Ethics Committee and Priorities During the Pandemic

To address the ethical aspect of “managing numerous patients, with or without Covid, admitted to healthcare facilities during the epidemic”, the French Health and Solidarity Minister called upon the “CCNE” (National Consultative Ethics Committee). Two weeks later, on November 17, 2020 the “CCNE” published its recommendations.

The rapidly formed working group at the “CCNE” based their new recommendations on previous ones, such as Opinion N° 106, from February 2009 on “Ethical Issues Raised by a Possible Influenza Pandemic”, and the March 13, 2020 opinion entitled “Ethical Issues in the Face of a Pandemic “. In addition, the committee evaluated the advances in scientific knowledge, medical practice, and input from other European countries facing the same challenge, as well as recent hearings and contributions from national and international companies.

This past October, the French healthcare system was again overwhelmed in its’ attempt to treat both Covid and non-Covid patients during the “second wave” of the pandemic. The latest recommendations issued by the “CCNE” are based on experience from the initial outbreak.

Primarily, it points out that current resources are insufficient to meet healthcare needs, and it emphasizes that it is impossible to rapidly recruit and train enough healthcare workers to meet current needs.

Emergency reorganization decisions implemented to accommodate Covid patients, such as postponing surgical and medical procedures to dedicate more beds to COVID patients and prioritizing the persons needing care and treatment, raised a number of ethical issues. Although we are facing an unprecedented emergency situation, our healthcare system shouldn’t be based on exceptions.

Prioritizing during a Pandemic: An Ethical Challenge for Healthcare?

Prioritizing patients is a well-known practice employed during emergencies and disasters when healthcare workers are faced with the painful dilemma of “saving as many lives as possible while taking limitations into account.”  This is based on a benefit/risk ratio. When resources are insufficient, instead of doing triage, an egalitarian logic of “first come, first served” is applied. A more utilitarian logic would try to save as many lives as possible for the greater good of all.

Ethical values regarding patient care are being put to the test: will all patients be able to receive appropriate care? Are individual interests always compatible with the common good?

In pulmonary resuscitation units, admissions are primarily based on medical criteria which are thought to be objective, such as the severity of a patient’s condition, his prognosis and his future quality of life, based on “reasonable hope for substantial recovery”. The assessment is based on the four ethical principles of beneficience, respect for autonomy, nonmaleficence, and justice.

The “CCNE” Urges Vigilance

The “CCNE” highlights 4 aspects requiring vigilance:

• No matter how scarce the resources are, it can never justify relinquishing ethical principles that demand solidarity, attention to the most vulnerable and justice. Making medical decisions which are ethical would be facilitated by creating ethical support teams, and employing collegial procedures, on a case-by-case basis.
• Prioritizing patients could be driven by a decision to provide care to those who would be most affected if treatment were postponed or cancelled. Regardless of the circumstances, every patient should receive basic treatment, comfort care and palliative care if necessary.
• Resources could be better managed by decentralizing the territorial control of the healthcare system, and eliminating the lines drawn between public vs. private, hospital vs. city, and healthcare vs. social care. Situational awareness should be based on real feedback from healthcare workers and patients.
• The confidence and support of all citizens should be increased by allowing them to take a more effective part and by restoring democratic deliberations.

8 Recommendations Suggested by the CCNE:

1. To optimize access to healthcare by improving the coordination between city officials, public and private hospitals, medical-social establishments (nursing and retirement homes) and reserve healthcare personnel.
2. To develop a meaningful “triage” scale to designate “warning threshold levels” in order to better manage “Covid and non-Covid patients” and to minimize deprogramming any medical activities.
3. To establish a decision-making flow chart, which is ethical, collegial and interdisciplinary, with written traceability and clear communication, to reschedule medical activities and to prioritize patients, on a case-by-case basis, which takes the patient’s wishes into account.
4. To provide healthcare for the most urgent cases and for patients who are at greater risk if their care is withheld or postponed. It must remain “ethically prohibited” to prioritize based on age, disability or precarity. No protocol should be used without considering the ethical implications on a case-by-case basis.
5. To reinforce democratic healthcare: Patients and loved ones must be consulted for all decisions regarding an exceptional circumstance and designated “user representatives” should be consulted for decisions involving healthcare coordination.
6. To improve healthcare access for everyone by providing communication updates for medical activities, whether they are ongoing, postponed, or cancelled.
7. To provide ethical support to the teams confronted with the ethical dilemma of choosing priorities, by creating mobile or on-call outreach programs to help comply with ethical requirements.
8. To collect feedback from local workers to assess the consequences of prioritization decisions.

Attributing resources when they are insufficient is an ethical public health issue which deserves to be evaluated collectively, beyond the scope of the medical profession.

The “CCNE” encourages the government to re-examine its priorities, taking account of the lessons learned from the initial phase of the pandemic, and it points out that failing to respect some fundamental rights just to minimize health risks has been strongly disputed. Can individual health concerns be given priority at the cost of restricting our rights and by relegating priority access to healthcare for certain selected individuals?

Any new public health policies should take into account the current lack of essential health resources and the time required to train healthcare professionals. Will the “Ségur” health agreements signed in July 2020 be adequate?

For more information, the French Society for Counseling and Palliative Care organized an online symposium on November 20, entitled “Can Triage Be Ethical?” to clarify this sensitive issue.