How should we decide who gets treatment?

The hospital is now almost full – the constant drip drip of Coronavirus patients hour-by-hour, shift-by-shift is taking its toll. After almost two weeks of eerie quiet, the last couple of days has seen a significant acceleration in the number of patients arriving.

Corridor conversations are abuzz with talk of how we will decide which patients to ventilate. Coronavirus can cause lungs to fill up with fluid that can take weeks to clear and give rise to secondary bacterial infections. Many of these patients also have multiple underlying medical problems which all adds up to the grim statistics we keep hearing of only 50% (an uncomfortably round number) of patients surviving to get off ventilators. These statistics make open heart surgery look like a Sunday picnic where a mortality of 10% would raise eyebrows and a referral to the GMC [General Medical Council].

So who should get intensive care treatments? The current conundrum is an extension of the rationing decisions that are taken every day. In ‘normal’ times no single approach to rationing dominates - talking this through with colleagues generates a moral equivalent of paper rock scissors.

Maximising the overall social benefit for the money we spend seems to be the starting point of the UK government. Unfortunately, it is not politically tenable to ask for the votes of a patient who has paid into the tax system all their life but is then denied care. It is no accident that NICE is kept at arm's length to government.

Equality of opportunity or ‘ending the postcode lottery’ might sound great as a political slogan. But in the midst of this outbreak this means denying curative heart treatments because a COVID patient should have an equal right to the ventilator, even though they are not likely to survive. Do doctors really weigh the life of a drug addict equally against a war hero?

Equality of outcome – ‘levels the playing field’ by prioritising treatment for the worst off in society and completely ignores potential for clinical benefit. Using this approach we could see ventilators apportioned based on people with the worst health or even based on a complex and ultimately arbitrary web of identity politics.

But these times are not normal – clinical decisions are often made very rapidly in the middle of the night with imperfect information. For instance, should we intubate a patient? Should we commence CPR? Decisions must be made within seconds or minutes. As case numbers rise they'll be made by people with less and less experience of normal intensive care treatments. 

As we end our break, my fellow doctors seem unable to answer how we will decide who will get ventilator treatment when faced with multiple patients with little to choose between them.

In truth, I sense we will continue to fudge the rationing system and get to an answer that has at least a veneer of a considered ethical approach. Discussions such as this one help doctors caucus their colleagues' opinions and smooth out the greatest sources of disagreement. Thankfully we are partly satisfied in the knowledge that our decisions cannot be undone and each patient is sufficiently distinct that we can offer reasons to (retrospectively) rationalise our actions.