The allocation of scarce health resources is always a subject that makes my students uncomfortable, and it is certainly one that politicians wish to avoid. Determining who is entitled to health services, based on prioritization criteria, creates some discomfort among the population as the pronunciation of the name Voldemort in Harry Potter.
Posted yesterday at 10:00 a.m.
This year, I asked my students this question: “In recent years, the government has struggled with long waiting lists for heart surgery so that many patients cannot be treated within a so-called ‘reasonable’ time. The patients on the waiting list are as follows, in order of arrival. All of them are at high risk of heart attack, which the next time around will be fatal:
- A 45-year-old pedophile
- A 98 year old man
- A mother of four, 32, single parent
- A young 20 year old student
You have to choose who will take priority. “
The majority of my students, after several readings, indicated that their choice fell on the person who initially presented the most chances of survival following the operation, thus eliminating the 98 year old man. . Afterward, the discomfort was palpable. From a moral point of view, the exclusion of the pedophile seemed to go without saying. As many of my students work in the health sector, their duty to care and help, without value judgment, however, prevented them from relying on their moral judgment.
Some of the students therefore opted for utilitarian analysis which aims at the greatest good for the greatest number of people. This analysis often involves the use of a mathematical formula which makes it possible to give a numerical value to the quality of life and the number of years of life gained (QALYs) following a medical intervention (INESSS uses QALYs in its assessment to recommend or not drug coverage).
When applied from a societal perspective, this analysis includes the benefits of the intervention, not only for the person receiving it, but also, for example, for those close to them who could benefit from it (children, elderly person who depends on the intervention). help from their family caregiver, etc.).
In the example above, the mother of the family would thus possibly have priority. This exercise has the disadvantage of requiring some analysis time, which is more difficult in an emergency context, and may disadvantage, for example, the elderly or patients with chronic diseases who are likely to have a lower numerical value.
Another part of my students opted instead for randomization (or lottery), a more egalitarian view of resource allocation. Many of these students saw in this option the absence of the weight of the decision. This also had the advantage of a quick choice and not liable to be subject to arbitrariness.
Finally, students have chosen to prioritize the young 20-year-old student, thus adhering to a known principle of prioritization, namely that of prioritizing a young person rather than an elderly person in order to give him the same chances of living the same number of cycles. of life. In the past, it is on this principle that proposals for prioritization protocols for ventilation devices have been based in the potential context of an influenza pandemic. It is also on this principle, after the application of clinical criteria only (chances of survival), that the current triage protocol is based, developed in the context where we lack, in Quebec, intensive care beds intended for patients. patients who have COVID-19. For equal life cycles, however, the nursing staff would be given priority. If none of these criteria allows prioritization, then randomization is preferred.
At present, in the field, everything indicates that prioritization, including the choice of allocation of intensive care beds, will possibly be required in large centers. This time, it would not be for lack of equipment, but rather for lack of personnel.
The initiation of the protocol is the prerogative of the Ministry of Health and Social Services (MSSS): an establishment is not authorized to use the protocol to manage an overload which is only local. He must first inform the MSSS, and the coordination of intensive care beds, which may be able to find beds in neighboring establishments to unload the establishment in question.
Unfortunately, we have to admit that this logic only works in part: (1) the “welcoming” region must have expertise in intensive care, which is generally less expertise than in large centers and (2) transfer is only possible for patients who are clinically stable.
Without being able to refer to the prioritization protocol developed by a group of experts and after numerous consultations, healthcare teams could opt for a random triage where morals or personal choices could, particularly in a context where exhaustion is present. , influence decisions.
The allocation of limited health resources is difficult to accept, but is justified when it is transparent and when it is based on a procedure that has been the subject of discussions and consultations. In order to protect the population and the care teams (from any legal recourse in particular), it would therefore be relevant for the MSSS to consider, publicly, the possibility of triggering the triage protocol if the large centers were to find themselves short of beds. This message would not only make it possible to convey the seriousness of the situation, but also promote the preparation of the care teams who may be called upon to make heartbreaking choices.
* Mélanie Bourassa Forcier is also Director of Health Law and Policy Programs and Fellow Researcher at CIRANO.