The very idea of rationing health care is something usually reserved for battlefields, or massive disasters such as earthquakes or typhoons. But indeed, such rationing is a grim reality as caregivers in north and north central Idaho consider “triage protocols” in the shadow of a new surge of COVID-19.
“One of the things we insist on in our triage protocols is that the individual doctor at the bedside should not be the one making that decision, because that doctor may not know that there is a bed available in a hospital six doors away,” said Dr. Matthew Wynia, founder of the University of Colorado’s Center for Bioethics and Humanities.
“So there really needs to be a committee that has good situational awareness of where the beds are, across the city or across the whole state.”
Wynia visited with Morning Edition host George Prentice to talk about crisis standards, a growing level of frustration and even anger among physicians and what he calls, “the three R’s” of pandemic ethics.
“There is an enormous amount of anger. There's even anger across states.”Dr. Matthew Wynia
Read the full transcript below:
GEORGE PRENTICE: It is Morning Edition on Boise State Public Radio News. Good morning. I'm George Prentice. This morning, we continue our conversations regarding bioethics and more specifically, Crisis Standards of Care. And we're fortunate to invite Dr. Matthew Wynia, director of the University of Colorado’s Center for Bioethics and Humanities and the founder of the Center for Patient Safety at the American Medical Association. Dr. Wynia, a good morning.
DR. MATTHEW WYNIA: Good morning.
PRENTICE: When it comes to pandemic ethics, I have heard you refer to the “three R’s” :Restriction, Rationing and Responsibility. Could you talk a little bit about the third R, if you will, the Responsibility? It seems as if we have shifted so much, if not all of the responsibility on the shoulders of our caregivers.
WYNIA: Years ago, when we were thinking about the responsibilities in the pandemic, we were really thinking mostly about: Will doctors and nurses come to work in the event that there is an infectious illness that doesn't have a treatment, that doesn't have a vaccination? And how will we ensure that people will come to work? And as it turns out, when the pandemic came along, doctors did show up, nurses did show up, EMTs did show up for work. And instead, the conversation around the ethics of caring for each other has really devolved much more into the general public, and the responsibilities of organizations, of employers, of the government, and as you alluded to, of individuals towards each other, towards our neighbors, towards our families. What responsibility do we have now that we have a vaccine, for example, to be vaccinated, even though there are side effects of the vaccine, even though it might cause you to take a day off of work, that kind of thing? And you may feel you're a very low risk person, but do you have a responsibility to the rest of the community to reduce the spread of the disease among the low risk population? It's been a very interesting evolution of that aspect of ethical issues in pandemics.
PRENTICE: We keep hearing the word “triage.” So, I'm trying to imagine this in my mind's eye: when triage is performed, is it fair for a doctor - well, I guess that fairness goes out the window - but are we talking about a doctor having to decide yes or no to someone? What if there's similar care available somewhere else?
WYNIA: One of the main points of having Crisis Standards of Care, of having triage protocols ready in advance, is that it hopefully allows you to avoid having to make the most difficult decisions, because, for example, one of the things we insist on in our triage protocols is that the individual doctor at the bedside should not be the one making that decision, because that doctor may not know that there is a bed available in a hospital six doors away. So there really needs to be a committee that has good situational awareness of where the beds are, across the city or across the whole state, who can then make decisions about allocating those scarce resources to do the most good.
PRENTICE: I've heard a lot of laypeople, such as myself, keep saying, well, it's all about saving the most lives. Is that accurate?
WYNIA: Well, that is the first order criteria that we tend to use. You don't want to use precious, limited resources on someone who is not going to make it. And you also don't want to spend precious resources on someone who is going to survive, even without getting those resources. So, it's really this balancing act of trying to find the optimal use of resources to give to those people who will survive if they get them and will not survive if they don't. And that is the first order criteria. That said, there are other things that also come into play: issues of equity come into play and other ways of looking at fairness across the allocation system.
PRENTICE: But then we open up the conversation of a 12 year old versus an 80 year old…quantity versus quality.
WYNIA: And that's within the framework of saving the most lives. So, you're still in the first order framework here of let's try to save the most lives. Then, someone is going to ask, “Does a life that has 30 years to live count the same as a life that has two years to live? And that need not be correlated with age? If someone has end-stage pancreatic cancer - they may have only a year or so to live - would you give the same resources to that person as you would to someone else who may be 80 years old, but doesn't have that kind of an end stage illness?
PRENTICE: Let's talk about guilt and anger. It seems forever ago, but it was only six months ago that there was “vaccination guilt” of those that were getting the vaccine feeling guilty about those who hadn't got theirs yet. And now we're at a stage of anger of people who are vaccinated; and they're getting angry at those who choose not to be.
WYNIA: Yeah, and I think you will see that in double or triple form. If you talk to anyone in the health care system who sees the current wave of infections and death as being avoidable. And so, there is an enormous amount of anger. There's even anger across states. You know, if you go to the ICUs in Colorado right now, my colleagues in the ICU are fielding 30, 40 calls a day from out of state hospitals seeking to transfer patients to us. And I have to say, there are people in our ICUs that are starting to say, really, you know, ”We're pretty full right now. Is it our responsibility to bail out the states that are not doing what they need to do to keep community transmission rates low?”
PRENTICE: Is it your sense that mandates or requirements - whatever word people choose - is it your sense that they can sometimes backfire?
WYNIA: Oh, absolutely. There are ways in which any kind of a legislated type requirement can cause people to become entrenched and defensive rather than, “Ok, I'll go ahead and do it.” The question is not so much, can they ever backfire for any given individual? It's do they tend to backfire on balance or do they tend to get us closer to the goal? And on balance, they do tend to get us closer to the goal. We have a lot of experience over many, many years, not just this pandemic, of what it takes to bring a global epidemic to a close. We've done it with measles. We've done it with rubella. We've done it with chicken pox. We've done it with many, many illnesses. And what it takes in the end is typically a good vaccine, and the requirement that people use that vaccine because there are folks who won't want to get any vaccine. Every time we've had a vaccination program, there's a small cadre of people who will refuse to get it. This one's been a larger cadre of people for understandable reasons. This vaccine was developed very rapidly. So, people have more questions about it. That's legitimate, although at this point, we now have more experienced clinically with this vaccine in terms of the numbers of people who've received it and how closely they've been followed over the last year. We have much, much more information on this vaccine than we've had on any prior vaccine that is in widespread use, pre pandemic.
PRENTICE: So many competing health systems. I know here in Idaho, were…. well, quite simply, they were competing. But I have to say that I am impressed by how doctors and especially administrators have been talking to each other, and sharing with one another, unlike any time we've ever seen before.
WYNIA: We saw the same thing in Colorado. I don't know that every state has seen this, but there are a number of excellent examples around the country of health systems which are normally in competitive posture towards each other, being willing to share resources, to share information, to transfer patients back and forth, and even to transfer equipment and personnel back and forth, if needed, in order to keep the community as safe as possible. I would love to see some of that communal spirit survive the pandemic and go on and become the new normal for us. It would certainly be a better normal than where we're coming from. I think if we want that to happen, we're going to have to be very proactive about maintaining it. It will not just maintain itself. The basic underlying structure of a competitive marketplace is not something that will just change on its own because people are feeling good about each other right now.
PRENTICE: Dr. Matthew Wynia, director of the University of Colorado's Center for Bioethics and Humanities. We've been lucky to have him for a few minutes this morning. Dr. Wynia, thank you so much.
WYNIA: Oh, my pleasure, thank you for having me on today.
Find reporter George Prentice on Twitter @georgepren
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