What are the views of Quebec and Ontario citizens on the tiebreaker criteria for prioritizing access to adult critical care in the extreme context of a COVID-19 pandemic?

BACKGROUND: The prioritization protocols for accessing adult critical care in the extreme pandemic context contain tiebreaker criteria to facilitate decision-making in the allocation of resources between patients with a similar survival prognosis. Besides being controversial, little is known about the public acceptability of these tiebreakers. In order to better understand the public opinion, Quebec and Ontario's protocols were presented to the public in a democratic deliberation during the summer of 2022. OBJECTIVES: (1) To explore the perspectives of Quebec and Ontario citizens regarding tiebreakers, identifying the most acceptable ones and their underlying values. (2) To analyze these results considering other public consultations held during the pandemic on these criteria. METHODS: This was an exploratory qualitative study. The design involved an online democratic deliberation that took place over two days, simultaneously in Quebec and Ontario. Public participants were selected from a community sample which excluded healthcare workers. Participants were first presented the essential components of prioritization protocols and their related issues (training session day 1). They subsequently deliberated on the acceptability of these criteria (deliberation session day 2). The deliberation was then subject to thematic analysis. RESULTS: A total of 47 participants from the provinces of Quebec (n = 20) and Ontario (n = 27) took part in the online deliberation. A diverse audience participated excluding members of the healthcare workforce. Four themes were identified: (1) Priority to young patients - the life cycle - a preferred tiebreaker; (2) Randomization - a tiebreaker of last resort; (3) Multiplier effect of most exposed healthcare workers - a median acceptability tiebreaker, and (4) Social value - a less acceptable tiebreaker. CONCLUSION: Life cycle was the preferred tiebreaker as this criterion respects intergenerational equity, which was considered relevant when allocating scarce resources to adult patients in a context of extreme pandemic. Priority to young patients is in line with other consultations conducted around the world. Additional studies are needed to further investigate the public acceptability of tiebreaker criteria.

Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review.

Background: To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers. Objectives: To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic. Methods: The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies. Results: Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19. Conclusions: There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers. Supplementary Information: The online version contains supplementary material available at 10.1007/s44250-023-00027-9.

[The distribution of health resources: a hybrid model of equality and maximization]. / La distribution aléatoire des ressources en santé: pour un modèle hybride équilibrant les principes de justice et de maximisation.

In the allocation of resources for health care, it is generally acknowledged that models based exclusively either on efficiency and maximizing the cost/benefit ratio of interventions, or on equity and justice through the notion of "maximin," are unsatisfactory when taken separately. To fill this gap, this commentary suggests a hybrid model of resource allocation that integrates the idea of a random distribution of resources using a lottery. The general aim of this model is to safeguard the notions of justice and equal access to resources to the maximum extent possible in a climate where budget restrictions and the economic downturn may lead to future reductions in services.

[The Canadian plan to struggle against influenza epidemics: legal plea for a normative global approach]. / Le plan canadien de lutte contre la pandémie d'influenza : plaidoyer pour une approche normative globale.

The Canadian pandemic influenza plan for the health sector lies within a logic of precaution aiming at the effective prevention of human infections by the highly pathogenic influenza virus H5N1. Since the plan is designed as guidelines elaborated by the Canadian authorities to regulate behaviours should a pandemic occur, it possesses an eminent normative value. Yet, in spite of the attention being given by the experts to scientific and logistic measures, it seems clear that the Canadian plan has not undergone a thorough normative analysis, although it includes ethical considerations. The objective of this article is to show that a wider normative analysis should not be restricted to the elaboration of an ethical framework applicable to predetermined interventions. Such an analysis should also take into consideration how rational choices are made through the epistemological approach used by the experts.