Sunday, 19 April 2020

Ethics Briefing for Covid19 Policy: Interesting Experience in Germany and a Plea for the Swedish Context

Coronavirus covid-19 - Kristianstads kommun

As the Covid19 pandemic continues to sweep the world, states are struggling to shape policies according to their epidemiological situation, resources and political possibilities. It is very obvious that all this policy-making has far-reaching ethical implications on many levels. It regards the identification of relevant values, the balancing of these in cases of conflicts, the pragmatics of implementing "ideal" solutions in a non-ideal world, and the normative aspect of deciding how competing institutional "rules" or "guidelines" for balancing values and implementing the outcome may be traded off in cases of tension.

All of this is, of course, a well-known aspect of the area of public health ethics, such as it has evolved over the last two decades. It regards both principal issues of what should be done, and issues about how this should be done to be done in an acceptable way. These issues are especially complicated due to the multi-sectorial and multi-level nature of public health, and the advanced and dynamic uncertainty under which all decisions on pandemic (and much other public health) policy needs to be taken.

One level is, of course, the implications for the healthcare system and, in effect, clinical medical ethics, of a far-reaching public health crisis, such as a pandemic. In this area, I was engaged, together with several colleagues with direct experience of this particular issue, in a working party that speed developed specific guidelines for ICU resource allocation for the Swedish context. However, albeit thorny and highly complex ethical considerations are recognised to be built into both public health and infectious disease policy in the Swedish central policy document in this area, the Swedish public health authorities have no organised way of dealing with the ethical tensions that necessarily appear on a daily basis. This inspired some of my colleagues – themselves not public health ethicists but recognising the need – to publish a plea for an ethics councel function  to be linked to the Swedish public health agency, Folkhälsomyndigheten. Such a councel has to involve different comnpetences, of course, besides public health ethics and relevant health science, not least advanced knowledge of (relevant) law, economics and politics.

Interestingly, I have been recently involved in exactly this type of endeavour related to Covid19, not in Sweden, but in Germany. It started when I was contacted, as one of several public health ethics specialists, to be part of an ad hoc ethics briefing to the Bavarian public health authorities with regard to sevaral of the type of basic value and norm.-conflicts briefly sketched above. The work was led from the Ludwig Maximilians University of Munich, where Verina Wild (bioethicist and public health specialist), quickly organised an international expert group to answer a set of questions formulated by the state authorities. This work (with links to the full briefing from the group to the Bavarian authorities) is described here. Additionally, the German federal Ethikrat has issued several statements on the ethical dimensions of the Covid19 policy response, and also there specific public health ethical competence is in place, eg. Alena Buyx.

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In addition, German scholarly organisations in social medicine and public health have organised a Covid19 "competence centre" with specific working groups being coordinated for several areas, one of which is ethics. The coordinators for ethics is, once again, Verina Wild and her Munich colleagues Jan-Christoph Heilinger and Georg Marckmann, and they have invited a broad group of international scholars from the public health ethics field, among these myself. We have just finalised the first policy brief, which attempts to sketch in a few pages the complex landscape of consideration offered from a public health ethical perspective on pandemic policy. The final versionis now public via the competence centre website. A number of more specific briefs are planned, and will appear shortly.

I do believe that many states would do well to follow the German example. Besides the expertise of discovering, describing and analysing ethical and related legal and political dilemmas, relevant scholars are also able to articulate more clearly the logic of reasoning behind made policy decisions, thereby helping governments and agencies to better dodge conspiracy-like speculations of why certain decisions are made due to hazy explanations and arguments.  Among these, my own country Sweden, where there already exist a number of internationally recognized public health ethics scholars, besides myself, e.g., Bengt Brülde, Jessica Nihlén Fahlqvist, Kalle Grill and Erik Malmqvist, and additional legal scholarly expertise relating to the health policy area, such as Moa Kindström Dahlin and Ulrika Sandén.


Friday, 27 March 2020

New Swedish Guidelines for ICU Priority Setting in Exceptional Circumstances

This post was updated March 30, 2020 with criteria for rationing outside ICU!

During the last two weeks, I have, together with a bunch of philosophy and bioethics colleagues specialised on these kinds of questions not only in theory but also in practice, contributed to a speedy development of of new central guidelines on ICU priority setting and resource allocation from the National Board of Health and Welfare (one of the central governing authorities of the Swedish healthcare system). The guidelines address exceptional circumstances, such as an unusual high pressure of cases that exceeds normal capacity, and are, of course, prompted by the Covid19 pandemic. Lars Sandman, head of the national Center for healthcare priority setting, led the work, and it took a little less than two weeks to go from zero to end product. Besides philosophers, the National Council for Medical Ethics, representatives of the Ethics Delegation of the Swedish Society of Medicine, and ICU specialist consultants have contributed.

As the legal language of Swedish public documents is Swedish, this is also the language of the guidelines. This full version can be read and downloaded here. But, as there has been quite a bit of international interest, here is a short English summary by myself (ie. this is not an official translation from NBHW):

Health care priority setting is already regulated by special laws, where non-instrumentality, equal treatment and non-discrimination, priority based on patient need only, and ban on unnecessary waste of resources are the key principles decided by the Swedish Parliament since before.

First of all, ICU capacity should be strengthened by rationing less acute or important care, or care than can be postponed without severe consequences (and without disturbing management of the pandemic), so that an exceptional ICU situation is avoided as far as is practically possible. There is a specific appendix in the full guidelines setting out rationing principles to this effect (see below).
In exceptional circumstances, ICU should focus on patients where the treatment can do the most good, thus focusing more on the prognosis of the treatment than the severity of the condition (both dimensions of patient need). This means that indication for ICU may be strengthened to exclude some patients with severe conditions that are given ICU in normal circumstances to give extra time for planning and family contact.
While the legal regulation excludes chronological age as priority basis in its own right, it allows for life expectancy (if given successful care) to be part of the assessment of the patient need for a resource (besides the severity of the condition and the immediate prognosis of the treatment). Factors to assess life expectancy in the clinic are:
  • Extent and severity of vital organ failure
  • Extent and severity of pre-existring co-morbidities
  • High chrononological age in combination with a bad prognosis after intensive care
Priority groups are patients with:
Priority 1
Severe condition or injury with >12 months life prognosis, otherwise meet indication for ICU, and don't suffer severly decreased life expectancy (see above). If there is necessary to make a choice between patients in this group, patients with a general longer life expectancy (higher biological age) should be given priority.
Priority 2
(a) One or several serious systemic diseases with extensive functional impact, and/or (b) expected survival of 6-12 months based on pre-existing underlying disease.
Priority 3
Bad prognosis in ICU, and where ICU is normally undertaken only to provide time for planning, or family contacts.

These priority groups should ground resource allocation both when assessing new patients, and when reassessing patients admitted to ICU care, and may therefore also ground discontinuation of ICU care, to free resources for new patients with a higher priority.

Patients who are denied or taken off ICU should receive best possible palliative and other care to manage their care need given the ICU resource allocation.
There are also some sections on management of staff ethical stress, and of how to involve patients and family in the decisions.

In the preparatory stage, it was discussed whether or not the guidelines should include the feature of being crucial for life saving societal functions as a further item to sort among those in priority group 1. There seems to have been agreement that the requirement of equal treatment for all patients with similar need of care could support this idea if the circumstances are extremely prolonged (as loss of critical staff could then undermine the treatment prospects for future patients). However, the general assessment was that the crisis possibly caused by the Covid19 pandemic for Swedish ICU care would probably not be of this nature, especially in view of the time it would take for someone to return to work after a very critical ICU episode. Should the situation change, the guidelines may be amended to this effect.

These are the rationing criteria for healthcare outside ICU, in order to free capacity for ICU in an Covid19 crisis, mirroring the priority setting criteria above, and based on the same legal principles. They apply on the condition that rationing can free resources/capacity for ICU, and that the rationing does not impede communicable disease control work: 
RATIONING GROUP 1: Elective procedures that may be postponed without deterioratiuon of the condition; 
GROUP 2: Elective procedures that may be postponed without threat to life, abeit with negative effect on QoL: 
GROUP 3: Elective or acute procedures that are unlikely to restore health and likely to lead to prolonged care with risk of ICU need; 
GROUP 4: Acute procedures where postponement will affect QoL during the delay, but not lead to a worse longterm prognosis; 
GROUP 5: Acute procedures where postponement will affect QoL also in the longterm, but not be a threat to survival. 


Friday, 13 March 2020

Longstanding Conscientious Refusal Assault to Undermine Swedish Abortion Policy Ended by European Court.

Ellinor Grimmark
Ellinor Grimmark, one of the midwifes
For a number of years, two openly pro-life Swedish midwifes have been fronting for radical conservative US activist Christian organization Alliance Defending Freedom (ADF), to run a legal case against Swedish County Councils (that run the publicly funded healthcare system) in order to invalidate the Swedish model for freedom of conscience and conscientious objection in healthcare. In particular, the assault has been focused on the strong pro choice abortion legislation in Sweden, as both cases have been about trying to establish health professionals' (here midwifes) legal right to refuse to perform tasks related to abortion (everything from informing women about their rights and options to assist in the actual performance of a procedure). Since having an abortion at a public hospital is a positive right in Sweden, a midwife or other obstetric professional working in the public healthcare system can always be assigned to such duties, and it would be impossible to run the system is this was not the case. Therefore, a legal right to conscientious refusal in this area could very well be strategically exploited by anti-abortion propaganda ventures to undermine Swedish abortion policy.Read more and learn how this assault has now been stopped, and how other European countries may profit from that.

I blogged about this push, as well as the general issue of conscientious refusal in healthcare, in 2015. That post led to invitations to contribute to two separate special ethics journal issues on the topic, one of which describes the Swedish solution to conscientious refusal and is linked above. The other one, authored with Danish colleague Morten Ebbe Juul Nielsen, presents a general argument against the notion of conscientious refusal as a legal right required by the generally embraced legal human right to freedom of conscience. Simple put, as long as employment and choice of profession is voluntary, the latter freedom does not require a right to refuse particular work tasks.

The midwifes have been fronting the ADF campaign by running legal procedures complaining about religious discrimination, or breach of their freedom of religion, against (potential) employers who have denied them a right to refuse any dealings with abortion care, or refused employment after a declaration of such a right as a condition to accept employment. The case have been run through the Swedish legal system, and then, with one of the midwifes, Ellinor Grimmark, on to the European Court of Human Rights. Since 2014, bankrolling and legal councel has come from ADF, confirmed by its representative Robert Clarke.  Two days ago, the court delivered its decision to rule the application for the court to try her case to be inadmissible. In short, this means that the court cannot see any indication of discrimination or restriction the right to religious freedom in Grimmark's (and ADF's) writ. This has also been my impression from day 1 – what ADF and Grimmark have been asking for is not equal rights to others, but for special privilege. But, please, don't let me be the judge, read the decision for yourselves!

The court decision's most important implication is, however, not that the Swedish solution to the phenomenon of conscientious objection has been vidicated, and that its abortion policy has been safeguarded against radical religious conspiracy. It also means that all European countries can safely adopt the Swedish solution to conscientious refusal in healthcare, without fear of legal damage.