By Beatrice Brown
Critical resources for handling the COVID-19 pandemic, including ventilators and ICU beds, are quickly becoming scarce in the US as the number and density of infections continue to rise. Leading bioethicists have crafted guidelines for the ethical rationing of these scarce resources during the pandemic. On March 16, The Hastings Center published “Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic,” detailing three ethical duties for health care leaders: 1) duty to plan; 2) duty to safeguard; and 3) duty to guide. The report also contains a compilation of materials on resource and ventilator allocation.
More recently, on March 23, two insightful pieces were published in the New England Journal of Medicine: “The Toughest Triage — Allocating Ventilators in a Pandemic” by Truog, Mitchell, and Daley, and “Fair Allocation of Scarce Medical Resources in the Time of Covid-19” by Emanuel et al. These two pieces complement each other well and lay a crucial foundation for the inevitable resource allocation that clinicians and hospitals will be forced to practice in the coming weeks. As such, here, I summarize the central takeaways from these two articles while understanding their recommendations in tandem, as well as reflect on the importance of bioethics during these times of medical crisis and how the work of this field must adapt to changing circumstances.
Truog, Mitchell, and Daley explain that “Of all the medical care that will have to be rationed, the most problematic will be mechanical ventilation.” With current estimates of the number of people in the US that will require hospitalization and the percentage of those hospitalized who will need to be put on a ventilator, “the number of patients needing ventilation could range between 1.4 and 31 patients per ventilator.” Given these numbers, it is clear that some sort of allocation will have to be done — it is not so much a matter of “if,” but a matter of degree. Although patients have a right to refuse life-sustaining treatment (both ethically and legally), Truog, Mitchell, and Daley explain that “Withdrawal of a ventilator against the wishes of the patient or surrogate, however, is primarily done only in states and hospitals that permit physicians to unilaterally withdraw life support when treatment is determined to be futile.” There may be cases during this pandemic where a ventilator must be withdrawn from one patient to make the resource available to another patient, yet the authors explain that this decision cannot be justified through either a patient’s/surrogate’s right to refuse treatment nor the futility of treatment (since in the absence of a pandemic, the treatment would be continued, despite low chances of survival). Given these ethical dilemmas for clinicians, which will cause a great amount of distress, Truog, Mitchell, and Daley advocate for a triage committee, “composed of volunteers who are respected clinicians and leaders among their peers and the medical community,” that should be tasked with making these withdrawal and allocation decisions.
Emanuel et al. lay out four core ethical values for rationing health resources in a pandemic: maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off. They argue that these values yield six recommendations for allocating resources during the COVID-19 pandemic: 1) maximize benefits; 2) prioritize health workers; 3) do not allocate on a first-come, first-served basis; 4) be responsive to evidence; 5) recognize research participation; and 6) apply the same principles to all COVID-19 and non-COVID-19 patients. Most relevant here, within recommendation 1, Emanuel et al. argue that removing a patient from a ventilator to provide it to others in need is justifiable to maximize benefits during a pandemic. They state that they support “many guidelines [that] 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.” The authors thus provide the ethical justification for the tragic decisions that clinicians will have to face as articulated eloquently by Truog, Mitchell, and Daley. Furthermore, Emanuel et al., like Truog, Mitchell, and Daley, recommend that the burden on individual clinicians be mitigated by guidelines that are developed and implemented by various bodies in their respective institutions, such as triage officers or committees of experienced physicians and ethicists.
Often, the work of bioethics is guided by the four principles laid out by Beauchamp and Childress in their seminal work Principles of Biomedical Ethics: 1) respect for autonomy; 2) beneficence; 3) non-maleficence; and 4) justice. Times of crisis, though, require that we be flexible in our application of these principles. In the absence of a pandemic, we may think the removal of a ventilator without the patient’s/surrogate’s consent and without treatment being futile to be unthinkable: it would violate the patient’s autonomy, as well as the principle of non-maleficence. But during a pandemic, the violation of these two principles for any particular patient may be warranted when we are maximizing benefits, as called for by Emanuel et al., so long as the requirements of justice are fulfilled. By maximizing benefits, we strive to fulfill the principles of respect for autonomy, beneficence, and non-maleficence for the greatest number of patients, while saving the greatest number of lives in a manner that accords with the principle of justice. While a focus on individuals in the absence of a pandemic is appropriate in the everyday work of clinical bioethics, a focus on populations is necessitated by the presence of a pandemic. These times of crisis require our wholehearted commitment to the principles of bioethics and to the well-being of a population. No doubt, this is a difficult task when it comes to rationing — clinicians involved will undoubtedly feel moral distress, and this moral distress must be mitigated. To truly fulfill the aims of bioethics for generations to come, we must adapt to ensure these scare resources are ethically allocated, and we must learn from these moments of scarcity and worry to be better prepared for the future — both the pieces by Truog, Mitchell, and Daley and by Emanuel et al. fulfill these worthwhile goals.