The coronacrisis brings difficult choices

Lars Sandman has little time for relaxing nowadays. As head of the National Centre for Priority Setting in Health Care at Linköping University, he is working intensively with colleagues on questions that concern prioritising in corona-centred healthcare. “I think of myself as an on-call ethics specialist”, he says.

Lars Sandman, professor of ethics in healthcare and head of the National Centre for Priority Setting in Health Care at Linköping University. Charlotte Perhammar

At the end of March, the National Board of Health and Welfare in Sweden adopted guidelines for administering intensive care to patients with COVID-19. Drawing up the new guidelines had taken two weeks, whereas such enquiries normally take several months. Lars Sandman, professor of ethics in healthcare, led the enquiry. One of the consequences of the guidelines is that the healthcare system may now be forced to withhold treatment from intensive care patients who normally would have a chance of survival.

Has it been difficult to formulate these guidelines from an ethical point of view?
"No, the ethical platform here is perfectly clear. I’ve been working with colleagues on questions about setting priorities in healthcare for 20 years. The new guidelines are based on the three principles of the ethical platform for setting priorities: human dignity, needs and solidarity, and cost-effectiveness. These were passed by the Swedish parliament as long ago as the 1990s, and have been supported since then by a strong political consensus."

The human dignity principle states that people have equal worth, and have the right to care independently of age, gender, education, social status or economic resources.

The needs and solidarity principle makes it clear that those with the most severe diseases are to receive care first.

The cost-effectiveness principle requires that there be a reasonable relationship between the cost and the effect of treatment.

Questions of priority are now in focus in the societal debate in a completely new way. How do you view this?
"It’s positive that people gain insight into work with setting priorities in healthcare, and the ethical balancing act that is often required. And we are going to have a high pressure on the health and medical care system for a long time. At the moment, a care debt is growing to all those who are compelled to wait and are not receiving the care and treatment they otherwise would have received. So questions about setting priorities will be very important for a long time."

The new guidelines from the National Board of Health and Welfare clarify the three principles for setting priorities, which are brought into sharp focus. When selecting between patients who need intensive care, one of the factors that the healthcare personnel are to consider is the biological age of the patient. This is not the same as the number of years lived, but the magnitude of the probability for survival in the future.

"Healthcare personnel are accustomed to setting priorities on an overall scale: they do it all the time. But the guidelines have now been clarified, which means that the healthcare system can be forced to select between individuals on the basis that another patient has a higher probability of survival. The situation may arise in which the personnel are compelled to withhold treatment from a patient who would normally receive it. They are not accustomed to setting priorities in this way."

What will happen with the severely sick patients who risk not receiving intensive care, leading to their death?
"They will receive palliative care – end-of-life care – to ensure that they are comfortable. Palliative units for COVID-19 patients are being established in several healthcare regions."

Are the guidelines being applied throughout Sweden now?
"Yes, and several regions are working with local adaptations of them. One example is to determine how resources can be freed, and how the palliative care can be adapted to the situation. We provide the ethical platform on which they can base their decisions. Several regions, for example, have contacted us with questions about the loved ones of a dying patient. Should they be allowed to meet the patient? Is it possible to find digital solutions to bring the loved ones close to the patient? Of course, this is not ideal, but it may be better than not having any form of presence. What can you do when there is insufficient personal protective equipment for loved ones? We put forward ideas and conduct a discussion with the personnel based on various alternatives."

Do you ever doubt that the priorities you recommend for intensive care are the best ones?
"It’s always possible, of course, to doubt and raise questions. We are conscious of the enormous responsibility and challenges we face in this work. But we who have drawn up the guidelines together possess enormous expertise, from such fields as intensive care, disaster medicine and ethical research. It’s difficult for us to see that there are any better alternatives on which to set priorities from an ethical point of view."

Is there anything that surprised you while working with the ethical guidelines?
"Not really. Well, actually... I think I was surprised at how many people accept the priorities we set, and understand them. I’m surprised that there haven’t been any powerful negative reactions, either from the healthcare system or from the general public."

What do you believe to be the cause of this?
"Maybe it’s to do with the Swedish collective psyche. We are rational, trust the authorities, and have the ability to think through which alternatives are realistic. It appears that people understand that these priorities must be set."

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