In a Pandemic, Deciding Who To Save First is a Harsh Reality
Physicians are bound by a code to serve their patients. This Hippocratic Oath has evolved over the centuries, but the basic idea remains: to share knowledge, to never cause harm, and to care for the sick as best as they can.
What happens, though, when hospitals and medical facilities are inundated and reach their saturation point? When the number of patients far exceeds the number of caregivers, not to mention resources, how will doctors decide who to prioritize?
It’s comforting to believe that health professionals will come to our aid and help us get better if and when we need it. But with the COVID-19 crisis spreading faster than ever, doctors are going to have face an uncomfortable reality sooner rather than later: choosing who gets potentially lifesaving treatment, and who doesn’t.
“There’s no question that hospitals and healthcare workers already have priority setting in mind,” says Yves SJ Aquino, a physician and a philosopher. Dr. Aquino has a medical degree from the University of the Philippines College of Medicine and a PhD in bioethics from Macquarie University in Sydney, Australia. He currently teaches bioethics and public health ethics at Macquarie University.
“Hospitals are used to performing evaluations regarding which patients get treatments over others,” he says. “Priority setting is much more apparent in tertiary hospitals such as the Philippine General Hospital, where resources are almost often limited if not inadequate.”
Dr. Aquino says health care workers are trained to perform priority setting during triage, or the process of evaluation to determine which patient should be treated first. They are also likewise trained in rationing, or the provision of treatments based on some set criteria, as in organ transplantation.
“Given limited organs for transplantation, clinical specialists appeal to a set of criteria to decide which patient gets the organ first,” he says.
“The COVID-19 outbreak is not an entirely new phenomenon for medical professionals,” Dr. Aquino adds. “What is different this time is the scale. The scale highlights not only the limitations of our health care system but also the ethical conflicts that can arise during a pandemic.”
Life or death
We’re already seeing this happen in some parts of the world. In Italy, for instance, medical facilities are stretched to near-breaking point in Lombardy, the country’s worst-hit region, forcing doctors there “to decide not to intubate some very old patients,” according to the New York Times.
Ethical dilemmas related to healthcare and medical treatment aren’t new. Personnel in medical facilities with limited resources may understandably have had to make them for years. But the coronavirus pandemic is throwing it further into the spotlight and forcing people to confront the harsh reality.
“The baseline principle involved in medical resource allocation tends to be fairness, usually in the form of impartiality,” Dr. Aquino. “This principle means that each person has an equal chance of accessing treatments regardless of their sex-gender, age, socio-economic status, or ethnolinguistic identity. It means there is no preferential treatment for persons because of personal relationships or social standing. The principle states that you ought not to prioritize politicians, celebrities, or family members over any member of the general population.”
The principles of fairness in healthcare can also be understood as equity, according to Dr. Aquino.
“Equity goes beyond assuring equal access to health services by taking into account structural levels of disparity among social groups,” he says. “An equitable allocation of medical treatments may imply that we ought to prioritize vulnerable or disadvantaged groups.”
Here in the Philippines, the issue of ethical guidelines related to resource allocation is something health leaders will need to address, especially after a few major hospitals have announced that they have reached full capacity and are no longer accepting COVID-19 patients for long-term care.
“It is ethically justified for hospitals to turn away patients if they’ve reached full capacity,” says Dr. Aquino. “If the hospital exceeds its full capacity, there are harmful repercussions with domino effect. For example…you will have crowded hospital spaces. This can increase the chance of transmitting hospital-acquired infections. Crowding can also quickly deplete resources and lead to overworked staff. With insufficient resources, the hospital cannot provide adequate treatment to admitted patients. And once you have overworked staff, there is greater risk of human errors that impact on the quality of care.”
Then, of course, there's the issue of some politicians reportedly "jumping the line" in their haste to get themselves tested for the coronavirus. Dr. Aquino believes this to be unethical.
"The problematic notion of social worth enables people in positions of political power or influence to feel entitled—entitled that they deserve immediate medical care, including diagnostic tests, more than the health care workers, more than the patients with symptoms of viral infection, or more than the general population," he says.
In an article published in the New England Journal of Medicine, Dr. Lisa Rosenbaum says some Italian doctors she spoke with have had no choice but to make the most difficult decisions. In one case, an 80-year-old who was “perfect physically” developed COVID-19–related respiratory failure. He died because mechanical ventilation could not be offered
“There is no way to find an exception,” one of the Italian doctors told Dr. Rosenbaum. “We have to decide who must die and whom we shall keep alive.”
A separate article in the same journal, titled "Fair Allocation of Scarce Medical Resources in the Time of Covid-19," proposed some pretty concrete ethical guidelines in the inevitable scenario that the coronavirus pandemic causes a severe shortage in hospital beds, ventilators, and medical personnel.
“The choice to set limits on access to treatment is not a discretionary decision, but a necessary response to the overwhelming effects of a pandemic,” says Dr. Ezekiel Emanuel and his colleagues. Dr. Emanuel is vice provost for global initiatives and chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. “The question is not whether to set priorities, but how to do so ethically and consistently, rather than basing decisions on individual institutions’ approaches or a clinician’s intuition in the heat of the moment.”
Taking into account their own research and analysis, as well as previous proposals, Dr. Emanuel and his team identified four key values to allocate resources in the event of a pandemic: maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off.
From these values, Dr. Emanuel and the team developed six specific recommendations intended to guide medical professionals to rationalize precious resources in this time of the coronavirus pandemic.
1| Maximizing benefits
The most important value according to Dr. Emanuel and his colleagues, maximizing benefits essentially means “saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment.
“Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment,” the article adds. “Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life.”
The collective of medical professionals even provides an example: They believe removing a patient from a ventilator in order to provide it to another with better chances of living is the ethical thing to do, despite the fact that some doctors might refuse to do so.
“However, 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,” they say. “We agree with these guidelines that it is the ethical thing to do.”
“In ethics, we refer to this as utilitarianism, which states that the moral status of an act or decision is based solely on its tendency to promote benefits and avoid harms,” Dr. Aquino says about maximizing benefits. “In the context of medical resource allocation, maximizing benefit implies at least two practical guidelines.
"First, the principle may imply that we ought to choose patients who are more likely to benefit from the intervention. For example, medical professionals may need to prioritize patients who are more likely to recover with the intervention than patients for whom interventions are already futile. Second, the principle may imply that medical professionals ought to establish allocation criteria that can promote health benefits for the greater number of people.”
2| Prioritize health workers
The thinking here is simple and straightforward: Resources to identify and treat COVID-19 cases should be directed toward frontline health workers first.
“These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: They are essential to pandemic response,” the article states. “If physicians and nurses are incapacitated, all patients—not just those with COVID-19—will suffer greater mortality and years of life lost.”
3| Do not allocate on a first-come, first-served basis
Conventional thinking suggests that whoever gets to something first should be prioritized. But according to Dr. Emanuel and his team, “equality should be invoked and operationalized through random allocation, such as a lottery.”
The collective argues that treatments for coronavirus qualify as urgent, which means the first-come, first-served approach would unfairly benefit patients living nearer to health facilities. They also expressed worry that first-come, first-served would encourage crowding and even violence.
“Finally, first-come, first-served approaches mean that people who happen to get sick later on, perhaps because of their strict adherence to recommended public health measures, are excluded from treatment, worsening outcomes without improving fairness,” they add.
4| Be responsive to evidence
Dr. Emanuel and his colleagues advise that “prioritization guidelines should differ by intervention and should respond to changing scientific evidence.” In other words, there is always a chance that policies may change depending on the latest available information.
As an example, the article says older patients should be prioritized if and when a COVID-19 vaccine is finally developed. The doctors reason that the vaccine prevents rather than cures, so it would only make sense to place older patients ahead of younger ones (immediately after health care workers and first responders, of course).
“If the vaccine supply is insufficient for patients in the highest risk categories—those over 60 years of age or with coexisting conditions—then equality supports using random selection, such as a lottery, for vaccine allocation.”
5| Recognize research participation
Dr. Emanuel and his team argue that, if a person is involved in clinical trials or research involving responses to the COVID-19 threat, he or she should be given priority in treatment and care.
“Their assumption of risk during their participation in research helps future patients, and they should be rewarded for that contribution,” the doctors say. “These rewards will also encourage other patients to participate in clinical trials. Research participation, however, should serve only as a tiebreaker among patients with similar prognoses.”
6| Apply the same principles to all COVID-19 and non-COVID-19 patients
When hospitals are at full capacity and resources and medical staff are scarce, doctors should not distinguish between those afflicted with COVID-19 and those who aren’t. The rationale emphasizes, according to the article, “fair allocation of resources that prioritizes the value of maximizing benefits applies across all patients who need resources.
“For example, a doctor with an allergy who goes into anaphylactic shock and needs life-saving intubation and ventilator support should receive priority over COVID-19 patients who are not frontline health care workers,” it adds.
As Dr. Aquino says, local health professionals and institutions may already have priority setting and resource allocation policies in place, and these may understandably prove useful in a pandemic of this scale. It’s yet another challenge our healthcare frontliners will have to contend with in the fight against COVID-19.