Transcript: Deciding Who Lives: Ethics in a Pandemic | Apr 14, 2020

Steve sits in a room with white walls, a low slanted ceiling and several framed pictures on the walls including one of George Drew and one of Walter Kronkite. He's slim, clean-shaven, in his fifties, with short curly brown hair. He's wearing a pale blue shirt and a spotted blue tie.

A caption on screen reads "Deciding who lives: Ethics of a pandemic. @spaikin, @theagenda."

Steve says IF MEDICAL FACILITIES BECOME OVERBURDENED BY A SURGE IN COVID-19 CASES, TOUGH ETHICAL DECISIONS MAY NEED TO BE MADE ABOUT WHO RECEIVES LIFESAVING CARE AND WHO DOESN'T. WHAT GOES INTO MAKING THOSE CALLS? LET'S ASK, IN HALIFAX, NOVA SCOTIA, SISTER NUALA KENNY, RETIRED PEDIATRICIAN AND PROFESSOR EMERITUS OF BIOETHICS AT DALHOUSIE UNIVERSITY...

Nuala is in her sixties, with short wavy white hair. She's wearing a printed jacket and a pink blouse.

Steve continues IN THE NATION'S CAPITAL, DR. JAMES DOWNAR, HEAD OF PALLIATIVE CARE AT THE UNIVERSITY OF OTTAWA, A CRITICAL CARE PHYSICIAN AT THE OTTAWA HOSPITAL. HE ALSO RECENTLY LED IN THE DRAFTING OF ONTARIO'S LAST RESORT GUIDELINES...

James is in his thirties, with short brown hair and a goatee. He's wearing a checkered shirt.

Steve continues AND IN KINGSTON, ONTARIO, UDO SCHUKLENK, ONTARIO RESEARCH CHAIR IN BIOETHICS AND A PROFESSOR OF PHILOSOPHY AT QUEEN'S UNIVERSITY...

Udo is in his fifties, clean-shaven and bald. He's wearing a blue suit and a red sweater.

Steve continues AND WE ARE DELIGHTED TO WELCOME THE THREE OF YOU TO OUR PROGRAM TONIGHT. JAMES, WHY DON'T YOU START US OFF HERE. HOW WOULD YOU CHARACTERIZE WHAT CHANGES WHEN YOU SHIFT FROM NORMAL CLINICAL ETHICS TO PANDEMIC ETHICS.

The caption changes to "James Downar. University of Ottawa. The Ottawa Hospital."

James says SO IN A VIRAL PANDEMIC LIKE THE ONE WE'RE FACING NOW, WHAT WE'RE CONCERNED ABOUT IS A SITUATION OF A VERY MAJOR SURGE IN DEMAND FOR CRITICAL CARE RESOURCES. OUR SYSTEM IS USED TO HANDLING MINOR OR EVEN MODERATE SURGES AS A MATTER OF NORMAL COURSE, AND WE TYPICALLY RUN AT OR NEAR CAPACITY IN NORMAL TIMES. WHEN WE GET TO THE SURGES THAT WE'VE SEEN IN NORTHERN ITALY OR IN THE UNITED STATES, WHERE EVEN A VERY WELL RESOURCED SYSTEM GETS OVERWHELMED, YOUR PRIORITIES DO HAVE TO SHIFT. YOU HAVE MORE DEMAND THAN RESOURCES TO MEET THAT DEMAND, AND YOU HAVE TO START YOUR SHIFTS AND YOUR FOCUS RATHER THAN FOCUSING ON INDIVIDUAL... IMPROVING INDIVIDUAL OUTCOMES IN TERMS OF BOTH MORBIDITY AND MORTALITY TO THEN FOCUSING ON POPULATION OUTCOMES, TRYING TO ENSURE THAT THE RESOURCES ARE USED IN A WAY THAT BENEFITS THE MOST PEOPLE, AND THE IDEA IS, OF COURSE, THAT IF SOME PEOPLE ARE ULTIMATELY GOING TO DIE OF A CONDITION THAT MIGHT HAVE BEEN FIXABLE HAD EVERYBODY BEEN ABLE TO GET THE RESOURCES, YOU JUST WANT TO MAKE SURE THAT YOU'RE DOING THAT AS FEW TIMES AS POSSIBLE. AND USING YOUR RESOURCES IN A STRATEGIC WAY AS A RESULT OF THAT. SO THAT SHIFT FROM...

Steve says FORGIVE ME, DR. DOWNAR. LET ME GET SISTER NUALA KENNY JUST TO FOLLOW UP SINCE YOU SAID IT IS A DIFFICULT SHIFT, AND I WANT TO KNOW FROM SISTER NUALA KENNY, HOW DIFFICULT, HOW PROBLEMATIC IS THAT SHIFT FOR DOCTORS AND HEALTH CARE PROFESSIONALS IN THE TIME OF A PANDEMIC?

The caption changes to "Nuala Kenny. Dalhousie University."

Nuala says WELL, I THINK JAMES HAS SET THIS UP VERY WELL. AS A PARTICULAR PHYSICIAN, PEDIATRICIAN, PEDIATRIC PALLIATIVE CARE AND END-OF-LIFE CARE, AND PHYSICIAN ETHICS, THIS IS NOT ONLY SOCIALLY A DISTINCT CHANGE, BUT FOR PHYSICIANS, AND OTHER CAREGIVERS, AND OTHER CAREGIVERS. THIS IS PROFOUND BECAUSE PHYSICIANS' FUNDAMENTAL ETHICS, FUNDAMENTAL DRIVE IS TO ACT FOR LIFE, CERTAINTY TO PROLONG LIFE UNTIL... HARM BEING DONE BY TREATMENTS OR FACILITIES. SO THE ISSUE OR THE DIFFERENCE HERE IS PROFOUNDLY DIFFERENT IN TERMS OF PUBLIC [INDISCERNIBLE]
CONCERNED ABOUT FAIRNESS AND THE ISSUE OF PARTICULAR CONCERNS
[INDISCERNIBLE] THE MORAL DISTRESS OF PHYSICIANS AND OTHER CAREGIVERS IN HAVING TO BEHAVE IN SUCH A DIFFERENT WAY.

Steve says HMM. PROFESSOR SCHUKLENK, WHAT WOULD YOU ADD TO THAT?

The caption changes to "Udo Schüklenk. Queen's University."

Udo says WHEN YOU THINK ABOUT THE... WHEN YOU THINK ABOUT THE HEALTH CARE PROFESSIONALS, WHAT ALL THESE PROFESSIONALS DO, DOCTORS IN PARTICULAR WHEN THEY DO THEIR GRADUATION OATHS, THEY ALWAYS PROMISE TO SERVE THE PUBLIC GOOD, AND TYPICALLY WHAT IS UNDERSTOOD WHEN YOU THINK ABOUT PATIENT CARE IS WHAT IS IN THE BEST PUBLIC INTEREST IS THAT THEY DO WHAT IS IN THE PATIENT'S BEST INTEREST. THAT IS EASY WHEN YOU HAVE NO EMERGENCY CIRCUMSTANCES WHERE LOTS OF PEOPLE NEED PARTICULAR RESOURCES. WHEN DOCTORS SUDDENLY HAVE TO CHOOSE BETWEEN PATIENTS THAT THEY WILL BE ABLE TO SERVE, THINGS CHANGE BECAUSE SUDDENLY IT'S NOT ANY LONGER ABOUT WHAT IS IN ONE PATIENT'S BEST INTEREST BUT HOW IS THE PUBLIC GOOD SERVED BEST, AND THAT COULD WELL MEAN, FOR INSTANCE, THAT CERTAIN PATIENTS ARE NOT SERVED, AND THAT'S JUST THE NATURE OF THE EMERGENCIES AND WHY WE ARE HAVING THIS DISCUSSION TODAY.

Steve says DR. DOWNAR, CAN YOU JUST GIVE US A LITTLE MORE INFORMATION ABOUT THE ROLE YOU PLAYED IN DRAFTING THE PROVINCE OF ONTARIO'S SO-CALLED LAST-RESORT GUIDELINES?

Udo says SO, YEAH, AS THIS... AS THIS PANDEMIC WAS UNFOLDING IN CHINA AND ITALY, IT BECAME OBVIOUS THAT IF THOSE... IF COUNTRIES WITH THOSE LEVELS OF RESOURCES WERE FACING THE STRAINS THAT WE WERE SEEING, THAT CANADA, WHICH HAS ROUGHLY THE SAME NUMBER OF CRITICAL CARE BEDS PER HUNDRED THOUSAND POPULATION OF ITALY WOULD VERY LIKELY FACE SOME OF THE SAME CHALLENGES, AND IT SEEMED ONLY PRUDENT TO PREPARE FOR THAT EVENTUALITY. WE HAD A PANDEMIC PLAN FROM ABOUT 15 YEARS AGO THAT WAS DEVELOPED IN THE WAKE OF SARS AND WAS INTENDED FOR THE USE OF WHAT WE THOUGHT WOULD HAVE BEEN AN INFLUENZA PANDEMIC. THOSE HAVE NEVER REALLY MATERIALIZED TO THE DEGREE THAT ANYBODY FEARED, BUT WE HAD DONE... THERE HAD BEEN A NUMBER OF SURVEYS AND OTHER TYPE OF ENGAGEMENT ACTIVITIES DONE TO TRY TO ENSURE THAT WE UNDERSTOOD THE VALUES OF ONTARIANS WHEN IT CAME TO DEVELOPING, YOU KNOW, A TRIAGE PLAN FOR WHAT WOULD HAPPEN IF OUR RESOURCES WERE INADEQUATE TO MEET THE SURGE IN DEMAND. SO WE THEN TOOK THIS ORIGINAL PLAN, WE TRIED TO UPDATE IT BASED ON SOME OF THE NEWER DATA THAT'S COME OUT. WE HAVE A LOT BETTER INFORMATION NOW THAN WE'VE HAD IN PREVIOUS YEARS ABOUT HOW TO PROGNOSTICATE OR IDENTIFY PEOPLE WHO ARE AT VERY HIGH RISK OF DEATH IN THE ICU OR SOON AFTER AN EPISODE OF CRITICAL ILLNESS, AND ON THAT BASIS WE TRIED TO SORT OF CHANGE AROUND SOME OF THE INFORMATION, THE CRITERIA THAT WERE LISTED IN IT. THE OTHER BIG DEVELOPMENT THAT WE MADE, AND AGAIN THIS WAS IN CONJUNCTION WITH OUR REGION BIOETHICS GROUP AND WORKING WITH SPECIALISTS IN DIFFERENT FIELDS WAS ALSO THE IDEA OF TRYING TO USE THE TOOLS AND USE THE PLANS TO MAKE THE SYSTEM AS ADAPTIVE AS WE COULD, SO WHAT WE'RE CALLING PROPORTIONALITY. THE BIG FEAR OF MANY IS IF WE DO START TO INITIATE A PROTOCOL, WE DON'T WANT TO SORT OF OVERSHOOT, IF YOU WOULD. WE WANT TO MAKE SURE THAT IF YOU ARE RESTRICTING THE USE OF CRITICAL CARE RESOURCES TO SOME PEOPLE THAT YOU'RE DOING IT TO THE SMALLEST DEGREE NECESSARY AND FOR A SHORT AS POSSIBLE. YOU KNOW, GIVE EVERYBODY A CHANCE THAT YOU POSSIBLY CAN, AND WHEN YOU RESTRICT IT, ONLY RESTRICT IT AS MUCH AS YOU HAVE TO. THOSE ARE THE BIG PRIORITIES, YEAH.

Steve says OKAY, I DO WANT TO READ SOMETHING HERE, AND WE SHOULD SAY THE GUIDELINES SO FAR HAVE NOT BEEN RELEASED BY THE ONTARIO GOVERNMENT, BUT A DRAFT, BUT WE DON'T KNOW IF THIS IS THE FINISHED PRODUCT, BUT THIS WAS A DRAFT THAT WAS LEAKED TO A FEW OUTLETS, INCLUDING CAN "THE GLOBE AND MAIL," AND I WANT TO READ AN EXCERPT OF THAT DRAFT.

A quote appears on screen, under the title "A draft of the last resort guidelines in Ontario." The quote reads "The guiding principles are utility (those who derive maximum benefit receive the care); proportionality (the number harmed by the protocol should not exceed the number harmed under a first-come, first-served approach); and fairness)("priority should not be given to anyone on the basis of socio-economic privilege or political rank).
The triage contains three levels. The first, when the system reaches 200-per-cent capacity, would deny life-saving treatment to those with more than an 80-per-cent chance of death from trauma...
The second level denies life-saving treatment to those with more than a 50-per-cent chance of death. The third level applies to those with more than a 30-per-cent chance of death."

Quoted from Sean Fine, Mike Hager and Tom Cardoso, The Globe and Mail. April 2, 2020.

Steve says SO, JAMES, LET ME PUT THIS TO YOU. IF THESE PROTOCOLS HAVE TO BE TRIGGERED, WHO MAKES THE FINAL DECISION ON WHO GETS CARE AND WHO DOESN'T?

James says YES, SO THAT'S IMPORTANT THAT IF WE ARE GOING TO INITIATE THIS PROTOCOL THE DECISION SHOULD NOT BE TAKEN BY INDIVIDUAL PHYSICIANS AT THE BEDSIDE ACTING AUTONOMOUSLY. THIS IS GOING TO BE TAKEN ON A REGIONAL LEVEL, POSSIBLY A PROVINCIAL LEVEL, AND IT WILL BE TAKEN BY PEOPLE AT A COMMAND TABLE WHO ARE... A COMMAND TABLE WHERE THERE IS REPRESENTATION OF THE CRITICAL CARE LEADERSHIP IN ALL REGIONS OF THE PROVINCE AS WELL AS OTHER DIRECTION FROM PEOPLE WORKING WITH ONTARIO HEALTH AND THE MINISTRY. THE IDEA IS THAT THEY ARE GOING TO BE LOOKING AT WHAT IS THE CURRENT OCCUPANCY OF CRITICAL CARE RESOURCES, WHAT IS THE RATE OF NEW CASES COMING IN, AND WITHIN PARTICULAR REGIONS, HOW ARE THE TRANSPORTATION RESOURCES DEPLOYED. ARE THEY ABLE TO MOVE PEOPLE AROUND, AND THE IDEA IS THAT IF IT SEEMS LIKE YOUR SYSTEM IS ABOUT TO BE... ABOUT TO BE OVERWHELMED, THAT THE NUMBERS ARE GREATER THAN THE RESOURCES THAT YOU HAVE, THAT A DECISION WILL BE TAKEN TO INITIATE THE TRIAGE PROTOCOL, EITHER ON A REGIONAL LEVEL OR ON A PROVINCIAL LEVEL, BUT IDEALLY NOT ON A HOSPITAL LEVEL, AND WE CAN TALK ABOUT REASONS FOR THAT AND WHY.

Steve says OKAY, LET'S GET SOME FEEDBACK. SISTER KENNY, WHAT DO YOU THINK OF THESE GUIDELINES?

Nuala says WELL, IT'S DIFFICULT TO RESPOND WHEN I HAVEN'T SEEN THEM.

A voice says EXACTLY.

Nuala says BUT FROM THE TWO REPORTS AND THE STATEMENTS THAT WERE MADE THERE, I CAN MAKE SOME COMMENTS. OF COURSE I WANT TO COMMEND JAMES AND HIS COMMITTEE, WORKING GROUP, BECAUSE AS HE SAID, WE'VE SPENT A LONG TIME... I WAS INVOLVED IN SARS AND IN THE FOLLOW-UP FOR OVER 10 YEARS IN TRYING TO LEARN LESSONS ABOUT PUBLIC HEALTH AND EPIDEMIC INFLUENZA PLANS. SO WE SPENT A LOT OF TIME WITH THIS. THERE ARE SOME THINGS ABOUT THIS
[INDISCERNIBLE] THAT ARE DIFFERENT, THAT ARE DIFFERENT. WHAT I WANT TO SAY IS THREE LITTLE SHORT COMMENTS TO EMPHASIZE THE IMPORTANCE OF HAVING A PROTOCOL, OF WHAT JAMES AND HIS COMMITTEE IS DOING. FIRST, I THINK IT'S CRUCIALLY IMPORTANT THAT THE PUBLIC UNDERSTAND THE MAGNITUDE OF THE DIFFERENCES BETWEEN ORDINARY MEDICAL DECISION MAKING AND THIS SITUATION. I THINK THE ISSUE OF WHO TRIGGERS, WHO MAKES THE DECISION HAS TO BE INVOLVED WITH MORE THAN DOCTORS AND WITH MORE THAN THE MEDICAL PROFESSION BECAUSE THIS IS ABOUT THE
[INDISCERNIBLE] AND DOCTORS ARE BEING FORCED TO ACT DIFFERENTLY. THE GOVERNMENT HAS TO BE INVOLVED, WHICH CLEARLY MEANS THE COMPLEXITY OF THE ISSUE OF AT WHAT LEVEL AND
[INDISCERNIBLE] IS IMPORTANT. BUT THIS IS BIGGER THAN
[INDISCERNIBLE] I WOULD SAY THAT THE PRINCIPLE OF THE THREE THAT WERE LISTED AS THERE, UTILITY, PROPORTIONALITY AND FAIRNESS, ALL HAVE AN OBVIOUS NEED FOR
[INDISCERNIBLE]. MY SECOND AND THIRD COMMENT WOULD BE, I'M SORRY, BUT I WOULD ALWAYS PUT FAIRNESS FIRST. AND HERE I WOULD MAKE THE EXPLICIT DISTINCTION THAT IN PANDEMIC [INDISCERNIBLE] MUST BE UNDERSTOOD BECAUSE IT HAS MANY ESSENTIAL [INDISCERNIBLE] AS EQUITY. IN EQUITY YOU TREAT PEOPLE FAIRLY TAKING INTO ACCOUNT PARTICULAR CIRCUMSTANCES. THE PARTICULAR CIRCUMSTANCES OF THEIR HEALTH, THEIR SOCIO-ECONOMIC STATUS, ALL OF THAT WILL BE TAKEN INTO ACCOUNT AND TAKEN INTO ACCOUNT FAIRLY BY MEDICAL CRITERIA. SO I WOULD SAY A SPECIFICATION OF FAIRNESS IS EQUITY. AND FINALLY OF ALL THE OTHER THINGS WE MIGHT INCLUDE, JAMES, I WOULD HAVE INCLUDED THE PRINCIPLE OF RECIPROCITY. I THINK MAYBE SOME PEOPLE SEE THAT AS UNDER PROPORTIONALITY, BUT MY UNDERSTANDING IS THAT THOSE WHO ARE CLEARLY THE GREATEST BURDEN, DOCTORS AND NURSES, AND CLEANERS AND PERSONAL CARE WORKERS, THOSE WHO ASSUME THE GREATEST BURDEN OF RISK MUST IN FACT BE GIVEN A GREAT PROTECTION. THERE ARE HUGE ISSUES HERE OF THAT RECOGNITION. THIS IS NOT ABOUT HAVING THE MOST MONEY, BUT IF YOU'RE AN ICU DOCTOR OR AN ICU NURSE, CARING FOR THE SICK AND THEN HAVE TO LEAVE AND YOU HAVE A PARTNER OR SPOUSE AND LITTLE CHILDREN INVOLVED, WE NEED TO TAKE INTO ACCOUNT THE MOST FUNDAMENTAL PRINCIPLES, THAT ISSUE OF RECIPROCITY AND WHAT IT ACTUALLY REQUIRES FOR US TO IN FACT BE RESPONSIBLE FOR ALL IN THIS EVENT.

Steve says WELL, IT'S A GOOD THING WE'VE GOT A PROFESSOR OF PHILOSOPHY HERE AS WELL, BECAUSE THAT'S A WHOLE OTHER APPROACH TO THIS ISSUE. PROFESSOR SCHUKLENK, HOW DO YOU SEE IT?

The caption changes to "Connect with us: Twitter: @theagenda; Facebook, agendaconnect@tvo.org, Instagram."

Udo says THE FIRST THING I WANT TO SAY REALLY IS WHAT IS STRANGE AT THIS POINT IN TIME WHERE WE ARE NOW WEEKS INTO THIS PANDEMIC, AND FRANKLY EVEN INTO THIS PANDEMIC IN CANADA, THAT PEOPLE ARE STILL KERFUFFLING AROUND WITH WRITING THESE GUIDELINES THAT, FRANKLY, SHOULD HAVE EXISTED FOR A LONG TIME AND THAT ALSO SHOULD HAVE BEEN IN THE PUBLIC DOMAIN FOR A LONG TIME, AS NUALA POINTED OUT, SO THAT THE PUBLIC KNOWS BASICALLY WHAT THE POLICIES LOOK LIKE AS THEY WILL AFFECT SOME OR MANY OF US. WE DON'T KNOW THAT YET. AND, FRANKLY, AT THE MOMENT WE HAVE THIS SECRET COMMITTEE ORGANIZING THEIR SECRET DOCUMENTS, AND AT ONE POINT WE WILL FIND OUT, BUT REALLY WE'RE ALL SPECULATING ABOUT THE CONTENT OF THE DOCUMENT RIGHT NOW THAT WE ARE DISCUSSING BECAUSE WE HAVEN'T SEEN IT. AND I DON'T BLAME JAMES FOR THAT BECAUSE IT'S NOT HIS RESPONSIBILITY, BUT THAT IN ITSELF, FROM A PROCEDURAL POINT OF VIEW, IS SHOCKING. THE SUBSTANCE OF THE DOCUMENT IS DIFFICULT, AGAIN, TO SPECULATE ON THE CONTENT BECAUSE WE HAVEN'T SEEN IT. BUT IF YOU TALK ABOUT UTILITY, YOU HAVE TO DECIDE WHAT UTILITY YOU HAVE IN MIND. BECAUSE ARE YOU AIMING TO GO FOR THE MAXIMUM NUMBER OF LIVES SAVED? ARE YOU GOING FOR THE MAXIMUM NUMBER OF LIFE YEARS SAVED IN A POPULATION? IT'S STILL UNCLEAR TO ME, TO BE HONEST, HOW THEY PLAN TO GO ABOUT IT. LAST POINT I WOULD PROBABLY WANT TO MAKE IS, AND MAYBE JAMES HAS A GOOD RESPONSE TO THIS, I'M STRUGGLING TO SEE WHEN YOU THINK ABOUT WHAT HAPPENED IN ITALY THAT YOU COULD REALLY HAVE SOME CENTRAL COMMAND STRUCTURE IN TORONTO THAT COULD MAKE THESE DECISIONS FOR SOMETHING THAT WOULD HAPPEN, FOR INSTANCE, IN THE HOSPITAL IN KINGSTON. IT'S RIDICULOUS PROPOSITION. PROCEDURALLY IT'S IMPOSSIBLE. YOU WOULD WANT A TRIAGE COMMITTEE SET UP IN EACH HOSPITAL, BASICALLY, THAT LOOKS AT THESE ISSUES AND MAKES THESE SORTS OF DECISIONS ON A HOSPITAL LEVEL. YOU COULD WELL HAVE A PROVINCIAL COMMITTEE THEN THAT LOOKS AT ALLOCATING RESOURCES BETWEEN HOSPITALS, BUT THESE URGENT DECISIONS THAT WOULD HAVE TO BE MADE WOULD HAVE TO BE MADE ON A LOCAL LEVEL, AND WHILE IT IS RIGHT THAT NOT A DOCTOR OR A NURSE AT THE BEDSIDE SHOULD MAKE THESE DECISIONS, IT SHOULD CERTAINLY BE A COMMITTEE WITHIN A HOSPITAL, AND THIS IS TRUE PRETTY MUCH FOR, I DON'T KNOW, MASSACHUSETTS AT THE MOMENT AND NOW IN THE BOSTON AREA, THIS IS HOW THEY ORGANIZED IT. I KNOW THIS IS HOW THEY ORGANIZE IT IN GERMANY, SO I'M PUZZLED ABOUT THE IDEA THAT THERE ARE THESE PEOPLE THAT WE DON'T KNOW, BUT APPARENTLY IN TORONTO, WHO WILL DEAL WITH THESE THINGS.

Steve says SOME IMPORTANT THINGS TO FOLLOW UP ON THERE, JAMES, LET'S TACKLE THEM. NUMBER ONE, I KNOW IT'S NOT YOUR RESPONSIBILITY TO DO IT, BUT SHOULD THE PROVINCIAL GOVERNMENT MAKE THESE GUIDELINES PUBLIC EVENTUALLY?

James says I CAN TELL YOU THAT THAT IS THE TOP PRIORITY, TO GET THESE OUT THERE FOR MULTIPLE REASONS. ONE OF THEM IS TO GET INPUT. WE HAVE RECEIVED A LOT OF INPUT AND SUGGESTIONS, AS YOU KNOW... AS YOU ALLUDED TO EARLIER, THE DOCUMENT WAS LEAKED, AND WE HAVE GOTTEN A LOT OF VERY HELPFUL FEEDBACK FROM MANY DIFFERENT PARTIES ABOUT THAT. AND IT'S DEEPLY APPRECIATED. A LOT OF THAT WAS AROUND SHARPENING LANGUAGE AND MAKING SURE THAT WHAT WE WERE TRYING TO ACHIEVE WOULD NOT BE MISINTERPRETED AT THE BEDSIDE. AGAIN, TRANSPARENCY, UDO'S POINTS ARE WELL TAKEN, THAT WE NEED TO PROMOTE THAT, AND I CAN TELL YOU THAT THAT IS THE TOP PRIORITY RIGHT NOW.

Steve says TO FOLLOW UP ON LOCAL TRIAGE AS OPPOSED TO SOME CENTRAL TABLE, YOU KNOW, WHO KNOWS, MAYBE 500 MILES AWAY MAKING THE DECISION. WHAT'S YOUR VIEW ON THAT?

James says SO JUST TO BE VERY CLEAR, WHEN WE'RE MAKING INDIVIDUAL DECISIONS AND WHEN WE WOULD BE MAKING INDIVIDUAL DECISIONS ABOUT TRIAGE FOR INDIVIDUALS, IN A BUILDING, THAT WILL BE MADE LOCALLY BY LOCAL INDIVIDUALS.

Udo says OH, OKAY.

James says THE QUESTION OF WHEN TO INITIATE A TRIAGE PROTOCOL OR THE TRIAGE GUIDELINE IN THE DOCUMENT, THAT DECISION TO SAY WE ARE NOW AT LEVEL ONE, WE ARE NOW AT LEVEL TWO, THAT DECISION IS GOING TO BE MADE IN TORONTO. AND PART OF THE REASON FOR THIS IS BECAUSE THE DIFFERENCE BETWEEN US AND SOME OF THE OTHER REGIONS IS BECAUSE OUR SYSTEM IS FULLY CENTRALIZED, LIKE WE HAVE ONLY A SINGLE TIER SYSTEM. WE ACTUALLY DO A LOT OF REGIONAL ORGANIZATION, SO THERE'S LOTS OF REGIONAL SPECIALIZATION. WITHIN REGIONS, INDIVIDUAL HOSPITALS HAVE BEEN LABELLED AS THE COVID HOSPITALS WHERE ALL PEOPLE ARE GOING TO BE TAKEN. SO IT WOULDN'T BE FAIR TO HAVE RULES INDIVIDUALLY IN EACH HOSPITAL BECAUSE WE WOULD EXPECT DIFFERENT BURDENS AND DIFFERENT PATIENTS COMING IN. WE WOULD NEED TO MOVE PATIENTS AROUND WITHIN THE SYSTEM IN ORDER TO MAKE BEST USE OF THE RESOURCES. THAT DECISION DOES NEED TO BE TAKE ON A... NOT JUST A SINGLE HOSPITAL. BUT INDIVIDUAL DECISIONS ABOUT WHAT TO DO WITH THIS PERSON, THIS PERSON AND THIS PERSON, THAT'S GOING TO BE NOT TAKEN PROVINCIALLY. THAT WILL BE TAKEN LOCALLY.

Steve says LET ME GO TO SISTER KENNY WITH THIS. I KNOW YOU SAID EQUITY AND FAIRNESS OUGHT TO BE, YOU KNOW, THE PRIME CONSIDERATION HERE. YOU KNOW, PEOPLE ARE GOING TO BE WATCHING THIS RIGHT NOW AND THEY'RE GOING TO SAY THEY CANNOT IMAGINE... LISTEN, I DON'T KNOW, BUT I'M... THIS IS MY SUSPICION WHAT THEY WILL BE SAYING. THEY CANNOT IMAGINE A SET OF CIRCUMSTANCES WHEREBY AN 80-YEAR-OLD WIDOWER, FOR EXAMPLE, GETS PRIORITY TREATMENT OVER A 35-YEAR-OLD FATHER OF FIVE. DOES THAT MAKE SENSE?

Nuala says YES.
[INDISCERNIBLE] THE QUESTION OF FAIRNESS AND ONE IS THE SPECIFIC DECISION THAT MIGHT BE MADE IN THE CASE OF A SPECIFIC OLDER PERSON. IF I'M 75, I'M VERY CONCERNED... AS I'M 75, I'M VERY CONCERNED ABOUT AGEISM. THE ISSUE OF FAIRNESS IS BROADER AND DEEPER ONE. IF I MAY, LET ME GO BACK TO THE FINISH WHERE... WE HEARD JAMES AND [INDISCERNIBLE] BECAUSE I THINK THE ISSUE OF THE DECISION-MAKING HERE AND PUBLIC AND [INDISCERNIBLE] I THINK THERE'S A CONCERN RELATING TO FAIRNESS THAT PEOPLE WILL BE FRIGHTENED, TERRIFIED IF WE INCREASE THE [INDISCERNIBLE]
PEOPLE KNOW JUST HOW DIFFERENTLY WE HAVE TO MAKE DECISIONS ABOUT ALLOCATION OF SCARCE TECHNOLOGICAL RESOURCES, NOT CARE, ACCESS TO TECHNOLOGY IN THE TIME OF A PANDEMIC. IF IT GETS TO THAT. SO ON THE ONE HAND I THINK WE'RE NOT PUTTING THESE GUIDELINES OUT BECAUSE WE'RE WORRIED ABOUT
[INDISCERNIBLE] I THINK PEOPLE ARE FEARFUL THAT THEY ARE NOT GOING TO BE TREATED FAIRLY. PRECISELY BECAUSE THEY DON'T KNOW WHAT THE RULES ARE. SO I THINK THE FAIRNESS ISSUE, QUITE FRANKLY, AND UDO I'M SURE COULD GIVE YOU AN ENTIRE COURSE ON CONCEPTIONS OF FAIRNESS. I'M SAYING THAT WHAT SHOULD BE ABSOLUTELY PRIME FOR ALL OF US IN CANADA IS THAT WHEN A PERSON HAS A MAJOR MEDICAL CONDITION, SEPARATE FROM CORONAVIRUS OR CORONAVIRUS, THAT THERE IS NO AUTOMATIC EXCLUSION BY REASON OF THE DIAGNOSIS ITSELF. THEY DON'T AUTOMATICALLY COME OUT OF CONSIDERATION. WHAT WE HAVE DEVELOPED IS A RIGOROUS SET OF INCLUSIONS AND EXCLUSIONS CRITERIA THAT ARE BASED ON MEDICAL FACTS BECAUSE THIS IS ACCESS TO A MEDICAL SET OF RESOURCES. SO I THINK THAT THE ISSUE OF FAIRNESS I WOULD MAKE EXPLICITLY AS [INDISCERNIBLE] BECAUSE IT DOES REQUIRE [INDISCERNIBLE]
PARTICULAR CIRCUMSTANCES. AND THE PARTICULAR CIRCUMSTANCES HERE WOULD THEN BE OUTLINED AS VERY SPECIFIC. PEOPLE WOULD BE ABLE TO SEE THE CRITERIA. SO THE FACT THAT YOU ARE 78 YEARS OF AGE AND HAVE CONGESTIVE HEART FAILURE DOESN'T MEAN THAT YOU ARE NOT CONSIDERED. BUT AS WE LOOK THROUGH
[INDISCERNIBLE] TO THIS PERSON AND COMPARED TO LIKELY
[INDISCERNIBLE] THE FAIRNESS THAT WE WOULD HAVE TO MAKE IS IN THIS TIME [INDISCERNIBLE] YOU LIKELY HAVING MORE BENEFIT FROM THE SCARCE RESOURCES WHEN WE DON'T HAVE RESOURCES FOR ALL.

Steve says UDO, LET ME FOLLOW UP FROM THIS ANGLE, AND I HAVE HEARD FROM MEMBERS OF THE DISABILITY WORLD, FOR EXAMPLE, WHO HAVE SAID, YOU KNOW, WE'RE ACCUSTOMED TO ALWAYS GETTING THE SHORT END OF THE STICK, AND WE HAVE GREAT FEARS THAT IF THERE'S ONE VENTILATOR AND TWO PEOPLE WHO NEED IT, THAT THE DISABLED PERSON, BE IT A PHYSICAL DISABILITY, BE IT AN EMOTIONAL OR INTELLECTUAL DISABILITY, THEY'RE GOING TO GET THE SHORT END OF THE STICK AUTOMATICALLY AGAIN. DO THEY HAVE REASON TO BE FEARFUL OF THAT?

Udo says AT THE MOMENT, THEY CERTAINLY DON'T. WHEN YOU THINK OF PROCEDURES THAT YOU COULD PUT IN PLACE IN OTHER CIRCUMSTANCES, I MEAN, ONE POSSIBILITY WOULD BE VERY SIMILAR WHERE EVERYONE IS TREATED EQUALLY AND SIMPLY USE A LOTTERY AMONG THOSE WHO NEED THE PARTICULAR RESOURCE, REGARDLESS OF AGE AND WHATEVER OTHER CONDITIONS. YOU HAVE, OF COURSE,
[INDISCERNIBLE] OUTCOMES IF YOU DO THAT. OR YOU COULD PICK A FIRST COME FIRST SERVE PROCEDURE. WHOEVER IS FIRST IN THE BED STAYS THERE AND WHATEVER WE THROW ALL RESOURCES AT THAT NO MATTER WHAT. AGAIN, IF YOU DO THAT, YOU HAVE SOME [INDISCERNIBLE] OUTCOMES. SO THE IDEA THAT INSTEAD YOU AIM FOR SOMETHING LIKE LIFE YEARS THAT YOU CAN PRESERVE, MOST PEOPLE THINK THAT IT'S INTUITIVELY PLAUSIBLE AND IT WOULDN'T REALLY AFFECT DISABLED PEOPLE. FOR THE SAKE OF THE ARGUMENT, I'M 55 NOW, SO LEAVING NUALA OUT FOR THE MOMENT, IN HER 70S, I'M 55 NOW. YOU COULD IMAGINE THAT I'M IN A WHEELCHAIR. I COULD STILL TEACH AS AN ACADEMIC, OF COURSE. AND I MIGHT NEED ONE OF THESE VENTILATORS OR AN ICU BED. THE OTHER PATIENT WAITING, WE ARRIVE ROUGHLY AT THE SAME TIME AT THE HOSPITAL, COULD BE ONE OF MY UNDERGRAD STUDENTS. A 20-YEAR-OLD KID. WE HAVE NO SIGNIFICANT CO-MORBIDITIES SO WE PROBABLY HAVE THE SAME SHOT AT SURVIVAL. IF THAT WAS THE SITUATION, IT WOULD BE COMPLETELY BIZARRE THAT I WOULD HAVE A SHOT AT THE RESOURCE AND... BASICALLY THAT I WOULD BE PRIORITIZED OVER THE 20-YEAR-OLD BECAUSE IF YOU GIVE THE RESOURCE TO THE UNDERGRADUATE STUDENT, THE 20-YEAR-OLD, WHEN YOU LOOK AT AVERAGE AGE IN CANADA, GUYS DIE IN THE AVERAGE AGE OF 80, GIVE OR TAKE. SO I WOULD HAVE ANOTHER 25 YEARS. THE 20-YEAR-OLD WOULD HAVE ANOTHER 60 YEARS, ALL GOING WELL.

Steve says WELL, BUT LET ME...

Udo says FROM A RESOURCE PERSPECTIVE, IT MAKES PERFECT SENSE, OF COURSE, TO DEPLOY THAT RESOURCE TO ASSIST THE 20-YEAR AS OPPOSED TO ME. WHETHER OR NOT I'M IN A WHEELCHAIR MAKES NO DIFFERENCE TO ANY OF THAT.

Steve says LET ME JUMP IN WITH THIS. WHAT IF YOU HAVE FIVE KIDS AND THE 20-YEAR-OLD HAS NO KIDS AND THE FIVE KIDS DEPEND ON YOU AND YOUR PAYCHEQUE FOR THEIR SUSTENANCE. DOES THAT ADD A WRINKLE TO THE CONSIDERATION?

Udo says THAT DOES ADD A WRINKLE TO THE CONSIDERATION IF YOU HAD TIME AND HEALTH CARE SYSTEM TO GO THROUGH ALL OF THESE DETAILS. LIKE, WHAT IS THE POSSIBILITY THAT THE 20-YEAR-OLD MIGHT BE HAVING SEVEN CHILDREN. WE DON'T KNOW ANY OF THIS BECAUSE THEIR LIFE BASICALLY HAS NOT EVOLVED TO THAT POINT THAT IT WOULD KNOW THAT. SO I THINK THAT'S UNREALISTIC. I'M JUST THINKING TO COMPARE REALLY LIKE WITH LIKE. TWO PEOPLE, SAME NEEDS, SAME SURVIVAL PROBABILITIES. IT SEEMS TO ME, THEN, THAT WHOEVER IS YOUNGER SHOULD BE PRIORITIZED OVER SOMEBODY WHO IS OLDER, EVEN IF SOMEBODY LIKE ME, FOR INSTANCE, WHO COULD EASILY LIVE FOR ANOTHER 25 YEARS HAPPILY EVER AFTER IF I MAKE IT TO THE OTHER SIDE.

Steve says JAMES, I'M LITERALLY DOWN TO MY LAST MINUTE MERE, AND I NEED TO ASK YOU THIS. HOW LIKELY DO YOU THINK IT IS THAT THESE LAST RESORT ETHICAL GUIDELINES WILL AT SOME POINT NEED TO BE USED IN THE PROVINCE OF ONTARIO DURING THIS PANDEMIC?

James says WELL, IT'S APRIL 14 AT THE TIME OF THIS RECORDING. WHAT WE ARE SEEING SO FAR IS A BIT OF A... QUITE A BIT OF A FLATTENING OF THE CURVE, SUGGESTING THAT THE PUBLIC HEALTH MEASURES THAT WE PUT IN PLACE HAVE BEEN EFFECTIVE. THAT'S GOOD NEWS. THERE'S A BUT. WHAT IT MEANS, OF COURSE, IS THAT THERE'S STILL A VERY LARGE PROPORTION OF THE POPULATION THAT HASN'T BEEN INFECTED. IT'S NOT LIKE THE VIRUS IS GOING TO PASS OVER US. WE ARE NOT PARTICULARLY CLOSE TO GETTING ANY SORT OF TREATMENTS OR CURES OR ANY SORT OF VACCINES, SO THE ARGUMENT OF WHETHER WE'VE ACTUALLY AVOIDED THE PROBLEM OR SIMPLY, YOU KNOW, DELAYED IT EVER SO SLIGHTLY, I WOULD SUGGEST THAT WE NEED TO BE PREPARED. I WOULD SAY THAT THERE'S STILL A VERY HIGH LIKELIHOOD BECAUSE OF THE NATURE OF THESE ILLNESSES THAT PEOPLE WITH COVID ARE COMING IN, THEY ARE STAYING SICK AND THEY ARE STAYING SICK FOR A LONG TIME. SO EVEN A SLOWER RATE OF INFECTION COULD OVERWHELM OUR SYSTEM QUITE EASILY IF WE'RE NOT CAREFUL. BOTTOM LINE IS WE DON'T KNOW WHAT THE FUTURE IS GOING TO HOLD. WE CAN HOPE FOR THE BEST AND WE SHOULD, BUT WE HAVE TO PREPARE. AND SO HAVING PLANS LIKE THIS ARE FAR BETTER THAN NOT HAVING PLANS, BECAUSE AGAIN, REMEMBER, IF WE GET TO A SITUATION WHERE THE SYSTEM IS GETTING OVERWHELMED, THAT'S UP TO COVID. THAT'S NOT UP TO US. ALL WE CAN CHOOSE, THEN, IS HOW WE RESPOND TO IT, AND IT'S MUCH BETTER TO HAVE A PLAN THAN TO NOT HAVE A PLAN.

The caption changes to "Producer: Eric Bombicino, @ebombicino."

Steve says ON THAT OMINOUS BUT OBVIOUSLY REALISTIC NOTE, I WANT TO THANK ALL THREE OF YOU, JAMES DOWNAR IN OTTAWA, UDO SCHUKLENK IN KINGSTON, SISTER NUALA KENNY IN HALIFAX FOR BEING WITH US ON "THE AGENDA" TONIGHT. WE'RE REALLY GRATEFUL FOR YOUR SUBMISSIONS. THANK YOU.

All the guests say Thank you.

Watch: Deciding Who Lives: Ethics in a Pandemic