There has already been rationing of testing in the United States and rationing of critical care resources is likely if severely ill COVID-19 patients surge significantly.
The novel coronavirus (COVID-19) pandemic is raising thorny medical ethics dilemmas.
In China and Italy, there have been reports of care rationing as the supply of key resources such as ventilators has been outstripped by the number of hospitalized COVID-19 patients. China, the epicenter of the pandemic, has the highest reported cases of COVID-19 at more than 80,800 as of March 17, according to worldometer. Italy has the second-highest number of COVID-19 cases at nearly 28,000 cases.
The severest form of COVID-19 includes pneumonia, which can require admission to an ICU and mechanical ventilation. "Those are not just things, there are expertly trained healthcare workers who man those domains. There just isn't enough of these resources than what we anticipate needing," says James Tabery, PhD, associate professor in the University of Utah Department of Philosophy and the University of Utah School of Medicine’s Program in Medical Ethics and Humanities.
He says the COVID-19 outbreak poses four primary ethical challenges in the healthcare sector.
In the United States, caring for the anticipated surge of seriously ill COVID-19 patients is likely to involve heart-wrenching decisions for healthcare professionals, Tabery says. "The question is how do you ration these resources fairly? With treatment—we are talking about ICUs, ventilators, and the staff—the purpose is you are trying to save the severely sick. You are trying to save as many of the severely sick as you can."
The first step in managing critical care resources is screening out patients who are unlikely to need critical care and urging them to self-quarantine at home, he says.
"But eventually, you bump up to a place where you not only have screened out all of the folks who are at low risk of serious illness, but you have millions of people across the country who fall into high-risk groups. If they get infected, many are going to need access to ventilators, and the way you do that ethically is you screen patients based on medical utility," Tabery says.
Medical utility is based on scientific assessments, he says. "You basically look at the cases and try to evaluate as quickly and efficiently as possible the likelihood that you can improve a patient's condition quickly."
Rationing of critical care resources would be jarring for U.S. clinical staff.
Under most standard scenarios, a patient who is admitted to an ICU and placed on mechanical ventilation stays on the machine as long as the doctors think the patient is going to get better, Tabery says.
However, the COVID-19 pandemic could drive U.S. caregivers into an agonizing emergency scenario.
"When there are 10 people in the emergency room waiting to get on a ventilator, it is entirely feasible that you would be removing people from ventilators knowing that they are going to die. But you remove people from ventilators when your evaluation of the medical situation suggests that patients are not improving. If a patient is not improving, and it doesn't look like using this scarce resource is a wise investment, then you try it out on another patient who might have better luck," he says.
There has been rationing of COVID-19 testing in the United States since the first novel coronavirus patient was diagnosed in January.
While there are clinical benefits to COVID-19 testing such as determining what actions should be taken for low- and high-risk patients, the primary purpose of testing during a pandemic is advancing public health, Tabery says.
"The primary purpose of the test is pure public health epidemiology. It's about keeping track of who has COVID-19 in service of trying to limit the spread of the disease to other people. When that is the purpose, the prioritization isn't so much about who is at greatest risk. It's about who is more likely to interact with lots of people, or who is more likely to have interacted with more people."
A classic example of rationing COVID-19 testing based on public health considerations is the first reported infection of an NBA player, he says.
"For the Utah Jazz player who had symptoms, it made sense to test him very quickly because it was clear that he had interacted with a lot of people. Once he tested positive, the testing of the other players was not because public health officials thought the players were more valuable than the average person on the street. It was because the players had come into contact with more people than the average person on the street."
3. Healthcare workers
The COVID-19 pandemic involves competing obligations for healthcare workers, Tabery says. "On the one hand, they have a set of obligations that inclines them to go to work when they get the call. On the other hand, healthcare workers have their own interests—they don't want to get sick, which can incline them not to work," he says.
"The punchline is there is an ethical consensus that healthcare workers have a prima facie duty to work because of everything that has been invested in them, because of their unique position where not just anybody can replace them, because society looks to them to serve this function, and because they went into this profession and are expected to go into work," he says.
However, the obligation of healthcare workers to show up for their jobs is not absolute, Tabery says. "If hospitals don't have personal protective equipment, they are in no position to tell their staff to show up and work. If a hospital cannot provide even a basic level of safety for their employees to do their job, then they are turning their hospital not into a place to treat patients—they are turning it into a hub to exacerbate the problem."
When a vaccine becomes available, policymakers, public health officials, and healthcare providers will face rationing decisions until there is sufficient supply to treat the entire U.S. population, Tabery says.
"When the vaccine comes out, the first group you are going to want to prioritize are healthcare workers, who are at risk of getting infected by doing their jobs and saving lives. You would also want to prioritize people who serve essential functions to keep society going—the people who keep the water running, the lights on, police, and firefighters. Then you want to start looking at the high-risk groups," he says.
Online medical ethics resources
The American Medical Association has the following online resources to help guide ethical decision making by clinicians and other healthcare workers during the COVID-19 pandemic:
- AMA Code of Medical Ethics
- AMA Code of Medical Ethics: Guidance in a pandemic
- COVID-19 Ethics Resource Center
- COVID-19 podcast about resource scarcity and healthcare worker obligations during pandemics
Editor’s note: This story was updated on March 24, 2020.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Rationing of care for novel coronavirus patients has been reported in China and Italy.
Medical utility based on scientific patient profiles should guide decisions to ration critical care resources such as ventilators, medical ethicist James Tabery says.
In a pandemic, public health considerations should drive decisions on prioritizing who is tested for disease, he says.