Although the Centers for Disease Control and Prevention (CDC) outlines general principles, it is up to each hospital, health system, and state to decide policy. The result is a mixed system. States like New York and Minnesota have detailed guidelines for resource allocation; Others have not talked much about it.
Bioethics experts and hospital leaders from across the country are now discussing online how to formulate COVID-19 algorithms, brainstorm, and share policy drafts in hopes of ensuring equity.
“We don’t want a situation where we put doctors by the beds, with the role of making decisions patient by patient,” said Felicia Cohn, clinical professor of bioethics at UC Irvine School of Medicine.
Setting clear guidelines is also important to the public. Shifting from routine to extreme emergency care during a crisis can be perplexing for those who are denied care, and families who are suddenly no longer allowed to visit or help make health decisions.
“People are used to certain rights and privileges,” Cohn admitted. “In a public health crisis, the context changes completely. We stop enjoying rights that we normally would have.”
In determining who should receive treatment when resources are scarce, experts say that the most pressing criterion is the possibility of survival: who is more likely to die and who can be saved?
More clinical guidance is needed to determine the chances of a coronavirus patient recovering, but new information is emerging. A recent study of infected adults in mainland China showed that the elderly, as well as those showing signs of sepsis or underlying problems like hypertension and diabetes, were at increased risk of death.
Faced with a tiebreaker choice – how to allocate resources to people with a similar probability of survival – health workers could resort to a secondary criterion: Who would have the greatest long-term benefit?
Someone with a longer potential life could have a greater benefit than someone who has already lived long.
A third criterion could be: Are you a health worker, who would go on and could save more people?
Some argue that those who work to save lives, such as respiratory therapists or intensive care physicians, deserve higher priority because they are needed to return to the fight and avoid further deaths in the future.
Health systems have long faced ethical questions about how to allocate limited resources.
“The organs are rationed every day, and many people who do not have the possibility of having a transplant die,” said Arthur L. Caplan, chief of the division of medical ethics at the New York University School of Medicine, in that city, which runs the Bellevue Hospital.
And in the past two decades, a series of infectious disease outbreaks – SARS, H1N1, and Ebola – have depleted resources and sometimes forced doctors to offer specialized treatment only to the most critically ill patients. The reports were archived and forgotten.
“The final act of most pandemics is amnesia,” said Markel. “We have received many warnings. This type of crisis has been talked about for at least 20 years. But we all tend to go back to normal later.”
Experts said that before forcing doctors to decide who lives and who dies, hospitals and governments must work to increase the efficiency of the fractured American health system.
They could free beds by postponing certain surgeries, share transportation, allow doctors to cross state lines, and exercise anywhere in an emergency, waive patient treatment costs, and authorize hospitals for military and veterans to serve civilians.
“The least ethical thing to do is ration when it could be avoided by having had better exchange and cooperation between the institutions,” Caplan said.
The public can also prepare. Anyone who feels strongly that they would choose to sacrifice for a younger person, or with fewer health complications, could update their advance health care directive now before it is too late. “It’s one of the things that hasn’t really been talked about,” Wynia said. “If someone would rather say, ‘Take care of the young man, I’m fine,’ they should say it now, while they can still speak.”