Coronavirus could force difficult choices on health systems
The discomfiting idea that some people belong at the front of the queue is already codified
The hope of coronavirus containment is giving way to the strategy of delay. The disease has reached every continent bar Antarctica. Italy, the worst-affected country in Europe, has a nationwide quarantine.
Covid-19, for which there is no vaccine or cure, presents a defining challenge for any government, whose first duty is to protect citizens. Transparency will be critical if health services become overwhelmed: the UK is fortunate in having a public health response led by experts who offered clear, timely advice — a contrast to the chaos unfolding in the US.
In northern Italy, intensive care beds are already filling up fast. Healthcare may be rationed. If so, ethicists say, the public should be made aware of the reasoning behind difficult choices, such as who will be given intensive care beds and ventilators in the event of a shortage. “How will resources be allocated when demand hits surge and capacity is limited?” asks Hugh Whittall, director of the London-based Nuffield Council on Bioethics, which has led consultations that have previously fed into pandemic planning. “It’s important that the principles for constructing that guidance are transparent, public and clearly set out, and that the government prepares the ground for what might come.”
The discomfiting idea that some people belong at the front of the healthcare queue is already codified. The US Centers for Disease Control, for example, prioritises access to limited stocks of pandemic flu vaccine by splitting the population into five tiers. Tier 1 occupants include military personnel deployed overseas, frontline healthcare workers, those in the emergency services and law enforcement, pandemic vaccine manufacturers, pharmacists, pregnant women and children aged 35 months and under. In a severe pandemic, mortuary staff and energy infrastructure personnel (tier 2) are favoured over bankers and transport workers (tier 3).
Healthy adults aged under 65, if not included in a higher professional tier, rank the lowest. Interestingly, priorities can change according to the profile of a disease: over-65s are tier 2 in a low severity pandemic but drop to tier 4 in a high-severity scenario.
Once illness strikes, that picture changes. Sick workers are unlikely to recover in time to assist in the first wave of an epidemic. Occupational usefulness becomes secondary to clinical need, but healthcare workers are still prioritised.
Maxwell Smith, a bioethicist at Western University in Ontario who has written widely on pandemic ethics, believes the 2003 Sars outbreak focused thinking on who should be prioritised for life-saving treatment. Decisions should be made in a trustworthy, inclusive and fair manner to have legitimacy: “If we’re not going to have people upset and protesting, this needs to be done in advance,” he said. “If we wait until we’re scrambling for ventilators, the odds are that we won’t be able to go through that reasoned decision-making process.”
The broad utilitarian aim of saving the most lives is difficult to judge in a severe pandemic. The usual “sickest first” approach can see ventilators being assigned to those too ill to survive. “First come, first served” might also be jettisoned; efficient use of scarce resources is itself an ethical imperative, meaning spaces might go to those most likely to recover. A “fair innings” argument favours younger patients — but Covid-19, unlike flu, leaves babies and young children relatively unscathed.
If the pool of equally needy patients far exceeds capacity, Mr Smith said, lotteries are an option. Novartis ran a lottery to choose the first compassionate-use recipients of its $2.1m experimental gene therapy Zolgensma. Even in extremis, this is hard on those with losing tickets. It is wiser to improve the odds now: handwashing and self-isolation can spread the healthcare burden and buy time for a vaccine. Ultimately, it gives more of us a chance of winning.