Should we sacrifice older people to save the economy?

h/t Bioedge

A senior Republican politician from Texas sparked a media firestorm this week after suggesting that older people should consider sacrificing their lives for the economy in the face of the coronavirus crisis. 

Dan Patrick, a former radio talk show host who is now Lieutenant Governor of Texas, made the comments on Monday night while talking to Fox News presenter Tucker Carlson. 

In response to a question about lifting social distancing measures, Patrick said, 

“Let’s get back to living...Let’s be smart about it. And those of us who are 70-plus, we’ll take care of ourselves, but don’t sacrifice the country.”

Patrick expressed grave concern that the COVID-19 crisis could “bring about a total economic collapse” and “potentially the collapse of our society”, and said that many “grandparents” like himself would be willing to expose themselves to a higher level of risk to save the economy. 

The comments made headlines across the US, with ethicists and commentators labelling Patrick's views "simplistic" and "odd". 

Peter Wehner, a senior fellow at the Ethics and Public Policy Center, said that Patrick’s comments were premature, and were inconsistent with the pro-life values of the Republican Party. 

“There’s an attitude toward the elderly of ‘Let them eat cake,’ ” said Wehner, who has worked in three Republican administrations. “This is very odd for the pro-life party that for so long it pushed a certain ethic”. 

Ashish Jha, a professor of global health at Harvard University, accused Patrick of setting up a false dichotomy between public health and the economy. 

“It is possibly the dumbest debate we’re having...People are being incredibly simplistic and are not thinking through this beyond the next two weeks. The number of people who have emailed me and said, have you thought about the economic effects? You know, it turns out, I’ve thought about that!”

Patrick’s comments were followed the next day by a statement from President Trump that he would like to see “the country opened” by Easter. “You’re going to lose more people by putting a country into a massive recession or depression,” Trump told reporters during a White House News Conference on Tuesday.  

US ethicists issue utilitarian manifesto for coronavirus rationing

h/t Bioedge

As the US braces itself for an exponential increase in COVID-19 cases, several US doctors and ethicists have published an article arguing forcefully for utilitarian healthcare rationing. 

The new article -- published in the New England Journal of Medicine on Monday -- deals with the complexities of the current COVID-19 crisis in the United States, and considers how scarce resources such as ventilators and vaccines should be allocated in light of our current understanding of the disease and pandemic modelling. 

The lead author of the article, academic and influential healthcare policy commentator Ezekiel Emanuel, has previously written at length about the allocation of scarce lifesaving resources, and, specifically, the allocation of vaccines in a pandemic. 

In this article, Emanuel and colleagues argue that healthcare rationing in the COVID-19 pandemic is inevitable: “...unless the epidemic curve of infected individuals is flattened over a very long period of time — the Covid-19 pandemic is likely to cause a shortage of hospital beds, ICU beds, and ventilators”. 

The real question, the authors suggest, “is not whether to set priorities, but how to do so ethically and consistently”. 

But what should our ethical framework for resource allocation look like? 

“In the context of a pandemic, the value of maximizing benefits is most important”, the authors argue.

Where we are allocating ventilators, for example, we should prioritise those patients who have the greatest likelihood of survival if given access to a ventilator, but who would be unlikely to survive otherwise. This would likely mean prioritising younger patients: 

“Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment. Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life.” 

The authors also note that rationing may mean withdrawing treatment from some patients who have a poorer prognosis than others. 

“Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission”.

The withdrawal of treatment is not the same as killing, they argue: 

...many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent. We agree with these guidelines that it is the ethical thing to do.” 

The authors also consider how we should allocate a coronavirus vaccine, should one be developed. The moral calculus is inverted in this case, they suggest. While younger, healthier patients should be given priority access to ICU, older patients with chronic illnesses should be given priority access to a vaccine: 

“...younger patients should not be prioritized for Covid-19 vaccines, which prevent disease rather than cure it, or for experimental post- or pre-exposure prophylaxis. Covid-19 outcomes have been significantly worse in older persons and those with chronic conditions. Invoking the value of maximizing saving lives justifies giving older persons priority for vaccines immediately after health care workers and first responders”. 

In an op-ed in the New York Times, Emanuel and two co-authors of the study stressed the importance of high-level ethical reflection on pandemic rationing, and warned of the risk of front line clinicians making “well-intentioned, but ad hoc choices under extreme pressure”.  

But some commentators are concerned that the high-level ethical reflection so far has missed some of the most serious ethical challenges presented by the COVID-19 crisis. In a letter to the Times, Former Democratic Congressman Tony Coelho said some medical professionals were trying to marginalize seniors and the disabled: 

“Even in a crisis, self-designated “experts” are trying to marginalize people with disabilities and seniors. Instead, let’s develop policies that “flatten the curve” and prepare to treat all those who may find themselves vulnerable to Covid-19”.  

Xavier Symons is Deputy editor of BioEdge 

Is euthanasia an essential service?

h/t Bioedge

Is euthanasia an essential service? That is the question that Canadian health officials are grappling with in the coronavirus epidemic.

At least two clinics in Ontario have stopped providing euthanasia (or medical assistance in dying, as it is called in Canada) to prevention transmission and to free up health-care resources. Others regard it as essential and are relaxing the rules to allow “virtual assessments of eligibility”.

“It’s not a decision that we have taken lightly,” said Andrea Frolic, of Hamilton Health Sciences, which has shuttered its program. “It’s heartbreaking for us, as it is for patients and families seeking this care."

“I think it’s really unfortunate. I don’t know their rationale for having shut it down completely," Chantal Perrot, a Toronto MAID provider, told the Globe and Mail. “I don’t understand how they could not see MAID as an essential service for people who are at end of life.”

The University Health Network in Toronto is continuing to provide MAID to inpatients during the pandemic. “We had to make some very difficult decisions with respect to other services and programs that were put on hold or shuttered during this pandemic," said Mark Bonta, who is in charge of euthanasia at UHN. "Given that MAID is something that is listed as a human right for our patients … we recognized it was important that this be deemed an essential service.”

Stefanie Green, a Victoria doctor and the president of the Canadian Association of MAID Assessors and Providers (CAMAP,) said the health authority on Vancouver Island has also deemed assisted dying an essential service. Officials there are even providing protective equipment to doctors who are still willing to help patients access euthanasia.

Michael Cook is editor of BioEdge