April 24, 2020
|A patient suffering from COVID-19 is seen on a ventilator in the intensive care unit of a hospital in Paris April 1, 2020. (CNS photo/Benoit Tessier, Reuters)|
When ventilators are in short supply, several key ethical principles can assist clinicians:
During the COVID-19 crisis, some commentators have recommended taking tough choices out of the hands of front-line clinicians and handing them over to dedicated triage officers or triage committees to decide. In a recent article in the New England Journal of Medicine (NEJM), for example, Dr. Robert Truog and his collaborators offer this approach as a way to “protect” clinicians:
“Reports from Italy describe physicians ‘weeping in the hospital hallways because of the choices they were going to have to make.’ The angst that clinicians may experience when asked to withdraw ventilators for reasons not related to the welfare of their patients should not be underestimated — it may lead to debilitating and disabling distress for some clinicians. One strategy for avoiding this tragic outcome is to use a triage committee to buffer clinicians from this potential harm.”
The main goal during triage, however, cannot be to “buffer clinicians” or “soften the angst” of what is clearly a difficult and challenging set of decisions. Nor is it to “save the most lives possible in a time of unprecedented crisis,” as proposed in the NEJM article. Nor is it to favor those with “the best prospects for the longest remaining life,” as others have suggested, by relying on a utilitarian calculus that favors the young and the strong.
The goal must instead be to make allocation decisions based on evenly applied practices, as fair as possible, across the spectrum of patients, without turning to biased “quality of life” assessments. Even in a pandemic, the first priority remains the provision of outstanding patient care.
Triage scenarios involve emergency situations. In an emergency, as the plane’s engines flame out, the captain should not be sidelined in favor of a remote “landing committee” working to bring the plane to a safe touchdown. Instead, passengers should be able to entrust themselves to a pilot with professional skills, instincts, and expertise, somebody who is fully invested in the critical task at hand. The pilot’s personal involvement in the fate of his passengers mirrors the physician’s accompaniment of his patients in a time of crisis, with these front-line clinicians properly assuming a key role in making decisions about the allocation of limited medical resources.
Rather than trying to offload responsibility to a committee to “mitigate the enormous emotional, spiritual, and existential burden to which caregivers may be exposed,” as the NEJM article phrases it, front-line clinicians, together with their patients and/or health care agents, should manage these critical decisions, with triage committees serving in advisory, rather than decision-making or adjudicating, capacities.
If rationing becomes necessary, sound ethical principles not only enable responsible triage decisions to be made but can also help clinicians to avoid panic and calmly accompany each patient entering a health care facility, including those facing their final days and hours.
Rev. Tadeusz Pacholczyk, Ph.D. earned his doctorate in neuroscience from Yale and did post-doctoral work at Harvard. He is a priest of the diocese of Fall River, MA, and serves as the Director of Education at The National Catholic Bioethics Center in Philadelphia. See www.ncbcenter.org
During the COVID-19 crisis, some commentators have recommended taking tough choices out of the hands of front-line clinicians and handing them over to dedicated triage officers or triage committees to decide.