Corona Daily 451: The Doctor’s Dilemma: Part Final

Yesterday, I talked about the worldwide rationing of masks, tests, protective gears, ICU beds, ventilators, medicines. (Vaccines when they appear will also need to be rationed.) As the numbers shoot up, the health care fraternity is increasingly forced to make life-death decisions.

In their paper “Fair allocation of medical resources in the time of Covid-19”, bio-ethicist Dr Ezekiel Emanuel and his colleagues make important recommendations. This medico-ethical framework is well worth considering for any hospital in any country.

Saving lives and saving years of life: Assuming life expectancy to be 80, saving one 20-year old is more utilitarian than saving two 60-year olds. The two older patients will lose 20 years each, whereas the younger patient will live another 60 years if saved. Hospitals should decide the balance between lives and life-years and consistently apply it.

(Of course, this approach can’t take into account the economic or mental quality of the patient’s life. If that young 20-year old has a miserable life, he may have another 60 years of misery. Such considerations are beyond the scope of ethics in medicine.-R.)

Doctors, nurses top priority: Medical front line workers and first responders (ambulance) fighting covid-19 should get top priority irrespective of their age or condition. A single doctor or nurse saved may save another hundreds or thousands of lives. The paper calls it their instrumental value. Similarly, if there is a vaccine developer, saving her before others is critical. Besides being fair, this strategy boosts the morale of the medical staff.

Triage officers and lottery: The paper opposes a first-come-first-served policy by pointing out several shortcomings. If prognosis is similar across patients, random selection or lottery is suggested. Wealth or fame should not be considered. (The Trumps and Johnsons of this world will anyway manage on their own). The system should be transparent – patients should be informed about the rules in advance.

Removing a patient from the ICU or ventilator to make space for another is ethical; it is not killing, and doesn’t require a patient’s consent.

A key suggestion is to appoint a neutral triage medical officer or a committee, to take these decisions. Making life-death choices for patients they are treating would traumatize the doctors. (Unfortunately, front-line doctors are reportedly making those decisions in many countries, including Italy).  

Priorities differ for vaccines: Health workers remain at the front of the queue for vaccines. Older people can be prioritized next.  Though a younger person may be first given a ventilator (curative), a vaccine in shortage (preventive) should be given to old people first.

Don’t distinguish between Covid-19 patients and others: The health care system that is strained by Covid-19 is either refusing to entertain other patients, or other patients are reluctant to visit labs and hospitals. Several pregnant women are delivering at homes, despite the inherent risks. The paper suggests applying the triage rules equally for Covid-19 and non-Covid-19 patients. The lives of patients suffering from other diseases are as valuable as those inflicted with covid-19.

Ravi