Nowhere have the ethical conundrums faced by doctors during the coronavirus pandemic been more clearly sketched than in Italy. The whole country is in lockdown after a slow start on quarantine measures allowed the disease to spread quickly. For some reason, perhaps just statistical, the death rate there appears to be far higher than in China or other countries – about 5%, compared to a world rate of about 3.4%.
However, what is clear is that Italy’s hospitals are struggling under the load of seriously ill patients. More than 1000 have died and there are not enough ventilators to treat patients with acute breathing difficulties. This has prompted an extraordinary call by the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) to implement a system of triage, or healthcare rationing. If a patient appeared too sick to benefit from a ventilator, doctors would let him die so that they could care for other sick patients. Out the window goes the “first in, first served” principle. In a time of “castastrophe medicine”, they argue, utilitarian principles must be followed.
"It may become necessary to establish an age limit for access to intensive care. This is not a value judgment but a way to provide extremely scarce resources to those who have the highest likelihood of survival and could enjoy the largest number of life-years saved…
"This is informed by the principle of maximizing benefits for the largest number. In case of a total saturation of resources, maintaining the criterion of 'first come, first served' would amount to a decision to exclude late-arriving patients from access to intensive care."
In other words, patients over, say, 80, or patients who have other medical conditions like diabetes or heart failure, would be left to die.
At the moment this is only the gloomy prognostication of a handful of utilitarian-minded doctors. But the argument will surface again and again if conditions worsen.
A bioethicist in Milan, at the heart of the epidemic, Michele Aramini, of the Catholic University of Milan, told Avvenire:
In exceptionally serious moments such as these, one can deviate from normal practice but without ever losing sight of the general horizon. I mean that first of all every effort must be asked and made to increase the places in the wards.
If this is not enough, doctors must evaluate the situation case by case in multidisciplinary teams, and not alone with the yardstick of criteria established a priori. All people always retain the right to be treated.
However, extreme measures must be suspended as soon as possible in order not to create new substitute practices for those which have always inspired the conduct of specialists.
And, writing in the Sydney Morning Herald, bioethicist Xavier Symons (also deputy editor of BioEdge, emphasised that a utilitarian, however useful in emergencies, should not reinforce stigma and discrimination:
But while rationing on the basis of capacity to benefit may be inevitable, health authorities – and, indeed, society generally – have a grave duty to avoid endorsing ageist and ableist prejudice in the discourse surrounding the COVID-19 outbreak.
Michael Cook is editor of BioEdge
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