Rationing: Who Gets Care

April 1, 2020 by David Nitkin | Categories: Healthcare Series One: Issues | Tags: Equality, Healthcare

The Issue

Who should receive priority attention when they are suspected of falling victim to COVID-19? There are serious consequences to the difficult but realistic situation where choices must be made to determine who can be treated and who cannot. These consequences of making such individual treat-do not treat decisions often includes guilt, harm and recrimination for losers and winners alike. The toll on physicians, health administrators and caregivers making these life and death decisions contributes greatly to post-traumatic stress .

Choices are often in conflict and not easily compatible. Maximize the number of lives saved. Protect the most vulnerable. Quarantine target populations. Treat only those likely to survive. The fear is “catastrophic medicine”—not having enough ventilators or hospital beds, which is a genuine probable reality in some of the more severe forecasts of infection and mortality rates. When do you say yes to one patient or take a ventilator off another patient? What do we do when all ventilators and intensive care units are in use?

Spanish Flu, 1918

Ethical and Moral Dilemmas

Rationing care or triage is a chilling business. There are a few important acknowledged criteria:

(a) consumption of resources;
(b) certainty of positive outcome;
(c) the availability of Personal Protective Equipment (PPE) such as gowns, masks, respirators, and ventilators; and
(d) contribute to freeing up beds faster.

Which ones should take precedence?

Based on two months of the international spread of the disease, it would appear as if eighty per cent of those who contract the droplet-spread virus, experience it in mild form. About five per cent of the total, however, end up on ventilators. One out of every two patients in intensive care will likely succumb to the illness. The most serious are treated with intubation, which has serious effects on walking, the incidence of lung infections like pneumonia, and cognitive ability.

Difficult choices are ahead

Ventilators are typical standard of care for COVID-19 patients with serious complications. Guidelines for their use which exist in certain countries like the United States and Canada, typically include responsibilities and duties of care using a multi-stakeholder framework, such as

Duty to care: for patients.
Duty to steward resources. This is also referred to as distributive justice and duty to plan
Transparency.

Triage decisions both in and outside hospitals typically involve such variables as patient age, pre-existing health conditions, the existence of relatives or family members, and the number of available ventilators. The application of such principles vary. Here are six possible answers about who might most merit being saved:

Younger and healthier patients who have their whole lives to live. They have more potential years of life to live and are at greatest likelihood of survival. They are most likely to recover quickly and vacate a hospital bed.
Older, compromised patients who are at the greatest risk. Without intervention, they are least likely to survive.
First come, first served. They may be in more severe condition.
Those who are able to pay.
Those who provide leadership or enrich the character of a society – artists, health-care professionals, and the like.
Random lottery.

Random, first come-first served, lottery choices are all subjective. In that way, they don’t reflect clinical judgements, nor necessarily serve the goal of saving the most lives.

Legal and Values Dimensions:

In 2006, the World Health Organization (WHO) drew up guidelines for just who gets care when it assessed such pandemic challenge decision-making involving bird flu. Those WHO bureaucrats concluded that all lives were valuable, and that public health administrators should seek to save the maximum number of lives.

Doctors, nurses, firefighters, lab technicians and ambulance paramedic workers, as well as water and power supply technicians, are at the front lines of participating directly and indirectly in such decisions. They are trained to assess ration choices through two types of prisms:

(a) ones for whom the result is diminution of the supply of caregivers, vital but scarce supply medical equipment, and available hospital beds; and
(b) others for whom the prognosis for recovery is promising—ones whose lives are threatened but there is a good chance of recovery if they are treated.

Physicians have a professional duty of care not only to their patients but also to themselves, the community, health-care institutions, and colleagues. They are expected to compassionately serve patients, use available resources wisely, wear protective equipment, educate the public, avoid conflicts of interest in serving relatives and family members.

The best treatment information available to us now is that there is no cure; that some drugs approved for other illnesses like HIV may help with care for the afflicted; and that a vaccine may take a year before it is tested and found effective. The vaccine must be understood as preventive care for future patients, not a cure or remission for those compromised by or infected by the pandemic.

David Nitkin

David Nitkin, founder of EthicScan, is a full-time organizational ethicist. David’s original writing, teaching, consulting and research focuses upon ethical decision making; enhancing corporate accountability and reporting; and developing corporate ethics assurance programs, including transparency, risk management, integrity management, and safe partnering.

David has provided ethics training, advice and research for over 200 clients both internationally and in Canada who collectively employ over 750,000 employees. He consults and trains widely with a variety of clients, including corporations, industry associations, public service sector organizations (integrity commissions, human rights commissions, and anti-corruption tribunals social agencies, professional ethics certification organizations, not-for-profits; and civil society organizations.