HEALTHCARE professionals serve on the front lines of the war against human disease. However, practising medicine is an ethical endeavour at heart, not merely utilisation of technical skills. James F. Childress, a leader in the bioethics field, notes that “only professionals who stand on the firing line or in the trenches can really appreciate the moral problems of medicine”. Medical ethics is the framework within which physician-patient-family interactions play out.
Advances in scientific knowledge and biomedical technologies provide physicians with new ways of helping patients but this also increases the complexity of decisions about what constitutes ethically correct treatment. Ethical challenges are compounded in extraordinary situations like the Covid-19 pandemic when patients are many but resources — staff, supplies and equipment — severely limited.
At such times, familiar ethical norms governing clinical practice must give way to public healthcare ethics that prioritise the greater good over interests of individual patients. A different set of principles guide treatment decisions; these can be morally difficult and emotionally distressing for healthcare professionals (HCPs).
The country is drifting into the eye of the Covid-19 storm. There is progressive increase in confirmed infections (13,000 and rising) and fatalities. Covid-19 is a respiratory disease caused by a virus that attacks the lungs. In early April, there were 3,300 ventilators in 137 hospitals in Pakistan. Health systems far better staffed and equipped than Pakistan buckle under the sheer numbers of patients requiring critical respiratory management. HCPs are confronted with the question: who should live when not all can live? Employing medical criteria and empirical data, countries are developing ethical guidelines to assist HCPs in making these difficult decisions.
Who should live when not all can live?
It is unclear how many infected patients across Pakistan are currently in intensive care units and/or on ventilators, but it is inevitable that in the coming days, Covid-19 patients requiring these services will overwhelm available resources. Ethical guidelines that exist, from the Pakistan Medical & Dental Council and its ilk, cover medical practice in normal times focusing on the patient-physician dyad in which autonomy and decision-making by individual patients is essential.
Patients deemed medically worse off receive preference for intensive care over others, and it is unethical to remove patients from ventilators for use by others considered more medically ‘salvageable’.
This individual patient-centred ethical paradigm will have to change should the pandemic intensify and increasing numbers of patients require intensive care including ventilation. Public healthcare ethics will be needed to maximise benefits for the greatest number and save as many lives as possible with limited resources.
This utilitarian approach in allocating resources originates from medical/surgical war experiences and is termed ‘triage’, a French word initially used for sorting/separating of wool and coffee beans based on quality. In the 18th century, Dominique-Jean Larrey — a surgeon in Napoleon’s army — first used triage in sorting battlefield casualties, prioritising treatment for soldiers most likely to be returned to war.
Ethical guidelines for the Covid-19 pandemic employ this concept in decisions about allocation of scarce resources, termed “responsible stewardship of resources” by authors of an article in the March issue of The New England Journal of Medicine. Infected patients determined on medical grounds to be most likely to survive (using a combination of criteria such as younger age, absence of pre-existing diseases, functional outcome) would be given preference for ventilators. In severe limitations of ICU beds, aggressive treatment could be withdrawn from a patient showing unsatisfactory progress and provided to another likely to survive.
These decisions are immensely distressing, morally and emotionally, and would be taken by a team of doctors to lessen the burden. Existing guidelines recommend that infected healthcare providers be prioritised for treatment based on reciprocity towards those who risk their lives for others, and because HCPs can resume duties following recovery.
Pakistan has no ethical guidelines yet at a national level addressing these issues. The Centre of Biomedical Ethics and Culture, SIUT has developed, with input from key stakeholders in public and private healthcare institutions, concise Covid-19 guidelines providing a contextualised ethical framework for allocation of scarce resources.
These have been widely disseminated nationally, and sent to federal government officials (response awaited). The document aims to assist HCPs/institutions in formulating standard operating procedures before we are sucked into the vortex. We can hope we never have to make such decisions but wisdom demands we prepare for the worst.
The writer is chairperson, Centre of Biomedical Ethics and Culture, SIUT.
Published in Dawn, May 3rd, 2020