For years we have been teaching our students how proud they should be to become doctors in our country—Italy—where equity is a constitutive value, and where health is guaranteed by the Constitution as a right for every individual, regardless of his/her citizenship and including for the many migrants who seek refuge here.
We believe equity and universality to be foundational values of the Italian and the European culture, but we are also concerned that by idealising and trivialising the right to health, and not addressing ethical questions that arise in difficult situations when care may have to be rationed, we are sometimes forgetting to be fair.
While public opinion was still swinging between amazement, disbelief, and denial of reality, the covid-19 epidemic swept across our country exposing the weaknesses of our healthcare system, from family medicine, to hospital acute care, and rehabilitation.
Luckily, so far, the system has been challenged in the richer northern regions such as Lombardy; had the pandemic hit southern Italy with similar force, the consequences could have been much worse.
Nevertheless, even in northern regions, something that we’re still trying to deny happened: at peak pressure, intensive care beds, ventilators and staff in many hospitals have been insufficient.1-4 Choices have been made in allocating intensive care resources, resting initially and entirely on the shoulders of the clinicians.
Italy was not at all prepared for these kinds of decisions: no emergency plans for a flu epidemic—the most likely to be hypothesized—had ever been developed, let alone shared among experts and stakeholders.
At the beginning of the epidemic in Italy, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) made a brave effort—even though somehow a little naïve—to try to fulfil the need for consistent and transparent criteria for the admission to intensive care units (ICUs) during the pandemic emergency. The recommendations issued by SIAARTI suggest that, if rationing medical equipment and interventions became necessary, the maximum individual benefit in terms of expected life years—likelihood of survival plus remaining likely years of a patient’s life—should be prioritised. According to this principle, the drivers for admission should be the clinical picture, taking into account “biological” (not mere chronological) age, co-morbidities and preexisting functional status.5,6
SIAARTI’s recommendations were drafted under pressure without an opportunity for them to be shared and discussed more broadly within the medical community.
On publication, the document sparked a heated debate in the media among physicians, philosophers and the legal profession.7 While on the one hand the recommendations were received with gratitude and appreciation by many clinicians, on the other hand they were severely opposed in the name of the ethical obligation on doctors to protect the lives of their patients and not to discriminate in providing treatment.
Now cases in Italy are slowing, it is time to reflect on the decisions that had to be made at the time, but yet it appears this will not be the case.
Recently, the National Bioethics Committee, the ethical advisory board of the Government, has issued a document on the allocation of intensive care resources during the covid-19 pandemic, which recognises that the only admissible criterion to employ in a “pandemic emergency triage” is a clinical one. Nonetheless, it does not actually address the core ethical issue: how are we still respecting the right to health of the individual and the duty to care when rationing, and what are the ethical reasons that justify rationing choices?
While the document accepts age as a parameter to consider when evaluating the clinical situation and prognosis, it doesn’t specify how much age would weigh in terms of additional remaining likely years of life, and it makes no distinction between chances of short-term survival and of long-term survival. Leaving so many unsolved questions means leaving too much space for arbitrary decisions.
This “decision pressure” can be a source of severe moral distress for the physician. It can also be a generator of large inequities, as individual judgement can be biased by experience, emotion, exhaustion, subjectivity and personal values.
Avoiding making explicit allocating choices, especially at the beginning of an epidemic surge, could result in a “first-come, first-served” approach and even more unfair outcomes, based on totally random factors such as the timing of onset of the disease or the physical distance from the hospital.8
The protection of the right to health is an essential principle, and it must be interpreted as the protection of the highest level of health achievable. When demands dramatically exceed available resources, if transparent and shared allocation and selection criteria are not established, great inequities can follow.
In the coming years, other new and complex issues of rationing of limited resources will likely arise. If we wish to respect the values that inspire our system, we have to be ready to face them properly, developing assessments based not only on clinical ethics (patient-centered) but also on public health ethics (community-centered).
The way we have approached these issues in the last few weeks and how we approach them in the future will be the mirror of the values we actually stand for as a community.
Lucia Craxì is assistant professor in bioethics, department of biomedicine, neuroscience and advanced diagnostics (BiND), University of Palermo, Italy
Marco Vergano is chair of the ethics section, Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI), and consultant, department of anesthesia and intensive care, San Giovanni Bosco Hospital, Turin, Italy
Competing interests: MV reports he was the lead author of the SIAARTI covid-19 clinical ethics recommendations. There are no other declarations.
- https://www.ansa.it/sito/videogallery/italia/2020/03/20/coronavirus-borrelli-mancano-posti-in-terapia-intensiva-non-ci-risulta_5746bc30-b752-4ee1-903e-55a515482070.html (Accessed on 04/03/2020)
- Nacoti M, Ciocca A, Giupponi A, Brambillasca P,Lussana F, Pisano M et al. At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy: Changing Perspectives on Preparation and Mitigation. NEJM Catalyst Mar 21 2020. (Accessed on 04/03/2020)
- Rosenbaum L. Facing Covid-19 in Italy – Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. N Engl J Med 2020; 10.1056/NEJMp2005492. doi:10.1056/NEJMp2005492
- https://www.corriere.it/politica/20_marzo_11/coronavirus-gori-denuncia-pazienti-lasciati-morire-poi-si-scusa-655be6a2-638e-11ea-9cf4-1c175ff3bb7c.shtml?refresh_ce-cp (Accessed on 04/03/2020)
- Società Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva. Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances. (Access on 04/20/2020)
- Vergano, M., Bertolini, G., Giannini, A. et al. Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the Italian perspective during the COVID-19 epidemic. Crit Care 2020: 24: 165. https://doi.org/10.1186/s13054-020-02891-w
- https://portale.fnomceo.it/anelli-fnomceo-su-documento-siaarti-nostra-guida-resta-il-codice-deontologico/ (Access on 03/04/2020)
- Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020 Mar 23. doi: 10.1056/NEJMsb2005114.