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The Ethical Way to Ration Coronavirus Hospital Care

The Ethical Way to Ration Coronavirus Hospital Care

Thursday, 26 March, 2020 - 06:45

If Covid-19 spreads as fast as experts predict, the memories that will stick with Americans years down the road will be of desperately ill people turned away from hospitals.

The US has no capacity to cope with even a small surge in intensive care patients. There will be shortages of health care workers and equipment — especially respirators, which ran far short of the need in Italy.

But even under these terrible circumstances, there are ways to be as fair as possible about who receives care.

The public won’t tolerate rationing decisions made on the spot by governments, hospitals or hospital administrators — these will seem arbitrary and unfair. Coordination and uniformity across hospitals is critical, says Nir Eyal, a professor of bioethics at Rutgers University who has studied healthcare rationing. The alternative to a uniform plan is arbitrariness or a system where the people with the most money or the sharpest elbows get the best care. We need to allocate resources in a way that saves the most lives in the fairest way.

What’s needed are rules based on scientific and ethical principles, and put forward after long deliberation. Fortunately, the World Health Organization already has guidelines for dealing with healthcare shortages during a pandemic — drawn up in 2006, in response to the threat that an extremely deadly strain of bird flu would spread from person to person. These guidelines took weeks of collaborative work between scientists and ethicists.

“Now it’s as if there’s amnesia” says Daniel Wikler, a Harvard University professor of ethics and population health, who helped craft guidelines for the World Health Organization and the state of Massachusetts. Similar guidelines, he said, were created at a national level. But because bird flu later appeared to be a dud, he says, the world forgot about the plan.

It’s time to remember. The bird flu plan was aimed at a viral threat very much like the one we face now. That deadly virus, H5N1, jumped from birds to a few humans in the early 2000s. Some aspects of the threat were different, but the ethical principles are the same. Shortages of ICU beds or ventilators will mean that even the “least bad course of action will be awful,” he says. But we still have to implement what’s least bad.

The guidelines created for bird flu consider all lives equally valuable and seek to maximize the number saved, Wikler explains. Under those guidelines, patients would be divided into broad priority categories. In the first would be those whose deaths would cost other lives – health care workers, firefighters, police, and the people who keep up essential public works such as the water supply.

The next division is between the sickest and those likely to recover. Normally, the sickest people would be given first priority for intensive care treatment, but in a pandemic, priority should go to those whose lives are threatened, but who have a good chance of pulling through if treated. Those people would have priority over sicker people who have very little chance to survive even with medical care.

Those classifications won’t be enough, Wikler says. If there’s a big surge in cases, hospitals might see multiple people in the same category and beds for only half of them. If that happens, people should be chosen through random lottery. There’s more than ethical value in this approach: In scientific studies, randomization is a tool used to learn what works and what doesn’t. It sounds cruel to say we’re using people as guinea pigs, he says, but doctors can save lives down the road by learning as much as possible as they go along.

Nobody knows how big this pandemic will get or how US efforts at social distancing will help. But we do know that even in the best-case scenarios, hospital beds are scarce. The US has 12% fewer total beds than it did in 1975. According to a Kaiser Family Foundation study, quoted in the Wall Street Journal, there are 2.8 beds per 1,000 people in the US, while other developed countries such as Germany, Australia and Japan have an average of 5.4 beds per 1,000 people.

In the same WSJ piece, Harvard epidemiologist Mark Lipsitch has estimated that if things progress the way they did in Wuhan, the US will need three times as many ICU treatments as the number of ICU beds that are available.

So Americans need to plan for rationing but also seek to minimize it, though efforts to build field hospitals, or temporary hospitals in existing buildings such as hotels. The Chinese built a giant new hospital in the midst of their crisis. And the drastic changes in our lives with social distancing could help minimize a surge in cases. The object is not only to save ourselves but to save others, and save the principles of community and fairness that hold us together.


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