Allocating Scarce Resources in the Time of Covid: Who Shall Live When Not Everyone Can Live?
By Jody Cramsie
Life-saving treatment is being denied sick people. Elective surgeries are canceled and on hold. Don’t confuse the benign-sounding term “elective” with frivolous or optional. Elective refers to procedures that are medically necessary but may not be an immediate emergency. Elective surgeries save lives. If they didn’t, doctors would not be justified in performing them. And time does matter, even with elective procedures — hearts might not continue beating with a damaged valve; cancerous tumors may metastasize the longer they are left in the body. These patients are getting sicker, and some are dying.
Why is it happening? Hospitals everywhere, including here, are explicitly rationing healthcare. Hospitals are using their scarce resources treating voluntarily unvaccinated Covid patients. Hospitals are overrun and overwhelmed by the crushing waves of these Covid patients – these people who made personal and socially destructive decisions and now want to go to the head of the line, despite their own culpability in their present condition. And hospitals are agreeing with that, and prioritizing those patients at the expense of others.
Every fiber of my being says this is not fair. But what does fairness have to do with it? Does fairness even matter? What are the biomedical ethical rules and considerations hospitals are using to justify their decisions on this life and death allocation of scarce resources? Are there other ethically defensible decisions that could be made by these organizations in these perilous times?
There are four core principles recognized in biomedical ethics:
1. Beneficence – the affirmative obligation to act for the benefit of the patient
2. Nonmaleficence – the obligation not to harm the patient
3. Autonomy – the recognition that the patient has the power to make decisions and choices by exercising their capacity for self-determination
4. Justice – the fair and equitable distribution of the benefits and burdens
Autonomy requires consideration of the individual’s right to make free decisions regarding their health. It includes the ability of the individual to understand those choices, including the consequences of the decision. The patient then goes forward voluntarily.
Of course, the autonomy of one person is not unchecked; it can be limited when that person’s autonomous action causes harm to another person or persons. If autonomy is primarily concerned with the rights of the individual, justice requires a balancing of benefits and burdens among all those concerned. It involves social cooperation, serving the common good, and maximizing benefits within the system as a whole, while making the difficult choices in balancing the equities.
Let me be clear: I am speaking of post-vaccine Covid treatment issues. I believe that is a morally relevant distinction within this discussion of allocation of scarce resources. This pandemic may be a crisis of such magnitude that many of the principles of biomedical ethics could/should be challenged.
In many ways, the voluntarily unvaccinated Covid patient made their treatment priorities known. They voluntarily assumed the risk and refused to mitigate any possible future damages, to themselves, their families and society. Why not respect that autonomous decision when having to allocate scarce resources, which at the same time serves the goals of equity and fairness required by justice?
Accordingly, I suggest that hospitals (not individual doctors or nurses) could make an ethically defensible policy to put sick Covid patients in the queue and not automatically give them priority. I believe this could be done by fully respecting the voluntarily unvaccinated Covid patient’s prior decision to refuse medically appropriate and possibly life-saving treatment.
I believe the equities could be balanced by hospitals developing a policy that is planned, principled and justified by an appeal to ethical standards. It would be well reasoned with input from ethicists, legal advisors, risk managers, hospital administrators and staff, and other stakeholders. The policy would be announced and widely disseminated so all people know and understand it is not reactive to any specific individual or group of individuals, but transparent and objective and consistent with the hospital’s mission and responsibility to the entire community.
Government has failed to lead on this issue. It has a vital and legitimate role in alleviating the horrendous conditions under which hospitals are laboring. It has left hospitals and communities with the heavy burden of the moral distress being caused by hospitals’ forced allocation of resources. Government should marshal its resources to set up Covid-specific treatment centers, thus creating space in hospitals for the care of other sick patients. If hospitals, on their own, are setting up temporary treatment areas in staff rooms, hallways and parking garages (!!), surely appropriate temporary treatment areas should be set up for Covid patients with top priority government action.
Autonomy is crucial. Ever increasing levels of self-determination and development of individual potential is one of the hallmarks of human progress. None of us can live happily or productively without it. But it’s nothing without justice, which is often elusive. This could move the arc of justice a little closer to within society’s reach.
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