Sunday, March 15, 2020

CORONA ETHICS Two COVID 19 positive critical cases with one ventilator whom to save?

Two COVID 19 positive critical cases with one ventilator whom to save?
This situation is being faced by Italy
Coronavirus is forcing doctors to decide who they’ll save

Dr K K Aggarwal
President CMAAO, HCFI and Past national President IMA

A lack of resources could mean that younger, healthier patients are prioritised, while others are left to die. Currently Italy is facing serious challenges, with demand for critical care far outstripping supply. Health officials there are having to make very difficult decisions about who to treat – in the knowledge that deciding not to treat will very likely lead to death.
As per Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care, guidelines advising doctors how to deploy scarce resources when the need for them is outstripped by the demand of critically ill patients. The guidelines state that priority should be given to those who have, first, “greater likelihood of survival and, second, who have more potential years of life”.

As a result, patients with underlying conditions and elderly patients, who are deemed to stand less chance of surviving the virus, may not be treated in favour of healthier and/or younger people who have more chance of recovery.

Utilitarianism – which aims at maximising the number of lives saved. This approach does not value any one life over another – all lives are equally valuable – but it does say that we should focus resources where they are likely to save the most lives. This prefer “first come, first served” queuing system. That seems familiar, impartial, equitable and fair.
That may well be the best strategy in normal times – but a pandemic is not normal. It is an emergency, and while emergencies do not call for a suspension of ethics, they do call on us to revisit our priorities – and that will always be horribly uncomfortable.

1.       Person first in the queue is suffering from Covid-19. He is an older – but not elderly – person, with an underlying lung condition that means they need critical care. Treatment would not be futile – it might save their life – but to choose to treat them would require an extended period of critical care and the outcome would be uncertain.
2.       The next two people in the queue are of similar age and have been hit hard by the virus, but they do not suffer with underlying lung problems. They are more likely to survive. They also need critical care to get them over the worst effects of the virus, but because they have no underlying health conditions they will pass out of the danger zone faster, meaning that both of them are likely to be saved in less time, and for less resource, than it would take to try to save the first patient.
In this scenario, assuming that all three cannot be given critical care, it appears to make sense to treat the person who will take up fewer resources with a more certain outcome and free up the bed faster.

The knock-on effect is that elderly people and those with underlying health conditions – who are less likely to benefit from treatment and would take longer to see benefits – might not receive treatment.

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