COMMENTARY

Who Gets a Ventilator? Rationing Aid in COVID-19 -- An Ethicist's View

Arthur L. Caplan, PhD

Disclosures

April 08, 2020

This transcript has been edited for clarity.

Hi. I'm Art Caplan. I'm at the NYU Grossman School of Medicine, where I run the Division of Medical Ethics. I'm speaking to you today under terrible and sad circumstances. I want to talk about the challenge of resource allocation in situations where rationing is inevitable.

I'm going to speak about not only my own thoughts—although my thoughts are melded in here—but I've been listening to, commenting on, and involved in discussions with institutions all around the United States and some in Europe. I'm trying to bring to you what the thinking is in terms of policies and practices from both clinical and ethical experts around the country regarding how to make these very difficult decisions.

This is not the first time we've had to ration. In the American healthcare system, we've been rationing organs for transplant for four decades. I helped design that system, I know the rules, and I know it has a good deal of public support.

Let's not forget that people die every day without a transplant because we never have enough organs, sadly, to give them. It's a situation that has affected a large number of Americans, but not a majority.

Now everybody is thinking—whether I have insurance, whether I'm rich, no matter who I am—I could face not getting into a hospital to get on a ventilator, and not getting into the intensive care unit (ICU). It's not rationing that is panicking people; it's that rationing, maybe for the first time, applies to any and all Americans—and they're not used to that.

If you had good insurance or if you were rich, you figured you'd beat the rationing scheme, but now it looks like everyone has become a transplant patient. How do we manage this? What do we do?

Many institutions are making policies and finalizing them as I talk to you. I have in my possession about 70 policies from different hospital health systems, so I have a pretty good idea of what they're thinking. I want to give you the highlights of that so that you can perhaps help formulate a policy where you are or understand the thinking that has emerged.

First, it's important to articulate to everybody—all medical staff, nursing, palliative care, social work—that we're going to give everybody an equal chance. To be fair, everybody has to feel that they have equal opportunity. Whether you're disabled, transgender, rich, uninsured, a prisoner, or even someone who doesn't have papers to be here, we ought to consider everybody as a potential candidate for the required healthcare resources if they get sick. We don't rule out categories of people.

That has to be asserted, because that makes people support rationing rules. If they think they're getting the bum's rush because of who they are—their religion, their race, their gender—then they're not going to support whatever rules we create. It's important to articulate that and make that clear.

Then, what rules should we follow? Well, in transplant and in other situations of rationing that we encounter due to bombings or hurricanes or natural disasters, we try to use the resources we have to save the most lives.

That's what we do in transplant. We know there aren't many livers. We know there aren't many hearts. When trying to advocate among very seriously eligible people who might benefit, you try to make a medical judgment about who's doing best.

I think that's the first rule that we have to go to when allocating beds and personnel and to try to help somebody in allocating ventilators and other forms of respiratory support. If you are an 85-year-old with four underlying diseases who has just had a heart attack 10 minutes before, you're probably not at the same access in a scarce rationing scenario as a very healthy 25-year-old.

Conversely, if you're a very unhealthy 25-year-old with many chronic diseases, multiple injuries, and who also has a viral infection, and you're up against a 60-year-old with nothing else except the viral infection, then the 60-year-old might trump you. It's not a strict age cutoff. It is basically trying to determine who is likely to do best.

I don't think that even if you're 80 you should be ruled out in principle, nor do I think that if you're 10 you should absolutely go first, no matter what. We have to have medical judgment about who's likely to do well.

I know that medical judgment may be based on incomplete information. You're in the ER; you don't have time to order up all the labs you want; and you may have to make a judgment on the history, the physical, and the presentation, and that's how it's going to be.

Next rule. Well, age does come into play, because young people generally do better than old in terms of responding to treatments. I do think that at that point, once you've made a medical judgment, you can use age as a surrogate for who's likely to do best.

What next? Well, one group is healthcare workers, and I think that can be a tiebreaker, because we want the workforce to be there and we want people to come to work. If, other things being equal, you have two medically suitable candidates about the same age, I would give the nod—and this is me speaking personally—to the healthcare worker. I wouldn't use that as my first criterion to screen, but I'd use it as a tiebreaker.

Those are some of the patterns of thinking that I think are involved in justice. Fairness is giving everybody a shot. Justice is sorting out everybody you've got who might need a resource and using principles that make sense to determine who's going to get a scarce resource.

The third area is whether we have people whom we're not going to consider eligible at all. It could be that someone comes in with a very bad cold or bad infection but is permanently vegetative. It's a kind of disability, but I think someone who has no hope of recovering consciousness or has an underlying cancer that we know is going to kill them in a few days or a week isn't going to make it onto scarce resources either. They're just ruled out because their prognosis is so very grim or their quality of life is so extremely, extraordinarily limited.

Let me be clear: That's not the same as being in a wheelchair or having physical limitations. That's saying that in the case of someone who is so impaired that their quality of life is basically nonexistent, I don't think we want to push resources in that direction.

Another tough dilemma: Once you're on life support, once you're getting the ventilator, what happens if people come in who seem to be better in terms of likelihood to succeed? I think we may have situations where we have to take someone off who has been on for 8 or 9 days of ventilator support and isn't responding, and we have someone who comes in who is young and otherwise healthy and looks like they would do better. We have to be prepared to make very tough decisions about ending support when we might not have under normal circumstances.

It's even been suggested that if someone's on a ventilator and has COVID-19, we automatically make them DNR—do not resuscitate. Well, I'm not ready to go there, because I think you have to still look at that case by case.

If someone has a heart attack, they've been in there for a while, and they don't look like they're doing well, the resuscitation team would have to gear up to protect themselves, and there may not be time to do that. In that case, there may be no crash cart call; I'm not going to ask people to come in under those circumstances and sacrifice themselves. That's a very tough call.

Some hospitals may be able to keep their resuscitation team geared up, relatively speaking, ready to go if that happens. That makes it different from place to place. I don't favor an automatic DNR for everybody who's got the virus and is on life support, but it's going to be likely that the ability to resuscitate them, should they have an arrest, is very limited. We have to understand that.

A few other points. If we're going to roll out these policies, whatever principles are being used at your institution, or in your practice, or that you're involved with, you have to be ready to explain them to the staff clearly and make sure they have support. These are emotionally awful decisions. I would have social work, psychiatry, and psychology ready to talk to the staff.

We also need to have people ready to talk to families. If someone is being told that their loved one's going to die, they need to have support for palliative care and for psychological and emotional support.

Does your living will count under these circumstances? Probably not. We're probably going to have to suspend that. Even if you said in a piece of paper that you want everything, and to do everything, I don't think that's going to hold in a pandemic emergency.

Across the board, there are miserable, difficult, tough decisions that we're going to have to face. We should be ready to be transparent about them. We should be ready to make those decisions. We should be ready to support our peers, our colleagues, and those who work with us in the dining halls and in the laundry so they understand what's going on as much as the doctors and the nurses.

Then, we have to be ready to give emotional support to families, who I think are going to need a lot of it when they face rationing for the first time.

I'm Art Caplan at the NYU Grossman School of Medicine. Thank you for watching.

Arthur L. Caplan, PhD, is director of the Division of Medical Ethics at New York University Langone Medical Center and School of Medicine. He is the author or editor of 35 books and 750 peer-reviewed articles as well as a frequent commentator in the media on bioethical issues.

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