In various parts of our country, on dates that loom in the near to middle distance, there won’t be enough ventilators to take care of critically ill people. A recent New England Journal of Medicine article, “The Toughest Triage – Allocating Ventilators in a Pandemic,” shares that if Italy is any guide, we may find ourselves in a situation where up to 31 patients are competing for one ventilator. In Italy, doctors are “weeping in the hospital hallways” because of the excruciating decisions they are being forced to make. In Spain, people sick with Covid-19 are lying on hospital floors because the beds and chairs are full.
The discussion about rationing ventilators is no longer hypothetical, as it was in a 2015 report prepared by New York state. Our thinking about medical ethics comes out of dilemmas that date far back in American history. We have long had to make decisions about how to manage risk and what values we cleave to as we make public health decisions. Two hundred years ago, the scourge of smallpox terrified many Americans. Reverend Cotton Mather learned of a strategy discovered centuries earlier in China for trying to create immunity—inoculating a healthy person with the dried pus of a smallpox victim. Smallpox was raging in Boston, and Mather encouraged local authorities to inoculate the citizens. Nearly all of the city’s physicians refused, arguing that inoculation was both dangerous and impious, and that God had chosen to send the disease. Mather and other city clergy won the debate. Later, prophylactic vaccination became broadly accepted in the United States. The ethical doctrine of utilitarianism had carried the day.
Our medical system has long had two competing ethical paradigms. Deontology, championed by Immanuel Kant, holds that actions have inherent rightness and wrongness, and we should be governed accordingly. In this philosophy, the well-being of the individual is paramount, and the ends do not justify the means. The Hippocratic Oath, “First, do no harm,” is the most famous exemplar. It’s a human rights-based view, often manifested as a code of ethics. Competing against it, however, is utilitarianism, which is often framed as the greatest good for the greatest number of people. In this view, some people may have to be sacrificed for the good of the many. Widespread vaccination is a utilitarian public health stance. Clinical trials are also run on a utilitarian model, as there is often no way to test new drugs and medical devices without putting some at risk.
In normal times, we are pretty comfortable with utilitarian principles, though we sometimes prefer that someone else do the risk-taking for us. That’s why we often pay people to participate in clinical trials. Traditionally, the wealthy in our country have been able to buy themselves superior medical care and greater safety. Covid-19 is a game-changer. We’re in a foreign landscape of upsetting discussions of who will get a ventilator and who will be left – ideally with palliative care – to die. In Italy, news articles report that doctors making wrenching decisions are prioritizing the young over the old. Our society is a little less comfortable with the idea that the young are inherently more valuable, but in utilitarian terms, they are: they have more years left to live. But does a college sophomore or a young store clerk have more to contribute than a brilliant 50-year-old scientist? Does it matter? If a health care professional needs a ventilator, should she or he be prioritized? How about the random justice of a lottery, as in The Hunger Games? Each of us is likely to have some gut reactions about these questions, about our values, our sense of ethics, our fatalism or willingness to fight to survive, and our fear.
I’m reminded of the 2004 earthquake and tsunami in the islands of the Indian Ocean. Something miraculous was going on. The ocean pulled far back from the shore, revealing the seabed for the first time. Fish flopped on the pebbly sand, an invitation to an easy dinner. Locals and tourists alike stood and stared – at a tiny white wave in the distance. The white crest drew closer and closer, growing in size, and still people stared, until it became clear that it was a massive tsunami that would engulf them all. They ran, they climbed, they died – 200,000 of them. Covid-19 reminds me of that wave gathering force. First it is small and indistinct and hardly worth paying attention to. Then it grows, coming faster and faster, and suddenly it is massive, demolishing everything in its path.
There are many documents with ethical principles and complex algorithms about who should be prioritized for lifesaving care when there isn’t enough to go around. These documents are now being pulled out of the deep file drawers of state governments. Some of our fate is entwined with our SOFA (Sequential Organ Failure Assessment) score, which predicts our likelihood of organ failure and death if we’re in an ICU. Using SOFA is akin to military triage on the battlefield. Medics have traditionally used color-coded tags for those beyond hope (black), the urgent but potentially salvageable (red), the less severely damaged (yellow), and the walking wounded (green). Medical professionals and government leaders are now using the metaphors and language of war.
We’re also in an active debate about the economic harm of the pandemic versus the harm of potentially losing millions of lives. We might recoil from these sorts of calculations, but they are going on all around us. (See the New York Times, “Hard Math: Some Economists Want to Measure the Economic Costs of Saving Lives”.) This, too, isn’t new. During George W. Bush’s presidency, the EPA, when evaluating the harm of sooty power plant emissions, concluded that if you are over 70 in our country, your life is worth only 2/3 of that of a younger person. In this sort of economic calculus, and given that Covid-19 is much more lethal to our older members of society, we may end up making an ethical choice to bid parents and grandparents adieu. It’s all ethically murky: is there a way to conceptualize greater and lesser harms when we don’t want any of the choices with which we are faced?
The New England Journal of Medicine recommends we not torment our agonized and overworked physicians with these decisions. Various authorities instead recommend letting separate committees make the decisions, tell the families, and be a transparent voice of reason in unreasonable times. It will be painful either way. Underneath the rational thinking and the algorithms is a deep well of shock and grief. It’s not until we lose something we thought we had – an illusion of safety, a belief that we had enough – that we realize how fortunate we have been.