Posted on April 3, 2020 at 2:21 PM
Dr. Goold’s post is a commentary on Laurence McCullough’s post, “In Response to COVID-19 Pandemic Physicians Already Know What to Do”
by Susan Dorr Goold, MD, MHSA, MA
Professor McCullough, a distinguished scholar in bioethics and the history of bioethics, wisely exhorts us to learn from past experience as we confront the COVID-19 pandemic. We should not rush to develop brand new criteria for allocating scarce resources in intensive care units (ICUs), says McCullough, but should instead rely on what we have learned over many years. “When every critical care bed is occupied by patients under the condition of medical reasonableness,” says McCullough, “patients in the emergency department or elsewhere in the hospital for whom a trial of critical care management is medically reasonable should be informed that access to critical care clinical management in the hospital will not be offered and the team will attempt transfer or, failing transfer, do the best that it can.” In other words, a patient with a reasonable chance of benefit from ICU care, even if they have more chance of benefit than an existing ICU patient, might be denied admission because of bad timing. This first-come-first-served approach, while appealing due to its simplicity and ease of implementation, does not satisfy even the most biologically reductionist, utilitarian conception of fairness. Furthermore, we know from decades of experience that access to care is disproportionately worse for minorities and low-income persons. Bad timing is more likely to occur for them. While we may not have a universally accepted conception of (perfect) justice to apply to health and healthcare, we can easily recognize some examples of injustice. Biological reductionist triage criteria, in theory, should minimize bias that might unfairly consider morally irrelevant patient characteristics such as social worth or race. How do we, or should we, take into consideration existing health disparities such as higher rates of diabetes and heart disease, that will undoubtedly affect the probability of survival? Poverty and illness are mutually reinforcing. Inequities in health, that exist already, show signs of worsening due to the pandemic. How can, and should, the professional ethics of triage that McCullough relies on respond? “Ethical rationing benefits from a just system, and a just system needs ethical rationing.” (Goold and Solomon, 2008)
Fortunately, says McCullough, “Statements [of professional associations] express professional commitments that have been forged from decades of clinical experience and reflection, passed from generation to generation, refined in training programs and clinical investigation, and embodied in day-to-day clinical decisions about the allocation of all sorts of scarce critical care and other healthcare resources.” In ordinary circumstances, or even most mass casualties, this seems to work pretty well. Like solid organs, blood products and, during shortages, some drugs (Shuman 2020), intensive care beds, ventilators, and the personnel required to care for intubated patients are, typically, a fixed or nearly-fixed resource. At times, need exceeds the supply. When this happens, patients whose severity of illness would normally warrant staying in the ICU may instead be discharged to another unit, and less severe patients who might normally be admitted to an ICU might instead be treated elsewhere. Some evidence suggests that intensive care physicians are quite effective in judging who will be at the least risk when discharged from the ICU (Strauss 1986). Less is known about how effectively admission decisions are made (Singer et al, 1983), which may be more vulnerable to being affected by social inequities, and certainly seem to differ depending on setting (Koeck et al, 1998). While a number of possibilities exist for differences across settings related to the need for admission to or continued care in an ICU, including cultural norms and attitudes about “a good death,” the resources available almost certainly play a role.
McCullough argues that the rules are the same in conditions of scarcity: “The goal becomes prevention of unacceptable opportunity cost: the use of a critical care bed for a patient for whom in deliberative clinical judgment that use is not medically reasonable and that use blocks access to that critical care bed for a patient for whom it is medically reasonable to initiate critical care management.” However, when capacity is strained to its utmost, even prudent stewardship of limited intensive care resources by experienced professionals will face decisions that differ exponentially from those faced in ordinary times. If you have a full ICU and a patient or two in the ER who needs an ICU bed you may, as an intensivist, make considered judgments about who, of all of them, is likely to do the best without an ICU bed (Barbash et al 2019), even if, in deliberative clinical judgment, that use would be medical reasonable. When you have a full ICU, extra ICUs that are also full with patients who would certainly benefit from continued intensive care, patients on non-ICU floors (with clinicians working beyond their usual capacity and experience), and the number of patients needing intensive care increasing every day, both the capacity to make considered judgments and the speed at which they must be made can easily overwhelm even the most experienced professionals. Healthcare workers’ infections will exacerbate this scarcity. Allocation decisions in these conditions of extreme and prolonged scarcity will challenge even the most well-prepared organizations and professionals. There is no question that the degree of scarcity means that health care organizations and clinicians will, and must, change their usual approach to meet the crisis.
Many in bioethics have participated in disaster preparedness and pandemic planning, including using the best evidence about contagiousness, illness predictions and fatality rates, to develop plans for how to fairly allocate extremely scarce resources in case of these events, often making sure that health care professionals caring directly for the patients (e.g., intensivists) are not the only ones making those decisions so as to prevent both implicit bias in such decisions, to safeguard trust in physicians and the role of clinicians as advocates for their patients and, importantly, to recognize the emotional toll on clinicians. Yes, organizational leaders and government officials need to support physicians and other clinicians, by recognizing their expertise not just during but before, in planning for public health crises, and protecting them from harm. Draw on their front-lines, growing by the hour experience but recognize they may not “already know what should be done.” We are now facing the need to make all sorts of decisions in some locations with limited evidence, including for critical care resources, and, like a virus, that is likely to spread. While I, for one, am grateful for the lessons about allocating intensive care during ordinary times, I am also grateful for the proactive planning by public health and hospitals and bioethicists for a severe pandemic. Still, I worry about those involved in making allocation decisions, and those caring for patients for whom such decisions result in morbidity or mortality. While we should learn from many years of experience allocating intensive care, we must also learn from experiences humans have faced that more closely resemble what we now confront (Navarro et al 2016, Stern, Cetron and Markel 2009). Let us also learn from this pandemic, especially about the need for excess capacity in healthcare (Berki 1972), the need for greater investment in public health personnel, research and infrastructure, the need to lessen preexisting health inequities, and both cherish and strengthen our capacity as families, communities, nations and the human race to place the public interest and the common good over our own.