By: Andrew Peterson, Adrian M. Owen, Charles Weijer.
In the race to save lives in the Covid-19 pandemic, we must not sacrifice those most vulnerable.
Covid-19 kills not only by attacking the respiratory system, but also by attacking the health care system. Overwhelmed ICUs may not have enough ventilators for patients in respiratory distress. The tragic result is that many Covid-19 patients who might have been saved die.
Triage policies help us allocate scarce resources. They provide explicit rules so that patients with the best chances of survival receive ventilators first. To date, triage policies have focused on allocating ventilators in acute care hospitals. But what about the more than 8,000 ventilators currently in use in nursing homes across the United States—or other countries—to keep alive patients who have suffered strokes or traumatic brain injuries? Could these be put to better use in the fight against Covid-19?
A recent article in the LA Times suggests the answer is “yes.” Dr. Govind Persad, a coauthor of influential guidelines for fair allocation of scarce resources, believes that forcibly extubating a nursing home patient on a ventilator to treat a Covid-19 patient is ethical. He asks us to consider the following hypothetical scenario:
“A 78-year-old grandmother has been on ventilator support for five years in a subacute facility and is expected to remain on it for the foreseeable future. Covid-19 has reached a senior apartment complex nearby, and doctors are looking everywhere for more ventilators. They think one more ventilator would give them a chance of saving another 78-year-old grandmother in the senior apartments who is growing worse with viral pneumonia, and, once she is off the ventilator, to save some of her neighbors, who are not yet sick but who they expect to be sick in a few weeks.”
Persad thinks the answer lies in the numbers. If the average Covid-19 patient requires the use of a ventilator for 11 days, this would allow us to save eight lives in three months. Extubating the 78-year old grandmother, according to Dr. Persad, would allow us “to save more lives….” The tradeoff is difficult but ethically justifiable.
We think this is wrong.
First, ventilators taken from patients in nursing homes would save far fewer lives than suggested.
The estimate of lives saved over the course of three months assumes that all ventilated Covid-19 patients survive. But reports from China and the United States suggest alarmingly high mortality rates. A recent study published in JAMA states:
“As of April 4, 2020, for patients requiring mechanical ventilation (n = 1151, 20.2%), 38 (3.3%) were discharged alive, 282 (24.5%) died, and 831 (72.2%) remained in hospital. Mortality rates for those who received mechanical ventilation in the 18-to-65 and older-than-65 age groups were 76.4% and 97.2%, respectively.”If we assume the mortality rate for ventilated patients is 80%, and that patients who die spend approximately 7 days in the ICU while patients who survive are ventilated for approximately 11 days, the net number of lives saved by a single reallocated ventilator is just one in three months.
Even this estimate may be optimistic. Nursing homes ventilators are much simpler and less flexible than those used in ICUs. Might survival outcomes with repurposed ventilators be even worse? We simply don’t know.
Second, some believe that the life of a person with a disability is less valuable. The impact of this bias on our moral judgments is pernicious. It may cause us to find even flawed arguments persuasive and stay our hand from checking the numbers carefully.
To his credit, Dr. Persad argued recently in the Denver Post that policies that seek to save the most lives will also save more people with disabilities. But whether or not this is actually the case, protecting people with disabilities should be more than a happy consequence of a policy. It should be a core protection.
Third, we must not merely strive to maximize the number of lives saved, we must also protect those who cannot speak for themselves.
In the rush to save lives, we must remain attentive to all of our ethical duties. Physicians owe nursing home patients a duty of care, and this duty must not be abrogated in the current pandemic. Physicians must ensure patients receive needed care and they must remain steadfast patient advocates.
All of us, including health providers, policy makers, and citizens, have a duty to protect the vulnerable. Those without power are at the greatest risk during times of crisis. We must ensure that their voices are heard and that the value of their lives is given full measure.
The New York State Task Force on Life and the Law addressed the question of reallocating ventilators in nursing homes in a pandemic explicitly. They concluded that it should not be done. Forcibly extubating patients at nursing homes might save more lives, but such actions would “[conflict] with the societal norm of defending vulnerable individuals and communities.”
Dr. Persad and others rightly emphasize a duty to steward scarce resources. But this shouldn’t cause us to neglect the ethical duty of care and the duty to protect the vulnerable. Respecting these duties in the current pandemic requires that we not reallocate ventilators currently in use in nursing homes and other chronic care facilities.
Authors: Andrew Peterson, Adrian M. Owen, Charles Weijer.
Affiliations:
AP is assistant professor of philosophy in the Institute for Philosophy and Public Policy at George Mason University, USA.
AMO is professor of cognitive neuroscience and imaging at Western University, Canada.
CW is professor of philosophy, medicine, and epidemiology and biostatistics at Western University, Canada.
Competing interests: AP and AMO have no interests to disclose. CW receives consulting income from Cardialen and Eli Lilly & Company.
Twitter: AP @_APeterson_ AMO @Comadork CW @charlesweijer