The COVID-19 pandemic has brought the vulnerabilities of our health care systems and inequalities in our societies to light, especially with the introduction of physical distancing measures and the rising number of admitted patients in hospitals.
Since fighting a pandemic is a multi-pronged approach, a number of possible bioethical dilemmas and red flags can arise in situations, such as resource allocation or when imposing restrictive measures.
Dr. Ross Upshur, Associate Director of the University of Toronto-affiliated Lunenfeld-Tanenbaum Research Institute at Sinai Health, outlined some of his concerns regarding bioethical decisions in an interview with The Varsity.
Upshur was a co-author of “Stand on Guard For Thee,” a series of ethical guidelines and issues that the U of T Joint Centre for Bioethics Pandemics Influenza Working Group drafted during the 2002–2004 SARS outbreak.
According to Upshur, the most important takeaway from the guidelines is that pandemics raise critical ethical questions that are important to address. “As SARS-CoV-2 is showing us, we may lack important scientific evidence to inform our decisions and so [our] values will be a helpful way to orient our thinking,” he wrote.
“As many of us [who] have done work in ethics know, you cannot presume agreement on which values should prevail or how they are interpreted and implemented in policy, which is why preparedness and public engagement is important.”
Facing resource shortages due to the pandemic
Upshur remarked that, when drafting guidelines for the COVID-19 pandemic, the first problem that arises is time. The second is getting people to pay attention. He also wrote that, “There is a debate about whether ethics expertise actually exists.”
A paper published in the New England Journal of Medicine, co-authored by Upshur, highlights how some health care resources face shortages in the first place. According to the paper, which used data from US hospitals, ventilator shortages might have more to do with the limited number of staff who are trained to operate them rather than the number of ventilators itself.
“Diagnostic, therapeutic, and preventative interventions will also be scarce,” according to the paper. Other solutions, such as pharmaceutical products and experimental treatments, are being studied. However, even if these products prove effective, it will take time to supply them.
Deciding how to allocate resources
Given these shortages, the question emerges as to how hospitals allocate treatments. In an interview with The Varsity, Dr. Kerry Bowman, a conservationist and bioethicist cross-appointed to the Faculty of Medicine and the School of Environment, illuminated some of these decisions.
“The great recommendation after SARS was our hospitals have to have surge capacity,” he said. “Surge capacity is exactly like it sounds. If we have a surge in cases, the hospitals have to be able to accommodate for that.”
“Therefore, it looks like the best way from an ethical point of view [on how] to make those decisions is how do we maximize survival,” he said. “We need to choose people that are most likely going to be able to get on a breathing machine, survive that, get off [of it], and continue on with their lives.”
However, this mindset isn’t necessarily the ideal method. “Many countries are beginning to strike age limits, such as no one over 60. I think that’s very problematic, and I don’t think that fits with Canadian values.”
Bowman clarified that while he thought that age was an extremely important medical factor, he did not think it should be the only deciding factor.
Upshur, on the other hand, conveyed that these decisions should be based on four values: maximizing the benefits of scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to people who are worse off.
What about research funding?
Money also plays a role in research allocation during a pandemic, such as when discussing the budgets that certain hospitals in Toronto allocate toward research and development. For example, the SickKids Research Institute funding in this area, for the 2018–2019 fiscal year, was $245.5 million dollars. During a pandemic, the question emerges as to whether it is wise to continue to allocate this much money to emerging technologies.
According to Bowman, “massive amounts of money” have been invested into emerging technologies — from stem cell research to CRISPR-Cas9, an approach to genome editing. “With this pandemic, we may have to re-evaluate if so much money going into emerging technology is really the best way to go, when in fact we don’t have a public health infrastructure that is robust enough and our hospitals don’t have surge capacity,” he said.
According to Upshur, at the end of the day, the pandemic sheds light on the theme of ethics and public health. “A pandemic of this magnitude has been predicted for many years,” he wrote. He noted that since 2003, the world has faced numerous “public health emergencies of international concern (PHEIC) by the [World Health Organization(WHO)] under the International Health Regulations.”
“There will be more in the future. We are all vulnerable to these novel pathogens and they also expose the vulnerability of our health, economic and social systems.”
How people in Canada can respond
“This pandemic will require… all of society [to respond] and will require Canadians to make sacrifices the likes of which we have not had to make since WW-2,” emphasized Upshur. “Without vaccines or medications, we are reliant on each other and so solidarity, a value often mentioned by WHO Director General Tedros, is critically important.”
Upshur continued, explaining that a decade from now, “we may be able to look back with pride that we pulled together and managed a coherent response, or look back in shame that we did not do what was required of us to end the pandemic and that many died and were ill on account of our actions.”
“This is in our hands, and our hands alone.”