system to allocate scarce resources without counting any group out, and which seems to be gaining traction in the US. It uses an 8-point scale, the first four measure the patient’s chance of surviving hospitalisation based largely on a SOFA score – short for sequential organ failure assessment – which calculates how well organs are working.
The next four points score life expectancy against existing medical conditions, the number of years the patient is likely to live, given existing medical condition… less than a year or less than 5. Among the conditions identified are Alzheimer’s disease, late-stage heart failure, and, in patients over 75, end-stage kidney disease.
No pun intended, White’s model, while intending to achieve fairness can actually worsen outcomes for Blacks – in the US – because statistics show that they are more likely to have kidney disease than Whites.
With the substantial work already done in the Caribbean Region by review Ethics Committees, there might be little difficulty having them customise protocols for saving as many lives as possible.
Presently, Mr. Steele, you seem to have St Lucia who knows what it is to have overwhelmed hospitals – in your camp. Field hospitals, as suggested by the NDC, are a good idea, especially since they are moveable, they can be sent to any part of the Caribbean, if and when needed. Strategic guidelines for their use, can be written into the committee’s protocols.
Rationing is inevitable in overwhelmed hospitals. However, considerably more lives can be saved if care is taken to establish a well-thought out, fair and transparent framework that does not reinforce existing inequality.
As White said “…the only thing worse than developing a clear allocation framework is not developing one.”.