If COVID-19 patients overwhelm hospitals’ capacities, physicians will need models for making ethically defensible decisions about who gets intensive care beds or ventilators. Two physician-ethicists evaluated existing guidelines for rationing care and laid out a score-based framework for determining priority access to scarce resources.
The AMA and the Centers for Disease Control and Prevention are closely monitoring the COVID-19 global pandemic. Learn more at the AMA COVID-19 resource center, the JAMA COVID-19 resource center and the AMA Journal of Ethics® COVID-19 ethics resource center, and consult the AMA’s physician guide to COVID-19.
Following are highlights from a JAMA® Viewpoint essay by Douglas B. White, MD, director of the Program on Ethics and Decision Making in Critical Illness at the University of Pittsburgh, and Bernard Lo, MD, professor of medicine emeritus and director emeritus of the Program in Medical Ethics at University of California, San Francisco School of Medicine. Dr. Lo is also the recipient of the AMA Foundation’s 2014 Isaac Hayes, MD, and John Bell, MD, Award for Leadership in Medical Ethics and Professionalism.
Issues with categorical exclusions
Some groups of patients with comorbid conditions, such as severe lung disease and severe cognitive impairment, are excluded access to intensive care units per professional society guidelines and some states’ recommendations.
“This violates the principle of justice because it applies additional allocation criteria to some patients but not others, without making clear what is ethically different about the patients that would justify doing so,” the authors wrote. “Categorically excluding patients will make many feel that their lives are ‘not worth saving,’ which may lead to perceptions of discrimination.”
In addition, the authors noted, categorical exclusions are too rigid to be applied in a dynamic crisis, when shortages are likely to surge and decline episodically.
“They also violate a fundamental principle of public health ethics: use the means that are least restrictive to individual liberty to accomplish the public health goal,” the authors wrote. “Categorical exclusions are not necessary because less restrictive approaches are feasible, such as allowing all patients to be eligible and giving priority to those most likely to benefit.”
Read the AMA Code of Medical Ethics’ opinion on allocating limited health care resources, and learn more about other ethical advice that is highly relevant in the context of the COVID-19 pandemic.
Score-based framework
The most common recommendation for allocating scarce ventilators is to prioritize patients who are most likely to survive. But the authors noted several other ethically relevant considerations, such as the number of patient life years saved, the opportunity for the patient to pass through all of life’s stages, and whether the patient has lifesaving responsibilities.
“Because no single criterion captures all morally relevant values, multiple criteria should be integrated into a single tool to prioritize which patients should receive ventilators when not all can,” the authors wrote, noting that Pennsylvania recently endorsed just such an approach.
Using this allocation framework, Drs. White and Lo wrote that decision-makers should do the following.
Include everyone. All patients who meet usual medical indications for ICU beds and ventilators are eligible.
Assign a priority score using a scale of one to eight. A lower score indicates higher likelihood of benefit. This number is based on both the likelihood of surviving to hospital discharge, which is assessed using an objective measure of acute illness severity, and whether the patient has an advanced condition that would substantially limit their near-term survival even if they survived the acute hospitalization.
Subtract for lifesaving responsibility. Individuals who perform tasks vital to the public health response are given heightened priority.
Break ties based on age. Priority should be given to younger patients because they have experienced fewer of life’s stages.
The authors also summarized the challenges of withdrawing life support from one patient to give it to another and recommended steps for easing the distress caused to patients, families and professionals by reallocation of resources.
Dr. White was interviewed about this article by Howard Bauchner, MD, editor-in-chief of JAMA and senior vice president of AMA scientific publications and multimedia applications, for a recent episode of the “Conversations with Dr. Bauchner” podcast.
Subscribe to the “Conversations with Dr. Bauchner” podcast. Each week, he interviews leading researchers and thinkers in health care about their recent JAMA articles. Go beyond article recap and delve into the background, context and implications of the study or editorial. A recent episode features an interview with Michelle N. Gong, MD, MS, chief of critical care medicine at Montefiore Medical Center in the Bronx.
