Ethics Of Rationing Health Care If System Becomes Overwhelmed
[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.
–Dana
Hello.
Dana (4fb37f) — 3/20/2020 @ 6:29 pmIf 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.
So, the young, strong and successful person dies and the suicidal, diabetic ne’er-do-well gets the ventilator? The smoker dies because his sins are disfavored? Seems like ethics is one of those oxymoron things.
Kevin M (ab1c11) — 3/20/2020 @ 6:32 pmSave the young, save the healthy, save the productive. Give chloroquine and other anti-virals to less symptomatic people earlier in the disease process rather than critical cases until we have enough in supply lines for everyone—that will save the most lives in terms of both quantity of lives and quantity of life remaining per patient saved; it will also reduce the most injury to survivors:
Make America Ordered Again (23f793) — 3/20/2020 @ 6:35 pmHope I’m hallucinating but I just felt an earthquake.
harkin (b64479) — 3/20/2020 @ 6:35 pmSelf-isolate beneath a desk.
Make America Ordered Again (23f793) — 3/20/2020 @ 6:36 pmThe decisions should be based on survivability, responsibility, impairments and age, and if not a doctor who? A social worker? A lawyer? A politician? A minister? All of these will ALSO have skewed judgements, but only a doctor can answer all of them.
I submit that each patient has an identical opinion about the value of their own life. Why even go there?
Kevin M (ab1c11) — 3/20/2020 @ 6:38 pmI am waiting for lawsuits over ventilators and courts issuing injunctions.
Kevin M (ab1c11) — 3/20/2020 @ 6:39 pmI would also look at their cell phones and see what they’ve been up to. The 70yo who’s been trying to isolate might get the nod in my book over the 20yo who’s been clubbing all week.
Kevin M (ab1c11) — 3/20/2020 @ 6:40 pmGreat idea for a TeeVee show– here’ the pitch meeting; a group of overworked medicos face a relentless onslaught of doctoring and must ‘triage’ patients, deciding who gets what, who lives, who dies– then wash away their guilt- and clense their wounds- in a government hovel called, ‘The Swamp.’
We’ll call it “M.A.S.H.”
DCSCA (797bc0) — 3/20/2020 @ 6:41 pmAnother argument I saw for treating the healthiest/youngest is that whichever patient recovers faster frees scarce resources to save someone else. So if the 17 year old will need the respirator for a week to get well, and the 75 year old needs it for two weeks before they can be taken off, there’s a pretty clear decision criterion that has nothing to do with trying to quantify the “quality” of different peoples’ lives.
Dave (1bb933) — 3/20/2020 @ 6:43 pmRe Earthquake:
Sorry, semi-false alarm.
There was a quake but it was a 5.0 near Carson City at 6:33.
That’s nothing to sniff at but if it had been in the Bay Area and I’d been able to feel it up here in the Mother Lode it would have been very bad news.
harkin (b64479) — 3/20/2020 @ 6:45 pm_
@6 I don’t know that that is true. If I had to choose between myself and an otherwise healthy 30 yr old mother of three, I choose for her to get the ventilator. She had dependents who need her a lot, I do not.
Nic (896fdf) — 3/20/2020 @ 6:48 pm@11 Yeah, I just barely caught the edge of the Napa quake a couple of years ago and I suspect I’m closer than you are. It would have been a big ol’ shaker if you could feel a quake up there from the bay area.
Nic (896fdf) — 3/20/2020 @ 6:51 pmI don’t know that that is true. If I had to choose between myself and an otherwise healthy 30 yr old mother of three
That’s not the point. The article contrasted a doctor’s view of “quality of life” issues versus the patient’s view of the value of his own life, unrelated to that of another. It’s not like they’re going to put the two of you in a room for rock-paper-scissors.
The doctor might well make the same decision regarding responsibility and age that you make, everything else being equal.
Kevin M (ab1c11) — 3/20/2020 @ 6:53 pmThis bastard’s inciting panic!
I joke but I don’t envy these people. I don’t disagree with Kevin on seeing who was a team player. The same folks who refuse to vaccinate and go out and have a great time, laughing at the suckers, will be the most difficult to deal with when they need help. It’s just the way of the world.
Dustin (b18b7a) — 3/20/2020 @ 7:00 pmThe more of the decision you put on the individual doctor the faster you burn his sanity and over all mental health. This is going to burn out a lot of it anyway and I don’t think an algorithm or clinical formula can be made perfect but the closer to an objective across the board protocol we have the better.
frosty (f27e97) — 3/20/2020 @ 7:03 pmThe question is academic. The people with the best health care insurance or fattest wallets will get the best care. As somebody might say, “that’s been the story of life”.
nk (1d9030) — 3/20/2020 @ 7:07 pmSpeaking of brutal choices to be made:
As Hospitals Prepare for COVID-19, Life-Saving Trans Surgeries Are Delayed
https://www.vice.com/amp/en_us/article/wxekyz/transgender-surgeries-delayed-coronavirus-hospitals
harkin (b64479) — 3/20/2020 @ 7:32 pm_
Decisions may very likely come down to all being awful and not ethical, but necessary:
This from an interesting discussion about how decisions like these are made.
Dana (4fb37f) — 3/20/2020 @ 8:58 pmThat seems cruel and absurd to me.
It’s not the physician’s fault that there are too many cases for the available equipment.
Doctors can never save everyone that comes to them, even in normal times. If they do the best they can, and save some who would have otherwise died, they should be proud of their work.
Dave (1bb933) — 3/20/2020 @ 9:33 pm20. Not only can doctors not save everyone that comes to them, but if you need a ventilator, there’s a 95+% chance you won’t make it regardless.
Gryph (08c844) — 3/20/2020 @ 9:36 pmSo my city, with 8 and a half million people, has 30% of America’s COVID-19 cases. Lovely.
Make America Ordered Again (23f793) — 3/20/2020 @ 9:41 pmThe people with the best health care insurance or fattest wallets will get the best care. As somebody might say, “that’s been the story of life”.
That’s not entirely true, but I expect that Trump, Bloomberg, Biden and Bernie all have respirators reserved for them. Bill Gates probably has an ICU at his house.
Kevin M (ab1c11) — 3/20/2020 @ 10:10 pm“When a man of your daddy’s wealth dies of cancer, you know they haven’t found a cure.”
Conrad Hunter (Steve Forrest) – North Dallas Forty
harkin (b64479) — 3/20/2020 @ 11:00 pm_
Give it to the rich they will just buy (take) it anyway!
one percent (7a901f) — 3/21/2020 @ 12:03 amR.I.P. Kenny Rogers
‘You gotta know when to hold’em; and when to fold’em.’
DCSCA (797bc0) — 3/21/2020 @ 1:13 amHealth care…like all goods…is constantly “rationed”. Either by the market or by planners and providers.
Ragspierre (d9bec9) — 3/21/2020 @ 6:30 amDoctors have been making these decisions on a regular basis since before Hippocrates. A long list of fuzzily defined factors are evaluated in the doctors mind, and the right decision is make.
The ventilator dilemma is a fiction. Intubating a patient is a major step. That’s what Do Not Resuscitate orders are all about. Once your hooked up you improve, or the family makes a decision to “pull the plug.”
I’ve been involved twice. Prayful times.
In short, we must trust the medicos to do the best for the most people. Second guessing serves no purpose.
Iowan2 (bbb95d) — 3/21/2020 @ 7:17 amShocka…brought to us by the same underlings who brought us “Russia! Russia!, Russia!”
Yet, some are still buying the daily does of rancid swill they are selling.
I reckon they might possibly be correct eventually.
MJN1957 (28ce29) — 3/21/2020 @ 7:24 amIn my mid-seventies. Have a directive to physicians in the house, with my doctor, and known to my family. DNR/DNI for me. No tubes down my throat. A good dose of morphine at the end would be nice. Life is great but impermanent, and futile prolongation of the dying process is something I don’t want.
Fred (c46b99) — 3/21/2020 @ 8:42 am