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The Ethical Minefield of Prioritizing Health Care for Some with COVID-19

Hospital ethics committees around the country are looking for guidance to a few recent policy models, advanced in medical journals and in public discussions, regarding the allocation of resources during the pandemic.

Ira J. Bedzow, Ph.D. Lila Kagedan, M.Ed.

However, many of these example policies rely on two dubious assumptions. First, they make a distinction between public health ethics and clinical ethics and frame these decisions in terms of public health. This distinction is meant to focus on the welfare of the general population rather than those individual patients toward whom physicians have a fiduciary responsibility. This then justifies making decisions based on “the greatest good for the greatest number” even if certain individuals may suffer from it.

“We are at war with a virus that threatens to tear us apart,” the World Health Organization Director-General, Tedros Adhanom Ghebreyesus, told world leaders in a virtual summit on the coronavirus pandemic Thursday. Such dramatic phrasing as “the war against COVID-19” and “physicians are on the front lines of battle” is heard everywhere today -- in the media, and from politicians and health care workers around the globe. As US hospitals grapple with the influx of infected patients, this war analogy is creating a morally problematic way of thinking about how to allocate resources to the critically ill. In a war, we want to treat and return the strongest and fiercest soldiers to the battlefield to kill the enemy. In a pandemic that is straining medical resources and health care systems, we want something different: to save civilians’ lives in a way that maintains our own humanity. Ethicists use the term “triage” to explain how onthe-ground decisions about health care are decided in a medical emergency. While “triage” has become an accepted medical term, its roots in wartime practice has the potential to influence who should get treatment for COVID-19 based on factors that are not strictly clinical. This influence does not apply when there are resources -- even if limited -- to be had, but rather when critical capacity is overwhelmed and decisions must be made about how to treat too many people with too few resources. We do not fight a disease in the same way that we fight an enemy during wartime. We should therefore be making decisions based on concerns that are clinically relevant to survival. And we should not be making utilitarian decisions that make assumptions about who would remain, and compose the best society, after the pandemic is over.

The mistake of this type of thinking is that it frames these triage decisions incorrectly: as matters of public health. Medical professionals in the hospital serve a clinical role and should be making clinical decisions. Public health policies are about prevention of disease and utilize overarching community strategies such as “shelter at home.” They are not meant to deal with individual treatment decisions -- even if there are many -- that need to be made in the moment. Moreover, even if one were to apply public health ethics here, the fundamental values of clinical ethics would still apply -- just on a larger scale. As such, we cannot simply throw out values, such as equity and social justice, because they are harder to maintain in a triage environment. Second, not only are these ethicists’ example policies for resource allocation utilitarian in the sense of saving the most lives, they would also create policies that prioritize saving the most “life-years.” Saving the most “life-years” does not mean that those with the highest chance of survival from COVID-19 would get treated first. It means that, between two people with somewhat equal chances of survival, those perceived to have the most years left to live would get greater consideration. The moral justification for this prioritization is that it gives younger people the opportunity to live through life stages that they have yet to reach. While some ethicists try to explain that this choice does not consider intrinsic worth or social utility, it is very hard not to see this as a way of saying “Well, older people, you have had a good run. Let’s let the younger people have a chance to get old now as well.” There are other ways to respond to the challenge of choosing between cases of equal mortality, such as “first come, first served” or lottery selection. Of course, in the case of COVID-19, age is often clinically relevant,