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OtherArt of Family Medicine

Why I won’t see you on the barricades

Disability and COVID-19

Shane Neilson
Canadian Family Physician June 2020, 66 (6) 449-450;
Shane Neilson
Practising physician at Student Health Services at the University of Guelph in Ontario, Assistant Clinical Professor of Medicine (Adjunct) at the Waterloo Campus of McMaster University, and a McMaster postdoctoral student in health humanities awarded the Talent grant through the Social Sciences and Humanities Research Council.
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  • Why we triage
    Joel R Wohlgemut
    Published on: 02 July 2020
  • RE: Why I won't see you on the barricades.
    Leah Seaman
    Published on: 25 June 2020
  • RE: Why I won't see you on the barricades
    Carol P Herbert
    Published on: 12 June 2020
  • Published on: (2 July 2020)
    Page navigation anchor for Why we triage
    Why we triage
    • Joel R Wohlgemut, Family Physician, Ingersoll, ON

    Rhetorical questions, we know, are not questions at all, but statements. Reading Dr. Shane Nielsen’s recent article on disability and COVID-19 (1) I felt that the audience would have been better served had he posed his “thought experiment” as a true experiment, without presupposition of the outcome: “if a 44-year-old physician without a history of addiction, bipolar disorder, and autism appeared alongside one who did in the emergency department, both in respiratory distress, who gets the ventilator preferentially?” Dr. Nielsen indicates that he has the “lived experience” to know, but clearly this is rhetorical. Frankly, the Intensive Care Unit triage document that I had the opportunity to review as part of my work planning for pandemic response in southwestern Ontario would not have provided any guidance in this scenario, as the medical conditions Dr. Nielsen lists could not be reliably linked to impaired survival of a serious infectious illness.

    I find it problematic that Dr. Nielsen characterizes the ethos of triage planning as "nonnormative life is less worthy of investment." While a utilitarian approach has its weaknesses, its principal strength is the recognition that outcomes matter to us as human beings. Having two people die rather than one (because a scarce resource was used to prolong the life of a frail patient who ultimately dies, and a patient with a better chance of survival was denied a life-saving short-term intervention) will strike...

    Show More

    Rhetorical questions, we know, are not questions at all, but statements. Reading Dr. Shane Nielsen’s recent article on disability and COVID-19 (1) I felt that the audience would have been better served had he posed his “thought experiment” as a true experiment, without presupposition of the outcome: “if a 44-year-old physician without a history of addiction, bipolar disorder, and autism appeared alongside one who did in the emergency department, both in respiratory distress, who gets the ventilator preferentially?” Dr. Nielsen indicates that he has the “lived experience” to know, but clearly this is rhetorical. Frankly, the Intensive Care Unit triage document that I had the opportunity to review as part of my work planning for pandemic response in southwestern Ontario would not have provided any guidance in this scenario, as the medical conditions Dr. Nielsen lists could not be reliably linked to impaired survival of a serious infectious illness.

    I find it problematic that Dr. Nielsen characterizes the ethos of triage planning as "nonnormative life is less worthy of investment." While a utilitarian approach has its weaknesses, its principal strength is the recognition that outcomes matter to us as human beings. Having two people die rather than one (because a scarce resource was used to prolong the life of a frail patient who ultimately dies, and a patient with a better chance of survival was denied a life-saving short-term intervention) will strike most people as an unfortunate, and undesirable, outcome. Normativity is not the issue here; the reality of being biological creatures means that we all die, but we recognize markers of the imminence of that death. These markers are not perfect, but insisting on perfection is an abdication of our ability and responsibility to exercise moral judgment. Strict application of a “first come, first served” approach, with only a careful documentation of arrival times, might satisfy a desire to highlight the equality of all people, but its passivity violates the desire to create better outcomes for more people.

    Without a doubt, those of us working in healthcare, and particularly those of us without identified disabilities, need to listen to the voices of people such as Dr. Nielsen regarding protection for vulnerable individuals. However, many triage documents expressly recognize this need (2,3) and engaging in the planning activity itself does not, contrary to Dr. Nielsen’s assertion, constitute an intrinsic betrayal of these members of our societies.

    References

    1. Neilson S. Why I won’t see you on the barricades. Disability and COVID-19. Can Fam Physician 2020;66:449-50.
    2. Upshur REG, Faith K, Gibson JL, Thompson AK, Tracy CS, Wilson K, Singer PA. Stand on guard for thee. Ethical considerations in preparedness planning for pandemic influenza. Toronto: University of Toronto Joint Centre for Bioethics; 2005.
    3. Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. Ethical considerations for decision making regarding allocation of mechanical ventilators during a severe influenza pandemic or other public health emergency. Centers for Disease Control and Prevention; 2011.

    Show Less
    Competing Interests: None declared.
  • Published on: (25 June 2020)
    Page navigation anchor for RE: Why I won't see you on the barricades.
    RE: Why I won't see you on the barricades.
    • Leah Seaman, family physician, locum NTHSSA

    I so much appreciate Dr. Shane Neilson's article and the points he raises.

    I think we have, most of us physicians, accepted that in time of dire overwhelm of our system, as in northern Italy, we would make decisions which would limit the elderly, and possibly the disabled, access to care, to ventilators, etc. We have not had much public discussion, not even within small rural and remote hospitals and health centres, with respect to this issue.

    While we are in this relative "lull" in COVID activity, this would be a good time for in-depth conversations, leadership from top ethicists, etc. at local, regional, and national levels. Is the College up for leading in this?

    At the least, I would be very interested to hear more from Dr. Neilson, and to engage in further discussion with him on this vital issue that lies at the basis of our collective and individual values for life itself.

    Thank you/Mahssi cho,

    Leah Seaman MD, CCFP

    Competing Interests: None declared.
  • Published on: (12 June 2020)
    Page navigation anchor for RE: Why I won't see you on the barricades
    RE: Why I won't see you on the barricades
    • Carol P Herbert, Retired academic family physician and former dean, Schulich School of Medicine & Dentistry, Western University

    Thanks to Shane Nielson for so eloquently describing the ethical problem in a triage strategy that discriminates against disabled or elderly individuals as well as people with chronic conditions. There are no easy approaches to allocation when resources are limited, but we must closely question strategies that systematically disadvantage the already disadvantaged. Structural inequity is a reality in Canada as it is elsewhere, and it becomes more obvious when choices are made by those who have traditionally held positions of power and authority. I think The Third Rail is a great addition to CFP.

    Competing Interests: None declared.
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Canadian Family Physician: 66 (6)
Canadian Family Physician
Vol. 66, Issue 6
1 Jun 2020
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Why I won’t see you on the barricades
Shane Neilson
Canadian Family Physician Jun 2020, 66 (6) 449-450;

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Canadian Family Physician Jun 2020, 66 (6) 449-450;
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