Everyone who 'needs' a ventilator will not get one. When there are two patients and one ventilator, the one with the greatest survival chance should get the ventilator first.
As practicing clinicians, we’ve sometimes had problems getting our patients the care they need. But often, that has been because an insurance company thought it wasn’t “medically necessary.” Does a grandmother with debilitating rheumatoid arthritis need a special pain medication that costs $1,000 a day? Does a hypertensive, seriously obese patient need a gastric bypass operation?
We are lucky that about half of people with coronavirus have no symptoms but will become immune, just like most symptomatic people. According to the World Health Organization, 1 in 7 cases require hospitalization and 5% require intensive care with ventilators to survive. But as we can see happening in Italy, France and the United Kingdom, the pandemic is about to expose unprecedented scarcity of U.S. medical resources. It’s a problem that will affect people regardless of insurance or social class. With U.S. shortages of coronavirus tests, swabs and personal protective equipment now, some rationing is already in effect. Very shortly, there will likely be too few critical care resources, from ventilators to ICU beds.
Studies of clinicians show that when resources are truly scarce, clinicians stay medical in our reasoning. In a 2016 PLOS One study, Swiss researchers asked 1,267 respondents who should have access to a hospital bed during an epidemic. Clinicians thought that patients who have the best prognosis — most likely to recover and are youngest — should get beds. But patients and families saw it differently — in a pandemic, most think that those who are sickest should get beds first.
Who will 'live longer'
In a series of 15 focus groups among 324 people, Johns Hopkins researchers found that over half of health care workers would use “live longer” as the first principle about who gets a ventilator in a pandemic, but barely a quarter of lay people would, preferring “survive current illness.” Few people liked a lottery, or “fewer life stages” or “first come, first served” or “value to others” as the first rationing principle.
The Code of Medical Ethics of the American Medical Association refers to the scarcity of “access to ventilators during an influenza pandemic” and rejects allocation policies based on social worth and how difficult treatment is to give, or on how much health care someone has used. The AMA also says medical need comes first — including likelihood and anticipated duration of benefit, and change in quality of life. Quality of life is best self-determined and is about what an individual values, and how an individual assures and maintains that value.
Physicians are usually focused on keeping patients alive, regardless of other factors, and often recommend and deploy all available treatment, even if the treatment is undesired or ultimately futile. In a study of 1,818 patients published in The Journal of the American Medical Association just last month, 38% of those admitted to the ICU with Provider Orders for Life-Sustaining Treatments (POLST) forms, which usually seek to limit treatment including resuscitation in case of death, received some of that treatment anyway.
As clinicians, we believe in caring and the right of all individuals to receive the care they choose. We have been well trained in the power of medical science and in the idea of providing the best care to individuals. We have not been well trained to consider community needs, the most effective or economic use of resources, or in the ethical implications of an individualistic approach when there is absolute scarcity.
Now, in this pandemic, we need that training. We need to learn and engage the principles of disaster medicine, as did the recent Italian ethics guidelines. We must rely on defined clinical ethical processes and team-based decisions, and consider fairness to others. Fairness does not mean identical treatment — it means that important community goals are served, and that the vulnerable are protected. This is not a time for individualism.
If we are to care fairly for all, scarcity will force us to consider more than pure medical need. Stewarding scarce resources is also an ethical duty. Everyone who “needs” a ventilator will not get one. When there are two patients and one ventilator, the one with the greatest survival chance — not the greatest bank account, “social value,” past contribution or place in line — should get the ventilator first. Engaging clinicians in palliative care, clinical ethics consultation and social work will be essential to help make decisions, minimize suffering, and speak with patients and families about these disastrous, necessary choices.
Scarcity of caring never has to be a medical phenomenon. Let’s get patients a ventilator who need it, want it and likely can survive to leave the hospital. Build your immunity, practice good hygiene, take a walk outside in nature safely and avoid unnecessary emergency department visits — so that clinicians will need to make as few of these heart-breaking decisions as possible.
This column is written by a group of inaugural Media and Medicine fellows at Harvard Medical School:
Dr. John La Puma, author, "Ethics Consultation: A Practical Guide" (Jones and Bartlett, 1994), Santa Barbara, California.
Dr. Adham Sameer A. Bardeesi, Beth Israel Deaconess Medical Center, Boston.
Vivian Kobusingye Birchall, Africa2U, Acton, Massachusetts.
Dr. Divya Chhabra, Columbia/Cornell New York Presbyterian Child & Adolescent Psychiatry, New York City.
Dr. C. Ann Conn, Advanced Pain Institute, Covington, Louisiana
Dr. Alia Galadari, Bordeaux, France
Gillian Gould, Ph.D., The University of Newcastle, Newcastle, Australia.
Kimberly Grocher, Weill Cornell Medicine/Fordham University, New York.
Dr. Azmatulah Hussaini, Virtua Hospital, Mount Holly, New Jersey.
Jacqueline Zhan Fraise, The Clinic, Shanghai.
Dr. Yolanda Kirkham, University of Toronto, Canada.
Dr. Brenda Kubheka, Health IQ Consulting, Johannesburg area, South Africa
Dr. Jules Lipoff, Penn Medicine, Philadelphia.
Naila Russell, MedStar Health, Charlotte Hall, Maryland.
Dr. Asha Shajahan, Grosse Pointe, Michigan.
Dr. Mary Pan Wierusz, Kaiser Permanente, Seattle.
Dr. Rose Zacharias, Orilla, Ontario.