Who should be operated on first?

More than 158,000 Quebecers are waiting for an operation, including 17,500 for more than a year. Who should go under the knife first? Health ethicists have been pondering the question since the start of the pandemic crisis. Three years later, they share their findings in a new book, Clinical ethics in times of pandemic. What lessons for the future?.

“What we have learned is that the current system deserves to be redesigned. There is certainly a fairer and more equitable way to provide access to surgery in Quebec,” said in an interview with the Duty Marie-Eve Bouthillier, ethicist at the CISSS de Laval, who led with the D^rs Antoine Payot and Nathalie Gaucher the collective work published by Éditions du CHU Sainte-Justine.

According to her, it is time to “dust off” the current operating methods, based on the principle according to which each doctor prioritizes the patients appearing on his individual waiting list according to their clinical conditions and the operating time he needs. has.

“In the time of the pandemic, we thought that there should be a single list [d’attente]perhaps by specialty,” says M^me Bouthillier, who participated in the drafting of the prioritization protocol for access to surgeries of the Ministry of Health during the crisis. “But it may be a bit of utopia. »

The three authors of the chapter devoted to this subject – the surgeon Serge Legault, the clinical ethicist Michel Lorange and the cardiologist Martine Montigny – propose to set up “a central technical platform by region, fed by operating requests from all the surgeons “. “The scheduling of surgeries is done at the regional level and takes into account the clinical needs of all patients, as well as considerations of quality of life and social integration. Surgeons would be assigned an operating priority according to the condition of their patient,” they suggest.

Difficult questions to ask

Access to surgery is one of the many topics covered in the 180-page book, the fruit of the collaboration of some forty authors and prefaced by Dr.^D Joanne Liu, former international president of Doctors Without Borders.

The collective work addresses the famous triage protocol determining who would have been entitled to a bed or a respirator if they had run out during the pandemic. A disaster scenario that never happened, but still sends shivers down my spine.

Quebec is no longer there. However, he faces several difficult questions. Hospital beds remain closed due to severe staff shortages. Should choices be made about which patients to hospitalize? Aren’t we doing it a little already? After all, Quebec has just announced the deployment of home hospitalization, which aims in particular to free up hospital beds.

“Yes, there is already movement and decisions that have been made in this direction, says Marie-Eve Bouthillier. But there is still a long way to go. Beds are precious and should be used for people who really need them. »

At the end of April, 12% of patients hospitalized in Quebec no longer required acute care. The government’s target is 8%. “Hospitalizing people for social reasons or because they have no other places to go, well that, of course, we have to organize ourselves differently”, continues the professor of clinical ethics at the University of Montreal (UdeM).

The well-being of healthcare workers must also be at the center of the government’s priorities, according to the D^r Antoine Payot, director of the clinical ethics unit at the CHU Sainte-Justine and of the clinical ethics office at the UdeM Faculty of Medicine. “How can we restore a form of power and legitimacy to the caregivers involved and perhaps break down the hierarchies that have been formed and which nevertheless demobilize some of the caregivers? »

During the crisis, doctors and health professionals worked hand in hand to find “creative ways not to close beds”, thus breaking the traditional silos. “The pandemic has subsided and we are returning a little to our old habits, deplores the D^r Payot. I have the impression that, now that we are no longer in a hurry, this dynamic has less of its raison d’être, at least in the eyes of the general organization. »

$50,000 drugs at any cost?

Quebec society will also have to think about its health system, which “has reached its limits”, according to Marie-Eve Bouthillier. “Can we continue to do everything, all the time, for everyone? I think the answer is no. But how are we going to do it? I don’t have the answer to this question yet. »

She cites as an example experimental cancer treatments, which cost $50,000 or $100,000 and whose benefits can be uncertain. The system should “perhaps not” offer them “absolutely, at all costs, all the time”, she argues. “Sometimes, some doctors offer them somewhat out of a logic of hope or out of fear of talking about palliative and end-of-life care, or even because in medicine, the curing [guérir] surpasses the caring [prendre soin] “, she observes.

However, Quebec does not have unlimited means, recalls M^me Buthillier. Choices will have to be made. “I think it’s not just the network [de la santé] to choose. It is up to society, to the citizens,” she concludes.

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