Scores of Americans are in critical condition from the Covid-19 virus and so is our country. Covid-19 has eviscerated New York City and marches toward other urban areas across the United States. Dire predictions of anywhere from 100,000-240,000 US deaths were soberly delivered by @DrAnthonyFauci and @DrDeborahBirx at @PresidentTrump’s press briefing on March 31. Their modeling relied upon continued mitigation efforts such as social distancing, hand washing, and non-essential business closures. Ignoring such guidance could see the numbers explode into the millions.
The current focus is on treating individuals suffering with the Coronavirus, as it should be. Sadly, we are subjected to one of human nature’s less-appealing characteristics, that of a blame game, arising when a fear of the unknown lingers.
Accusations of a decades long lack of preparedness are unfortunately true but in a country of 327million people and a pandemic of unknown course, the truth is that no one knows enough about the virus trajectory to pinpoint exact needs. Another truth is that the allocation of extremely scarce resources has been studied and debated for decades. As a result, large binders of policies and guidelines are stored in paper or electronic files throughout the country’s public health departments and hospitals.
The reaction to this allocation is now out in the open with a bright light shining upon rationing and triage. The public’s response is one of disbelief. Even physicians and nurses are having a hard time grappling with the concept. Why? Because neither was offered a strong medical ethics curriculum while in training.
So, we are where we are. It is what it is.
In addition to the unquestionable stresses being experienced by overwhelmed healthcare systems, there is a concurrent tension that must be openly recognized, i.e., the equilibrium between preserving the health of uninfected individuals as well as preserving the health of the economy. The “cure cannot be worse than the problem” may be an inarticulate way of synthesizing the need for that equilibrium, but it is a reality and one that requires the same life-saving efforts provided to an individual.
@ArthurCaplan, PhD, Chief Ethicist at NYU Langone School of Medicine in New York City brings a career of opining on moral issues facing the medical community and is widely acclaimed for his works. In a just released interview by @JamesHamblin in The Atlantic, he focuses on the patient, answering the difficult ethical questions about rationing and triage.
As a bioethicist, such questions are familiar territory and address the quandary clinicians face in a pandemic as well as other crises where resources are strained. The work done by bioethicists over years of research and respectful deliberations on some of life’s most difficult decisions has already happened. It just has not been brought into a public forum until now.
@EzekielEmanuel MD, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania is another highly respected bioethicist. Emanuel’s Opinion column in the New York Times on March 28 addresses the health of the economy and a proposal for incrementally rebuilding the workforce.
Returning the economy to health is just as critical as returning the patient to health. Do we use the utilitarian principle where we seek the best outcome for the greatest number of people? This would mean a gradual return to a full economy, taking calculated risks. It would be a triage in many respects.
In patient triage, the patients most likely to survive are treated first using available albeit scarce resources. Those least likely to survive are kept comfortable.
In triaging the nation, healthy individuals with the greatest likelihood of contributing most to rebuilding the nation’s economy could be released from at-home restrictions and return to work first. An incremental process…one building block upon another. Those most vulnerable and the least likely to contribute to that re-growth would remain restricted much longer although more comfortable because of the gradual opening of the economy around them.
The current crisis places critically ill patients on mechanical ventilators in intensive care units. The country, our second patient, is critically ill and in intensive care, with a diagnosis of multi-system [organ] failure, i.e., a shut-down of the economy. The nation’s ventilator is the $2.2trillion rescue package.
Both the patient and the country will need to be weaned toward a healthy state. An inability to do so for either results in the death of both. Triaging an individual into treatment and a country out of treatment is a delicate balance, never having been done at this level of magnitude before.
The capacity to make ethical choices and take moral action is a heavy weight for all involved. They need our prayers and support.