A made-in-B.C. ethical framework will guide decisions over scarce resources if COVID-19 cases start overwhelming B.C. hospitals.
Should a young, healthy student get a ventilator before an older medical doctor?
Which is more important, an individual’s freedom and privacy or the health of the wider population?
These are the types of questions that a B.C. government COVID-19 ethical framework considers. It doesn’t actually answer these questions, but it gives a set of values and questions that should be asked in the event such decisions become necessary.
So far, the COVID-19 situation is fairly stable in B.C., with 1,724 people who have tested positive and 87 who have died as of April 14. Of those, 109 people are hospitalized and 51 are in intensive care, both numbers that have been consistent over the past couple of weeks. Our hospitals, which have prepared for the worst, still have room and ventilators to spare.
But COVID-19 is far from over and it’s worthy to consider how decisions should be made that curtail people’s freedoms or invade their privacy in order to prevent people from dying.
“Any infringements on personal rights and freedoms must be carefully considered, and the least restrictive or coercive means must be sought,” the framework says.
Those thoughts lead to other questions. Are humans naturally self-centered or are we capable of making sacrifices for the greater good? So far, in B.C., it appears we are capable of considering the greater good, but protests calling for society to reopen have popped up in Vancouver and the United States.
The standard social contract says we’re willing to hand over some of our liberties, in return for some security. But how far and how long can it go, especially when coupled with unprecedented economic pain?
This ethical framework doesn’t answer that, but it does give some key principles that decision makers must consider, like respect, protection from harm, fairness, cooperation, reciprocity, proportionality, flexibility and justice.
Those are all very nice words, but what exactly do they mean? What is meant by respect, for example?
“To whatever extent possible, individual autonomy, individual liberties, and cultural safety must be respected,” the document says. “This means respect for privacy and confidentiality, and an obligation on behalf of leaders and care providers to be truthful and honest to individuals affected.”
Consider this against the real world news that Google and Apple are working on apps to track whether people come into contact with someone who tests positive for COVID-19. That sounds great, but it means accepting that these mega tech companies are going to know where we all are at all times and the exact location of people who test positive.
They say the information will be anonymous, so privacy shouldn’t be a concern. But I think we all remember George Orwell’s 1984 well enough to be at least a little resistant to something like this.
B.C.'s top doctor, Bonnie Henry, said B.C. is considering the use of contract-tracing apps including one from Singapore, but that the province is also being mindful about privacy concerns.
Where does my liberty begin and your safety end? Right now it's about six feet, but as this pandemic continues we may have to wrestle with such questions more seriously. In the meantime, the public health authorities consider these questions on behalf of society.
Details about fairness in the ethical framework say, “everyone matters equally but not everyone may be treated the same.”
What that means is that those who most need and can derive the greatest benefit from resources, like ventilators, ought to be offered resources preferentially, the document says. Also, resources should be used and distributed in a way that gives the most benefit to the greatest number of people and things like race, age, disability, ethnicity, socioeconomic status should not factor in.
“The underpinning of all of these really challenging and difficult decisions is that all lives are created and seen as equal,” Henry, B.C.’s provincial health officer, said in her April 14 briefing. “That's where we're starting with all of our ethical frameworks, including for ventilator allocation, but then there is some objective criteria about people’s ability to recover that would underpin how we would do that, should we be in that position.”
If we do reach the point in B.C. where such decisions need to be made, there is a promise within the document that all decision making will strive to be open, transparent and inclusive. It says decision makers may have to justify the decisions they make, which are expected to be “reasonable” and based on evidence and practicality.
A decision-making process is laid out, including a list of core values like public safety, care-provider safety, sustainability, justified decision making, proportionate restriction, fair accountability and respect for patients and families, patient wellbeing, trust, equity and integrity.
This ethical framework contains all of the right words and it’s good to be prepared for tough decisions that could come, but many questions remain. Let’s hope we never have to answer them.
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