Who gets treatment? The life and death decisions of Covid-19
Daniel Sokol is a medical ethicist and barrister: If the NHS’s intensive care capacity is breached, how do we decide which patients should get priority? Daniel Sokol considers the various ethical arguments
Sir Patrick Vallance, the UK government’s chief scientific adviser, explained on 18 March that the aim of the various Covid-19 measures is to ensure that the NHS’s intensive care capacity is not breached.
If it is, tragic decisions about who lives or dies will be necessary. Which patients, whether suffering from Covid-19 or other life-threatening conditions, should get priority?
This is important for ethical, social, and legal reasons. Clinicians want to act morally, avoid accusations of bias and injustice, and not get sued by patients or their relatives for negligence.
The simplest rule of resource allocation is “first come, first served.” As ethicist Jonathan Ives explains, it is “familiar, impartial, equitable, and fair.” Yet, even in accident and emergency departments, this rule has exceptions. A patient with a severe head injury will be seen before a patient with a humble cut on his leg even if admitted to hospital later. This is fair because the patient with the head injury has a greater medical need.
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Medical need also requires a capacity to benefit from treatment. There is little point in giving an intensive care bed to a patient unlikely to survive or who has a poor prognosis even if admitted to ICU. So, in a situation where the ICU is overwhelmed, “first come, first served” is out and medical need is a more promising candidate.
Medical need (with capacity to benefit), however, is not enough to resolve the Covid-19 problem. Patient A may have the greatest medical need but his needs may be so significant that treating him will entail the death of several other patients with lesser need. Patient A may require a ventilator for several weeks, whereas the other patients only for a few days to allow their lungs to recover from Covid-19. In that situation, Patient A should not jump to the front of the queue despite his greater medical need.
In fact, even if Patient A were already on a ventilator, there is a strong ethical argument for removing him from it to allow the other patients access to that precious ventilator.
In fact, even if Patient A were already on a ventilator, there is a strong ethical argument for removing him from it to allow the other patients access to that precious ventilator. This is emotionally more difficult, of course, because it goes against the instinct of clinicians to do the best for their patient and feels like abandonment, but it would maximise the number of lives saved.
For every candidate patient, there must be a careful assessment of their medical condition, their prognosis, and the likely burden that treatment will impose on the healthcare system. This requires both clinical expertise and an understanding of the current capacity of the hospital and perhaps the region. A scoring system that incorporates the various criteria is sensible. This needs to be kept under regular review as the medical condition evolves and the availability of staff and equipment fluctuates. A patient may be high priority one day and low another.
Another question relates to whether preferential treatment should be given to certain groups of people, such as clinicians and other key workers. In the military context, some situations justify giving priority to those who can be returned to duty most quickly. If a ship is under attack, it makes good sense to treat the people who can keep the ship afloat ahead of the others.
Whether that argument applies with Covid-19 depends on the effectiveness of the treatment and how quickly clinicians will be able to return to work.
“my view is that preferential treatment for key workers is morally justified. The ship must not sink”
Another reason for giving preferential treatment is to maintain or boost morale. Already, I have heard reports of healthcare workers refusing to come to work out of fear. Absenteeism will be lower if clinicians are assured they will jump the queue if they contract the disease. Some also argue that society has reciprocal obligations towards those who put themselves at risk when caring for the community and that preferential treatment falls under that duty.
If there is good evidence that sufferers of Covid-19 can recover quickly and return to work, and there is such a shortage of key workers that lives are at risk, then my view is that preferential treatment for key workers is morally justified. The ship must not sink.
Other non-clinical factors, such as whether patients have young children or their contribution to society, should surely be ignored. Taking into account those value judgments would create unnecessary complications and endless argument.
Medical ethics is a practical discipline. For it to be useful, it cannot simply ask interesting questions. It must provide concrete advice for clinicians on the frontline. Whatever conclusions are reached about the fair allocation of limited resources, they must be communicated to members of the public in advance of any crisis. To do otherwise might lead to panic and protests at the worst possible time, when hospitals are under extreme pressure.
Daniel Sokol is a medical ethicist and barrister. He has sat on clinical ethics committees involved in pandemic flu preparations and advised military doctors on ethical decision making in conflict situations. He is the author of Tough Choices: Stories from the Front Line of Medical Ethics. This article also appeared at the British Medical Journal.