If and when there are not enough ventilators for all the COVID-19 patients who need them, hospitals can expect lots of public scrutiny. Clear, consistent, and transparent policies can make the ethical rationale behind decisions obvious to everyone.
“Consistency across hospitals and health systems promotes public trust, fairness, and social justice,” says Douglas B. White, MD, MAS, director of the program on ethics and decision-making in critical illness at University of Pittsburgh School of Medicine.
White developed a model hospital policy for allocating scarce clinical care resources that has been adopted by hundreds of U.S. hospitals.1 The policy was created after several years of intensive engagement with citizens’ groups, ethicists, and disaster medicine experts. “A major strength of this allocation framework is that it avoids categorically excluding large groups of citizens while still allowing priority to go to those most likely to benefit,” White explains.
Physicians also benefit from relying on this kind of policy. “It can promote clinician morale in not feeling like you are the only one having to make these tragic choices,” White offers.
Ethicists are challenged to develop new contingency triage plans to cover the COVID-19 crisis. “However, much of the background for these plans comes from earlier influenza epidemics. For example, the H1N1 pandemic of 2009,” says Dennis M. Sullivan, MD, MA (Ethics), professor emeritus of pharmacy practice at Cedarville (OH) University.
When limited resources (such as mechanical ventilators) become scarce, “autonomy must give way to utilitarian considerations, with the goal of protecting the most lives in the at-risk population,” Sullivan says.
Ideally, clinicians in this situation turn to guidance from previously established allocation protocols. “Their objectivity helps to ensure fairness and justice in the midst of difficult decisions,” Sullivan adds.
The normal principles of medical ethics still apply, Sullivan stresses. Healthcare providers still must consider beneficence, nonmaleficence, distributive justice, and autonomy. They must do so up until the point where resource scarcity triggers a policy shift. “Therefore, it is imperative that the circumstances that invoke a resource allocation policy be well understood beforehand,” Sullivan underscores.
A definite “trigger” should signal when to shift clinical decision-making from the traditional model (based on medical principlism) to a resource-allocation model (focused on saving the most lives). “Individual hospitals within a city or region should mutually coordinate their efforts to decide when an allocation crisis is at hand,” Sullivan adds.
Clear demarcation also is necessary when the resource allocation model no longer applies. The hospital’s triage committee should look at this daily to determine whether it is time to revert to the standard ethical framework. “It is important that providers understand when there is an ‘all-clear’ moment, when normal rules of medical ethics become operative once more,” Sullivan says.
If they are faced with allocating scarce resources, ethicists might need to “decide the most ethical framework for making ‘unethical’ decisions,” says Pamela J. Grace, RN, PhD, FAAN, associate professor of nursing and ethics at Boston College.
The conflict between what is best for the individual and what is best for the larger community is the issue. “The poorest and most disadvantaged groups are likely to be disproportionately among the sickest patients, bearing the brunt of the decisions,” Grace laments.
Typically, ethicists encourage clinicians to respect patients’ autonomy. Now, utilitarian principles are coming into play. “This perspective essentially allows some individuals to be harmed if it will result in a benefit to a larger number,” Grace says.
Those with chronic illness are more susceptible to COVID-19, and chronic illnesses are disproportionately present among the poor and other disadvantaged groups. Thus, rationing decisions are more likely to negatively affect these patients. “Theories of social justice recognize that the least well-off should receive the most help,” Grace notes.
However, in a time of scarce medical and personnel resources, the focus will be on saving those most likely to survive. “Ethicists can help by reminding people to consider nuances when making allocation decisions, and keeping their biases about who or which groups are worthy in check,” Grace offers.
One argument is that allocation decisions should be made by groups instead of one individual clinician. On the other hand, a group decision could conflict with a provider’s clinical judgment. “This is one reason why ethics committees are, for the most part, advisory rather than directive,” Grace observes.
Inevitably, clinicians are going to face cases in which they disagree with what their institution’s guidance says they should do. “When clinicians cannot do what they think is the right thing, they suffer moral distress,” Grace notes.
- White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA 2020; Mar 27. doi: 10.1001/jama.2020.5046. [Epub ahead of print].