A Summary of Medical Ethics during a Global Pandemic for Internal Medicine Residents as of March 30, 2020
By Bridget R. Durkin, MD, MBE & Erik Saka, MD, MBE
Headlines like this have been flooding the newsfeeds of popular media, and medical journals have also highlighted the ethical quandaries of our current pandemic.
As residents, we are encountering questions that most of us never expected to encounter during our entire professional careers. Estimates suggest that there are only ~100,000 ventilators available in the US with surge capacity, and the need is anticipated to peak at 1 million ventilators at current rates (as of 3/26/2020, using this epidemic calculator). These estimates may under-represent the deficit since ventilator need will not be evenly distributed across all hospitals and geographic regions with available ventilators.
Many of these challenging questions are not directly related to what treatment is best, but how we determine who receives available treatments at a given time. In short, not just what to do, but what is the right thing to do. Otherwise known as medical ethics.
This essay is in three parts, which you can jump to depending on your time and interest. Each section should take about ten minutes.
If you are currently on service and want the practice take-aways without the background, jump to Part 3.
This essay will:
1) Outline the most common ethical principles at play in approaching these decisions
2) Explore general approaches to the allocation of limited resources, specifically mechanical ventilation
3) Review Penn Medicine specific guidelines being put in place
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Part 1: Ethical Principles
Ethics is generally thought of as the moral principles or standards of right and wrong action. Bioethics or Medical Ethics are these actions specifically related to health care.
Bioethics is too complex a topic to be explained entirely in an essay, and is most useful when it is shared and discussed. If possible, do not read this alone! Read this along with your intern or co-resident across the resident room (by 6 feet). Discuss with your non-medicine spouse or roommate. Text your co-resident who is also on quarantine!
We are even writing this together!
(Don’t panic: picture from a previous, non-social distancing time.)
Erik Saka, PGY-2 Anesthesia / Critical Care, MD & M.Bioethics
Bridget Durkin, PGY-2 Internal Medicine / Primary Care, MD & M.Bioethics
Bioethics as it is commonly taught in medical school is based upon the Four Principles of Bioethics. Can you recall them before looking at the chart below? Text your buddy!
Before looking at the chart, let’s review a brief case:
Mr. Green is a 75 year-old male with PMH of severe COPD, CAD s/p DES x 2, with DLBCL on third-line chemotherapy. He develops respiratory distress on the floor. CXR and labs are concerning for volume overload. You and your attending are concerned that if he is intubated, he has a poor chance of ever being extubated given his underlying lung disease and cancer. You are worried that by intubating him, you will only prolong the dying process and cause more pain to the patient. You raise this concern to Mr. Green, and he repeats that he would like to be intubated.
Ask your partner: “What would you do?”
Most of us would agree that this patient should be intubated given his wishes.
A Brief Overview of the Four Principles of Bioethics:
Autonomy
patients may exercise control over their body and accept or reject proposed treatment
Non-maleficence
a practitioner should “first, do no harm” or at least maximize good over harm
Beneficence
a practitioner should act in the best interest of a patient
Justice
healthcare resources should be distributed in a fair and just manner; balancing the needs of an individual and others in the system
These were proposed by the philosophers Beauchamp and Childress in their book Principles of Bioethics (1979) following The Belmont Report. The Belmont Report was written by the federal government after the Tuskegee Syphilis Study to protect patients and prevent further medical abuses. This system is often called Principlism.
Which ethical principles are involved in this case? Text your buddy!
Most often in our ordinary pre-COVID lives, we encountered conflicts between a patient’s (or, by extension, a family’s) autonomy and our desire toward non-maleficence. A patient, like Mr. Green, may desire a certain type of treatment, for example a feeding tube or a tracheostomy or even CPR (autonomy). The medical team may be concerned that providing that treatment may do more harm than good (non-maleficence).
In the ED or on the floor, we sometimes encounter patients who want to exercise autonomy by leaving Against Medical Advice. This has to be balanced against the principle of beneficence, the desire to treat the patient’s underlying infection, uremia, or toxidrome.
Commonly in today’s health care (and legal system), autonomy is privileged. Unless a patient does not have capacity to make their own healthcare decisions, patients are allowed to leave AMA. Patients (not physicians) typically decide on code status, even if a majority of physicians would consider CPR futile. (Note: we say typically, because this is not necessarily the only or most ethical way to proceed).
The final Principle, justice, is rarely addressed in our day-to-day at the hospital. Most physicians and ethicists do not feel that justice is helpful in evaluating an individual patient's course of treatment. We rarely discuss the justice of CAR-T cell therapy, with a single course running into the millions of dollars for a single patient, versus the inability of thousands of diabetic patients in the same community to access insulin due to cost at a fraction of a single CAR-T treatment. Many of us have taken care of patients that have come from LTACHs (long term acute care hospitals), or have sent patients there, where those patients may be on a ventilator for months or years. We never discuss the cost to society of this patient’s choice.
However, there are a few extraordinary circumstances in which we invoke the principle of justice. You may be familiar with a system of medical triage, for emergency situations during which there are not enough resources to treat all patients. Triage is designed to focus resources on those most likely to benefit from treatment, i.e. live; even if it means leaving others to die.
We are also familiar with transplant allocation systems, which are designed to benefit the greatest number of people, ideally without regard to their social status or wealth. Our current system is predicated on the idea that those who are sickest get organs first, in order to maximize the number of lives saved and minimize the number of people who die waiting for transplant. We use formalized objective scoring systems as a complex triage calculator.
Applying the principle of justice via Triage can feel deeply uncomfortable in a hospital setting when treating individual patients, because––if given limitless resources, time, and personnel–– some of these patients may survive with proper treatment. One reason justice feels different than the other Principles is because justice is best supported by a different ethical philosophy than the other three Principles.
How do we justify justice?
The allocation of limited resources relies on the ethical theory of Utilitarianism. Utilitarianism promotes actions which maximize the outcome of the greatest well-being for the most number of people.
Another common ethical framework is deontology, which states actions are intrinsically right or wrong, and which action to choose should be guided by one’s duties. One example of a fundamental duty is the Golden Rule: treat others as you would want to be treated.
Much of our day-to-day hospital ethics is guided by deontologic ideas, such as each person is of infinite worth. This means that we cannot put a cost on a human life, and so we do not consider cost to an individual or healthcare system when we are deciding about immunotherapies or time on a ventilator. Furthermore, deontology suggests that each person is a “master of their own kingdom” and gets to decide for themself what is best for themself. In this way, we honor the patient by supporting their choices for mechanical ventilation or feeding tube, even if it is not the choice we would make for ourselves. Deontology is closely tied to the Principles of autonomy, beneficence and non-maleficence.
Many medical ethicists would say that the Four Principles are necessary but not sufficient when encountering complex ethical situations in the hospital.
Part 2: How Do We Allocate Scarce Resources during this Pandemic?
WARNING: This section does not contain definitive answers regarding ventilator allocation. Instead, it investigates the issues at play, and explores positions on various sides of the debate. It occasionally references both New York and Pennsylvania state ventilator allocation guidelines. Part 3 will review the Pennsylvania state guidelines in more detail.
Let’s go back to our case, and expand it to see how these ethical frameworks come into play now.
Now, in addition to Mr. Green 75 year-old who is requiring intubation–– you receive a call about John Brown, a 35 year-old male with no prior medical history, with recent travel to Seoul for a bachelor party, who presented with 3 days of rhinorrhea, myalgia, and dyspnea on exertion, and was noted on CT scan to have bilateral ground glass opacities in both lungs. Today, he has severely increased work of breathing, dyspnea and hypoxia, requiring ICU level care and intubation.
In a normal situation, distribution of many healthcare resources is based on “first come, first serve” or what we will call primacy in this essay. If a patient is on a ventilator in the ICU, even if another patient with better chances of survival needs a ventilator, the new patient will be intubated but will wait for a ventilator and ICU room. If the MICU is not available, they will go to an overflow room in the CCU or even be transferred to a nearby ICU at Presbyterian or Pennsylvania Hospitals.
We discussed above the ethical principles upon which healthcare distribution is done during normal times, but as you suspected from the vignette this patient has a COVID infection and in this scenario these are not normal times. In this case, our MICU is full and all ventilators in our healthcare system are occupied other than the one intended for Mr. Green.
What do you do? Do you give the ventilator to Mr. Green or Mr. Brown?
Ask your co-resident (or roommate or spouse) what they think!
As discussed above most triage strategies are based on maximizing survival for the greatest number of patients, or utilitarianism (the greatest good for the greatest number). But first, let’s consider:
Is there even a fair way to do this?!
Some would argue that, given our limited knowledge of the disease, and the complexity of factors predicting whether a patient recovers from COVID, that the best way to proceed would be by lottery. Everyone gets a number and those selected are allotted ventilator therapy.
This admits the limitations of utilitarianism that tries to predict the outcome that provides the most benefit. A lottery approach relies more on deontology that acknowledges that all patients, regardless of any other factors, deserve an equal shot at treatment. However, many ethicists would argue that external factors do influence patient selection.
If we attempt to create a triage system, what does maximizing the greatest good mean?
Should we maximize the total number of lives saved? The most number of years-of-life saved (prioritizing those who are younger)? The total number of years of life saved discounted for disability, e.g.using WHO’s QALYs (prioritizing the most healthy)?
Hospitals in Italy have been prioritizing based on age. Is that fair?
It is simple, straightforward, and quick. In certain Italian hospitals, no one over 65 years-old is eligible for a ventilator. Using age has the advantage of allowing individuals operating within overwhelmed systems to make immediate decisions, using a single objective data point. In the case of COVID-19, a triage based on age has the advantage of also helping to prioritize those most likely to live since younger patients generally have better survival. But this has the disadvantage of not addressing a patient’s individual health status. That brings us to the following question:
Should we triage based on comorbidities?
Looking at the extremes, it might seem foolish to triage based on age without including comorbidities. An otherwise healthy 67 year-old might live to 85 (the average life expectancy in Center City). A 35 year-old with Stage 4 breast cancer has an average survival of less than 5 years. But as we look closer, triaging based on disabilities raises some difficulties: a 45 year-old with Sickle Cell Disease has an average life expectancy of 54 years-old. A patient with poorly controlled insulin-dependent diabetes may be poorly controlled because they are in- and out-of-insurance. Our most vulnerable patients (patients of color, low socioeconomic status, with substance use) are the most likely to have comorbidities; are we compounding the wrongs already done to them by triaging based on medical problems?
Many ethicists note that these triaging strategies, despite being useful, do amount to a type of discrimination, i.e. age-ism and/or able-ism, based on age and disabilities. New York and Pennsylvania state guidelines have both explicitly rejected including age as a triage criteria. Some people with disabilities have even filed a federal complaint about rationing plans that they feel will unfairly prioritize others.
But what if Mr. Green was a physician? Should healthcare workers receive preferential treatment?
This is an important question: tell your friend what you think before reading on.
Some ethicists argue that healthcare workers and others who have skills useful in saving lives should be preferred since they will be useful in saving more lives later. Others refute this argument by saying that after 3-6 weeks on a ventilator and further recovery time, they will no longer be instrumental in the current crisis.
Other ethicists argue that it is important to take care of healthcare workers if they get sick, so they will continue to come to work before they are sick and care for others. Under this view, taking care of health care workers is important under the philosophy of both utilitarianism (because it incentivizes workers) and deontology (because there is something intrinsically good or fair in reciprocating their behavior of placing themselves at risk in order to serve others’ needs). This is similar to how we approach living kidney donors: if you donate a kidney and later develop ESRD, you will be given some preference on the kidney waiting list.
But what about those who are not health care workers who are putting themselves at risk in order to serve the population needs, such as environmental service workers or grocery clerks? Do they receive the same preferences due to their actions? Or not, because their training does not require the same level of personal and societal investment and they are more easily replaced?
Preferential treatment for essential workers is a very controversial topic. There is currently little consensus on whether this should be considered during resource triage. New York’s guidelines reject including any healthcare worker status; whereas Pennsylvania’s (which we will review later in greater detail) allow for it as a tie-breaker criterion.
Patients already on ventilators, such as lung transplant recipients or those in vegetative states may have been receiving ventilator therapy for months. Do they have a right to the ventilator they have been on chronically? Or does this mean that they have already received a fair opportunity for recovery and should be triaged accordingly?
Some would argue that they are requiring a limited resource and must be considered equally alongside COVID patients. Others might say that these patients had conditions that would under usual circumstances be treated. According to the NY State Ventilator Allocation guidelines, all chronically ventilated patients at LTACHs would not be triaged unless they are transferred to an acute care hospital, where they would be triaged the same as any other patient coming in who needs a ventilator. This specific scenario is not addressed in the current Pennsylvania guidelines.
In addition to the criteria used for ventilator triage, there are also ethical considerations regarding how the process is done.
Who should decide?
Should the team and attending who is taking care of the patient? This has the advantage of leveraging their in-depth knowledge about the patient, as well as the relationship that they have already built. However, there is a lack of objectivity, especially when teams are being overwhelmed; each team may want to prioritize “their” patients over those of others and may consciously or unconsciously try to create medical reasons for their priority on the ventilators.
Both the New York and Pennsylvania state guidelines endorse the creation of a third-party Triage team, who will apply the triage assessment guidelines and make a determination about the eligibility of a patient for ventilator therapy. This strives to preserve the therapeutic relationship between healthcare team and patients
How often should patients be reassessed?
Right now, data from China and Italy suggests an average time on a ventilator consistent with generalized ARDS of roughly 2-6 weeks. If we reassess and retriage too rapidly, no one will have a chance to benefit: patients who have been on a ventilator for only 48 hours and are just beginning to recover might be removed from ventilators. If we wait too long to reassess, we are returning to the idea of Primacy or First Come First Served.
Should we be encouraging opportunities for patients to exercise autonomy?
Should we be asking patients when we admit them, not only our usual code status questions, but also:
If there were not enough breathing machines to treat everyone, would you volunteer to give your ventilator to a younger patient, even if that means dying naturally without breathing support?
Some ethicists would argue that by being asked by a person in power (their doctor), there is the risk of the patient being unfairly coerced. Others would say that it is only right to ask for volunteers before imposing the decision. A popular headline cites Italian reports that a priest died after giving up his ventilator for another patient.
What are the ethics of sharing ventilators?
New York-Presbyterian Hospital is currently treating two patients with a single ventilator.
Is it more ethical to use a single ventilator for multiple patients, even if the settings are not as optimized and therefore likelihood of survival for each patient is worse? The current survival benefit is unknown. But for a thought experiment: what if a single patient on a vent has a 50% chance of survival, and if there are 4 patients on a vent, they each have a 12.5% chance? Is it better to give one person a 50% chance or 4 people at 12.5% chance?
If overall survival odds are comparable, both deontology and utilitarianism support that splitting the ventilator is ethical. From a utilitarian standpoint splitting is ethical if splitting the vent either increases or does not change the cumulative survival of all patients on the ventilator. According to deontology, each person’s life is of infinite worth so increasing the chance to save more lives is ethical (even if it decreases overall odds of survival). This suggests that splitting ventilators is worth further investigation in order to determine the actual odds of helping multiple patients. This new innovation has not yet been considered in any state guidelines.
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Part 3. Pennsylvania Guidelines regarding Allocation of Scarce Resources
Wow, we’ve covered a lot: the ethical frameworks supporting allocation of ventilators, questions that go into allocation triage, but I’m on service today and I want to know WHAT DO WE DO?
This problem is currently being addressed in the United States on the state level. There are national guidelines published by the Institute of Medicine back in 2009, and individual states such as Michigan, Maryland, Minnesota and New York State have all made individual guidelines or are currently updating them. Each state has its own set of guidelines and unique guiding principles. They vary widely in scope and detail. New York guidelines are 272 pages long, but Pennsylvania addresses the question in 8 pages. There is no one “correct” answer in these situations, and the thoughts and ideas you discussed with your partner above are also important ethical considerations.
That’s all great, but what are we going to do at UPHS?
Here in Pennsylvania, Drs. Scott Halpern from Penn Medicine (ethicist and Pulmonary / Critical Care attending) and Douglas White from UPMC have proposed the following guidelines summarized below [all tables below taken from these guidelines]:
1. Triage decisions will not be made by the primary team; instead a designated physician Triage Officer will be responsible. If possible, this MD will be supported by an acute care nurse and hospital administrator.
2. In the ED or on the floor during acute decompensation, providers would perform the immediate stabilization of any patient in need of critical care, as they would under normal circumstances, including ventilation if necessary. During the next 90 minutes, the Triage Officer(s) would perform ICU and ventilator Triage based upon the following considerations: 1) saving the most lives; and 2) saving the most life-years. To do this fairly, the following points system is proposed:
Under Drs. Halpern and White’s guidelines, each patient would receive a score of 1-4 based on their acute illness, with additional points (2 or 4) being added based on their comorbidities. They would receive a points total from 1 to 8, with priority being given to those with a lower number.
The following chart provides examples of such comorbidities:
Of note, this system avoids any hard exclusion criteria. The authors hope that this would, among other reasons, avoid the perception that some groups' lives are “not worth saving.” If resources are available, all would be eligible for mechanical ventilation.
By contrast, NY State’s Guidelines start with the exclusion criteria outlined below:
The Pennsylvania guidelines suggest that patients can be grouped into three Triage groups for ease of triage and to avoid allowing marginal differences in point totals (e.g. 2 vs 3) from impacting which interventions a patient is eligible for:
This framework also proposes the following be considered as tie-breakers among patients with equivalent scores:
Stage of Life-cycle. If there are not enough resources to provide to all patients within a priority group, priority should go to younger patients. Recommended groups are: age 12-40, age 41-60; age 61-75; older than age 75.
This tiebreaker is based on feedback from community members in Maryland who helped develop an earlier version of this system. The public showed a preference for prioritizing younger individuals, suggesting (perhaps a deontologic belief... ) that there is intrinsic good in a person experiencing all the stages of life—childhood, young adulthood, middle age, and old age.
Role in public health response. Those whose work directly supports the provision of acute care to others should be prioritized as a tie-breaker or even as negative points during the Triage process. This includes not only physicians, but also nurses, respiratory therapists, and environmental service staff.
Allocation of ventilators should be based not only on the number of ventilators currently available, but the projected volume of new cases.
Regarding reassessment, the Pennsylvania guidelines note reassessment should be based on the clinical course of the disease. They do not offer a specific timeframe for COVID-19. By contrast, New York’s guidelines propose reassessment at 48 hours and then 120 hours. For COVID-19, the time frame needed to show improvement might be 3-7 days based on current data. Under the Pennsylvania guidelines, the patient will be reassessed at that time point, and those showing improvement will be allowed to continue with the intervention. In this framework, they are not compared directly to those undergoing initial Triage. Patients may be reassessed earlier if they undergo an acute decline in status (for example: new shock, DIC, stroke).
All patients who are not eligible for interventions such as ICU or mechanical intervention or ECMO will continue to receive medical care focused on palliation.
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The Pennsylvania guidelines outlined above are thoughtful and rigorous, but they are not perfect; it is impossible to create a singular ethical framework that satisfies everyone’s concerns. They strive to find the balance between proposing a useful, concrete framework and making assumptions based on incomplete information.
The healthcare system and the world is facing a situation unlike one we have ever encountered before. This essay post explores in depth the issue of ventilator allocation; it does not directly address other shortages such as PPE, health care professionals, or vaccinations although these same ethical frameworks are at play.
We, as a health system and as a nation, will continue to refine our approach and ethical principles based on experience. Your experiences, thoughts, and responses are crucial in creating an ethical framework for this crisis and for the everyday care you provide to our patients.