The criteria for the prioritization of patients are not so neutral

Les critères pour privilégier des patients ne sont pas si neutres

Photo: Jonathan Nackstrand Agence France-Presse
In addition to the chances of survival, the life expectancy after the procedure, and the question of the cycle of life would also be taken into account.

An exceptional crisis imposes measures equally exceptional. At the beginning of April, we learned that in the event of a shortage of respirators in Quebec, the patients with the greatest chance of survival from a clinical point of view would be privileged. The goal was clear and certainly virtuous to save as many lives as possible based on clinical criteria. Criteria established as indicators neutral to avoid any drift in ideological terms. But these criteria are they as impartial as they appear ?

In addition to the chances of survival, the life expectancy after the procedure, and the question of the cycle of life would also be taken into account. Thus, if the chances of survival of both patients were identical, a 20-year-old could be privileged in the face of a patient who has already had the privilege of living 60 years.

Here — as elsewhere in the world, these clinical criteria have been presented as screens of neutrality that is used to determine a fair and equitable way that would qualify for too few resources.

“But behind these clinical criteria, there are socio-economic criteria “, noted Vardit Ravitsky, a professor of bioethics at the Department of social and preventive medicine of the School of public health of the University of Montreal.

“People disadvantaged throughout their lives due to poverty, circumstances of life, because they have not had access to the resources, because they are born with an illness or a disability, all these people will have less chance of survival, a good life expectancy and will need further treatment. “

These patients will therefore be penalized in the difficult choices of resource allocation. “It is extremely problematic,” stresses Vardit Ravitsky, adding that a sense of injustice may arise in certain strata of the population. “Without an honest discussion, I fear that we will lose the confidence of the public. “


Value of a life

Behind this ethical debate lies also the issue of the value of every human life. “It is certain that there are people more vulnerable and more fragile. But their life does it have less value ? “, question the ethicist René Villemure.

Be limited to the scientific dimension, it’s reduce the debate to an issue of accounting, he believes. “[The doctors] will tell you, on that one I can invest 10 000 $ and he will be able to live after that, on the other, it is less certain. “

And to say that one is based on scientific evidence to make these choices, heart-rending, it is cut short the conversation by claiming that it is conducted on the basis of what is true and what is tangible. A discussion that elides the social and human dimension attached to every human life, argues René Villemure, who agrees that this is very slippery ground.

“A life is worth a life. All lives are equal. Even if one has the impression that it has developed a less high value of the elderly here as compared to other companies “, he says.

But one might ask if it is really just a doctor’s preference of a 20-year-old who sells drugs and brings the unhappiness in the face of a lady of 63 years who does volunteer work and attends one of his grandchildren ? Or is it really fair to foster the survival of a young person who has not complied with the containment measures at the expense of a person that he himself would have contaminated ?

“This idea of trying to assess the value of a person goes against the basis of any clinical ethics, prevents Vardit Ravitsky. These judgments are subjective, cultural and biased, and they bring a discrimination awful. “It is necessary to keep as far away as possible from this type of reasoning,” she says. Because this young criminal or the careless people may not have not had the privilege of having access to a quality education and grow up in a healthy environment, which may have an impact on their life choices as well as on their values.

The professor reminds us that this error has been committed in Seattle in the 1960s. A limited amount of machines for performing dialysis was available. In order to determine who would be entitled to precious treatment, a committee nicknamed the “ God committee ” had been created. The discussions were focused on the social value and human of each patient. It was estimated if it had children, if he was going to the church, if it was an employer, if he had actively contributed to the company, and so on, A drift extremely questionable and pernicious since completely subjective and subject to multiple biases. “This created a strong reaction in the population and, since that time, we are extremely aware that they must never go in that direction in an attempt to assess the value of a person,” says Vardit Ravitsky.

Priority to the COVID-19

These rifts ethical result of the scarcity of resources. And in the time of a pandemic, shortages may be many : for the fans, protective equipment, medical beds, intensive care, screening tests, medications, and also human resources.

Many patients awaiting a surgical intervention consider today to be penalized because of choices made in the allocation of resources and the management of risk.

“I wonder who I am compared to a person of the COVID-19, who I am in relation to other citizens,” inquired Pierre Taillefer, who discovered a cancer mass in the lung at the beginning of the month of march. “The government is committed to extraordinary means to contain the crisis of the coronavirus, but it has a ways too extraordinary for people with cancer ? “

“Ethics is the art of making choices in difficult circumstances,” recalls René Villemure. Ethics, therefore, is everywhere at the moment, even if we hear little about.

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