The distribution of healthcare resources equitably among the population in need is one of the issues that bioethics examines in the field of healthcare. The principle of justice, defined in principlist and personalist bioethics, as well as the principle of subsidiarity added by the latter, seeks to regulate the use of available healthcare resources and facilities in such a way that their use benefits the greatest number of people, avoiding discriminatory criteria based on unfair decisions, and also by facilitating that the most vulnerable, in particular, receive care proportionate to their needs.
Exceptional situations — such as the one we are currently experiencing — may arise in which the demand for healthcare resources and services far exceeds supply. The tremendous dilemma of deciding who may be the beneficiary of these resources or of essential medical care must be determined by strictly adhering to well-founded bioethical criteria, which advocate the correct application of the above principles without unfair discrimination.
Conditions of armed conflict, environmental disasters or pandemics such as the present one may provoke this dramatic imbalance between available means and the care needs of the population. In such circumstances, it is necessary to decide to whom the resources should or should not be allocated, even at the risk of compromising the patient’s recovery or survival.
Faced with a situation such as the current coronavirus pandemic, and the need to utilize many intensive care-related resources, including invasive, assisted breathing devices, patient demand for this life support can far exceed the number of respirators available, in addition to the consumables needed to operate them and the qualified technical staff who must apply and monitor them.
The tragic dilemma arises when faced with the quandary of which patients are to be intubated and which are not, with the consequences that may result from these decisions. A similar dilemma may arise when there is a need to intervene surgically or to attend to any other life-threatening emergency.
It is the “catastrophic” application of the principle of justice, which requires clinicians to “cease treatment” in patients who, under other circumstances, might recover if the resources were sufficient. The criterion of applying them to patients with a better chance of survival and with fewer sequelae expected is, in principle, the right one, the least bad, knowing that a decision is taken in which the double effect occurs, whereby patients who might have survived will die after making the selective decision; however, this is the only possibility that exists, with no alternatives.
If this selective approach is applied correctly, in reality, patients would not be allowed to die as if it were a form of euthanasia, but rather in an attempt to save those who are most likely to survive with the minimum of serious sequelae, given the limited resources. The death of these patients is not sought, or even tolerated, but is simply inevitable.
The proper application of the principles of justice and subsidiarity requires that, before making decisions such as those outlined above, all possible alternatives should be explored, including the possibility of referring patients to other hospitals or treatment areas, the reallocation of resources for other requirements to be applied to patients in life-threatening situations, human and material resource planning in order to anticipate demand and to be able to cope with atypical situations such as the current one, optimization of available resources (such as sharing a single respirator by two patients, as reported yesterday in a hospital in Madrid), and others that at all costs try to avoid application of the selection or “triage” of patients who are eligible for intensive care.
Patient selection criteria
The application of triage for selecting candidates for intensive care unit (ICU) admission and the application of invasive mechanical ventilation should be restricted, as specified, in extreme situations in which patient referral to other centers or the allotment of new resources are insufficient to adequately address demand in the hospital or ICU. Therefore, it should always be the last option, not applicable when care can be provided by other means.
An initial criterion for making this selection would be the possibility of obtaining a significant benefit and reversibility of the severity of the condition in the treatment recipients, in whom invasive mechanical ventilation, for example, would be indicated. Careful assessment of the chances of survival of these patients and the magnitude of the sequelae they may suffer as a result of the progress of their disease is needed. Accordingly, those with the best prognosis for recovery and survival with the minimum of sequelae would be selected.
The application of other criteria in a discriminatory manner, such as the age of the patient or other circumstances such as psychiatric disorders, dementia or any other form of disability or dependency, would not be bioethically acceptable, because it would mean acting against respect for the dignity that every human being possesses regardless of his or her circumstances, and would move away from the basic criterion of selection based on the possibilities of survival with no serious sequelae.
Finally, the care to be given to all patients, especially the most vulnerable, should include, whenever possible, psychological and spiritual care, which should be extended to their family circle or carers, as an essential component in the support of the patient and, specifically, of those undergoing palliative care or in the terminal phase.
Particular mention should be made of management of the bereavement upon the death of the patient by their family and close friends, which may be hindered in extreme situations such as the present. The measures and procedures needed should be structured so that, even in difficult situations prompted by the requisites for isolation and risk of transmission, family members could see the patient at the end of their life if at all possible, by implementing the necessary precautionary measures, and say goodbye to them after their death, which would help overcome their grief.
Julio Tudela – Pharm PhD
Bioethics Observatory – Institute of Life Sciences