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December 6, 2023

When there are too many patients, what's ethical?

By SARAH ELBASHEER | April 5, 2020



A 2017 ethical framework for medical rationing developed by Hopkins researchers has gained new relevance during the coronavirus pandemic. 

As the number of people with the coronavirus (COVID-19) rises steadily, hospitals contend with a possible overflow of patients and face difficult decisions.

With the lack of adequate medical supplies, how do health-care workers choose between patients when distributing limited life-saving treatment?

To create a framework for dealing with such crises, researchers from the Hopkins School of Medicine and the Berman Institute of Bioethics conducted a study: “Too Many Patients... A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters.”

The study considered public perspectives by taking feedback from Maryland residents as well as recommendations from medical practitioners, ethicists and public health specialists. A scoring system was developed to represent a numerical measure of a patient’s benefit from the rationed supplies. These scores were based on prospects for the patient’s short-term survival, long-term survival, stage of life and pregnancy. A lottery system is then applied in the case of equal scoring.

The work was submitted to the Maryland Department of Health in 2017, but it has recently been propelled into the spotlight. The framework is informing preparations for medical rationing in hospitals in Maryland, and in hospitals across the world, as they near a crisis.

“The hard thing about a pandemic, and making preparations for it, is the uncertainty,“ Alan Regenberg, a bioethicist who worked on the project, wrote in an email to The News-Letter.

Regenberg described how the ethical questions which the framework addresses were unnerving and distressing to the community members who helped inform it. While researchers knew that a pandemic or similar disaster was impending, it was difficult to convey this possibility.  

“The activity of any plan for crises is way less when there is no crisis,” Ruth Faden, a collaborator with Regenberg on the project, said in an interview with The News-Letter. “If we don’t have to think about it, people don’t want to think about it.”

The U.S. has been criticized for its lack of preparation in its response to the virus. However, Faden believes that while we could have been better prepared, it’s not likely that this dilemma would have been entirely avoidable. She says that it’s important to acknowledge the situation and strategize from now on.

Both Faden and Regenberg agreed that a key goal is to improve cooperation across all levels of specialty.

“Government leaders should have access to a range of experts (clinicians, scientists, ethicists),” Regenberg wrote. “Our best hope for minimizing the inevitable harms that would come from rationing is clearly identifying this risk now, and making sure the public has every opportunity to understand how (and why) the allocation will work if it comes to that.”

Regenberg wrote about his worries in the lack of strong federal leadership that is needed for resources to be shared across state lines.

“Trying to divide hospitals and health systems by state lines is going to be unhelpfully messy in a situation where additional chaos is a problem,” Regenberg wrote.

He explained that there will be deep ethical problems if there ends up being significant harm from rationing in hot-spot states such as New York, while other states have an abundance of resources. There is also the question of whether this issue applies to responses globally.

“This is a global pandemic, so everyone is feeling the pressure to hold on to their precious resources,” Regenberg wrote.

As the pandemic develops, there will be similarly difficult ethical issues that leaders and scientists will need to collaborate to solve.

“Closing schools will not fall equally across the population,” Faden said.

Faden explained the difficulties faced by health-care workers and essential employees, who now also have to function as homeschool teachers for their kids.

“What about all the children that are extremely disadvantaged and are home insecure or in and out of homelessness? Where school was their safe place?” Faden emphasized.

The extent of the issue also goes beyond schools. As an expert on justice theory, Faden pointed out numerous examples which she says are simply not being discussed.

“We need to start national conversations about the full range of essential workers,” Faden said.

Beyond the health professionals on the frontlines of the pandemic, everyone who cleans, prepares meals and changes the sheets at the hospital, as well as their families, are at risk.

Furthermore, Faden mentioned the people who are off the radar when it comes to labor standards in food preparation: migrant farm workers who are at significant risk due to their crowded housing and transportation.

Another issue that we may face in the future is in the distribution of a vaccine. Where demand will likely outstrip supply, there will need to be a prioritization in its allocation. The ethics of this situation will be different from current medical rationing — where frontline health-care providers and other essential workers who are at the greatest risk will be initially protected.

“It's going to be difficult to get a clear list of who should be on the essential worker list — lots of roles will be needed from doctors to grocery store clerks,” Regenberg wrote.

According to Faden, these ethical issues of the pandemic are a result of problems that already existed. Amongst these, the way health care is organized and delivered, and the unbalance in the education of children.

“The planning is, I think, shining a light on all the ethical fault lines in our society today,” Faden said. “Concerns about workers... they were there before, they just weren’t treated. [Coronavirus] is just making the fissures in our social fabric bigger.” 

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