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The Ethics of COVID-19

The Toughest Triage — Allocating Ventilators in a Pandemic.
https://www.nejm.org/doi/full/10.1056/NEJMp2005689

Fair Allocation of Scarce Medical Resources in the Time of Covid-1
https://www.nejm.org/doi/full/10.1056/NEJMsb2005114

Ted Rosen, MD commentary

Please read these articles when you get a chance. They are short and to the point. Behind the scenes, there is already or will soon be a serious ethical problem for the healthcare community. There is a critical shortage of everything needed to deal with the COVID-19 pandemic: masks, gloves, gowns, testing kits, swabs to obtain naso-pharyngeal specimens, properly trained medical personnel and hospital beds. But nothing may be more closely associated with an infected individual’s outcome than the availability of a ventilator.

Even if social-distancing measures can reduce infection rates by 95 percent, it is estimated that 960,000 Americans will still need intensive care, and a proportion of those will require a ventilator as ARDS sets in, followed by multiorgan failure. Keep in mind, by the time a ventilator is deployed, the patient has a roughly 70-90% likelihood of death; But without the ventilator, the patient will almost certainly die. However, there are only about 180,000 ventilators of all types (only 62,000 are full function) in the U.S. and, more pertinently, only enough respiratory therapists and critical-care nursing staff to safely look after 100,000 ventilated patients over three shifts every single day.

Therein lies the related ethical questions: Who gets a ventilator in the first place? Who stays on a ventilator and for how long? The first article highlights the psychological toll that making literally life and death decisions might take on those delivering frontline care, and suggests that an institutional triage group should make such decisions, rather than the bedside clinician.

The related paper discusses the four fundamental principles which may guide rationing of scarce resources in such a situation:

  1. Maximizing the benefits produced
  2. Treating people equally
  3. Promoting and rewarding societal value and
  4. Giving priority to the worst off.

Clearly, neither an individual’s person’s wealth nor ability to pay should determine who lives or dies. Similarly, neither a lottery system nor first-come/fist-serve seem logical or fair. In a pandemic, most ethicists feel that principle #1 should be the most widely employed. Maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment. Put another way, maximizing benefits by utilizing scarce resources (in this case a ventilator) 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. Maximizing benefits requires consideration of overall prognosis, which may mean giving priority to younger patients and those with fewer coexisting conditions. Nobody wants to kill Grandma by denying her a ventilator or taking her off of such support, but we might just be forced to do precisely that. This simple dictum is further confounded by the fact that the same scarce resources may be needed to insure survival of individuals who are critically ill due to non-COVID-19 diseases. What should we do with patients with heart failure, cancer, or traumatic injuries who require short-term ventilator assistance? Ethical decisions will be made, and society will need to cope with them.