[guest post by Dana]
In light of the pandemic and the limited number of ventilators available nationwide, inevitable discussions about the prioritizing of treatment if the system becomes overwhelmed, have begun. From The Los Angeles Times:
Three patients — a 16-year-old boy with diabetes, a 25-year-old mother and a 75-year-old grandfather — are crammed into a hospital triage tent and struggling to breathe. Only one ventilator is left. Who gets it?
Do they allocate intensive-care beds on a first-come, first-served basis? Do they pull one patient with a limited chance of survival off a ventilator to give it to another with better odds?
If two patients have equal medical need and likelihood of recovery, do they pick the youngest? Or the one with the greatest number of dependents? Should physicians and respiratory therapists, or even police officers and firefighters, be jumped to the front of the line?
With the upward trajectory of Americans testing positive for coronavirus, medical professionals are faced with decisions about who should receive treatment if there is a very limited number of ventilators and hospital beds available. In the U.S., we are at the discussion and planning stages. In Italy, planning is long over with – the hard decisions are already being made:
Without enough ventilators to deal with the influx of patients, doctors are denying services to the elderly in favor of young and otherwise healthy patients.
“There is no way to find an exception,” a doctor in northern Italy told the New England Journal of Medicine. “We have to decide who must die and whom we shall keep alive.”
To see the problem in the starkest of terms, Johns Hopkins reports that the U.S. has fewer than 100,000 intensive-care beds. But it would probably need a total of 200,000 in a moderate outbreak and 2.9 million in an outbreak akin to the 1918 Spanish flu.
In Washington state, which has been hit extremely hard by the outbreak, about 280 clinicians and officials from across the state, participated in a conference call concerning the difficult subject of prioritizing treatment of patients if the system becomes overwhelmed:
Fearing a critical shortage of supplies, including the ventilators needed to help the most seriously ill patients breathe, state officials and hospital leaders held a conference call on Wednesday night to discuss the plans, according to several people involved in the talks. The triage document, still under consideration, will assess factors such as age, health and likelihood of survival in determining who will get access to full care and who will merely be provided comfort care, with the expectation that they will die.
Cassie Sauer, chief executive of the Washington State Hospital Association, said that the decision was being made statewide in order to keep individual doctors from having to make the difficult decision:
“It’s protecting the clinicians so you don’t have one person who’s kind of playing God,” she said, adding, “It is chilling, and it should not happen in America.”
Dr. Chris Spitters, interim health officer for the Snohomish Health District, explained that medical professionals will be better off having an actual plan in place, rather than just hoping it gets better:
“I would love to learn a month from now that the social distancing measures we adopted did indeed curb the outbreak enough to avoid going into that crisis zone of activity,” Dr. Spitters said. “But that would be poor planning — to simply hope.”
Determining the criteria:
“They look at the criteria — in this case it would likely be age and underlying disease conditions — and then determine that this person, though this person has a chance of survival with a ventilator, does not get one,” Ms. Sauer said.
“This is a shift to caring for the population, where you look at the whole population of people who need care and make a determination about who is most likely to survive, and you provide care to them,” she said. “Those that have a less good chance of survival — but still have a chance — you do not provide care to them, which guarantees their death.”
Fordham University’s Charles Camosy, who is an associate professor of theological and social ethics, and whose work focuses on ethics and policy, explains why he disagrees with making any rationing decisions based soley upon age:
The Italians have already faced the bedeviling moral dilemmas of rationing, and in a guidance to providers, the Italian government has recommended that resources be rationed by age… age-based rationing is “a way to provide extremely scarce resources to those who have the highest likelihood of survival and could enjoy the largest number of life-years saved.”
Bioethicists like me disagree over which values should guide rationing, but we generally agree about focusing on those who can benefit from the treatment. If the age of a patient makes it unlikely she would benefit, the hard truth is that limited resources will likely go to someone else.
But then there is the “number of life years” the patient could “enjoy,” as the Italians put it. This consideration comes from providers’ growing tendency to think either implicitly or explicitly about how many “quality-adjusted life years” their interventions might produce. It is a poisonously utilitarian and inherently discriminatory mentality. It is ageist — discriminatory against the elderly — and ableist — discriminatory against the disabled — to its core.
He then explains the danger of using a “quality of life’ argument: we know that throughout Europe, it is believed that babies born with Down syndrome are deemed so without quality of life that they are better off not having been born at all (see: Iceland):
But anyone who loves someone with Down syndrome knows that they are some of the most joyful people on earth. What if a corona victim competing for a bed or ventilator has Down syndrome? Even some US hospitals are considering using “quality of life” as part of their rationing process.
So who should make the decision about care rationing?
It should not be up to physicians to decide whose subjective quality of life deserves to be prolonged. Physicians almost always rate the quality of life of their patients significantly lower than patients do themselves — and miss the fact that their patients often prefer length of life to quality of life (whatever that means). In short, they are terrible deciders about who should live and who should die.
Camosy points readers to protocols established in 2008 by the state of New York, in case of a pandemic likethe one we are currently facing. “Allocation of Ventilators in a Public Health Disaster” informs decision-makers that “age and health problems or disabilities unrelated to what is causing the epidemic shouldn’t serve as the basis for rationing. Prognosis for recovery is what matters.”
In other words:
A New York hospital could choose to give its last ventilator to the 72-year-old marathon runner rather than to the 57-year-old pack-a-day smoker. Again, based only on prognosis for recovery. The objectivity of the standard removes much of the physician’s subjective ideology from the picture.
The protocol also says that the public should make sure our views are reflected in state and hospital policies when an epidemic hits. We are late to the party, but there is no time like the present to be heard and hold the health-care community to transparent ethical standards.
Again, physicians and hospitals are doing heroic work under traumatic conditions. We are beyond blessed to have them. But it is in supremely difficult conditions like the current one when cultures tend to abandon their core values.
If rationing arrives, we must stand up unambiguously for the marginalized and vulnerable, the elderly and disabled, lest what Pope Francis has decried as the modern throwaway culture deems them expendable.
Prayerfully, it doesn’t come to this.