Hospitals across the world are suffering from a severe shortage of medical supplies. This serious dilemma, combined with the explosive growth of critically ill patients, means that medical workers must ration. In simpler terms, the number of sick patients exceeds the resources available to care for them. The first immediate recognition of rationing started in the United States when it was discovered that there was a lack of N95 masks. In South Korea, the shortage of intensive care unit (ICU) beds has forced many patients to die at home, awaiting hospital admission. Dire shortages of hospital gowns, gloves and eyewear have created a global surge in demand for personal protective equipment, also known as PPE. (Emanuel, et al). The worldwide demand for tests have led to controversy regarding who deserves priority testing after CNN reported that several NBA players had been tested despite ordinary Americans struggling to get access to tests. (Levenson, et al) Many countries are using methods to reduce the spread of illnesses by social distancing and increasing supply of equipment. However, other countries, such as the United States currently, are at the point where medical workers must decide who gets what resources. It’s a gut-wrenching question: who lives, and who dies?
THE FOUR BIOETHICAL PRINCIPLES
Throughout our class, we learnt about these four principles to analyze cases.
- Autonomy: To be independent, self-directing, and free of coercion.
- Non-maleficence: To avoid and prevent harm to all persons.
- Beneficence: To provide benefit and advantage to all persons.
- Justice: To have access to services, fairness and equity to all persons.
WHAT YOU NEED TO KNOW
Many medical workers have already received guidelines on triage measures they must take due to rationing. However, this can vary depending on which hospital they work. Triage, (which means “choice” or selection”) is needed when a number of patients simultaneously need medical attention and workers can’t attend to all of them at the same time. Traditional triage involved dividing patients into three categories:
- Those likely to survive with care.
- Those unlikely to survive with care.
- Those likely to survive with care but won’t without care.
Priority is typically given to those in the third category. The greatest risk that is faced during triage is distinguishing patients based on prejudice. This is why decisions must not be made on irrelevant factors, such as ethnicity, age, socio-economic status, mental status or sexual orientation. However, when a crisis hits, these factors may be taken into account. (Jonsen, et al.)
Decisions on how to allocate these limited resources are made in the full knowledge that medical staff must prioritize several patients over others – and that not all lives can be saved. Life and death must be justifiable; from a clear ethical basis. There are multiple ways to interpret what “fair” allocation looks like – some believe it involves considering social contribution, using a lottery-based system, or helping the worst-off first. But above all, most agree that the right thing to do is to allocate resources that results in the greatest amount of people saved. (Wrigley). This maximizes beneficence, a bioethical principle which provides advantage to all.
THE CASE STUDY
Let’s say hypothetically that you are a front-line physician treating patients suffering from the coronavirus. At the moment, you are treating two infected patients – take a look at the infographic on the left. Both patients have a high prognosis of surviving if given a ventilator. Unfortunately, your hospital only has one left – and Tom and Ava both need it. Who do you give the ventilator to?
Here are the steps in which hospitals would take if this case study was real:
Firstly, lifesaving ventilation would be offered based on who is most likely to survive as a result of that intervention. This means that they must be facing life-threatening conditions to get the ventilator. Some Italian hospitals have given priority to younger patients with severe illness, and those with fewer co-existing health conditions as they typically have a higher chance of living longer. While Ava has a health condition that could threaten her prognosis, Tom has less years to live. In addition, by saving Tom, you may also be saving others as his job is essential to the pandemic response. This is a form of beneficence for all as he is likely to make relevant contributions in the future. The same goes for PPE and tests, as healthcare workers have a higher risk of contracting COVID-19 and are instrumental in the pandemic.
Choosing between patients would typically breach the bioethical principles, especially beneficence and non-maleficence. However, one could argue that justice, a principle which promotes fairness to all is promoted. Healthy, young patients are likely to have a speedy recovery and free up ventilators for others quicker. This would reflect on beneficence and the ethical goal of saving the greatest number of lives. In particular, many physicians have emotionally struggled to withdraw ventilators from unresponsive patients so others can benefit from them. However, many ethical guidelines that this act errs on the point of saving others, rather than causing the death of one.
Some argue that paying for these resources allows for more autonomy. While this does allow for more decision-making towards the individual, it is a clear breach of justice, and can skew healthcare in favour of the powerful and wealthy. Clear communication between patient and healthcare provider allows for more power, as stated by Dr. Wynia in the New York times: “The most morally defensible way to decide would be to ask the patients [when possible]”. (Fink).
Choosing between patients based on social merit, age, and health histories also breaches justice – shouldn’t every person be worthy of curative treatment? Others argue that this practice is discriminatory and goes against justice, non-maleficence and beneficence. A level playing field – meaning that each person has equal access to healthcare – would promote these principles more.
Trying to maximize lives saved will inevitably be imperfect. In bioethics, the four principles that are upheld must be flexible in times of crisis. A focus on the greater population is necessitated by the presence of COVID-19. The well-being of the population should be prioritized rather than the rights of an individual. These criteria must be open, clear and available to the public. We trust our medical workers to use their power ethically. Without clarity and fairness, our trust in healthcare systems would become irreparably damaged in the future. We may fall victim to the second wave of COVID-19 soon. (Beaumont). As our world continuously becomes more globally connected, the spread of illness will be more rapid. Let’s go forward with confidence in the future – prepared for any crisis.
HOW CAN YOU HELP?
In the comments below, please let me know:
- How can you take action during COVID-19 using the steps above?
- Does your community or country face a lack of medical supplies? If so, what ideas do you have to help your community?
- If you were a physician, would you give the ventilator to Ava or Tom? Why?
Please feel free to respond and start a discussion within the comments!