During the third wave of COVID-19, Manitoba hospitals were overwhelmed. They simply didn’t have the capacity to treat all those who needed critical care. As a result, some patients were exported to other provinces.
Did you ever wonder how it was decided which very sick patients would be treated locally, close to family and friends, and which would be sent for treatment to Ontario or Saskatchewan? Who made those allocative decisions, and on the basis of what criteria did they select the unlucky candidates?
Perhaps these triage decisions were made by individual doctors at the patients’ bedside, each doctor following the dictates of his or her own conscience. Or perhaps each hospital or each regional health authority had its own policy. The citizens of Manitoba were, and to this day remain, completely in the dark.
The government of Manitoba had no apparent triage plan during the third wave. Now, as we wait for the fourth wave to descend upon us, precipitated by the superbly infectious delta variant, Manitoba still has no announced triage protocol. Since the beginning of the COVID-19 pandemic, the government of Manitoba seems to have consistently failed to plan in advance.
Health Minister Audrey Gordon was asked recently by the Winnipeg Free Press whether the province was finally developing triage guidelines. She equivocated.
For some time, Manitoba doctors have been petitioning the minister to implement and publicize a triage plan. They continue to warn that our health-care system may once again be swamped; at that point, Manitoba’s doctors and hospitals will need guidelines to assist them in deciding who should (and who should not) get optimal medical care. Lives will hang in the balance.
Even when pressed, however, Gordon "wouldn’t promise to enact a triage protocol," nor would she promise to consult the public about any guidelines under development. Wrapping herself in the banner of "transparency," the minister assures us the government is committed to releasing "all the information that we believe the public needs to know."
Hmmm. They will decide, in their own good time, what we need to know about which patients should receive priority life-saving treatments, and the citizenry is expected gratefully to accept their wise decisions.
Contrast the modus operandi of the government of Manitoba with that of governments in Ontario, Quebec and Alberta.
Unlike Manitoba, Ontario developed triage guidelines during the COVID-19 third wave. The document was sent secretly to Ontario hospitals but was later leaked to the public. It mandated hospital intensive care units to withhold life support from patients unlikely to survive at least 12 months. However, patients already on life support would continue to be sustained no matter how poor their prognosis. This approach is a compromise between first-come-first-served and save-as-many-lives-as-possible.
Quebec, which had the decency to make its plan public, allows doctors to remove patients with a poor prognosis from life support, in order to make resources available to those more likely to benefit. So in Quebec, those with the poorest chance of survival will be sacrificed in order to maximize the number of lives saved.
Alberta, whose health-care system is currently near the breaking point, has adopted triage protocols which, like Quebec’s, opt to save the greatest number of lives possible. Those most likely to survive at least a year will be given priority. Patients already on life support will be assessed daily and will be taken off life support when their survival prospects deteriorate. No appeal will be allowed from these medical decisions.
Are these approaches ethically defensible? Where some patients will likely benefit greatly from an ICU bed, while others will benefit only marginally, "first come, first served" doesn’t seem like the right moral principle. For example, if the patient who came first is unlikely to survive long, while the patient who came second is young and otherwise healthy, then the latter should be favoured.
There is a danger, however, that giving doctors the discretionary power to select which patients have the best medical prognosis may result in unfair discrimination against the elderly, racialized minorities and the disabled. That’s why we need objective rules to guide life-and-death medical decision-making.
This much seems clear: at a time when Manitoba’s critical-care capacity is once again under threat, the government has a responsibility both to health-care providers and to the general public to formulate and to publicize a plan for the distribution of scarce health-care resources. Nor should the task of formulating a triage plan be assigned solely to a panel of experts; "stakeholder groups," such as the elderly and the disabled, should be consulted. The consultation process should open to participation from the general public as well.
Critical scrutiny by an informed public is essential if we are seeking to sustain public trust in our health-care system. It’s not enough for the health minister to pay lip-service to "transparency"; trust must earned by means of genuine openness to public discussion and debate.
Arthur Schafer is founding director of the Centre for Professional and Applied Ethics at the University of Manitoba.