Considering life and death questions is squirm-inducing enough in the abstract, sitting in an armchair. The COVID-19 outbreak is throwing urgent ethical and moral issues down our backs, like hot coals.
Why do I have to stay inside my house? How will we decide who gets a ventilator and who doesn’t?
The imperative for social distancing and the dread of a crushed health system rationing access to care are closely linked. The purpose of one is to avoid or minimize the other.
Health care workers know this is nothing new. Our private actions have always had public consequences to people we’ll never see. Health care in America has always been rationed, in insidious and complex ways, by our patchy, inefficient and unequal distribution of resources.
Our individual fates have always been tied together by millions of invisible threads of duty and neglect.
COVID-19 has only tightened those threads around our necks.
Disease and cure
The message from health care experts is clear. Every citizen is a sandbag in the line of defense against coronavirus. Go out of the house and you are removing your sandbag self from the rampart.
That’s a tough order for many Americans. Leonard Fleck, a medical ethicist and MSU philosophy professor, said that drastic collective action poses a challenge to traditional American individualism.
“One of the things we learned from China, a society radically different from our own in terms of political behavior, is that if you really sharply diminish large- or even relatively small-scale human contact, you can contain the epidemic,” Fleck said.
But a backlash against social distancing, from President Donald Trump on down, is mounting. “Don’t let the cure be worse than the disease” is Trump’s new catchphrase, and it is catching.
In an Op-ed in The New York Times, David Katz, the founding director of the Yale-Griffin Prevention Research Center, pleaded for a more targeted strategy to fight the coronavirus, citing the “social, economic and public health consequences of this near total meltdown of public life.”
Nigel Paneth, an epidemiologist and pediatrician at MSU, factors the skeptics into a stark formula.
“The devastation of this epidemic will be in exact proportion to the number of people in the population who hold these views and refuse to follow sensible public heath advice,” Paneth said.
The pop culture reference making the rounds on the Internet is the morally bankrupt Mayor Larry Vaughn of the movie “Jaws.” Pressured by the local Chamber of Commerce and tourist bureau, Vaughn insists that the beaches of his seaside New England town are “open for business,” despite a marauding killer shark.
An “open for business” strategy of relaxing social distancing rules, letting the virus run its course and developing “herd immunity,” Paneth said, would lead to a “catastrophic” outcome.
If the death rate of COVID-19 is somewhere between 1 percent and 3 percent, as many researchers report, between 2 million and 6 million Americans would die in the attempt to achieve herd immunity, Paneth said.
“The endgame is not for the virus to run through the people,” Paneth said. “The scenarios have been done.
You’ll get an immune population next year but you’ll have several million casualties along the way and you’ll absolutely destroy the health care system.”
In the absence of a vaccine, Paneth said, social distancing is the only tool available to avoid crushing the American health system.
“This comes up over and over again in American history,” Paneth said. “We take pride in the rugged individual — ‘I don’t need any help, I can do it myself.’ This is one of those times where they are really going to clash.”
No one is safe
The coronavirus crisis has exposed the glaring inequalities, not only in the American health system, but in the broader social safety net.
“It’s a problem of justice and it’s also a public health problem,” Fleck said. “We still have 28 million people who are uninsured and 50 million to 75 million people who have marginal insurance. They have policies from their employers with something like a $5,000 front-end deductible.”
Many of those people are “out in the world,” Fleck said, getting sick and possibly making others sick, because they can’t afford health care.
Americans have already shown they can act collectively to improve health outcomes on a vast scale. The introduction of Medicare and Medicaid led to dramatic improvements in mortality rates, especially among the young and old, Paneth said.
In 1976, when Paneth was a chief resident in Jacobi Hospital in the Bronx, the newborn nursery was an intense place to work, as physicians struggled to get premature babies through their vulnerable weeks. Paneth was amazed when a physician who worked in the nursery 10 years earlier told him that back then, it was the easiest job in the hospital, because all you had to do was come in at night and sign a death certificate whenever a nurse called.
“They didn’t use mechanical ventilation,” Paneth said. “You kept them warm, you tried to feed them and if they died, they died. It was triage.”
Paneth said that with Medicare, in mortality among older people was equally dramatic.
“In their 80s an 90s, they didn’t get surgeries,” Paneth said.
Health care experts hope the coronavirus outbreak might rekindle the spirit of collective action to build a stronger health care system. Suddenly, dozens of commentators have remarked, socialized medicine doesn’t look so bad.
It would be easier for wealthier Americans to ignore the plight of the uninsured and underinsured if they weren’t potential vectors for a deadly virus that knows no barriers — or potential competitors for limited resources in a pandemic-crushed health system.
But the systemic problems that make the United States vulnerable to a pandemic reach far beyond the medical system. Christine Mitchell, director of the Center for Bioethics at the Harvard Medical School, talked about the ethics of fighting coronavirus with Issac Chotiner in the March 11 New Yorker.
Mitchell said that people who live in poverty, don’t have insurance or paid sick leave “are elements of the way our society is structured and has failed to meet the needs of our general population, and they influence our ability to manage a crisis like this.”
Collective action doesn’t come naturally to many Americans, but the coronavirus outbreak is also laying bare the limits of individualism. When a deadly virus is on the loose, the problem of millions of uninsured people suddenly becomes your problem, even if you have a platinum plan. Americans of all classes will soon be jostling in hospital hallways for the same few ventilators.
“Suddenly, the poor state of public health in America is becoming a life-or-death problem for even the most privileged,” Michelle Goldberg wrote in Tuesday’s New York Times.
The crisis is a ringing reminder of the moral imperative to take care of each other. “This is where we need to have a much tighter and more secure safety net, to deal with a situation like this and not have to try to invent something on the fly that’s may or may not work,” Fleck said.
As Goldberg pointed out, no amount of money can buy care that’s not there: “No one is safe from the coronavirus until everyone is.”
Life and death
The federal government has not, so far, handed down national rationing guidelines for the coronavirus pandemic.
But the question is far from academic. In Italy, a shortage of ventilators has led to care being withheld from older patients, or patients who are unlikely to survive, to give younger, healthier patients a chance to live.
The New York Times reported over the weekend that a federal grant program has already helped hospitals, states and the Veterans Health Administration draw up guidelines to develop “what are essentially rationing plans for a severe pandemic,” and that these plans are being dusted off as the coronavirus spreads.
Individual states, medical associations and hospitals are drawing up their own guidelines, but there are still no generally agreed-upon best practices when it comes to rationing.
According to a Patient Rights statement on Sparrow Health System’s website, patients have the right to call for an ethics consultation “if a conflict of an ethical nature arises” during a patient’s care. Sparrow’s ethics committee arranges a conversation “among all those involved with the patient’s care.”
“Ideally, discussions end with everyone agreeing about the best course of action,” the statement reads.
“Ethics committees are brought in on complex questions, usually at the level of an individual — should a baby be taken off a ventilator?” Paneth said.
Paneth is specially trained in pediatrics and pregnancy.
“Sometime there are very painful dilemmas, with nonviable or barely viable babies who would have to be treated for a long time,” he said. “Similar questions apply to adult patients, and that’s where the hospital ethics committees weigh in.”
Michigan’s Department of Health and Human Services has guidelines in place for the “distribution of scarce medical resources in an ethical fashion” in emergencies.
The guidelines find two categories of criteria for rationing acceptable: medical prognosis (“the likelihood of a positive medical response”) and whether or not the patient performs “essential social functions.”
Among those who perform “essential social functions” listed in the Michigan guidelines are health care workers, first responders, public health scientists, police, firefighters, military and energy and telecommunications workers.
The Michigan guidelines declare two types of criteria “unacceptable” when allocating health care: “social characteristics” including race, gender, sexual orientation, religion and disability unrelated to immediate medical prognosis; and “social worth,” including job status, education, political affiliation and familial relationships, along with the patient’s likely ability to pay.
Guidelines differ from state to state. New York’s, for example, does not give priority to health care workers and first responders.
New York’s guidelines, drawn up in 2015, include extensive “ventilator allocation guidelines” in the case of an influenza pandemic, based on solely clinical criteria: “immediate or near-immediate mortality, even with aggressive therapy.” Age alone is not recommended as a criterion, but the New York guidelines point out that advanced age often figures into a patient’s prognosis anyway.
Michigan’s guidelines say rationing by age “could be considered in limited circumstances.”
Fleck was on the ethics committee that worked on the guidelines in 2011.
“There was a group of about 30 of us, appointed by the governor, to come up with some of the ethical considerations that had to be taken into account,” he said.
The ethics committee ran through several scenarios, including one where SARS turned out to be as bad as the 1918 Spanish flu, which killed about 50 million people worldwide.
“If something like that were to occur, our ICUs would be overwhelmed in no time at all,” Fleck said.
Some members of the committee pushed harder for clear age cutoffs.
“Under that radical scenario, we said, no one over age 70 would be treated — hard stop,” Fleck said. “‘We’re sorry, we hope you’ve had a good life, but there are younger people who will benefit more from access to life prolonging care and we’re going to have to meet their needs first.’”
That, Fleck said, is a simple utilitarian approach — the greatest good for the greatest number.
“A lot of people find that off-putting when we’re talking about life and death decisions, but there is something of an egalitarian aspect to it as well,” he said.
The “hard stop” age cutoff was not incorporated into the guidelines.
“That is not something that is easy to sell,” Fleck said. “The governor did not want to promulgate this, as we had recommended.”
The finished guidelines point out that rationing care by “numerical age, quality-adjusted life-years, disability-adjusted life-years, or some other measurement based upon longevity or functioning raises several difficult issues,” mainly by “making an explicit differentiation between people on the basis of age.”
Michigan’s guidelines also mention a lottery as a possible “tie-breaker” if all other factors are equal and there is still a shortage of care, but stop short of recommending it.
If such rationing has to be implemented, the Michigan guidelines recommend that the decisions be made by “persons removed from the clinical context,” thus lifting the burden of life-and-death decisions from beleaguered nurses and doctors.
Will it come down to rationing at all?
Health care workers from around the world have asserted that the health care system has an ethical obligation to avoid rationing care whenever it can.
That brings the discussion full circle, to the social distancing tools the world is deploying in the hope of avoiding, or at least minimizing, the terrible prospect of rationing care.
“We’ve got a wildfire out there,” Paneth said. “We have to stop adding fuel to the fire. Wildfires survive if they can find fresh fuel. Fresh fuel is people who have not yet been infected. Every time you get people together, you open the door to spreading the fire.”