Doctors in dire circumstances, with their own lives at risk, are now deciding which COVID-19 patients will be left to die. We're past debates over whether this should happen. Our leaders made that decision months ago, by dismissing coronavirus as a "hoax," failing to get surveillance testing up and running, and refusing to mobilize America's industrial might to make ventilators and other desperately needed equipment. There'll be time for accountability for the denial, falsehoods and dithering. For now, the virus has seized the moment. Agonizing decisions are upon us. Expect them to come in waves, as the coronavirus surge sweeps the nation, overtopping intensive-care capacity in many places—New York City now, perhaps Detroit and New Orleans in the days ahead, and countless towns with smaller populations but much less life-preserving capability. Ethicists and public health agencies have long-imagined such a nightmare scenario, but they've not made rules for it. The World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC) have spotlighted numbers of lives saved, relative youth, chances for therapeutic success and avoidance of discrimination against the disadvantaged as criteria for rationing care that prolongs lives. But they've avoided the bitter work of deciding—of saying whether the aged should be sacrificed first, how disability and life expectancy should affect one's place in line, or whether a patient's potential to help others (as, for example, a physician or first responder) should count. They've thus left this task to doctors and hospitals, who have no chance of getting "right" answers since there aren't any. Whatever they do—leaving 80-something grandmothers to suffocate from virus-infused fluid in their lungs, or putting infected ICU nurses on ventilators so they can live to save lives, or picking between the survival chances of two 25-year-olds unable to breathe—tragedy and ire will ensue. So the best that we can do, as our sacred values are forced against one another, is to manage the hurt and anger. We can start by embracing what we most agree upon: that our overarching goal is to save life. Let's prioritize the chance of therapeutic success—recovery from COVID-19—and not issue divisive rules about whether disability, prior illness or age should count for or against people in dire circumstances. And let's insist that patients and their loved ones, at such terrifying moments, be able to know that their doctors stand by them. "In each house where I come," the Hippocratic oath proclaims, "I will enter only for the good of my patients." "suspended" to pursue best outcomes for the many. That's flat wrong. The Hippocratic promise to keep faith with sick people who are afraid and, in this crisis, alone, is more urgent than ever. It's essential to our trust in doctors and the health care system. More than that, fear, while in crisis, that your doctor might act to speed your demise fans existential cruelty. At the bedside, each patient's doctor should be her or his champion. Yet decisions that are the stuff of nightmares must be made. The answer is to ensure that life-and-death rationing isn't done by a patient's clinical caregivers. Every setting in which such terrible judgments must be rendered should have a panel of several clinicians immediately available to make the needed calls. No one on the panel should be involved in care for the patient whose life is at stake. It's fine, though, for panel members to be involved in care for others; indeed, that'll be necessary since an "all hands on deck" approach to care is essential. (Clinicians on the panel should recuse themselves when their own patients' fates are considered.) Avoid toxic, divisive rules. Make sure doctors remain their patients’ champions. And, above all, save as many lives as possible, writes Georgetown University's M. Gregg Bloche. Would that abstract rules could provide clear answers in all circumstances, but they cannot. Clinical circumstances are too complex. There are too many unknowns and unknowables. Human judgment is essential. This judgment should focus on chances for recovery from COVID-19. Judgments about relative human worth would inflame bitterness and ensure lasting social division. We should also demand safeguards against translation of wealth and other privileges into life-and-death advantage. Permitting only a patient's caregiver to present to a panel tasked with these dreadful decisions, then closing panel deliberations to all outside, would provide some security. Research documents the pervasive role of such privilege in health care provision. The current crisis exponentially increases opportunity for such advantage-seeking. Along with mitigation of the virus's spread must come mitigation of its toxic effect on our social trust and connectedness. Withholding life-saving care from some of us to save others will worsen this toxicity. Doing so in ways that minimize this damage is a matter of urgency. Source
