A 12-year-old patient and a 78-year-old patient have COVID-19. Both require mechanical ventilation, but only one ventilator is available. The older patient is an infectious disease physician who has experience treating patients with COVID-19, and his research is in COVID-19 vaccine development. Who should get the ventilator?
As the number of COVID-19 infections continue to rise, health care providers may soon be asked to consider the question posed in the case above. As pediatric cardiologists and bioethicists who practice in the United States and care for sick children on a daily basis, we have not yet had to grapple with decision-making when resources are limited.
These questions are no longer abstract. Italy is already grappling with limited resources consequent to the COVID-19 pandemic. A thoughtful ethical perspective is helpful in providing guidance when questions arise such as: if the number of patients who need high level of support, such as a ventilator, exceeds the number of actual ventilators available in the hospital, which patients should be prioritized? Who will decide which patients will get prioritized?
In most circumstances, patients in the U.S. can usually be transferred to another hospital if a hospital is full or does not have enough ICU beds. For example, during influenza season, hospitals coordinate within their community to ensure that care is provided to everyone who needs it. But what if the local hospitals are also full?
In 2012, the Institute of Medicine (IOM) issued a multivolume report setting up a framework for crisis standards of care, a project undertaken in response to the 2009 H1N1 pandemic. Such standards were defined to be a “substantial change in the usual health care operations and the level of care it is possible to deliver … justified by specific circumstances and … formally declared by a state government in recognition that crisis operations will be in effect for a sustained period.” The series outlines what is likely to happen in situations where there is a crisis (i.e., major natural disaster, pandemic etc.) and how states and communities should prepare.
The report also includes what ethical principles should be used if rationing of resources is needed and provides a framework to guide the public health infrastructure. It is important to not only evaluate what is ethically permissible in the setting of scarce resources but also what is ethically unacceptable, regardless of scarce resources.
Specifically, the IOM report outlined the following key ethical principles to apply when resources are scarce: fairness; the duty to care; the duty to steward resources; transparency; consistency; proportionality; and accountability.
Fairness does not mean that everyone is treated identically. Fairness requires that when there are differences in treatment, those differences should be based on appropriate differences between groups of people. For example, if a community decides to give preferential treatment such as a vaccine that is in short supply, the priority “should stem from such relevant factors as greater exposure or vulnerability and/or promote important community goals, such as helping first responders or other key personnel stay at work.”
Health professionals have a duty to provide care to the individual patient, but they should not simultaneously be asked to make resource allocation decisions that are intended to benefit the group rather than an individual. Health professionals may also face competing obligations such as caring for a patient at work versus caring for a family member at home or taking care of small children if school is closed. The IOM report states that a robust disaster response system should provide support for workers to “meet their personal obligations so they will also be able to meet professional obligations.”
Health care professionals and institutions have a duty to steward scarce resources so that they are not wasted. For example, health care providers should not provide face masks to those who ask for them when they are not warranted. They should also not use these resources for themselves unless it is clinically indicated.
The IOM report called for a public engagement process in order to create ethical policies that reflect a community’s values. This is a thorough process with input from community members, stakeholders, public health officials and professional groups that goes through many iterations. Many states have used their public engagement process to develop a CSC plan that addresses the possibility of an influenza pandemic or other scenarios where health care resources would be expected to become scarce.
It is important that different hospitals in the same affected area treat patients similarly in order to promote fairness. For example, if patients with mild symptoms are soon able to receive testing for the virus at one hospital, other local hospitals should be made able to offer the same testing.
Burdens such as school closures or quarantines should be proportional to the risks and scale of disaster. These should be done only when clear benefits to the community are expected from the burden. In Seattle, where the U.S. outbreak is the largest, many schools have been closed, which is burdensome but likely commensurate with the current risk of transmission. Finally, individuals within the health care system should remain responsible and accountable for their actions.
The principles outlined by the IOM are meant to be used by states to engage the local community to set priorities and goals. In Illinois, for example, the Illinois Department of Health Catastrophic Incidence Response Annex, published in 2018, outlines the state’s disaster response system and includes an ethical analysis of resource allocation during a catastrophic incident that requires crisis standards of care.
The document provides helpful advice to health care providers such as: “Whenever possible, avoid making definitive decisions (such as who to treat/not to treat or triaging to palliative care) alone, instead rely on pre-defined processes and/or team-based decisions.” It also specifically recommends prioritizing specific workers only when it “clearly supports critical infrastructures and the health of the population.”
Making ethical decisions in a time of crisis or limited resources may not be easy for many health care workers. The “right” decision is often not obvious. In these situations, health care workers are encouraged to use the principles elucidated by the IOM and to ask for help from those who have already considered these situations, which are now no longer hypothetical. Public health officials should promote transparency and use their specialized knowledge and skills to ensure that public trust is maintained in a changing situation. Health care providers will look to a well-organized response that is grounded in science and ethics as the U.S. responds to COVID-19.
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