By Kelsey Berry
Much of the recent Ebola coverage has brought to the forefront principles of disaster triage and served as a reminder of the inescapability of rationing health care resources. A piece in The New Yorker recently highlighted the plight of pregnant women and their apparent exclusion from standard Ebola wards in Sierra Leone. Professor and Ethicist Nir Eyal at Harvard Medical School was quoted discussing the role of disaster triage guidelines in allocating resources for Ebola in the case of pregnant women.
Pregnant women have long been identified as more vulnerable to viral infections than other healthy adults, due perhaps to immune system changes occurring naturally during pregnancy. This may have accounted for the increased mortality rate among pregnant women during the 2009 H1N1 influenza pandemic in the US (17% in pregnant women vs. 0.02% in the general population), and it may impact Ebola survival rates as well. A smaller 1995 Ebola outbreak in Kikwit, Zaire had a case fatality rate among pregnant women of 93%, and anecdotal accounts from the current epidemic in Sierra Leone state a 100% case fatality rate. Recent figures from West Africa put the case fatality rate in the general population at 70%. These statistics, among other concerns for resource utilization, lead to an ethical dilemma: whether and how to allocate scarce resources to pregnant women in the present ebola epidemic in West Africa.
If the mortality rates from Kikwit are accurate, Dr. Eyal notes that it means that, “what’s needed to justify giving regular priority to a pregnant woman is a willingness to allow six other people to perish to save her.” But, he notes, the permissibility of excluding pregnant women is sensitive to these rates; if they are wrong, than so too may be triaging pregnant women last.
Of course, only if we are solely concerned with maximizing good outcomes given a limited budget would the comparison of expected survival rates be fully determinative of our rationing scheme. Differences in need and urgency also justifiably impact allocation decisions between individuals. Balancing these dimensions is complex, and we can only guess at how health care professionals are making these difficult determinations in Sierra Leone. However, at least in the case of pregnant women, it seems that prospects for survival are given significant weight in triage decisions. This seems partially intuitive — given one resource to be allocated between two candidates, it seems reasonable to allocate it to the individual who has at least some chance of benefiting from it. And here, it seems that pregnant women are less likely to benefit (at least in terms of survival).
However, I think we should investigate the reasons for the high mortality rate among pregnant Ebola patients before using it to justify differential priority for resource allocation. One reason, given above, is that an effect of pregnancy (immunosuppression) may cause pregnant women to be less responsive to the available care. On this view, we could think of pregnancy as a temporary disability, the presence of which makes survival less likely and undermines what can be accomplished with treatment. Many would argue that allocating on the basis of disability constitutes invidious discrimination. In a refined view, Francis Kamm identifies the causal connection between a disability and a treatment’s reduced capacity to bring about a good outcome “linkage”. She claims that when choosing between two patients for life-saving treatment, one disabled and the other non-disabled (holding need and urgency constant), one could justifiably select the non-disabled patient on grounds that his survival prospects are better – even when linkage is present – and this would not count as invidious discrimination. Though I have a few misgivings about this view, Kamm offers plausible arguments supporting it (which I will not go into now – though take a look at her recent Bioethical Prescriptions, Ch. 21, among other pieces).
If instead the deplorable survival rates for pregnant women is not due entirely to a natural inequality in immune response, but instead due to an unjust institutional arrangement that prevents pregnant patients from achieving prospects equal to those in the general population (and that pregnant patients would have otherwise been able to achieve absent the injustice), we have a different set of concerns on our hands. Whether judgments about allocation favoring the non-disabled patient given linkage of this sort remain justifiable, is an open question.
What this brief discussion highlights is that, even in cases where individuals have equal need and urgency, comparing survival prospects to make outcome-sensitive allocation decisions requires a more refined investigation of the underlying circumstances. There are several other ethical considerations that should also play into judgments on how to triage pregnant women, and that I was fortunate to discuss with Dr. Eyal a few weeks ago – I will leave these to the comments section to raise.
Note: I refer to pregnancy as a “disability” with caution, and do so only to emphasize its apparent relationship to worse prognoses for Ebola patients.