by Arthur Caplan, Ph.D.
Rationing has always been present in the American health care system. Some poor individuals have not had access to certain treatments due to a lack of health insurance or hospitals not willing to accept them if they cannot pay. And those in the transplant field have had to contend for decades with a shortage of organs forcing organized rationing in which many more die than benefit from access to a life-saving liver, heart or lung. Emergency medicine personnel in big hospitals drill frequently on how to triage after a terrorist attack, a huge chemical plant explosion, an earthquake or other disaster. And those dying of terminal illnesses who cannot get into a clinical trial must sometimes compete with one another for a chance to use a scarce, unproven experimental drug as a last-ditch ‘Hail Mary’ in trying to defeat their cancer or ALS.
What the Covid19 pandemic has done is raise the prospect of rationing for every American and in fact for everyone in the world. No matter who you are, no matter where you live if the virus sickens you and you require intubation, a ventilator and an ICU bed it is likely that in areas where demand suddenly surges you may not be able to access what you need due to shortages of equipment, protective gear, health care personnel or even a hospital that can deal with your level of illness and infectivity.
Some, such as Dr. Deborah Birx, The White House coronavirus response coordinator, suggest any discussion of how to ration is premature and irresponsible;
“To say that to the American people, to make the implication that when they need a hospital bed, it’s not going to be there, or when they need that ventilator, it’s not going to be there — we don’t have evidence of that right now,” she said.” (NY Times 3/27)
Certainly no one wants to cause panic. But given the stark reality of possible shortage in equipment and personnel, especially in the New York/New Jersey area, it would be grossly irresponsible not to begin planning for every contingency including rationing.
NYU LMC and hundreds of other health care institutions and systems around the world are finalizing their plans or getting ready to roll them out to their workforces.
What is the right thing to do when faced with the harsh reality of the unavoidability of rationing? In considering other areas where rationing has been a fact of daily life, two major ethical considerations emerge—fairness and justice.
Fairness refers to the determination of who will be considered for a scarce resource and how is that decided. Will doctors make the emotionally wrenching decision on their own or will there be guidelines based on input from many sources? And whatever the process, shouldn’t we be committed to the idea that everyone will be offered consideration for scarce resources no matter who they are meaning the rich are considered equally along with the poor and your ethnicity, religion, gender, disability, geographic home or cultural background will not be used to exclude you. Fairness demands that even prisoners, the homeless and those with cognitive impairments are seen as part of the community of persons who will be given the opportunity to obtain a scare resource. Experience shows that when equal opportunity is not followed public support for rationing even in the face of scarcity collapses into complaints, threats and even violence.
So, if we are all in the lifeboat together, then how ought we choose. What is just? Some argue for a kind of lottery, first come first served get the scarce treatment. I don’t agree. This is not how to allocate scarce resources while exposing health care workers to risk of infection when the fate of a patient is futile or a huge long-shot – this makes no ethical sense.
When resources are scarce on the lifeboat or in the ICU the just choice is, in my view, to save the most lives. That means estimating who is likely, based on their physical condition, to fare the best if they get a respirator, intubation and a bed in the ICU whether due to Covid19 or any cause. So, the person with underlying respiratory disease, a history of vaping and other serious chronic conditions won’t get the same priority as an otherwise healthy but very sick Covid19 patient. Note age is not the first factor to consider, physiology is. If there is still too much demand than other factors start to shape a rationing decision; age, with children going first, status as a health care worker so as to keep the hospital staffed or the ability to be safely discharged without requiring huge hospital out-patient support services.
If people believe there is a fair chance for themselves and their families without the rich, the squeaky wheels and celebrities shoving to the front of the line they will support the miserable choices involved in rationing and those who must make them. If patients and families think they have a fair, meaning equal opportunity to obtain a life-saving treatment they will accept the rules for distributing them as they do for transplants and the emergency use of very scarce drugs.
Which is not to say that all involved in these wrenching decisions do not need support. Health care workers need emotional support, patients not selected need palliative care and emotional support and so do their families and friends. Kindness, understanding, sympathy and caring must not ever be rationed.