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 relief because 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 ventilators and 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.
As a doctor, and, it seems an especially accomplished doctor, you are not the one to decide who gets the machine? That’s EXACTLY the brass-tacks decision that laypeople trust you have the expertise and fortitude to make given your granted medical degree! You, the doctor, are complaining that you should not be burdened with this sacred responsibility – yet paramedics and firefighters and police – when faced, let’s say – with a multi-vehicle disaster – dutifully triage? I’m dumbfounded by this opinion statement. Shame on you.
This is something that is upsetting as a cancer patient. I already had an unpleasant experience last summer at my local hospital. Before I even left the ER, before the problem was identified, two doctors tried their best to convince me to sign a dnr. I wouldn’t. I have tolerated chemo and side effects for years. I have a decent quality of life despite cancer. I have a loving and supportive family and friends. A different doctor found and treated the problem they would have put me in hospice for. An independent decision-maker is good on one level but allows for generalization and prejudice. I don’t have a solution, just an abundance of concern as things progress.
You mention bioethicists, clinicians, health care leaders, scoring systems, and unbiased groups of medical experts, but I would add one other person to the list: the patient. We can and should try to save all lives, but if a shortage occurs, we should be asking personally who would be willing to go without. Leaving the patient out of that decision is the ultimate disservice.
Kirk, I agree with you 100%. Patients with an incurable painful disease and lousy prognosis may very well choose to not be helped further should they get Covid-19, and their choice MUST be respected. Those so inclined should write it down, carry a card that states wishes and limits. For those for whom a Power of Attorney has been appointed: write down what the family thinks is best for the (Alzheimer etc) patient. The numbers of sufferers who would choose to depart if Covid-19 hits them might be quite surprizing. And this somewhat lightens some of the worst burdens in this global crisis.
“If rationing occurs”?
Healthcare is rationed every day in America. The system we use is called “price rationing,” where resources are provided to those with the money or health insurance coverage to afford the high price. This is the same system we use to ration luxury cars and champagne.
Please try to be more precise in your thinking. It doesn’t do anyone any good to pretend that, in normal times, health care is available to all Americans who need it. It’s not.
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