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[ICU Management & Practice]: 新型冠状病毒感染大流行:分配稀缺资源时的道德困境
2020年05月26日 研究点评, 进展交流 暂无评论

COVID-19 Pandemic: The Ethical Dilemma of Allocating Scarce Resources

Coronavirus pandemic continues to intensify as does the shortage of ventilators and beds. In countries where cases are multiplying at a tremendous rate, a critical question that is being asked is: what criteria should be used to guide rationing decisions? What should be done when demand for ventilators and other intensive treatment exceeds the supply? 
A new viewpoint addresses these concerns and provides a framework that could be used for making allocating decisions. Here are the key takeaways:

Excluding Patients with Comorbid Conditions from Receiving Mechanical Ventilation 

Some recommendations that have been proposed during the COVID19 crisis suggest that large groups of patients with comorbid conditions such as Class III or IV heart failure, severe chronic lung disease, end-stage renal disease, severe cognitive impairment, and other similar comorbidities should be excluded. Are these exclusions justified? Are they ethical? Not really. The very fact that these recommendations are allocating recourses to some patients but not others is, in itself, a violation of the principle of justice. You cannot categorically exclude patients because, in your opinion, their lives are not worth saving. Also, how is this recommendation supposed to be used in a dynamic crisis such as COVID19? When you violate the fundamental principles of public health ethics, you cannot possibly be right. You can give priority to patients who are most likely to benefit from these resources, but you cannot categorically exclude one patient over the other. 

Allocating Resources Based on Likelihood of Survival

Another common approach that is being recommended is to allocate scarce ventilators to patients who are most likely to survive. This strategy also ignores certain basic ethical considerations. If this policy is used, people will prioritise a patient who stands to lose 40 years of life compared to one who may only have a few more years to live. What are we saying here? Everyone doesn't deserve the equal opportunity to pass through all stages of life? That younger individuals should get priority only because they have more years to live? The use of the life-cycle principle in allocating decisions is again unethical and biased. If this policy is followed, then the most essential lives that need to be saved are those of healthcare workers and first responders. Aren't they providing the most value today? Allocating resources such as ventilators should not be based on sex, race, religion, disability, insurance status, wealth, citizenship, social status, or social connections.

What should be done then? Clearly, the above ideas are unethical and immoral. A multiprinciple allocation framework can be used to implement a fairer and more ethical system. It is impossible to have a single criterion that will capture all morally relevant values. Hence, an allocation framework that is based on allocating resources to all patients who meet usual medical indications for ICU beds and ventilators would be more effective. However, ventilator use should be presented as a time-limited therapeutic option. It cannot be an unlimited promise as it can set expectations that will most probably not met. Also, the duration of mechanical ventilation cannot be too brief. This will raise the issue of withdrawing ventilators form patients who, if treated for a few more days, may have survived. Finally, the burden of allocation decisions should not be put on treating physicians as they already have too much to deal with. 
It is imperative that with this crisis intensifying the way it is, hospitals and decision-makers implement policies that allocate scarce resources more fairly and that these policies support dying patients as fairly as they support those who are expected to survive.

Source: JAMA

«« COVID-19: From Hydroxychloroquine to Plasma Administration 

COVID-19: Quarantine Measures, Laws and Limits »»

References:

White DB, Bernard L (2020) A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. doi:10.1001/jama.2020.5046

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