Medical school didn’t teach me how to decide which of my patients should live and which should die if it becomes rationing of medical equipment or treatment becomes necessary. But I’ve spent most of my time recently planning for the possibility that my colleagues and I may need to make precisely that decision.
Reports have emerged from Italy about doctors choosing who would receive lifesaving medical care and who would not. New York’s governor, Andrew Cuomo, pleaded this week for 30,000 ventilators, three times the 10,000 ventilators currently available. As I write this, there are more than 80,000 confirmed cases of Covid-19 in the United States. If the number of people with severe cases outstrips the number of ventilators, will doctors decide who gets one?
Even though the U.S. is one of the richest countries in the world, rationing health care is not new here.
In the 1960s, people living with kidney failure fought for a limited number of dialysis machines. At first, panels considered “social worth” when deciding who got dialysis. This injustice led to federal funding for dialysis for all Americans with kidney failure. But money doesn’t solve all problems. As a doctor who cares for critically ill patients, I have seen countless children die waiting for a liver or heart transplant. Every day 20 Americans die while waiting for an organ transplant, a kind of decision-less rationing. When resources are scarce, hard decisions must be made.
The Covid-19 pandemic is already forcing hard decisions. Doctors in New York City are delaying surgeries for patients, some of whom may die waiting. Some hospitals have changed infection-control policies to reserve personal protective equipment, risking the transmission of other difficult-to-control infections. While many systems have transitioned to telehealth, canceling clinics to promote social distancing means that some will go without needed medical care.
On March 25, the federal government agreed to provide $2 trillion in financial reliefbecause of Covid-19 but, again, money may not solve the problem.
As the director of the Center for Bioethics and Medical Humanities at Northwestern University, I am one of many people planning for who gets the next available ventilator if supplies are limited and rationing becomes necessary. Here is what you should know about those plans and how they are being made:
First, past health care crises like the Ebola outbreaks, severe acute respiratory syndrome (SARS), and the H1N1 influenza pandemic prompted much advance planning. In 2012, the Institute of Medicine published guidance for what to do in a crisis like Covid-19. Many states used this report to create their own plans, including Illinois, where I practice. Importantly, input from the public is also available.
Second, bioethicists, clinicians, and health care leaders across the country are sharing information to help provide consistency from one hospital to another. Douglas B. White, who directs the Program on Ethics and Decision Making in Critical Illness at the University of Pittsburgh School of Medicine, and Scott Halpern, professor of medicine at the University of Pennsylvania, have circulated a plan based on a process published in a top medical journal that hundreds of hospitals across the country are using as a guide. In some areas, statewide plans are being implemented. To be sure, sharing doesn’t ensure consistency. But it will certainly help.
Third, every plan should support shared ethical values. This means starting with the idea that every life is worth saving and that the goal is to help the most people possible. To accomplish this, many plans use a scoring system based on objective information about each patient’s medical condition. Using a scoring system to help predict who will survive helps avoid biased decision-making.
Of course, no scoring system is 100% accurate. And many people worry that certain groups with underlying health problems, including those who are disabled, homeless, incarcerated, or poor, are disadvantaged by such scoring systems. And even with a scoring system, there needs to be a plan for breaking ties.
Fourth, a physician’s ethical duty is to care for his or her patients. If I am taking care of two patients in the intensive care unit who both need a ventilator, I should not be the one to decide who gets the machine. That decision should be made by others, preferably a group of medical experts who don’t know anything about the patients involved except the facts they are given.
Fifth, not using lifesaving treatments does not mean we stop caring. For those who may not survive, palliative care is essential to help relieve pain, difficulty breathing, and other symptoms, and support psychological and spiritual distress.
Finally, resources are available for how these decisions might be made. The New England Journal of Medicine recently published articles about allocating ventilatorsand rationing scarce resources. The Hastings Center, a nonpartisan, nonprofit organization, has an entire website on the ethics of resources during Covid-19.
I have had to learn many lessons about being a doctor since finishing medical school. I wish this wasn’t one of them.
Kelly Michelson, M.D., is director of the Center for Bioethics and Medical Humanities at Northwestern Feinberg School of Medicine and a physician in the pediatric intensive care unit at Ann & Robert H. Lurie Children’s Hospital of Chicago.
