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A Tough Triage: How Does One Fairly Allocate Scarce Medical Resources during the COVID-19 Pandemic?


Hi there! I’m Jenna.

OVERVIEW

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. 

  1. Autonomy: To be independent, self-directing, and free of coercion. 
  2. Non-maleficence: To avoid and prevent harm to all persons. 
  3. Beneficence: To provide benefit and advantage to all persons. 
  4. 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: 

  1. Those likely to survive with care.
  2. Those unlikely to survive with care.
  3. 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.

Connie Titchen, 106-years-old and one of the oldest survivors of COVID-19.
(Cullen, et al).

MY RESPONSE

CONCLUSION

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: 

  1. How can you take action during COVID-19 using the steps above?
  2. Does your community or country face a lack of medical supplies? If so, what ideas do you have to help your community?
  3. 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!

Works Cited

Click here for the bibliography of this webpage. 

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COMMENTS: 15
  1. April 23, 2020 by Sophie

    Hi Jenna! This was an amazing presentation and I can tell that you really know a lot about your topic. To answer your questions above, my family and I have all sewed masks for ourselves, and are working on making some for relatives. I live in the US and there is an extreme lack of supplies (seems to me like mostly ventilators, masks, and general PPE is the biggest issue right now. Personally, I would give the ventilator to Ava, as she s younger and has more of her life left to live. Most likely, she has more family connections and she is still in the middle of her education. Great work!!

    • April 25, 2020 by Jenna

      Hi Sophie! It’s so awesome that your family has sewed masks. I also have a sewing machine at home and I’ve ordered some elastics because I plan to make some for my relatives. Thanks for checking out my page!

  2. April 23, 2020 by Megan Lin

    Hi! I really loved your page, I thought you were clear and concise, and your use of infographics is great, as a visual learner, they were super helpful!

    I wanted to talk about question 3, and I think I would give the ventilator to Tom; with Ava, her health could influence the effectiveness of the ventilator. Tom also could further benefit finding a cure for COVID-19, and Ava is young, which increases her health. But that could also show that Ava should live, because of her youth. In conclusion, I would definitely be conflicted having to choose, but I thought including that case study/example, it was really helpful understanding the dilemma doctors must go through!

    • April 25, 2020 by Jenna

      Hey Megan! I’m happy you liked the infographics! I would definitely have a difficult time choosing who to give the ventilator, too!

  3. April 23, 2020 by Scott

    Jenna this was a really good page. It definitely has me thinking hard about the topics you brought up and I have a lot more empathy for healthcare workers that have to make these decisions every day. Have you looked into what steps are being taken by the government to help regulate where equipment should go? In the US, leadership on a local and national level are facing criticism for their allocation of resources, but it seems like the 4 principles you talked about would be very helpful leadership of all levels to consider.

    • April 25, 2020 by Jenna

      Hi Scott, thank you very much! I’ve researched some of the government measures they are taking in various countries, and I think that some of them seem to be not helpful in terms of containment of COVID-19. Bioethics is super important in pandemics, and it definitely shocks me that some hospitals/governments do not have an advisory board for them currently!

  4. April 24, 2020 by Hannah Trotman

    Hi Jenna, I loved your project so much! I think this is such an interesting topic especially because of its relevance to us today and I really enjoyed reading your page. Way to go!

    • April 25, 2020 by Jenna

      Hey Hannah! Thank you so much, glad you enjoyed it!

  5. April 24, 2020 by Jeremy

    This was a great way to quantify bioethics in the challenges we are facing in real-world society! The case study was a great way to outline the ethical dilemmas of the issue in a way that was digestible for those who haven’t studied the principles of bioethics for an extended period of time. I also thought it was great how you catered the presentation to everyday individuals, not making the issue seem distant and giving people options for ways they can help out. Great page!

    • April 25, 2020 by Jenna

      Hello Jeremy! Thank you for your kind words.

  6. April 24, 2020 by Natassia Wong

    Jenna, this is an amazing page! I love the infographics! To answer your questions, social distancing is huge to prevent the overall spread of the virus. Only buying what you need is important and identifying what those things are. (eg. you don’t need an N-95 mask just to go to the grocery store). In Canada, some provinces have much higher numbers than where I’m from, but there are many efforts into preventing medical supply shortages. It’s hard to say which I would choose but my initial response before reading your breakdown of the situation was to save Tom because he could make significant contributions to saving more lives. Nice job!

    • April 25, 2020 by Jenna

      Thank you, Natassia! I agree – while masks are important for social safety, I think the most heavy-duty medical supplies should be for those who have the highest risk of possible infection. My province in Canada also had higher numbers when the outbreak first started, but it was because we started our curve of infections earlier.

  7. April 25, 2020 by Jenna

    Hey Hannah! I’m so glad you enjoyed it!

  8. April 27, 2020 by Rubi Katz

    Hi Jenna, I loved your project and the relevancy to the past few months. If I were the one to choose between Tom and Ava I would pick Ava. Ava will hopefully have many more years to live then Tom and at that time she can create a family, get a job and make an impact on society. Allocating the supplies to Ava wouldn’t just help her it would also help a lucky unemployed person get a job (Tom’s job). I really enjoyed reading your page, good job!

  9. April 27, 2020 by Amiya Tiwari

    [* Shield plugin marked this comment as “Pending Moderation”. Reason: Whoops. Google reCAPTCHA was not submitted. *]
    Hi Jenna! Amiya here; you did FANTASTIC. Great job creating a project is concise but still provokes thought! I absolutely love how you used a case study to get your point across.

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