Transcript: Is Ontario's Crisis Triage Discriminatory? | Jan 13, 2021

Steve sits in the studio. He's slim, clean-shaven, in his fifties, with short curly brown hair. He's wearing a gray suit, white shirt, and gray plaid tie.

A caption on screen reads "Is Ontario's crisis triage discriminatory? @spaikin, @theagenda."

Steve says THE PROVINCE PRESENTED NEW MODELLING DATA YESTERDAY AND THE CO-CHAIR OF ONTARIO'S COVID-19 SCIENCE ADVISORY TABLE SAID, IN THE DAYS AHEAD, DOCTORS WILL HAVE TO MAKE CHOICES THEY DON'T WANT TO MAKE, "CHOICES ABOUT WHO WILL GET THE CARE THEY NEED AND WHO WILL NOT." WHAT WILL GUIDE DOCTORS IN THOSE EXCRUCIATING MOMENTS ARE TRIAGE PROTOCOLS WHICH ONTARIO UPDATED IN DECEMBER. WITH US NOW TO CONSIDER THE PARAMETERS FOR MAKING SUCH LIFE-AND-DEATH DECISIONS, PARTICULARLY AS THEY MAY APPLY TO PEOPLE WITH DISABILITIES, WE'LL INTRODUCE OUR GUESTS, AS IS OUR CUSTOM HERE, FROM FURTHEST AWAY TO CLOSEST TO OUR STUDIO, STARTING IN THE NATION'S CAPITAL WITH: DR. JAMES DOWNAR, HEAD OF THE UNIVERSITY OF OTTAWA'S DIVISION OF PALLIATIVE CARE AND A CRITICAL CARE PHYSICIAN AT THE OTTAWA HOSPITAL, WHO CO-LED THE DRAFTING OF ONTARIO'S CRISIS TRIAGE GUIDELINES...

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

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

Udo is in his fifties, clean-shaven and bald. He's wearing a yellow shirt.

Steve continues IN THE PROVINCIAL CAPITAL, IN PARKDALE: MARIAM SHANOUDA, STAFF LAWYER AT THE ARCH DISABILITY LAW CENTRE...

Mariam is in her late thirties, with long wavy brown hair. She's wearing a printed black shirt.

Steve continues AND IN MIDTOWN: DAVID LEPOFSKY, CHAIR OF THE ACCESSIBILITY FOR ONTARIANS WITH DISABILITIES ACT ALLIANCE AND A VISITING PROFESSOR AT THE OSGOODE HALL LAW SCHOOL.

David is in his fifties, clean-shaven and balding. He's wearing a black suit, white shirt and striped tie.

Steve continues WE'RE DELIGHTED TO WELCOME ALL FOUR OF YOU BACK FOR AN IMPORTANT CONVERSATION ON TVO TONIGHT. JUST BEFORE WE GET TO IT, WE THOUGHT IT MIGHT BE USEFUL TO HAVE A SHORT EXPLAINER ON WHAT CRISIS TRIAGE ACTUALLY IS. SHELDON, WHY DON'T WE START WITH THAT? IF YOU WOULD?

A clip plays in which key words and concepts pop up highlighted in different colours as Jeyan Jeganathan speaks.

He says WHAT IS CRISIS TRIAGE. A CRISIS TRIAGE PROTOCOL IS ACTIVATED IN THE CASE OF A PUBLIC HEALTH EMERGENCY, SUCH AS A PANDEMIC OR NATURAL DISASTER, WHEN THE DEMAND FOR MEDICAL SERVICES DRAMATICALLY EXCEEDS THE SUPPLY. A TRIAGE PROTOCOL IS A SET OF GUIDELINES TO DETERMINE THE ALLOCATION OF LIMITED MEDICAL RESOURCES DURING SUCH AN EMERGENCY. THE PRINCIPLE OF TRIAGE IS TO SAVE AS MANY LIVES AS POSSIBLE BY PRIORITIZING EMERGENCY TREATMENT ACCORDING TO CRITERIA OFTEN INCLUDING THE PERSON'S CHANCE OF SURVIVAL OR LIFE EXPECTANCY. FOR EXAMPLE, UNDER A TRIAGE PROTOCOL, IT COULD BE CONSIDERED JUSTIFIABLE TO REMOVE AN OLDER FRAILER PATIENT FROM A VENTILATOR IN ORDER TO SAVE A YOUNGER PATIENT. WHEN THE PRIORITY OF PATIENTS CAN'T BE MADE BASED ON MEDICAL NEED, SOME TRIAGE PROTOCOLS DETERMINE TREATMENT BY FIRST COME FIRST SERVED OR A LOTTERY SYSTEM.

The clip ends.

Steve says OKAY. THANKS TO JEYAN JEGANATHAN FOR THAT BACKGROUNDER. DR. JAMES DOWNAR, LET'S START WITH YOU. HOW CLOSE IN YOUR VIEW ARE WE IN THE PROVINCE OF ONTARIO TODAY HAVING TO ENACT CRISIS PROTOCOLS?

The caption changes to "James Downar. University of Ottawa."
Then, it changes again to "Inching closer to capacity."

James says WE HAVEN'T ENACTED THEM YET BUT I THINK IT'S FAIR TO SAY WE ARE GETTING CLOSE. AS OF THIS MORNING, WE HAD ABOUT 404 PATIENTS WITH COVID IN OUR ICUs, BUT OUR TOTAL ICU CENSUS FOR THE PROVINCE IS AT A LITTLE OVER 1800 RIGHT NOW. FOR COMPARISON, A YEAR AGO, WE DIDN'T HAVE ON ANY GIVEN DAY I THINK EVEN 1700 BEDS AVAILABLE AND NOW WE'RE CARING FOR 1800 PATIENTS. SO WE DEFINITELY HAD TO EXPAND OUR CAPACITY, AND WE'RE STARTING TO FEEL THE STRAIN, PARTICULARLY IN SOME AREAS AROUND THE GTA AND IN THE SOUTHWEST OF THE PROVINCE. IT'S IMPORTANT TO SHOW... TO NOTE THAT THE LIMITATIONS ARE REALLY PROBABLY NOT BEDS ANYMORE OR VENTILATORS, BUT ACTUALLY TRAINED STAFF. YOU CAN BUY VENTILATORS. YOU CAN BUY BEDS. AND YOU CAN FIND SPACE IN A HOSPITAL. IT'S A LOT HARDER TO GET TRAINED AND EXPERT STAFF TO MANAGE CRITICALLY ILL PATIENTS IN A SHORT PERIOD OF TIME AND I THINK THAT'S MORE THAN LIKELY GOING TO BE THE LIMITATION WE HIT BECAUSE OF COURSE MANY OF OUR STAFF ARE STARTING TO FEEL THE STRAIN THEMSELVES, THE EFFECTS OF THE COVID PANDEMIC THROUGH ILLNESS, BURNOUT, OR OTHER PROBLEMS, FAMILY CONSIDERATIONS, THAT WE'RE FEELING A STRAIN ON OUR HUMAN RESOURCE CAPACITY.

Steve says LET ME JUMP IN...

James says WE'RE NOT THERE YET BUT WE'RE NOT FAR.

Steve says GOTCHA. PEOPLE MAY BE DOING THE MATH IN THEIR HEAD RIGHT NOW SAYING, OKAY, 400 PATIENTS RIGHT NOW. CAPACITY FOR 2100 IN ICU. THAT FEELS LIKE A BIG GAP. SO WHY WOULD WE BE CLOSE?

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

James says WELL, 2100 WOULD BE THE ACTUAL PHYSICAL VENTILATORS AND BED SPACES. AND AS I JUST MENTIONED, ACTUALLY THE LIMITATION IS PROBABLY NOT GOING TO BE VENTILATORS AND BED SPACES BUT RATHER STAFF. THE FACT WE MAY HAVE A BIG SURGE IN ONE AREA OF THE PROVINCE AND NOT THE OTHER. WE'RE DOING OUR BEST TO MOVE PATIENTS AROUND AS QUICKLY AS WE CAN. THAT'S NOT AS FAST A PROCESS AS YOU MIGHT THINK. THE MODELLING DATA WE SAW YESTERDAY SUGGESTED IN A MATTER OF WEEKS WE COULD BE LOOKING AT 800 TO A THOUSAND COVID CASES WHEN YOU ARE DEALING WITH 1200 TO 1400 CASES OF PEOPLE BEING CRITICALLY ILL FOR OTHER REASONS, NOTHING TO DO WITH COVID, AND THAT'S NOT LIKELY TO GO DOWN SUBSTANTIALLY, THE MATH IS NOT COMPLICATED. WE WILL JUST SIMPLY NOT HAVE ENOUGH SPACE FOR EVERYBODY.

Steve says SOME OF YOU WERE ON THIS PROGRAM SEVERAL MONTHS AGO WHEN WE FIRST TACKLED THIS TOPIC, AND DR. JAMES DOWNAR, ONE MORE FAST FOLLOW-UP WITH YOU. THE ORIGINAL TRIAGE PROTOCOLS CAME OUT IN MARCH. THEY WERE RESCINDED IN SEPTEMBER. AND AS WE SUGGESTED OFF THE TOP, YOU'RE PART OF THE SORT OF TABLE OF EXPERTS WHO TRIED TO DRAFT THOSE PROTOCOLS. HOW COME THEY WERE WITHDRAWN IN SEPTEMBER?

The caption changes to "Replacing the original protocols."

James says SO THEY WERE WITHDRAWN WITH THE IDEA THAT THEY WERE BEING REPLACED WITH A NEWER AND SORT OF UPDATED GUIDANCE. YOU KNOW, THE PROCESS IS SORT OF A PROCESS OF CONTINUOUS REVISION AND IMPROVEMENT. AS WE GET MORE DATA AND AS WE GET MORE INPUT. SO, YOU KNOW, WHEN WAVE ONE HAPPENED, IT'S IMPORTANT TO REMEMBER THAT WE SAW ALL AROUND THE WORLD, EVERY OTHER JURISDICTION THAT WAS GETTING HIT WITH COVID WAS BEING OVERWHELMED AND GOING INTO TRIAGE SCENARIOS. WE HAD A VERY SHORT PERIOD OF TIME TO GET SOMETHING TO GO. WE GOT SOMETHING OUT THE DOOR THAT WAS READY FOR USE. VERY FORTUNATELY THE FLATTENING OF THE CURVE DID OCCUR. OUR PUBLIC HEALTH MEASURES WERE EFFECTIVE AND WE DIDN'T HAVE TO USE THEM. BUT THE PROCESS WAS FROM THE START, YOU KNOW, WE REFER TO THESE AS GREEN DOCUMENTS, RIGHT? SO THEY'RE ALWAYS SORT OF CONSTANTLY IN GROWTH AND MODIFICATION AS WE GET MORE INPUT, MORE HELPFUL INPUT AND MORE UP-TO-DATE DATA. EVEN IF WE WERE TO HAVE TO USE TRIAGE NOW IN THE COMING WEEKS AND MONTHS, THAT DOCUMENT ITSELF WOULD NOT BE CONSIDERED I THINK FINAL OR THAT APPROACH WOULDN'T BE THE FINAL APPROACH. YOU KNOW, WE WOULD ALWAYS BE INTERESTED IN A PROCESS OF GETTING NEW INFORMATION, UPDATING AND IMPROVING THE DOCUMENT IN ANY WAY THAT WE CAN.

Steve says OKAY. MARIAM SHANOUDA, WHY DON'T YOU COME IN AT THIS POINT AND TELL US WHAT YOUR ORIGINAL CONCERNS WERE WITH THE ORIGINAL CRISIS TRIAGE PROTOCOLS THAT CAME OUT TEN MONTHS AGO?

The caption changes to "Mariam Shanouda. Arch Disability Law Centre."

Mariam says YEAH. SO THERE WERE SEVERAL, PROCEDURAL AND SUBSTANTIVE. SO PROCEDURALLY, THERE WAS A LACK OF TRANSPARENCY. I HEAR WHAT JAMES IS SAYING IS IT WAS A VERY ROUGH TIME WE THOUGHT WAS HAPPENING AROUND THE WORLD. WE WANTED TO MAKE SURE THAT DOCTORS HERE DIDN'T HAVE TO BE PUT IN THE POSITION THAT DOCTORS IN WUHAN AND ITALY AND OTHER PARTS OF THE WORLD WERE EXPERIENCING. YOU KNOW, ANOTHER ISSUE, THOUGH, WAS LACK OF CONSULTATION. AND WE ARE NOW IN JANUARY 2021, WE'RE IN THE MIDST OF WAVE TWO. WE'VE HAD... OR THE GOVERNMENT HAS HAD TEN MONTHS TO BE MORE TRANSPARENT, TO HOLD THESE CONSULTATIONS, AND, YOU KNOW, TO JAMES' POINT THAT IT WAS SUPPOSED TO BE REPLACED. WE DON'T KNOW WHAT IT'S BEEN REPLACED WITH. THE ONTARIO HUMAN RIGHTS COMMISSION HAS WRITTEN TO THE GOVERNMENT AND TOLD THEM: PLEASE PROVIDE US WITH WHAT HAS BEEN DISTRIBUTED TO THE HOSPITALS AS OF DECEMBER, AND WE HAVEN'T GOTTEN THAT OPPORTUNITY TO REVIEW THAT PROTOCOL. SO WE DON'T KNOW WHAT IT'S BEEN REPLACED WITH. AND THERE'S STILL BEEN A LACK OF CONSULTATION. THERE'S STILL A LACK OF TRANSPARENCY. SUBSTANTIVELY AND, STEVE, I DON'T KNOW IF I'M JUMPING AHEAD, BUT THE TOOLS THAT WERE IMPLEMENTED OR ADVISED TO BE USED AS A GUIDE BY DOCTORS, LIKE THE CLINICAL FRAILTY SCALE, WERE OF DEEP, DEEP CONCERN TO PERSONS WITH DISABILITIES.

Steve says LET ME JUMP IN THERE, IF I CAN. THAT WILL TAKE ME NICELY TO DAVID LEPOFSKY. THE CLINICAL FRAILTY SCALE THAT WAS JUST REFERENCED, DAVID, PERHAPS YOU COULD TELL US WHAT IT IS AND WHAT YOUR CONCERN WITH IT WAS.

The caption changes to "David Lepofsky. Accessibility for Ontarians with Disabilities Act Alliance."

David says OKAY. AND I THINK I'M GOING TO ANSWER THAT WITH THE QUESTION YOU ASKED DR. DOWNAR BUT WITH A MUCH MORE DIRECT ANSWER. THE PROTOCOL WHICH DR. DOWNAR CO-WROTE AND WHICH WAS IN PLACE FROM MARCH UNTIL THE END OF OCTOBER WAS INHERENTLY AND UNJUSTIFIABLY DISCRIMINATORY AGAINST PATIENTS WITH DISABILITIES, AND EVENTUALLY, AFTER WE FINALLY GOT A CHANCE OVER THE SUMMER TO PROVE THAT AND SHOW THAT AND DEMONSTRATE IT TO THE GOVERNMENT'S ADVISORY BIOETHICS TABLE, OF WHICH DR. DOWNAR IS A MEMBER, EVEN THE BIOETHICS TABLE AGREED THAT WHAT THEY HAD EARLIER RECOMMENDED WAS ACTUALLY DISCRIMINATORY UNFAIRLY AGAINST PEOPLE WITH DISABILITIES.

Steve says BUT HAVE THEY FIXED THAT NOW?

The caption changes to "David Lepofsky. Osgoode Hall Law School."

David says WELL, ONLY IN PART. THEY HAVEN'T. THEY TOOK IT AWAY, ONE PART, BUT THEY'VE ACTUALLY LEFT IT IN PLACE IN ANOTHER PART. SO WHAT IS THE CLINICAL FRAILTY SCALE? WHAT THAT EARLIER PROTOCOL HAD INCLUDED AND THE ONLY THING WE'VE SEEN LATELY STILL LEAVES DANGLING OUT THERE AS A TOOL THAT CAN BE USED, AMONG OTHERS, IS BASICALLY SAYS TO DECIDE WHICH... WHICH CRITICAL CARE PATIENTS NEEDING LIFE-SAVING CRITICAL CARE WILL BE TRIAGED IN OR OUT, WILL BE ALLOWED IN OR RATIONED OUT. THIS WILL DEPEND ON WHETHER THEY HAVE A PROGRESSIVE DISEASE, AND IF SO, WHETHER THEY ARE INCAPABLE OF DOING SOME OR ALL OF 11 ACTIVITIES OF DAILY LIVING WITHOUT ASSISTANCE, LIKE GETTING OUT OF BED OR SHOPPING OR DOING THEIR FINANCES. AND SO FOR PATIENTS WITH DISABILITIES, THAT MEANS PEOPLE WITH DISABILITIES TAKE AWAY YOUR ASSISTANCE AND SEE IF YOU CAN DO IT YOURSELF. WELL, THAT'S A FUNDAMENTAL VIOLATION OF BASIC HUMAN RIGHTS PRINCIPLES, MUCH LESS IS IT A FAIR ASSESSMENT OF WHETHER THEY ARE LIKELY TO LIVE OR DIE IF TREATED. AND SO WE POINTED OUT THAT WHAT THE BIOETHICS TABLE DR. DOWNAR HAD RECOMMENDED LAST SPRING AND WHICH THE GOVERNMENT LEFT IN PLACE OVER MONTHS WAS IN FACT DISCRIMINATORY AND PRESSURED AND PRESSURED. FINALLY, THE BIOETHICS TABLE AGREED AND EVENTUALLY THE FORD GOVERNMENT RESCINDED IT. THEY SHOULD HAVE DONE THAT SIX MONTHS AGO.

The caption changes to "Watch us anytime: tvo.org, Twitter: @theagenda, Facebook Live, YouTube."

Steve says OKAY. LET'S GET UDO SCHUKLENK IN HERE AT THIS POINT, BECAUSE WE'VE GOT MEDICAL PEOPLE, WE'VE GOT ADVOCATES FOR DISABLED PEOPLE HERE. WE NEED A GOOD BIOETHICIST, AND THAT'S YOU. TELL US THE TIGHTROPE THAT ALL GROUPS ARE WALKING IN A CASE LIKE THIS BECAUSE WE'RE DEALING WITH SOME OF THE MOST... THIS ISN'T THE RIGHT WORD, BUT YOU KNOW WHAT I MEAN... SOME OF THE MOST TREACHEROUS ETHICAL CONSIDERATIONS OF LIFE AND DEATH THAT ARE IMAGINABLE HERE. WHAT'S THE MISSION?

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

Udo says WELL, YES, YOU'RE RIGHT. YOU'VE GOT TO ASK YOURSELF AS A GOVERNMENT OR AS PEOPLE WRITING GUIDELINES: WHAT IS IT THAT YOU'RE AIMING FOR? BECAUSE YOU FIND YOURSELF IN A SITUATION THAT... YOU KNOW, OUR TITLE HERE TODAY IS THE CRISIS TRIAGE DISCRIMINATORY, AND THE LONG AND SHORT OF THAT IS, IT IS, AND IT HAS TO BE. IT HAS TO DISCRIMINATE... YOU HAVE TO MAKE CHOICES, FOR INSTANCE, THEY HAVE TO DECIDE WHETHER THEY MAKE SURE THAT SOMEBODY SURVIVES BASED ON THEIR LIFE EXPECTANCY OR ON THEIR QUALITY OF LIFE BECAUSE THEY ARE UNABLE TO TREAT EVERYBODY. SO FOR THAT REASON, ANY TRIAGE IS DISCRIMINATORY. ON THE BASIS OF THE DECISIONS THEY MAKE, ALWAYS SOMEBODY WILL DIE AS A RESULT OF THEIR DECISION. AND THE ONLY REASON WHY THAT IS NECESSARY IS BECAUSE THEY KNOW AT THE OUTSET THAT EVERYBODY WHO NEEDS CARE WON'T BE ABLE TO GET THAT CARE. THE QUESTION THEN IS FOR THE DECISION THAT IS BEING MADE. IN OTHER WORDS, THE DISCRIMINATORY DECISION IS BEING MADE AND THIS DISCRIMINATION IS VEIL. THE OLD PROTOCOL, THAT THIS DISCRIMINATES UNFAIRLY AGAINST DISABLED PEOPLE.

Steve says DO YOU LIKE THE NEW PROTOCOLS BETTER?

Udo says I ACTUALLY THINK THE NEW PROTOCOL IS PRETTY GOOD. I WOULDN'T HAVE WRITTEN IT THAT WAY. HERE WHAT THEY'RE DOING ESSENTIALLY IS THEY'RE STILL TRYING TO PRESERVE THE MAXIMUM NUMBER OF LIVES THAT IT CAN PRESERVE AND THEY HAVE SORT OF A RIDER ON THAT. THEY'RE SAYING YOU NEED TO ENSURE AT LEAST THAT SOMEBODY DOES NOT JUST SURVIVE BUT SURVIVES AT LEAST FOR 12 MONTHS AFTER... AFTER THE INTERVENTION. IN HEALTH ECONOMICS, FOR INSTANCE, WHEN THEY TALK ABOUT [indiscernible] AND THE ETHICS OF THAT, THEY OFTEN... FOR OTHER THINGS, FOR INSTANCE FOR MAXIMUM NUMBER OF LIVES YOU CAN PRESERVE AS OPPOSED TO JUST LIVES. IT WOULDN'T MATTER THEN WHETHER SOMEONE IS 50 OR 94, JUST TO GIVE YOU ONE EXAMPLE, THEN THE YOUNGER PERSON... THE DISCRIMINATION IS IN FAVOUR OF THAT PERSON.

Steve says DR. JAMES DOWNAR, YOU'VE HEARD SOME OF THE CRITICISMS AND SOME OF THE SUPPORT OF YOUR EFFORTS SO FAR. I SHOULD GIVE YOU A CHANCE TO COMMENT ON WHAT YOU'VE HEARD SO FAR.

The caption changes to "James Downar, @jamesdownar."
Then, it changes again to "Probability of surviving 12 months."

James says AGAIN. I DON'T WANT ANYTHING I'M SAYING HERE TO BE A PERSONAL CRITICISM OF ANYBODY ON THE SHOW OR ANYBODY ELSE, FOR THAT MATTER. I DO THINK IT'S IMPORTANT, THOUGH, TO JUST CORRECT A FEW POINTS IN TERMS OF PROCEDURE. WE HAVE BEEN ENGAGED IN EXTENSIVE CONSULTATION WITH MANY, MANY GROUPS, INCLUDING DISABILITY GROUPS, INCLUDING CLINICAL GROUPS, INCLUDING, YOU KNOW, GROUPS REPRESENTING INDIGENOUS POPULATIONS... MANY OTHERS. THE LIST GOES ON. LITERALLY HUNDREDS OF PEOPLE OVER A MATTER OF MONTHS TO GET INPUT TO GO INTO THIS DOCUMENT. AND THE CONSULTATION CERTAINLY IS BY NO MEANS OVER. I THINK EVERYONE IS COMMITTED TO AN ONGOING PROCESS OF TRYING TO REFINE AND REVISE THIS IN A POSITIVE WAY. SO JUST TO BE VERY CLEAR ABOUT THAT. THE OTHER THING THAT'S IMPORTANT TO SAY IS THAT THE BIOETHICS TABLE I THINK AT NO POINT EVER SAID THAT THEY FELT THAT THE PROTOCOL OR THE DOCUMENT THAT WE PRODUCED WAS UNJUSTIFIABLY DISCRIMINATORY. WHAT WE ARE TRYING TO DO IS THAT WE HAVE A NUMBER OF PRINCIPLES THAT WE'RE TRYING TO SORT OF BALANCE HERE, RIGHT? THAT BROADLY SPEAKING IT'S THE DESIRE TO SAVE AS MANY LIVES AS POSSIBLE BUT ALSO TO BE PROCEDURALLY FAIR AND TRYING TO MAKE SURE THAT WE'RE NOT,, YOU KNOW,, DISPROPORTIONATELY AFFECTING ONE POPULATION VERSUS ANOTHER. YOU'RE TRYING TO DEFEND HUMAN RIGHTS AND PROTECTING LIVES, TRYING TO FIND THE BEST WAY TO BALANCE THAT IS HARD. THERE'S NO ONE RIGHT ANSWER.

Steve says COULD I ASK YOU ONE THING?

James says SURE, GO AHEAD.

Steve says WE HEARD FROM UDO SAYING THAT THE NOTION THAT YOU SHOULD BE ABLE TO SURVIVE FOR AT LEAST 12 MONTHS AFTER CARE IS A CONSIDERATION IN HOW DOCTORS WILL DO THEIR WORK, AND I GUESS I JUST NEED TO KNOW, WHAT'S MAGIC ABOUT 12 MONTHS? HOW DID YOU LAND ON THAT?

James says THE CHALLENGE HERE, RIGHT, IS THAT YOU'RE TRYING TO... WHEN YOU'RE TALKING ABOUT SAVING LIVES, THERE'S MANY WAYS TO CAPTURE THE CONCEPT OF SAVING LIVES. ARE YOU TRYING TO HAVE THE MOST PEOPLE SURVIVE JUST TO THE POINT THAT YOU CAN GET THEM OFF OF LIFE SUPPORT? WELL, NOBODY REALLY THINKS THAT THAT'S THE PURPOSE OF HEALTH CARE OR CRITICAL CARE TO SURVIVE LITERALLY TO THE POINT YOU MAKE IT TO THE ICU DOOR. YOU'RE HOPING TO SURVIVE FOR SOME PERIOD OF TIME AND MAKE A RECOVERY. IF YOU START TO GET OUT TO FIVE AND TEN AND TWENTY YEARS, IT BECOMES IMPLICITLY AGEIST. THERE MAY BE PEOPLE JUST BECAUSE THEY'RE IN AN ADVANCED AGE WOULD NOT HAVE THAT MANY YEARS TO LIVE BUT IT'S NOT REALLY ABOUT THEIR MORTALITY RISK PER SE. SO YOU'RE TRYING TO FIND A BALANCE BETWEEN A PROTOCOL THAT TALKS ABOUT SURVIVAL AND RECOVERY AND NOT GET TOO FAR INTO AGEISM. IT'S NOT, STRICTLY SPEAKING, ABOUT WHO IS GOING TO LIVE, HOW LONG, AND THE INDIVIDUAL MIGHT SURVIVE. IT'S ABOUT MORTALITY RISK. SO THE PURPOSE OF THESE TOOLS... AND I'D LIKE TWO MINUTES TO TALK ABOUT THE TOOLS, IF I CAN? THE IDEA IS THAT WE'RE TRYING TO CREATE TIERS OF RISK. AND IDEALLY, IF WE HAVE ENOUGH RESOURCES, EVERYBODY GETS THE RESOURCES, RIGHT? WE'RE NOT... NOBODY IS EXCLUDED FROM CRITICAL CARE UNDER THE PROTOCOL. THE IDEA IS THAT ASK THE DEMAND, AS THE SURGEON DEMAND CLIMBS AND WE GET TO THE POINT WHERE WE JUST LITERALLY DO NOT HAVE ENOUGH TO GO AROUND, WE'RE TRYING TO FOCUS OUR RESOURCES ON THE PEOPLE WHO ARE MOST LIKELY TO BENEFIT, PEOPLE WHO ARE MOST LIKELY TO SURVIVE IF THEY GET CRITICAL CARE BUT NOT SURVIVE IF THEY DON'T. SO THAT WOULD BE THE BENEFIT IN THAT SENSE. BUT THE IDEA, IS IT 12 MONTHS, IS IT 6 MONTHS, IF YOU'RE LOOKING AT 12-MONTH RISK IT'S THE SAME AS 6 MONTHS OR 18 MONTHS. THE FOCUS ON THE DURATION OF TIME WHERE YOU'RE LOOKING AT THE DATA IS NOT REALLY A SUBSTANTIVE CONCERN BECAUSE WHETHER YOU LOOKED AT THEIR MORTALITY AT 6 MONTHS OR 12 MONTHS, IT WOULD END UP BEING THE SAME INDIVIDUALS. WE'RE JUST TRYING TO SAY THAT WE HAVE DATA AND A LOT OF THE MORTALITY PREDICTION TOOLS AND CLINICAL GUIDANCE THAT WE'RE GIVING PEOPLE IS FOCUSED ON DATA OF MORTALITY OUT TO A YEAR BECAUSE THAT IN THE PUBLIC'S LITERATURE IS WHAT WE HAVE.

The caption changes to "Subscribe to The Agenda Podcast: tvo.org/theagenda."

Steve says I GET YOU.

James says AND I COME BACK...

Steve says YOU'VE GOT TO FORGIVE ME, DR. JAMES DOWNAR, I HAVE TO TRY TO KEEP THE TIME HERE AS EQUAL AS POSSIBLE. LET ME GET TO MARIAM ON THIS NEXT QUESTION. IT'S A REAL HARD QUESTION BUT THIS IS ALL LIFE AND DEATH STUFF WE'RE DEALING WITH TODAY. UNDER WHAT CIRCUMSTANCES, IN YOUR VIEW, SHOULD SOMEONE BE PULLED OFF A VENTILATOR IN ORDER TO GIVE IT TO SOMEONE ELSE, BECAUSE THAT'S THE SCENARIO THAT MANY DOCTORS AND NURSES ARE GOING TO BE LOOKING AT POTENTIALLY IF WE DON'T FLATTEN THE CURVE?

The caption changes to "Mariam Shanouda, @mariamshanouda."
Then, it changes again to "Ethics versus human rights."

Mariam says YEAH. YOU KNOW, STEVE, I HAVE A REAL PROBLEM WITH EXAMPLES LIKE THAT BECAUSE WHAT WE'RE TALKING ABOUT... AND THIS GOES BACK TO WHAT PROFESSOR SCHUKLENK SAID AND DR. DOWNAR SAID ABOUT ETHICAL PRINCIPLES AND THE HUMAN RIGHTS FRAMEWORK. AND THEY'VE BEEN EQUATED FROM THE VERY BEGINNING WITHIN THIS TRIAGE PROTOCOL. AND THAT'S PROBLEMATIC FOR SEVERAL REASONS. THE FIRST IS THAT ETHICAL PRINCIPLES ARE JUST THAT, THEY'RE PRINCIPLES. THE HUMAN RIGHTS FRAMEWORK THAT WE HAVE ARE QUASI-CONSTITUTIONAL RIGHTS AND IMPOSED UPON ALL OF US. SO YOU SHOULDN'T BE DRAFTING A TRIAGE PROTOCOL TO ANSWER QUESTIONS LIKE THE ONE YOU JUST POSED BY LOOKING AT ETHICAL PRINCIPLES. YOU SHOULD BE LOOKING AT A HUMAN RIGHTS FRAMEWORK. SECOND, THE ETHICAL PRINCIPLES THAT DO GUIDE THIS DOCUMENT ARE... SOME OF THEM, IN AND OF THEMSELVES, DISCRIMINATORY. BY WAY OF EXAMPLE, UTILITARIANISM. IT WAS MENTIONED AT THE TOP OF THE PROGRAM AND MENTIONED BY DR. DOWNAR AND PROFESSOR SCHUKLENK. IT TALKS ABOUT THE MAXIMUM BENEFIT OF GOOD FOR THE MAXIMUM NUMBER OF PEOPLE. THE PROBLEM IS THAT WHEN WE LOOK AT THIS, PERSONS WITH DISABILITIES HARDLY EVER COMPRISE THAT MAXIMUM GROUP OF PEOPLE THAT HAVE RECEIVED THAT BENEFIT. SO THE ENDS JUSTIFY THE MEANS WHICH PRETTY MUCH IS UTILITARIANISM WILL ALWAYS BE DISCRIMINATORY TO PERSONS WITH DISABILITY...

Steve says IF YOU DON'T USE THAT PHILOSOPHY, WHAT SHOULD YOU USE?

Mariam says THE HUMAN RIGHTS FRAMEWORK. IT TALKS ABOUT THE DUTY OF TO ACCOMMODATE AND UP TO THE POINT OF UNDUE HARDSHIP. IT'S NOT THIS IDEALISTIC IDEA OF FAIRNESS, IT'S SUBSTANTIVE FAIRNESS AS SET OUT IN SECTION 15 OF THE CHARTER. SO TO DILUTE OR TO EQUATE ETHICAL PRINCIPLES WITH HUMAN RIGHTS FRAMEWORK IS TO DILUTE A VERY ROBUST SYSTEM. AND JUST ONE MORE POINT, AND ON THAT STEVE, TO SAY THAT WE JUST DON'T HAVE TIME, WE'RE IN A PANDEMIC, WE NEED TO BE EFFICIENT... THIS IS THE TYPE OF SCENARIO WHERE HUMAN RIGHTS MATTER THE MOST. HUMAN RIGHTS AREN'T TRIGGERED WHEN THINGS ARE EASY AND PEOPLE ARE LIVING A HAPPY LIFE. HUMAN RIGHTS ARE ESPECIALLY TRIGGERED IN THESE MOST DIRE OF TIMES, AND WE CAN'T TRAMPLE OVER THEM FOR THE SAKE OF EFFICIENCY AND TRAMPLING THEM BY PUTTING IN ETHICAL PRINCIPLES AS TAKING PRIMACY OVER HUMAN RIGHTS. I DON'T THINK THAT'S APPROPRIATE.

Steve says UDO SCHUKLENK, CAN I GET YOUR VIEW ON WHETHER WE SHOULD TAKE A MORE HUMAN RIGHTS BASED LENS ON THIS ISSUE VERSUS A PHILOSOPHICALLY UTILITARIAN LENS ON THIS. WHAT'S YOUR VIEW?

The caption changes to "Udo Schuklenk, @schuklenk."

Udo says I'M BIASED HERE. I DON'T CARE ABOUT OUTCOMES. THAT'S THE PROBLEM WITH HEALTH CARE SYSTEMS. THEY ALWAYS TRY TO MAXIMIZE HUMAN WELL-BEING. I HAVE ISSUES WITH THE HUMAN RIGHTS ARGUMENT BECAUSE THE TRUTH IS NONE OF THESE CHARTER RIGHTS ARE ABSOLUTE. THEY CAN ALL BE OVERRIDDEN, PROVIDED WE HAVE A GOOD JUSTIFICATION FOR THAT. SO WHAT THE PREVIOUS SPEAKER HAS JUST DONE, BASICALLY, SHE HAS HIDDEN BEHIND A HUMAN RIGHTS... AND SHE DODGED THE QUESTION. AND THE QUESTION REMAINS: IF YOU'RE SOMEBODY WHO IS IN A HOSPITAL SETTING... AND I WORKED MANY YEARS AGO IN SAN FRANCISCO SO I'VE ACTUALLY... SOUTH AFRICA SO I'VE ACTUALLY SEEN THIS. THERE'S A PATIENT THERE THAT IS ON A VENTILATOR, HAS NOT A REALLY GOOD OUTLOOK IN TERMS OF SURVIVAL, AND THERE'S SOMEBODY ELSE WHO NEEDS ACCESS TO THAT VENTILATOR AND YOU KNOW THAT THIS PERSON WITH A MUCH HIGHER PROBABILITY WILL BE ABLE TO LEAVE THAT HOSPITAL. ARE YOU THEN GOING TO, AS THE PREVIOUS SPEAKER HAS JUST DONE, NO, WE CAN'T DO THIS, WE MUST NOT DO THIS, OUTCOMES DON'T MATTER, IT'S ALL ABOUT RIGHTS. ARE YOU SAYING WE STAND BY, WE WAIT FOR THIS PERSON TO DIE AND THE OTHER PERSON IS ALSO GOING TO DIE BUT WE CERTAINLY WOULD NOT WEAN THAT PERSON OFF THE VENTILATOR. IN SOUTH AFRICA OF COURSE THEY WEANED THAT PERSON OFF THE VENTILATOR IN ORDER TO SAVE THAT OTHER LIFE?

Steve says DAVID LEPOFSKY, DO YOU WANT TO WEIGH IN?

The caption changes to "David Lepofsky, @DavidLepofsky."

David says THEY GIVE YOU IDEAS FROM THE POINT OF VIEW OF BIOETHICS. I'M SORRY, BUT WE LIVE IN A COUNTRY THAT'S GOVERNED BY LAW AND THE RULE OF LAW AND WHAT PROFESSOR SCHUKLENK SAID, SOMEONE NEEDS TO EXPLAIN TO ME WHY IT IS NOT CULPABLE HOMICIDE UNDER OUR CRIMINAL CODE. EVEN UNDERLYING ALL OF THIS DISCUSSION HAS BEEN EVEN THIS IMPLICIT PREMISE THAT SOMEHOW THE GOVERNMENT CAN SEND A MEMO TO HOSPITALS DECIDING WHO LIVES AND WHO DIES WITHOUT ANY PROPER LEGAL AUTHORITY. THE BIOETHICS TABLE IN ITS MOST RECENT WRITING HAS SUGGESTED A GREATER RECOGNITION THAT WE NEED TO HAVE A LEGAL SUPPORT, BUT I'M TELLING YOU CATEGORICALLY, ANY DOCTOR WHO DOES WHAT PROFESSOR SCHUKLENK JUST SAID, WITHOUT LEGAL AUTHORITY, BETTER BE CONSULTING A LAWYER AND FAST. THIS IS NOT A QUESTION OF PHILOSOPHY FIRST. THE LAW PREVAILS. SECOND, DR. SCHUKLENK'S UNDERSTANDING OF THE WAY THE CHARTER OF RIGHTS AND HUMAN RIGHTS WORKS I'D RESPECTFULLY SUGGEST IS FUNDAMENTALLY AND SEVERELY FLAWED. I KNOW THIS STUFF. I TEACH IT. I'VE PRACTISED IT FOR DECADES. AND LET ME JUST ADDRESS A COUPLE OF OTHER POINTS. DR. DOWNAR SAID, OH, THERE'S BEEN LOTS OF CONSULTATION. YES, LAST SUMMER AND FALL... LAST SUMMER WE HAD DISCUSSIONS WITH THE BIOETHICS TABLE. IT'S AN EXTERNAL ADVISORY BODY THAT ADVISES THE GOVERNMENT. WE HAVE NOT BEEN ABLE TO HAVE ONE WORD OF CONVERSATION WITH ANYBODY IN THE MINISTRY OF HEALTH WHO IS ACTUALLY MAKING THE DECISIONS. THEY HAVE REFUSED TO TALK TO US. THE MINISTER OF HEALTH HAS REFUSED TO ANSWER ANY OF OUR SIX LETTERS WITH OUR MOST BASIC INQUIRIES. THE IMAGE YOU GOT FROM DR. DOWNAR OF, OH, THIS IS ALL SO CONSULTATIVE. YES, THE EXTERNAL HUMAN SHIELDS THE BIOETHICS ARE OUT THERE BUT THE PEOPLE MAKING THE ACTUAL DECISIONS AREN'T. AND WHY THAT'S SIGNIFICANT, STEVE, IS BECAUSE THE ONE TIME WE HEARD TWO MINUTES FROM SOMEBODY WHO IS ACTUALLY A MEMBER OF THE GOVERNMENT'S INTERNAL BODY CALLED THEIR CRITICAL CARE COMMAND CENTRE, A DR. ANDREW BAKER, ON A CONFERENCE CALL THAT WE HAD TO GIVE OUR INPUT A COUPLE OF WEEKS AGO, HE TOOK A POSITION OR AN APPROACH WHICH IS AT ODDS WITH THE BIOETHICS TABLE'S RECOMMENDATIONS AND I FUNDAMENTALLY BELIEVE AT ODDS WITH OUR HUMAN RIGHTS CODE AND OUR CHARTER OF RIGHTS. I'M HAPPY TO GO INTO IT IF WE HAVE TIME...

Steve says WELL, FORGIVE ME, I WISH WE DID. UNFORTUNATELY, WE DON'T. AND I REALLY NEED TO LET UDO RESPOND TO THE COMMENTS YOU JUST MADE. SO GO AHEAD, UDO?

Udo says NO, NO, ACTUALLY, I WANTED TO JUST SAY THAT WE HAVE COMMON GROUND WITH REGARD TO THE STATUS OF THE DOCUMENT BECAUSE I AM JUST LIKE YOU COMPLETELY PUZZLED ABOUT IT. WHEN YOU LOOK AT THE CHARTER THAT THE BIOETHICS TABLE ITSELF HAS, IT'S VERY CLEAR THAT THESE DOCUMENTS THEMSELVES ARE MEANINGLESS UNTIL GOVERNMENT ADOPTS IT, WHETHER THEY DO IT IN THE FORM OF LEGISLATION OR OTHER MEANS. BUT RIGHT NOW AT LEAST THE DOCUMENT HAS NO STANDING UNTIL IT IS ADOPTED BY GOVERNMENT. IT'S JUST THE OPINION OF THIS TABLE, AND THE TABLE ITSELF MAKES VERY CLEAR THAT THIS IS HOW IT UNDERSTANDS ITSELF. IT BASICALLY PROVIDES GOVERNMENT WITH THIS SORT OF GUIDANCE DOCUMENT AND GOVERNMENT DECIDES WHAT TO DO WITH THAT. PRIOR TO THAT THAT DOCUMENT DOESN'T HAVE STANDING AND IT SHOULDN'T, OF COURSE.

David says EVEN UNDER IT, WE TAKE ISSUE WITH THE 12-MONTH TIME LINE. WE THINK IT'S TOO LONG. WE TAKE ISSUE WITH THE LACK OF DUE PROCESS. THE DOCUMENT RECOMMENDS MORE THAN THERE WAS BEFORE BUT PATIENTS DESERVE INDEPENDENT LEGAL SAFEGUARD WHERE THEIR VERY RIGHT TO LIFE IS AT RISK, AND WE TAKE ISSUE WITH THE FACT THAT IN EFFECT UNDER THE DOCUMENT THAT WE ARE NOW TALKING ABOUT, WHICH IS THE ONE THE GOVERNMENT CIRCULATED AFTER REPEATED PRESSURE AND QUESTIONS IN THE LEGISLATURE, NOT BEFORE... EACH DOCTOR ASSESSING EACH PATIENT WOULD ULTIMATELY BE A LAW UNTO THEMSELVES, APPLYING NO CLEAR STANDARDS WITH RAMPANT ROOM FOR SUBJECTIVITY AND THEREFORE SERIOUS RISK OF BIAS, INCLUDING BIAS... INCLUDING DISCRIMINATION AGAINST PEOPLE WITH DISABILITIES THAT THEY MAY NOT EVEN BE AWARE THEY'RE DOING...

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Steve says DAVID, LET ME JUMP IN HERE BECAUSE WE'RE DOWN TO OUR LAST FEW MINUTES, UNFORTUNATELY, AND BECAUSE YOU'RE VISUALLY IMPAIRED, YOU COULD NOT SEE DR. DOWNAR SHAKING HIS HEAD IN THE MIDST OF THAT ANSWER. DR. DOWNAR, DO YOU WANT TO PUSH BACK ON THAT?

The caption changes to "tvo.org/theagenda; agendaconnect@tvo.org."

James says ON A FEW POINTS. RIGHT OFF THE BAT I JUST THINK IT'S REALLY IMPORTANT TO NOTE THAT THE PURPOSE OF THESE CLINICAL TOOLS ARE THEY WOULD BE APPLIED TO SPECIFIC MEDICAL CONDITIONS FOR WHICH THEY ARE RELEVANT FOR PREDICTING MORTALITY. THERE'S ONLY ONE ELIGIBILITY... THERE'S ONLY ONE PRIORITIZATION CRITERIA WE USE AND THAT'S MORTALITY RISK. REFERENCES TO THINGS LIKE THE CLINICAL FRAILTY SCALE ARE ONLY APPLIED TO PEOPLE WITH FRAILTY, NOT PEOPLE WITH DISABILITIES, CHRONIC DISABILITIES, PEOPLE WHO ARE YOUNGER THAN 50. THESE ARE PEOPLE FOR WHOM THE CLINICAL FRAILTY SCALE IS NOT PROGNOSTIC. YOU DON'T APPLY CLINICAL FRAILTY SCALE, THE SAME WAY YOU WOULDN'T USE YOUR CANCER TOOLS TO PROGNOSTICATE FOR SOMEBODY WHO HAS CANCER. IT'S ALSO EXTREMELY IMPORTANT TO NOTE THAT EVEN THIS NOTION OF HUMAN RIGHTS. HUMAN IMBUE EVERYTHING WE DO. THE IDEA THAT WE'RE SORT OF SACRIFICING HUMAN RIGHTS I JUST DON'T THINK IS CORRECT. THE PURPOSE OF HAVING CLEAR, EXPLICIT CRITERIA IS THAT THEY ARE THE ANTIDOTE TO IMPLICIT BIASES, THEY ARE THE ANTIDOTE TO SUBJECTIVE JUDGMENTS, IS TO PUT CLEAR CLINICAL TOOLS OUT THERE...

David says DR. DOWNAR.

James says LET ME FINISH, DAVID. I DIDN'T INTERRUPT YOU. THERE ARE CLEAR STANDARDS THAT PEOPLE CAN APPLY, SOMEBODY WITH HEART FAILURE CAN BE COMPARED TO SOMEBODY WITH CANCER CAN BE COMPARED TO SOMEBODY WHO COMES IN FOLLOWING A CAR ACCIDENT AND WE'RE TRYING TO TREAT EVERYBODY AS FAIRLY AS POSSIBLE. AGAIN, WE DON'T WANT TO RESTRICT ACCESS TO ANYBODY. WE WOULD LOVE IT IF WE COULD SIMPLY OFFER CRITICAL CARE TO EVERY SINGLE PERSON. THE NOTION, THOUGH, THAT THERE'S THIS SORT OF PUSHING ASIDE OF HUMAN RIGHTS... YOU KNOW, SOME OF CANADA'S FOREMOST RIGHTS LAWYER THAT JOCELYN DOWNEY ROAD AN EDITORIAL THAT OUR ONTARIO PROTOCOL SHOULD BE ADOPTED NATION-WIDE. OUR PROTOCOL HAS BEEN SERVED AS THE INSPIRATION FOR SIMILAR PROTOCOLS THAT WERE ACCEPTED WITH ENTHUSIASTIC SUPPORT OF DISABILITY GROUPS IN QUEBEC...

Steve says I GOT YOU. I'VE DOWN TO A MINUTE AND A HALF AND I WANT TO GIVE DAVID LEPOFSKY A CHANCE TO RESPOND.

David says DR. DOWNAR CONCEDED IN CONVERSATIONS WITH US AT HIS BIOETHICS CONSULTATION THAT THE CLINICAL FRAILTY SCALE WHICH HE IS A PASSIONATE DEFENDER OF INCLUDES SUBJECTIVE CALLS BY DOCTORS.

Steve says DON'T THEY DO THAT EVERY DAY ANYWAY, DAVID?

David says NOT WHEN YOU'RE DOING OBJECTIVE ASSESSMENTS. THE POINT IS, DON'T TELL US THAT IT IS AN OBJECTIVE REQUIREMENT WHEN IT IS A SUBJECTIVE ONE. EACH DOCTOR WILL BE A LAW UNTO THEMSELVES. NOT ONLY THAT, BUT WHEN I ASKED DR. DOWNAR LAST SUMMER, DURING THESE CONSULTATIONS, HOW ABOUT HOW DOCTORS MAKE PALLIATIVE CARE ASSESSMENTS WHETHER YOU'VE GOT THREE MONTHS TO LIVE TO QUALIFY. THAT'S THE SITUATION IF YOU GET INTO PALLIATIVE CARE, NOT WHETHER YOU GET CRITICAL CARE, BUT DR. DOWNAR SAID THAT DOCTORS LIE. HE'S NOT MEANING LIE I DON'T BELIEVE IN A NASTY SENSE, HE'S SAYING THAT ESSENTIALLY, IF I UNDERSTAND CORRECTLY, THEY WILL SAY WHAT THEY NEED TO SAY TO GET THE PERSON IN. BUT THAT'S THE SAME KIND OF SUBJECTIVE RISK WE'RE FACING HERE WHEN YOU CHANGE THREE MONTHS TO 12 MONTHS.

Steve says I'VE GOT TO GIVE HIM 30 SECONDS TO RESPOND TO THAT. DR. DOWNAR, FINISH IT OFF.

James says WHAT I SAID WAS THAT WHEN THERE'S SCOPE FOR AND THE ABILITY TO USE JUDGMENT, THAT PHYSICIANS SOMETIMES WILL GIVE PROGNOSIS THAT ARE SHORTER THAN RESOURCES IN A HOME CARE SETTING. THESE ARE PHYSICIANS USING THEIR DISCRETION TO GET MORE RESOURCES FOR THEIR PATIENTS BECAUSE THEY'RE ADVOCATING FOR THEIR PATIENTS. THAT IS WHAT I SAID VERY CLEARLY TO YOU, MR. LEPOFSKY. THEY'RE NOT LYING TO SUIT THEIR NEEDS OR CONVENIENCE. THAT'S A VERY IMPORTANT DISTINCTION, MR. LEPOFSKY.

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

Steve says WE NEED YOU FOUR BACK FOR ANOTHER PROGRAM. AS MUCH AS WE HAD A GOOD HALF HOUR ON THIS, WE NEED MORE TIME. I'M GRATEFUL TO JAMES DOWNAR, UDO SCHUKLENK, DAVID LEPOFSKY, MARIAM SHANOUDA FOR JOINING US ON TVO TONIGHT. THANK YOU ALL VERY MUCH.

The caption changes to "Subscribe to The Agenda Podcast: tvo.org/theagenda."

David says THANKS SO MUCH.

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