Written by Joshua Parker and Ben Davies
One of the impending tragedies of the COVID-19 pandemic is a grave mismatch between the supply of ventilators and the numbers needing them. This situation, as seen in Italy, is predicted to be mirrored here in the UK. Coronavirus can cause acute respiratory distress syndrome for which the management is mechanical ventilation on the ICU. This represents these patients’ only chance at survival. Part of the response to the incoming tsunami of patients requiring ventilation is to produce more ventilators. This is a reasonable way to try to lessen the mismatch between supply and demand. However, producing more ventilators cannot be the solution in isolation. As a complex piece of medical equipment, ventilators need trained staff to operate them and provide the additional care ventilated patients require. There has been a significant push to attempt to ensure enough ventilator trained staff as possible. Both staff and ventilator shortages present significant issues; yet it is shortages of ventilators that account for the bulk of ethical discussion so far. It is therefore worth exploring some of the ethical problems that might arise should there be plenty of ventilators, but not enough staff.
Imagine an intensive care unit that is fully staffed. It has 100 beds, each occupied by a ventilated patient. The survival rate in this ICU is 20%, so we can expect 20 patients to survive admission. Due to the COVID pandemic there are many patients on the COVID ward whose only chance of survival is ventilation. Additional ventilators are made and set up in the ICU. No extra ICU staff can be found, so the ventilated patient capacity of ICU has increased without any extra staff.
A predictable result is that staff will now be overstretched to a greater degree than they were. Staff will be able to devote less time to each patient and will therefore be able to take care of each individual less well. As such, it is plausible that the survival rate in the ICU drops, say to 15%. This does not mean that more patients will die, though it depends on the size of the increase. But for patients who were already on ICU (‘existing patients’), their chance of survival has reduced. For those given the chance of ventilation (‘new patients’), their survival has gone up (from 0).
Two issues emerge from this hypothetical scenario. First, there could come a point where adding more patients to an ICU without any increase in staff results in fewer patients surviving because staff are so overstretched. This point may be a long way off for now. But it suggests that even if we take the view that our goal should be as many patients surviving as possible, simply increasing the number of ventilators is not automatically the right course of action.
There is much to be said for maximising the number of lives saved. But a second issue that will concern some is the fairness of asking those on ICU to reduce their chance of survival. This is a difficult judgement to make. The numbers we have presented involve a 5% reduced chance of survival for existing patients, and a 15% increase for new patients. But what if the numbers looked different? Would it seem just as reasonable if existing patients saw their survival chances drop by 15% in order to give a 5% increased chance to new patients (assume that this would still result in more patients living overall)?
If we do not simply want to maximise the number of lives saved, there are three potentially relevant considerations. The first is relative sacrifice and gain. Thomas Scanlon (1998) suggests that ethics requires principles that nobody could reasonably reject. Morality may demand that I am prepared to make sacrifices, even considerable ones, to benefit others. This seems particularly true when the good I will benefit from – a public hospital bed, etc. – are no more mine than anyone else’s. Yet it may be more reasonable for me to reject a principle that requires me to give up a considerable amount in order for you to gain much less. If my chances of survival move down from moderate to poor, and yours move up from zero to poor, might it be reasonable for me to object that my sacrifice was not worth it, even from an impersonal view?
The second issue is absolute benefit. In moving from a 20% survival rate to a 5% rate, we move from one group of patients having a small but moderate chance, and another having no chance at all, to a larger group of patients with a very low chance of survival. One principle we might appeal to here is the idea that there should be a minimum quality of care that all patients are entitled to so long as it is possible to provide it. Adding increasing numbers of ventilators, and hence patients, without also increasing staff compromises this quality of care for patients who were already in the ICU. The result might be that nobody gets the minimal quality of care because staff are overstretched. On the other hand, one might note that if we refuse to increase capacity, there are still patients who do not receive this quality of care.
Finally, there is clearly an issue of equality. Assuming that all patients have the same claim to medical care, can we really justify using something as arbitrary as ‘first come first served’ to justify inequalities in the level of care they receive? What’s more, a policy that favours those who first occupy beds may contribute to unjust outcomes in other ways.
While it is clearly crucial to procure more ventilators, the ethical consequences of doing so are not straightforward (we have not even mentioned the psychological, physical and emotional effects on overstretched staff) when there are limits on staff numbers. Indeed, it is worth highlighting that while the case of ventilators is illustrative, the consequences might be similar for many other healthcare resources or shifts in service provision. Increasing beds without a corresponding increase in staff; redeploying away from cancer and towards COVID-19 patients; there are many issues where shifts or increases in resources raise ethical problems. The practical upshot is familiar: medical staff need to be protected from infection, have access to testing to enable them to work, and cared for. This is not only what medics deserve in their own right; it is essential if a significant increase in ventilators is not to cause a further ethical crisis.
Dr Parker is a GP registrar, and Education Fellow in Ethics and Law at Wythenshawe Hospital, Manchester.