One of the interesting effects of our efforts to flatten the curve of corona virus.
This is that we were taking this big surge of Corona virus and we've squashed it so that it occurs over a large period of time.
But what our health system has also done is it's pushed down on normal health care needs to squash them out of the way to make way.
But what that's done is then created a bulge of cases that's waiting and is needing health care.
Hello, I'm Katrien Devolder.
This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all.
This is a special edition on ethical questions raised by the Corona pandemic.
Here in the U.K., we're passed the peek of the corona virus pandemic.
That new and complex ethical questions are arising because of measures to protect health care personnel.
Many health care services are running at a much lower capacity than before the pandemic.
There are now enormous waiting lists of patients whose treatments have been put on hold.
How should we choose which of these patients can be treated and which ones will have to wait?
Dominic Wilkinson, professor of medical ethics and consultant in newborn intensive care, sheds some light on these complex issues.
OK, so there has been a lot of talk about rationing of intensive care resources in the past few months.
And is that issue still relevant in the U.K. now that we're actually past the peak of the pandemic?
The biggest ethical challenge in the first phase of the pandemic was the difficulty
of anticipating very large numbers of patients with with Coronavirus COVID- 19.
Now we're now in a different phase of the pandemic with the number of cases are falling.
And one of the big problems that's emerged is that the the huge efforts that the health system has engaged in
to free up capacity for patients with COVID-19 has come at the cost of all sorts of other health care needs.
So now there's this big difficulty in how to move back to caring for those other patients as the cases of COVID-19 reduce.
The challenge of that is that it is two fold.
First is that there will be ongoing cases of COVID-19 over the next months to potentially longer,
depending on when there's either enough immunity or there's a vaccine.
So there's going to be that's in the background and that will presumably increase again when there's more spread in the community.
The second is the health system is having to be very organised in a very different way to try and reduce,
spread and reduce risk for health professionals.
And that is not an efficient way of looking after lots of patients with non COVID illness.
If you have to take extra precautions in your operating theatre to reduce the amount of virus that might be around,
the operation might take twice as long as normal.
If the operation takes twice as long as normal that means in an operating day, you can do half as many patients as you would normally.
And there is a huge backlog of patients who have not had their operations, but also all their other medical care over the last few months.
So you've got COVID-19 in the background.
You've got patients needing ongoing health care.
But and reduced ability to do that.
And a huge backlog we have in the coming months a huge challenge of competing needs of different patients.
Do different considerations come in play?
So people have thought about how to allocate scarce medical resources amongst COVID-19 patients.
So do we have to think in a similar way about sharing resources between COVID and non COVID patients so that
the ethical principles look to be similar in that there isn't anything intrinsically special about COVID-19.
It's the illness or people who have this. It's not that this illness is deserving of treatment more than other illnesses.
And the ethical principles that have been sort of applied to rationing or prioritisation of COVID treatment also apply to other illnesses.
But there is a challenge when we're talking about other illnesses is that it's it's very difficult to compare.
For example, how do we compare a patient who's had a stroke with a patient who's got COVID-19?
How do we compare the needs of patients with non-life threatening illnesses with those of COVID-19?
So there is an issue of commensurability. That's both, epistemic, it is difficult to get the relevant facts straight,
When we're talking about different illnesses, what would be the impact on quality of life or QUALY's?
I mean, if we wanted to talk in a purely econometric trick way, we could talk about the QUALY's of stroke treatment versus COVID treatment.
But the data is often not there to enable comparisons.
But then there's also a philosophical issue we can think about two big competing ethical theories or principle.
So one is benefit. If we prioritise benefit, we say, how can we do the greatest good for the greatest number?
That's obviously a utilitarian way of framing that.
And on the other hand, we have equality and fairness and we can say how do we treat people's needs equally?
These two ethical principles compete. when we've got relatively large amounts of resources,
it's relatively easier to favour equality.
It doesn't come at the cost of huge amounts of benefit.
At the peak of the pandemic, where it's very obviously a question of how many lives do we save?
An egalitarian approach of, for example, tossing a coin to decide who gets the ventilator is, to most people's minds, is completely inadequate.
It's simply a question of how do we save the most lives? Where we are now is somewhere in between.
And in a sense, that makes it more difficult because we now have to choose between these competing values.
And that leads us to the other really difficult element of the pandemic,
which is uncertainty when it comes to trying to plan, relaxing our health system and restarting surgery.
We simply don't know quite how many cases of COVID-19 we will have.
Obviously, if there'll be very few, we can open up the health system a lot if is going to be quite a lot around the corner.
We can't open the health system very much.
So this balance between the health care needs is is intensely complicated by the fact that we don't know what to do or how best to do it.
So how do we go about choosing between health care needs of various types of non-COVID patients?
So should we prioritise essential cancer patients? Patients who need some certain types of operations, how do we even start choosing who goes first?
So within every area of medicine at the moment, health professions are trying to work out, well, how do we deal with our big backlog of patients?
Do we simply work through our waiting list from those who were about to be seen or have had their operations cancelled?
And we add new people to the bottom of the list and we'll get to them
In some time. Or do we do something else?
Again we can think about an egalitarian approach which would say, for example,
maybe you just take first come first served, you take the cue model and say, well, who's at the front of the queue?
We'll deal with them. We'll get to the back of the queue. Eventually. Versus a utilitarian approach, which would say, hang on,
There is nothing ethically relevant with when you arrive for needing health care.
And operating first come, first served or some queue system means that you treat people at the front of the queue who might be quite capable
of waiting at the cost of people who are in the middle or the back of the queue who have no capacity to wait.
Who, for example, will come to serious harm through waiting. That doesn't make any sense from the utilitarian point of view.
The practical challenge of trying to to apply a utilitarian approach to the big backlog
of patients is is firstly that it can be very difficult to choose between patients.
On what basis do you re prioritise this list?
So it's quite a difficult task to do. And of course, it will be very unpopular with those patients, for example,
who were just due to have their surgery in early April or late March and who were cancelled and who now suddenly
find themselves at the back of the back of the list and being told that they've got another six months to wait.
So it will be politically challenging and also personally challenging for the health professionals.
There may be patients, for example, who are on on the list who because of the backlog, would no longer be considered for surgery.
So it might be, for example, given the current state of the health system that health professionals say,
look, certain types of surgery we're not ready to do at the moment. It's the benefits too small.
And we've got too many patients to care for. But there may be patients like that already on the list of people who said, yes, we'll operate on you.
So do you say to them, I know we said we'd do your operation, but now actually we changed our mind.
So here you've got a problem that's exactly parallel to the withholding and withdrawing problem that you get with ventilators and intensive care.
One option, it would be interesting politically to know how many patients would be
willing to forego their surgical spot in the next six months and say,
well, actually, given the pressures on the health system and also perhaps given the uncertainties of perhaps catching COVID.
If you go into hospital for an operation or an appointment in the next little while, perhaps I'll wait until next year.
I'll put off my surgery for my knee or shoulder or or whatever it is, something like that is important.
I think it's also important for clinicians to pay attention to those patients who
are waiting and to look at ways to mitigate the costs and harms to those patients.
So that might include ways to check in on those patients, making sure that if they're developing more serious symptoms,
for example, to say that their chest pain is worsening, that they can be re referred, they can be shifted up on the list.
Or if it looks like actually that they need a different sort of therapy, maybe they need physiotherapy while they're waiting,
that they're prioritised for those other therapies because here they are being being made to wait.
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