Reports that hospitals in Italy have had to ration medical care amid the worst COVID-19 outbreak in Europe have people around the world wondering: What if we run out of doctors or medicine? Who gets cared for, who is left to die, and who decides?
The rumors out of Italy proved unfounded. The mayor of one town in the region of Lombardy told The New York Times a lack of equipment “forced the doctors to decide not to intubate some very old patients,” but a physician in that city disputed the claim and said the situation had not reached that level. Lombardy’s resources are stretched thin, but the central Italian government is providing needed backup, the Journal of the American Medical Association reported.
Still, the questions raised by the worries in Italy deserve attention sooner rather than later, according to medical ethicists. Preparing for the scarcity of medical resources ahead of time will help healthcare workers prevent another situation like Hurricane Katrina in 2005, when doctors reportedly resorted to euthanizing some patients to free up already limited resources.
“I think they made bad decisions in New Orleans because they hadn’t thought about it ahead of time,” said Daniel Sulmasy, acting director of Georgetown University’s Kennedy Institute of Ethics.
To that end, one Italian medical group released guidelines to help guide doctors through decisions related to rationing treatment. The Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) said it wanted to relieve the doctors from the responsibility of some of the “emotionally burdensome” choices they may have to make.
The document, released 10 days ago, outlines procedures for “disaster medicine,” with decision-making processes similar to those used by soldiers on a body-littered battlefield. The writers included a 15-point list of recommendations for doctors faced with an “imbalance between needs and available resources” as they attempt to guarantee treatment for patients with the best chance of recovery. At one point, the writers suggest “it may be necessary to place an age limit on entry into intensive care.”
Ryan Nash, director of the Ohio State University Center for Bioethics and Medical Humanities, said the decision of soldiers to save a wounded comrade requires close assessments of individual cases, not sweeping utilitarian rules like age limits. But he recognized the shortage of necessary equipment could still lead to difficult decisions.
“In the case of pandemic, you have to deal with the reality of the resources that you have,” Nash said. “If you have the scenario of no ventilators … you can ask, which of my patients on a ventilator is not going to survive?”
Although age could play a role in the decision, he said officials should base the final call on the situation and “best clinical judgment,” not an age cutoff.
Sulmasy said the SIAARTI guidelines address that complexity by including other criteria such as the presence of other illnesses and the previously expressed wills of the patients.
“Age is certainly a criterion, but the overall criterion has to be prognosis … whether the person is going to benefit from being on the ventilator or not,” he said. “They’re only saying to do this if nothing else works.”
The document also advises doctors to seek a second opinion and, when possible, to make decisions with the patient and his or her family. Sulmasy said the document from SIAARTI isn’t “a statement of what they are doing. It’s a statement of what they might have to do if they reach the point of being totally overwhelmed.”
Meanwhile, the United States is reacting to its own medical emergency through social distancing. State officials encourage compliance with the cautionary measures as one way for people to care for the elderly and medically vulnerable and avoid overwhelming hospitals in the country. Although young people can contract COVID-19 with minimal side effects, they could spread the disease to the elderly, who are at a higher risk of death. When Washington Gov. Jay Inslee banned gatherings of over 250 people on Wednesday, he gave no specific legal penalties for breaking the ban, but added, “You might be killing your grandfather if you don’t do it.”
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