The first person is a 12-year-old with COVID-19, the disease caused by the new coronavirus. The second person is 74 years old and has COVID-19, too, but he’s an infectious diseases doctor and an expert in vaccine development.
Neither is breathing very well, and the window to choose who gets the machine, which mechanically helps patients struggling to breathe, is closing quickly. Unlike other forms of treatment, experts note, “the decision about initiating or terminating mechanical ventilation is often truly a life-or-death choice.”
So, says Timothy Christie, a medical ethicist, you have the 12-year-old, the 74-year-old and a choice:
“One is going to live and one is going to die.”
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Who do you save?
***
Save the child or save the doctor is the first scenario that Christie, regional director of ethics services for Horizon Health Network in New Brunswick, will put to the network’s ethics board this week.
He’s writing a discussion paper outlining different scenarios, which the board will discuss at length. What they decide will become policy should New Brunswick reach the point where COVID-19 patients overwhelm its health-care system and force its doctors into the same position as their Italian counterparts, who’ve had to make heartbreaking life-or-death decisions with alarming frequency.
That hasn’t happened in Canada. Yet.
But across the country, hospitals and medical ethicists are readying for similar shortages.
1:29 Montreal hospital foundation launches ventilator challenge
Montreal hospital foundation launches ventilator challenge
A recent study from the University of Toronto, University Health Network and Sunnybrook Hospital says Ontario could run short of machines and space to ventilate very sick patients in a little over a month. Companies like Dyson are trying to produce as many new ventilators as fast as they can.
“Public health is going to do whatever it can to reduce the impact of this epidemic so that you don’t go beyond your capacity,” chief public health officer of Canada, Dr. Theresa Tam, told reporters on March 28.
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“Having said that, of course, you have to prepare for much more worst-case scenarios.”
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A worst-case scenario is an inadequate number of ventilators.
It’s what’s happening right now in Italy, where doctors consider age, pre-existing medical conditions and whether a person has a family to help them recover before deciding who gets a coveted intensive care unit (ICU) bed — where they can access intubation, ventilators and other life-saving treatment — and who doesn’t.
It’s also happening in the United States. The country’s top infectious disease expert, Dr. Anthony Fauci, said on March 29 that he expects upwards of 100,000 deaths linked to COVID-19.
2:57 Coronavirus outbreak: Trump tells reporter ‘don’t be a cutie pie’ when pressed about ventilator supply
In Michigan, one hospital says patients who have severe health issues like heart, lung, kidney or liver failure, as well as terminal cancer or severe burns, may be ineligible for critical care in a worst-case scenario.
In states like Alabama and Washington, similar worst-case plans indicate that people with intellectual disabilities may not be prioritized for life-saving treatment.
In the likely event Canada runs short, Kerry Bowman, a bioethicist at the University of Toronto, says Canadians need to talk about how we choose who gets life-saving treatment and who doesn’t.
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The hope is that if Canadians continue to self-isolate and physically distance themselves, we will flatten the curve, reduce the surge of people needing critical care resources at the same time and, in doing so, avoid more deaths.
2:07 B.C. health officials release medical models of worst-case coronavirus scenarios
B.C. health officials release medical models of worst-case coronavirus scenarios
But if it isn’t enough, Bowman says, “people have a fundamental right to know” how we’ll pick who gets what care.
“It’s not just what decisions were made but how people made those decisions that’s going to be very very important,” he says.
“Trust is the cornerstone of every element of health care.”
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In 2003, the SARS outbreak killed 44 Canadians and infected more than 400 others in Toronto. In the aftermath, a provincial working group, made up of doctors and ethicists, put together a report for providing critical care during future pandemics.
“Every human life is valued and every human being deserves respect, caring and compassion,” the group noted — even if not every person gets critical care. Like Bowman, the working group said transparency and accountability in developing triage protocols are key.
To do that, the group stressed that health-care systems would need an effective strategy for when their services were stretched thin by a sudden influx of patients. In the short term, doctors and nurses can double up on shifts, but a pandemic is about long-term sustainability.
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Part of ensuring sustainability will mean knowing when to implement pandemic triage protocols, the group wrote. Do it too soon and you risk unnecessarily hurting patients, do it too late and you’ll use many resources on only a few patients and risk filling all critical care beds, limiting care options for anyone who comes after.
0:34 Coronavirus outbreak: Dr. Fauci says deaths from COVID-19 in the U.S. could top 100,000
Coronavirus outbreak: Dr. Fauci says deaths from COVID-19 in the U.S. could top 100,000
“One of the strongest recommendations after SARS was our hospitals had to have surge capacity. They don’t,” Bowman says. He isn’t blaming hospitals; he’s blaming a lack of public funding.
“We’ve put off ethical decisions and we’ve put off major (health-care) changes… which has gotten us into big trouble with this outbreak.”
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Right now, Judy Illes, professor of neurology at the University of British Columbia and Canada Research Chair in neuroethics, says Canada is “in triage… not rationing.”
In other words, we’re deciding who goes first and who goes second. We haven’t yet started deciding who gets and who doesn’t.
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But any plan requires “good ethics principles,” she says.
“There’s no black and white, no right and wrong — it’s all balance.”
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In balancing risk and benefit, Illes says a utilitarian framework used by Canadian hospitals and health-care systems will focus on making choices that maximize the best outcomes for the highest number of people.
These are hard choices but “a necessary response to the overwhelming effects of a pandemic,” wrote 10 doctors in the New England Journal of Medicine on March 23.
“The question is not whether to set priorities, but how to do so ethically and consistently.”
Those 10 doctors recommend prioritizing COVID-19 tests, personal protective equipment, ICU beds, ventilators and vaccines for front-line health-care workers and those who provide the critical infrastructure that keeps hospitals operating.
3:53 How to support health-care workers during the COVID-19 crisis
How to support health-care workers during the COVID-19 crisis
“These workers should be given priority not because they are somehow more worthy but because of their instrumental value,” the doctors wrote. “They are essential to pandemic response.”
The doctors also suggest that in some cases, it will be necessary to remove somebody who is already on a ventilator to give it to someone else who may have a better prognosis.
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“(That) will be extremely psychologically traumatic for clinicians,” the doctors cautioned, and yet:
“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’s consent.”
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In cases where two patients have a similar prognosis, the doctors recommend deciding based on a lottery method because sticking with the usual “first come, first served” health-care approach would be unfair to those who become critically ill later during the outbreak.
2:30 Trudeau promises “millions more items” of protective gear
Trudeau promises “millions more items” of protective gear
“These are essential conversations,” says Bowman, even though he expects to be called a fearmonger for trying to discuss it now with the public.
“We cannot simply wait until people are being taken off ventilators or denied ventilators to start having this conversation,” he says.
“Let’s hope this never happens, but we have to be prepared.”
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If Toronto health organizations learned anything after SARS, it is that not speaking openly about difficult life-or-death decisions can be damaging, several ethicists wrote in the BMC Medical Ethics journal a few years after the outbreak.
“The costs of not addressing the ethical concerns are severe,” they wrote in 2006. “Loss of public trust, low hospital staff morale, confusion about roles and responsibilities, stigmatization of vulnerable communities and misinformation.”
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Christie, the bioethicist in New Brunswick, says that after the ethics committee decides on a policy, it will be communicated to the broader public.
The work, Christie says, is very much in progress — a point echoed by many of the hospitals, provincial health authorities and physician licensing bodies to which Global News reached out.
In Nova Scotia, a health ministry spokesperson said an ethical framework is in progress but “it’s a little too soon” to share publicly. While a ministry spokesperson in Quebec did not respond to requests for comment, a spokesperson for the Jewish General Hospital in Montreal said there is a provincial working group putting together triage guidelines.
Ontario recently announced an ethics table, which the University of Toronto Joint Centre for Bioethics would lead, to help devise a plan for prioritizing who gets treatment.
While a spokesperson for B.C. did not provide responses on the province’s approach, Bowman says his understanding is a provincial ethics group has also been convened there.
It would be beneficial to have those policies sync up nationwide, says Illes, the neuroethicist.
“We have disproportionate people with disabilities, socio-economic challenged people, Indigenous people across different provinces, but their rights and their views and their needs need to be taken into consideration,” she says.
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“A strong policy that’s harmonized, that takes all those factors into consideration, is the best way forward.”
1:57 Taking stock of Canada’s ICU beds, number of ventilators
Taking stock of Canada’s ICU beds, number of ventilators
While Canadians cannot gather in person right now to share their opinions, Illes says she is pleased to see “vital” public engagement happening through medical opinion pieces and webinars, like the two-hour virtual discussion the University of Alberta recently hosted on pandemic ethics.
“We want to stay socially engaged, even more than we are normally, and support each other,” Illes says. “If there’s a silver lining to this story, it’s how well we can band together as Canadians in terrible times.”
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Christie has had to make life-or-death decisions before. But this might be the first time he has to make end-of-life decisions “because of blatant rationing.”
“We were trying to be conservative, realistic and practical, but this is exponentially worse than any of us had planned for,” he says. “It’s hard to believe how big it’s getting and how quickly.”
It’s why he says this needs to be a community endeavour. It’s not only about an ethics committee deciding who gets a ventilator and who doesn’t — if that’s what it comes to.
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It’s about asking people to self-isolate when they’re sick or have been exposed to the virus or are newly home from travelling abroad. It’s about asking everyone to take physical distancing seriously so there is no surge in patients needing critical care.
“This situation is no one’s fault, but we have to deal with it,” Christie says.
“I would rather us be heartbroken but really agonize over making good decisions.”
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— With files from the Associated Press and Reuters
A B.C. teen has a suspected case of H5N1 avian flu — the first known human to acquire the virusin Canada.
The provincial government said on the weekend that B.C.’s chief veterinarian and public health teamsare still investigating the source of exposure, but that it’s “very likely” an animal or bird.
Human-to-human transmission is very rare, but as cases among animals rise, many experts are worried the virus could develop that ability.
The teen was being treated at BC Children’s Hospital on Saturday. The provincial health officer said there were no updates on the patient Monday.
“I’m very concerned, obviously, for the young person who was infected,” said Dr. Matthew Miller, director of the Michael G. DeGroote Institute for Infectious Disease Research at McMaster University in Hamilton, Ont.
Miller, who is also the co-director of the Canadian Pandemic Preparedness Hub, said there have been several people infected with H5N1 in the U.S.,and almost all were livestock workers.
In an email to The Canadian Press on Monday afternoon, the Public Health Agency of Canada said “based on current evidence in Canada, the risk to the general public remains low at this time.”
WHAT IS H5N1?
H5N1 is a subtype of influenza A virus that has mainly affected birds, so it’s also called “bird flu” or “avian flu.” The H5N1 flu that has been circulating widely among birds and cattle this year is one of the avian flu strains known as Highly Pathogenic Avian Influenza (HPAI) because it causes severe illness in birds, including poultry.
According to the World Health Organization, H5N1 has been circulating widely among wild birds and poultry for more than two decades. The WHO became increasingly concerned and called for more disease surveillance in Feb. 2023 after worldwide reports of the virus spilling over into mammals.
HOW COMMON IS INFECTION IN HUMANS?
H5N1 infections in humans are rare and “primarily acquired through direct contact with infected poultry or contaminated environments,” the WHO’s website says.
Prior to the teen in B.C., Canada had one human case of H5N1 in 2014 and it was “travel-related,” according to the Public Health Agency of Canada.
As of Nov. 8, there have been 46 confirmed human cases of H5N1 in the U.S. this year, the Centers for Disease Control and Prevention says. There is an ongoing outbreak among dairy cattle, “sporadic” outbreaks in poultry farms and “widespread” cases in wild birds, the CDC website says.
There has been no sign of human-to-human transmission in any of the U.S. cases.
But infectious disease and public health experts are worried that the more H5N1 spreads between different types of animals, the bigger the chance it can mutateand spread more easily between humans.
WHAT ARE THE SYMPTOMS OF H5N1?
Although H5N1 causes symptoms similar to seasonal flu, such as cough, fever, shortness of breath, headache, muscle pain, sore throat, runny nose and fatigue, the strain also has key features that can cause other symptoms.
Unlike seasonal flu, most of the people infected in the U.S. have had conjunctivitis, or “pink-eye,” said Miller.
One reason for that is likely that many have been dairy cattle workers.
“At these milking operations, it’s easy to get contamination on your hands and rub your eyes. We touch our face like all the time without even knowing it,” he said.
“Also, those operations can produce droplets or aerosols, both during milking and during cleaning that can get into the eye relatively easily.”
But the other reason for the conjunctivitis seen in H5N1 cases is that the strain binds to receptors in the eye, Miller said.
While seasonal flu binds to receptors in the upper respiratory tract, H5N1 also binds to receptors in the lower respiratory tract, he said.
“That’s a concern … because if the virus makes its way down there, those lower respiratory infections tend to be a lot more severe. They tend to lead to more severe outcomes, like pneumonias for example, that can cause respiratory distress,” Miller said.
WILL THE FLU VACCINE PROTECT AGAINST H5N1?
We don’t know “with any degree of certainty,” whether the seasonal flu vaccine could help prevent infection with H5N1, said Miller.
Although there’s no data yet, it’s quite possible that it could help prevent more severe disease once a person is infected, he said.
That’s because the seasonal flu vaccine contains a component of H1N1 virus, which “is relatively closely related to H5N1.”
“So the immunity that might help protect people against H5N1 is almost certainly conferred by either prior infection with or prior vaccination against H1N1 viruses that circulate in people,” Miller said.
HOW ELSE CAN I PROTECT MYSELF?
The Public Health Agency of Canada said as a general precaution, people shouldn’t handle live or dead wild birds or other wild animals, and keep pets away from sick or dead animals.
Those who work with animals or in animal-contaminated places should take personal protective measures, the agency said.
This report by The Canadian Press was first published Nov. 11, 2024.
Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.
MADISON, Wis. (AP) — A conservative prosecutor’s attorney struggled Monday to persuade the Wisconsin Supreme Court to reactivate the state’s 175-year-old abortion ban, drawing a tongue-lashing from two of the court’s liberal justices during oral arguments.
Sheboygan County’s Republican district attorney, Joel Urmanski, has asked the high court to overturn a Dane County judge’s ruling last year that invalidated the ban. A ruling isn’t expected for weeks but abortion advocates almost certainly will win the case given that liberal justices control the court. One of them, Janet Protasiewicz, remarked on the campaign trail that she supports abortion rights.
Monday’s two-hour session amounted to little more than political theater. Liberal Justice Rebecca Dallet told Urmanski’s attorney, Matthew Thome, that the ban was passed in 1849 by white men who held all the power and that he was ignoring everything that has happened since. Jill Karofsky, another liberal justice, pointed out that the ban provides no exceptions for rape or incest and that reactivation could result in doctors withholding medical care. She told Thome that he was essentially asking the court to sign a “death warrant” for women and children in Wisconsin.
“This is the world gone mad,” Karofsky said.
The ban stood until 1973, when the U.S. Supreme Court’s landmark Roe v. Wade decision legalizing abortion nationwide nullified it. Legislators never repealed the ban, however, and conservatives have argued the Supreme Court’s decision to overturn Roe two years ago reactivated it.
Democratic Attorney General Josh Kaul filed a lawsuit challenging the law in 2022. He argued that a 1985 Wisconsin law that prohibits abortion after a fetus reaches the point where it can survive outside the womb supersedes the ban. Some babies can survive with medical help after 21 weeks of gestation.
Urmanski contends that the ban was never repealed and that it can co-exist with the 1985 law because that law didn’t legalize abortion at any point. Other modern-day abortion restrictions also don’t legalize the practice, he argues.
Dane County Circuit Judge Diane Schlipper ruled last year that the ban outlaws feticide — which she defined as the killing of a fetus without the mother’s consent — but not consensual abortions. The ruling emboldened Planned Parenthood to resume offering abortions in Wisconsin after halting procedures after Roe was overturned.
Urmanski asked the state Supreme Court in February to overturn Schlipper’s ruling without waiting for a lower appellate decision.
Thome told the justices on Monday that he wasn’t arguing about the implications of reactivating the ban. He maintained that the legal theory that new laws implicitly repeal old ones is shaky. He also contended that the ban and the newer abortion restrictions can overlap just like laws establishing different penalties for the same crime. A ruling that the 1985 law effectively repealed the ban would be “anti-democratic,” Thome added.
“It’s a statute this Legislature has not repealed and you’re saying, no, you actually repealed it,” he said.
Dallet shot back that disregarding laws passed over the last 40 years to go back to 1849 would be undemocratic.
Planned Parenthood of Wisconsin filed a separate lawsuit in February asking the state Supreme Court to rule directly on whether a constitutional right to abortion exists in the state. The justices have agreed to take the case but haven’t scheduled oral arguments yet.
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This story has been updated to correct the Sheboygan County district attorney’s first name to Joel.
CAPE CANAVERAL, Fla. (AP) — Better catch this week’s supermoon. It will be a while until the next one.
This will be the year’s fourth and final supermoon, looking bigger and brighter than usual as it comes within about 225,000 miles (361,867 kilometers) of Earth on Thursday. It won’t reach its full lunar phase until Friday.
The supermoon rises after the peak of the Taurid meteor shower and before the Leonids are most active.
In 2025, expect three supermoons beginning in October.
What makes a moon so super?
More a popular term than a scientific one, a supermoon occurs when a full lunar phase syncs up with an especially close swing around Earth. This usually happens only three or four times a year and consecutively, given the moon’s constantly shifting, oval-shaped orbit.
A supermoon obviously isn’t bigger, but it can appear that way, although scientists say the difference can be barely perceptible.
How do supermoons compare?
This year features a quartet of supermoons.
The one in August was 224,917 miles (361,970 kilometers) away. September’s was 222,131 miles (357,486 kilometers) away. A partial lunar eclipse also unfolded that night, visible in much of the Americas, Africa and Europe as Earth’s shadow fell on the moon, resembling a small bite.
October’s supermoon was the year’s closest at 222,055 miles (357,364 kilometers) from Earth. This month’s supermoon will make its closest approach on Thursday with the full lunar phase the next day.
What’s in it for me?
Scientists point out that only the keenest observers can discern the subtle differences. It’s easier to detect the change in brightness — a supermoon can be 30% brighter than average.
With the U.S. and other countries ramping up lunar exploration with landers and eventually astronauts, the moon beckons brighter than ever.
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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.
