Why I won’t see you on the barricades

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.