Bioethicist Thomas Cunningham (Loyola Marymount Bioethics Institute) writes:
Thanks as always for your continued commentary and wise read of the news of interest to the world and to philosophers, broadly conceived.
Sometime around March, you discussed allocation of scarce resources in US hospitals on your blog. At that time I suggested there was a consensus in the bioethics community about how to do this. I am writing today to revise my assessment, as this is very much in the news and may remain of interest to you and your readers.
Here in Los Angeles, we are experiencing absurdly low supplies for various resources. Speaking generally, and not about my health system in particular, I am aware of shortages in ventilators, machines that deliver high concentrations of oxygen to patients, oxygen itself, hemodialysis machines, feeding pumps, IV machines, the lines that they require to deliver therapies to patients, and other equipment. Hospitals are also seeing such unprecedented volumes of hospitalized patients that they have considered implementing triage protocols to allocate patients to lower levels of care that have adequate staffing, as reported here.
The first article above gets it right regarding the lack of consensus on triage: “Doctors and ethicists in Los Angeles and across the U.S. have not been able to agree on a single methodology for prioritizing patients, or even concur on the appropriate factors when determining who should get medical care.” But this is not the whole story. There is general consensus on basic principles, including that bedside rationing is ethically sub-optimal, and that rationing decisions during this pandemic crisis should be made by individuals or teams operating independently of bedside physicians and staff.
The dissensus concerns what specific protocols to implement and why. Some have argued for incorporating egalitarian corrections for equity into triage protocols (e.g., White and Lo in a recently published paper). Yet, this approach has only recently been codified, so few if any are using it. Most are instead using protocols that include fewer equity concerns, like essential worker status or life-cycle position to break ties within priority groups (e.g., White and Lo’s original approach). My sense is that most jurisdictions and facilities go even further, removing all factors from consideration that may be construed as entailing bias in decision making, such as age, gender, ethnicity, disability status, and so forth. California’s guidance is a perfect example of this approach.
As a philosopher and clinical ethicist, I find this lack of consensus disappointing and concerning, especially as we may enter a phase in the coming weeks where such protocols will effect patients when implemented. My principle concern is that we have not succeeded quickly enough in marrying consequentialist approaches to allocation—prioritizing with a singular focus on maximizing benefit, in terms of saving the most lives—with egalitarian approaches that recognize a legitimate duty to allocate resources in light of the harms that populations have suffered from this specific crisis. Additionally, I am concerned with the weaknesses in modeling the phenomenon of rationing in actual hospital settings. This is an issue of knowledge: We know too little, with inadequate certainty, about how hospitals function to tailor principled allocation protocols to fit the conditions of their implementation.
I am a philosopher of science by training, so it is no wonder these weaknesses are the ones that disturb me. I would hope that in the future these profound, real-world implications of ethics and epistemology in medicine attract the attention of philosophers. People have died because of bedside rationing. Many more will die because of widespread triage if we must do this. How well the protocols are designed and implemented is likely to influence how many die (though that’s an empirical question).
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