{"id":4846,"date":"2020-04-24T13:32:10","date_gmt":"2020-04-24T13:32:10","guid":{"rendered":"https:\/\/tvndy.ca\/?p=4846"},"modified":"2020-11-16T11:27:17","modified_gmt":"2020-11-16T16:27:17","slug":"webcast-archive-cma-framework-for-ethical-decision-making","status":"publish","type":"post","link":"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-cma-framework-for-ethical-decision-making\/","title":{"rendered":"Webcast Archive: CMA Framework for Ethical Decision Making"},"content":{"rendered":"<p>During the COVID-19 pandemic, we will not present our webcast, due to technical problems caused by heavy internet usage. However we are providing the text as a bulletin to offer up-to-date information about assisted suicide, euthanasia and ending-of-life practices for the disability community.<\/p>\n<p><b>CMA FRAMEWORK FOR ETHICAL DECISION MAKING<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Before we get to policies for allocating life-saving medical resources, here are a couple of things to keep in mind.<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">A person living in a nursing home probably already has a medical condition that may make them more likely to get sick with the Coronavirus, and might make it harder to recover from it.\u00a0 Medical staff often act as gatekeepers by not transferring elderly and disabled people to the hospital where intensive care would give them a better chance of recovering. In this way, they are never considered under the terms of allocation protocols, and the beliefs about their ability to recover become a self-fulfilling prophecy.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">In an <\/span><a href=\"https:\/\/www.thehastingscenter.org\/when-it-comes-to-rationing-disability-rights-law-prohibits-more-than-prejudice\/\"><span style=\"font-weight: 400;\">article<\/span><\/a><span style=\"font-weight: 400;\"> published by the Hastings Center (a bioethics think-tank), disability rights activist Ari Ne\u2019eman says that discrimination in health care goes beyond \u201cstereotypes, quality of life assessments, or judgments about a patient\u2019s relative worth based on disability or age,\u201d and \u201ccategorical exclusions\u201d for certain diagnoses.\u00a0 He says ending such discrimination takes more than \u201csimply eliminating irrational prejudice,\u201d because for many disabled people, their impairments and need for scarce medical resources (like ventilators) are linked to their ability to recover from COVID-19.\u00a0 He suggests that the duty to make \u201creasonable accommodations\u201d (changing a policy to make it possible for a disabled person to benefit from the service being provided) in disability rights laws might require a hospital to use \u201cmore resources to afford them equal status\u201d such as by allowing a disabled person who needs breathing support extra time on a ventilator.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The Canadian Medical Association has issued <\/span><a href=\"https:\/\/policybase.cma.ca\/en\/viewer?file=%2fdocuments%2fPolicypdf%2fPD20-03.pdf#phrase=false\"><span style=\"font-weight: 400;\">guidelines<\/span><\/a><span style=\"font-weight: 400;\"> for how hospitals should decide who gets scarce health care resources during the COVID-19 pandemic. The CMA\u2019s recommendations are taken directly from an <\/span><a href=\"https:\/\/www.nejm.org\/doi\/pdf\/10.1056\/NEJMsb2005114\"><span style=\"font-weight: 400;\">article<\/span><\/a><span style=\"font-weight: 400;\"> in the New England Journal of Medicine at the end of March.\u00a0\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The NEJM article begins by talking about four \u201cfundamental values\u201d that shape proposals for resource allocation:<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">maximizing the benefits produced by scarce resources;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">treating people equally;\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">promoting and rewarding activities that benefit others; and\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">giving priority to the worst off.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">It\u2019s when these values are put into practice that disabled people can end up at a disadvantage.<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Sometimes making the most of scarce resources is done through policies designed to save the most lives.\u00a0 But such policies can conflict with saving disabled people who might need more time on a ventilator than a non-disabled person.\u00a0\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">When maximizing resources is done by saving the most \u201clife years\u201d possible, that penalizes disabled people, whether they die sooner, or doctors just assume they\u2019ll die sooner because they have a disability.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Promoting and rewarding activities that benefit others is usually done by giving higher priority to people who work in helping professions or civil service, like health care workers, police, and firefighters.\u00a0 If a disabled person is unable to work, they are likely to be given a lower rank.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The CMA offers six recommendations.\u00a0 We tried to simplify the language to make it understandable; hopefully we have captured the subtle meanings.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Recommendation 1 has several parts:\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">\u201cThe value of maximizing benefits is most important.\u201d This means \u201csaving the most lives\u201d<\/span> <span style=\"font-weight: 400;\">and helping each person live as long as possible. This view is shared by most experts.<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Comment: This is where a reasonable accommodation (such as allowing a disabled person more time on a ventilator) would be needed to prevent discrimination.\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Medical professionals should not compute \u201cquality of life,\u201d and \u201cquality-adjusted life-years,\u201d because it takes too much time.\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Comment: This agrees with item 2 of the <\/span><a href=\"https:\/\/autisticadvocacy.org\/wp-content\/uploads\/2020\/04\/Evaluation-framework-for-crisis-standards-of-care-plans-4.9.20-final.pdf\"><span style=\"font-weight: 400;\">Evaluation Framework<\/span><\/a><span style=\"font-weight: 400;\"> for crisis care plans that we referred to last week.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">All patients, especially those facing the possibility of intensive care, are encouraged to say in an advance care directive what quality of life they would regard as acceptable and when they would refuse ventilators or other life-sustaining treatments.\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Comment: Like the Ontario triage protocol we looked at <\/span><a href=\"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-ontario-triage-protocol\/\"><span style=\"font-weight: 400;\">last week<\/span><\/a><span style=\"font-weight: 400;\">, the CMA recommendation puts pressure on people to give up their right to life-saving medical care.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">People who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated.\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Comment: The Evaluation Framework and other <\/span><a href=\"https:\/\/www.hhs.gov\/sites\/default\/files\/ocr-bulletin-3-28-20.pdf\"><span style=\"font-weight: 400;\">policies<\/span><\/a><span style=\"font-weight: 400;\"> to prevent disability discrimination call for an \u201cassessment of [each] patient\u2019s ability to benefit from treatment.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Removing a patient from a ventilator or an ICU bed to provide it to others in need can also be justified.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient\u2019s consent.\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Recommendation 2: Scarce resources should go first to front-line health care workers, first-responders and people who keep important utilities and systems running. Wealthy, famous or powerful people should not get special priority.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Recommendation 3: Equality should be achieved through random allocation by lottery, rather than on a first-come, first-served (FCFS) basis.<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">FCFS favours people who live in cities or near health centres.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">FCFS encourages crowding when people rush to get vaccines or scarce supplies, which can lead to violence.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">It also penalizes people who avoided getting sick because they stayed away from other people.\u00a0\u00a0<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Recommendation 4: Guidelines for who gets what resource will be different depending on the resource, and should be based on scientific evidence.\u00a0 Since older people are more likely to get sick and have worse outcomes, they should get higher priority for help geared toward prevention and testing, like vaccines. On the other hand, younger people, who are more likely to benefit from treatments aimed at curing the disease, should get higher priority for ICU beds and ventilators.\u00a0\u00a0<\/span>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Comment: This recommendation seems to use categories to limit access to scarce resources, instead of looking at each person\u2019s ability to recover.<\/span><\/li>\n<\/ul>\n<\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Recommendation 5: People who participate in research to prove the safety and effectiveness of vaccines and treatments should get priority over similar people who did not take part in clinical trials.\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Recommendation 6: There should be no difference in allocating scarce resources between people with Covid-19 and those with other medical conditions.<\/span><\/li>\n<\/ul>\n<p><b>NDY BLOG ON COMPLAINT OVER NEW YORK VENTILATOR ALLOCATION PROTOCOL\u00a0<\/b><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">This week, Not Dead Yet CEO Diane Coleman wrote on the <\/span><a href=\"http:\/\/notdeadyet.org\/2020\/04\/will-our-sofa-scores-become-self-fulfilling-prophecies.html?fbclid=IwAR0WXfirzovOM_lUCEos7RVNVQrYVVOPE_q0J7Y2fme-v1ZBc_XCcAquU3M\"><span style=\"font-weight: 400;\">NDY blog<\/span><\/a><span style=\"font-weight: 400;\"> of a federal <\/span><a href=\"https:\/\/www.dropbox.com\/s\/h3hjktdvz3qxes3\/2020.04.07%20-%20Ventilator%20Rationioning%20-%20OCR%20Complaint%20FINAL.pdf?dl=0\"><span style=\"font-weight: 400;\">complaint<\/span><\/a><span style=\"font-weight: 400;\"> filed against the state of New York\u2019s Department of Health over its 2015 <\/span><a href=\"https:\/\/www.health.ny.gov\/regulations\/task_force\/reports_publications\/docs\/ventilator_guidelines.pdf\"><span style=\"font-weight: 400;\">Ventilator Allocation Guidelines<\/span><\/a><span style=\"font-weight: 400;\">. The complaint says the New York guidelines \u201cdisqualify many people with disabilities from ventilator access simply because they have underlying conditions that may intensify symptoms and slow recovery, which violates both the ADA and section 504 [of the Rehabilitation Act].\u201d\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">The New York guidelines use the SOFA, or \u201cSequential Organ Failure Assessment\u201d score, where \u201cpeople with pre-existing conditions are by default going to receive higher (worse) SOFA scores.\u201d Disabled people \u201cmay live day-to-day without any complications, but with a condition that presents abnormalities in one or more of the six key organs and systems measured using SOFA.\u00a0 These individuals would be disadvantaged in a triage situation prior to considering any symptoms that result directly from COVID-19.\u201d<\/span><\/li>\n<\/ul>\n   ","protected":false},"excerpt":{"rendered":"<div class=\"entry-summary\">\n<div class=\"entry-summary\">\nThis week, we look at the Canadian Medical Association&#8217;s Framework for Ethical Decision Making During the Coronavirus Pandemic, and news from Not Dead Yet of a complaint over a ventilator allocation protocol in New York.\n<\/div>\n<div class=\"link-more\"><a href=\"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-cma-framework-for-ethical-decision-making\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &ldquo;Webcast Archive: CMA Framework for Ethical Decision Making&rdquo;<\/span>&hellip;<\/a><\/div>\n<\/div>\n<div class=\"link-more\"><a href=\"https:\/\/tvndy.ca\/en\/2020\/04\/webcast-archive-cma-framework-for-ethical-decision-making\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> &ldquo;Webcast Archive: CMA Framework for Ethical Decision Making&rdquo;<\/span>&hellip;<\/a><\/div>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[92],"tags":[776,442,923,731,99,94,779,727,62,770,101,468,156,724],"class_list":["post-4846","post","type-post","status-publish","format-standard","hentry","category-webcast-archive","tag-covid","tag-diane-coleman","tag-end-of-life-en-2","tag-hospice","tag-medical-aid-in-dying","tag-medical-assistance-in-dying","tag-not-dead-yet","tag-nursing-home","tag-palliative-care","tag-rationing","tag-suicide","tag-terminal","tag-triage","tag-ventilator","entry"],"_links":{"self":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4846","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/comments?post=4846"}],"version-history":[{"count":2,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4846\/revisions"}],"predecessor-version":[{"id":5025,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/posts\/4846\/revisions\/5025"}],"wp:attachment":[{"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/media?parent=4846"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/categories?post=4846"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tvndy.ca\/en\/wp-json\/wp\/v2\/tags?post=4846"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}