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Answering the tough questions — how do health authorities decide who gets scarce resources?

Road ahead: It is a crucial issue as Australia assesses its shortage of ICU beds – currently about 2,200 beds, and well short of what health authorities expect will be needed.

AS the coronavirus pandemic widens, each one of us is called on to make decisions – based on answering to deep moral questions.

This ranges from the mundane decisions we make about how much toilet paper to take from the supermarket shelves, to the life-and-death calls that doctors have to make about which patients to treat.

David Kirchhoffer, the director of the Queensland Bioethics Centre at Australian Catholic University, has examined how health authorities decide who gets scarce resources and which patients to treat with increasingly scarce resources.

It is a crucial issue as Australia assesses its shortage of ICU beds – currently about 2200 beds, and well short of what health authorities expect will be needed.

“The question, as is often the case in ethics, is more complicated than it appears,” Dr Kirchhoffer said.

He said most people who had visited an emergency room would be aware of the procedures that already exist.

“This is usually based on an assessment of whose need is most urgent based on consideration of factors like who is likely to suffer the most harm without treatment, who is more likely to benefit from treatment, and who might be able to obtain the required treatment elsewhere,” Dr Kirchhoffer said.

There are also clinical guidelines to deal with patients that refuse treatment, or who are unlikely to benefit from it – sometimes called medical futility.

However beyond this, the risk with COVID-19 is that the health system is rapidly becoming overburdened and simply unable to care for everyone.

“If two people present at emergency at the same time with acute respiratory distress that is likely to kill them, and there is only one ventilator available, a decision must be made about who gets the ventilator based on a clinical assessment of who is more likely to therapeutically benefit from treatment,” Dr Kirchhoffer said.

Similar decisions are already being made when it comes to testing for COVID-19.

“The shortage of diagnostic kits for COVID-19 means that only people who are deemed to meet certain criteria are being tested. We simply cannot test everyone,” he said.

It is already documented that in some places like Italy the elderly have been denied treatment because they’re too old to benefit. Dr Kirchhoffer warns against making critical care decisions based on broad-based blanket criteria like a patient’s age.

“Every case and context should still be assessed on an individual basis regarding the likelihood of therapeutic benefit relative to the context … if one of the people was 60 but otherwise fit and healthy, while the other was 25 with a severe pre-existing life-limiting condition, it would make no sense to use only age as the criterion upon which to base the decision to treat.”

He said accurate assessments should be made by people best able to assess the situation in a given context.

Health authorities decide what criteria people should meet before they can be tested because they know how many tests are available, where they are and who is likely to be infected.

But general practitioners dealing with individual patients make the decision on whether they meet those criteria and should be tested.

Tough decisions: “The shortage of diagnostic kits for COVID-19 means that only people who are deemed to meet certain criteria are being tested. We simply cannot test everyone.”

In an emergency room context, Dr Kirchhoffer said it was usually the decision of the clinical team treating the case or the most senior doctor.

That’s not to say patients and their families don’t have a say in the matter too.

“Typically, these decisions are, as far as possible, to be made with the informed consent of the patient if they have capacity and are competent, and with relevant others, for example family or people with executive power of attorney for health matters … where disputes arise, and time allows, escalation procedures are in place to obtain second opinions or to refer the decision to a higher authority,” Dr Kirchhoffer said.

But while procedures are already in place to ration health care and treatment when necessary, Dr Kirchhoffer warned there could be dangerous consequences if those procedures were blindly followed.

“The greatest long-term danger of healthcare rationing is probably that we might start to think differently about the worth of certain people in our society,” Dr Kirchhoffer said.

“We are in danger of allowing the current crisis to change the way we think about certain groups of people in our society and the rights that they have.

“We are in danger of allowing a calculative or economic rationality to change the way we speak and the way we think about who matters and about why we do what we do. We are in danger of losing sight of each other as human persons.”

During this coronavirus crisis, decision making and the careful use of resources will be largely the responsibility of doctors and other health carers.

“We provide medical care to all because we believe that all human beings have equal dignity, that is, the same inherent worth. They are not reducible to their economic value or utility. They are beyond ‘price’. There is no age at which one ceases to possess this dignity,” Dr Kirchhoffer said.

“We must ensure that we do not allow the current public health crisis and the need to think carefully about how best we use health resources to be translated into a legitimisation of practices or ways of thinking that diminish the worth of any group of human beings.

“We do not want to end up in a society that treats the aged, or people with disabilities, or people of low socioeconomic status as ‘expendable’.”

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