Challenging times: COVID-19, Scarce Resources and Difficult Allocation Decisions
Sivan Tamir
Policy Counsel and Senior Research Fellow, Israel Tech Policy Institute; Research Fellow, International Center for Health, Law and Ethics, Haifa University
This time of turbulent pandemic, sees society in a state of anxiety and confusion, waiting for this epidemic surge to pass. During routine periods, medical technologies allow practitioners to provide much-needed healthcare, ameliorate health and quality of life and save lives, all through prevention, diagnosis, monitoring, treatment, and care. In times of a public health crisis, the harsh reality of dwindling medical staff (due to suspected/verified infection), coupled with limited availability of some medical technologies and ICU beds – compels medical practitioners to determine fates.
Lessons learned thus far from the Chinese experience, indicate that about 5% of patients infected with COVID-19, suffer from critical illness and require ventilation support. This puts the main focus of the present battle, on ventilators – designed to assist or replace respiratory functions. Estimates suggest that in the United States, for instance, approximately 960,000 people will need ventilators over the course of the COVID-19 pandemic, while current stock stands at less than 200,000 ventilators. It appears that other countries face a shortage of a similar scale, ranging from thousands to tens of thousands of ventilators.
Ventilator scarcity prompts governments to boost purchase and manufacturing of ventilators, initiate massive repair of non-functioning ones, and harness tech companies' skill and ingenuity towards creative endeavours of adapting other ventilator designs into ICU-standard ventilators, and printing 3D ventilators and necessary components. A shared feeling of urgency and a sense of solidarity, have spurred academia and tech companies to venture various Open Source Ventilator projects. However, it is widely-assumed that albeit such exceeding efforts – most countries affected by the virus will exhibit an unprecedented shortage of ventilators. China, Italy, Spain and France, have already met such dire shortage, with the latter three still desperately struggling with it. The later supply of further ventilators will meet a shortage of qualified technicians and respiratory therapists.
In a reality of scarce ICU resources – relevant medical professionals will be put in extremely difficult positions, where having to make gut-wrenching allocation decisions. As demand exceeds capacity, decisions guiding triage and allocation will be based on prioritization of patients, according to an agreed framework of ethical principles.
In such times, while some support adherence to the customary principles of first-come, first-served (based on order of arrival, reflecting the physician's fiduciary duty towards one's currently-treated patients), or sickest-first, others take the view that these should make way for other crisis-specific principles. It is essentially a call for relaxation of just, equitable, and uncompromising values, typical during non-crisis periods, in favour of pandemic-adapted principles. These principles, intended at minimising the physical harm of pandemic, by maximising the outreach of beneficial care, occasionally call upon physicians to shift the fiduciary duty towards their currently treated single patient – to one towards a more abstract (concept of) public benefit. Such shift seems to run against the core of physicians' medical education and prove challenging to some dicta of the Hippocratic Oath.
Various such principles have been suggested for adoption. Most of them express a utilitarian approach, seeking to ensure maximization of net benefit to the public. These are the most prominent candidate principles to employ in ICU resource allocation predicaments:
§ Greatest good for greatest number – This principle calls for the distribution of scarce ICU resources in a way that maximizes lives saved, essentially excluding from intensive care severely ill patients requiring significant resources and attention, for the benefit of multiple patients that are less ill and require fewer resources.
§ Saving the most (number of) lives, as well as the most life-years – A more nuanced version of the former principle, reflecting the importance of responsible stewardship of resources. Its emphasis on most life-years saved entails a preferential treatment of younger patients, who stand to benefit more years if saved.
§ Saving those with the best odds of survival – Another principle, seemingly instrumental for the success of the former one (the greatest number of lives + most life-years), entailing a prognosis-dependent prioritisation, excluding poor-prognosis patients from access to ventilator support.
This principle evokes another principle, that of Fair chances versus maximization of best outcomes. The principle advocates concentrating efforts on patients with the best chances of survival, at the expense of those with merely a fair chance of doing so, intentionally excluded from ventilator access although standing a reasonable chance to survive.
It appears from the literature, that the first three above-cited principles, rather enjoy a consensus among both scholars and medical practitioners.
Additional principles include:
§ The Life cycle principle – While being an egalitarian principle at core, by granting every individual an equal opportunity to live through all stages of life (from infancy, through childhood and adolescence – to adulthood), it essentially gives relative priority to younger patients who have yet to experience other, more advanced phases of life, over older patients. Its application is limited to prioritization cases, where the patients significantly differ in age from one another. This principle is criticized for reflecting ageism, and its application may, in fact, result in inequality.
§ Social worth – A principle evaluating a patient's value to society, in terms of past and present contribution through professional qualifications or social participation, in the broad and in the instrumental sense. Namely, the principle acknowledges, promotes and rewards instrumental value, by prioritising patients who are health workers, particularly physicians, nurses and technicians specialized in intensive care, anesthesiology, and palliative care; epidemiologists; and professionals keeping critical infrastructure functioning. This principle has been criticized as problematic, since it assigns a different value to the lives of essentially equal persons, on the merits of professional qualifications. In addition to being an unequal prioritisation principle, it is also criticised for being reductive – portraying the professional skills of a person as her total contribution to society.
§ Treating people equally – A background principle assigning same worth and warranting equal treatment for the following patient subgroups: patients with similar prognoses, or of the same age group (both with/without underlying comorbidities – that is, having more than one disease or condition in the same patient at the same time); patients estimated of having equal chances of recovery; COVID-19 patients and patients whose need for ICU resources is unrelated to COVID-19. Equal treatment could arguably be guaranteed through first-come, first-served prioritisation, or random (lottery-like) allocation.
Any principle adopted, reflects a variety of considerations, sets of values and beliefs. Every principle is faulty in some respects and constructive in others. Just as no model can accurately predict the magnitude and persistence of the pandemic outbreak – so too can no single trustworthy principle exist that justly treats all patients by offering equal (or any) chances of survival, all while allowing the health system to remain functional throughout the crisis. To remedy that deficiency to some extent, it would be prudent to adopt a widely-accepted set of complementing, or hierarchical, allocation principles.
Having determined that, a second-order consideration comes to mind: one, concerning the pragmatic challenge of informing all relevant physicians about the selected ethical framework of allocation principles, and ensuring its effective implementation in a uniform, consistent manner throughout the state's hospitals, all in a dire situation of a pandemic outbreak. The current non-harmonised implementation of different principles across hospitals in a given country is problematic and may be difficult to justify.
As for who ought to make such decisions – it is imperative that where there is sufficient time (recognising that typically speed is of the essence), sensitive allocation decisions will not be made by the treating physician. Arguably, failing to do so will entail an emotional burden as well as a conflict with one's fiduciary duty towards her patient (say, where a newly-arrived patient is competing for the same ICU resources, with an earlier-admitted patient). Suggested alternative decision-making mechanisms include a triage officer, a designated ad-hoc ethics committee comprised of senior physicians and a clinical ethicist, a three-wise-men council, etc. All of these commonly share the desire to distance the treating physician from such emotionally tolling decisions.
Lastly, here are some of the ethical-policy-level effects of our presently grim reality: Italy, in the face of conditions of immense distress, aiming to maximise the benefits for the greatest number of people, has reluctantly resorted to employing allocation principles based on age limit, saving the most life years, and best odds of survival. This web of principles sadly entails ageism.
In the U.S., in its desperate hour of acute scarcity of ICU resources (human and machine, alike), some hospitals are now considering the adoption of a previously unimaginable policy – that of universal do-not-resuscitate orders for COVID-19 patients, regardless of the patients' wishes or those of their family members. Implementing such a policy would differentially treat COVID-19 and non-COVID-19 patients, equally requiring life support by mechanical ventilation, due to the infection risk to the insufficiently protected medical staff, in case of the former patients. Other hospitals stop short of implementing such a sweeping COVID-19-specific policy, yet consider overriding the wishes of the COVID-19 patient or family members, on a case-by-case basis. However, considering the inconceivably high toll of COVID-19 victims, putting Italy, the U.S. and other COVID-19-ridden countries, such as France and Spain, at an impossible position – no judgment is intended here.
Furthermore, some scholars even endorse the idea of actively withdrawing ICU care, including ventilators – from patients already occupying them, for the sake of patients with better prognosis. They deem it a justifiable action, one that supports the maximizing benefits principle. Such action, notwithstanding the weighty moral and ethical dilemmas involved, would be explicitly prohibited under the Israeli Dying Patient Act of 2005.
To conclude, it seems that the "desperate times call for desperate measures" adage, has never been more relevant or true. Human society will prevail, if such measures will be taken in the most limited manner, over the shortest possible period of time and with respect to the minimal number of patients.
Sources:
Ethics Subcommittee of the Advisory Committee to the Director, United States Centers for Disease Control and Prevention, "Ethical considerations for decision making regarding allocation of mechanical ventilators during a severe influenza pandemic or other public health emergency", Atlanta: Centers for Disease Control and Prevention; 2011 (www.cdc.gov/about/pdf/advisory/ventdocument_release.pdf).
Douglas B. White, Mitchell H. Katz, John M. Luce, and Bernard Lo, "Who Should Receive Life Support During a Public Health Emergency? Using Ethical Principles to Improve Allocation Decisions", Ann Intern Med. 2009 January 20; 150(2): 132–138.
Centers for Disease Control and Prevention, "Interim Updated Planning Guidance on Allocating and Targeting Pandemic Influenza Vaccine during an Influenza Pandemic"; https://www.cdc.gov/flu/pandemic-resources/national-strategy/planning-guidance/index.html
Taylor Kain and Robert Fowler, "Preparing intensive care for the next pandemic influenza", Critical Care (2019) 23:337; https://ccforum.biomedcentral.com/articles/10.1186/s13054-019-2616-1
Ezekiel J. Emanuel, Govind Persad, Ross Upshur, Beatriz Thome, Michael Parker, Aaron Glickman, Cathy Zhang, Connor Boyle, Maxwell Smith, and James P. Phillips, "Fair Allocation of Scarce Medical Resources in the Time of Covid-19", NEJM (March 23, 2020); https://www.nejm.org/doi/full/10.1056/NEJMsb2005114
Department of Health [UK], "Responding to pandemic influenza – The ethical framework for policy and planning" (November 2007); https://www.gov.uk/guidance/pandemic-flu
Naomi Xu Elegant, "Ventilators are key to preventing coronavirus deaths—but does the world have enough of them?" Fortune (March 17, 2020); https://fortune.com/2020/03/17/coronavirus-ventilator-shortage/
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Emma Reynolds and Eoin McSweeney, "'Desperate' shortage of ventilators for coronavirus patients puts manufacturers on wartime footing", CNN Business (March 19, 2020); https://edition.cnn.com/2020/03/19/business/coronavirus-ventilators-manufacture-intl/index.html
James Temple, "An open-source ventilator design has been submitted for fast-track approval", MIT Technology Report (Mar 24, 2020); https://www.technologyreview.com/s/615374/an-mit-team-hopes-to-publish-open-source-designs-for-a-low-cost-ventilator/
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SIAARTI [Italian Society for Anesthesia Analgesia Resuscitation and Intensive Care], "Clinical Ethics Recommendations for Admission to Intensive Care and For Withdrawing Treatment in Exceptional Conditions of Imbalance Between Needs and Available Resources", Translation: Joseph A. Raho (6.3.2020).
Ariana Eunjung Cha, "Hospitals consider universal do-not-resuscitate orders for coronavirus patients", The Washington Post (March 26, 2020); https://www.washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-resucitate/