May 2020 Pulse
One of the greatest challenges that doctors and healthcare professionals face in the situation of a widespread virus outbreak like the current Covid-19 pandemic has to do with decisions they have to make on a daily basis concerning which patients should have access to the limited supply of services and medical equipment, such as ICU beds and mechanical ventilators.
In the case of the United States, for example, conservative estimates show that the needs of patients infected by the coronavirus will go well beyond the capacity of hospitals if the spread of the disease is not impeded. Unless the epidemic curve of infection is flattened, the Covid-19 outbreak is likely to cause an acute shortage of hospital beds, ICU beds and ventilators.
A pandemic brings to the fore acute issues concerning the ethics of triage and the rationing of services and medical equipment. Triage is the process of determining the priority of treating patients based on the severity of their condition. And rationing during a health crisis or emergency like a pandemic refers to the allocation of medical equipment, services, and resources.
Although many countries (especially those with more developed healthcare systems) have put in place strategies for rationing during pandemics, they will still face enormous challenges when the disease is spreading uncontrollably.
In addition, most physicians are not trained as wartime medics and have never experienced the challenge of having to make battlefield triage decisions. And a raging pandemic, like the current coronavirus outbreak, creates the exact harrowing conditions that many doctors and healthcare professionals are quite unfamiliar with.
Although modelling the virus can in some ways provide important data that can be used to project the demand for resources, modelling the Covid-19 pandemic has been challenging because there’s still much about the disease that scientists do not know.
The ultimate goal of the triage and rationing is of course to save as many human lives as possible, and to serve human health and dignity, despite great constraints due to limited resources. For the Christian, this goal is of great importance because it is premised on the fact that human beings are bearers of the divine image (Genesis 1:27) and that human life is sacred.
In addition, decisions regarding triage and rationing must always be guided by the principles of duty, justice, equality, fairness, and transparency. And because these principles are so foundational to the practice of medicine, they should never be abandoned, even at a time of crisis.
Yet, as Aaron Kheriaty has pointed out:
… something lingers always in the background of our efforts. There is an inescapably tragic undercurrent to all of this, however upright our intentions. This one unsettling fact always remains to haunt us: If hospitals exceed their surge capacity, patients who otherwise would have lived will die. Lives will be lost simply because we lacked the resources to offer everyone the basics of modern medicine.
Difficult and painful choices have to be made. Allowing a patient access to a medical equipment or service in a situation where there’s limited supply would mean depriving another access to them that would cost them their lives.
Already in ordinary times, such difficult decisions are being made. In exceptional times, such as during a pandemic, these decisions are multiplied many times over! As an Italian ICU physician told the BBC, ‘Normally, doctors make such decisions once every two weeks. But now, we have to make them three or four times a day!’
One of the most pressing problems faced by countries such as Italy and the United States is the shortage of ventilators.
The Centres for Disease Control and Prevention estimate that at the height of the pandemic, 2.4 million to 21 million Americans will require hospitalization. Based on statistics garnered from Italy, 10 to 25 percent of hospitalized patients would require ventilation, in some cases for several weeks. This means that the number of patients in the US requiring ventilation could be between 1.4 and 31 patients per ventilator.
Although shortages of other equipment and services during a pandemic are not uncommon, the shortage of the mechanical ventilator is different. This is because when a patient’s breathing deteriorates to a point that a ventilator is needed, there is only a narrow window within which physicians can work. And when a ventilator is removed from a fully-ventilated patient is removed, he or she will die within minutes.
The basic principle that even in a crisis situation the goal must be to save as many lives as possible should of course be upheld. But it does not answer the pressing question of whose life is more worthy of saving when it is simply not possible to save every patient.
For instance, should the ventilator be used for a seventy-five-year-old patient with many underlying medical conditions such as diabetes and heart disease, or for a middle-aged doctor who became infected with Covid-19 while caring for infected patients in the frontline?
Most ethicists would support the view that during a national health crisis or emergency, the focus must shift from that of the most beneficial treatment to individual patients to the priority of populations or groups of patients that are most vulnerable or that will most likely benefit from the prudent stewardship of limit resources.
But this principle does not make the decision for the above hypothetical case any easier and less conflicted.
One of the most respected physicians and ethicists, Daniel Sulmasy, in an article published by The New York Daily, entitled, ‘Respirators, our Rights, Right and Wrong: Medical Ethics in an Age of Coronavirus’, asserts that even in a situation where the healthcare system is overwhelmed, doctors should not ‘discriminate against patients by rationing on the basis of age, social worth or disability.’
‘Our judgements about who gets treatment should be based on whether the treatment is worthwhile, not on whether the patient is “worthy” of treatment’, he adds.
While I fully understand the convictions behind this assertion, as Sulmasy would know very well, in a pandemic it is not always possible to uphold this ideal and painful judgement calls that transgress it will have to be repeatedly made.
For example (again hypothetical), should the ventilator be used for a frontline middle-aged nurse who has contracted Covid-19 while caring for patients or for a Head of State (perhaps a member of the country’s royal family) or the Prime Minister of a nation heading the special task-force to battle the pandemic?
What should we do in a situation where two patients with similar prognosis are in need of ventilators, and only one is available? In such circumstances, many ethicists maintain that equality should be invoked and operationalised through random allocation, such as a lottery, that is, allowing chance to determine who gets ventilated.
Some, however, have argued that perhaps a first-come, first -served allocation process would be a fairer approach than the lottery system. But as Ezekiel Emanuel et al have pointed out, ‘treatments for coronavirus address urgent need, meaning that a first-come, first-served approach would unfairly benefit patients living nearer to health facilities.’
The challenges of the pandemic triage are enormous, and physicians and healthcare workers have to make difficult and often traumatic decisions every day as they treat infected patients. While every patient must be accorded full dignity and every human life regarded as sacred, the lack of resources means that physicians have to decide who lives and who dies.
Under the impossible conditions of a pandemic, physicians cannot avoid making such decisions even as they seek to exercise responsible stewardship of resources and maximise their benefits.
But these decisions must always be made with regret, repentance and profound sorrow.
Dr Roland Chia is Chew Hock Hin Professor at Trinity Theological College (Singapore) and Theological and Research Advisor of the Ethos Institute for Public Christianity.