Editor’s Note: The doctor. Ira Bedzow is an associate professor of medicine, director of the Biomedical Humanities and Ethics Program and holder of the UNESCO Chair in Bioethics at New York University of Medicine. Lila Kagedan is a Clinical Ethics Specialist and Assistant Director of the Ethics and Biomedical Humanities Program at New York University of Medicine. The opinions expressed in this article belong to the authors. See more opinion pieces on CNN.
(CNN) – “We are at war with a virus that threatens to destroy us,” World Health Organization Director General Tedros Adhanom Ghebreyesus told world leaders at a virtual summit on the coronavirus pandemic on Thursday.
Phrases as dramatic as “the war on covid-19” or “the doctors are on the front lines of battle” are heard today everywhere, in the media, and by politicians and health workers around the world. world.
As hospitals in the United States face the influx of infected patients, this analogy of war is creating a morally problematic way of thinking about how to allocate resources to critically ill patients. 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 depleting medical resources and health care systems, we want something different: save the lives of civilians in a way that preserves our humanity.
Ethics specialists use the term “triage” to explain how healthcare decisions are made during an emergency. While “triage” has become an accepted medical term, its roots as a wartime practice have the potential to influence who should be treated for covid-19, depending on factors that are not strictly clinical.
This influence does not apply when resources are available, even if they are limited, but rather when critical capacity is overwhelmed and decisions have to be made about how to treat many people with very few resources.
We do not fight disease in the same way that we fight an enemy during war. Therefore, we must make decisions based on clinically relevant concerns for survival. And we shouldn’t make utilitarian decisions that assume who will stay and make the best society, once the pandemic ends.
Hospital ethics committees across the country are seeking guidance for some recent policy models, seen in medical journals and in public discussions, regarding resource allocation during the pandemic.
However, many of these models are based 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 differentiation is intended to focus on the well-being of the general population rather than those individual patients to whom physicians have a fiduciary responsibility. This justifies decision-making based on “the greatest well-being for the greatest amount possible,” even if certain people may suffer from it.
The error of this type of thinking is that it incorrectly frames these triage decisions as public health issues. Health professionals in the hospital play a clinical role and must make clinical decisions. Public health policies address disease prevention and use general community strategies such as “home confinement.” Doctors are not meant to deal with individual treatment decisions, even if there are many, that need to be made on the spot.
Furthermore, even if one were to apply public health ethics here, the core values of clinical ethics would still apply, only on a larger scale. As such, we cannot simply shed values, such as equity and social justice, because they are more difficult to maintain in a triage environment.
Second, the model policies of these ethicists for the allocation of resources are not only utilitarian in the sense of saving as many lives as possible, but also tend to create policies that prioritize saving those who have a greater “expectation of lifetime”. Preserving those with possibly the most “life expectancy” does not mean that people with the highest survival probability for covid-19 will receive treatment first.
It means that, between two people with somewhat equal chances of survival, those who perceive that they have the longest number of years to live would receive greater consideration. The moral justification for this prioritization is that it gives younger people the opportunity to live the stages of life that they have not yet reached.
Although some ethicists try to explain that this option does not consider intrinsic value or social utility, it is very difficult not to see this as a way of saying: “Well, old people, they had a good life. Let younger people have the opportunity to grow old too. ”
There are other ways to respond to the challenge of choosing between cases of equal mortality, such as “arrived first, attended first” or lottery selection. Of course, in the case of covid-19, age is often clinically relevant, since with age come other factors or physiological conditions that will affect the chances of survival. But we must be fully aware of when we are considering a clinical factor and when we are subjecting a patient to social bias.
We understand the motivation to be utilitarian and want to maximize “life expectancy”: clarify the rules and it is easy to feel that “life is good, so more life is better”. But clarity alone is not good morals.
Prioritizing “life expectancy” for the sole purpose of giving young people the opportunity to grow old is a non-clinical social decision as much as any other we should try to avoid.
The potential quantity should not be considered real. We can assume that a younger person will live longer, but you can never be sure that this is the case.
We should not be utilitarian based on assumptions that are beyond clinical relevance. Ethics committees and medical professionals have no moral authority to presume the value of “life expectancy” or who will make the greatest contribution to society when the pandemic ends.
Guidelines for ethical resource allocation should adhere to covid-19 overall survival prospect considerations. Indirect factors, such as age, disability, and comorbidity (existing physiological conditions that make a patient more vulnerable), should only be considered in relation to prognosis and survival.
It will seldom be the case that all considerations for resource allocation for two covid-19 patients are exactly the same. And if there is a case where this is the case, we should not simply refer to the general guidelines that make decision-makers soldiers on the front lines.