B.C. COVID policy may favour ‘utility’ over age, disability: critics

The head of a leading Canadian pro-life organization as well as disability rights advocates are raising alarms about a little-known B.C. government COVID-care policy that if implemented could prioritize the welfare of “society” over the rights of individual patients.

Natalie Sonnen, executive director of LifeCanada, says a health ministry document on ethical decision-making is so open to interpretation it could take the delivery of health care in a utilitarian direction.

“To me, it’s not just utilitarianism,” Sonnen said in an interview. “It’s communism.”

The policy in question is found in a document entitled “COVID-19 Ethical Decision-Making Framework,” which was provided to The B.C. Catholic in response to a request for the province’s pandemic triage policy – a plan that would be enacted should B.C. hospitals be overwhelmed by COVID-19 patients.

Dated Dec 24, 2020, the policy is described as “a key tool to assist local, regional and provincial ethically defensible decision-making” in the face of the COVID-19 pandemic. Among the “key ethical principles and values related to the goals or ends we should pursue” are  “utility,” “distributive justice,” and “just distribution of benefits and harms.”

Controversy is currently swirling over triage policies in Quebec and Ontario, and with vaccine shortages in Canada and new variants of the COVID-19 virus emerging around the world, concern about hospital-care capacity is rising.

Asked for B.C.’s triage policy, health ministry officials and the Fraser Health and Vancouver Coastal Health authorities pointed to the decision-making framework document found on the B.C. Centre for Disease Control website.

Rather than being an actual-triage policy, the document is a guide to creating ethical policies.

One aspect of the framework particularly concerns Sonnen. Entitled the “Harm Principle,” it reads: “Society should protect itself from harm. To protect the public from harm, real or imminent, especially from risk of infection and serious illness or death, those responsible for the health and safety of the population are justified in intervening and impinging on individual autonomy and choice, if necessary.”

That declaration would be in conflict with The Catechism of the Catholic Church, which declares, “Even if death is imminent, the ordinary care owed to a sick person cannot be legitimately interrupted.”

Sonnen pointed out the classical understanding of the “do no harm” principle is centred not on society as a whole but on the individual. “It is the basic rule that one can never harm a human being for any reason, and if there is ever any doubt about whether harm is being done, to err on the side of refraining,” she said.

The B.C. framework’s Harm Principle, however, turns that concept on its head, said Sonnen. “Their principle says that you can impinge upon a person in order not to harm society,” without defining what is meant by society. “It’s just a nebulous concept.”

Christian author C.S. Lewis often warned of the dangers of progressive, authoritarian, and communist governments putting the welfare of the state over that of the individual, Sonnen said. “That’s what I see happening with this [Harm] Principle.”

It appears the Harm Principle is also being used “to enact draconian policies, like shutting down churches, borders, medical procedures, etc., to protect ‘society,’ while causing great harm to individuals,” she said.

The uncertainty over triage policies in B.C. follows controversies in Quebec and Ontario, where health authorities have made public details of triage policies describing how doctors and nurses would decide who receives life-saving treatment. At last report, Quebec had finalized its policy, while Ontario’s was still being developed.

The policies, designed to be a practical guide for allocating limited resources, have sparked concern among some medical ethicists and advocates of the elderly and disabled.

Andrew Robb, a staff lawyer with the Disability Law Clinic of the Disability Alliance B.C., said in an interview that the alliance received only “vague and generic” information in response to a request it made last spring to see the province’s COVID triage policy.

The government referred the alliance to the same ethical decision-making framework document to which The B.C. Catholic was directed. As a result, Robb filed a freedom of information request last June to see any actual triage policy. He said the health ministry responded that the request is still being processed.

He also wrote Health Minister Adrian Dix last spring, saying the alliance is “very concerned that a triage protocol may result in people being denied care based on their disabilities.”

“It’s clearly an important issue,” Robb said. “ And it is frustrating how long it is taking” to get the information.

The National Post reported last month that Ontario’s COVID-19 Bioethics Table had asked the provincial government to suspend temporarily the requirement for doctors to obtain consent of patients or families before withdrawing life-sustaining treatment, “should COVID-19 crush hospitals.”

Lawyer Mariam Shanouda, of Toronto’s ARCH Disability Law Centre, told the newspaper she was “flabbergasted” by the request. “This is literally life and death, and to not only give doctors that power to operate outside [the law] but to insulate them from any liability whatsoever, that is not something to be taken lightly.”

 In Quebec, CTV News reported last month that hospital staff were being trained on the province’s “advanced triage protocol” to enable them to decide who is cared for, and who is not, should “resources get too tight to treat everybody.” Under the system, a triage committee would makes decisions based on which patients would benefit the most from ICU care.

The unprecedented move concerns Dr. Paul Saba of Montreal, who recently published a book in which he predicted COVID triage policies will “lead to discrimination based on age, pre-existing health conditions, and disability.”

“It’s totally unacceptable,” Dr. Saba told CTV. “ICU and intensive care beds are and should always be available to those who need the most intensive care. It goes completely against our model for health care, which is that you provide care for everybody, regardless of who they are, based on their need, and not based on survivability.”

He told The B.C. Catholic that governments can and must find the resources to treat everyone equally, and not ration health care.

Eugene Bereza, a medical ethicist at the McGill University Health Centre, pointed out that aspects of Quebec’s treatment-selection criteria seem to weigh against the elderly. “What we’re saying is people, the elderly, who have had their life to live, so to speak, will be less prioritized than someone in their twenties, who haven’t had an opportunity to go through those life cycles.” he told CTV.

Writing last spring on the ethics of care during the pandemic, Dr. R. J. Snell, academic director for the Aquinas Institute for Catholic Life at Princeton University, said the best criterion for determining prioritization of care is “greatest need.” Neither “age or disability [are valid] reasons to prioritize or restrict care,” he declared. That said, prioritization is permissible if other factors mean treatment is likely to fail for some and succeed for others.

The issue of denying care to the aged also worries Dr. Moira Mary McQueen, director of the Canadian Catholic Bioethics Institute in Toronto. McQueen said in an email interview with The B.C. Catholic that the triage issue is a complex one and that the Catholic Church has no specific policy on it. “It’s accepted that in time of war, disasters, and emergencies, decisions have to be instantaneous, and doctors, paramedics, and others are trained to first help those who would most benefit.”

It is difficult to think of a better approach, she said, but noted that, “The prudent and moral swiftness required is, to say the least, challenging, and any ‘policy’ approach, as governments are asked for, will have gaps.”

Writing last year in response to the COVID crisis in Italy, McQueen said she was startled to read guidelines from the country’s college of intensive-care physicians stating, “It may become necessary to establish an age limit for access to intensive care.” Such a declaration, she observed, represents an “immoral, utilitarian stance [that] must be strongly resisted. It represents a ruthless disregard for the elderly, seeing them as a means to an end instead of as a dignified ‘ends’ in themselves, as Catholic teaching reminds us …”

With COVID-19 numbers falling slightly in B.C., it may be that problematic, morally challenging triage protocols will not have to be employed here. Similarly, the possibility is waning that a special COVID-19 field hospital, which was set up within the Vancouver Convention Centre last April, will have to be activated.

Nevertheless, B.C. Liberal health critic Renee Merrifield told The B.C. Catholic that British Columbians have the right to know exactly what the NDP government is planning should variant-driven COVID-19 infection rates suddenly shoot upward.

“I think those are things that should be being done by the ministry,” Merrifield said, but “we don’t have any communication at this point from the ministry or from the health authorities.”