Utilizing parents to hand-bag ventilate when resources are scarce: Is it ethical?

By Emily E. Barsky and Sadath Sayeed

Amidst the COVID-19 pandemic, many nations are coping with what resource limited settings are all too familiar with—ventilator scarcity.  In low-income countries, people— and particularly children— frequently die of reversible, acute respiratory failure due to across-the-board resource scarcity.  Some such settings have responded to this by allowing parents to be active participants in medical care provisions— specifically, providing hand-bag ventilation to their children.  Medical staff place an endotracheal tube but rather than connecting it to a ventilator, they connect it to an Ambu bag and ask parents to compresses and releases the bag to inflate and deflate the child’s lungs, hopefully resulting in adequate gas exchange for survival.

This ethically fraught practice of parental hand-bag ventilation is predictably anguishing to observe for those of us accustomed to clinical resource abundance.  It is morally jarring to see mothers crouched next to intubated children, tirelessly performing hand-bag ventilation hour after hour, clinging to a desperate hope of recovery. It is even more horrifying to learn the following day that a child passed away after ventilation stopped when the mother fell asleep.  It is easy to conclude that this shift in responsibility is indefensible, unfairly displacing burden and guilt onto family members with overwhelming odds of a devastating outcome.

Yet it is worth pausing to ask: if your own child or loved one faced this terrible dilemma, would it be unreasonable to want to participate in hand-bag ventilation in an attempt to save your child, if the only alternative was death?  The era of COVID-19 brings this closer to home than many of us ever anticipated.

In this article, we aim to encourage deeper reflection on this complex predicament.  We argue that despite a strongly plausible intuition suggesting the impermissibility of parental participation in hand-bag ventilation, it may still be defensible.  Our analysis leads us to an ethically provocative, context-sensitive algorithm for allowing parental participation in hand-bag ventilation, while situating this micro-ethical dilemma within the larger problematic quest for global health equity.

It is our hope that this article stimulates both discussion regarding the practice of parental hand bag ventilation and much needed empirical work in this area.  Finally, we hope this line of discussion sheds light more broadly on chronic, global issues of rationing and resource scarcity that are currently and acutely being felt by so many.


Paper title: Parental Manual Ventilation in Resource Limited Settings: An Ethical Controversy

Author(s): Emily E. Barsky1,2, Sadath Sayeed2,3


1 Division of Pulmonary Medicine, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA

2 Harvard Medical School, Boston, Massachusetts, USA

3 Department of Global Health and Social Medicine, Harvard Medical School, and Division of Newborn Medicine, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA

Competing interests: None


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