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Healthcare centers across the country are hard-pressed for resources necessary to care for patients with COVID-19, like PPE and respirators, which has led to difficult questions regarding who receives care.

March 23, 2020

Medical Ethicist Weighs In on Questions Raised By Coronavirus

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COVID-19 is placing unprecedented pressure on the U.S. health system, with medical professionals and supplies in high demand. As New York State faces a potential shortage of respirators and intensive care unit beds due to the exponential rise in coronavirus cases, healthcare systems may have to answer the difficult question: Who receives care when there isn’t enough for everyone?

Dr. Kim Overby, a medical ethicist in the Department of Science and Technology Studies, said that while it is difficult to make guidelines for who receives care first, it is essential to do so.

Overby believes that many factors, including lives saved, equity, efficiency and saving front-line medical workers should be balanced with public input.

“We are facing an absolute medical scarcity, which is very rare for the United States,” Overby said. “There need to be consistent, transparent guidelines that help to prevent ad hoc bedside decision making, which can be stressful for healthcare staff, family, and patients.”

The medical care industry is already working on reducing the impact of implicit bias in how clinicians make decisions about patient care, including when to make pain management recommendations. This is especially important as hospitals in the U.S. will reach capacity as more coronavirus patients become hospitalized.

Overby expressed concern that bias issues will also emerge in triage decision making — the process of determining which patients need priority treatment — if there are no clear guidelines on who should receive care first.

“There is also always the potential for explicit or implicit biases if you do it [rationing decision making] bedside, ad hoc. There needs to be consistent, transparent guidelines,” Overby said.

According to Overby, values balanced in the creation of guidelines include efficiency, which she defined as “maximizing the total benefits to society” and equity, which she defined as “giving people equal access to a scarce resource.” Another value is giving priority to the worst off, which entails helping those most in need — but are still able to benefit — before those who are struggling less.

“We need to make sure there is a process of public engagement and dialogue for this instead of just having guidelines appear, because that would undermine public trust,” Overby said.

Even the idea of saving lives, which seems straightforward, can be measured in different ways.

“Saving the most lives, typically in healthcare that is looked at as survival to hospital discharge, is one potential principle, but a second one that is really relevant is maximizing life years (for patients),” the medical ethicist said.

The value of a year of life for different patients is another difficult question often discussed by medical ethicists. One way this is examined is through the life-cycle principle.

Overby defined the life-cycle principle as, “giving every individual the equal opportunity to live through different stages of lives tends to prioritize young people first because they haven’t had the opportunity to experience every stage of life to the extent of people who are older.”

One final concern that is often considered in allocating medical resources is instrumental value, or the multiplier effect — people who could save others after being saved themselves, therefore contributing to future care, according to Overby. However, this may not be an effective strategy for care rationing during the coronavirus pandemic.

“With this particular disease, it is not clear that physicians and nurses would be able to come back in a short time to help on the frontlines. There seems to be a protracted recovery period,” Overby said.

While all of these different principles and values must be weighed to decide what the guidelines will be, Overby worries that digital outreach strategies will miss parts of society, especially because of inequities in access to technology.

“Not everyone has access to high speed Wi-Fi. There are many people who will be impacted by these decisions who will not be able to have input,” Overby said.

The medical ethicist added that implementing these guidelines is just as important as establishing them.

“People need to feel like there is legitimate oversight. There have to be processes for appeal and revising individual decisions if people disagree,” said Overby.

Correction, March 24, 12:39 p.m.: A previous of version of this article misstated the values that Overby defined for creating medical ethics guidelines. The third value is giving priority to the worst off while they can still benefit, rather than ‘rule of rescue.’