COVID19 and the ethics of hospital triage decision-making

There is a lot of talk these days about the predicted coming wave of COVID19 patients needing ICU beds and ventilators in particular, and the inevitable need to prioritise in terms of access. Based on what I'm reading I am somewhat reassured that the right decision criteria will be deployed. Medicine, as always when it comes to the crunch, moves speedily from publicly professed deontological values and handwaving right to consequentialist, if not outright utilitarian, decision-making. That is a good thing. You want to use your limited available resource to maximise the number of life-years preserved. It'll mean, among many other things, that you need to prioritize looking after infected health care workers first (incidentally, that doesn't include clinical ethicists :). It'll also mean to remove people who would need long-term intensive care from beds that could otherwise be utilised by a larger number of patients with better odds of faster recovery. This will be a big challenge for health care professionals who put much store in the acts and omissions doctrine, thinking mistakenly that they're less responsible for the death of someone they omitted to admit to an ICU bed, even though they could have chosen to move a patient with worse odds out of that bed. You are responsible for the choices you make, an act of omission is still an act that you are morally responsible for. 

What makes this less straightforward in practice than it looks like is that what 'the odds' are will inevitably change over time, as health care professionals begin gathering information about what does and doesn't work. This is something we saw during the Ebola virus outbreak of 2014/15. Death rates were staggeringly high and went down considerably as a result of the experience and knowledge gained by the attending health care workers. A case in point, the limited currently available evidence suggests that the vast majority of people who get on ventilators die anyway (the two papers that I have seen peg the mortality rate between 86%-97%), so the current debate about lack of ventilators might be a lot of noise about nothing. I wouldn't be surprised, however, if that changed over time, so this is something that makes allocation decisions more difficult, as the decision-making needs to be continuously updated, based on the rapidly accumulating evidence. Now, while this may well lead to different practical decisions, the normative criteria used to evaluate that evidence should remain pretty stable.

The really important bit though is that hospitals, by now, should have transparent resource allocation decision frameworks in place. They should have communicated those to their staff and made clear that to them that those criteria are binding on everyone. They should also communicate those criteria to the public. Nothing breeds suspicion, conspiracy theories and panic better than non-transparent decision-making procedures in a time of crisis. People need to understand that there is not one rule for them and another one for others who are better connected, as it were. We are all in the same boat, really. 

Which takes me to my last point. This all strikes me as obvious. So I went (16 March 2020) to the COVID19 bits of the website of our local Kingston Health Science Centre (the new name for KGH/Hotel Dieu), to find out what their policies look like, and, to my surprise, there is no relevant information. There's invariably important information about restrictions, like how many visitors will be admitted, and it's all eminently sensible. However, the hospital communicates nothing about what will substantively drive its triage nurses' and clinicians' decision-making should the predicted wave of COVID19 hit the hospital, and you're unfortunate enough to end up there, as a patient. That is unacceptable. Patients and their loved ones have a right to know how life-and-death triage decisions will be made at the hospital where they or their loved ones will be admitted. Incidentally, if everyone knows the basis on which decisions will be made, patient expectations would be realistic from the outset, which can only help in such circumstances. 

Ted Hsu not standing for re-election in Kingston and the Islands riding

Ted Hsu, Liberal MP for Kingston and the Islands declared today that he won't be seeking re-election. In characteristic honesty he explained in his farewell note that it's just too much work to represent our riding in federal parliament. He'll stick around for the remainder of this parliament probably while he's looking for a new job.

I've made no secret out of my strong opposition to Hsu. This guy was never a liberal to begin with. So, I am glad to see soon the back of him. Other than a bizarre pro-life foray in federal parliament, his other claim to fame was to defend science against the Conservative's onslaught. He deserves credit for the latter.

Hsu bet on every candidate other than Trudeau in the federal leadership race. Call him principled or incompetent, as far as his political judgment is concerned, Hsu must have realized that he wouldn't be finding himself in any position of actual influence in the likely up-coming Trudeau administration. Worse, Trudeau made clear that he doesn't want pro-life activists in his caucus. There wasn't really anywhere to go for Ted Hsu. He succeeded remarkably well in terms of isolating himself in the federal Liberal Party and its parliamentary caucus.

Personally I hope Hsu will move to his actual political home, the Green Party of Canada. It's run by fellow Christian Elizabeth May. She is also known to lack political judgment and so engages in political support for racist, homophobic, misogynist sects like Falun Gong.

After Sophie Kiwala's selection for our provincial government I hold little hope that the local Liberal riding association will be able to find a competitive replacement for Mr Hsu, but apparently that doesn't quite matter. Kingston seems to elect whoever the Liberals decide to put up. Interesting times ahead.

Oh well, democracy first-past-the-post style

Canada's progressive parties (ie the Greens, Liberals and the NDP) owe the progressive majority in Canada a very big apology. They (together with the country's electoral system) are primarily to blame for the fact that a 39% share of the vote translated into a majority conservative government. It's a silly system where such a minority of the vote (a significant minority of the vote against a 58% share on the progressive side of things) can attain majority power. I for one hope that the NDP and Liberals will stop slaughtering each other, get their heads together and create a social-liberal party along European lines to stand against the conservative minority in the country that otherwise will keep on running this place in perpetuity.

Part of the Liberal Party of Canada's problem is that it is not so clear any longer what it is that it stands for, ideologically. The liberal matters (privacy, abortion, gay rights, name it) have by and large been decided in Canada in support of liberal core values. It's not clear what else the party would have to offer to its electorate unless the conservatives decide to undermine those rights. Incidentally, how little the party has left in terms of ideological conviction is best displayed by the election of its Kingston and the Islands candidate, Ted Hsu. Hsu, a self-proclaimed pro-lifer, ran on a platform that was decidedly incoherent. He droned on about liking the Cuban health care system yet wanted to contract out government services. His campaign within the Liberal Party's for selection for the local candidacy for parliament was - in my judgment - decidedly homophobic in its implicit attacks on the only openly gay candidate who was also competing in that race. All of this - these days - is fair game in the so-called Liberal Party of Canada. You might want to study Hsu's supporters attacks on me on this blog. They truly speak volumes. It is no big surprise then, to my mind, that the Liberal Party of Canada has been reduced to what it is today. Political liberalism would show itself to be decidedly intolerant toward such behaviours and views. Hsu, by the way, won the local race. His main competitor on the conservative side of things was a candidate whose main claim to fame was that she doesn't like paying taxes. The choices the local ridings were given by the two mainstream parties (well, as far as the Liberals are concerned, formerly mainstream) were painful to watch in action.

One of the few bright sights in this election was that of the Green Party leader Elisabeth May getting elected to a seat - incidentally unseating a conservative government minister. Having been a Green politician in another life I am naturally thrilled that she made it, alas even the Green contribution to the vote splitting will undoubtedly have helped the conservatives attaining majority power.

Well, there we go, alea iacta est...

this snowstorm is coming our way ...

and now there's a near blizzard warning.

Anonymous vouching and such stuff

Some time ago I attacked Ted Hsu on this blog. Ted Hsu, whatever one might think of him, deserves credit for at least saying what he believes in, even if that does not win him votes, and even if - in the eyes of this commentator - his stances on important issues do not add up. I respect people I disagree with, as long as they have thought about what they believe in, and as long as they put their names to their views.

Bizarrely, yesterday a friend or acquaintance of Mr Hsu told me (in a response to the same blog entry) both how much of a person of integrity Mr Hsu is (I have no reason to doubt his integrity and have never suggested otherwise) and that he's progressive (I have serious reason to doubt that, but then, I suspect what's progressive these days is very much in the eyes of the beholder). Mr Hsu's friend or acquaintance also kind of vouched for Mr Hsu, he or she gave a character witness. Nothing at all is wrong with  this. Where the witness giving turned bizarre was when the friend of acquaintance decided to attack me anonymously. When questioned the rationale given was that he or she always uses his or her pseudonym on the internet. Obviously, if you were to use the pseudonym Don Quixote on the web and you decided to give witness on your friend, you do make a fool of yourself. Why should anyone care about an anonymous writer vouching for someone else about whom we actually know more than about the writer who busies him- or herself vouching?

At least this is something I won't hold against Mr Hsu. You cannot control your friends and acquaintances who decide to praise you anonymously.

For what it's worth, the Liberal Party riding association chose Mr Hsu as its candidate for parliament in the next federal elections. Congratulations are due to Mr Hsu. He fought a bitterly contested campaign well, and he won (no doubt the other pro-life candidate's second preference votes would have flown to him, because he failed to win outright in the first round). Nonetheless, a win is a win is a win! Good on him!

I have supported Bill Flanagan, who lost narrowly to Mr Hsu. Let me predict then that our riding will fall to the conservatives (whose pro-life candidate offers a more coherent conservative package than Mr Hsu) in the next election as a result of this decision of the local Liberal party's membership. But hey, that's what democracy is all about.

Ted Hsu - Liberal Pro-Life Pro-Choice Candidate

There is an interesting race going on in the Liberal riding of Kingston and the Islands. The current member of parliament, Peter Miliken, has decided to step down. Unsurprisingly - we're not in North Korea after all - there's a bunch of candidates gearing up to become the next official Liberal party candidate for parliament.

Five people - sadly all guys - are on the ticket. It's been all a quite Canadian  affair - as in polite, not to say sedate - so far. That is until one of the candidates, Ted Hsu (a Princeton trained physicist) decided to go on the attack. Hsu is an interesting chap. I went to the first all-candidates event the Liberals organised. Being a bioethics professor, I worked for the last year or so fairly intensely on a Royal Society report on end-of-life decision-making in Canada. I asked Hsu where he stands on the matter of decriminalising assisted dying in some form or shape. Anywhere between 60-75% of Canadians (more than 80% in Quebec) support such a policy change. To my surprise Hsu prevaricated and went on to say that he would have to be very very certain that that would have to be a good idea. That his electorate overwhelmingly supports such a policy change was of little consequence to him. The language of 'very very certain', of course, makes no sense. Either you're certain or you're not. There is no such a thing as 'very very certain'. I became suspicious that Hsu might actually be a closeted pro-lifer. I disagree but respect folks holding such views. However, I am skeptical as to whether the Liberal party is really their natural home. Hsu put his foot in his mouth during the event on some other issues. For instance, he praised Cuba's health care system and suggested that we'd learn from it, while he busily suggested the outsourcing of government services. Doesn't really gel, or does it?

Well, Hsu's public stance on the pro-life issue doesn't exactly gel either. During the second all-candidates' event, when pressed, he acknowledged to be a pro-lifer. Some of my feminist colleagues have suggested that pro-life is a euphemism hiding what really amounts to an anti-choice and anti-freedom ideology. Good on Hsu for being honest on this sensitive issue though. Obviously the question then remains how that hangs together with his professed liberalism. Well, in a youtube attack video going after one of his competitors, Bill Flanagan, Hsu comes out both as pro-life and pro-choice. - Think having your cake and eating it... - He explains that he supports women's legal right to choose, and that he would not curtail the use of Canadian tax monies to support developing world health services that support abortions. Of course, being pro-life - by definition - means to subscribe to the view that abortion is akin to murder.  You know, your baseline as a pro-lifer is the idea that fetal cell accumulations should be treated as if they were persons (as Catholics want us to see it). So, here we have a professed pro-lifer who subscribes to the view that tax monies should be used to support what pro-lifers considers akin to murder.

Mr Hsu, this stance of yours doesn't gel. It's comparable to saying that you're against nuclear power, that's it's a bit like a crime against humanity (pro-life ideologues are wont to comparing abortion to the Holocaust, mass murder, genocide and other such niceties), but that you won't switch off any existing legally operating power plant. I wonder how you would deal, if you ever got elected, with proposed legislation designed to decriminalise assisted dying? Your very very certain is clearly just a cover for saying 'never'. I for one am not looking forward to any conscience vote you might be able to cast should you ever get elected, Mr Hsu. I'm glad to note that at least you wouldn't touch existing legal reproductive rights of women, even though you subscribe to ideological views that consider those exercising such rights as murderers. I have got to say, this is about as plausible as celebrating Cuba's health system and wanting to outsource government services.

What's next Mr Hsu?

Christian weirdos in Kingston

Guess what, I went for a walk with two guys (one gay, one straight) along the shoreline of Lake Ontario in Kingston. Here is how we became victims of a vicious Christian ambush. Three youngish women (perhaps teenagers) surrounded us.

They had been thoroughly trained to identify 'sinners' and make them repent. So, they asked us whether we all believe in God (at which point my slightly smarter and faster German friend quietly disappeared in the direction of the water, aiming to demonstrate that he can walk on the same).

Well, I have lived in anglosaxon countries for a bit too long, so I am a tad bit politer, even when I interact with weirdos. Anyhow, the God gals went over their cue cards and explained to us that God loves us. They knew that they were speaking to gay guys, and we all know what God thinks of gay guys, don't we? Well, God supposedly loves us because God loves all sinners (to be fair, that makes sense to me, because - from what I gather - sinners live kinda more interesting lives then those who manage to live without sin, so why shouldn't God love the more adventurous crowd?). Well, eventually the God girls decided to go for the kill. They realised that probably the self-identified atheist gay guy (your's truly) might run away, screaming in mental anguish. So they resorted to grabbing my friend's and my hand. There we stood in a circle holding hands. (Honestly... I was looking for a hidden camera somewhere as it was all too farcical to be true!) Straight guys would probably have loved that scene, reasonably attractive young women holding hands with two guys they never met before in their whole lives, at the Lake shore, the sun going down, you get the picture. Back to the God squad going for the kill... - One of the girls started reading a kind of confession, and asked God for forgiveness from another one of her cue cards. She asked us every few lines to repeat after her. It was truly hilarious. I duly repeated after her the stuff about sinners and forgiveness and God loving me (I never met God, but they seemed quite certain that God really loves me, so who was I to argue with them???).

So, beware, if you're wandering along Lake Ontario in Kingston, Ontario, and you go peacefully about your business (eg enjoying the tranquility of the lake), there's odd Christian weirdos out there hassling you for no particular reason. They also think it's perfectly appropriate to invade your space and privacy. No big surprise in that, I suppose, seeing that were on a mission. They invited me and my friend to meet the rest of their forgiving crowd during church times. It didn't seem to occur to them that their sanctimonious self-rightous bull*#@# could sensibly be construed as highly offensive by halfway educated people who don't think about sex among consenting adults in terms of sin but in terms of fun. As most selfrighteous people, however, they seemed very comfortable about their own holiness.

Kingston beware! Nobody knows how many of them have been let loose by their local pastor. I think Tourism Kingston ought to warn visitors coming to town that there is Christians out and about that are on a mission. May be some kind of Christians-on-a-mission alert? Telling tourists that there is no need to call the mental health services or the police. These Christians are harmless. They will leave eventually.

Ooops, our oil reserves are finite - what a surprise

Quite funny, the Green movement has told us (well, at the time I was a very active part of it) some 20 years ago that we're running out of oil, and that - among other things - we need to reconsider our predominant modes of transport (a 1 ton vehicle to transport a 70kg body to the supermarket around the corner; academics like myself flying frequently to a far-flung corner of the world to give a 15-20 min presentation that could have been presented just as well by audio-videolink - but hey, what else do we have to feel good about ourselves :-).

It goes without saying we Greenies were variously called tree-huggers, stupid, romantic, naive or a combination of these things. Well, we were right, of course, our resources on this planet are very much finite (hence the idea that we need continuing economic growth to be happy is so remarkably and so obviously silly, yet it drives everything that we do).

So, fast forward to mid 2008. The oil price has reached breathtaking heights, and while we should be mostly concerned about the impact this will have on the affordability of food products, if you watch TV (presumably on your giant flat screen TV, which happens to have replaced ovens in many homes because they're emanating so much heat) you will be forgiven for thinking that the oil price issue is really about airline survival and the Hummer (the ridiculous GM car still produced for the Homer Simpson types of the real world - reportedly men with really really small penises). There is some good news, though, airlines shut down plenty of planes; here is hoping that Air Canada might fall by the wayside altogether, but things are not looking promising because the airline has long since begun to treat its customers particularly badly, so it might survive longer than some of its better behaved competitors.

There's also some huha about GM shutting down car factories in various countries. The truth is, of course, that this is a small reason for celebrations as it will bring us closer to keeping much-needed energy reserves for longer. Of course, for some bizarre reason, those in power (let's call them our 'representatives') do not seem to bother about putting efficient public transport systems in place. I live currently a lot of the time in Kingston, a medium-sized city in Ontario. The public transport system does arguably not even deserve the name system. The bus stops don't display information as to the route of the buses that happen to stop there on the odd occasion, indeed, even information about when buses can be expected to stop there (it's called a timetable in Europe) is not on display. Surely it can't surprise then that people take their giant American car out for a ride to the supermarket. So, decades after we knew we couldn't go on like we did, we chose collectively to stick our head in the sand and voted for GM's Hummer, Chrysler's 300C (incidentally a car driven by Barack Obama the supposedly so clever US Senator trying to become the next President of the USA), and my all-time favourite car, the Maserati Sedan.

Ok, I'm getting off my soap box now. Guess all I'm saying is, ask yourself more often what the impact of your action on the environment and future generations is. If your action is incompatible with a high-quality environment and existing future generations of people, don't do it unless you really have no choice (slight inconvenience isn't the same as saying that you really have no choice).

Conflict of interest declaration: I can't drive, so decent public transport would make a big difference to my life.

Globespan follow-up, attack on Glasgow airport

Well, (see posting below) Globespan wasn't as bad for me as it could have been. We did not crash. Our plane departed only an hour late, because too few stewards and stewardesses bothered showing up for work (no kidding, we were waiting for replacements to drop in so we could finally leave Glasgow). The food in Globespan's business class and the service provided by its staff were immaculate (mind you, not up to Virgin standards, but then, their prices were several light years below Virgin's, too). The plane was an ageing (ex Iceland Air) 757-200. The business class consisted of a few leather seats with minimal recline that probably have seen better times during their long life-span. There were no individual inflight entertainment units, not even in business class (in other words, worse than Virgin's economy).

On arrival in Hamilton we were greeted by a cheerful ground staff member who said that we were lucky to be only an hour late, as the day before the airline managed to organise a 22 hour delay... so, in balance, you're probably better off not to consider this airline for your travel purposes.

On a more cheerful note, let me assure you that I am entirely innocent and was not involved in this!

I guess I was also lucky for another reason. Had I arrived just one day later, I would not have been able to leave Toronto to go to Kingston, because militant indigenous people decided to block train tracks (possibly for good reasons). So, all trains were canceled.