Choices To Protect Canadian Lives and Jobs

June 18, 2020 by David Nitkin | Categories: Healthcare Series Two: Futures | Tags: Healthcare

The Issue

COVID-19 has wrought many changes on our citizens, including deaths, expansion of ever-renewed emergency powers, and shutdown of many factories and service-economy businesses. Policy makers – both elected and appointed – have to determine what level of risk is too high, given their understanding of the nature of the virus, the state’s coffers, and the needs of the population. The Prime Minister and provincial premiers attempt to get the best possible advice from disease-control and public-health specialists. Then they must temper that with respect for the civil rights of the people and insights into a public consumed by a mix of fear, emotional exhaustion, and dislocation of work and family life.

This blog post suggests that the policies chosen and implemented to fight the first wave of coronavirus were chosen from a very narrow part of possible management choices. It identifies an ethical framework that might suggest other ways to address wave-two choices in combating the virus.

Government Public-Health Emergency Powers

In the event of terrorism, an economic meltdown, or a pandemic such as the COVID-19, governments may invoke powers under either public-health legislation or emergency-management legislation. Public-health legislation allows a government, and regional health authorities to undertake a broad number of activities to manage responses to public-health events such as pandemics. Emergency management legislation, by contrast, allows a government to facilitate and support the coordination of responses to public-health events as they change over time.

The direct coronavirus crisis risks are more complicated than is immediately apparent. They include

Personal infection, hospitalization and ventilation
Transmission to other healthy individuals
Specifically vulnerable populations (seniors with co-morbidity, those with food and shelter insecurity, lack of access to heat and clean water, and/or economic security)
Citizens who define wearing a mask or limiting the size of religious gatherings not as disrespecting mother nature but rather as violation of their personal freedoms
False positive test results: that is, someone tested is cleared but is actually infected

The list of indirect risks is just as lengthy:

Risk that the treatment (self-isolation etc.) is worse than the disease, in terms of: economic devastation, bankruptcies, unemployment, inability to pay mortgages and loss of homes, crash of stock markets and housing markets, loss of retirement savings
Governments’ response to this risk has been to print money at an unprecedented rate, which runs the risk of contributing to hyper-inflation.
Adverse mental effects and psycho-social trauma as a result of self-isolation, including anxiety, depression, marital strife, and suicide.
An increase in overdose deaths due to narcotics abuse (such as Fentanyl in Vancouver) due to people receiving unusual financial handouts from the government, now allowing them to afford more drugs than previously.
People who should have gone to hospital but didn’t because of fear of COVID-19, as well as elective surgeries that were cancelled, has increased the previous backlog by at least an estimated three months.
A child not being in school has consequences including anxiety, stress, and delaying learning and social development.
Stress for parents now working from home, looking after children and trying to home-school them, simultaneously, a seemingly impossible task.

Another substantive indirect risk is that governments, both democratic and authoritarian, have an opportunity to increase and concentrate their powers..The government’s ability to act swiftly, decisively (and, where needed, secretly) against major threats frequently has “door opening” consequences such as (a) superseding limitations on governmental powers, (b) limiting and threatening individual rights, freedoms and liberties; (c) concentrating constitutional powers in the hands of a few elected officials, often without parliamentary review or oversight; and (d) an unwitting acceptance of rule-making and extension through the convenience of emergency powers.

In any future crisis, government will take as its starting point the experience of extraordinary powers and authority granted and exercised during previous emergencies. What might have been seen as sufficient “emergency” measures in the past may not be deemed enough for further crises as they arise. Much like increasing the dosage of a medication in order to experience the same level of relief, so too with emergency powers. Once they have experienced the ability to operate with fewer restraints and limitations, they are unlikely to be willing to give up such freedom.

Testing, Tracing and Tracking

A large part of the discussion of how best to loosen up social distancing, stay-at home (stay in place) restrictions, and allow businesses to reopen focuses on choices about testing, tracing and tracking. As discussed in the EthicScan Blog The Future: Tracing, Tracking and Ethics (May 21, 2020), there is a debate whether to trace and track the whole population (universal) or those with probable cause (targeted). The debate looks like this:

DESCRIPTION	OLD SCHOOOL CONTACT TRACING	NEW SCHOOL BIG TECH TRACKING:
Method	Call up folks and talk to them about where, when and who they’ve been in contact with	Access people’s cellphone data to track their whereabouts in the days before they tested positive.
Application	Universal or targeted	Universal leading to targeted
Involvement of Individuals	Teams of tracers determine patterns and follow up with individuals	Trackers use data on cell phones to send messages to individuals (whose phone data revealed they had been in the same spaces) to get tested
Experience	Overwhelmed after a “super-spreader” infected thousands of people at a conference or a party	Move beyond cell phones to integrate with health care, consumer purchase, mobility and public services data
Major Limitation	Significant manpower required	Threat: Big Tech violations of privacy rights
Countries where Applied	United States, United Kingdom	South Korea, China, Israel

According to select experts, here are some international comparative results:

The strongest testing programs seem to be Ireland, China, South Korea, Singapore and United Arab Emirates
The nations potentially, initially identified as leaders in protecting the most vulnerable seem to be found in China, Germany, South Korea and Sweden
There are thousands of people waiting for results from a coronavirus test because the system handling them is overwhelmed.
There are differences of opinion among researchers about the application of the findings from the respective methods to aid in projecting future outbreaks
Ethically, as distinct from legally, it is a matter of debate whether differences in strategies across provinces is inherently a bad thing.

It makes a lot of sense to treat places with many virus cases differently from another with only a few – not only with respect to contact tracing, but also with respect to how far things can open up, and how quickly. Some public health consultants believe that it is better for government to do this uniformly well and do it right for all Canadians rather than to permit testing differences across provinces, particularly as tracing those who may have been infected may involve crossing provincial boundaries. The one complication is that constitutionally health delivery is a provincial responsibility. Others prefer regional or targeted strategy that targets the known unwell (the vulnerable), rather than everyone. Whatever a provincial government does in this tracing, tracking and testing space would require significant interactions and synergies between other provincial governments, Ottawa, and local public health units across the country.

Strategies to Realize Public Health Goals

Surprisingly, the strategies to realize goals of public health policy in a pandemic are neither publicly debated nor easy for hospital administrators or medical officers of health to prioritize with certainty. Nor are they mutually exclusive. They would include:

(a) minimizing death from the disease;
(b) maximizing crowd immunity;
(c) flattening the curve (keeping the demand for ICU beds from being overwhelmed);
(d) shortening the duration of the disease;
(e) finding a cure; and
(f) minimizing the economic impact of social and business restrictions).

For over thirty years of consulting practice, EthicScan has used a Harm Triangle to help corporations and institutions make such ethical choices. The mountain-shaped triangle has three zones:

Doing Good at the top;
Doing No Harm in the middle; and
Minimizing Harm at the bottom.

Ethically the best choice is a strategy as high up the Harm Triangle as Possible. In other words, a Doing No Harm strategy is better than Minimizing Harm; Doing Good is superior to Doing No Harm.

Choices for Canada

Strategies will vary by geography, circumstance, the severity of threat and other factors. Here’s my personal hypothetical classification of COVID-fighting strategies as we emerge from the first wave in Canada.

Minimize Harm	Do No Harm	Do GOOD
Quarantining and social distancing for everyone	Widespread, active and accurate testing including recovered and asymptomatic individuals	Decrease rather than delay infection and death rates
Flatten the curve	Those with confirmed immunity allowed to resume a version of normal activity	Find a vaccine cure or an effective treatment for the infection
Close all factories and offices	Quarantining those elderly with multiple complications (co-morbidities)	Mandatory screening before enter public space like hospital and nursing home
Lowest risk workers be allowed to return to work	Compulsory testing when enter store or pharmacy or restaurant	Regularly screen health-care workers
Total harm minimization (save as many lives and jobs as possible all at same time)	Staged distancing rules depending on spread of infection	Quarantine only the most vulnerable (not the whole population)
Travel bans on discretionary interprovincial road traffic	Intentional immunity through voluntary exposure (build up herd immunity)	Voluntary self-quarantine of elderly, chronically ill, and those immunocompromised before they get sick(er)
Voluntary wearing of masks outside the home	Travel bans on discretionary international air travel	Voluntary self-quarantine of elderly before they get sick
Temporarily suspend all needed hospital-based operations that aren’t COVID related	Ramping up the curve by building more ICU capacity	Empower priority need families with at home support, education and testing

Source: EthicScan, Trends, Forecasts and Outlooks Resource Kit (June 2020)

Do you agree with above analysis? Morally, are lives different dependent upon whose is being saved? You might ask, how could any moral person not support minimizing loss of human life as the pre-eminent moral value? As a serious traditional Jew myself, the value of saving a single life is paramount in my tradition. But there appear to be fifteen or twenty other choices relevant to COVID decision-making that are higher up the Harm Triangle. Many of them are predicated on an understanding that four in every five deaths are among those 80 years of age who are likely to die in the very near future due to other comorbidities and complications with or without a pandemic.

There are certain points or cautions worth stressing about this approach:

1. Canada’s Leaders Haven’t Chosen Strategies High up the Hierarchy: The harm we experience is being done by the coronavirus, by travellers who brought it to Canada, and by those who spread it. Canada’s leaders are struggling to reduce harm, or at least trying to do that. If harm is done (to the economy or health care of the non-COVID population, for example), that was done knowingly, for the greater good of reducing harm to people’s health. Most of what has been Canada’s stage one virus “flatten the curve” management strategy is the lowest standard, minimizing harm option. There undoubtedly are reasons but the point is true, or at least as accurate as is the table. That standard is inferior to that of physicians, whose standard, using the Hippocratic Oath, is Doing No Harm.

2. Data Difficulties: According to a former provincial medical officer of health who has experience relative to previous SARS and H1N1 outbreaks, there is far less access to, or transparency about health-data outcomes available to inform decisions today. Less national and local data, and less national data on the WHO web-site. Many alternative policy choices require health-statistics data that simply and regrettably are not available.

3. Stakeholder Complexity: A total harm-minimization approach recommended by some has much elegance and power but, unless I am wrong, it doesn’t appear to address the different real-world stakeholder interests pertaining to a single variable. For example, job loss. It is usually defined simply as loss of a job for the employer, but what about in terms of the worker’s family’s interests, or the utility of the job versus another if a critical national product — say, masks or shields– is being produced? These are important distinctions for a policy decision maker.

Conclusion

The adoption and renewal of emergency powers in this crisis calls upon us to be vigilant, especially if serious questions exist about the implications of management and communications strategies taken and not taken. It is my hope that this blog helps expand active public debate and constructive engagement.