As the US braces itself for an exponential increase in COVID-19 cases, several US doctors and ethicists have published an article arguing forcefully for utilitarian healthcare rationing.
The new article -- published in the New England Journal of Medicine on Monday -- deals with the complexities of the current COVID-19 crisis in the United States, and considers how scarce resources such as ventilators and vaccines should be allocated in light of our current understanding of the disease and pandemic modelling.
The lead author of the article, academic and influential healthcare policy commentator Ezekiel Emanuel, has previously written at length about the allocation of scarce lifesaving resources, and, specifically, the allocation of vaccines in a pandemic.
In this article, Emanuel and colleagues argue that healthcare rationing in the COVID-19 pandemic is inevitable: “...unless the epidemic curve of infected individuals is flattened over a very long period of time — the Covid-19 pandemic is likely to cause a shortage of hospital beds, ICU beds, and ventilators”.
The real question, the authors suggest, “is not whether to set priorities, but how to do so ethically and consistently”.
But what should our ethical framework for resource allocation look like?
“In the context of a pandemic, the value of maximizing benefits is most important”, the authors argue.
Where we are allocating ventilators, for example, we should prioritise those patients who have the greatest likelihood of survival if given access to a ventilator, but who would be unlikely to survive otherwise. This would likely mean prioritising younger patients:
“Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment. Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life.”
The authors also note that rationing may mean withdrawing treatment from some patients who have a poorer prognosis than others.
“Because maximizing benefits is paramount in a pandemic, we believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission”.
The withdrawal of treatment is not the same as killing, they argue:
...many guidelines agree that the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent. We agree with these guidelines that it is the ethical thing to do.”
The authors also consider how we should allocate a coronavirus vaccine, should one be developed. The moral calculus is inverted in this case, they suggest. While younger, healthier patients should be given priority access to ICU, older patients with chronic illnesses should be given priority access to a vaccine:
“...younger patients should not be prioritized for Covid-19 vaccines, which prevent disease rather than cure it, or for experimental post- or pre-exposure prophylaxis. Covid-19 outcomes have been significantly worse in older persons and those with chronic conditions. Invoking the value of maximizing saving lives justifies giving older persons priority for vaccines immediately after health care workers and first responders”.
In an op-ed in the New York Times, Emanuel and two co-authors of the study stressed the importance of high-level ethical reflection on pandemic rationing, and warned of the risk of front line clinicians making “well-intentioned, but ad hoc choices under extreme pressure”.
But some commentators are concerned that the high-level ethical reflection so far has missed some of the most serious ethical challenges presented by the COVID-19 crisis. In a letter to the Times, Former Democratic Congressman Tony Coelho said some medical professionals were trying to marginalize seniors and the disabled:
“Even in a crisis, self-designated “experts” are trying to marginalize people with disabilities and seniors. Instead, let’s develop policies that “flatten the curve” and prepare to treat all those who may find themselves vulnerable to Covid-19”.
Xavier Symons is Deputy editor of BioEdge