How should we ration care during the COVID-19 pandemic?

By Liam Butchart, Kristin Krumenacker, Aymen Baig.

As we have all seen over the course of the COVID-19 pandemic so far, our healthcare systems are not built for the stress of the deluge of patients who have presented with illness from the virus. Therefore, institutions and governments have had to come up with ways to choose between people who need treatment when resources become scarce. As difficult as it is for patients and families, some resources must be rationed and difficult decisions made about who most needs medical care.

Typically, these methods have focused on doing the most good for the greatest amount of people – in philosophical terms, they are utilitarian, where outcomes are weighed against each other. In our Western society, this is the way we usually think about moral dilemmas, even though other approaches exist. Think of the classic Trolley Problem, where we are asked to pull the lever to sacrifice one person for the lives of five others; many of us will make that decision for the greater good. However, as many people have discovered, this method of weighing people against each other can feel callous and cold in our current circumstances: it ignores the unique vibrancy of each person, as patients are condensed into scores and formulas that determine their care.

But it does not have to be this way, necessarily. We are medical students who have taken courses in compassionate care, bioethics and feminist thought. One of these classes was on a moral approach known as the ethics of care; specifically, we learned about Eva Kittay’s work in her book Learning from My Daughter. When COVID struck and hospitals began having to ration care using algorithms that focused on weighing patients, we saw an opportunity to take what we had learned and apply it to an important issue.

The result was first an oral presentation at the Institute of Medical Ethics’ 2021 Student Conference, where we presented our approach of using the quality of caring relationships to determine moral actions like rationing decisions. We were able to receive important feedback, which led to our paper. In the essay, we suggest that the current system of rationing could be improved by incorporating the insights of feminist scholars, who focus on the individual dignity of each person and on our inherent interrelationships. This leads to the value of care for dictating moral choices – like who will get a ventilator when multiple patients need one.

Like Kittay, we view care as having multiple components: care involves intention, benefit for the person being cared for, and autonomy. We must intend to do right by the person we are caring for and have the skills to benefit them; the person receiving care must also choose to take up the care that we offer. Enacting these principles requires open and honest discussions with patients and families, and also requires us as patients to recognize that we have obligations to other patients and providers, too. Through a process of discussion and medical evaluation, providers can offer the most appropriate medical care for each patient.

For some people, this method – rather than simply comparing people’s expected qualities of life – might seem more convoluted and may invite an uncomfortable level of subjectivity. However, we suggest that subjectivity is an implicit part of the human experience – something that feminist philosophers have long argued. Additionally, though this approach may appear more complicated, it better attends to the people within the patients who need care, rather than just the patients’ medical presentations, as they are too often treated as collections of parts that need repair.

But we maintain that there is a place in the bioethics discussion for a care-based approach. We could all learn to be a bit more caring to others – and ourselves – during this trying time. By utilizing or even just considering a care-based approach to rationing, we may make measurable improvements to the way that people are treated in the hospital and at the end of their lives. And that, we think, is valuable.


Paper title: A Different Approach to Medical Decision-Making in Difficult Circumstances: Kittay’s Ethics of Care

Authors: Liam Butchart, Kristin Krumenacker, Aymen Baig

Affiliations: Center for Medical Humanities, Compassionate Care, and Bioethics, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA

Competing interests: None

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