The impact of the COVID-19 virus is straining health systems around the world, raising questions and forcing decisions regarding how best to care for those who are sick.
A little over three months ago, this new strain of coronavirus began to draw the attention of the world as it rapidly spread through the Wuhan province of China. Today, it is in almost every country on the planet.
This epidemic has grabbed our attention because we know so little about the nature of the virus. We do know the virus spreads rapidly and attacks the respiratory system.
We also know infected patients who are critically ill require a lot of medical resources to support them, and health care workers are running low on the equipment they need to protect themselves and slow the spread of the disease.
A growing shortage of ICU beds, ventilators and personal protective equipment (PPE) has many asking about the allocation of health care resources.
Last week, we saw physicians in New York City use a single ventilator on multiple patients at the same time.
These events have forced society to think about the allocation of scarce resources.
The Washington Post, New York Times, Fox News and CNN have all published articles asking about the allocation of ventilators and even possible blanket “do not resuscitate” orders.
For many, these are new questions. How do we decide who gets a ventilator?
The truth is these questions are not new. They are as old as Hippocrates and the Babylonian physicians.
Epidemics have been fought since the dawn of human civilization. As a society, we have not been forced to face these types of questions since the Spanish Flu epidemic of 1918.
Since the H5N1 flu pandemic in 2005, public health experts have been working with bioethicists to think through how to allocate resources during a global pandemic. The 2009 H1N1 pandemic made such guidance all the more vital.
The World Health Organization, Centers for Disease Control and Prevention and the Veterans Health Administration all have exhaustive manuals and guidebooks about the topic.
These manuals construct different guidelines and patient assessment criteria for resource allocation.
One of the most used is the VA’s “Meeting the Challenge of Pandemic Influenza: Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health Administration.”
The model recommended by the VA attempts to remove social worth criteria from the triage process by adopting a utilitarian approach coupled with some overriding deontological values. In short, patients need to be triaged for survivability.
If a patient is likely to die regardless of maximum therapy, the health system might need to refer that patient to palliative medicine and redirect equipment to another patient.
In addition, triage specialists need to think through the length of therapy a critically ill patient might need.
If a critical patient is projected to spend a month on a ventilator, it might be better to use that same ventilator on someone who would need fewer days hoping to then use it again on a third patient.
This strategy maximizes the number of people who can be helped.
In addition, the VA has recommended exclusionary criteria during a shortage. All exclusions are based on critical disease processes and are expected to not survive regardless of maximum therapies.
It is important to note the process is designed to avoid forcing the triage specialist to make nonmedical value judgments associated with a patient’s age, gender, race or social worth.
We do not want a situation like Italy where patients over a certain age were denied ventilators. A blanket statement like this is ageism.
While it is true the average older patients tend to have more comorbidities (“two or more disorders or illnesses occurring in the same person”) than younger patients, the severity of comorbidities should dictate allocation, not a single demographic.
It is human nature that when faced with a crisis, we make knee-jerk responses and often forget to consult our personal or societal values.
Therefore, it would behoove ethicists, denominational leaders and theologians to familiarize themselves with these approaches as the VA is not alone in its thinking.
Similar approaches to the VAs are used in over a dozen states and countless health systems. Some approaches add more social value judgments than others.
While no one wishes for a shortage of equipment or staff, the possibility is real. Therefore, we need to ask the difficult question of values, such as, what values did the government or health system use to establish their plan?
During a crisis, vulnerable groups always are forgotten or overlooked. Groups that might become vulnerable during a crisis are patients with mental health issues, people recovering from addiction, individuals suffering from dementia or delirium, the older population and those in poverty.
If our society is forced to make these difficult decisions, we as the moral community need to evaluate how and why decisions were made in order to ensure vulnerable populations are not dismissed, overlooked or discriminated against.
Senior Staff Chaplain and Clinical Ethicist at the Baptist Health Medical Center in Little Rock, Arkansas.
